Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to initiate a written grievance for one of 37 residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff failed to initiate a written grievance when the resident reported a missing coat. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/2/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact. On 3/14/23 at 3:31 p.m., an interview was conducted with R6. The resident stated someone stole their winter coat in November 2022. R6 stated this was reported to multiple staff and the coat was supposed to be replaced but it had not yet been replaced. A review of R6's clinical record failed to reveal documentation regarding R6's missing coat. A review of the November 2022 and December 2022 grievances failed to reveal documentation regarding R6's missing coat. On 3/16/23 at 9:17 a.m., an interview was conducted with OSM (other staff member) #1 (the director of social services). OSM #1 stated missing clothing is a concern/grievance. OSM #1 stated if a resident reports missing clothing, then she writes up a grievance and staff looks through the laundry. OSM #1 stated that if the missing clothing is not found then she talks to the resident to see if they want to be reimbursed for the missing clothing or if they want the clothing replaced. OSM #1 stated R6 did report a missing green coat and the coat was replaced. OSM #1 stated there was no grievance form regarding the missing coat because the replacement coat was purchased for R6 as a Christmas gift. On 3/16/23 at 9:34 a.m., ASM (administrative staff member) #2 (the director of nursing) provided evidence that a coat was purchased on 12/16/22. ASM #2 stated there probably was not a grievance form regarding R6's missing coat because the reporting of missing clothing is a behavior that R6 presents with, and the staff typically accommodates the resident. ASM #2 stated R6 has lost multiple pairs of white pants and the staff has reimbursed the resident. On 3/16/23 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 were made aware of the above concern. The facility policy titled, Resident Grievances and Concerns Policy documented, 3. Investigation. The Grievance Committee/Grievance Official shall complete an investigation of the resident's grievance. This may include a review of facility processes, programs and policies, as well as interviews with staff, residents and visitors, as indicated, and any other review deemed necessary by the Grievance Committee .5. Grievance Decision. Upon completion of the review, the Grievance Official will complete a written grievance decision that includes the following: a. The date the grievance was received. b. A summary of the statement of the resident's grievance. c. The steps taken to investigate the grievance. d. A summary of the pertinent findings or conclusions regarding the resident's concern(s). e. A statement as to whether the grievance was confirmed or not confirmed. f. Whether any corrective action was or will be taken. g. If corrective action was or will be taken, a summary of the corrective action. If corrective action will not be taken, then an explanation of why such action is not necessary .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide adequate supervision for one of 37 residents in the survey sample, Residents #272. This deficiency is cited as past non-compliance. The findings include: The facility staff failed to have effective interventions implemented to prevent Resident #272 from wandering into other resident rooms. Resident #272 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: diabetes mellitus, hypertension and adult failure to thrive. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/21/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, which indicated the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring limited assistance for bed mobility, transfer, hygiene and bathing; supervision for walking, locomotion, dressing and eating. A review of the annual MDS dated Section E: 0200 A. Physical behavior symptoms exhibited towards others e.g., abusing other sexually. Coded=0 behavior not exhibited. A review of the comprehensive care plan dated 9/11/21, revealed, FOCUS: Resident is at risk for alteration in psychosocial wellbeing related to visitation restrictions, social distancing, and other protective restrictions in facility. Resident enjoys watching Western movies, listening to movies playing doorway bingo and other doorway activities. Impaired cognitive-communication function/impaired thought processes related to mild dementia. INTERVENTIONS: Encourage social activities for additional socialization opportunity. Provide activity items resident requires to complete self-initiated activities. Keep resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Encourage resident to make routine, daily decisions. A review of the social worker (SW) progress noted dated 1/5/22 at 10:19 AM, revealed, Nurse updated SW that resident is taking advantage and rubbing on a female resident. The SW will speak with resident. OSM (other staff member) #1, the director of social work, wrote this note. A review of the social worker progress (OSM #1) note dated 1/5/22 at 10:38 AM, revealed, Talked to resident about acting inappropriate to another resident. The resident was not very happy with SW, but said he understood to stay away. A review of the nursing progress note dated 2/13/22 at 6:31PM, revealed, Resident has been wandering into other resident's rooms. Resident has been redirected multiple times and becomes angry and curses at this writer. Resident said, There's no damn problem with me going in there. They don't mind. Why are you still here? Why don't [you] go home! A review of the nursing progress note dated 3/17/22 at 8:26 PM, revealed, Resident had an incident with a female resident. Police were notified and resident was placed on one-to-one observation. Resident was interviewed by detectives and removed from facility by police. A review of the facility's five-point plan dated 3/17/22, revealed, Root Cause Analysis Results: Unable to determine at this time as no previous sexual behavior documented. Action Items: Head to toe assessment was completed on female resident. RP (responsible party) and physician notified. Resident transferred to ER for evaluation. She will be monitored for any changes in behavior. Male resident was placed on 1:1. RP and police notified. Male was arrested and removed from facility by police officers. Residents with a BIMs of 12 and above were interviewed to determine if they had concerns and felt safe in the facility. Actions completed on 3/17/22. An interview was conducted on 3/14/23 at 4:23 PM with ASM #1, the administrator and ASM #2, the director of nursing. When asked about Resident #272's behaviors, ASM #1 stated, we were aware that he would go through the halls, that he had been redirected. ASM #2 stated, we do that with multiple residents. We were aware he was sometimes going into other people's rooms. For those he was showing interest in, there was a stop sign put up on those resident rooms. When asked if he would respond to the stop sign, ASM #2 stated, he was redirectable. ASM #1 stated, some stop signs were put up. I think I had talked to him a month before the incident (January), and things seemed to have calmed down. When asked to describe actions on 3/17/22, ASM #1 stated, once we realized what had happened, we called the police. We separated them. We put him on 1:1. He acknowledged that he had touched her, and he was arrested. He was sent to the hospital. Survey team conducted multiple interviews of staff on the evening shift. An interview was conducted on 3/14/23 at 5:35 PM with CNA (certified nursing assistant) #2, when asked if she remembered Resident #272, CNA #2 stated, No I do not remember him. An interview was conducted on 3/14/23 at 5:35 PM with RN (registered nurse) #2, when asked to describe Resident #272's behavior, RN #2 stated, Mainly I worked downstairs, when I up there working, he liked to wander, he liked to watch TV in the sitting area by the elevator. He would come back to get snacks then go to his room. When asked if he wandered, what actions were put into place? RN #2 stated, Never remember him going in any other resident's rooms, do not remember any interventions. He was alert and oriented, do not remember any behaviors. An interview was conducted on 3/14/23 at 5:41 PM with CNA #6, when asked if she remembered Resident #272, CNA #6 stated, yes, I used to work with him. He was okay. He was nice. He was chill. Never had a problem with him. Did not have good memory, he could be forgetful. I never witnessed any trouble with being angry toward staff. If he had a problem with someone, he would tell you and that was with staff only. He did not have any problems with other residents. He would wander into other residents' rooms. He was just peeking. We used stop signs to try to keep him out of resident rooms. We would watch where he focused and put up a stop sign. He used to really peek in Resident #74's room a lot. He would sit and stare into her room. We had a stop sign there. We had no idea, that he had any inclination of sexual behaviors. It is the last thing we would ever have expected. An interview was conducted on 3/15/23 at 8:57 AM with CNA #1, when asked what she remembered about Resident #272's behaviors, CNA #1 stated, took care of him on the 3-11 PM shift, he really needed redirected. Trying to go into other resident rooms. When asked to describe events of 3/17/22, CNA #1 stated, we had just laid Resident #74 down. I was at nurses' station talking with the nurse and saw him (Resident #272) speeding out of Resident #74's room. I went down the hall and heard water running in his bathroom and he was washing his hands in his room. He was in the room right across from Resident #74. He acted like nothing happened. He would be very aggressive verbally; he would curse at me and some other staff but not with residents. I got the nurse and unit manager and explained that something had happened. Resident #74's brief was torn open and feces was smeared all over. I stayed late, and they called the police. This was first time of physical contact by Resident #272 and Resident #74 or any female resident to my knowledge. Resident #272 was alert and aware of his surroundings and what was going on, he may have had a little dementia. An interview was conducted on 3/15/23 at 9:25 AM with OSM (other staff member) #3, the physical therapist assistant. When asked if he remembered Resident #272, OSM #3 stated, yes, I know him very well. I never thought anything like would happen. He was always very cordial to me. He was never verbally aggressive to me. I almost thought I was dreaming when I heard about this situation. I remember them blocking the door to Resident #74's room, he had been in the room or looking in the room and they put the stop sign up. If I see anything happening, I address it immediately. An interview was conducted on 3/15/23 at 1:56 PM with RN #3. When asked if she remembered Resident #272, RN #3 stated, yes, he liked to be in his room and in his bed, get up for breakfast, come watch TV and lay down till lunch and go to activities. I never saw him going into any resident rooms. If you tried to redirect him, he would get abrupt with you. I mainly had to redirect him from taking cereal or snacks off of the cart. When asked to describe the events of 3/17/22, RN #3 stated, I was sitting at the nurses' station and CNA #1 was talking with me and I was on the computer and I saw a flash of him going from one side of the hall to the other side. We went down there and you could see, in Resident #74's room, that the sheet was brown and we looked at her, the resident stated I am okay, I am okay, I am alright. She was fidgety. Resident #272 was in the [his] bathroom washing his hands. We told the unit manager and the police were called and we moved the female resident. An interview was conducted on 3/15/23 at 2:15 PM with RN #1, the unit manager. When asked to describe Resident #272's behavior, RN #1 stated, 'he was fine with residents, he would get agitated with redirection, he was a wanderer, he was nosey, would look in rooms, cereal and snack cart. He would raise his voice at times with staff when redirected. He was flirtatious, most of females enjoy that. When asked to describe the event on 3/17/22, RN #1 stated, RN #4 called me and she felt that Resident #272 had done something to Resident #74. I told the administrator. I went to Resident #74's room and saw bowel movement on bedsheet, I asked RN #4 what had happened and she stated that she had seen Resident #272 roll quickly from Resident #74's room to his room across the hall. RN #4 went into Resident #272's room and there was bowel movement smeared in the sink. We sent them both to the hospital as soon as the incident happened. When Resident #74 returned from the hospital we had move her room to the first floor. On 3/15/23 at 6:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing (DON), were made aware of the findings. An interview was conducted on 3/16/23 at 9:58 AM with RN #4. When asked to describe the events of 3/17/22, RN #4 stated, one of the aides had told me that Resident #272 was leaving Resident #74's room. In Resident #74's room there was stool smeared across her bed and her [brief] was torn open and stool was on it. I went to Resident #272's room and saw stool on his hands and in the sink where he was washing his hands. We called the police. A review of the facility's Resident Observation policy dated 5/28/21 revealed, To provide enhanced observation as a temporary safety mechanism during an acute episode where a resident is endangered. Procedure: A) Charge nurse will contact DON who, if necessary, will consult with administrative staff and/or Director of Mental Health, if applicable, to determine the appropriate observation/interventions if resident meets one of the following criteria: 1. Resident is a danger to themselves, to include but not limited to: self-harm; suicidal ideation/threat; 2. Resident is acting out behaviorally, to include but not limited to: throwing items; continuous screaming/disruptive behavior; 3. Resident is a danger to others, to include but not limited to: homicidal comments/threats/actions; 4. Immediate risk of elopement. B) DON will assign a staff member to complete appropriate observation/interventions which may include but are not limited to every 15 or 30 minutes checks or 1:1 monitoring. A review of the facility's five-point plan dated 3/17/22, revealed, Root Cause Analysis Results: Unable to determine at this time as no previous sexual behavior documented. Action Items: Head to toe assessment was completed on female resident. RP (responsible party) and physician notified. Resident transferred to ER for evaluation. She will be monitored for any changes in behavior. Male resident was placed on 1:1. RP and police notified. Male was arrested and removed from facility by police officers. Residents with a BIMs of 12 and above were interviewed to determine if they had concerns and felt safe in the facility. Weekly resident interviews will be conducted with residents with BIMS of 12 and above by the Social worker/designee for 12 weeks. Skin checks of 10 residents with a BIMS of 11 and below will be conducted by director of nursing/designee for 12 weeks. Weekly staff interviews with 10 staff members to ask if any unusual or concerning behaviors occurred. Staff education regarding abuse 3/17/22-3/21/22. Resident Council meeting on 3/18/22 to discuss abuse and reporting of abuse. Discussion at QAPI (quality assurance process improvement) committee on 3/18/22. Actions completed on 3/21/22. This deficiency is cited as past non-compliance. No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for a urinary catheter for one of 37 residents in the survey sample, Resident #53. The findings include: For Resident #53 (R53), the facility staff failed to secure the resident's urinary catheter bag in a sanitary manner. A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. (1) A review of R53's clinical record revealed a physician's order dated 2/12/23 for a urinary catheter. On 3/15/23 at 8:19 a.m., R53 was observed lying in bed. The resident's urinary catheter bag was secured to the bed frame under the bed and touching the floor. On 3/16/23 at 10:33 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that if a resident is lying in bed, then their urinary catheter bag should hang on a bar under the bed and should not touch the floor because someone could step on it and because of infection. On 3/16/23 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Indwelling Urinary Catheter Care Procedure documented, 10. Check drainage tubing and bag to ensure that the catheter is draining properly, and no kinks are present. The urinary drainage bag must be placed below the bladder level but not on the floor. No further information was presented prior to exit. Reference: (1) https://medlineplus.gov/ency/article/003981.htm

