Based on observation, resident interview, and facility document review, it was determined that facility staff failed to promote resident's dignity for one of 10 residents in the survey sample, Resident #8 (R8). The findings include:For R8, the facility staff failed to provide privacy for the catheter collection bag. R8 was admitted to the facility with diagnoses that included but were not limited to urinary retention (1). The admission MDS (minimum data set) was not due at the time of the survey. The facility's Clinical Admission assessment for R8 dated 08/14/2025 documented in part, Level of cognitive impairment: b. alert (some forgetfulness). On 08/25/2025 at approximately 3:47 p.m. observation of the catheter collection bag hanging on lower portion of bed uncovered. Further observation revealed the contents of the collection bag could clearly be seen. On 08/27/2025 at approximately 7:45 p.m. observation of the catheter collection bag hanging on lower portion of bed uncovered. Further observation revealed the contents of the collection bag could clearly be seen. The physician's order for R8 documented, Indwelling catheter 16FR (French) with 10cc (cubic centimeter) balloon to bedside straight drainage for diagnosis/Hx (history) of urinary retention. Order Date Date:8/14/2025. On 08/27/2025 at approximately 9:15 a.m. an interview was conducted with R8. When asked how he felt about the catheter collect bag not being covered and that the urine could be seen by anyone walking into his room, he stated that it bothered him that the urine could be seen by anyone coming into his room. The facility's policy Resident Rights Under Federal Law documented in part, 1. Resident Rights. The resident has a right to a dignified existence, self-determination, andcommunication with and access to persons and services inside and outside the facility:1.1. The facility must treat each resident with respect and dignity and care for each residentin a manner and in an environment that promotes maintenance or enhancement of his/herquality of life, recognizing each resident's individuality. On 08/27/2025 at approximately 3:10 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, interim director of nursing, were made aware of the above findings. No further information was provided prior to exit. References:(1) A condition where your bladder doesn't empty all the way or at all when you urinate. This information was obtained from the website: https://my.clevelandclinic.org/health/disease/15427-urinary-retention.

Based on observation, resident interview, and staff interview, the facility staff failed to provide accommodation of needs for one of ten residents in the survey sample, Resident #6 (R6). The findings include:For Resident #6 (R6), the facility staff failed to maintain the resident's call bell within reach. On 8/25/25 at 3:37 p.m., R6 was observed lying in bed. The resident stated staff answer the call bell, but this can only happen when the call bell is within reach. R6 further stated the call bell is not always within her reach. At this time, R6's call bell was observed on the floor, out of the resident's reach. On 8/25/25 at 3:41 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that when a resident is in bed, the call bell should be placed next to him or her or clipped on him or her, so the call bell is within the resident's reach. R6's call bell was observed with LPN #1. LPN #1 stated the call bell was not within R6's reach. On 8/26/25 at 4:08 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the interim director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on staff interview, clinical record review and facility document review, the facility staff failed to notify the responsible party as required for one of 10 current residents in the survey sample, Resident #8 (R8). The findings include:The findings include: For R8, facility staff failed to notify the responsible party (RP) that medication, Daptomycin (1), was not available for administration on 08/15/2025. R8 was admitted to the facility with diagnoses that included but were not limited to left foot infection. The admission MDS (minimum data set) was not due at the time of the survey. The facility's Clinical Admission assessment for R8 dated 08/14/2025 documented in part, Level of cognitive impairment: b. alert (some forgetfulness). The physician's order for R8 documented in part, Daptomycin Intravenous Solution Reconstituted 500 MG (milligram) (Daptomycin). Use 10 ml (milliliter) intravenously (into a vein) one time a day every other day for left foot gangreen [sic] (2) for 23 Days. Order Date Date:8/15/2025. The EMAR (electronic medication administration record) for R8 dated August 2025 documented the physician's order as stated above. Further review of the eMAR revealed it was coded HD on 08/15/2025 for Daptomycin. The Chart Codes / Follow Up Codes on the eMAR documented in part, HD=Hold/See Nurse Note. The facility's nurse's note for R8 dated 08/15/2025 documented, Daptomycin Intravenous Solution Reconstituted 500 MG. Use 10 ml intravenously one time a day every other day for left foot gangreen [sic] for 23 days, per pharmacy it will be delivered next run np (nurse practitioner) (Name of NP) aware. Review of the facility's nurse's notes for R8 dated 08/15/2025 through 08/16/2025 failed to evidence documentation of R8's responsible party being notified of the Daptomycin not being available on 08/15/2025. Review of the facility back up pharmacy system inventory list failed to evidence Daptomycin. On 08/26/2025 at approximately 1:54 p.m. LPN (licensed practical nurse) #1. When asked to describe the procedure when a physician ordered medication is not available for a resident she stated that the pharmacy is called to find out the status of the medication such as a problem with the scrip or a delay in sending the medication, notify the nurse practitioner or physician regarding the status of the medication and notify the responsible party. She further stated that the status of the medication and notification to the nurse practitioner or physician and responsible party it is documented in the progress notes. After reviewing the nursing progress notes for R8 regarding the daptomycin she stated she could not locate the documentation. The facility's policy Change in Condition: Notification of. Documented in part, A Center must immediately inform the patient, consult with the patient's physician, and notify,consistent with their authority, the patient's representative, where there is: A need to alter treatment significantly (that is, a need to discontinue or change an existing formof treatment due to adverse consequences, or to commence a new form of treatment) On 08/27/2025 at approximately 3:10 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, interim director of nursing, were made aware of the above findings. No further information was provided prior to exit. References:(1) Used to treat certain blood infections or serious skin infections caused by bacteria. This information was obtained from the website: https://medlineplus.gov/druginofo/meds/a608045.html. (2) The death of tissues in your body. This information was obtained from the website: https://medlineplus.gov/gangrene.html.

Based on observation, staff interview, facility document review, the facility staff failed to maintain a clean and comfortable environment for one of ten residents in the survey sample, Resident #4 The findings include: For Resident #4 (R4), the facility staff failed to maintain the resident's fall mats and floors in a clean and comfortable environment. Observation was made of R4's room on 8/25/25 at 4:02 p.m. The resident was in bed; there were fall mats on both sides of the bed. The fall mats had evidence of liquids having been spilled and the surveyor's shoes stuck to the fall mats. There were bits of paper on both sides of the bed. There were dirt and debris behind the bed and nightstand. On 8/26/25 at 10:59 a.m., an interview was conducted with OSM (other staff member) #5 (the director of environmental services). OSM #5 stated all resident rooms are cleaned every day. OSM #5 stated that in the morning, the cleaning consists of pulling the trash, cleaning surfaces, sweeping, moping, cleaning the bathroom, and replacing toiletries. OSM #5 stated that later in the day, the housekeeping staff completes a walk through and the walk through consists of pulling the trash, cleaning debris on the floor, wiping the bedside tables, pulling the trash, and replacing toiletries. OSM #5 stated fall mats should be lifted up, pulled away from the bed, and cleaned every day.A second observation was made on 8/26/25 at 2:00 p.m. The resident was not in bed but both fall mats were down. There was evidence of spills on the fall mats. An interview was conducted with OSM (other staff member) #9, environmental services, on 8/26/25 at 2:03 p.m. OSM #9 observed the fall mats and stated there were in need of cleaning. The facility policy, Accommodation of Needs, documented in part, The resident/patient (hereinafter patient) has the right to a safe, clean, comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely.ASM (administrative staff member) #1, the administrator, and ASM #2, the acting director of nursing, were made aware of the above concern on 8/27/25 at 3:11 p.m. 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 evidence efforts to resolve a grievance for one of ten residents in the survey sample, Resident #1.The findings include: For Resident #1 (R1), the facility staff failed to evidence efforts to resolve a written grievance sent to the former administrator by R1's responsible party in November 2024. This is cited as past non-compliance with a date of compliance of 5/10/2025.A review of the facility grievances from 1/1/2024 to the present documented one grievance dated 4/13/2024 for care concerns. The grievances failed to evidence any concerns from November 2024.On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/9/2025 the resident was assessed as being severely impaired for making daily decisions. The resident was assessed as being dependent on staff for ADLs (activities of daily living).The resident demographic information documented a family member as the responsible party and health care representative.On 8/25/2025 at 2:56 p.m., a telephone interview was conducted with R1's responsible party who stated that they had sent a written complaint to the former administrator back in November 2024 regarding concerns regarding wound care procedures and other care concerns. R1's responsible party stated that they were told that the administration was looking into her concerns, but she never received any follow up or resolution on the concerns.On 8/26/2025 at 1:22 p.m., an interview was conducted with ASM (administrative staff member) #3, former director of nursing. ASM #3 stated that she recalled ASM #6 receiving a letter from R1's responsible party and she was pretty sure that the former administrator had investigated the situation and followed up with the family member.On 8/27/2025 at 9:47 a.m., an interview was conducted with ASM #6, former administrator. ASM #6 stated that she remembered R1's responsible party emailing something to her with something about wounds in it. She stated that if she remembered correctly she thought that the former director of nursing had investigated it and discussed the concerns thoroughly with R1's responsible party. ASM #6 stated that she was not sure if an official grievance was completed but it probably should have been since it was sent in an email. She stated that she did recall that an investigation was completed and a timeline was done and discussion completed with the responsible party. ASM #6 stated that R1's responsible party came in frequently and had concerns often which were all addressed directly.On 8/27/2025 at 12:27 p.m., an interview was conducted with ASM #1, the current administrator. ASM #1 stated that grievances could come from residents or family and came in writing or verbally. She stated that when a family had a concern they tried to have a meeting within 72 hours to discuss any concerns and a resolution. She stated that when she started working at the facility they had identified a gap in the grievance procedure and had implemented a performance improvement project for identification and resolution of grievances. ASM #1 stated that now they had a whiteboard that they documented the grievances on, came up with a response within two days and the manager followed up with the family member to make sure the issue was resolved. She stated that she could not find any documentation of the concern sent in by R1's responsible party in November 2024.On 8/27/2025 at 1:08 p.m., ASM #1 provided evidence of the performance improvement project for grievances with a date of compliance of 5/10/2025.Review of the plan of correction for Grievances included an assessment of the current problem, a root cause analysis of the identified problem, a plan to correct the problem and the team responsible for implementing the plan of correction. Review of the plan of correction documented an audit of the 2023 and 2024 grievances, education provided to all department heads on the grievance procedure, implementation of new processes, and audits of grievances. Review of the education, audits and tracking from 5/10/2025 to the present documented resolution of concerns. Implementation of the plan of correction was verified by resident and staff interviews. There were no current concerns regarding grievance resolution or follow-up during the survey dates.The facility policy Grievance/Concern revised 10/15/24 documented in part, .The Administrator will serve as the Grievance Officer who is responsible for overseeing the grievance process, including Civil Rights grievances/concerns, receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances, for example, the identity of the patient for those grievances submitted anonymously, issuing written grievance decisions to the patient, and coordinating with state and federal agencies, in consultation with the National Law Department, as necessary in light of specific allegations.On 8/27/2025 at 3:11 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the interim director of nursing were made aware of the findings cited as past non-compliance.No further information was provided prior to exit.Past Non-Compliance