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services per physician orders, for two of 37 residents in the survey sample, Residents #18 and #31. The findings include: 1. For Resident #18 (R18), the facility staff failed to administer oxygen at the physician prescribed rate of four liters per minute. A review of R18's clinical record revealed a physician's order dated 1/22/23 for oxygen at four liters per minute via nasal cannula every shift. R18's comprehensive care plan revised on 1/24/23 documented, Oxygen as needed . On 3/14/23 at 12:40 p.m. and 3/15/23 at 2:31 p.m., R18 was observed lying in bed receiving oxygen via nasal cannula at one and a half liters per minute, as evidenced by the middle of the ball in the oxygen concentrator flowmeter positioned on the one-and-a-half-liter line. On 3/16/23 at 10:33 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated nurses should know how much oxygen to administer to a resident based on the resident's physician's order. RN #1 stated the middle of the ball in the oxygen concentrator flowmeter should be on the four-liter line if the physician's order is for four liters. On 3/16/23 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The oxygen concentrator manufacturer's instructions documented, 2. Check the flow meter to make sure that the flow meter ball is centered on the line next to the prescribed number of your flow rate. The facility policy titled, Oxygen Administration (all routes) Policy documented, Licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider. No further information was presented prior to exit. 2. For Resident #31 (R31), the facility staff failed to administer oxygen at the physician prescribed rate of three liters per minute. R 31's comprehensive care plan revised on 5/10/22 documented, Oxygen as ordered by the physician . Further review of R31's clinical record revealed a physician's order dated 12/5/22 for oxygen at three liters per minute via nasal cannula every shift. On 3/14/23 at 12:39 p.m. and 3/15/23 at 8:28 a.m., R31 was observed lying in bed receiving oxygen via nasal cannula at three and a half liters per minute, as evidenced by the middle of the ball in the oxygen concentrator flowmeter positioned on the three-and-a-half-liter line. On 3/16/23 at 10:33 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated nurses should know how much oxygen to administer to a resident based on the resident's physician's order. RN #1 stated the middle of the ball in the oxygen concentrator flowmeter should be on the three-liter line if the physician's order is for three liters. On 3/16/23 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on observations, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to properly store medications for one of 37 residents in the survey sample, Resident #59. The findings include: For Resident #59 (R59), the facility staff failed to secure a bottle of Vitamin D 10000 IU (international units) and one bottle of multivitamins in the resident room. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/21/2023, the resident scored 10 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. On 3/14/2023 at 1:46 p.m., an observation was made of Resident #59's (R59) room. R59 was not in the room at the time however their family member was in the room. R59's family member stated that the resident was in therapy. Observation of R59's room revealed two bottles of medication on top of the nightstand beside the bed. One bottle was labeled Vitamin D 10000 IU and one bottle of multivitamins were observed. On 3/14/2023 at 3:30 p.m., R59 was observed in bed asleep. The bottle of Vitamin D 10000 IU and the bottle of multivitamins remained on top of the nightstand beside the bed. On 3/15/2023 at 8:15 a.m., R59 was observed sitting in the wheelchair in their room. The bottle of Vitamin D 10000 IU and bottle of multivitamins remained on top of the nightstand beside the bed. When asked about the medications, R59 stated that they did not know why they were there. R59 stated that the nurse had brought them down the day before and left them and they were not sure why. R59 stated that they normally took Vitamin D and a multivitamin every day but had not taken any from the bottles and was going to ask the nurse about them when they came in. The physician orders for R59 documented in part, Multivitamin Oral Tablet (Multiple Vitamin) Give 1 tablet by mouth one time a day for supplement. Order Date: 02/16/2023. Start Date: 02/17/2023. The physician orders further documented, Cholecalciferol Oral Tablet 50 MCG (2000 UT) (Cholecalciferol) Give 1 tablet by mouth one time a day for supplement. Order Date: 02/16/2023. Start Date: 02/17/2023. A resident self-administration of medication assessment for R59 dated 2/22/2023 documented R59 being a candidate for self-administration of medications. On 3/15/2023 at 1:57 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated that medications needed to be secured by keeping them locked up. LPN #4 stated that the medications in R59's room were brought in by the family and they could not keep them on the medication cart because they were not prescribed. LPN #4 stated that when family members brought medications in they were given to the unit manager to be locked up and not left in the room. LPN #4 stated that they had given the Vitamin D and Multivitamin back to the family member to take home on 3/14/2023 and they had left them in the room. LPN #4 stated that they had observed the bottles on the nightstand when they went into the room this morning and they should not have been left there because it was a safety issue. LPN #4 stated that they would remove the medication and follow up with the family to ensure that they would take the medication home. The facility policy, Storage and Expiration Dating of Medications, Biologicals dated 12/01/07 documented in part, .Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors .Facility should store bedside medications or biologicals in a locked compartment within the resident's room . On 3/15/2023 at 5:06 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for one of 37 residents in the survey sample, Resident #26. The findings include: For Resident #26 (R26), the facility staff failed to maintain an accurate ADL (activities of daily living) documentation record for February 2023. On the most recent MDS (minimum data set), a five day admission assessment with an ARD (assessment reference date) of 2/8/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) indicating they were cognitively intact for making daily decisions. Section G documented R26 required extensive assistance of one person for bed mobility and limited assistance of one person for transfers, toileting and personal hygiene. The comprehensive care plan for R26 documented in part, At risk for self care deficit severe sepsis and amputation. Date Initiated: 02/05/2023. A review of the ADL documentation for R26 failed to evidence documentation of personal hygiene, mouth care, bladder and bowel continence, barrier cream application, behavior monitoring, skin observations or toilet use on the evening shift (3:00 p.m. to 11:00 p.m.) on 2/13/2023. On 3/15/2023 at 2:12 p.m., an interview was conducted with CNA (certified nursing assistant) #3. CNA #3 stated that ADL care was documented in the medical record. CNA #3 stated that some of the staff work 12 hour shifts but they still documented the ADL care in eight hour shifts in the medical record. CNA #3 stated that if the ADL documentation was left blank they could not say that the care was not provided, but that it was not documented. On 3/16/2023 at 11:30 a.m., an interview was conducted with CNA #5. CNA #5 stated that they documented ADL care in the computer and had to complete the documentation before they could leave. CNA #5 stated that if the ADL documentation was blank it meant that no one documented anything. CNA #5 stated that if the care was not documented, the record was not complete because it did not show what they did for the resident. The facility policy, Medical Records Storage and Retention Policy dated April 2008 failed to evidence guidance regarding maintaining a complete and accurate medical record. On 3/16/2023 at 11:47 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement the comprehensive care plan for three of 37 residents in the survey sample, Residents #32, #31, and #6. The findings include: 1. For Resident #32 (R32), the facility staff failed to implement the care plan to attempt non-pharmacological interventions as part of the resident's pain management program. A review of R32's physician orders revealed the following order dated 1//17/23: Oxycodone-Acetaminophen (opioid pain medication) 5-325 mg (milligrams) .Give 1 tablet by mouth every 8 hours as needed for moderate or severe pain. A review of R32's March 2023 MAR (medication administration record) revealed the resident received the Oxycodone-Acetaminophen as ordered on 3/2/23, 3/4/23, 3/6/23, 3/11/23, 3/12/23, and 3/14/23. Further review of the clinical record revealed no evidence that non-pharmacological interventions were offered to R32 prior to the administration of Oxycodone-Acetaminophen on all six of the dates in March 2023. A review of R32's care plan dated 9/6/17 and most recently updated 10/2/17 revealed, in part: [R32] has diagnosis of chronic pain .Staff to attempt non-pharmacological interventions. On 3/16/23 at 10:33 a.m., RN (registered nurse) #1 was interviewed. She stated prior to administering an as needed pain medication, she attempts to reposition the resident or offer ice packs as non-pharmacological interventions and if those do not help, or if the resident refuses the non-pharmacological interventions, she asks the resident to rate and describe the location of the pain. She stated the facility's EMR (electronic medical record) software prompts the nurse to write a progress note for each as needed medication and she would document the non-pharmacological interventions and the location of the pain in the progress note. She stated non-pharmacological interventions are important because they give the residents an option other than medication and the purpose of the care plan is to show different aspects of how to care for a resident. She stated the care plan lets the facility staff know what the resident needs, and the resident's goals, and typically nurses are mostly responsible for implementing a resident's care plan, although other departments have some specific aspects of the care plan for which they are responsible. She stated all nurses have access to the care plan through the EMR. On 3/16/23 at 11:47 a.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Comprehensive Care Planning, revealed, in part: All staff must be familiar with each resident's Care Plan and all approaches must be implemented. No further information was provided prior to exit. 2. For Resident #31 (R31), the facility staff failed to implement the resident's comprehensive care plan for oxygen administration. R31's comprehensive care plan revised on 5/10/22 documented, Oxygen as ordered by the physician . Further review of R31's clinical record revealed a physician's order dated 12/5/22 for oxygen at three liters per minute via nasal cannula every shift. On 3/14/23 at 12:39 p.m. and 3/15/23 at 8:28 a.m., R31 was observed lying in bed receiving oxygen via nasal cannula at three and a half liters per minute, as evidenced by the middle of the ball in the oxygen concentrator flowmeter positioned on the three-and-a-half-liter line. On 3/16/23 at 10:33 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the purpose of the care plan is, Different aspects of how to care for them, being able to review what they need, what their goals are, things that happened in the past to prevent in the future. RN #1 stated care plan implementation depends on the intervention but typically the nurses are responsible. RN #1 stated nurses can easily access residents' care plans through the computer system. RN #1 stated nurses should know how much oxygen to administer to a resident based on the resident's physician's order. On 3/16/23 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 3. For Resident #6 (R6), the facility staff failed to implement the comprehensive care plan for pain management. R6's comprehensive care plan dated 3/7/17 documented, At risk for pain r/t (related to) multiple health risk factors. Non-pharmacological interventions as appropriate . Further review of R6's clinical record revealed a physician's order dated 11/23/20 for tramadol 50 mg (milligrams)- one tablet by mouth every eight hours as needed for pain rated six to ten. A review of R6's March 2023 MAR (medication administration record) revealed the resident was administered as needed tramadol on 3/2/23, 3/4/23, 3/6/23, 3/7/23, 3/9/23 and 3/11/23. Further review of R6's clinical record (including the March 2023 MAR and March 2023 progress notes) failed to reveal non-pharmacological interventions were attempted on 3/2/23, 3/4/23, 3/6/23, 3/7/23, 3/9/23 and 3/11/23. On 3/16/23 at 10:33 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the purpose of the care plan is, Different aspects of how to care for them, being able to review what they need, what their goals are, things that happened in the past to prevent in the future. RN #1 stated care plan implementation depends on the intervention but typically the nurses are responsible. RN #1 stated nurses can easily access residents' care plans through the computer system. RN #1 stated nurses should attempt non-pharmacological interventions and should not immediately give medications because nurses should give more options. RN #1 stated she documents non-pharmacological interventions in the progress notes. On 3/16/23 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete pain management program for two of 37 residents in the survey sample, Residents #32 and #6. The findings include: 1. For Resident #32 (R32), the facility staff failed to offer non-pharmacological interventions and assess for the location of a resident's pain prior to administering an as needed pain medication on multiple occasions in March 2023. A review of R32's physician orders revealed the following order dated 1/17/23: Oxycodone-Acetaminophen (opioid pain medication) 5-325 mg (milligrams) .Give 1 tablet by mouth every 8 hours as needed for moderate or severe pain. A review of R32's March 2023 MAR (medication administration record) revealed the resident received the Oxycodone-Acetaminophen as ordered on 3/2/23, 3/4/23, 3/6/23, 3/11/23, 3/12/23, and 3/14/23. Further review of the clinical record revealed no evidence that non-pharmacological interventions were offered to R32 prior to the administration of Oxycodone-Acetaminophen on all six of these dates in March 2023. The record revealed no evidence that the resident's pain location was assessed or documented on 3/2/23, 3/11/23, 3/12/23, and 3/14/23. On 3/16/23 at 10:33 a.m., RN (registered nurse) #1 was interviewed. She stated prior to administering an as needed pain medication, she attempts to reposition the resident or offer ice packs as non-pharmacological interventions and if those do not help, or if the resident refuses the non-pharmacological interventions, she asks the resident to rate and describe the location of the pain. She stated the facility's EMR (electronic medical record) software prompts the nurse to write a progress note for each as needed medication and she would document the non-pharmacological interventions and the location of the pain in the progress note. She stated non-pharmacological interventions are important because they give the residents an option other than medication. After reviewing R32's March 2023 progress notes and MAR, RN#1 agreed that there was no documentation of non-pharmacological interventions at each administration, and a lack of documentation of the location of the resident's pain on four occasions. On 3/16/23 at 11:47 a.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Pain Management Protocol, revealed, in part: Non-pharmacological intervention[s] will be attempted prior to the administration of PRN pain medications. When it is determined the resident's pain will need pharmacological interventions: Documentation of administration of medications will be located in the electronic medication record (eMAR) .The effectiveness of the medication(s) will be identified on the eMAR. No further information was provided prior to exit. 2. For Resident #6 (R6), the facility staff failed to initiate a complete pain assessment on 3/6/23 when the as needed pain medication tramadol was administered, and failed to attempt non-pharmacological interventions on 3/2/23, 3/4/23, 3/6/23, 3/7/23, 3/9/23 and 3/11/23 when as needed tramadol was administered. R6's comprehensive care plan dated 3/7/17 documented, At risk for pain r/t (related to) multiple health risk factors. Non-pharmacological interventions as appropriate . Further review of R6's clinical record revealed a physician's order dated 11/23/20 for tramadol 50 mg (milligrams)- one tablet by mouth every eight hours as needed for pain rated six to ten. A review of R6's March 2023 MAR (medication administration record) revealed the resident was administered as needed tramadol on 3/2/23, 3/4/23, 3/6/23, 3/7/23, 3/9/23 and 3/11/23. Further review of R6's clinical record (including the March 2023 MAR and March 2023 progress notes) failed to reveal a complete pain assessment, including the location of pain, was completed on 3/6/23 and failed to reveal non-pharmacological interventions were attempted on 3/2/23, 3/4/23, 3/6/23, 3/7/23, 3/9/23 and 3/11/23. On 3/16/23 at 10:33 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that if a resident complains of pain, then she asks where the pain is located and if the pain is in their back or legs, she will try repositioning and ice packs before medication administration, if the resident allows this. RN #1 stated nurses should not immediately give medications because nurses should give more options. RN #1 stated she documents the location of pain and non-pharmacological interventions in the progress notes. On 3/16/23 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on staff interview and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary medication for one of 37 residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff administered the as needed pain medication, tramadol, outside of the physician's order for pain rated between six to ten on a scale of one to ten (one being least and ten being most) on multiple dates in January 2023 and February 2023. The staff administered tramadol for a pain rating less than six. A review of R6's clinical record revealed a physician's order dated 11/23/20 for tramadol 50 mg (milligrams)- one tablet by mouth every eight hours as needed for pain rated six to ten. A review of R6's January 2023 and February 2023 MARs (medication administration records) revealed the resident was administered as needed tramadol for pain rated less than six on the following dates: 1/3/23 (pain rated as two) 2/4/23 (pain rated as four) 2/20/23 (pain rated as zero) 2/23/23 (pain rated as zero) 2/28/23 (pain rated as three) 2/28/23 (pain rated as five) On 3/16/23 at 10:33 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the pain rating documented on R6's MAR beside as needed tramadol administration is the resident's initial pain rating. RN #1 stated if a resident complains of pain, then nurses should check the physician's orders to see what medication should be given based on the resident's pain rating. RN #1 stated that for R6, tramadol should only be given for a pain rated between six to ten. RN #1 stated R6 should have been administered Tylenol (per physician's order) instead of tramadol on the above dates. On 3/16/23 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled; Pain Management Protocol failed to document information regarding the above concern. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a call bell within reach for one of 28 residents in the survey sample, Resident #8. The facility staff failed to maintain Resident #8's call bell within reach on 8/24/21. Resident #8 was lying in bed and the resident's call bell was on the floor under the bed. The findings include: Resident #8 was admitted to the facility on [DATE]. Resident #8's diagnoses included but were not limited to diabetes, major depressive disorder and a history of falling. Resident #8's quarterly minimum data set assessment with an assessment reference date of 5/17/21, coded the resident's cognition as moderately impaired. Section G coded Resident #8 as requiring limited assistance of two or more staff with bed mobility and as requiring extensive assistance of one staff with transfers. On 8/24/21 at 12:04 p.m. and 12:47 p.m., Resident #8 was observed lying in bed watching television. The resident's call bell was under the bed and out of the resident's reach. On 8/24/21 at 12:47 p.m., CNA (certified nursing assistant) #1 walked into Resident #8's room, served a lunch tray, exited the room, obtained tea, walked back into the room, placed the tea on the table then exited the room. CNA #1 did not pick the call bell up from under the bed. On 8/25/21 at 10:08 a.m., an interview was conducted with CNA #1. CNA #1 stated call bells should be kept within residents' reach and CNAs round at least every two hours to make sure call bells are in place. CNA #1 stated she checks call bells each time she is in a resident's room. CNA #1 stated Resident #8 does sometimes use the call bell but it may become unclipped from the sheet and fall off the bed if the resident gets up. CNA #1 stated she could not remember if she observed Resident #8's call bell while serving lunch on 8/24/21. On 8/25/21 at 1:04 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Resident Communication System and Call light policy documented, It is the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath areas. The facility responds to resident needs and requests. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility document review, it was determined the facility staff failed to develop a baseline care plan for one of 28 current residents in the survey sample, Resident #430. The facility failed to develop a baseline care plan to address the physician prescribed anticoagulant medication Warfarin and monitoring for the medication for Resident #430 upon admission. The findings include: Resident #430 was admitted to the facility on [DATE]. Resident #430's diagnoses included but were not limited to: congestive heart failure 'CHF' (circulatory congestion and retention of salt and water by the kidneys) (1), heart block (conduction disorder of the heart whereby electrical impulses are slowed either partially or completely) (2), pacemaker (electrical device used to maintain a normal heart rhythm by stimulating the heart muscle to contract) (3) and chronic kidney disease (decreased function of the kidneys) (4). Resident #430's most recent MDS (minimum data set) assessment, a 5 day Medicare assessment, with an assessment reference date of 8/19/21, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status: coded the resident as supervision with eating; extensive assistance with transfer, bed mobility, dressing, hygiene, bathing and locomotion. Walking did not occur. MDS Section H- Bowel and Bladder: coded the resident as occasionally incontinent for bowel and always incontinent for bladder. A review of Resident #430's physician orders dated 8/13/21, documented in part, Warfarin Sodium (anticoagulant) (5) 2.5 milligram tablet, give 1 tablet by mouth one time a day every Monday, Wednesday, Friday for blood thinner. Warfarin 5 milligram tablet, give 1 tablet by mouth one time a day every Tuesday, Thursday, Saturday Sunday for blood thinner. A review of the MAR (medication administration record) documented administration of Warfarin 5 milligram and Warfarin 2.5 milligram as ordered from 8/14/21-8/25/21. Warfarin was held per physician orders on 8/19/21, 8/23/21 and 8/24/21. Review of Resident #430's baseline care plan dated 8/13/21, failed to document or address the administration of and monitoring for the prescribed anticoagulant medication. The baseline care plan, documented in part, FOCUS-The resident has a pacemaker related to dysrhythmia. The resident has a diagnosis of congestive heart failure. INTERVENTIONS-Assess/document/report to physician as needed any signs or symptoms of infection at incision site: redness, drainage and warmth. Monitor/document/report to physician as needed any signs or symptoms of congestive heart failure. Oxygen therapy and give medications as ordered. A review of the baseline care plan checklist dated 8/20/21, documented in part, Once the baseline care plan is completed, the resident and their representative will receive at least a summary of the baseline care plan that includes the following: (check off below items that were shared with resident/resident representative): a list of the resident's medications, therapy orders and dietary instructions given with explanation to resident/resident representative (print out orders and/or MARs 'medication administration record'). There was a check mark by a list of the resident's medications. A review of the nursing progress noted dated 8/16/20 at 12:44 PM, documented in part, Most Recent admission: [DATE] 12:44 PM. Check List: Summary of resident's medication, therapy orders, and dietary instructions shared. Social service needs and recommendations shared with resident/resident representative. PASARR recommendations shared with resident/resident representative. Baseline care plan given to resident/resident representative. Name of Resident and/or Representative Receiving 48 hour baseline care plan: Self and daughter Received on: 08/20/2021. An interview was conducted on 8/25/21 at 9:40 AM with RN (registered nurse) #2, the unit manager. When asked if anticoagulants should be on the care plan, RN #2 stated, Yes, anticoagulants should be on the care plan. RN #2 was shown the provided printed baseline care plan for Resident #430. RN #2 stated, Yes, this is the baseline care plan. I do not see it here [on Resident #430's baseline care plan]. Let me look up the comprehensive care plan, which will be done once he is here for 21 days. RN #2 stated, Oh here it is anticoagulant. When asked if Warfarin a high risk medication should it be addressed/included in the baseline care plan, RN #2 stated, Well, the care plan is to provide what care is needed for the resident. An interview was conducted on 8/25/21 at 9:53 AM with ASM (administrative staff member) #2, the director of nursing. When asked if anticoagulants should be included in the baseline care plan, ASM #2 stated, No, anticoagulants are not included in the baseline care plan. We just focus on falls, pressure/skin, nutrition, and ADL's (activities of daily living) and there is one other focus for the baseline care plan. Anticoagulants would be addressed in the comprehensive care plan. Purpose of the baseline care plan is to give a basis of care for the resident. An interview was conducted on 8/25/21 at 10:27 AM with RN #1, the MDS coordinator. When asked the purpose of the baseline care plan, RN #1 stated, Baseline care plan includes the basic items and a resident's orders. We do try to make sure everything is on the baseline care plan and we definitely make sure it is on the comprehensive care plan. On 8/25/21 at 1:00 PM AM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the above findings. The facility's Interim/Baseline Care Planning policy dated 8/11/20, documents in part, Within 48 hours of admission, the facility will develop and implement and interim/baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident until a comprehensive assessment can be completed, leading to a comprehensive care plan. The baseline care plan will include the minimum healthcare information necessary to care for a resident including but not limited to: initial goals based on admission orders, physician orders, dietary orders, therapy/rehab [rehabilitation] services, social services and resident goals. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 133. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 259. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 427. (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 119.(5) 2019 [NAME] Pocket Drug Guide for Nurses, Wolters Kluwer, page 406.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the comprehensive care plan for one of 28 residents in the survey sample, Resident #8. The facility staff failed to implemented Resident #8's comprehensive care plan for maintaining the resident's call bell within reach. The findings include: Resident #8 was admitted to the facility on [DATE]. Resident #8's diagnoses included but were not limited to diabetes, major depressive disorder and a history of falling. Resident #8's quarterly minimum data set with an assessment reference date of 5/17/21, coded the resident's cognition as moderately impaired. Section G coded Resident #8 as requiring limited assistance of two or more staff with bed mobility and as requiring extensive assistance of one staff with transfers. Resident #8's comprehensive care plan dated 2/16/17 documented, Self-care deficit. Resident has dx (diagnosis) Muscle Weakness, Gait Abnormality, CAD (coronary artery disease), Psychotic Disorder and Dementia. Keep call bell in reach . On 8/24/21 at 12:04 p.m. and 12:47 p.m., Resident #8 was observed lying in bed watching television. The resident's call bell was under the bed and out of the resident's reach. On 8/24/21 at 12:47 p.m., CNA (certified nursing assistant) walked into Resident #8's room, served a lunch tray, exited the room, obtained tea, walked back into the room, placed the tea on the table then exited the room. CNA #1 did not pick up the call bell from under the bed. On 8/25/21 at 10:08 a.m., an interview was conducted with CNA #1. CNA #1 stated call bells should be kept within residents' reach and CNAs round at least every two hours to make sure call bells are in place. CNA #1 stated she checks call bells each time she is in a resident's room. CNA #1 stated Resident #8 does sometimes use the call bell but it may become unclipped from the sheet and fall off the bed if the resident gets up. CNA #1 stated she could not remember if she observed Resident #8's call bell while serving lunch on 8/24/21. On 8/25/21 at 10:25 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the purpose of the care plan is to plan the resident's care. RN #1 stated that in order to implement a resident's care, nurses and CNAs would have to read and follow the care plan but many care planned items are present in physician's orders for nurses and the task panel for CNAs. Review of Resident #8's physician's orders and task panel failed to reveal documentation regarding maintaining call bells within reach. On 8/25/21 at 1:04 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Comprehensive Care Planning documented, D) All staff must be familiar with each resident's Care Plan and all approaches must be implemented. No further information was presented prior to exit. A review of the facility's policy Discharge and Transfer policy revised 10/5/17, which documents in part, Social Services or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor, if applicable. Copies will be sent to the Department of Health Ombudsman Office and filed in the business file and/or scanned into PCC (point click care) documents tab with administrator/designee signature, with the certified receipt if applicable. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 133. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 54. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 119.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory services in a sanitary manner for two of 28 residents in the survey sample, Resident #130 and Resident #72. 1. Resident #130's nebulizer mask and medication delivery tank was observed on separate occasions uncovered when not in use and the residents oxygen tubing was observed uncovered and wrapped around the top of an oxygen tank on the back of the resident's wheelchair. 2. The facility staff failed to store oxygen equipment in a sanitary manner for Resident #72. Nasal cannula tubing was observed uncovered and wrapped around the top of the tank that was not in use, located on the back of Resident #72's wheelchair. The findings include: 1. Resident #130 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: high blood pressure, chronic obstructive pulmonary disease (COPD -general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (1), pneumonia (An infection in one or both of the lungs.) (2), and atrial fibrillation (a condition characterized by rapid and random contraction of the atria of the heart causing irregular beats of the ventricles and resulting in decreased heart output and frequently clot formation in the atria)(3). The [Name of corporation] Admission/readmission Evaluation dated 8/22/2021 documented in part, 7. LOC (level of consciousness): alert and oriented X4 (person, place, time and situation). 16. One person assist for all ADLs (activities of daily living) except eating. The form documented the use of oxygen via a nasal cannula. The physician order dated, 8/23/2021, documented, Oxygen @ (at) 3 LPM (liters per minute) via nasal cannula every shift for sob (shortness of breath). Ipratropium - Albuterol Solution (used to prevent wheezing, difficulty breathing, chest tightness, and coughing in people with chronic obstructive pulmonary disease) (4) 0.5 - 2.5 MG/3 ML (milligrams per milliliter) 3 ML inhale orally every 6 hours as needed for wheezing. On 8/24/2021 at 11:00 a.m., observation of Resident #130's room, revealed a nebulizer machine sitting on Resident #130's nightstand. The nebulizer mask and the medication delivery container was not covered. Two other observations were made on 08/24/2021 2:21 p.m. and 8/25/2021 at 8:12 a.m., and revealed the nebulizer delivery container and mask were uncovered. On 08/25/2021 at 10:20 a.m. an interview and observation of Resident #130's nebulizer was conducted with LPN (licensed practical nurse) #2. LPN #2 was shown the nebulizer equipment that was uncovered. LPN #2 stated, It [nebulizer mask and medication delivery container] should be covered. Observation was made at this time of Resident #130 in wheelchair with an O2 (oxygen) tank on the back of the wheelchair. There was oxygen tubing wrapped around the tank top. When asked why the tubing was wrapped around the top of the tank, LPN #2 stated that it should be in a bag also and there should be another bag on the concentrator to store the tubing when it's not in use while the resident is hooked up to the tank. LPN #2 stated she needed three bags, one for nebulizer, one for tubing on the tank and one for the tubing on the oxygen concentrator. An interview was conducted with RN (registered nurse) #2, on 08/25/2021 10:29 a.m. When asked about nebulizer equipment storage when not in use, RN #2 stated it should be in a bag. When asked about oxygen tubing storage when not in use, RN #2 stated, it should be in a bag. When asked if oxygen tubing should be wrapped around the top of an oxygen tank on the back of a wheelchair, RN #2 stated, no. The baseline care plan dated, 8/23/2021, documented in part, Focus: The resident has altered respiratory status/difficulty breathing r/t (related to) dx (diagnosis) pneumonia, pleural effusion and acute hypoxic respiratory failure. The Interventions documented in part, Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Change O2 tubing per facility protocol. Provide oxygen as ordered. The facility policy, Oxygen Administration (all routes) Policy, documented in part, 3. When oxygen not in use, store oxygen tubing and nasal cannula or mask in separate, labeled plastic bag. According to Fundamentals of Nursing, 6th edition, [NAME] and [NAME], 2005, page 780, Box 33-2 Sites for and causes of nosocomial infections Respiratory Tract - Contaminated respiratory therapy equipment. ASM (administrative staff member) #1, administrator, and ASM #2, the director of nursing, were made aware of the above concern on 8/25/2021 at 1:02 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. (2) This information was obtained from the following website: https://medlineplus.gov/pneumonia.html (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 55. (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a601063.html 2. The facility staff failed to store oxygen equipment in a sanitary manner for Resident #72. Nasal cannula tubing was observed uncovered and wrapped around the top of the tank that was not in use, located on the back of Resident #72's wheelchair. Resident #72 was admitted to the facility on [DATE] with the diagnoses of but not limited to benign prostatic hyperplasia (an enlarged prostate) (1), high blood pressure, atrial fibrillation (2), sepsis,(your body's overactive and extreme response to an infection) (3), spinal stenosis, (Spinal stenosis causes narrowing in your spine. The narrowing puts pressure on your nerves and spinal cord and can cause pain.)(4) The Medicare, admission/5-day MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 8/8/21 coded the resident as moderately impaired to make daily cognitive decisions. Resident #72 was coded as requiring extensive assistance for bathing, hygiene, toileting, dressing, transfers, and bed mobility; supervision for ambulation and eating; and as incontinent of bowel. Observation was made of Resident #72 on 8/25/2021 at 08:06 a.m. The resident was up in the wheelchair with oxygen on via a nasal cannula connected an oxygen concentrator that was running. Observation of the oxygen concentrator flow meter revealed the oxygen flow rate was set at 2 LPM (liters per minute). An oxygen tank was observed on the back of the wheelchair, not in use with nasal cannula tubing wrapped around the top of the tank, uncovered. The physician orders dated, 8/10/2021, Oxygen @ (at) 2 LPM (liters per minute) via nasal cannula as needed. The comprehensive care plan for Resident #72, dated, 8/11/2021, documented in part, Focus: The resident has impaired cardiovascular status r/t (related to) high blood pressure, blood loss, and heart disease. The Interventions documented in part, Oxygen as ordered by the physician. An interview was conducted with LPN (licensed practical nurse) #1 on 8/25/2021 at 10:12 a.m. When the tubing wrapped around the oxygen tank located on the back of Resident #72's wheelchair was described to LPN #1, she stated the tubing should be stored in a bag when not in use. An interview was conducted with RN (registered nurse) #2, on 08/25/2021 10:29 a.m. When asked if oxygen tubing should be wrapped around the top of an oxygen tank on the back of a wheelchair, RN #2 stated, no. ASM (administrative staff member) #1, administrator, and ASM #2, the director of nursing, were made aware of the above concern on 8/25/2021 at 1:02 p.m. No further information was provided prior to exit. References: (1) This information was obtained from the following website: https://medlineplus.gov/enlargedprostatebph.html (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 55. (3) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=Sepsis&_ga=2.155403059.908502701.1629920181-1530802455.1629920181 (4) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=Spinal+stenosis+