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to submit an MDS (minimum data set) assessment in the required timeframe for one of ten residents in the survey sample, Resident #7.The findings include:For Resident #7 (R7), the facility staff failed to submit the admission MDS assessment within fourteen days of admission.Review of the facesheet for R7 documented an admission date of 8/9/2025.Review of the MDS assessments for R7 documented an admission assessment with an ARD (assessment reference date) of 8/15/25 in progress. The assessment failed to show a completion or submission date.On 8/26/2025 at 2:33 p.m., an interview was conducted with LPN (licensed practical nurse) #8, MDS coordinator. LPN #8 stated that the admission MDS was completed and submitted before the fourteenth day after admission. She stated that some of the MDS assessments had gotten behind due to staffing issues.According to the RAI (Resident Assessment Instrument) 3.0 User's Manual Version 1.19.1 October 2024, documented in part, .OBRA-Required Tracking Records and Assessments are Federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. These assessments are coded on the MDS 3.0 in items A0310A (Federal OBRA Reason for Assessment) and A0310F (Entry/discharge reporting). They include: Tracking records: Entry, Death in facility. Assessments: admission (comprehensive). Assessment Type/Item Set- admission (Comprehensive) - Assessment Reference Date (ARD) (Item A2300) No Later Than: 14th calendar day of the resident's admission (admission date + 13 calendar days).On 8/27/2025 at 3:11 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the acting director of nursing were made aware of the findings.No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility document review, the facility staff failed to develop and implement a baseline care plan for two of 10 residents in the survey sample, Resident #2 (R2) and R7. The findings include:1. For R2, facility staff failed to develop a baseline care plan for oral hygiene. R2 was admitted to the facility with diagnoses that included but were not limited to muscle weakness. On the most recent MDS (minimum data set), a 5 (five)-Day assessment with an ARD (assessment reference date) of 02/12/2024, R2 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. The baseline care plan for R2 dated 02/09/2024 documented, “Focus: Resident has COVID 19 (coronavirus disease 2019) infection. Date Initiated: 02/09/2024. Created on: 02/09/2024.; Resident/Patient requires assistance/is dependent for mobility related to: Date Initiated: 02/09/2024. Created on: 02/09/2024.” On 08/27/2025 at approximately 2:30 p.m. an interview was conducted with LPN (licensed practical nurse) #8, MDS coordinator. When asked how and when a resident’s baseline care plan is developed She stated that it is developed on the day of admission and they gather information from the resident’s record, care concerns, physician’s orders and diagnoses. LPN #8 was asked to review R2’s baseline care plan dated 02/09/2024 as described above. She further stated that a baseline care plan for R2 was not developed. The facility’s policy “Person-Centered Care Plan” documented in part, The Center must develop and implement a baseline person-centered care plan within 48 hours of admission/readmission for each patient/resident (hereinafter “patient”) that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care. The baseline care plan will ensure that patients who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for patients’ experiences and preferences.” On 08/27/2025 at approximately 3:10 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, interim director of nursing, were made aware of the above findings. No further information was provided prior to exit. 2. For Resident #7 (R7), the facility staff failed to implement the baseline care plan to provide pressure injury treatment as ordered on 8/15/2025. The MDS (minimum data set) assessment was not completed at the time of the survey. The nursing admission assessment dated [DATE] documented no skin issues. The baseline care plan for R7 documented in part, “Resident at risk for skin breakdown related to actual pressure ulcer, Advanced age(greater than 75 years), impaired cognition, incontinence, shear/friction risks. Resident has actual skin impairment: bruises to right outer forearm, right outer wrist, right and left antecubital space and left dorsum hand, and stage 2 to right Ischial Tuberosity. Date Initiated: 08/11/2025.” Under “Interventions” it documented in part, “…Provide wound treatment as ordered. Date Initiated: 08/11/2025…” The physician orders for R7 documented in part, “Clean area to right Ischial tuberosity with NS (normal saline), pat dry, apply calcium alginate and cover with dressing. Every day shift for wound care. Order Date: 08/11/2025.” Review of the eTAR (electronic treatment administration record) for R7 dated 8/1/25-8/31/25 failed to evidence treatment to the right ischial tuberosity wound completed on 8/15/2025. The progress notes for R7 failed to evidence refusal of the wound treatment on 8/15/2025. On 8/26/2025 at 2:55 p.m., an interview was conducted with LPN (licensed practical nurse) #4 who stated that wound care was completed by the wound nurse during the weekdays and by the floor nursing staff when she was not there and on weekends. She stated that the staff evidenced the treatments being done by dating the dressings before they applied them and by signing them off on the eTAR when done. LPN #4 stated that the purpose of the care plan was to document the things that they identified and put in place for goals and to prevent anything from happening. She stated that the care plan should be implemented for resident safety. On 8/27/2025 at 3:11 p.m., ASM (administrative staff member) #1 and ASM #2, the interim director of nursing were made aware of the concern. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services to promote healing of a pressure injury for two of 10 residents in the survey sample, Residents #1 and #7.The findings include:1. For Resident #1 (R1), the facility staff failed to provide pressure injury (1) treatment as ordered for dates in January and February 2025.On the most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 1/9/2025, the resident was assessed as being severely impaired for making daily decisions. R1 was assessed as having one Stage II pressure injury and two unstageable pressure injuries.The physician orders for R1 documented in part,- Venelex External Ointment (Balsam Peru Castor Oil) Apply to sacrum topically every day and evening shift for wound to sacrum. Start Date: 11/22/2024.- Calcium Alginate-Silver External Pad 4 (Calcium Alginate-Silver) Apply to Left Gluteus topically every day shift for Wound. Cleanse left Gluteus wound with NS (normal saline), pat dry, skin prep wound edges, apply calcium alginate - silver to wound bed and cover with dry dressing daily. Start Date: 12/28/2024.- Desitin Maximum Strength External Paste 40 % (Zinc Oxide (Topical)) Apply to sacrum topically every shift for MASD (moisture associated skin damage). Start Date: 12/27/2024.- Povidone-Iodine External Solution 10 % (Povidone-Iodine) Apply to right heel topically every day shift for wound care. Clean right heel with NS, pat dry, apply gauze soaked in Povidine and then dry gauze, wrap with Kling and ace bandage. Start Date: 01/15/2025.Review of the eTAR (electronic treatment administration record) for R1 dated 12/1-12/31/24 failed to evidence treatment to the sacrum on 12/24/24 evening shift.Review of the eTAR for R1 dated 1/1-1/31/25 failed to evidence treatment to the Left gluteus wound on 1/17/25, 1/19/25, 1/27/25, and 1/31/25, the sacrum on day shift on 1/17/25, and 1/19/25, and the right heel on 1/17/25, 1/19/25, 1/27/25, and 1/31/25.The progress notes for R1 failed to evidence refusal of the wound treatment on the dates listed above.The comprehensive care plan for R1 documented in part, Wound Management. Date Initiated: 03/18/2024. Under Interventions it documented in part, .Provide wound care per treatment order. Date Initiated: 03/18/2024.On 8/26/2025 at 2:55 p.m., an interview was conducted with LPN (licensed practical nurse) #4 who stated that wound care was completed by the wound nurse during the weekdays and by the floor nursing staff when she was not there and on weekends. She stated that the staff evidenced the treatments being done by dating the dressings before they applied them and by signing them off on the eTAR when done.The facility policy Skin Integrity and Wound Management revised 5/1/25 documented in part, .6. The licensed nurse will. 6.6 Perform daily monitoring of wounds or dressings for presence of complications or declines. 6.6.1 Document daily monitoring of ulcer/wound site with or without dressing.On 8/27/2025 at 3:11 p.m., ASM (administrative staff member) #1 and ASM #2, the interim director of nursing were made aware of the concerns.No further information was provided prior to exit.Reference: (1) A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm.2. For Resident #7 (R7), the facility staff failed to provide pressure injury treatment as ordered on 8/15/2025.The MDS (minimum data set) assessment was not completed at the time of the survey.The nursing admission assessment dated [DATE] documented no skin issues.The physician orders for R7 documented in part, Clean area to right Ischial tuberosity with NS (normal saline), pat dry, apply calcium alginate and cover with dressing. Every day shift for wound care. Order Date: 08/11/2025.Review of the eTAR (electronic treatment administration record) for R7 dated 8/1/25-8/31/25 failed to evidence treatment to the right ischial tuberosity wound completed on 8/15/2025.The progress notes for R7 failed to evidence refusal of the wound treatment on 8/15/2025.The baseline care plan for R7 documented in part, Resident at risk for skin breakdown related to actual pressure ulcer, Advanced age(greater than 75 years), impaired cognition, incontinence, shear/friction risks. Resident has actual skin impairment: bruises to right outer forearm, right outer wrist, right and left antecubital space and left dorsum hand, and stage 2 to right Ischial Tuberosity. Date Initiated: 08/11/2025. Under Interventions it documented in part, .Provide wound treatment as ordered. Date Initiated: 08/11/2025.On 8/26/2025 at 2:55 p.m., an interview was conducted with LPN (licensed practical nurse) #4 who stated that wound care was completed by the wound nurse during the weekdays and by the floor nursing staff when she was not there and on weekends. She stated that the staff evidenced the treatments being done by dating the dressings before they applied them and by signing them off on the eTAR when done.On 8/27/2025 at 3:11 p.m., ASM (administrative staff member) #1 and ASM #2, the interim director of nursing were made aware of the concern.No further information was provided prior to exit.

Based on observation and clinical record review, facility staff failed to provide care and services for an indwelling catheter for one of ten residents in the survey sample, Resident #8 (R8). The findings include:For R8, the facility staff failed to keep the catheter collection bag (1) off the floor. R8 was admitted to the facility with diagnoses that included but were not limited to urinary retention (2). The admission MDS (minimum data set) was not due at the time of the survey. The facility's Clinical Admission assessment for R8 dated 08/14/2025 documented in part, Level of cognitive impairment: b. alert (some forgetfulness). On 08/26/2025 at approximately 8:18 a.m. observation of R8's catheter collection bag revealed it was lying flat on the floor next to R8's bed. The physician's order for R8 documented, Indwelling catheter (3)16FR (French) with 10cc (cubic centimeter) balloon to bedside straight drainage for diagnosis/Hx (history) of urinary retention. Order Date Date:8/14/2025. The comprehensive care plan for R8 dated 08/19/2025 documented in part, Focus. Resident requires indwelling foley catheter Date Initiated: 08/19/2025. Under Interventions it documented in part, Keep catheter off floor. On 08/27/2025 at approximately 3:10 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, interim director of nursing, were made aware of the above findings. No further information was provided prior to exit. References:(1) Urine drainage bags collect urine. Your bag will attach to a catheter (tube) that is inside your bladder. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000142.htm. (2) A condition where your bladder doesn't empty all the way or at all when you urinate. This information was obtained from the website: https://my.clevelandclinic.org/health/disease/15427-urinary-retention. (3) A tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to maintain a complete and accurate medical record for one of ten residents in the survey sample, Resident #1.The findings include:For Resident #1 (R1), the facility staff failed to maintain an accurate medical record.Review of R1's clinical record documented a discharge date of [DATE].The progress notes for R1 documented in part,- [DATE] 07:40 Note : Significant change to reflect hospice closed due to resident death on 2/21.- [DATE] 20:15 (8:15 p.m.) Date of Service: 2025-03-12, Visit Type: Advanced care planning, Details: Chief complaint: ACP (advanced care planning) discussion w/ RP (responsible party), daughter in presence of DON (director of nursing) as res (resident) continues to decline. Res is seen for overall decline in condition and has been hospitalized 5 times this year for various issues of PVD (peripheral vascular disease), anemia, AMS (altered mental status), wound infections and PN (pneumonia). Pt is seen today at bedside with daughter to discuss ACP. Spoke w/ RP in regards to overall decline, multiple hospitalizations. Res has become more contracted w/ poor po (by mouth) intake, continues w/ multiple nonhealing wounds. Informed RP daughter, [Name of daughter] of poor prognosis based on aforementioned. Recommended hospice at this time, suggested she speak with family about what they would like to do moving forward. Res is DNR (do not resuscitate). Answered questions in regards to current condition. Informed daughter about recommendations by vascular to not be aggressive but to continue current woud [sic] management and that surgery/amputations would hasten mortality. Daughter is still wanting to get recommendations on this from PCP (primary care physician) and is to have an appt within the week. Discussion 20 minutes in presence of DON. RP states she will speak with sisters and get back to staff. Signed Date : 2025-03-12.On [DATE] at 10:10 a.m., an interview was conducted with ASM (administrative staff member) #6, nurse practitioner. ASM #6 stated that she no longer worked at the facility but worked with R1 when they were there. She stated that she had written the note dated [DATE] and that it was prior to them leaving the facility and was after R1 had expired. She stated that it probably should have been a late entry.On [DATE] at 12:27 p.m., an interview was conducted with ASM #1, the administrator. ASM #1 reviewed the progress note for R1 dated [DATE] and stated that the resident was not in the facility on that date. She stated that the medical record was not accurate.The facility policy Clinical record: Charting and documentation dated [DATE] documented in part, . Documentation shall be completed at the time of service, but no later than during the shift in which the assessment, observation, or care service occurred. Documentation shall be timely and in chronological order. When documentation occurs after the fact, outside the acceptable time limits, the entry shall be clearly indicated as late entry.On [DATE] at 3:11 p.m., ASM #1, the administrator and ASM #2, the interim director of nursing were made aware of the findings.No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, the facility staff failed to develop and/or implement the comprehensive care plan for three of ten residents in the survey sample, Resident #3, Resident #1, and Resident #8. The findings include: 1. For Resident #3, the facility staff failed to implement the comprehensive care plan to utilize two persons for bed mobility, resulting in the resident falling out of the bed and suffering a fracture of the distal right femur of the right below the knee amputation. The comprehensive care plan dated, 9/15/23, and with a readmission date of 9/23/23, documented in part, “Focus: Resident/Patient requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to: Amputation of R (right) BKA (below the knee amputation).” The interventions documented in part, “8/17/23 - Provide resident/patient with extensive assist of 2 for bed mobility.” The CNA Kardex dated, 8/25/25, documented in part, “Ambulation/Mobility/Transfers - Provide - resident/patient with extensive assist of 2 for bed mobility.” The admission nurse’s note dated, 9/23/23 at 2300 (11:00 p.m.), documented in part, “She is 2 person assist for her ADLs. Incontinence for her bowel and bladder.” The nurse’s note dated, 9/24/23 at 3:16 a.m. documented, “Resident had a fall at 0200 (2:00 a.m.). When the aide was changing her, she rolled over and slipped out of bed. She had a small skin tear on her right stump. Writer put a dressing on her right stump. Vitals are wnl (within normal limit). Resident complained for pain 10/10. Called 911 at 0245 (2:45 a.m.) Resident left the building at 0300 (3:00 a.m.).” An interview was conducted with LPN #6 on 8/26/25b at 10:10 a.m. LPN #6 reviewed the care plan and stated the admission date is on the care plan so that it was in effect at the time of the fall. The Kardex was reviewed with LPN #6. LPN#6 stated even though it was dated 8/25/23, it was still in effect until any changes are made. An interview was conducted with LPN #3 on 8/26/25 at 10:46 a.m. LPN #3 stated the purpose of the care plan is to provide adequate care for the well-being of the residents. She stated it should be followed. The above care plan was reviewed with LPN #6. LPN #6 stated if the care plan says two person assist then there should be two people in the room while providing care. The facility policy, “Person Centered Care Plan,” documented in part, “The Center must develop and implement a baseline person-centered care plan within 48 hours of admission/readmission for each patient/resident (hereinafter “patient”) that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care… A comprehensive, individualized care plan will be developed within seven days after completion of the comprehensive assessment (admission, annual or significant change in status) and review and revise the care plan after each assessment. After each assessment means after each assessment known as the Resident Assessment Instrument (RAI) or Minimum Data Set (MDS). Care plan includes measurable objectives and timetables to meet a patient’s medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. For newly admitted patients, the comprehensive care plan must be completed within seven days of the completion of the comprehensive assessment and no more than 21 days after admission.” ASM (administrative staff member) #1, the administrator and ASM #2, the acting director of nursing, were made aware of the above concern on 8/26/25 at 4:04 p.m. No further information was provided prior to exit. 2. For Resident #1 (R1), the facility staff failed to A) implement the comprehensive care plan to provide incontinence care/toileting assistance on multiple dates in 12/2024, 1/2025 and 2/2025, B) implement the comprehensive care plan to provide pressure injury treatment as ordered for dates in January and February 2025 and C) develop the comprehensive care plan to address contracture management. On the most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 1/9/2025, the resident was assessed as being severely impaired for making daily decisions. R1 was assessed as always being incontinent of bowel and bladder and being dependent on staff for toileting hygiene. It documented R1 having functional limitation in range of motion to both upper and lower extremities with no splint or brace assistance use. The assessment further documented R1 having one Stage II pressure injury and two unstageable pressure injuries. The comprehensive care plan for R1 documented in part, - “Resident is incontinent of bowel and bladder and is unable to cognitively or physically participate in a retraining program. Date Initiated: 03/29/2024.” Under “Interventions” it documented in part, “Provide incontinence care to maintain dignity and comfort and to prevent incontinence related complications… Date Initiated: 03/29/2024.” - “Wound Management. Date Initiated: 03/18/2024.” Under “Interventions” it documented in part, “…Provide wound care per treatment order. Date Initiated: 03/18/2024.” The care plan failed to evidence documentation regarding management of R1’s contracture of the lower leg. A) Review of the ADL (activities of daily living) documentation for R1 from 12/1/2024-12/31/2024 failed to evidence incontinence care provided on day shift on 12/20/24, 12/23/24, and 12/31/24, on evening shift on 12/12/24, 12/18/24, 12/20/24, and 12/23/24 and on night shift on 12/15/24 and 12/31/24. The dates were blank or documented with “-97” with the documentation key showing “-97-not applicable.” Review of the ADL documentation for R1 from 1/1/2025-1/31/2025 failed to evidence incontinence care provided on day shift on 1/9/25, 1/13/25, 1/20/25, 1/24/25, 1/25/25, 1/28/15, and 1/29/25, on evening shift on 1/3/25, 1/5/25, 1/7/25, 1/9/25, 1/18/25, 1/20/25, 1/24/25, 1/27/25, and 1/30/25. The dates were blank or documented with “-97” with the documentation key showing “-97-not applicable.” Review of the ADL documentation for R1 from 2/1/2025-2/28/2025 failed to evidence incontinence care provided on day shift on 2/3/25 and 2/15/25, on evening shift on 2/11/25, 2/15/25, 2/16/25 and 2/19/25. The dates were blank or documented with “-97” with the documentation key showing “-97-not applicable.” On 8/27/2025 at 11:30 a.m., an interview was conducted with CNA (certified nursing assistant) #4 who stated that incontinence care was provided every two hours and as needed during the shift. She stated that the care provided to residents was evidenced by their documentation in the electronic medical record. CNA #4 stated that there should be no blanks or “97” on the documentation because it meant “not applicable.” She stated that if a resident was always incontinent it should never be “not applicable” for incontinence care, and it should be dependent and 1- or 2-person assistance for each shift. On 8/26/2025 at 2:55 p.m., an interview was conducted with LPN (licensed practical nurse) #4 who stated that the purpose of the care plan was to document the things that they identified and put in place for goals and to prevent anything from happening. She stated that the care plan should be implemented for resident safety. B) The physician orders for R1 documented in part, - “Venelex External Ointment (Balsam Peru Castor Oil) Apply to sacrum topically every day and evening shift for wound to sacrum. Start Date: 11/22/2024.” - “Calcium Alginate-Silver External Pad 4 (Calcium Alginate-Silver) Apply to Left Gluteus topically every day shift for Wound. Cleanse left Gluteus wound with NS (normal saline), pat dry, skin prep wound edges, apply calcium alginate - silver to wound bed and cover with dry dressing daily. Start Date: 12/28/2024.” - “Desitin Maximum Strength External Paste 40 % (Zinc Oxide (Topical)) Apply to sacrum topically every shift for MASD (moisture associated skin damage). Start Date: 12/27/2024.” - “Povidone-Iodine External Solution 10 % (Povidone-Iodine) Apply to right heel topically every day shift for wound care. Clean right heel with NS, pat dry, apply gauze soaked in Povidine and then dry gauze, wrap with Kling and ace bandage. Start Date: 01/15/2025.” Review of the eTAR (electronic treatment administration record) for R1 dated 12/1-12/31/24 failed to evidence treatment to the sacrum on 12/24/24 evening shift. Review of the eTAR for R1 dated 1/1-1/31/25 failed to evidence treatment to the Left gluteus wound on 1/17/25, 1/19/25, 1/27/25, and 1/31/25, the sacrum on day shift on 1/17/25, and 1/19/25, and the right heel on 1/17/25, 1/19/25, 1/27/25, and 1/31/25. The progress notes for R1 failed to evidence refusal of the wound treatment on the dates listed above. On 8/26/2025 at 2:55 p.m., an interview was conducted with LPN (licensed practical nurse) #4 who stated that wound care was completed by the wound nurse during the weekdays and by the floor nursing staff when she was not there and on weekends. She stated that the staff evidenced the treatments being done by dating the dressings before they applied them and by signing them off on the eTAR when done. LPN #4 stated that the purpose of the care plan was to document the things that they identified and put in place for goals and to prevent anything from happening. She stated that the care plan should be implemented for resident safety. C) Review of the diagnosis information for R1 documented a diagnosis of contracture of muscle, unspecified lower leg dated 11/21/2024. The progress notes for R1 documented in part, - “09/11/2024 physiatry progress note… PRIOR FUNCTIONAL STATUS: Patient resides in a long term care facility. Patient is a long-term care resident of the facility who was max dependent for transfers to wheelchair or geriatric chair depending on the day. Patient has a knee brace to prevent contractures. Patient uses a manual wheelchair and a mechanical lift for transfers…” The physician orders documented in part, - “Resident to wear right hand splint for 3-6(hrs.)on and as tolerated at night with skin checks as well as tolerated check skin pre/post application. Hand wash and leave to dry as needed for hygiene purposes. Order Date: 08/02/2024. End Date: 09/05/2024.” - “Resident to wear Left leg brace for >6(hrs.)on and as tolerated at night with skin checks as well as tolerated check skin pre/post application. Hand wash and leave to dry as needed for hygiene purposes. Order Date: 08/02/2024. End Date: 09/06/2024.” Review of the physical therapy discharge summaries for R1 documented services provided between 3/18-4/10/24, 6/19-8/2/24, 9/9-10/24/24, 11/22-12/10/24, and 1/6-2/4/25. The PT (physical therapy) Discharge summary dated [DATE] documented in part, “…Discharge recommendations: wear knee flexion brace to L knee 7x a week 6hrs daily with occasional skin checks performed. Can wear over night to patients tolerance .” The PT Discharge summary dated [DATE] documented in part, “…Discharge Recommendations: donn [sic] knee flexion contracture brace every day in gerichair unit manager has video demonstration for reference…” The PT Discharge summary dated [DATE] documented in part, “…Discharge recommendations. 24-hour care, Splint/brace and home exercise program for ROM (range of motion)/Contracture management.” On 8/27/2025 at 9:25 a.m., an interview was conducted with OSM (other staff member) #6 who stated that R1 was treated by therapy off and on during their stay at the facility for contracture management. She stated that R1 wore the knee brace as tolerated and would often refuse to wear it. She stated that when they discharged R1 they would train the nursing staff and the family on application of the brace and expected the brace to be applied as tolerated throughout R1’s stay at the facility. She stated that R1 was still able to use the knee brace until around January 2025 when there was a steady decline and she went to the hospital. She stated that R1 used the knee brace for contracture management since she was first admitted to the facility. On 8/27/2025 at 10:58 a.m., an interview was conducted with LPN (licensed practical nurse) #9 who stated that the care plan was developed by staff based on the needs of the resident. She stated that a resident at risk for contractures or a resident who used a splint or brace should have it addressed on the care plan. She stated that normally there was an order for the splint or brace and a place for them to sign them off on the treatment record. On 8/27/2025 at 3:11 p.m., ASM (administrative staff member) #1 and ASM #2, the interim director of nursing were made aware of the concerns. No further information was provided prior to exit. 3. For R8, the facility staff failed to follow the comprehensive care plan for an indwelling urinary catheter (1). R8 was admitted to the facility with diagnoses that included but were not limited to urinary retention (2). The admission MDS (minimum data set) was not due at the time of the survey. The facility’s “Clinical Admission” assessment for R8 dated 08/14/2025 documented in part, “Level of cognitive impairment: b. alert (some forgetfulness).” On 08/26/2025 at approximately 8:18 a.m. observation of R8’s catheter collection bag (3) revealed it was lying flat on the floor next to R8’s bed. The comprehensive care plan for R8 dated 08/19/2025 documented in part, “Focus. Resident requires indwelling foley catheter Date Initiated: 08/19/2025. Under “Interventions” it documented in part, “Keep catheter off floor.” On 08/26/2025 at approximately 2:55 p.m. an interview was conducted with LPN (licensed practical nurse) #4. When asked about the purpose of a resident’s care plan she stated the purpose of the care plan is to document things we have seen and to put in intervention to prevent anything from happening and show the resident goals. It should be implemented, for resident safety. On 08/27/2025 at approximately 3:10 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, interim director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) A tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm. (2) A condition where your bladder doesn’t empty all the way or at all when you urinate. This information was obtained from the website: https://my.clevelandclinic.org/health/disease/15427-urinary-retention. (3) Urine drainage bags collect urine. Your bag will attach to a catheter (tube) that is inside your bladder. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000142.htm.

Based on staff interview, facility document review and clinical record review, the facility staff failed to review and revise the comprehensive care plan for four of ten residents, Residents #5, # 9, #1, and #10. The findings include: 1. For Resident #5 (R5), the facility staff failed to review and revise the resident's comprehensive care plan regarding a fall on 12/13/24. A review of R5's clinical record revealed a nurse's note dated 12/13/24 that documented the resident was observed lying on the floor in the bedroom. Further review of R5's clinical record failed to reveal the resident's comprehensive care plan dated 10/10/23 was reviewed and revised regarding the 12/13/24 fall. On 8/26/25 at 1:55 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated the purpose of the care plan is to maintain each resident's well-being and safety. LPN #3 stated a resident's care plan should be updated when a resident falls. On 8/26/25 at 4:08 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the interim director of nursing) were made aware of the above concern. The facility policy titled, Person-Centered Care Plan documented, 7. Care plans will be: 7.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals . No further information was presented prior to exit. 2. For Resident #9 (R9), the facility staff failed to review and revise the resident's comprehensive care plan regarding falls on 4/30/25 and 8/3/25. A review of R9's clinical record revealed a nurse's note dated 4/30/25 that documented the resident was observed sitting on the floor in the bathroom, and a nurse's note dated 8/3/25 that documented the resident was observed sitting on the floor in front of the bed. Further review of R9's clinical record failed to reveal the resident's comprehensive care plan dated 2/12/25 was reviewed and revised regarding the 4/30/25 and 8/3/25 falls. On 8/26/25 at 1:55 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated the purpose of the care plan is to maintain each resident's well-being and safety. LPN #3 stated a resident's care plan should be updated when a resident falls. On 8/27/25 at 3:12 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the interim director of nursing) were made aware of the above concern. No further information was presented prior to exit. 3. For Resident #1 (R1), the facility staff failed to review and/or revise the comprehensive care plan after a fall on 6/16/2024. On the most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 1/9/2025, the resident was assessed as being severely impaired for making daily decisions. R1 was assessed as not having any falls since the previous assessment. The comprehensive care plan for R1 documented in part, “Resident is at risk for falls: cognitive loss, lack of safety awareness. Date Initiated: 03/18/2024.” The care plan failed to evidence a review or revision after the fall on 6/16/2024. Fall risk evaluations for R1 dated 3/17/24, 8/8/24, 9/7/24, 11/21/24 and 2/10/25 documented the resident at risk for falls. A change in condition evaluation dated 6/16/24 for R1 documented in part, “…Fall mats and low bed orders to be placed per DON (director of nursing) [Name of former DON]. This nurse was notified by nursing staff that the resident had fall [sic] onto the floor next to her bed. Upon entering her room, the resident was assisted back into bed with another nurse and staff. Neuro checks and vital signs checks were initiated. The resident reported that she attempted to get out of bed and rolled to the floor. No injuries were reported and no injuries observed during assessment. NP [Name of nurse practitioner] and resident RP (responsible party) [Name of RP] made aware of change in condition.” The evaluation failed to evidence a review and/or revision of the care plan. The neurological evaluation flow sheet documented checks completed per the protocol from 6/16/24-6/19/24. Review of the fall investigation dated 6/16/24 documented a fall with no injuries occurring in the resident’s room. The fall investigation failed to evidence a review and/or revision of the care plan. On 8/26/2025 at 2:55 p.m., an interview was conducted with LPN (licensed practical nurse) #4 who stated that the purpose of the care plan was to document the things that they identified and put in place for goals and to prevent anything from happening. LPN #4 reviewed R1’s care plan and stated that she did not see evidence that the care plan was reviewed and/or revised after the fall on 6/16/24. On 8/27/2025 at 1:56 p.m., an interview was conducted with LPN (licensed practical nurse) #7 who stated that the purpose of the care plan was to let staff know how to provide care and what to expect out of the resident. She stated that it documented behaviors, disease processes, and showed a quick synopsis of the patient and how to care for them. LPN #7 stated that the nurses updated the care plan after a fall and added an intervention as needed. She stated that this was done within 24 hours for prevention and safety to prevent further falls. The facility policy “Falls Management” revised 3/15/24 documented in part, “…Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. 2.1 Adjust and document individualized intervention strategies as patient condition changes…” On 8/27/2025 at 3:11 p.m., ASM (administrative staff member) #1 and ASM #2, the interim director of nursing were made aware of the concern. No further information was provided prior to exit. 4. For Resident #10, the facility staff failed to review and revise the comprehensive care plan after falls on 11/18/24, 1/6/25, 2/13/25 and 5/16/25. The comprehensive care plan dated created on 9/5/24 and revised on 8/2/25, documented in part, “Focus: Resident had actual fall on 08/02/2025 d/t (due to) resident wanting to sit on floor, sliding from wheelchair, self-transferring and reaching for items on the floor. Resident is at risk for further falls r/t (related to) cognitive loss, lack of safety awareness and he has impulsive behaviors, sliding from wheelchair, self-transferring. Interventions: 9/5/24 – provide resident/patient with opportunities for choice. Arrange patient’s environment to enhance vision and maximize independence large print signs on dresser. Encourage resident to atte4nd activities that maximize their full potential while meeting their need to socialize. drawers, adequate lighting, keep items in same location per patient’s request/needs. Bed in low position. Gently guide the resident from the environment while speaking in a calm reassuring voice when needed. Assist resident/caregiver to organize belongings for a clutter-free environment in the resident’s room and consistent furniture arrangement. 11/22/24 – Bolsters to bed. Fall mats on both sides of the bed while in bed. 1/9/25 – Frequent monitoring when in bed to ensure proper positioning and the (R10) is in the center of the bed.2-3-25 – dycem under cushion to wheelchair. 2/6/25 – Use the 4Ps: consider pain, position, placement and personal needs. Provide pt (patient) assistance if needed, utilize DME (durable medical equipment) when necessary. 4/2/25 – Encourage resident to attend meals in the dining room and provide rest periods in bed after meals. If resident is up for long periods, he becomes tired will attempt self-transfer to bed and has h/o (history of) falls related to self-transferring. 6/19/25 – Reposition items as needed to location within visual field. When resident is in bed or bed-side chair place the flowing personal items within reach: fluids. When resident is up in wheelchair encourage him to be in highly visible area for cueing.” The nurse’s note 11/18/24 at 5:18 p.m. documented, “Note: responding to call for help, entered room to observe resident sitting on floor beside bed, resident stated I wanted to sit on the floor. Assessed resident. no injuries noted. Neuro (neurological) check WNL(within normal limits) for resident. assisted up and onto bed.” Review of the care plan failed to evidence documentation of the care plan being reviewed and/or revised for the above fall. The nurse’s note dated, 1/6/25 at 8:00 a.m. documented in part, “One of the nurses found him (R10) on the floor in another resident room. The resident said he was just sleeping.” Review of the care plan failed to evidence documentation of the care plan being reviewed and/or revised for the above fall. The nurse’s note dated, 2/13/25 at 7:38 a.m. documented in part, “CNA (certified nursing assistant) rounding found resident on the floor during her rounds. Resident state hi is okay, he fell by accident.” Review of the care plan failed to evidence documentation of the care plan being reviewed and/or revised for the above fall. The nurse’s note dated 5/16/25 at 7:04 p.m. documented in part, “nurse is notified per CNA that pt slid down from the wheelchair, writer assessed the resident is next to the wheelchair, sit position, nurses help him back to his bed, denies pain, vital signs 121/73 (blood pressure),R (respirations)17,T (temperature)98.4,HR(heart rate)75.Head to toe assessment, sustain a laceration on the left intercostal/rib, ROM (range of motion) with easy, but not on left lower leg/contracture at that limb. Alertness at his baseline. Dr (doctor), aware and order neuro check, call back for changes. RP (responsible party), DON (director of nursing) aware.” Review of the care plan failed to evidence documentation of the care plan being reviewed and/or revised for the above fall. An interview was conducted with ASM (administrative staff member) #2, the acting DON, on 8/27/25 at 10:20 a.m. All of the above falls and the care plan were reviewed. ASM #2 stated that there was no evidence that the care plan was reviewed and revised for these falls ASM #1, the administrator and ASM #2 were made aware of the above concern on 8/27/25 at 3:11 p.m. 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 provide ADL (activities of daily living) care for dependent residents to two of 10 residents in the survey sample, Residents #1 and #2.The findings include:1. For Resident #1 (R1), the facility staff failed to provide incontinence care/toileting assistance on multiple dates in December 2024, January 2025 and February 2025. On the most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 1/9/2025, the resident was assessed as being severely impaired for making daily decisions. R1 was assessed as always being incontinent of bowel and bladder and being dependent on staff for toileting hygiene. Review of the ADL (activities of daily living) documentation for R1 from 12/1/2024-12/31/2024 failed to evidence incontinence care provided on day shift on 12/20/24, 12/23/24, and 12/31/24, on evening shift on 12/12/24, 12/18/24, 12/20/24, and 12/23/24 and on night shift on 12/15/24 and 12/31/24. The dates were blank or documented with “-97” with the documentation key showing “-97-not applicable.” Review of the ADL documentation for R1 from 1/1/2025-1/31/2025 failed to evidence incontinence care provided on day shift on 1/9/25, 1/13/25, 1/20/25, 1/24/25, 1/25/25, 1/28/15, and 1/29/25, on evening shift on 1/3/25, 1/5/25, 1/7/25, 1/9/25, 1/18/25, 1/20/25, 1/24/25, 1/27/25, and 1/30/25. The dates were blank or documented with “-97” with the documentation key showing “-97-not applicable.” Review of the ADL documentation for R1 from 2/1/2025-2/28/2025 failed to evidence incontinence care provided on day shift on 2/3/25 and 2/15/25, on evening shift on 2/11/25, 2/15/25, 2/16/25 and 2/19/25. The dates were blank or documented with “-97” with the documentation key showing “-97-not applicable.” The comprehensive care plan for R1 documented in part, “Resident is incontinent of bowel and bladder and is unable to cognitively or physically participate in a retraining program. Date Initiated: 03/29/2024.” Under “Interventions” it documented in part, “Provide incontinence care to maintain dignity and comfort and to prevent incontinence related complications… Date Initiated: 03/29/2024.” On 8/27/2025 at 11:30 a.m., an interview was conducted with CNA (certified nursing assistant) #4 who stated that incontinence care was provided every two hours and as needed during the shift. She stated that the care provided to residents was evidenced by their documentation in the electronic medical record. CNA #4 stated that there should be no blanks or “97” on the documentation because it meant “not applicable.” She stated that if a resident was always incontinent it should never be “not applicable” for incontinence care, and it should be dependent and 1- or 2-person assistance for each shift. The facility policy “Activities of Daily Living (ADLs)” revised 5/1/23 documented in part, “…Activities of daily living (ADLs) include: Hygiene – bathing, dressing, grooming, and oral care; Mobility – transfer and ambulation, including walking; Elimination – toileting; Dining – eating, including meals and snacks; Communication – including speech, language, and other functional communication systems… Documentation of ADL care is recorded in the medical record and is reflective of the care provided by nursing staff…” On 8/27/2025 at 3:11 p.m., ASM (administrative staff member) #1 and ASM #2, the interim director of nursing were made aware of the concerns. No further information was provided prior to exit. 2. For R2, facility staff failed to provide oral hygiene twice a day on 02/09/2024, 02/10/2024, 02/11/2024 and on 02/12/2024. R2 was admitted to the facility with diagnoses that included but were not limited to muscle weakness. On the most recent MDS (minimum data set), a 5 (five)-Day assessment with an ARD (assessment reference date) of 02/12/2024, R2 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section GG “Functional Abilities” code R2 as requiring set-up or clean-up assistance with oral hygiene. The ADL (activities of daily living) oral hygiene tracking sheet for R2 dated February 2024 was reviewed. The ADL legend documented in part, “Oral Hygiene – The ability to use suitable items to clean teeth. Dentures (if applicable0: The ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with the use of equipment.” On 02/09/2024 the evening shift (3:00 p.m. – 11:00 p.m.) was coded “03” (three) and the night shift (11:00 p.m. – 7:00 a.m.) was coded “97.” The ADL tracking sheet legend documented in part, “03- Personal Hygiene; 97 – not applicable.” On 02/10/2024 the day shift (7:00 a.m. – 3:00 p.m.) and evening shift were blank; the night shift was coded “01” (one). The ADL tracking sheet legend documented in part, “1- Oral Hygiene.” On 02/11/2024 the day shift (7:00 a.m. – 3:00 p.m.) and evening shift were blank; the night shift was coded “02” (two). The ADL tracking sheet legend documented in part, “2-Reason for Activity Not Occurring.” Further review of the coding on 02/11/2024 failed to evidence the reason for the activity not occurring. On 02/12/2024 the night shift was coded “03”; the day and evening shifts were blank. On 08/27/2025 at approximately 11:10 a.m. an interview was conducted with CNA (certified nursing assistant) #4. When asked to describe how often a resident should receive oral hygiene she stated two times a day. After reviewing R2’s ADL tracking sheet dated February 2024 for the coding for oral hygiene on 02/09/2024, 02/10/2024, 02/11/2024 and on 02/12/2024, CNA #4 stated R2 did not receive oral hygiene twice a day on 02/09/2024, 02/10/2024, 02/11/2024 and on 02/12/2024. On 08/27/2025 at approximately 3:10 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, interim director of nursing, were made aware of the above findings. No further information was provided prior to exit.