Based on employee record review and staff interview, it was determined that the facility staff failed to perform an annual performance review for one of five CNA (certified nursing assistant) records reviewed. The findings include: On 8/24/2021 at 4:15 p.m., a review of the facility's CNA annual training and performance review was conducted. Review of five CNA transcripts revealed one of five CNAs selected for review did not have an annual performance review. Review of CNA #2's transcript documented a hire date of 6/1/2018. Further review of the transcript documents provided dated 6/1/2020 through 6/1/2021 failed to evidence documentation of an annual performance review. On 8/24/2021 at approximately 4:45 p.m., a request was made to ASM (administrative staff member) #1, the administrator for the annual performance review for CNA #2. ASM #1 stated that CNA #2's annual performance review had not been completed. ASM #1 stated that CNA #2 only worked prn (as needed) and they were not sure when they had last worked. A request was made to ASM #1 for documentation verifying CNA #2's schedule since their anniversary date of 6/1/2021. On 8/25/2021 at approximately 7:30 a.m., ASM #1, the administrator provided the document Time Card Report 06/01/2021-08/24/2021 for CNA #2. It documented CNA #2 working the night shift (10:59 p.m.- 6:03 a.m.) on 7/15/2021. On 8/25/2021 at approximately 11:35 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that a member of the nursing team conducted the CNA performance reviews. ASM #2 stated that human resources notified them during a staff member's anniversary month that the evaluation was due by the end of the month. ASM #2 stated that they conducted the review or delegated to the unit manager if they were more familiar with the staff member. ASM #2 stated that staff who worked as needed were harder to catch up with than full time staff and they had not been able to do CNA #2's performance review because they had only worked one time since their anniversary date. ASM #2 stated that they performed the reviews face to face and they come in early to catch the night shift staff before they left to do the evaluations. ASM #2 stated that the performance evaluations were used to determine education needs if there were issues with the staff member. On 8/25/2021 at approximately 9:15 a.m., a request was made to ASM #1 for the facility policy for employee performance reviews. On 8/25/2021 at approximately 10:00 a.m., ASM #1 stated that the facility did not have a written policy for the employee performance reviews. ASM #1 provided a document titled, Performance Management which documented in part, Performance appraisals will generally be conducted after 90 days of employment and annually thereafter based on your date of hire .The performance appraisal provides a systematic and regular opportunity for you to discuss your work with your department head and to find out how you are developing and where you stand in relation to what is expected of you . On 8/25/2021 at approximately 1:00 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review it was determined the facility staff failed to ensure one the drug regime for one of 28 residents in the survey sample, Resident #72, was free of unnecessary pain medications. The facility staff administered Tylenol prescribed for Resident #72, for pain scale ratings above below the physician ordered parameters of 1-4 and administered Tramadol HCL for a pain rating 4, for which the physician prescribed Tylenol. The findings include: Resident #72 was admitted to the facility on [DATE] with the diagnoses of but not limited to benign prostatic hyperplasia (an enlarged prostate) (1), high blood pressure, atrial fibrillation (a condition characterized by rapid and random contraction of the atria of the heart causing irregular beats of the ventricles and resulting in decreased heart output and frequently clot formation in the atria)(2), sepsis,(your body's overactive and extreme response to an infection) (3), spinal stenosis, (Spinal stenosis causes narrowing in your spine. The narrowing puts pressure on your nerves and spinal cord and can cause pain.)(4) The Medicare, admission/5-day MDS (minimum data set) with an ARD (assessment reference date) of 8/8/21 coded the resident as being moderately impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance for bathing, hygiene, toileting, dressing, transfers, and bed mobility; supervision for ambulation and eating; was incontinent of bowel. The physician order dated, 8/9/2021, documented, Acetaminophen Tablet (Tylenol)(used to treat mild to moderate pain) (5) 325 mg (milligrams) Give 2 tablet by mouth every 8 hours as needed for pain scale 1-4. The physician order dated, 8/2/2021, documented, Tramadol HCL (hydrochloride)(centrally acting synthetic opioid analgesic used to relieve moderate to moderately severe pain) (6) Tablet 50 mg, Give 1 tablet by mouth every 6 hours as needed for pain. The August 2021 MAR (medication administration record) documented the above orders for Acetaminophen and Tramadol. The Acetaminophen was documented as administered on 8/15/2021 at 3:08 p.m. for a pain level of 5. The Tramadol was documented as administered on 8/6/2021 at 4:28 a.m. for a pain level of 4. The comprehensive care plan dated, 8/12/2021, documented in part, Focus: Altercation in musculoskeletal status r/t (related to) dx (diagnosis) Spondylosis with lumbar radiculopathy, spinal stenosis. The Interventions documented in part, Give med (medication) as ordered by the physician. Monitor and document for side effects and effectiveness. An interview was conducted with LPN (licensed practical nurse) #1, on 8/25/2021 at 10:09 a.m. The physician orders above were reviewed with LPN #1. When asked if the Tylenol should have been given for a pain level of 5, LPN #1 stated, no, it shouldn't have been given. When asked if the Tramadol should have been given for a pain scale of 4, LPN #1 stated, no the Tylenol should have been given An interview was conducted on 8/25/2021 at 10:15 a.m. with RN (registered nurse) #2, the unit manager. The above orders for Tylenol and Tramadol were reviewed with RN #2. When asked if the Tylenol should have been given for a pain level of 5, RN #2 stated, no the order says for pain level of 1-4. When asked if the resident should have received the Tramadol for a pain level of 4, RN #2 stated, no, the Tylenol should have been given for that level of pain. ASM (administrative staff member) #1, administrator, and ASM #2, the director of nursing, were made aware of the above concern on 8/25/2021 at 1:02 p.m. The facility policy, General Dose Preparation and Medication Administration documented in part, verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. Confirm that the MAR reflects the most recent medication order. References: (1) This information was obtained from the following website: https://medlineplus.gov/enlargedprostatebph.html (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 55. (3) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=Sepsis&_ga=2.155403059.908502701.1629920181-1530802455.1629920181 (4) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=Spinal+stenosis+ (5) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a681004.html (6) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=tramadol

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement infection control practices for one of eight residents in the medication administration observation, Resident #281. The facility staff failed to administer medication in a sanitary manner to Resident #281 on 8/25/21. LPN (Licensed practical nurse) #1 touched and administered a dropped pill to Resident #281 with gloved hands that were worn while touching the medication cart and vital sign machine. The findings include: Resident #281 was admitted to the facility on [DATE]. Resident #281's diagnoses included but were not limited to heart failure, muscle weakness and high blood pressure. Resident #281's admission minimum data set assessment with an assessment reference date of 8/18/21, coded the resident as being cognitively intact. On 8/25/21 at 8:34 a.m. LPN #1 was observed preparing Resident #281's medications with gloved hands. LPN #1 touched the medication cart with gloved hands then touched the vital sign machine with gloved hands while obtaining Resident #281's vital signs. After obtaining Resident #281's vital signs, LPN #1 administered medications to the resident. The resident dropped one pill on a blanket covering her. LPN #1 picked up the pill with the same gloves, placed the pill into the medicine cup and administered the pill to Resident #281. On 8/25/21 at 9:52 a.m., LPN #1 was asked what should be done if a resident drops a pill on his or her bed. LPN #1 stated the pill should be thrown away if it's on the bed for infection control reasons but she did not discard Resident #281's pill because it landed on the resident. LPN #1 was made aware that she was observed touching the medication cart and vital sign machine with the same gloves used to pick up the dropped pill then the pill was administered to Resident #281. LPN #1 stated she wasn't thinking and she was solely using the gloves for Resident #281. LPN #1 stated she did not know if this practice was sanitary. On 8/25/21 at 1:04 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility pharmacy policy titled, 6.0 General Dose Preparation and Medication Administration documented, 3.4 Facility staff should not touch the medication when opening a bottle or unit dose package. 3.5 If a medication which is not in a protective container is dropped, facility staff should discard it according to facility policy. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility staff failed to provide Resident # 44 and Resident # 44's representative written notification of a facility-initiated transfer on 05/26/2021 for Resident # 44. Resident #44 was admitted to the facility on [DATE]. Resident #44's diagnoses included but were not limited to: congestive heart failure 'CHF' (circulatory congestion and retention of salt and water by the kidneys) (1), atrial fibrillation (rapid, random contractions of the atria of the heart) (2) and chronic kidney disease (decreased function of the kidneys) (3). Resident #44's most recent MDS (minimum data set) assessment, a discharge return not anticipated assessment, with an assessment reference date of 8/10/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. Section O-Special Treatments and Procedures: coded the resident as dialysis 'yes'. A review of the eINTERACT (interventions to reduce acute care transfers) Transfer Form V5 dated 8/10/21, documented in part, Transfer to hospital. Resident sent to the emergency room related to shortness of breath and oxygen saturation dropping from 91% to 71% on room air. Alert but lethargic. Respirations 26. Color pale. A review of the nursing progress note dated 8/10/21 at 5:30 PM, documented in part, Order received from Dr. Clay to send resident to ER [emergency room] for SOB, low oxygenation, and AMS. Resident and a POA notified of the reason that she was going. Resident agreed, and verbalized understanding. Care plan goals sent with resident. On 8/24/21 at 4:45 PM, evidence of the provision of written notice to the resident/RP (responsible party) and ombudsman for the transfer of Resident #44 to the hospital on 8/10/21, was requested via written request for documents to the facility. Documents provided included: ombudsman notification and the above nursing progress note dated 8/10/21 at 5:30 PM. The facility staff failed to provide any evidence or documentation that Resident # 44 and Resident # 44's representative were provided written notification of Resident #44's facility-initiated transfer on 05/26/2021. An interview was conducted on 8/25/21 at 12:22 PM with OSM (other staff member) #2, social services director. When asked the process to provide written notification of transfer, OSM #2 stated, I do not keep copies of the letter, I get receipts for certified mail. I need to work on streamlining that process. There is no written information to resident unless they are their own RP (responsible party). An interview was conducted on 8/25/21 at 12:28 PM with OSM #3, the social worker. When asked if she had written evidence of documentation provided to Resident #44, who is her own RP, OSM #3 stated, No, I do not have any evidence for her. OSM #3 stated, I am aware that we need to send the letters out, but I did not realize we needed to have evidence of that. On 8/25/21 at 1:00 PM, ASM (administrative staff member) #1, the executive administrator and ASM #2, the director of nursing were made aware of the above findings. A review of the facility's policy Discharge and Transfer policy revised 10/5/17, which documents in part, Social Services or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor, if applicable. Copies will be sent to the Department of Health Ombudsman Office and filed in the business file and/or scanned into PCC (point click care) documents tab with administrator/designee signature, with the certified receipt if applicable. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 133. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 54. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 119. Based on staff interview, facility document review, and clinical record review, the facility staff to provide evidence of written notification to the resident and or RP (responsible party) for hospital discharges for four of 28 residents in the survey sample, Residents #67, #14, #35, and #44. The findings include: 1. The facility staff failed to evidence written notification to the RP [responsible party] of Resident #67's discharge to the hospital on 8/19/21. Resident #67 was admitted to the facility on [DATE], and most recently readmitted with diagnoses including a periorbital (around the eye) fracture, arthritis, and blindness. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/2/21, Resident #67 was coded as being moderately impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). A review of Resident #67's clinical record revealed the following note: 8/19/2021 11:06 a.m. Nursing Note Text: Order received from [name of Nurse Practitioner] to send resident to ER (emergency room) for HTN (hypertension) post fall, and the resident's needs can no longer be met in the facility. Res (resident) has been notified that she is going to ER and the reason she is going. Res is unable to voice understanding. Bed hold and care plan goals sent with resident. Resident's RP (responsible party) [name of RP] also notified of the above and of all the documents that accompanied the resident. A copy of the written notice to the resident/RP regarding this discharge was requested. On 8/25/21 at 7:30 a.m., the facility staff provided a packet of materials regarding the discharge. The packet did not contain any evidence that the resident/RP were notified in writing about the discharge. On 8/25/21 at 12:22 p.m., OSM (other staff member) #2, social services director, was interviewed. She stated she does send written notification to the resident/RP. However, OSM #2 stated she could not provide evidence of the notification because she does not keep copies of the letter. She stated she gets receipts for certified mail. On 8/25/21 at 12:28 p.m., OSM #3, social worker, was interviewed. She stated she does not have evidence of written notification of Resident #67's hospital discharge to the RP. When asked if she was aware of the need to have evidence of the notification, OSM #3 stated she did not. On 8/25/21 at 1:10 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Discharge/Transfer Letter Policy, revealed, in part: The Administrator or designee will complete the appropriate discharge letter utilizing State Specific forms .Social Service or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor, if applicable. Copies will be sent to Department of Health .and filed in the business file and/or scanned into [electronic health record] with certified receipt, if applicable. No further information was provided prior to exit. 2. The facility staff failed to provide Resident # 14 and the resident's representative written notification of a facility-initiated transfer on 05/19/2021 and 06/22/2021 for Resident # 14. Resident # 14 was admitted to the facility with diagnoses that included but were not limited to: rectal bleeding and diabetes. Resident # 14's most recent MDS [minimum data set], a quarterly assessment with an ARD (assessment reference date) of 05/30/2021, coded Resident # 14 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. The facility's Progress Note for Resident # 14 dated 05/19/2021 at 3:05 p.m., documented in part, Resident currently transferred to [Name of Hospital] for evaluation of possible GI [gastrointestinal (stomach and intestines)] bleed. The facility's Progress Note for Resident # 14 dated 06/22/2021 at 12:31 p.m., documented in part, Resident noted to have blood in her stool x 2 [times two] and has been loosing [Sic.] weight, GI [gastrointestinal] appointment in July, labs [laboratory tests] obtained 6/21/21 MD [medical doctor] suggest resident go to hospital but resident refused. Education provided to resident and resident agreed to go to ER [emergency room] for eval [evaluation]. Review of the clinical record and the EHR (electronic health record) for Resident # 14 failed to evidence that a written notification of discharge was provided to the resident and resident's representative for the facility-initiated transfer on 05/19/2021 and 06/22/2021 for Resident # 14. On 08/25/21 at 12:22 p.m., an interview was conducted with OSM [other staff member] # 2, social services director and OSM # 3, social worker. When asked about providing evidence that a written notification to a resident and a resident's representative of a facility initiated transfer OSM # 3 stated, I don't keep copies of the letter, I get receipts for certified mail. I need to work on streamlining that. There is no written information to the resident unless they are their own RP [responsible party]. When asked if they had a certified mail receipt for Resident # 14's facility initiated transfers on 05/18/221 and 06/22/2021, OSM # 3 stated no. On 08/25/2021 at approximately 1:00 p.m., ASM [administrative staff member] #1, the administrator and ASM # 2, director of nursing, were made aware of the above concern. No further information was presented prior to exit. 3. The facility staff failed to provide Resident # 35 and Resident # 35's representative written notification of a facility-initiated transfer on 05/26/2021 for Resident # 35. Resident # 35 was admitted to the facility with diagnoses that included but were not limited to: diabetes and muscle weakness. Resident # 35's most recent MDS [minimum data set] assessment, a significant change assessment with an ARD (assessment reference date) of 06/25/2021, coded Resident # 35 as scoring a 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. The facility's progress note for Resident # 35 dated 05/26/2021 at 12:40 p.m. documented in part, Order received from [Name of Doctor] to send [Resident # 35] to E.R. [emergency room] for CT [computerized tomography (x-ray images)] of abdomen .[Name of Transportation Company] picked up resident at 12:12 p.m. to transfer him to [Name of Hospital]. Review of the clinical record and the EHR (electronic health record) for Resident # 35 failed to evidence that a written notification of discharge was provided to the resident and resident's representative for the facility-initiated transfer on 05/26/2021 for Resident # 35. On 08/25/21 at 12:22 p.m., an interview was conducted with OSM [other staff member] # 2, social services director and OSM # 3, social worker. When asked about providing evidence that a written notification to a resident and a resident's representative of a facility initiated transfer OSM # 3 stated, I don't keep copies of the letter, I get receipts for certified mail. I need to work on streamlining that. There is no written information to the resident unless they are their own RP [responsible party]. When asked if they had a certified mail receipt for Resident # 14's facility initiated transfers on 05/18/221 and 06/22/2021, OSM # 3 stated no. On 08/25/2021 at approximately 1:00 p.m., ASM [administrative staff member] #1, the administrator and ASM # 2, director of nursing, were made aware of the above concern. No further information was presented prior to exit.