Based on observation, staff interview and facility document review, the facility staff failed to serve food in a sanitary manner in one of one facility kitchens. The findings include:On 08/25/2025 at approximately 1;30 p.m. an observation of the facility's dish room located in the kitchen was conducted with OSM (other staff member) 32, dietary manager. The observation revealed a 17-inch floor fan. Observation of the fan revealed it was sitting on the floor blowing air across the floor on to a rack of clean plate bases and covers. Further observation of the fan revealed the back fan guard with pieces of debris and greasy to the touch. When the observation of the fan as described above was pointed out to OSM #2, he agreed the fan was dirty immediately removed the fan from the dish room. On 08/25/0225 at approximately 4:30 p.m. an observation in the facility's kitchen revealed OSM #3 plating pureed cake into bowls for the resident's desert. Observation of OSM #3 revealed he sported a mustache and a tuff of hair under his lower lip. Further observation failed to evidence a covering over OSM 3's facial hair. At approximately 4:40 p.m., OSM #3 was observed on the tray line assembling resident's dinner trays without a cover over his facial hair. On 08/25/0225 at approximately 4:45 p.m. an observation in the facility's kitchen revealed OSM #4, cook wearing a pair of plastic gloves. Observations of OSM #4 revealed he opened and closed the walk-in refrigerator, wiping his hands on a dirty apron, handling resident's sandwiches, stacking dinner plates onto the tray line while placing fingers on the surface of the plates, plating dinner food items and placing his thumb on the surface of the plates, without changing his gloves between the tasks described. On 08/26/2025 at approximately12:49 p.m. an interview was conducted with OSM #1, district dietary manager and OSM #2, dietary manager. When asked to describe the procedure for keeping staff hair from falling into food OSM #2 stated staff wear hair nets and beard nets for facial hair. After describing the observation of OSM #3 without the mustache being covered OSM #2 stated the mustache should have been covered. When asked to describe the purpose of kitchen staff wearing gloves OSM #2 stated that it was to prevent staff from touching raw food and ready to eat food with their bare hands. After informed of the observation of OSM #4 as stated above OSM #2 stated that it was not sanitary, and the gloves should have been changed between each task. On 08/26/2025 at approximately 1:11 p.m. an interview was conducted with OSM #3, kitchen aide. After being informed of the observation of not having his mustache covered during meal preparation he stated that his mustache should have been covered. On 08/26/2025 at approximately 12:49 p.m. an interview was conducted with OSM #2, dietary manager. He stated that he started at the facility on January 15, 2025. When asked if he was aware of any concerns regarding meals being provided in a timely manner, providing meals according to resident preference and providing palatable food, he stated he had observations of the issues when he started based on his background of being a chef. OSM #1, district dietary manager, stated that the prior dietary manager was lacking in management that affected meals being provided in a timely manner, providing meals according to resident preference and providing palatable food. She further stated that the facility's kitchen was short staffed at that time. On 08/27/2025 at approximately 1:20 p.m. an interview was conducted with OSM #3 regarding the fan observed in the dish room. When asked why the fan should not be blowing on clean dishware he stated that it could cause contamination. The facility policy Staff Attire Procedures. 1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. On 08/26/2025 at approximately 4:00 p.m. ASM (administrative staff member) #1, administrator, and ASM #2, interim director of nursing, were informed of the above findings. No further information was provided prior to exit. Complaint deficiency

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of practice for one of four residents in the survey sample, Resident #1. The findings include: 1.a. For Resident #1 (R1), the facility staff failed to properly transcribe a physician's order in the electronic medical record on 5/16/23 for a left arm and hand x-ray. The x-ray was never obtained. A review of R1's clinical record revealed a note signed by the nurse practitioner on 5/16/23 that documented, Incident over the weekend where pt (patient) was found on the floor in his room. Seen today for assessment of injury .Musculoskeletal: Generalized weakness, Non-ambulatory, Left arm contractures and Left sided weakness-c/o (complains of) L (left) shoulder/arm pain when attempting to turn on L side .Will order x-ray of L arm to hand-scheduled tylenol in place. A physician's order dated 5/16/23 documented an order for an x-ray of the left shoulder to hand. Further review of R1's clinical record failed to reveal the x-ray was obtained. A review of an order/results list from the mobile x-ray company revealed the order for R1's x-ray on 5/16/23 was never submitted to the mobile x-ray company. On 5/31/23 at 8:24 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated the nurse practitioner enters orders for x-rays directly into the computer system then the nurses have to go under pending orders in the computer system, confirm the order, schedule the order, and contact the mobile x-ray company online or via phone. On 5/31/23 at 9:48 a.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated there is a glitch in the computer system that cannot be fixed. ASM #2 stated that if a provider or nurse puts an order into the system, staff must schedule the order for it to populate onto the MAR (medication administration record) or TAR (treatment administration record). ASM #2 stated sometimes the nurse managers will confirm and schedule orders so the orders will transcribe onto the MAR or TAR, then usually, the floor nurses will review the MAR or TAR and complete the order, such as scheduling an x-ray appointment with the mobile x-ray company. ASM #2 stated she has a new nurse manager who confirmed R1's x-ray order in the computer system but the new nurse manager did not know she had to schedule the order so it would transcribe to the MAR or TAR. ASM #2 stated the new nurse manager thought that by confirming the order, the order automatically translated to the MAR or TAR. On 5/31/23 at 10:20 a.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. The facility policy titled, Physician/Advanced Practice Provider (APP) Orders documented, Admission, Interim, Re-admission, and Renewal Orders: Must be entered into the electronic order management system . 1.b. For Resident #1 (R1), the facility staff failed to document and monitor the resident's left arm bruise. R1 sustained a fall on 5/14/23, was transferred to the emergency room, and returned to the facility on that same date. A review of R1's clinical record (including nurses' notes and skin assessments from 5/14/23 through 5/24/23) failed to reveal any documentation regarding a left arm bruise. A nurse's note dated 5/25/23 documented, Resident with a fall on 5/14/23 c/o (complained of) left hand at time of the fall x-ray 3 views done negative. Today bruising noted to left axillary area and upper left arm axillary area yellow/light purple, back of left arm with deep purple bruise in linear shape. On 5/30/23 at 5:00 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated she worked the Monday after (5/15/23) R1 sustained the 5/14/23 fall. CNA #1 stated that on that date, she observed a dark purple bruise located towards R1's shoulder and around the resident's under arm. On 5/30/23 at 5:11 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated she took a vacation in May and her first day back to work was on 5/20/23. LPN #4 stated that on that date, she observed a yellow bruise on R1's left upper arm between the resident's elbow and bicep. On 5/31/23 at 10:13 a.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated she was not aware of R1's left arm bruise until 5/25/23. ASM #2 stated it was difficult to see the bruise because of the location and R1's contracture. ASM #2 stated CNAs should report bruises to nurses and nurses should document and monitor bruises. ASM #2 stated that the staff said R1 had a fall on 5/14/23, went to the hospital and got checked out, but the staff still should have documented the bruise and continue to monitor. On 5/31/23 at 10:20 a.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. The facility policy titled, Skin Integrity and Wound Management documented, 5. The nursing assistant will observe skin daily and report any changes or concerns to the nurse. 6. The licensed nurse will: 6.1 Evaluate any reported or suspected skin changes or wounds; 6.2 Document newly identified skin/wound impairments as a change in condition .

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure a bed rail assessment was completed for one of four residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to assess the resident for risk of entrapment when bed rails were installed on the resident's bed on 3/27/23. A review of R1's clinical record revealed a bed rail evaluation list that documented a bed rail evaluation was completed on 3/3/23 and, No Bed Rail(s) to be used. A nurse's note dated 3/25/23 documented, Resident daughter, (name), came to this nurse with some concerns as followed: No bed rails on bed. Daughter educated about bedrail policy and bed rails will be reassessed and placed if appropriate. RP (Responsible Party) (name) on facetime with daughter and requested for bed rails to be placed on bed. Work order for bed rails put in for Monday morning. A maintenance work order created on 3/25/23 documented bed rails were installed on R1's bed on 3/27/23. Further review of R1's clinical record failed to reveal a bed rail evaluation (including an assessment to determine the risk of entrapment) was completed at that time. On 5/30/23 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #3 (the nurse who signed the above nurse's note). LPN #3 stated that on 3/25/23 she was the supervisor and was working on the medication cart that was located on the unit opposite of R1's unit. LPN #3 stated she spoke with R1's family regarding concerns that included a desire for bed rails. LPN #3 stated she would have to check the computer to see if the nurse caring for R1 on that date completed a bed rail evaluation. On 5/31/23 at 8:24 a.m., an interview was conducted with LPN #2. LPN #2 stated that nurses have to complete an assessment to make sure bed rails are appropriate and aren't going to cause a risk. On 5/31/23 at 10:20 a.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, Bed Rails documented, The Bed Rail Evaluation will be completed upon admission, re-admission, quarterly, change in bed or mattress, and with a significant change in condition.

Based on staff interview, facility document review and clinical record review, the facility staff failed to obtain a physician ordered x-ray for one of four residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to obtain a left arm and hand x-ray that was ordered by the nurse practitioner on 5/16/23. A review of R1's clinical record revealed a note signed by the nurse practitioner on 5/16/23 that documented, Incident over the weekend where pt (patient) was found on the floor in his room. Seen today for assessment of injury .Musculoskeletal: Generalized weakness, Non-ambulatory, Left arm contractures and Left sided weakness-c/o (complains of) L (left) shoulder/arm pain when attempting to turn on L side .Will order x-ray of L arm to hand-scheduled tylenol in place. A physician's order dated 5/16/23 documented an order for an x-ray of the left shoulder to hand. Further review of R1's clinical record failed to reveal the x-ray was obtained. A review of an order/results list from the mobile x-ray company revealed the order for R1's x-ray on 5/16/23 was never submitted to the mobile x-ray company. On 5/31/23 at 8:24 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated the nurse practitioner enters orders for x-rays directly into the computer system then the nurses have to go under pending orders in the computer system, confirm the order, schedule the order, and contact the mobile x-ray company online or via phone. On 5/31/23 at 10:20 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. On 5/31/23 at 11:40 a.m., ASM #2 stated the facility did not have a specific policy regarding x-rays.

2. For Resident #2 (R2), the facility staff failed to evidence a periodic review of advance directives with the resident or the resident's responsible party. A review of R2's clinical record revealed social services assessments dated 5/22/22 and 6/10/22. In both documents, all elements of question A5 were answered with No. Question A5 asked: Advance directives .in place? Additional conversation regarding advance care planning provided? Opportunity to complete advance directive offered? Advance directive educational materials, including state form, provided? On 1/24/23 at 3:52 p.m., OSM (other staff member) #3, the director of social services, was interviewed. She stated an advance directive includes a resident's code status, the appointment of a decision maker, and the resident's wishes in specific clinical situations. She stated she ordinarily discusses advance directives with the resident or RR (resident representative) on her first meeting with them. She stated if the resident or family members are unsure of advance directive decisions, she follows up within a week or so. She stated the care plan team tries to review advance directives at every quarterly care plan meeting. She admitted this discussion usually only includes code status. She stated, A lot of our long term care residents already have things in place. She stated she did not always include code status discussions in her progress notes. She stated she could not provide any evidence that R2's full advance directives had been reviewed at any point. She stated R2's niece is the RR, and that there has never been a questions of change with her. When asked how she knows this if the advance directives have not been reviewed, she stated she could not answer that question. On 1/24/23 at 4:36 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of these concerns. No further information was provided prior to exit. Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to periodically review advance directives for two of 29 residents in the survey sample, Residents #51 (R51) and #2 (R2). The findings include: 1. For R51, the facility staff failed to review information for formulating an advance directive with the resident and/or responsible party. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/25/2022, the resident was coded being moderately impaired for making daily decisions. The physician order dated, 12/21/2022, documented, Full Code. The Social Services Assessment and Documentation dated, 11/02/2021, 2/2/2022, 4/29/2022, 5/13/2022, 7/17/2022, and 8/4/2022, documented the following: Patient/resident responsible for self - yes Power of Attorney - Financial - no Conservatorship - no Court-appointed Guardian - no Advance Directives (Living Will, Healthcare Power of Attorney or Healthcare Proxy) in place? - no Additional Conversation regarding advance care planning provided - no Opportunity to complete advance directive offered - no Advance directive educational materials, including state form, provided - no Separate Healthcare Orders completed? - no. An interview was conducted with OSM (other staff member) #3, the director of social services, on 1/24/2023 at 3:52 p.m. When asked what an advance directive is, OSM #3 stated it was the code status, the appointment of a decision maker, the wishes with healthcare in certain circumstances. When asked when she discusses advance directives with resident and/or family members, OSM #3 stated she typically asks it when she first meets the resident for the first time. If they are not sure, she would follow up with the family. When asked when she does this, OSM #3 stated for the short-term resident, she follows up with the family and if there is a change in the resident's cognitive status, she stated she would follow up with the family at that time. When asked how often she reviews advance directives with residents, OSM #3 stated they try to review them during the quarterly care plan meeting. She stated they typically only discuss code status and a lot of their long-term care residents already have things in place. When asked where it is documented that she has discussed or given information to the residents about advance directives, OSM #3 stated it would be in her progress notes. When asked if she had asked R51 if they wanted information on formulating an advance directive, OSM #3 stated she wasn't sure if she had. The facility policy, Health Care Decision Making documented in part, Inform and provide written information to all patients concerning the right to accept or refuse medical or surgical treatment and, at the patient's option, formulate an advance directive. Provide a written description of the Center's policies to implement advance directives and applicable state law. Approach a capable patient who does not have an advance directive upon admission; the patient will be approached by the Social Worker or another designated staff person on admission, quarterly and with change in condition to discuss whether he/she wishes to consider developing an advance directive. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing were made aware of the above concern on 1/24/2023 at 4:36 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to notify the physician of a significant change in health for one of 29 residents in the survey sample, Resident #49. The findings include: For Resident #49 (R49), the facility staff failed to notify the resident's physician of a significant weight loss in December 2022. On the most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 12/5/22, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. A review of R49's clinical record revealed the resident weighed 173.2 pounds on 11/5/22 and 163 pounds on 12/2/22 which indicated a 5.89% loss. An assessment signed by the former RD (registered dietitian) on 12/2/22 documented, Resident triggered for -5.8% weight loss x1 month. Per unit manager, last month resident was not getting out of bed or eating very much. Resident is now at baseline, getting out of bed and going to dining room. Resident observed today in dining room requesting an extra helping of lunch. PO (By mouth) intake has been 75-100% at meals, receiving regular diet with large portions. RD will monitor weights at this time . Further review of the assessment and R49's clinical record to include December 2022 nurses' notes and physician note, failed to reveal R49's physician was made aware of the significant weight loss. On 1/24/23 at 1:21 p.m., an interview was conducted with OSM (other staff member) #5 (the current RD who began employment at the facility on 12/18/23). OSM #5 stated she thought the physician is automatically notified of significant weight losses via the computer system, but she emails the physician regarding significant weight losses and notifies the physician of the interventions that she puts in place. On 1/24/23 at 4:45 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. On 1/25/23 at 8:51 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated the nurses have to notify the physician regarding significant weight losses and there is no automatic notification through the computer system. The facility policy regarding notification of a change in condition documented, A Center must immediately inform the resident/patient, consult with the patient's physician .when there is: A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); 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 the facility abuse policy for reporting the final results of an allegation of abuse to the State Agency (SA) for one of 29 residents in the survey sample, Resident #11. The findings include: For Resident #11, the facility staff failed to implement the facility abuse policy for reporting the final results of an allegation of sexual abuse by another resident on 9/24/22. The facility abuse policy documented, 8.2 Report findings of all completed investigations within five (5) working days to the Department of Health . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/7/22, the resident scored 5 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. A nurse's note dated 9/24/22 documented a CNA (certified nursing assistant) observed a male resident inappropriately touching R11's body. An initial report regarding this event was submitted to the SA on 9/24/22. The report documented a CNA observed a male resident touching R11's breast area. On 1/24/23 at 12:29 p.m., ASM (administrative staff member) #1 (the administrator) provided a final investigation with the results of the allegation but stated she had no confirmation that the report had been sent to the SA. On 1/24/23 at 4:45 p.m., ASM #1 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 report the final results of an allegation of abuse to the State Agency (SA) within 5 working days, for one of 29 residents in the survey sample, Resident #11. The findings include: For Resident #11, the facility staff failed to report the final results of an allegation of sexual abuse by another resident on 9/24/22 to the State Agency. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/7/22, the resident scored 5 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. A nurse's note dated 9/24/22 documented a CNA (certified nursing assistant) observed a male resident inappropriately touching R11's body. An initial report regarding this event was submitted to the SA on 9/24/22. The report documented a CNA observed a male resident touching R11's breast area. On 1/24/23 at 12:29 p.m., ASM (administrative staff member) #1 (the administrator) provided a final investigation with the results of the allegation but stated she had no confirmation that the report had been sent to the SA. On 1/24/23 at 4:45 p.m., ASM #1 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, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided when two out of 29 residents in the survey sample were transferred to the hospital; Resident #18 and Resident #11. The findings include: 1. The facility staff failed to evidence provision of bed hold notification at the time of discharge for Resident #18. Resident #18 was transferred to the hospital on 9/29/22 and 11/12/22. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/1/22, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. There was no evidence of bed hold documentation provided to the resident or the resident's responsible party (RP) when the resident was sent to the hospital on 9/29/22 or 11/12/22. On 1/24/23 at 2:30 PM, LPN (licensed practical nurse) #3, the unit manager, stated there were no bed holds for this resident. On 1/24/23 at 4:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the market clinical lead was made aware of the findings. A review of the facility's Bed Hold policy 1/16/23, revealed, Purpose: To provide written notice of the bed hold policy to the resident/resident representative at the time of transfer out of the service location-this applies to all payers. Providing written notice to all residents at the time of transfer: When it is known that a resident will be temporarily transferred out of the service location. Provide the bed hold notice of policy and authorization form to the resident and representative, if applicable. If the resident representative is not present to receive the written notice upon transfer, the notice will be delivered via e-mail, fax, or hard copy by mail within 24 hours. Maintain a copy in the medical record. No further information was provided prior to exit. 2. The facility staff failed to evidence provision of bed hold notification at the time of discharge for Resident #11. Resident #11 was transferred to the hospital on 1/8/23. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/7/22, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. There was no evidence of bed hold documentation provided to the resident or the resident's responsible party (RP) when the resident was sent to the hospital on 1/8/23. On 1/24/23 at 2:30 PM, LPN (licensed practical nurse) #3, the unit manager, stated there was no bed hold for this resident. On 1/24/23 at 4:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the market clinical lead was made aware of the findings. A review of the facility's Bed Hold policy 1/16/23, revealed, Purpose: To provide written notice of the bed hold policy to the resident/resident representative at the time of transfer out of the service location-this applies to all payers. Providing written notice to all residents at the time of transfer: When it is known that a resident will be temporarily transferred out of the service location. Provide the bed hold notice of policy and authorization form to the resident and representative, if applicable. If the resident representative is not present to receive the written notice upon transfer, the notice will be delivered via e-mail, fax, or hard copy by mail within 24 hours. Maintain a copy in the medical record. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to develop a baseline care plan for an indwelling urinary catheter (1) for one of 29 residents in the survey sample, Resident #245 (R245). The findings include: For (R245) the facility staff failed to develop a baseline care plan to address the care and service for an indwelling urinary catheter. (R245) was admitted to the facility with diagnoses included but were not limited to benign prostatic hyperplasia (2). The most recent MDS (minimum data set), an admission assessment was not due at the time of the survey. The facility's nurse's note for (R245) dated 12/27/2022 documented in part, .admitted from (Name of Hospital) .Resident has an indwelling foley catheter 20 fr (French). On 01/23/23 at approximately 1:52 p.m., an observation of (R245) revealed they that they were lying in bed and had an indwelling urinary catheter in place. 01/24/23 at approximately 8:31 a.m., an observation of (R245) revealed they that they were lying in bed and had an indwelling urinary catheter in place. The physician's order for (R245) documented in part, Indwelling catheter 14FR with 10cc (cubic centimeter) balloon. Order Date: 1/20/2023. Review of (R245's) baseline care plan failed to evidence documentation for an indwelling urinary catheter. On 01/24/2023 at approximately 1:00 p.m., an interview was conducted with RN (registered nurse) #1, MDS Coordinator. When asked if the care plan in the EHR (electronic health record) for (R245) was a baseline care plan RN #1 stated yes. After reviewing (R245's) baseline care plan dated 01/20/2023 RN #1 stated that the care plan did not address an indwelling urinary catheter. RN #1 further stated that the care plan should have addressed (R245's) indwelling urinary catheter. The facility's policy Person-Centered care Plan documented in part, PRACTICE STANDARDS. 1. A baseline care plan must be developed within 48 hours and include the minimum healthcare information necessary to properly care for a patient including but not limited to: 1.2 Physician orders . On 01/24/2023 at approximately 4:35 p.m., ASM #1, administrator and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) A tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm. (2) An enlarged prostate. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to obtain weights as ordered for one of 29 residents in the survey sample, Resident #11. The findings include: The facility staff failed to follow physician orders for a weights to be obtained on admission [DATE]), for Resident #11. Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to: pulmonary edema, congestive heart failure and dementia. A review of the comprehensive care plan with a revision date of 1/10/23, revealed, FOCUS: Resident exhibits or is at risk for cardiovascular symptoms or complications related to CVA (cerebrovascular disease), CAD (coronary artery disease), HTN (hypertension), MI (myocardial infarction). Needs stents for blocked artery. INTERVENTIONS: Monitor weight as ordered. A review of the physician orders dated 1/10/23, revealed, Weigh on admission, the next day, then on Mondays for 4 weeks, then monthly. Per physician orders, weights should have been obtained on 1/11/23, 1/12/23, 1/16/23, 1/23/23. A review of weight documentation showed weights were obtained on 1/11/23, 1/16/23 and 1/23/23, however it was not obtained on 1/12/23. An interview was conducted on 1/24/23 at 11:00 AM with LPN (licensed practical nurse) #1. When asked the process for obtaining weekly weights, LPN #1 stated, weekly weights are on the assignment for the CNA to obtain. When asked if the physician ordered weights are not done, are the physician orders followed, LPN #1 stated, no, they are not. On 1/24/23 at 4:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the market clinical lead was made aware of the findings. A review of the facility's Weights and Heights policy 6/15/22, revealed, Purpose: To obtain baseline weight and identify significant weight change. Patients are weighted upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to implement physician-ordered fall interventions per the plan of care for one of 29 residents in the survey sample; Resident #47. The findings include: For Resident #47, the facility staff failed to ensure fall mat(s) were in place per the physician's order. A review of the physician's orders revealed one dated 5/11/22 for Floor mat while in bed. Observations of Resident #47 on 1/23/23 at 12:29 PM and 2:04 PM and on 1/24/23 at 11:15 AM, all revealed Resident #47 in the bed. There were no fall mats down and no evidence of fall mats present in the room for Resident #47. A review of the comprehensive care plan revealed one dated 3/7/22 for Resident has had actual fall and is at risk for further falls r/t (related to) cognitive loss, lack of safety awareness, Impaired mobility, impulsivity. This care plan included an intervention dated 3/7/22 for Fall mat(s) Indicate Number/side(s). On 1/24/23 at 11:15 AM an interview was conducted with LPN #2 (Licensed Practical Nurse). She stated that the fall mats should have been down if they were ordered. When asked if the care plan was being followed, she stated it was not, if fall mats were on the care plan. A review of the facility policy Falls Management was conducted. This policy documented, Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care On 1/24/23 at 4:30 PM, ASM #1 (Administrative Staff Member) (the Administrator) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey.

Based on observation, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide care and services for an indwelling urinary catheter (1) for one of 29 residents in the survey sample, Resident #245 (R245). The findings include: For (R245) the facility staff failed to the facility staff failed to keep the catheter collection bag (2) off the floor and failed to place the catheter collection bag below the level of the bladder. (R245) was admitted to the facility with diagnoses included but were not limited to benign prostatic hyperplasia (3). The most recent MDS (minimum data set), an admission assessment was not due at the time of the survey. The facility's nurse's note for (R245) dated 12/27/2022 documented in part, .admitted from (Name of Hospital) .Resident has an indwelling foley catheter 20 fr (French). On 01/23/23 at approximately 1:52 p.m., an observation of (R245's) catheter collection bag revealed that it was resting on the floor. On 01/24/23 at approximately 8:31 a.m., an observation revealed (R245) lying in their bed. Further observation revealed the catheter collection bag was on (R245's) mattress at the foot of the bed. The physician's order for (R245) documented in part, Indwelling catheter 14FR with 10cc (cubic centimeter) balloon. Order Date: 1/20/2023. On 01/24/2023 at approximately 12:34 p.m., an interview was conducted with LPN (licensed practical nurse) #4. When asked to describe the position of a resident's catheter collection bag LPN #4 stated that it should be position below the resident's bladder for proper drainage and off the floor to prevent contamination. When informed of the above observations LPN #4 stated that the collection bag was not placed correctly. The facility's policy Indwelling Catheter documented in part, 13. Secure catheter tubing to keep the drainage bag below the level of the patient's bladder and off the floor . On 01/24/2023 at approximately 4:35 p.m., ASM #1, administrator and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) A tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm. (2) Urine drainage bags collect urine. Your bag will attach to a catheter (tube) that is inside your bladder. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000142.htm. (3) An enlarged prostate. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services per physician's order, for one of 29 residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff failed to administer oxygen at the physician prescribed rate of four liters per minute. On the most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 12/25/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. R4's comprehensive care plan dated 10/20/22 documented, Resident exhibits or is at risk for respiratory complications related to hx (history) of acute hypoxic respiratory failure. O2 (Oxygen) as ordered via nasal cannula . Further review of R4's clinical record revealed a physician's order dated 12/23/22 for continuous oxygen at four liters per minute via nasal cannula. On 1/23/23 at 11:38 a.m. and 1/24/23 at 9:16 a.m., R4 was observed sitting up in bed receiving oxygen via nasal cannula between four liters per minute and five liters per minute, as evidenced by the ball in the oxygen concentrator flowmeter positioned between the four-liter line and the five-liter line. On 1/24/23 at 3:36 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated nurses should observe oxygen concentrators at eye level and adjust the ball in the concentrator to the correct physician ordered liter. LPN #5 stated the middle of the ball in the oxygen concentrator flowmeter should run through the four-liter line if the physician's order is for four liters. On 1/24/23 at 4:45 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, To properly read the flowmeter, locate the prescribed flowrate line on the flowmeter. Next, turn the flow knob until the ball rises to the line. Now, center the ball on the L/min (liters per minute) line prescribed. The facility policy regarding oxygen documented, Set liter flow per order. No further information was presented prior to exit.

Based on observation, resident interview, facility document review and clinical record review, the facility staff failed to provide food to accommodate a resident's preferences for one of 29 residents in the survey sample, Resident #43. The findings include: For Resident #43 (R43), the facility staff failed to provide an egg salad sandwich as listed on the resident's meal ticket during lunch on 1/23/23. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/17/22, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. On 1/23/23 at 11:15 a.m., an interview was conducted with R43. R43 stated they are served items like red meat that they are not supposed to have due to a diagnosis of pancreatitis, and are not served the items listed on the meal ticket that is served with the meal tray. On 1/23/23 at 12:33 p.m., R43's meal tray was observed. The meal ticket documented an egg salad sandwich was to be on the tray; however, the meal tray contained a pork barbeque sandwich and not an egg salad sandwich. On 1/24/23 at 1:07 p.m., an interview was conducted with OSM (other staff member) #1 (the dietary manager). OSM #1 stated meal tickets are created based on resident preferences. OSM #1 stated that during meal preparation, meal tickets are printed out then a dietary aide reads the ticket and calls out the order for the cook to plate. On 1/24/23 at 3:36 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated the nursing staff is supposed to compare the meal tickets to what is on the meal trays when serving meals, but the items documented on the tickets are not always on the meal trays. LPN #5 stated the nursing staff should make the residents aware if an item is on their ticket but not on the tray, ask the residents if they would like the item on the ticket but not on the tray and call the kitchen for the preferred item. LPN #5 stated this has been done but the preferred items are not always provided. On 1/24/23 at 4:45 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. On 1/25/23 at 8:39 a.m., OSM #1 stated egg salad was available during lunch on 1/23/23. OSM #1 stated there was a new employee on the line that day and he wasn't paying attention. The facility policy regarding food preferences documented, 7. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies & intolerances, and preferences. No further information was presented prior to exit.