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to ensure food storage in a safe manner, and failed to clean the kitchen stove. The walk-in refrigerator contained expired milk cartons and pudding. The stove top contained areas of built-up grease that was burned on to the grates, elements, and stove top surface. The stove top also contained ashy material that scraped up easily with a gloved finger. The findings include: On 8/24/21 at 10:50 a.m., observation was made of the facility kitchen. The walk-in refrigerator contained approximately 1 1/2 quarts of a dark brown, thick substance labeled nutritional pudding. The label had an expiration date of 8/23/21. The walk in refrigerator also contained 19 individual cartons of milk, all with expiration dates of 8/22/21. The stove top contained areas of crusty, black debris, which flaked off easily. Some of the debris had the appearance of ash. The loose debris was easily wiped away with a gloved finger. The stove top and grates contained areas of built-up grease. OSM (other staff member) #1, dietary manager was interviewed during this observation. She stated the milk and pudding were available for resident use, and should have been thrown out on their expiration dates. She stated the debris and grease build-up on the stove were from the current day's use, and would be cleaned at night. She stated the stove top is cleaned every evening after supper, and the grates are soaked in the large sinks and cleaned every night. On 8/25/21 at 7:47 a.m., observation was again made of the stove top. There were no changes from the previous day's observation. OSM #1 was interviewed at this time, and stated the stove top was dirty. She stated: Like I told you yesterday, we usually clean it every night. She stated she did not clean it last night because I don't have any staff. She stated she needs five people to work in the evenings, and it was just me last night. She stated she just did not get to the stove to clean it. When asked if the stove should have been cleaned of the loose debris and grease build-up, even if it was between a weekly scheduled cleaning, she said it should be. She stated the refrigerator should be checked each evening, and all expired foods should be thrown away. On /25/21 at 1:10 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Freezers and Refrigerators, revealed, in part: Food and Nutrition Services Director and staff will be responsible for ensuring food items in refrigerators and freezers are not expired or past perish dates. A review of the facility policy, Kitchen Sanitation and Cleaning Schedule, revealed, in part: Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule A review of the accompanying Closing Checklist for the Evening [NAME] revealed no daily tasks related to cleaning of the stove. The checklist documented: Wednesday: Take apart stove top & run through dish machine. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility document review it was determined facility staff failed to protect confidentiality of the medical record for one of 40 residents in the survey sample, Resident #25. The findings include: Resident #25 was admitted to the facility on [DATE] with a readmission on [DATE]. Resident #25's diagnoses included but were not limited to chronic obstructive pulmonary disease (1) and hyperlipidemia (2). Resident #25's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/01/19, coded Resident #25 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. On 9/04/19 at 4:39 p.m., LPN (licensed practical nurse) #8 was observed administering medication to Resident #25. LPN #8 pushed the medication cart to the hallway opposite the doorway to Resident #25's room. LPN #8 prepared one Omeprazole (3) 40 mg (milligram) tablet into a medication cup confirming the medication using the computer screen to view the eMAR (electronic medication administration record). LPN #8 proceeded to lock the medication cart drawers and take the prepared medication and a cup of water into Resident #25's room. The computer screen displaying Resident #25's medical record in the hallway was observed left unlocked when LPN #8 walked away from the cart to enter the resident's room. After administering the medication to Resident #25, LPN #8 exited the room and returned to the medication cart and stated, I forgot to lock the computer screen. On 9/05/19 at 3:57 p.m., an interview was conducted with LPN #8. When asked about the process of securing resident's medical records during medication administration, LPN #8 stated that the computer screen is locked when staff leave the medication cart unattended. When asked why this is done, LPN #8 stated that this to protect privacy and protect HIPPA (4). When asked about the observation made of the computer screen in the hallway left unattended with Resident #25's information visible on 9/4/19 at 4:39 p.m., LPN #8 stated that he forgot to lock the screen when he left to go into the room to give the medication. LPN #8 stated that the computer screen should have been locked to protect Resident #25's information from potentially being viewed by anyone walking in the hallway. The facility policy Safeguards. Privacy Policy #HIPAA (Health Insurance Portability and Accountability Act) 6 (six). Effective Date: 11/30/2016 documented in part, .will maintain appropriate administrative, technical and physical safeguards to protect the confidentiality, integrity and accessibility of PHI (Protected Health Information) consistent with the requirements of these HIPAA Policies and to safeguard PHI from intentional and unintentional non-permissible uses and disclosures. Under Procedure: A. General Safeguards. it documented (c) [name of facility] will use reasonable safeguards so that PHI on computer screens will not be visible to unauthorized persons, including locking down computer workstations when not in use or when leaving the workstation by activating a password protected screen saver and clearing PHI from the computer screen when the PHI is not actually being used. On 9/06/2019 at approximately 10:20 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services were notified of the findings. No further information was provided prior to exit. References: 1. Chronic obstructive pulmonary disease (COPD) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 2. Hyperlipidemia Cholesterol is a fat (also called a lipid) that your body needs to work properly. Too much bad cholesterol can increase your chance of getting heart disease, stroke, and other problems. The medical term for high blood cholesterol is lipid disorder, hyperlipidemia, or hypercholesterolemia. This information was obtained from the website: https://medlineplus.gov/ency/article/000403.htm. 3. Omeprazole Indications: Frequent heartburn (?2 days/week). Not intended for immediate relief of heartburn (may take 1-4 days for full effect). This information was obtained from the website: https://www.empr.com/drug/prilosec-otc/ 4. HIPPA The HIPAA Privacy Rule establishes national standards to protect individuals' medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically. The Rule requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. The Rule also gives patients' rights over their health information, including rights to examine and obtain a copy of their health records, and to request corrections. This information was obtained from the website: https://www.hhs.gov/hipaa/for-professionals/privacy/index.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence that any of the required documentation was provided to the receiving health care institution on transfer to the hospital for one of 40 residents in the survey sample, Resident #43. The findings include: Resident #43 was admitted on [DATE]; diagnoses included but are not limited to Alzheimer's disease, high blood pressure, dysphagia, anxiety disorder, and adult failure to thrive. The quarterly/5-day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/25/19 coded the resident as severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing; and extensive care for transfers, mobility, dressing, eating, toileting and hygiene. A review of the nurse's notes dated 7/14/19 documented, Around 4:15 a.m. resident observed with large amounts of coffee ground emesis on his clothing, mouth, and blankets. Vitals 136/92 (blood pressure), 69 (pulse rate), 97.3 (temperature), 18 (respiration rate), 85% (RA) (oxygen saturation at 85% on room air). (Medical office) on call, MD (medical doctor) notified ordered to send to ER (emergency room) for eval (evaluation). While this writer was in call to ER, CNA (certified nursing assistant) and other nurse report resident to begin projectile vomiting more coffee ground emesis. EMTx2 (two emergency medical technicians) arrived around 445am, resident out of facility via stretcher. Wife notified at 5a.m. Unit manager aware. Further review of the clinical record failed to reveal any evidence of what, if any, documentation was provided to the receiving facility upon the 7/14/19 hospital transfer. On 9/5/19 at 2:06 PM, in an interview with RN #2 (Registered Nurse), when asked what paperwork is sent to the hospital with a resident, RN #2 stated, face sheet, med list, care plan, bed hold, recent MD notes, recent labs, Advance Directives. When asked where staff document that these forms were sent, RN #2 stated, The eInteract transfer form. (This form was not completed for this hospital transfer). On 9/5/19 at 2:10 PM in an interview with LPN #2 (Licensed Practical Nurse) the unit manager, when asked what paperwork is sent to the hospital with a resident, LPN #2 stated, The med [medication] list, facesheet, Advance Directives, bed hold, plan of care. When asked where staff document that these forms were sent, LPN #2 stated, In the nurse's notes. On 9/5/19 at 2:15 PM, LPN #2 was notified of the missing documentation of what paperwork was sent to the hospital. On 9/5/19 at 2:26 PM, LPN #2 stated, It [eInteract transfer form] is not in the computer. LPN #2 stated that she did not see that the eInteract transfer form was completed or a nurse's note documenting what was sent. A review of a blank eInteract form revealed that the required information would have been provided if this form had been completed. Including the resident's demographic information, functional status, where the resident was sent to, the information of the responsible party, medications and treatments, devices, risk alerts, precautions, skin and wound care needs, immunizations, behavioral issues, and rehab therapy status. However, the form did not contain any prompting for providing the comprehensive care plan goals. She also provided a folder with a paper attached titled, E.R. Discharge Check Off List. This form documented the required transfer documents to provide to the receiving facility, including the comprehensive care plan goals. The inside of the folder included two copies of the bed hold notice. LPN #2 stated the remainder of the forms were electronic forms from the clinical record and would be printed according to the check off list and placed in the folder. However, a copy of the completed check off list for this resident's hospital transfer was not retained as evidence of that the items listed were completed and sent to the hospital. A review of the facility policy, Discharge/Transfer Letter Policy did not include any criteria of what documentation is required to be sent to the hospital upon transfer. No other policy for hospital transfers were provided. On 9/5/19 at the end of day meeting at approximately 5:00 PM, ASM #1 (Administrative Staff Member), the Administrator, was notified of the concern. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence that written notification of a hospital transfer was provided to the resident representative upon a hospital transfer for two of 40 residents in the survey sample, Residents #43 and #22. The findings include: 1. The facility staff failed to provide Resident #43 or the resident representative with written notification of a hospital transfer on 7/14/19. Resident #43 was admitted on [DATE], with diagnoses including but not limited to Alzheimer's disease, high blood pressure, dysphagia, anxiety disorder, and adult failure to thrive. The quarterly/5-day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/25/19 coded the resident as severely cognitively impaired in ability to make daily life decisions. A review of the nurse's notes dated 7/14/19 documented, Around 4:15 a.m. resident observed with large amounts of coffee ground emesis on his clothing, mouth, and blankets. Vitals 136/92 (blood pressure), 69 (pulse rate), 97.3 (temperature), 18 (respiration rate), 85% (RA) (oxygen saturation at 85% on room air). (Name of Medical office) on call MD (medical doctor) notified ordered to send to ER (emergency room) for eval (evaluation). While this writer was in call to ER, CNA (certified nursing assistant) and other nurse report resident to begin projectile vomiting more coffee ground emesis. EMTx2 (two emergency medical technicians) arrived around 445am, resident out of facility via stretcher. Wife notified at 5a.m. Unit manager aware. Further review of the clinical record failed to reveal any evidence that the facility provided the resident representative with written notification for the 7/14/19 hospital transfer. On 9/5/19 at 4:28 PM in an interview with OSM #1 (Other Staff Member), Social Services, when asked about providing the resident representative with a written notice of a hospital transfer, OSM #1 stated that she does not do that. On 9/6/19 at 8:45 AM, in an interview with ASM #1 (Administrative Staff Member) the Administrator, he stated that the facility has not been providing the resident/family/responsible party with a written notice of the resident being transferred to the hospital. A review of the facility policy, Discharge/Transfer Letter Policy documented, The Facility will complete discharge letters appropriately and according to all federal, state, and local regulations The following situations will result in immediate discharge / transfer from the facility as practicable and an immediate discharge/transfer letter will be issued: .4. An immediate transfer/discharge is required due to the resident's urgent medical needs D) Discharge notices must have the following components: 1. The reason for discharge/transfer, to include appropriate verbiage .2. The effective date of transfer/discharge; 3. The location to which the resident is transferred/discharged On 9/5/19 at the end of day meeting at approximately 5:00 PM, ASM #1 (Administrative Staff Member), the Administrator, was notified of the concern. No further information was provided. 2. The facility staff failed to provide Resident #22 or the resident representative with written notification of a hospital transfer on 7/15/19. Resident #22 was admitted to the facility on [DATE] with the diagnoses of but not limited to stroke, aphasia, high blood pressure, diabetes, gastrostomy, quadriplegia, dysphagia, adult failure to thrive, and contractures. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/15/19 coded the resident as severely impaired in ability to make daily life decisions. A review of the clinical record revealed a nurse's note dated 7/15/19 documented, Resident observed having seizure episodes around 0330 (3:30 AM), blood noted coming out of resident's mouth, possibly due to resident biting the inside of her mouth. Order received from (name of physician) to send resident to ED (emergency department) for seizures and the resident's needs can no longer be met in this Facility. RP (responsible party) has been notified. Further review of the clinical record failed to reveal any evidence that the facility provided the resident representative with written notification of the 7/15/19 hospital transfer. On 9/5/19 at 4:28 PM in an interview with OSM #1 (Other Staff Member), Social Services, when asked about providing the resident representative with a written notice of a hospital transfer, OSM #1 stated that she does not do that. On 9/6/19 at 8:45 AM, in an interview with ASM #1 (Administrative Staff Member) the Administrator, he stated that the facility has not been providing the resident/family/responsible party with a written notice of the resident being transferred to the hospital. On 9/5/19 at the end of day meeting at approximately 5:00 PM, ASM #1 (Administrative Staff Member), the Administrator, was notified of the concern. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to accurately code Resident #57's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 07/12/19, for oxygen use while a resident at the facility. Resident #57 was admitted to the facility 09/15/2011 with a readmission on [DATE] with diagnoses, that included but were not limited to shortness of breath and atrial fibrillation (1). Resident #57's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/12/19, coded Resident #57 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Section O of the MDS failed to evidence documentation of Resident #57 receiving oxygen therapy while a resident. On 9/04/19 at 11:26 a.m., an interview was conducted with Resident #57. Resident #57 stated that she uses her oxygen frequently during the day and wears it every night in bed. When asked how long she has been using oxygen Resident #57 stated, About a year now. Resident #57 was observed wearing a nasal cannula in her nose, that was connected to an oxygen concentrator during the interview in her room. Additional observations of Resident #57 using oxygen were made on 9/04/19 at 1:47 p.m. and 9/5/19 at 8:18 a.m. The physician order summary report dated 9/05/2019 documented, O2 (oxygen) at 3L/Min (liters per minute) as needed for SOB (shortness of breath). Order Date: 05/22/2019. Start Date: 05/22/2019. The progress note dated 07/5/2019 14:00 (2:00 p.m.) documented .O2 98.0%-6/28/19 14:45 Method: Oxygen via Nasal Cannula. The progress note dated 07/12/2019 11:00 (11:00 a.m.) documented .O2 98.0%-6/28/19 14:45 Method: Oxygen via Nasal Cannula. The eMAR (electronic medication administration record) dated 7/1/2019-7/31/2019, 8/1/2019-8/31/2019, and 9/1/2019-9/30/2019 for Resident #57 documented, O2 at 3L/Min as needed for SOB. Start Date- 05/22/2019 1030 (10:30 a.m.). The comprehensive care plan The resident has altered respiratory status/Difficulty Breathing r/t (related to) hx (history) of Pneumonia (2), CHF (congestive heart failure) (3), CAD (coronary artery disease) (4), and anxiety (5) Uses O2. Date Initiated 01/15/2018. Revision on: 07/19/2018. On 09/05/19 at 3:26 p.m., an interview was conducted with RN (registered nurse) # 1, MDS (minimum data set) coordinator regarding the assessment process for oxygen use. RN #1 stated that she utilizes the eTAR (electronic treatment administration record), physician orders and visualizing if the resident is wearing oxygen or not to conduct her assessments. RN #1 reviewed section J of Resident #57's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 07/12/19, and agreed that if failed to document oxygen use for Resident #57. RN #1 stated that she had revised the MDS for a medication and had thought she had included the oxygen as well. RN #1 stated that Resident #57 has been using oxygen for over a year now and that the MDS needed to be updated. On 9/05/19 at 3:57 p.m., an interview was conducted with LPN #8. When asked if Resident #57 wears oxygen, LPN #8 stated that she wears oxygen on a regular basis. LPN #8 stated that it is ordered as needed for shortness of breath but Resident #57 wears it frequently, especially when she is in her room. On 9/05/19 at 4:50 p.m., an interview was conducted with LPN #2, the unit manager. When asked if Resident #57 wears oxygen, LPN #2 stated, Yes, she uses it when in bed. On 09/05/19 at approximately 5:00 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: 1. Atrial fibrillation A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html. 2. Pneumonia An infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia. You can also get pneumonia by inhaling a liquid or chemical. This information was obtained from the website: https://medlineplus.gov/pneumonia.html. 3. Congestive heart failure A condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. This information was obtained from the website: https://medlineplus.gov/heartfailure.html 4. Coronary artery disease A common type of heart disease. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/coronaryarterydisease.html. 5. Anxiety Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary. Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain a complete and accurate Minimum Data Set assessment for three of 40 residents in the survey sample: #73, #15, and #57. The findings include: 1. The facility staff failed to correctly document the discharge disposition on Resident #73's discharge Minimum Data Set (MDS) Assessment with an ARD (assessment reference date) of 06/27/2019. Resident #73 was admitted to the facility on [DATE]. Her diagnoses included anemia (low red blood cells), hypertension (high blood pressure), and diabetes. Resident #73's most recent MDS Assessment was a Discharge Assessment with an ARD (assessment reference date) of 06/27/2019. The Brief Interview for Mental Status (BIMS) scored Resident #73 at a 99, indicating that the BIMS could not be completed. Resident #73 was coded as requiring extensive assistance of one person for bed mobility and transfers, and as requiring limited assistance of one person for ambulation. A review of Resident #73's closed record revealed Resident #73 was flagged as having discharged to the Hospital by the MDS system. Upon review of the discharge nurse's note dated 06/27/2019, it was discovered that Resident #73 had not discharged to the Hospital, but rather had had a planned discharge home with family. On 09/05/2019 at 3:26p.m., an interview was conducted with Registered Nurse (RN) #1, the MDS Coordinator. RN #1 was asked to review Resident #73's clinical record and confirm their discharge disposition. RN #1 confirmed that Resident #73 was discharged home with family. RN #1 was asked to review Resident #73's Discharge MDS and clarify whether or not it was accurate in its description of her discharge destination. RN #1 stated that the Discharge MDS was not accurate, and that she would file a correction immediately. RN #1 was asked if she followed the Resident Assessment Instrument (RAI) Manual when completing MDS Assessments, and confirmed that she did. Administrative Staff Member (ASM) #1, the facility Administrator, and ASM #2, the Director of Nursing, were informed of the findings at the end of day meeting on 09/06/2019. No further information was provided. 2. The facility staff incorrectly coded Resident #15's quarterly MDS dated [DATE] for the administration of insulin. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of but not limited to peripheral vascular disease, intervertebral disc disorders, ischemic heart disease, diabetes, depression, bladder dysfunction, osteoporosis, high blood pressure, and anxiety. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/13/19 coded the resident as cognitively intact in ability to make daily life decisions. The resident was coded as requiring extensive care for mobility, transfers, dressing, hygiene, and toileting; limited assistance for bathing; and supervision for eating. A review of the above MDS revealed in Section N Medications the resident was coded as having received insulin injections for seven days of the seven-day look back period. Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days. A review of the May 2019 and June 2019 MAR (Medication Administration Record) revealed that there were no current orders for insulin administration during the time of the above MDS. A review of the physician's orders revealed an order dated 11/28/18 for Insulin Regular Human Solution (1) per sliding scale . which was discontinued on 3/27/19. No further insulin orders had been written since that date. On 9/5/19 at 3:18 PM, in an interview with RN #2 (Registered Nurse), the MDS coordinator. RN #2 was asked about the completion of Section N of the MDS assessment. RN #2 stated that the look back period for medications is seven days and she looks at the MAR and the nurses notes to see if they were giving any of the listed medications during the look back period. When asked about the coding of Resident #15's quarterly 6/13/19 MDS assessment for insulin, RN #2 stated that it might be miscoded but that she would check on it. When asked what the facility uses as a policy for completing the MDS assessments, RN #2 stated the RAI manual. On 9/5/19 at 3:30 PM, RN #2 returned and stated that the 6/13/19 quarterly MDS was miscoded. On 9/5/19 at the end of day meeting at approximately 5:00 PM, ASM #1 (Administrative Staff Member), the Administrator, was notified of the concern. No further information was provided. A review of the RAI Manual 3.0, dated October 2017, page N-1 to N- documented, The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin, and/or select medications were received by the resident . 1. Review the resident's medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Determine if the resident received insulin injections during the look-back period. 3. Determine if the physician (or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) changed the resident's insulin orders during the look-back period. 4. Count the number of days insulin injections were received and/or insulin orders changed Enter in Item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received Enter in Item N0350B, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that the physician (nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) changed the resident's insulin orders For sliding scale orders: - A sliding scale dosage schedule that is written to cover different dosages depending on lab values does not count as an order change simply because a different dose is administered based on the sliding scale guidelines. - If the sliding scale order is new, discontinued, or is the first sliding scale order for the resident, these days can be counted and coded. For subcutaneous insulin pumps, code only the number of days that the resident actually required a subcutaneous injection to restart the pump. (1) Insulin - Insulin is a hormone produced by the pancreas to help the body use and store glucose. Glucose is a source of fuel for the body. With diabetes, the body cannot regulate the amount of glucose in the blood (called glycemia or blood sugar). Insulin therapy can help some people with diabetes maintain their blood sugar levels. Information obtained from https://medlineplus.gov/ency/patientinstructions/000965.htm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to develop a baseline care plan related to the use of bed rails for Resident #222. Resident #222 was admitted to the facility on [DATE] with diagnoses including, but not limited to: cancer of the esophagus and COPD (chronic obstructive pulmonary disease) (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/26/19, Resident #222 was coded as having mild cognitive impairment for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring the extensive assistance of one staff member for bed mobility and for transferring from bed to wheelchair. On the following dates and times, Resident #222 was observed sitting up in his bed: 9/4/19 at 1:19 p.m. and 3:59 p.m., 9/5/19 at 9:00 a.m. and 2:15 p.m., 9/6/19 at 7:40 a.m. A set of side rails (grab bars) was attached to both sides of the bed. The side rails were up during each observation. On 9/4/19 at 1:19 p.m., Resident #222 was interviewed. When asked about the side rails, he said, They are up all the time when I'm in the bed. I use them to help position myself. I hold on to them when I need some support. On 9/5/19 at 2:50 p.m., LPN (licensed practical nurse) #1, the assistant director of nursing, was interviewed. When asked about the purpose of a care plan, she stated, The care plan is how you know how to take care of a patient. LPN #1 stated, You have to have an updated care plan so you know how to take care of a patient. The staff can access the care plans at any computer. On 9/6/19 at 8:15 a.m., LPN #3 was interviewed. When asked about Resident #222's use of the side rails, she stated, Yes, he uses them to help with turning and mobility in the bed. A review of Resident #222's physician orders revealed there were no orders for use of the side rails. A review of Resident #222's care plan dated 8/20/19 failed to reveal any information related to Resident #222's use of side rails for bed mobility or transferring. On 9/5/19 at 5:00 p.m., ASM (administrative staff member ) #1, the administrator, and ASM #2, the DON (director of nursing) were informed of these concerns, and asked to present any evidence that Resident #222's baseline care plan included the use of side rails for bed mobility and transferring. On 9/6/19 at 8:54 a.m., ASM #2 stated, I agree this is a concern. The nurses see the devices as side rails, not side rails. That is why there is not an assessment or nothing on the care plan. We are doing a 100% audit, and updating the ones that need updating. We are doing some education on it. No further information was provided prior to exit. (1) COPD is a general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop a complete baseline care plan for two of 40 residents in the survey sample, Residents #67 and #222. The facility staff failed to develop Resident #67's baseline care plan to include the use of an incentive spirometer and staff failed to develop a baseline care plan related to the use of bed rails for Resident #222. The findings include: 1. The facility staff failed to develop Resident #67's baseline care plan to include the use of an incentive spirometer (1). Resident #67 was admitted to the facility on [DATE]. Resident #67's diagnoses included but were not limited to difficulty swallowing, tremor and surgical aftercare following surgery on the circulatory system. Resident #67's most recent MDS (minimum data set), a 14 day Medicare assessment with an ARD (assessment reference date) of 8/30/19, coded the resident as being cognitively intact. Resident #67's baseline care plan initiated on 8/16/19 failed to reveal documentation regarding an incentive spirometer. Review of Resident #67's clinical record failed to reveal a physician's order for an incentive spirometer. On 9/4/19 at 3:50 p.m., Resident #67 was observed in bed. An incentive spirometer was observed in a bag on the nightstand. On 9/5/19 at 3:18 p.m., Resident #67 was observed in bed. An incentive spirometer was observed in a bag on the nightstand. An interview was conducted with Resident #67 at this time and the resident was asked if she uses the incentive spirometer. Resident #67 stated she uses the incentive spirometer some but could not state when or how often she uses the device. On 9/5/19 at 2:50 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked if a resident's care plan should include the use of an incentive spirometer. LPN #1 stated yes. When asked why, LPN #1 stated, Because that's their personalized plan of care so you know how to take care of the patient and what's going on with them. On 9/5/19 at 5:12 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Care Plan documented, B) An 'Interim' Baseline Care plan must be developed within 48 hours of admission to insure that the resident's needs are met appropriately until the Comprehensive Care Plan is completed . No further information was presented prior to exit. (1) An incentive spirometer is a device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. Using the incentive spirometer teaches you how to take slow deep breaths. Deep breathing keeps your lungs well-inflated and healthy while you heal and helps prevent lung problems, like pneumonia. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to implement the comprehensive care plan for administering oxygen as ordered for Resident #57. Resident #57 was admitted to the facility 09/15/2011 with a readmission on [DATE] with diagnoses, that included but were not limited to shortness of breath and atrial fibrillation (1). Resident #57's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/12/19, coded Resident #57 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Section O of the MDS failed to evidence documentation of Resident #57 receiving oxygen therapy while a resident. On 9/04/19 at 11:26 a.m., an interview was conducted with Resident #57. Resident #57 stated that she uses her oxygen frequently during the day and wears it every night in bed. When asked how long she has been using oxygen, Resident #57 stated, About a year now. Resident #57 was observed wearing an oxygen cannula in her nose during the interview in her room. Observation of the oxygen concentrator revealed the oxygen flowrate to be set on 2 1/2 L/Min (liters/minute). Additional observations on 09/04/19 at 1:47 p.m. and on 09/05/19 at 8:18 a.m. revealed the oxygen concentrator flow meter was set on 2 1/2 L/Min (liter/minute). The order summary report dated 9/05/2019 documented, O2 (oxygen) at 3L/Min (liters per minute) as needed for SOB (shortness of breath). Order Date: 05/22/2019. Start Date: 05/22/2019. The comprehensive care plan The resident has altered respiratory status/Difficulty Breathing r/t (related to) hx (history) of Pneumonia (2), CHF (congestive heart failure) (3), CAD (coronary artery disease) (4), and anxiety (5) Uses O2. Date Initiated 01/15/2018. Revision on: 07/19/2018. Under Interventions/Tasks it documented, Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Date Initiated 01/15/2018, Revision on 01/15/2018. Provide oxygen as ordered. Dated Initiated: 01/15/2018, Revision on 01/15/2018. The eMAR (medication administration record) dated 7/1/2019-7/31/2019, 8/1/2019-8/31/2019, and 9/1/2019-9/30/2019 for Resident #57 documented, O2 at 3L/Min as needed for SOB. Start Date- 05/22/2019 1030 (10:30 a.m.). On 9/05/19 at 3:57 p.m., an interview was conducted with LPN #8. When asked if Resident #57 wears oxygen, LPN #8 stated that she wears oxygen on a regular basis. LPN #8 stated that it is ordered as needed for shortness of breath, but Resident #57 wears it frequently, especially when she is in her room. When asked to describe the process for setting the flowrate of oxygen, LPN #8 stated that you must get eye level to the concentrator and then turn the knob to the correct number that is ordered. When asked to describe the location of the line defining the oxygen number and the silver ball located inside of the flow meter, LPN #8 stated that the line should be aligned in the center of the silver ball. LPN #8 observed the flowmeter on the concentrator located in Resident #57's room and agreed that it was not administering 3L/Min as ordered. LPN #57 stated that the oxygen was set on the 2 1/2 liter/minute line. LPN #8 stated that when you look at it from standing it looks like it is on three but when you are eye level the flow rate is incorrect. When asked if Resident #57 is able to change the settings on the concentrator, LPN #57 stated No. On 9/05/19 at 4:50 p.m., an interview was conducted with LPN #2, the unit manager. When asked if Resident #57 wears oxygen, LPN #2 stated, Yes, she uses it when in bed. LPN #2 stated that she was concerned that the resident was changing it because it was being checked frequently. On 09/05/19 at 4:57 p.m., a request was made by written list to ASM (administrative staff member) #1, the administrator for the facility policy on oxygen administration. On 09/06/19 at 7:39 a.m., ASM #1 stated that the facility did not have a policy on oxygen administration and provided the manufacturer instructions for use for the oxygen concentrator used for Resident #57. The manufacturer instructions for use Philips Respironics, EverFlo, EverFlo Q, User Manual documented, Chapter 2: Operating Instructions, 6. Adjust the flow to the prescribed setting by turning the knob on the top of the flow meter until the ball is centered on the line marking the specific flow rate. A review of the facility policy, Care Plan revealed, in part, the following: D) All staff must be familiar with each resident's Care Plan and all approaches must be implemented . On 09/05/19 at approximately 5:00 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: 1. Atrial fibrillation A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html. 2. Pneumonia An infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia. You can also get pneumonia by inhaling a liquid or chemical. This information was obtained from the website: https://medlineplus.gov/pneumonia.html. 3. Congestive heart failure A condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. This information was obtained from the website: https://medlineplus.gov/heartfailure.html 4. Coronary artery disease A common type of heart disease. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/coronaryarterydisease.html. 5. Anxiety Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary. Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement the plan of care for two of 40 residents in the survey sample, Residents #222 and #57. Resident #222 and Resident #57 were observed receiving oxygen at a rate that was not prescribed by the physician. The findings include: 1. The facility staff failed to implement Resident #222's comprehensive care plan to administer oxygen at the physician-ordered rate. Resident #222 was admitted to the facility on [DATE] with diagnoses including, but not limited to cancer of the esophagus and COPD (chronic obstructive pulmonary disease) (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/26/19, Resident #222 was coded as having mild cognitive impairment for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). He was coded as receiving oxygen in the facility on all days of the lookback period. On the following dates and times, Resident #222 was observed sitting up in his bed. At each observation, he was wearing oxygen delivered through a nasal cannula connected to an oxygen concentrator. The dates, times, and rates of oxygen were as follows: - 9/4/19 at 1: 25 p.m. - 2.5 lpm (liters per minute) - 9/4/19 at 3:59 p.m. - 2.5 lpm - 9/5/19 at 9:00 a.m. - 3.5 lpm - 9/5/19 at 2:15 p.m. - 3.5 lpm A review of Resident #222's physicians' orders revealed the following order, written 8/19/19, Oxygen @ (at) 3 LPM (liters per minute) via nasal cannula every shift for SOB (shortness of breath). A review of Resident #222's comprehensive care plan dated 8/20/19 revealed, in part, the following, The resident has COPD. Is on O2 (oxygen) .Oxygen therapy as ordered by the physician. On 9/5/19 at 9:00 a.m., Resident #222 was interviewed. When asked if he adjusts his own oxygen rate, he stated, No, only the staff does that. I can't reach it, and I would not know what to do with it if I could reach it. On 9/5/19 at 2:50 p.m., LPN (licensed practical nurse) #5 was interviewed regarding how staff ensure residents are receiving oxygen at the physician-ordered rate. LPN #5 stated, Usually, I make my rounds first thing. I look on the computer to see my assignments. I look on the MAR (medication administration record) and TAR (treatment administration record) to see what needs to be done. This is a skilled floor. We have so many people in and out all the time. When asked if she was aware of Resident #222's physician-ordered rate, LPN #5 stated, I would need to check on that. I am not usually working over here. I would need to check. LPN #5 then checked the order for Resident #222's oxygen, and stated, It should be three liters. LPN #5 accompanied the surveyor to Resident #555's room. When asked what rate Resident #222's oxygen was set at, LPN #5 stated, Three and a half. I need to turn it down. She then adjusted the oxygen to the rate of three liters per minute. LPN #5 stated, I did check on that this morning. But he went out for therapy. When he came back, he was still on the tank. Someone must have moved him from the tank back to the concentrator. I didn't do it. On 9/5/19 at 3:10 p.m., LPN #1, the assistant director of nursing, was interviewed. When asked about the purpose of a care plan, LPN #1 stated, The care plan is how you know how to take care of a patient. LPN #1 stated, The staff can access the care plans at any computer. On 9/5/19 at 5:00 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the DON (director of nursing) were informed of these concerns. On 9/6/19 at approximately 10:30 a.m., ASM #2 gave the surveyor a copy of the facility's standard of practice regarding oxygen administration. The standard is from the Lippincott Manual of Nursing Practice, 10th edition, pages 239-240. A review of the standard revealed, in part, the following: Performance phase .3. Set the flow rate at the prescribed liters per minute. Feel to determine if oxygen is flowing through the tips of the cannula. A review of the facility policy, Care Plan revealed, in part, the following: D) All staff must be familiar with each resident's Care Plan and all approaches must be implemented . No further information was provided prior to exit. (1) COPD is a general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to administer oxygen at the 3 L/Min (liters per minute) flow rate prescribed by the physician for Resident #57. Resident #57 was admitted to the facility 09/15/2011 with a readmission on [DATE] with diagnoses, that included but were not limited to shortness of breath and atrial fibrillation (1). Resident #57's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/12/19, coded Resident #57 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Section O of the MDS failed to evidence documentation of Resident #57 receiving oxygen therapy while a resident. On 9/04/19 at 11:26 