Based on staff interview, facility document review and employee record review, it was determined that the facility staff failed to evidence maintenance of required certification for one of 25 employee record reviews. The facility staff failed to provide the evidence of required certification for one CNA (certified nursing assistant) that was hired within the last two years, CNA #2. The findings include: On 1/24/23 at 1:10 PM a review of nursing staff licenses and certifications was conducted an revealed that CNA #2 with a date of hire of 3/1/22 did not have their certification verified through the Department of Health Professions (DHP) until 1/23/23. OSM (other staff member) #2, the workforce manager stated there was no other certification pulled in her file until yesterday, when it was pulled [verified]. On 1/24/23 at 4:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the market clinical lead was made aware of the findings. According to the facility's Licensure and Certification of Personnel policy revised 7/1/22, revealed Purpose: To assure that employees are properly licensed, certified and /or registered to perform their duties. At the time of employment, employees who require a license, certification or registrations must be verified prior to employment and filed in the employee file. 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 ensure a complete and accurate clinical record for one of 29 residents in the survey sample; Resident #78. The findings include: For Resident #78, the facility staff failed to document the event details (where, how, why) of a fall on 12/14/22. A review of the clinical record revealed the following notes: 12/14/22: An SBAR (Situation, Background, Assessment, Recommendation) note documented that the resident had a fall. The form documented the resident had no pain and no changes in skin (for possible injuries) by checking off a box next to pain (no) and a box under skin next to no skin changes. However, there was no documentation that described the events of the fall (where, how, why). The section for Appearance: Summarize your observations and evaluation was left blank. In addition, the section Nursing Notes was left blank. On 1/24/23 at 2:15 PM, an interview was conducted with LPN #2 (Licensed Practical Nurse) She stated that a note should be documented that describes the details of the fall, including where, why and how. A review of the facility policy Clinical Record: Charting and Documentation was conducted. This policy documented, .3. Be concise, accurate, complete, factual, and objective . On 1/24/23 at 4:30 PM, ASM #1 (Administrative Staff Member) (the Administrator) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey.

2. For Resident #43 (R43), the facility staff failed to implement the resident's comprehensive care plan for honoring food preferences. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/17/22, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. R43's comprehensive care plan revised on 5/27/22 documented, Honor food preferences within meal plan. On 1/23/23 at 11:15 a.m., an interview was conducted with R43. R43 stated they are served items like red meat that they not supposed to have due to a diagnosis of pancreatitis, and are are not served the items listed on the meal ticket that is served with the meal tray. On 1/23/23 at 12:33 p.m., R43's meal tray was observed. The meal ticket documented an egg salad sandwich was to be on the tray; however, the meal tray contained a pork barbeque sandwich and not an egg salad sandwich. On 1/24/23 at 1:07 p.m., an interview was conducted with OSM (other staff member) #1 (the dietary manager). OSM #1 stated meal tickets are created based on resident preferences. OSM #1 stated that during meal preparation, meal tickets are printed out then a dietary aide reads the ticket and calls out the order for the cook to plate. On 1/24/23 at 3:36 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated the purpose of the care plan is for everybody to know the plan of care for the residents while they are present at the facility and so the nursing department and other departments can be on the same level and give resident care the proper way according to what their plan says. LPN #5 stated the nursing staff is supposed to compare the meal tickets to what is on the meal trays when serving meals, but the items documented on the tickets are not always on the meal trays. LPN #5 stated the nursing staff should make the residents aware if an item is on their ticket but not on the tray, ask the residents if they would like the item on the ticket but not on the tray and call the kitchen for the preferred item. LPN #5 stated this has been done but the preferred items are not always provided. On 1/24/23 at 4:45 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 #4 (R4), the facility staff failed to implement R4's comprehensive care plan for oxygen administration. On the most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 12/25/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. R4's comprehensive care plan dated 10/20/22 documented, Resident exhibits or is at risk for respiratory complications related to hx (history) of acute hypoxic respiratory failure. O2 (Oxygen) as ordered via nasal cannula . Further review of R4's clinical record revealed a physician's order dated 12/23/22 for continuous oxygen at four liters per minute via nasal cannula. On 1/23/23 at 11:38 a.m. and 1/24/23 at 9:16 a.m., R4 was observed sitting up in bed receiving oxygen via nasal cannula between four liters per minute and five liters per minute, as evidenced by the ball in the oxygen concentrator flow meter positioned between the four-liter line and the five-liter line. On 1/24/23 at 3:36 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated the purpose of the care plan is for everybody to know the plan of care for the residents while they are present at the facility and so the nursing department and other departments can be on the same level and give resident care the proper way according to what their plan says. In regard to care plan implementation for oxygen as ordered, LPN #5 stated there should be a physician's order for if the oxygen should be continuous or as needed, and there should be an order for how many liters should be administered. LPN #5 stated nurses should observe oxygen concentrators at eye level and adjust the ball in the concentrator to the correct physician ordered liter. LPN #5 stated the middle of the ball in the oxygen concentrator flow meter should run through the four-liter line if the physician's order is for four liters. On 1/24/23 at 4:45 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 observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for 4 of 29 residents in the survey sample; Residents #47, #43, #4, and #51. The findings include: 1. For Resident #47, the facility staff failed to implement the comprehensive care plan to ensure that physician-ordered fall mat(s) were in place. A review of the physician's orders revealed one dated 5/11/22 for Floor mat while in bed. A review of the comprehensive care plan revealed one dated 3/7/22 for Resident has had actual fall and is at risk for further falls r/t (related to) cognitive loss, lack of safety awareness, Impaired mobility, impulsivity. This care plan included an intervention dated 3/7/22 for Fall mat(s) Indicate Number/side(s). Observations of Resident #47 on 1/23/23 at 12:29 PM and 2:04 PM and on 1/24/23 at 11:15 AM, all revealed Resident #47 in the bed. There were no fall mats down and no evidence of fall mats present in the room for Resident #47. On 1/24/23 at 11:15 AM an interview was conducted with LPN #2 (Licensed Practical Nurse). She stated that the fall mats should have been down if they were ordered. When asked if the care plan was being followed, she stated it was not if fall mats were on the care plan. On 1/25/23 at 8:51 AM, an interview was conducted with LPN #6. When asked what was the purpose of the care plan, she stated that it is a plan of care with details for each individual resident of how to care for that resident. When asked if it should be followed, she stated absolutely. A review of the facility policy Person-Centered Care Plan was reviewed. This policy documented, The Center must develop and implement a baseline person-centered care plan A comprehensive person-centered care plan must be developed for each patient and must describe 4.1 Services that are to be furnished 7. Care plans will be: .Communicated to the appropriate staff On 1/24/23 at 4:30 PM, ASM #1 (Administrative Staff Member) (the Administrator) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. 4. For Resident #51 (R51) the facility staff failed to implement the care plan for periodically reviewing information regarding formulating an advance directive. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/25/2022, the resident was coded being moderately impaired for making daily decisions. The comprehensive care plan dated, 12/21/2022, documented in part, Focus: Resident/patient has an advanced directive FULL CODE. The Interventions documented in part, Offer opportunity to complete Advanced Directive. Provide Resident/Patient/Health Care Decision Maker with sufficient information to make an informed decision. Review contents and provide opportunity to update and/or make changes to Advance Directive with resident/patient and/or healthcare decision maker quarterly and as needed. The physician order dated, 12/21/2022, documented, Full Code. The Social Services Assessment and Documentation dated, 11/02/2021, 2/2/2022, 4/29/2022, 5/13/2022, 7/17/2022, and 8/4/2022, documented the following: Patient/resident responsible for self - yes Power of Attorney - Financial - no Conservatorship - no Court-appointed Guardian - no Advance Directives (Living Will, Healthcare Power of Attorney or Healthcare Proxy) in place? - no Additional Conversation regarding advance care planning provided - no Opportunity to complete advance directive offered - no Advance directive educational materials, including state form, provided - no Separate Healthcare Orders completed? - no. An interview was conducted with OSM (other staff member) #3, the director of social services, on 1/24/2023 at 3:52 p.m. When asked what an advance directive was, OSM #3 stated it was the code status, the appointment of a decision maker, the wishes with healthcare in certain circumstances. When asked when she discusses advance directives with resident and/or family members, OSM #3 stated she typically asks it when she first meets the resident for the first time. If they are not sure, she would follow up with the family. When asked when she does this, OSM #3 stated for the short-term resident, she follows up with the family. OSM #3 stated if there is a change in the resident's cognitive status, she stated she would follow up with the family at that time. When asked how often she reviews advance directives with residents, OSM #3 stated they try to review them during the quarterly care plan meeting. She stated they typically only discuss code status and a lot of their long-term care residents already have things in place. When asked where it is documented that she has discussed or given information to the residents about advance directives, OSM #3 stated it would be in her progress notes. When asked if she had asked R51 if they wanted information on formulating an advance directive, OSM #3 stated she wasn't sure if she had. An interview was conducted with LPN (licensed practical nurse) #6 on 1/25/2023 at 8:43 a.m. When asked the purpose of the care plan, LPN #6 stated, it's a plan of care with details for each individual resident of how to care for that resident. When asked if it should be followed, LPN #6 stated, Absolutely. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing were made aware of the above concern on 1/25/2023 at 9:05 a.m. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to review and revise the comprehensive care plan for three of 29 residents in the survey sample, Residents #49, #11 and #78. The findings include: 1. a. For Resident #49 (R49), the facility staff failed to review and revise the resident's comprehensive care plan after R49 inappropriate touched a female resident's breast. On the most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 12/5/22, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. A nurse's note dated 9/25/22 documented a CNA (certified nursing assistant) observed R49 inappropriately touch a female resident's breast. R49's comprehensive care plan dated 11/11/19 failed to reveal documentation that the care plan was reviewed and revised regarding the event. On 1/24/23 at 3:36 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated R49's care plan definitely should have been updated because the resident may inappropriately touch someone else (Note- R49 was moved to a different unit, evaluated by a psychologist and did not touch anyone else). On 1/24/23 at 4:45 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 regarding person-centered care plans documented, 7. Care plans will be: 7.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals . No further information was presented prior to exit. 1 For Resident #49 (R49), the facility staff failed to review and revise the resident's comprehensive care plan regarding a significant weight loss in December 2022. A review of R49's clinical record revealed the resident weighed 173.2 pounds on 11/5/22 and 163 pounds on 12/2/22 which indicated a 5.89% loss. An assessment signed by the former RD (registered dietitian) on 12/2/22 documented, Resident triggered for -5.8% weight loss x1 month. Per unit manager, last month resident was not getting out of bed or eating very much. Resident is now at baseline, getting out of bed and going to dining room. Resident observed today in dining room requesting an extra helping of lunch. PO (By mouth) intake has been 75-100% at meals, receiving regular diet with large portions. RD will monitor weights at this time . R49's comprehensive care plan dated 7/10/19 documented, (R49) is at nutritional risk r/t (related to) PMH (past medical history) of dysphagia (difficulty swallowing), anxiety/depression, psychosis, falls, dementia, hypothyroidism, T2DM (type 2 diabetes mellitus). Further review of R49's comprehensive care plan failed to reveal the care plan was reviewed and revised regarding the December 2022 significant weight loss. On 1/24/23 at 1:21 p.m., an interview was conducted with OSM (other staff member) #5 (the current RD). OSM #5 stated that when a resident sustains a significant weight loss, she reviews the care plan for what is working, what is currently relevant and what is not currently relevant; for example, extra calorie milk shakes were provided but the resident has not been drinking them. On 1/24/23 at 3:36 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated residents' comprehensive care plans are supposed to be reviewed and revised in regard to significant weight loss. LPN #5 stated she did not personally do this, but she would if she was asked to. On 1/24/23 at 4:45 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. 2. For Resident #11 (R11), the facility staff failed to review and revise the resident's comprehensive care plan after the resident was inappropriately touched by another resident. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/7/22, the resident scored 5 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. A nurse's note dated 9/24/22 documented a CNA (certified nursing assistant) observed a male resident inappropriately touching R11's body. A facility report dated 9/24/22 documented a CNA observed a male resident touching R11's breast area. R11's comprehensive care plan dated 2/28/18 failed to reveal documentation that the care plan had been reviewed and revised regarding the event. On 1/24/23 at 3:36 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated [R11's] care plan should have been reviewed and revised in case staff needed to look for signs of trauma later on. On 1/24/23 at 4:45 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 #78, the facility staff failed to review and/or revise the comprehensive care plan after falls on 12/14/22, 12/18/22 and 12/26/22. A review of the clinical record revealed the following notes: 12/14/22: An SBAR (Situation, Background, Assessment, Recommendation) note documented that the resident had a fall. The form documented the resident had no pain and no changes in skin (for possible injuries) by checking off a box next to pain (no) and a box under skin next to no skin changes. 12/18/22: An SBAR note documented, Nursing observations, evaluation, and recommendations are: Resident slid of the bed and lay on the mat beside [their] bed . 12/26/22: An SBAR note documented, Nursing observations, evaluation, and recommendations are: Resident found on floor mat on the side of the bed. Resident stated [they] was trying to get [their] shoes and slipped out of the bed. Further review of the clinical record revealed a comprehensive care plan created on 8/22/22 and most recently reviewed 11/7/22 for Resident is at risk for falls All interventions were dated as created on 8/22/22 and reviewed on 11/7/22. There were no revisions, additions, or evidence of review after each of the above falls. On 1/24/23 at 2:15 PM, an interview was conducted with LPN #2 (Licensed Practical Nurse) She stated that the care plan should be reviewed and revised after each fall. She stated that sometimes there is nothing else you can add to it. She stated that it is not documented that it was looked at, if there are no changes to it. On 1/25/23 at 8:00 AM, ASM #2 (Administrative Staff Member) the Director of Nursing, provided the facility incident reports for the above falls. There was nothing documented on these forms that the comprehensive care plan was reviewed after any of the above falls. These reports documented that they were not part of the medical record. She stated that there wasn't anything noted about the care plan on the incident reports or in the clinical record. On 1/25/23 at 8:15 AM, LPN #3 presented her computer screen of what were reportedly the same incident reports that were provided by ASM #2 above. On the computer screen she showed that there was a box checked for the care plan being reviewed. She stated that this section would not print on the above incident reports. There was no way to validate that this box was previously checked at the time of the incident and not immediately prior to showing the computer screen, as the clinical record did not evidence that the comprehensive care plan had been reviewed after each above falls, and ASM #2 had stated that there was no evidence in the incident reports or in the clinical record that the care plan was reviewed after each of the above falls. A review of the facility policy Person-Centered Care Plan was reviewed. This policy documented, Care plans will be: Reviewed and revised by the interdisciplinary team . On 1/24/23 at 4:30 PM, ASM #1 (the Administrator) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store, prepare and serve food in a sanitary manner in one of one facility kitchens and two of two facility unit pantries. The findings include: On 1/23/23 at 10:45 AM the kitchen tour was conducted with OSM #1 (Other Staff Member), the dietary manager. The following items were identified: 1. In the dry storage area: trash was on the floor, a plastic cup was on the floor, the floor was sticky, a dry cereal bag was open and exposed. 2. In the refrigerator: A facility generic plastic storage container of fudge was observed and expired on 1/13/23. A block of cheese in a plastic bag, was not sealed. 3. Equipment: The large standing mixer was clean and ready for use, and covered by a plastic bag, however crumbs were in the mixer bowl. 4. In the 2 facility unit pantries: The refrigerators and freezers were dirty, with dripped, sticky food residue. On 1/24/23 at 8:24 AM, an interview was conducted with OSM #1. She stated that the dietary staff are going to clean the unit pantries. She stated that items in storage should be sealed and labeled properly; that equipment ready for use should be clean; that floors should be clean and not sticky. She stated that food items should contain a received date, open date, and expiration date. She stated that she does a walk-through about 4 times a day looking for expired items. She stated she does not know how the fudge got missed, as it had been expired for 10 days as of the survey review date. A review of the facility policies provided were conducted as follows: The Equipment policy documented, All foodservice equipment will be clean, sanitary, and in proper working order. The Food Storage: Cold Foods policy documented, All Time/Temperature Control for Safety foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The Food Storage: Dry Goods policy documented, All dry goods will be appropriately stored in accordance with the FDA Food Code .5. All packaged and canned food items will be kept clean, dry and properly sealed. 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. The Environment policy documented, All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation On 1/24/23 at 4:30 PM, ASM #1 (Administrative Staff Member) (the Administrator) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to implement the facility policies for advanced directives one of 31 residents in the survey sample, Resident #251. The facility staff failed to evidence documentation Resident #251 was provided an opportunity formulate an advance directive and failed to verify the residents wishes with the regards to the residents code status (full code [the decision if the resident would like to have cardiopulmonary resuscitation in the event their heart stops or they stop breathing), or DNR [do not resuscitate]) upon admission. The findings include: Resident #251 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: encephalopathy (any brain disease or disorder.) (1), alcohol use, alcoholic cirrhosis of the liver (chronic disease condition of the liver in which fibrous tissue and modules replace normal tissue, interfering with blood flow and normal function of the organ.) (2), and gastroesophageal reflux disease (GERD -backflow of the contents of the stomach into the esophagus, usually caused by malfunction of the sphincter muscle between the two organs; symptoms include burning pain in the esophagus, commonly known as heartburn) (3). A MDS (minimum data set) assessment had not been completed as of the time of survey. The Nursing Documentation form dated [DATE] at 12:04 p.m. documented in part, Reason for note: admission/readmission. was checked. Under Additional details about note the following was documented in part, She is alert and oriented and is able to make needs known verbally with clear speech. In Section E - Health Decision Making, a check mark was documented, Health Decision Making reviewed/updated. The next question asked for Code Status (the decision if the resident would like to have CPR [cardiopulmonary resuscitation] in the event their heart stops or they stop breathing), it was blank. Further review of the clinical record including physician orders, nurses notes preadmission records, failed to evidence documentation such as a physician order or a conversation with the resident regarding her wishes in the event her heart stop beating or she stops breathing. Review of the baseline care plan dated [DATE], failed to evidence documentation related to the resident's code status. An interview was conducted with Resident #251 on [DATE] at 9:05 a.m. When asked if anyone, physician, nurse or social worker asked her preference in the event her heart stops or she stops breathing, since her admission on [DATE], Resident #251 stated no one had asked her that question. An interview was conducted with ASM (administrative staff member) #2, the center nurse executive, on [DATE] at 12:48 p.m. ASM #2 was asked about the process staff follows for obtaining the advanced directive and code status of a new admission. ASM #2 stated, On admission we have a batch order that addresses the advance directive order. Once the resident is in the facility, we ensure that it is current and verify the order. When asked if all residents, are asked what their code status is, ASM #2 stated, yes. When asked where staff document this interview regarding code status, ASM #2 stated, in the orders. ASM #2 stated, If the resident is alert and oriented, they ask them. ASM #2 stated if the resident is unable to make those decisions, they contact the family and if they can't get ahold of a family member then they are considered a full code. [DATE] at 2:27 p.m. an interview was conducted with LPN (licensed practical nurse) # 5, regarding resident code status determination. LPN # 5 stated usually if they (resident) come from the hospital, we know what their code status is before they get here. They normally get the information in report from the hospital. When asked if a resident has been here for several days, would you expect to see a code status in the chart, LPN # 5 stated she would expect it in a couple of hours after admission. LPN # 5 stated she would expect it to be in both the electronic record and the paper record. The facility policy, Code Status Orders, documented in part, Purpose: To ensure the patient's desired resuscitation wishes are documented in the medical record. Practice Standards: 1. Upon admission/readmission, a code status order is required as soon as possible as part of the patient's admission order set. Orders for code status include Full Code or DNR (do not resuscitate). 2. Staff should verify the patient's wishes with the regard to the code status (full code or DNR) upon admission. ASM #1, the center executive director, and ASM #2, the center nurse executive, were made aware of the above concern on [DATE] at 5:15 p.m. A request was made for documentation of Resident #251's code status. On [DATE] at approximately 8:00 a.m., an After Visit Summary dated [DATE] from the hospital Resident #251 was discharged from was provided for review. The After Visit Summary dated [DATE], failed to evidence any documentation addressing Resident #251's code status. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 192. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 114. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 243.

**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 develop a baseline care plan to address physician ordered antianxiety medication for one of 31 residents in the survey sample, Resident #252. The findings include: Resident #252 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: COPD (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (1), lung cancer, high blood pressure and diabetes. A MDS (minimum data set) assessment had not yet been completed prior to and during the time of survey. The Nursing Documentation dated 8/10/2021 at 9:17 p.m. documented in part, Reason for note: admission/readmission. Under question 3. Additional details about the note, the following was documented, Pt (patient) is A&O (alert and oriented) X4 (person, place time and situation). The form further documented, High Risk Medication Therapy with a check mark documented next to anti-anxiety medication. The physician order dated, 8/13/2021, documented, Lorazepam (Ativan) Tablet (used to treat anxiety)(2) 0.5 mg (milligram) Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 days. Reviewed of Resident #252's baseline care plan at the time of discovery of the above concern failed to address the use of an anti-anxiety medication for Resident #252. An updated care plan dated, 8/17/2021, documented in part, Focus: Resident is at risk for complications related to the use of psychotropic drugs, Buspar (used to treat anxiety disorders) (3), Wellbutrin (used to treat depressant)(4) and Ativan. An interview was conducted with LPN (licensed practical nurse) #7 on 8/17/2021 at 3:16 p.m. When asked the purpose of the care plan, LPN #7 stated it to find out more about the resident. When asked who develops the baseline care plan, LPN #7 stated the admitting nurse. When asked if a resident has a physician order for a PRN (as needed) anti-anxiety medication, should that be on the baseline care plan, LPN #7 stated, yes. On 8/17/2021 at 3:21 p.m. an interview was conducted with LPN #6, the nurse that updated Resident #252's baseline care plan on 8/17/2021. When asked why she updated the care plan on 8/17/2021, LPN #6 stated she was in the process of doing audits for the center nurse executive and saw the resident was on psychotropic medications and needed a care plan for them. When asked if the use of an antianxiety medication should have been on the baseline care plan when the resident was admitted , LPN #6 stated yes, that's why she was doing audits. The facility policy, Person-Centered Care Plan documented in part, The center must develop and implement a baseline person-centered careplan within 48 hours for each patient that includes the instructions needed to provide effective and person-centered care that meets professional standards of quality care. According to Fundamentals of Nursing Made Incredibly Easy [NAME] and [NAME], Philadelphia PA page 56: The first step in the nursing process--assessment--begins when you first see the patient. According to the American Nurses Association guidelines, data should accurately reflect the patient's life experiences, and his patterns of living .during the assessment you collect relevant information from various sources and analyze it to form a complete picture of your patient .it guides you through the rest of the nursing process, helping you formulate nursing diagnoses, expected outcomes, and nursing interventions. It serves as a vital communication tool for other team members- as a baseline for evaluating a patient's progress and for use as legal documentation .the initial assessment helps you determine what care the patient needs and sets the stage for further assessments .the history of the patient as well as medical problems are of great importance . and on page 65, A written care plan serves as a communication tool among health care team members that helps ensure the continuity of care .the care plan is developed on admission and includes the most significant problems and is reviewed and revised as necessary . ASM (administrative staff member) #1, the center executive director, and ASM #2, the center nurse executive, were made aware of the above concern on 8/17/2021 at 5:15 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/druginfo/meds/a682053.html (3) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a688005.html (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a695033.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, it was determined that the facility staff failed to implement the comprehensive care plan for three of 31 residents in the survey sample, Residents #81, #250 and #252. The facility staff failed to implement the comprehensive pain care plans for Residents #81, #250 and #252. The facility staff failed to assess the pain location, intensity and pain level rating and failed to attempt/ provide non-pharmacological pain interventions prior to administering physician prescribed as needed pain medications to Residents: #81, #250 and #252. The findings include: 1. Resident #81 was admitted to the facility on [DATE] with the most recent readmission on [DATE], with diagnoses that included but were not limited to: anemia (condition in which the hemoglobin content of the blood is below normal limits) (1), diabetes, high blood pressure, congestive heart failure (abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys) (2), COPD (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (3), and leukemia (one of the major types of cancer, malignant neoplasm of blood forming tissues) (4). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/7/2021, coded Resident #81 as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. In Section J - Health Conditions, the resident was coded as not being on scheduled pain medication and not receiving as needed pain medications. Resident 81 was coded as not having any pain in the past five days of the look-back period. The comprehensive care plan for Resident #81 dated, 8/2/2021, documented in part, Focus: Resident exhibits or is at risk for alteration in comfort related to acute pain, chronic pain. The Interventions documented in part, Offer the following non-pharmacological interventions (none were documented). Patient on Opioid therapy. Medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects of opioid medications, report to physician as indicated. Utilize pain scale. Encourage and assist resident to eliminated additional stressors or sources of discomfort. Manage pain by providing ice packs or cold compresses to applicable area. Manage pain by applying warm soaks to applicable area. The physician orders dated, 8/10/2021, documented, Oxycodone - Acetaminophen Tablet (used to relieve moderate to severe pain.) (5) 5-325 MG (milligrams) Give 1 tablet by mouth every 4 hours as needed for pain. The August MAR (medication administration record) documented the above physician order for Oxycodone-Acetaminophen. The MAR further documented the Oxycodone-Acetaminophen was administered on the following dates and times: 8/10/2021 at 1:30 p.m., 8/11/2021 at 11:45 a.m. and 8:20 p.m., 8/12/2021 at 9:38 a.m., and on 8/13/2021 at 6:38 p.m. Review of the nurse's notes documented the following for the above administered doses of Oxycodone-Acetaminophen: 8/10/2021 at 1:30 p.m. and 8/11/2021 at 8:20 p.m. and on 8/13/2021 at 6:38 p.m. - There was no documentation of the location of Resident #81's pain, level of pain rating per pain scale, and no documentation of non-pharmacological interventions offered prior to the administration of the medication. 8/11/2021 at 11:45 a.m. - c/o (complained of) pain in back. Resting in bed not effective. There was no documentation of the intensity or level of Resident #81's pain. 8/12/2021 at 9:38 p.m. - Resident complained of pain to right hand. Hand elevated on pillows. Did not relieve pain. There was no documentation of the intensity or level of Resident #81's pain. An interview was conducted with LPN (licensed practical nurse) #7 on 8/17/2021 at 3:16 p.m. When asked the purpose of the care plan, LPN #7 stated it's to find out more about the resident. When asked if it should be implemented and followed, LPN #7 stated, yes. On 8/17/21 at 4:31 p.m., an interview was conducted with ASM (administrative staff member) #2 (the center nurse executive). ASM #2 stated the purpose of the care plan was to tell staff how to take care of each resident. ASM #2 stated any licensed nurse can develop and implement a care plan. ASM #2 further stated she typically teaches nurses to care plan anything pertinent to a resident's diagnoses and why the staff is taking care of the resident. ASM (administrative staff member) #1, the center executive director, and ASM #2, the center nurse executive, were made aware of the above concern on 8/17/2021 at 5:15 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 33. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 138. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 332. (5) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682132.html. 2. The facility staff failed to implement Resident #251's comprehensive care plan for pain for Resident #250. The facility staff failed to assess Resident #251's pain intensity and level and failed to offer/ provide non-pharmacological pain interventions prior to administering physician prescribed as needed pain medications. Resident #250 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: status post knee replacement, diabetes, high blood pressure and rheumatoid arthritis (A chronic, destructive disease characterized by joint inflammation). (1) The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 8/9/2021, coded Resident #250 as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. In Section J - Health Conditions, the resident was coded as receiving scheduled pain medication. The resident was coded as having no pain at the time of the assessment. The comprehensive care plan for Resident #250 dated, 8/9/2021, documented in part, Focus: Resident exhibits or is at risk for alterations in comfort related to recent illness and hospitalization resulting in fatigue and activity intolerance. The Interventions documented in part, Evaluate pain characteristics, quality, severity, location, precipitating/relieving factors. Evaluate resident's coping mechanism to determine what measures work best (relaxation, diversional activities, visualization). Encourage and assist resident to eliminate additional stressors or sources of discomfort. Medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated. The physician order dated 8/8/2021, documented, Oxycodone HCL (hydrochloride) (used to relieve moderate to severe pain.) (2) Tablet 5 mg (milligrams) Give 1 tablet by mouth every 4 hours as needed for moderate pain. The August 2021 MAR (medication administration record) for Resident #250 documented the above physician order for Oxycodone. Further review of the MAR revealed documentation the as needed Oxycodone HCL (hydrochloride) medication was as administered on the following days and times: 8/11/2021 at 10:53 a.m., 8/13/2021 at 9:23 a.m., 8/14/2021 at 8:36 p.m., and 8/16/2021 at 8:35 a.m. Review of the nurse's notes for Resident #250 documented the following for the above-administered doses of Oxycodone: 8/11/2021 at 10:53 a.m. - Resident c/o pain in right knee, ice pack not effective. There was no documentation of a pain level or intensity of the pain. 8/13/2021 at 9:23 a.m. - Resident complained of knee pain unrelieved by repositioning. There was no documentation of a pain level or intensity of the pain. 8/14/2021 at 8:36 p.m. and 8/16/2021 at 8:35 a.m. - There was no documentation of location of pain, level of Resident #251's pain or non-pharmacological interventions offered prior to the administration of the medication. An interview was conducted with LPN (licensed practical nurse) #7 on 8/17/2021 at 3:16 p.m. When asked the purpose of the care plan, LPN #7 stated it's to find out more about the resident. When asked if it should be followed, LPN #7 stated, yes. On 8/17/21 at 4:31 p.m., an interview was conducted with ASM (administrative staff member) #2 (the center nurse executive). ASM #2 stated the purpose of the care plan was to tell staff how to take care of each resident. ASM #2 stated any licensed nurse can develop and implement a care plan. ASM #2 further stated she typically teaches nurses to care plan anything pertinent to a resident's diagnoses and why the staff is taking care of the resident. ASM (administrative staff member) #1, the center executive director, and ASM #2, the center nurse executive, were made aware of the above concern on 8/17/2021 at 5:15 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 511. (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682132.html. 3. The facility staff failed to implement the comprehensive care plan for pain for Resident # 252. Resident #252 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: COPD (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (1), lung cancer, high blood pressure and diabetes. A MDS (minimum data set) assessment was not completed during the time of survey. The Nursing Documentation dated 8/10/2021 at 9:17 p.m. documented in part, Reason for note: admission/readmission. Under question 3. Additional details about the note, the following was documented, Pt (patient) is A&O (alert and oriented) X4 (person, place time and situation). In Section H - Pain: Resident #252 was documented as having a pain level of 2 at the time of the assessment. The pain was described as soreness. The Pain Goal - acceptable pain level was documented as a 2. The comprehensive care plan dated, 8/17/2021, documented in part, Focus: Resident exhibits or is at risk for alteration in comfort related to acute pain. The Interventions documented in part, Utilize pain scale. Encourage and assist resident to eliminate additional stressors or sources of discomfort. A physician order dated, 8/10/2021, documented, Percocet Tablet (used to relieve moderate to severe pain.)(2) 10-325 MG (milligrams) (oxycodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain. The MAR (medication administration record) for August documented the above order for Percocet. The Percocet was documented as having been administered on the following dates and times: 8/11/2021 at 1:28 p.m. and at 9:31 p.m. 8/12/2021 at 8:37 p.m. 8/13/2021 at 6:38 p.m. 8/14/2021 at 6:15 a.m. and 7:28 p.m. 8/15/2021 at 5:03 a.m. and 6:50 p.m. 8/16/2021 at 6:37 p.m. 8/17/2021 at 3:28 a.m. There was no documentation on the MAR of a pain level. The nurse's notes were reviewed for the above dates and times and documented the following: 8/11/2021 at 1:28 p.m. - Resident c/o (complained of) pain in back. Resting in bed not effective. No documentation of pain level. 8/11/2021 at 9:31 p.m. - There was no documentation of pain level, location or non-pharmacological interventions. 8/12/2021 at 8:37 p.m. -There was no documentation of pain level, location or non-pharmacological interventions. 8/13/2021 at 6:38 p.m. - There was no documentation of pain level, location or non-pharmacological interventions. 8/14/2021 at 6:15 a.m. - c/o generalized body pain. There was no pain level or non-pharmacological interventions offered. 8/14/2021 at 7:28 p.m. -hip pain. There was no pain level or non-pharmacological interventions offered. 8/15/2021 at 5:03 a.m. - There was no documentation of pain level, location or non-pharmacological interventions. 8/15/2021 at 6:50 p.m. - There was no documentation of pain level, location or non-pharmacological interventions. 8/16/2021 at 6:37 p.m. - There was no documentation of pain level, location or non-pharmacological interventions. 8/17/2021 at 3:28 a.m. - There was no documentation of pain level, location or non-pharmacological interventions. An interview was conducted with LPN (licensed practical nurse) #7 on 8/17/2021 at 3:16 p.m. When asked the purpose of the care plan, LPN #7 stated it's to find out more about the resident. When asked if it should be followed, LPN #7 stated, yes. On 8/17/21 at 4:31 p.m., an interview was conducted with ASM (administrative staff member) #2 (the center nurse executive). ASM #2 stated the purpose of the care plan was to tell staff how to take care of each resident. ASM #2 stated any licensed nurse can develop and implement a care plan. ASM #2 further stated she typically teaches nurses to care plan anything pertinent to a resident's diagnoses and why the staff is taking care of the resident. ASM (administrative staff member) #1, the center executive director, and ASM #2, the center nurse executive, were made aware of the above concern on 8/17/2021 at 5:15 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. (2)This information was obtained from the following website:https://medlineplus.gov/druginfo/meds/a682132.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for one of 31 residents in the survey sample, Residents #30 and #87. The facility staff failed to review and revise Resident #30's comprehensive care plan when the resident fell on 6/8/21, 7/17/21 and 8/3/21. The findings include: Resident #30 was admitted to the facility on [DATE]. Resident #30's diagnoses included but were not limited to high blood pressure, major depressive disorder and muscle weakness. Resident #30's quarterly minimum data set assessment with an assessment reference date of 6/2/21, coded the resident's cognitive skills for daily decision making as severely impaired. Review of Resident #30's clinical record revealed the resident sustained falls without injury on 6/8/21, 7/17/21 and 8/3/21. Interventions were implemented to prevent future falls. Review of Resident #30's comprehensive care plan initiated on 2/1/21 failed to reveal the care plan had been reviewed or revised for the above falls. On 8/17/21 at 2:25 p.m., an interview was conducted with LPN (licensed practical nurse) #3, regarding the review and revision of comprehensive care plans for falls. LPN #3 stated care plans are a reference for care. On 8/17/21 at 4:31 p.m., an interview was conducted with ASM (administrative staff member) #2 (the center nurse executive). ASM #2 stated care plans should be reviewed and revised to reflect interventions put into place to prevent falls from reoccurring. On 8/17/21 at 4:58 p.m., ASM #1 (the center executive director) and ASM #2 were made aware of the above concern. The facility policy titled, Person-Centered Care Plan documented, 7. Care plans will be: 7.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals . 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, and during the course of a complaint investigation it was determined the facility staff failed to ensure the provision of care per professional standards for one of 31 residents in the survey sample, Resident #81. The facility staff failed obtain physician orders for treatment of Resident #81's left ankle pressure injury for prior to performing the treatment. The findings include: Resident #81 was admitted to the facility on [DATE] with the most recent readmission on [DATE], with diagnoses that included but were not limited to: anemia (1), diabetes, high blood pressure, congestive heart failure (2), COPD (chronic obstructive pulmonary disease) (3), and leukemia (4). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/7/2021, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. In Section N - Skin Conditions the resident was coded as having a stage III pressure injury. A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. (5). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (5) Observation was made of LPN (licensed practical nurse) #6 performing wound care on Resident #81 on 8/17/2021 at 8:00 a.m. Resident #81 had two pressure injuries. One on her left heel and one on her left outer ankle. LPN #6 proceeded to do wound care on both wounds. Review of the physician orders dated, 8/2/2021, revealed the following documentation, Hydrofera Blue* 4 (wound dressing) apply to L (left) heel topically every day shift for wound care. Cleanse with NS (normal saline), skin prep wound edges, cover with saline moistened Hydrofera blue and cover with dry dressing. Further review failed to evidence a physician order for treatment to the left ankle pressure injury. *Hydrofera Blue Ready-Border dressings provide the perfect option for atraumatic dressing changes. Using a gentle easy-on/easy-off silicone adhesive border, the dressing allows intimate contact of its non-cytotoxic antibacterial foam to the wound bed. (6) The comprehensive care plan dated, 8/2/2021, documented, Focus: Resident at risk for skin breakdown related to decreased activity and frail skin and or has actual skin breakdown to left heel and outer aspect of foot. The Interventions documented in part, Provide wound treatment as ordered. An interview was conducted with LPN #6 on 8/17/2021 at 8:17 a.m. The physician orders for Resident #81 were reviewed with LPN #6. When asked if she saw an order for the treatment of the left ankle wound, LPN #6 stated that after she left the room, she went and looked at the physician orders and noticed there was no order for the left ankle wound and had already contacted the nurse practitioner to get an order. When asked if there should be an order for each wound prior to providing treatment, LPN #6 stated, yes. The facility policy, Wound Dressings: Aseptic documented in part, 1. Verify order. ASM (administrative staff member) #1, the center executive director, and ASM #2, the center nurse executive, were made aware of the above concern on 8/17/2021 at 5:15 p.m. No further information was provided prior to exit. Complaint Deficiency References: (1) Anemia: condition in which the hemoglobin content of the blood is below normal limits. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 33. (2) Congestive Heart Failure: abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 138. (3) COPD: Chronic Obstructive Pulmonary Disease is 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. (4) Leukemia: one of the major types of cancer, malignant neoplasm of blood forming tissues. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 332. (5) This information was obtained from the following website: https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf (6) This information was obtained from the following website: https://hydrofera