a.m., an interview was conducted with Resident #57. Resident #57 stated that she uses her oxygen frequently during the day and wears it every night in bed. When asked how long she has been using oxygen, Resident #57 stated, About a year now. Resident #57 was observed wearing an oxygen cannula in her nose during the interview in her room. Observation of the oxygen concentrator revealed the oxygen flowrate to be set on 2 1/2 L/Min (liters/minute). Additional observations on 09/04/19 at 1:47 p.m. and on 09/05/19 at 8:18 a.m. revealed the oxygen concentrator flow meter was set on 2 1/2 L/Min (liter/minute). The order summary report dated 9/05/2019 documented, O2 (oxygen) at 3L/Min (liters per minute) as needed for SOB (shortness of breath). Order Date: 05/22/2019. Start Date: 05/22/2019. The eMAR (medication administration record) dated 7/1/2019-7/31/2019, 8/1/2019-8/31/2019, and 9/1/2019-9/30/2019 for Resident #57 documented, O2 at 3L/Min as needed for SOB. Start Date- 05/22/2019 1030 (10:30 a.m.). The comprehensive care plan The resident has altered respiratory status/Difficulty Breathing r/t (related to) hx (history) of Pneumonia (2), CHF (congestive heart failure) (3), CAD (coronary artery disease) (4), and anxiety (5) Uses O2. Date Initiated 01/15/2018. Revision on: 07/19/2018. Under Interventions/Tasks it documented, Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Date Initiated 01/15/2018, Revision on 01/15/2018. Provide oxygen as ordered. Dated Initiated: 01/15/2018, Revision on 01/15/2018. On 9/05/19 at 3:57 p.m., an interview was conducted with LPN #8. When asked if Resident #57 wears oxygen, LPN #8 stated that she wears oxygen on a regular basis. LPN #8 stated that it is ordered as needed for shortness of breath, but Resident #57 wears it frequently, especially when she is in her room. When asked to describe the process for setting the flowrate of oxygen, LPN #8 stated that you must get eye level to the concentrator and then turn the knob to the correct number that is ordered. When asked to describe the location of the line defining the oxygen number and the silver ball located inside of the flow meter, LPN #8 stated that the line should be aligned in the center of the silver ball. LPN #8 observed the flowmeter on the concentrator located in Resident #57's room and agreed that it was not administering 3L/Min as ordered. LPN #57 stated that the oxygen was set on the 2 1/2 liter/minute line. LPN #8 stated that when you look at it from standing it looks like it is on three but when you are eye level the flow rate is incorrect. When asked if Resident #57 is able to change the settings on the concentrator, LPN #57 stated No. On 9/05/19 at 4:50 p.m., an interview was conducted with LPN #2, the unit manager. When asked if Resident #57 wears oxygen, LPN #2 stated, Yes, she uses it when in bed. When asked the process for setting the flowmeter rate for oxygen on the concentrator, LPN #2 stated that you get down to eye level with the gauge and set it to the prescribed number. LPN #2 stated that LPN #8 had informed her that the oxygen for Resident #57 was set at 2 1/2 L/Min and that she had set it back to the prescribed rate of 3 L/Min. LPN #2 stated that she was concerned that the resident was changing it because it was being checked frequently. On 09/05/19 at 4:57 p.m., a request was made by written list to ASM (administrative staff member) #1, the administrator for the facility policy on oxygen administration. On 09/06/19 at 7:39 a.m., ASM #1 stated that the facility did not have a policy on oxygen administration and provided the manufacturer instructions for use for the oxygen concentrator used for Resident #57. The manufacturer instructions for use Philips Respironics, EverFlo, EverFlo Q, User Manual documented, Chapter 2: Operating Instructions, 6. Adjust the flow to the prescribed setting by turning the knob on the top of the flow meter until the ball is centered on the line marking the specific flow rate. On 09/06/19 at approximately 9:30 a.m., ASM #2, the director of nursing provided a copy of Lippincott Manual of Nursing Practice 10th Edition. Procedure Guidelines 10-12. Administering Oxygen by Nasal Cannula. ASM #2 stated that nursing used this as their standard of practice. Lippincott Manual of Nursing Practice 10th Edition documents in Procedure Guidelines 10-12. Administering Oxygen by Nasal Cannula. 3. Set the flow rate at the prescribed liters per minute . On 09/05/19 at approximately 5:00 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: 1. Atrial fibrillation A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html. 2. Pneumonia An infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia. You can also get pneumonia by inhaling a liquid or chemical. This information was obtained from the website: https://medlineplus.gov/pneumonia.html. 3. Congestive heart failure A condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. This information was obtained from the website: https://medlineplus.gov/heartfailure.html 4. Coronary artery disease A common type of heart disease. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/coronaryarterydisease.html. 5. Anxiety Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary. Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice, the comprehensive person-centered care plan, for three of 40 residents in the survey sample, Residents #222, #57, and #67. The facility staff failed to administer oxygen at the physician-ordered rate during multiple observations conducted for Resident #222 and #57, and failed to obtain a physician's order for Resident #67's use of an incentive spirometer. The findings include: 1. During multiple observations the facility staff failed to administer oxygen to Resident #222 at the physician-ordered rate. Resident #222 was admitted to the facility on [DATE] with diagnoses including, but not limited to cancer of the esophagus and COPD (chronic obstructive pulmonary disease) (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/26/19, Resident #222 was coded as having mild cognitive impairment for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). He was coded as receiving oxygen in the facility on all days of the lookback period. On the following dates and times, Resident #222 was observed sitting up in his bed. At each observation, he was wearing oxygen delivered through short tubes in his nose. The dates, times, and rates of oxygen were as follows: - 9/4/19 at 1: 25 p.m. - 2.5 lpm (liters per minute) - 9/4/19 at 3:59 p.m. - 2.5 lpm - 9/5/19 at 9:00 a.m. - 3.5 lpm - 9/5/19 at 2:15 p.m. - 3.5 lpm A review of Resident #222's physicians' orders revealed the following order, written 8/19/19, Oxygen @ (at) 3 LPM (liters per minute) via nasal cannula every shift for SOB (shortness of breath) A review of Resident #222's care plan dated 8/20/19 revealed, in part, the following, The resident has COPD. Is on O2 (oxygen) .Oxygen therapy as ordered by the physician. On 9/5/19 at 9:00 a.m., Resident #222 was interviewed. When asked if he adjusts his own oxygen rate, he stated, No, only the staff does that. I can't reach it, and I would not know what to do with it if I could reach it. On 9/5/19 at 2:50 p.m., LPN (licensed practical nurse) #5 was interviewed. When asked about how she makes sure residents are receiving oxygen at the physician-ordered rate, LPN #5 stated, Usually, I make my rounds first thing. I look on the computer to see my assignments. I look on the MAR (medication administration record) and TAR (treatment administration record) to see what needs to be done. This is a skilled floor. We have so many people in and out all the time. When asked if she was aware of Resident #222's physician-ordered rate, LPN #5 stated, I would need to check on that. I am not usually working over here. I would need to check. LPN #5 checked the order for Resident #222's oxygen, and stated, It should be three liters. LPN #5 accompanied the surveyor to Resident #555's room and observed Resident $#22's oxygen. When asked what flowrate the oxygen was set at, LPN #5 stated, Three and a half. I need to turn it down. She adjusted the oxygen to the rate of three liters per minute. LPN #5 stated, I did check on that this morning. But he went out for therapy. When he came back, he was still on the tank. Someone must have moved him from the tank back to the concentrator. I didn't do it. On 9/5/19 at 3:10 p.m., LPN #1, the assistant director of nursing, was interviewed. She stated, Everyone in the building checks the oxygen rate on all the devices - the concentrators and portable tanks. But only the nurse can adjust the rates. She stated the nurses check all the rates at the beginning of their shift, and as often as possible throughout the day. She stated the nurses verify what the rate should be against the physician's order. On 9/5/19 at 5:00 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the DON (director of nursing) were informed of the above concern, and were asked to provide the facility policy on oxygen administration. On 9/6/19 at 7:35 a.m., ASM #1 stated that the facility did not have a policy on oxygen administration. On 9/6/19 at approximately 10:30 a.m., ASM #2 provided a copy of the facility's standard of practice regarding oxygen administration. The standard is from the Lippincott Manual of Nursing Practice, 10th edition, pages 239-240. A review of the standard revealed, in part, the following: Performance phase .3. Set the flow rate at the prescribed liters per minute. Feel to determine if oxygen is flowing through the tips of the cannula. No further information was provided prior to exit. (1) COPD is a general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. 3. The facility staff failed to obtain a physician's order for Resident #67's use of an incentive spirometer (1). Resident #67 was admitted to the facility on [DATE]. Resident #67's diagnoses included but were not limited to difficulty swallowing, tremor and surgical aftercare following surgery on the circulatory system. Resident #67's most recent MDS (minimum data set), a 14 day Medicare assessment with an ARD (assessment reference date) of 8/30/19, coded the resident as being cognitively intact. Review of Resident #67's clinical record failed to reveal a physician's order for an incentive spirometer. Resident #67's baseline care plan initiated on 8/16/19 failed to reveal documentation regarding an incentive spirometer. On 9/4/19 at 3:50 p.m., Resident #67 was observed in bed. An incentive spirometer was observed in a bag on the nightstand. On 9/5/19 at 3:18 p.m., Resident #67 was observed in bed. An incentive spirometer was observed in a bag on the nightstand. Resident #67 was asked if she uses the incentive spirometer. Resident #67 stated she uses the incentive spirometer some but could not state when or how often she uses the device. On 9/5/19 at 2:50 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked what should be done for a resident using an incentive spirometer. LPN #1 stated, They should be taught how to use it. Educated why they are using it and make sure there is a goal attached to it. When asked if there should be a physician's order in place, LPN #1 stated, Uh huh. When asked why, LPN #1 stated, So the nurses are aware that needs to take place. That's our documentation proving it. When asked what information the physician's order should contain, LPN #1 stated Frequency, the goal, the reason they are using it. On 9/5/19 at 5:12 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. On 9/6/19 at 7:39 a.m., ASM #1 stated the facility did not have a policy for incentive spirometers. ASM #1 provided the facility standard of practice from the Lippincott Manual of Nursing Practice 10th edition. The standard of practice documented how to assist the patient using an incentive spirometer and documented, 1. Set the incentive spirometer indicator at the desired goal the patient is to reach or exceed . but did not document specific information regarding physician's orders. No further information was presented prior to exit. (1) An incentive spirometer is a device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. Using the incentive spirometer teaches you how to take slow deep breaths. Deep breathing keeps your lungs well-inflated and healthy while you heal and helps prevent lung problems, like pneumonia. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to assess Resident #222 for the use of bed rails, and staff failed to review risks and benefits for use of bed rails, and failed to obtain informed consent for the resident's use of bed rails. Resident #222 was admitted to the facility on [DATE]. Diagnoses include, but not limited to cancer of the esophagus and COPD (chronic obstructive pulmonary disease) (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/26/19, Resident #222 was coded as having mild cognitive impairment for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring the extensive assistance of one staff member for bed mobility and for transferring from bed to wheelchair. On the following dates and times, Resident #222 was observed sitting up in his bed: 9/4/19 at 1:19 p.m. and 3:59 p.m., 9/5/19 at 9:00 a.m. and 2:15 p.m., and on 9/6/19 at 7:40 a.m. A set of grab bars (side rails) were attached to both sides of the bed. The side rails were up at each observation. On 9/4/19 at 1:19 p.m., Resident #222 was interviewed. When asked about the side rails, he stated, They are up all the time when I'm in the bed. I use them to help position myself. I hold on to them when I need some support. A review of Resident #222's clinical record revealed no evidence that the facility attempted any alternatives prior to installing the side rails. There was no evidence of an assessment for the use of side rails, no evidence that Resident #222 was provided the risk and benefits for the use of side rails, and no evidence of informed consent by the resident or that the RR (responsible representative) for the use of side rails. A review of the physician orders for Resident #222 failed to reveal any orders for use of the side rails. A review of Resident #222's care plan dated 8/20/19 failed to reveal any information related to Resident #222's use of side rails for bed mobility or transferring. On 9/5/19 at 5:00 p.m., ASM (administrative staff member ) #1, the administrator, and ASM #2, the DON (director of nursing) were informed of the above concerns, and asked to present any documentation evidencing that alternatives had been attempted for Resident #222 prior to installing the side rails. Any documentation evidencing that Resident #222 had been assessed for the use of side rails, was informed of the risk and benefits of the use of the side rails, and evidence that Resident #222 or the RR (responsible party) had given informed consent for the use of side rails On 9/6/19 at 8:15 a.m., LPN (licensed practical nurse) #3 was interviewed. When asked about Resident #222's use of the side rails (grab bars), LPN #3 stated, Yes, he uses them to help with turning and mobility in the bed. On 9/6/19 at 8:54 a.m., ASM #2 presented the surveyor with a document, [Name of Corporation] Bed Rail assessment dated [DATE]. The document included the headings, Rationale, Risk Potential, and Consent. When asked why this assessment was dated 9/5/19 when the resident had been admitted on [DATE], ASM #2 stated, I agree this is a concern. The nurses see the devices as grab bars, not side rails. That is why there is no assessment or anything on the care plan. We are doing a 100% audit, and updating the ones that need updating. We are doing some education on it. No further information was provided prior to exit. (1) COPD is a general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for two of 40 residents in the survey sample, Residents #61 and #222. The facility staff failed to assess Resident #61 and Resident #222 for the use of bed rails, and staff failed to review risks and benefits for use of bed rails, and failed to obtain informed consent for the resident's use of bed rails. The findings include: 1. The facility staff failed to evidence that Resident #61 was assessed for the use of bed rails and staff failed to review the risks and benefits and obtain informed consent for the resident's use of bed rails. Resident #61 was admitted to the facility on [DATE]. Resident #61's diagnoses included but were not limited to heart failure, seizures and history of heart attack. Resident #61's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/21/19, coded the resident's cognition as moderately impaired. Section G coded Resident #61 as requiring extensive assistance of two or more staff with bed mobility. On 9/4/19 at 11:45 a.m., and 9/5/19 at 9:43 a.m., Resident #61 was observed lying in bed. Both bed rails (assist grab bars) were in the upright position while the resident was in bed. Review of Resident #61's clinical record failed to reveal a physician's order for the bed rails. Further review failed to reveal the resident was assessed for the use of the bed rails, failed to reveal the risks and benefits were reviewed with Resident #61 (or the representative) and failed to reveal informed consent was obtained prior to the use of the bed rails. Resident #61's care plan initiated on 8/8/19 failed to document information regarding the use of bed rails. On 9/5/19 at 2:30 p.m., ASM (administrative staff member) #1 (the administrator) presented a bed rail assessment completed for Resident #61 on 9/5/19. A note attached to the assessment documented, Used grab bars on admit for enablers. No longer using due to decline. New assessment and grab bars removed today. On 9/5/19 at 2:50 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked what should be completed for residents using bed rails. LPN #1 stated, So we would identify what diagnosis they would have that may assist. Assess their diagnosis, why that would help them, what is it going to help them do; bed mobility, turning and positioning, strengthening and safe transfers. When asked if staff assess the residents need for the use of side rails, LPN #1 stated, Yeah and make sure basically it's not going to put them at risk for any type of injury so we will assess that as well. LPN #1 was asked if the risks and benefits for using side rails are explained to the resident and if informed consent is obtained. LPN #1 stated, Yeah. If not necessary then we remove them. On 9/5/19 at 5:12 p.m., ASM #1 and ASM #2 (the director of nursing) were made aware of the above concern. A review of the facility policy, Bed Rails Policy, revealed, in part, the following: 'Bed rails' are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Procedure: 1. The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. 2. If a bed or side rail is used, the facility will: a. Assess the potential risks associated with the use of bed rails, including the risk of entrapment, prior to bed rail installation. b. Assess the risk versus benefits of using a bed rail and review them with the resident or if applicable, the resident's representative. c. Obtain informed consent for the installation and use of bed rails prior to the installation. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility staff failed to periodically review Resident #36's (or the resident's representative) decisions regarding advance directives. Resident #36 was admitted to the facility 12/03/2010 with a readmission on [DATE] with diagnoses, that included but were not limited to heart failure (1) and atrial fibrillation (2). Resident #36's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/17/19, coded Resident #36 as scoring a 6 (six) on the staff assessment for mental status (BIMS) of a score of 0 - 15, 6- being severely impaired for making daily decisions. Review of Resident #36's clinical record failed to reveal documentation of periodic review regarding advance directives. The comprehensive care plan for Resident #36 dated 07/26/2019 documented, Resident has chosen full code status. Date Initiated: 01/19/2018 Revision on: 01/19/2018. Under Interventions, it documented, Review per routine with resident and/or responsible party. Date Initiated 01/19/2018. Revision on: 01/19/2018. On 9/5/19 at approximately 4:40 p.m., a request was made to OSM #1 for any evidence of documentation of review of Advance Directives for Resident #36. On 9/6/19 at approximately 8:15 a.m., a request was made to OSM #4 for any evidence of documentation of review of Advance Directives for Resident #36. On 9/6/19 at approximately 9:00 a.m., a document titled, Acknowledgment of Receipt for Resident #36 was provided by OSM #4. Review of the document revealed a date of 12/3/2010 with the representative for Resident #36's signature acknowledging receipt of the facility's resident handbook. It documented, vi. Facility's Advance Directive Policy and explanation of Resident rights concerning Advance Directives . On 9/6/19 at approximately 10:00 a.m., ASM (administrative staff member) #1, the administrator provided the document Care Plan Conference Notes dated 8/11/19 for Resident #36. The document revealed DNR Status: Full Code but failed to evidence periodic review of Advance Directives for Resident #36. On 9/06/19 at approximately 10:20 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services, were made aware of the findings. No further information was provided prior to exit. References: 1. Heart failure A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/000158.htm. 2. Atrial fibrillation A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html. 6. The facility staff failed to periodically review Resident #14's (or the resident's representative) decisions regarding advance directives. Resident #14 was admitted to the facility 08/22/2017 with diagnoses, that included but were not limited to repeated falls and muscle weakness generalized. Resident #14's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 06/08/19, coded Resident #14 as scoring a 12 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 12- being cognitively intact for making daily decisions. On 9/04/19 at approximately 12:30 p.m., an interview was conducted with Resident #14. When asked if he is participates in his plan of care, Resident #14 stated that he has gone to meetings but not always. When asked if advanced directives are discussed with him at the meetings or at any other time, Resident #14 stated that he did not think so or did not remember it being discussed. Review of Resident #14's clinical record failed to reveal documentation of periodic review regarding advance directives. The comprehensive care plan for Resident #14 dated 07/26/2019 documented, Resident has full code. Date Initiated: 05/15/2018. Under Interventions, it documented, Review annually, PRN (as needed) with resident and/or responsible party. Date Initiated: 05/15/2018. On 9/5/19 at approximately 4:40 p.m., a request was made to OSM #1 for any evidence of documentation of review of Advance Directives for Resident #14. On 9/6/19 at approximately 8:15 a.m., a request was made to OSM #4 for any evidence of documentation of review of Advance Directives for Resident #14. On 9/6/19 at approximately 9:00 a.m., a document titled, admission Agreement Signature Page for Resident #14 was provided by OSM #4. Review of the document revealed a date of 08/24/17 with Resident #14's signature. It documented, 13. A written summary of the FACILITY Advance Directive policy. (App. C). I have not executed an Advanced Directive. The documented failed to evidence periodic review of Advance Directives. On 9/6/19 at approximately 10:00 a.m., ASM (administrative staff member) #1, the administrator provided the document Care Plan Conference Notes dated 618 for Resident #14. The document revealed DNR Status: Full Code but failed to evidence periodic review of Advance Directives for Resident #14. On 9/06/19 at approximately 10:20 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services, were made aware of the findings. No further information was provided prior to exit. Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement the Advanced Directives policy to ensure periodic reviews with resident and/or responsible party, were provided to formulate Advance Directives, or, if applicable, make changes to their existing Advance Directives or maintain them as written, for seven of 40 residents in the survey sample, Residents #22, #15, #30, #20, #57, #36, and #14. The findings include: 1. Resident #22 did not have any Advance Directives, the facility staff failed to conduct a periodic review to determine if the resident or responsible party wished to develop Advance Directives later. Resident #22 was admitted to the facility on [DATE]. Diagnoses included but are not limited to stroke, aphasia, high blood pressure, diabetes, gastrostomy, quadriplegia, dysphagia, adult failure to thrive, and contractures. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/15/19 coded the resident as severely impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living. A review of the clinical record failed to reveal the presence of any Advance Directives. Further review revealed that the resident/responsible party were provided with information for developing Advance Directives around the time of admission, dated 3/14/18. Review of the clinical record failed to reveal any evidence that the resident's Advance Directives status was periodically reviewed with the resident/responsible party, to provide an opportunity and determine if the resident and or RP (responsible party) wished to develop an Advance Directives later. On 9/5/18 at 4:32 PM, an interview was conducted with OSM #1 (Other Staff Member) Social Services. When asked about periodic review of residents Advance Directives, OSM #1 stated that it (advanced directives) is reviewed and documented in the care plan meetings. OSM #1 was informed that only code status was noted on the care plan meeting documentation and was asked about reviews of Advanced Directives. OSM #1 stated that only the code status is reviewed, the Advance Directives are not. OSM #1 was asked if she periodically reviews Advance Directives with residents who do not have one in place to determine if they wish to develop one, or to determine if a resident with an Advance Directives, wishes to change anything. OSM #1 stated, No, we only review code statuses. When asked , if she reviews their Advance Directives with residents that are newly admitted , OSM #1 stated she does not review them [Advanced Directives], only the code status. When asked if, Advance Directives are discussed during the first care plan meeting, OSM #1 stated only code status is discussed. On 9/6/19 at 8:02 AM, an interview was conducted with OSM #4, the Admissions Coordinator. OSM #4 was asked if newly admitted residents are provided any information on Advance Directives. OSM #4 stated, Yes, and I will ask them if they have one, and if so get a copy into the medical record. OSM #4 stated, I ask them if they know what an Advance Directive is and provide them information on it, and if they want to execute one, I direct them to the Social Worker or Administrator. When asked how the facility evidence the resident was provided with information on Advance Directives, OSM #4 stated, they are given a facility handbook which contains information on Advance Directives and they sign a receipt that they are given the handbook. She also provided pages from the resident's admission agreement that reflected that the resident was offered information and opportunity about developing Advance Directives. When asked about periodically reviewing the Advance Directives with residents to see if they wish to formulate one and or make any changes, OSM #4 stated, That is done in the meetings with the social worker (care plan meetings). I don't have anything to do with that. A review of the facility policy, Advance Directives Protocol documented, Written instructions about future medical care should you become unable to make decisions .These are also called healthcare directives. Upon admission and during Your Path Meetings, advance directives will be discussed with resident and/or resident representative to determine if any advance directives have be {sic} chosen Advance directives will be reviewed at minimum annually according to MDS schedule On 9/6/19 at 10:15 AM, ASM #1 (Administrative Staff Member), the Administrator, was notified of the concern. No further information was provided. 2. The facility staff failed to conduct a periodic review to determine if the Resident #15 or the responsible party wished to make any changes and or maintain the Advance Directives as written. Resident #15 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE], with the diagnoses of but not limited to: peripheral vascular disease, intervertebral disc disorders, ischemic heart disease, diabetes, depression, bladder dysfunction, osteoporosis, high blood pressure, and anxiety. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/13/19, coded the resident as cognitively intact in ability to make daily life decisions. The resident was coded as requiring extensive care for mobility, transfers, dressing, hygiene, and toileting; limited assistance for bathing; and supervision for eating. A review of the clinical record revealed the presence of Advance Directives in the resident's chart, dated 10/20/12. Further review of the clinical record failed to reveal any evidence that the resident's Advance Directives status was periodically reviewed with the resident/responsible party, to determine if, and provide opportunity for, making any changes to the resident's existing Advance Directives. On 9/5/18 at 4:32 PM, an interview was conducted with OSM #1 (Other Staff Member) Social Services. When asked about periodic review of residents Advance Directives, OSM #1 stated that it (advanced directives) is reviewed and documented in the care plan meetings. OSM #1 was informed that only code status was noted on the care plan meeting documentation and was asked about reviews of Advanced Directives. OSM #1 stated that only the code status is reviewed, the Advance Directives are not. OSM #1 was asked if she periodically reviews Advance Directives with residents who do not have one in place to determine if they wish to develop one, or to determine if a resident with an Advance Directives, wishes to change anything. OSM #1 stated, No, we only review code statuses. When asked , if she reviews their Advance Directives with residents that are newly admitted , OSM #1 stated she does not review them [Advanced Directives], only the code status. When asked if, Advance Directives are discussed during the first care plan meeting, OSM #1 stated only code status is discussed. On 9/6/19 at 8:02 AM, an interview was conducted with OSM #4, the Admissions Coordinator. OSM #4 was asked if newly admitted residents are provided any information on Advance Directives. OSM #4 stated, Yes, and I will ask them if they have one, and if so get a copy into the medical record. OSM #4 stated, I ask them if they know what an Advance Directive is and provide them information on it, and if they want to execute one, I direct them to the Social Worker or Administrator. When asked how the facility evidence the resident was provided with information on Advance Directives, OSM #4 stated, they are given a facility handbook which contains information on Advance Directives and they sign a receipt that they are given the handbook. She also provided pages from the resident's admission agreement that reflected that the resident was offered information and opportunity about developing Advance Directives. When asked about periodically reviewing the Advance Directives with residents to see if they wish to formulate one and or make any changes, OSM #4 stated, That is done in the meetings with the social worker (care plan meetings). I don't have anything to do with that. A review of the facility policy, Advance Directives Protocol documented, Written instructions about future medical care should you become unable to make decisions .These are also called healthcare directives. Upon admission and during Your Path Meetings, advance directives will be discussed with resident and/or resident representative to determine if any advance directives have be {sic} chosen Advance directives will be reviewed at minimum annually according to MDS schedule On 9/6/19 at 10:15 AM, ASM #1 (Administrative Staff Member), the Administrator, was notified of the concern. No further information was provided. 3. Resident #30 did not have any Advance Directives, the facility staff failed to conduct a periodic review to determine if the resident or responsible party wished to develop Advance Directives later. Resident #30 was admitted to the facility on [DATE], with the diagnoses including, but not limited to: high blood pressure, psychosis, anxiety disorder, diabetes, stroke, and affective mood disorder. The annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) coded the resident as being moderately impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing; extensive assistance for transfers, mobility, dressing, toileting and hygiene; and supervision for eating. A review of the clinical record failed to reveal the presence of any Advance Directives. Further review revealed that the resident and/or responsible party were provided with information for developing Advance Directives at the time of admission, dated 8/2/17. Review of the clinical record failed to reveal any evidence that the resident's Advance Directives status was periodically reviewed with the resident/responsible party, to determine if, and provide opportunity for, the development of Advance Directives later. On 9/5/18 at 4:32 PM, an interview was conducted with OSM #1 (Other Staff Member) Social Services. When asked about periodic review of residents Advance Directives, OSM #1 stated that it (advanced directives) is reviewed and documented in the care plan meetings. OSM #1 was informed that only code status was noted on the care plan meeting documentation and was asked about reviews of Advanced Directives. OSM #1 stated that only the code status is reviewed, the Advance Directives are not. OSM #1 was asked if she periodically reviews Advance Directives with residents who do not have one in place to determine if they wish to develop one, or to determine if a resident with an Advance Directives, wishes to change anything. OSM #1 stated, No, we only review code statuses. When asked , if she reviews their Advance Directives with residents that are newly admitted , OSM #1 stated she does not review them [Advanced Directives], only the code status. When asked if, Advance Directives are discussed during the first care plan meeting, OSM #1 stated only code status is discussed. On 9/6/19 at 8:02 AM, an interview was conducted with OSM #4, the Admissions Coordinator. OSM #4 was asked if newly admitted residents are provided any information on Advance Directives. OSM #4 stated, Yes, and I will ask them if they have one, and if so get a copy into the medical record. OSM #4 stated, I ask them if they know what an Advance Directive is and provide them information on it, and if they want to execute one, I direct them to the Social Worker or Administrator. When asked how the facility evidence the resident was provided with information on Advance Directives, OSM #4 stated, they are given a facility handbook which contains information on Advance Directives and they sign a receipt that they are given the handbook. She also provided pages from the resident's admission agreement that reflected that the resident was offered information and opportunity about developing Advance Directives. When asked about periodically reviewing the Advance Directives with residents to see if they wish to formulate one and or make any changes, OSM #4 stated, That is done in the meetings with the social worker (care plan meetings). I don't have anything to do with that. A review of the facility policy, Advance Directives Protocol documented, Written instructions about future medical care should you become unable to make decisions .These are also called healthcare directives. Upon admission and during Your Path Meetings, advance directives will be discussed with resident and/or resident representative to determine if any advance directives have be {sic} chosen Advance directives will be reviewed at minimum annually according to MDS schedule On 9/6/19 at 10:15 AM, ASM #1 (Administrative Staff Member), the Administrator, was notified of the concern. No further information was provided. 4. The facility staff failed to conduct a periodic review to determine if the Resident #20 or the responsible party wished to change anything or maintain the Advance Directives as written. Resident #20 was admitted to the facility on [DATE], with diagnoses that included but are not limited to, cerebrovascular disease, chronic obstructive pulmonary disease, Barrett's Esophagus, depression, and high blood pressure. The significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/13/19, coded the resident as cognitively intact in ability to make daily life decisions. The resident was coded as requiring total care for bathing, extensive assistance for transfers, mobility, dressing, toileting and hygiene; and supervision for eating. A review of the clinical record revealed the presence of Advance Directives in the resident's chart, dated 3/27/14. Further review of the clinical record failed to reveal any evidence that the resident's Advance Directives status was periodically reviewed with the resident/responsible party, to determine if, and provide opportunity for, making any changes to the resident's existing Advance Directives. On 9/5/18 at 4:32 PM, an interview was conducted with OSM #1 (Other Staff Member) Social Services. When asked about periodic review of residents Advance Directives, OSM #1 stated that it (advanced directives) is reviewed and documented in the care plan meetings. OSM #1 was informed that only code status was noted on the care plan meeting documentation and was asked about reviews of Advanced Directives. OSM #1 stated that only the code status is reviewed, the Advance Directives are not. OSM #1 was asked if she periodically reviews Advance Directives with residents who do not have one in place to determine if they wish to develop one, or to determine if a resident with an Advance Directives, wishes to change anything. OSM #1 stated, No, we only review code statuses. When asked , if she reviews their Advance Directives with residents that are newly admitted , OSM #1 stated she does not review them [Advanced Directives], only the code status. When asked if, Advance Directives are discussed during the first care plan meeting, OSM #1 stated only code status is discussed. On 9/6/19 at 8:02 AM, an interview was conducted with OSM #4, the Admissions Coordinator. OSM #4 was asked if newly admitted residents are provided any information on Advance Directives. OSM #4 stated, Yes, and I will ask them if they have one, and if so get a copy into the medical record. OSM #4 stated, I ask them if they know what an Advance Directive is and provide them information on it, and if they want to execute one, I direct them to the Social Worker or Administrator. When asked how the facility evidence the resident was provided with information on Advance Directives, OSM #4 stated, they are given a facility handbook which contains information on Advance Directives and they sign a receipt that they are given the handbook. She also provided pages from the resident's admission agreement that reflected that the resident was offered information and opportunity about developing Advance Directives. When asked about periodically reviewing the Advance Directives with residents to see if they wish to formulate one and or make any changes, OSM #4 stated, That is done in the meetings with the social worker (care plan meetings). I don't have anything to do with that. A review of the facility policy, Advance Directives Protocol documented, Written instructions about future medical care should you become unable to make decisions .These are also called healthcare directives. Upon admission and during Your Path Meetings, advance directives will be discussed with resident and/or resident representative to determine if any advance directives have be {sic} chosen Advance directives will be reviewed at minimum annually according to MDS schedule On 9/6/19 at 10:15 AM, ASM #1 (Administrative Staff Member), the Administrator, was notified of the concern. No further information was provided.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in the main kitchen freezer. In the main freezer a box of frozen green beans and lima beans were observed not closed and sealed exposing the food to the environment. The findings include: On 9/4/19 at 11:11 AM to 11:20 AM a tour of the kitchen was conducted with OSM #3 (Other Staff Member) the Assistant Dietary Manager. The following was identified: • A box of frozen green beans was found in the freezer, with the lid not securely closed and the bag inside was not sealed. The food was exposed to environment of the freezer. • A box of frozen lima beans was found in the freezer, with the lid not securely closed and the bag inside was not sealed. The food was exposed to environment of the freezer. On 9/4/19 at approximately 11:15 AM, OSM #3 stated it should be sealed. On 9/4/19 at approximately 11:17 AM, OSM #2, the Dietary Manager, was notified of the concern. A review of the facility policy, Storage of Frozen Foods documented, .11. Food stored in the freezer shall be covered, labeled and dated. On 9/5/19 at the end of day meeting at approximately 5:00 PM, ASM #1 (Administrative Staff Member), the Administrator, was notified of the concern. No further information was provided.