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to provide treatment and services consistent with professional standards of practice, to promote healing, prevent infection of pressure injuries for one of 31 residents in the survey sample, Resident #81. A. The facility staff failed to administer treatment to Resident #81's pressure injuries in a manner to prevent infection, and performed dressing changes to a pressure injury without a physician order. B. The facility staff failed to administer treatments per the physician order for Resident #81. The findings include: A. Resident #81 was admitted to the facility on [DATE] with the most recent readmission on [DATE], with diagnoses that included but were not limited to: anemia (1), diabetes, high blood pressure, congestive heart failure (2), COPD (chronic obstructive pulmonary disease) (3), and leukemia (4). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of [DATE], coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. In Section N - Skin Conditions the resident was coded as having a stage III pressure injury. A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. (5) Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (5) Observation was made of LPN (licensed practical nurse) #6 performing wound care to Resident #81's left ankle and left heel pressure injuries on [DATE] at 8:00 a.m. LPN #6 had her supplies for the treatment in a plastic bag. LPN #6 pushed the resident's over bed table out of the way and placed her bag of supplies on the foot of the resident's bed. She uncovered the resident's left foot and leg to the knee and then put on her gloves. Resident #81 raised her leg and rested it on her right knee. Observation revealed a dressing covering both Resident #81's heel pressure injury and left ankle pressure injury. LPN #6 proceeded to remove the dressing, which was dated [DATE]. LPN #6 then proceeded to discard her gloves and washed her hands. She put on clean gloves and then measured the ankle wound as 0.75 cm (centimeters) by 1 cm and no depth. LPN #6 measured the left heel wound as, 1.5 cm by 1.6 cm by less than .1 cm in depth. LPN #6, then took some 4x4 gauze pads out of bag of supplies on the foot of the resident's bed, and the wound cleaner bottle and sprayed the wound cleanser on the 4x4 gauze pads. She proceeded to wipe off the ankle wound. LPN #6 folded the 4x4 in half and then proceeded to cleanse the heel wound. After completing the heel wound, observation revealed, LPN #6 folded the 4x4 gauze pad again, so it was in quarters, and touched the ankle wound. LPN #6 then took skin prep out of the bag on the foot of the resident's bed, and stated she was glad she had two packages of the skin prep. She took one of the packages of skin prep and wiped around, the ankle wound in a circular motion. LPN #6 took the same skin prep pad and wiped around the heel wound. LPN #6 then took her scissors and a marker out of her left pocket. Placed both items on the resident's bed. She opened the package containing the Hydrofera blue dressing, picked the scissors up off the resident's bed, and without cleaning/ disinfecting the scissors, cut the first piece of Hydrofera blue dressing. She then placed this piece of dressing in her left hand. LPN #6 held the dressing that was cut in the palm of her left hand while she proceeded to cut the second piece of Hydrofera blue. While holding the two dressings in her left hand, LPN #6 opened a small bottle of normal saline. She then poured the normal saline over the Hydrofera blue while it was still in her hand, letting the excess normal saline flow into the trash can. LPN #6 placed the smaller cut dressing on the heel pressure injury. LPN #6 then took the bottle of wound cleanser and placed it on the resident's bed, while holding the other cut dressing in her hand, opened the package of a dry dressing with adhesive attached. She picked up the marker from the bed and proceeded to write the date and her initials on the outer side of the dressing. LPN #6 placed the cut dressing of Hydrofera blue on the heel pressure injury. Then applied the dry dressing to the wound. LPN #6 took another dry dressing with adhesive backing out of the plastic bag and proceeded to write, with the marker on the resident's bed, the date and her initials on it and placed it over the ankle wound. The physician orders dated, [DATE], documented, Hydrofera Blue* 4 (wound dressing) apply to L (left) heel topically every day shift for wound care. Cleanse with NS (normal saline), skin prep wound edges, cover with saline moistened hydrofera blue and cover with dry dressing. Further review of the physician's orders failed to evidence an order for treatment to the left ankle. *Hydrofera Blue Ready-Border dressings provide the perfect option for atraumatic dressing changes. Using a gentle easy-on/easy-off silicone adhesive border, the dressing allows intimate contact of its non-cytotoxic antibacterial foam to the wound bed. (7) An interview was conducted with LPN #6 on [DATE] at 8:17 a.m., regarding the above observed wound care and treatment of the two wounds at the same time. LPN #6 stated, I cleaned both of her wounds with the same gauze pad. I also should have used a separate skin prep for each wound. When asked if it's acceptable to place the wound supplies used on the resident's bed, LPN #6 stated, I've done both. Her table was full of her things. When asked if the Hydrofera blue should have been held in her hand while doing other tasks related to the wound, LPN #6 stated, no. When asked where she got her scissors used to cut the residents dressings, LPN #6 stated from her left pocket. When asked what else was in her pocket, she stated it has pens and the scissors. When asked if she should have cleaned the scissors prior to cutting a dressing that is going to be applied directly to the resident's wound, LPN #6 stated, yes. The physician orders for Resident #81 were reviewed with LPN #6. When asked if she saw an order for the care of the ankle wound, LPN #6 stated that after she left the room, she went and looked at the physician orders and noticed there was no order for the left ankle wound. LPN #6 stated she had already contacted the nurse practitioner to get an order. When asked if there should be a physician's order for each wound prior to providing a treatment, LPN #6 stated, yes. An interview was conducted with RN (registered nurse) #2, the assistant director of nursing, on [DATE] at 9:40 a.m. When asked if a resident has two wound, near the same area, can they be treated together or separate, RN #2 stated they should be treated separately. When asked if the nurse should use the same 4x4 gauze and skin prep for both wound treatments, RN #2 stated it all should be separate for each wound. When asked if scissors removed from a uniform pocket and used to cut dressings that are applied directly onto a wound should be cleaned or disinfected prior to use, RN #2 stated they should be cleaned and put on your clean field. When asked if it was acceptable to put the dressing supplies and scissors on the resident's bed, RN #2 stated, It's not a clean field. You should set up the bedside table as a clean or sterile field depending on the orders for the dressing. When asked if a nurse should keep a dressing in her gloved hand while performing other tasks of the wound care and using the normal saline to wet the dressing per the physician's order, RN #2 stated a nurse should set up their clean or sterile field. Open the dressing and lay it flat on the table, then pour the normal saline on it. When asked if a dressing can be kept in a nurse's gloved hand, RN #2 stated everything should be set on your field prior to starting the actual dressing. The comprehensive care plan dated, [DATE], documented, Focus: Resident at risk for skin breakdown related to decreased activity and frail skin and or has actual skin breakdown to left heel and outer aspect of foot. The Interventions documented in part, Provide wound treatment as ordered. The facility policy, Wound Dressings: Asceptic documented in part, 1. Verify order. 2 Gather supplies: approved disinfectant, bed protector, if applicable, clean barrier, specific type of wound wash/irrigation, gloves (two pairs) prepared label with date and initials, gauze, dressing/medications/ointment as ordered .4. Clean over bed table. 5. Place clean barrier on the over-bed table and place supplies on the barrier. 9. Position the area to be treated. 10. Place a plastic bag for soiled dressing supplies within easy reach. 11. Cleanse hands. 12. If patient has multiple wounds, in close proximity: Treat the less contaminated wound first. In separate locations: treat each as a separate procedure .14. Open dressings(s) without contamination. Keep the dressing/gauze within the open packet and place it directly on top of the barrier. 15. Prepare medication/ointment, if indicated, by placing on inner sterile package .19. Cleanse or irrigate wound as ordered. 20. Wipe any excess fluid form the surrounding skin using a dry, gauze wipe .22. Using swab or applicator, apply treatment medication as ordered. 23. Apply and secure clean dressing. Wound Care: Preventing Infection: Gather supplies (dressings, tape, scissors, sterile saline solution, cotton swabs, extra gauze and culture materials if indicated). Wash your hands thoroughly and don gloves. Ensure strict aseptic technique during dressing changes.(8) According to the U.S. Department of Health and Human Services Public Health Service, Agency for Health Care Policy and Research, Clinical Practice Guidelines, Treatment of Pressure Ulcers, Number 15 an AHCPR Publication No. 95-0652 page 64: The Clinical Practice Guidelines Treatment of Pressure Ulcers revealed in part the following information regarding pressure sore treatment: Infection Control: When treating multiple ulcers on the same patient, attend to the most contaminated ulcer last In a study conducted by the International Conference on Nosocomial and Healthcare related Infections in Atlanta Georgia, [DATE] showed that ordinary items can make your patients sick. In one study, a researcher gathered scissors that nurses and physicians kept in their pockets, as well as communal scissors left on dressing carts and tables. Three-quarters of the scissors carried microorganisms, including Staphylococcus aureus, Groups A and B streptococcus, and gram-negative bacilli. The solution is quite simple. If health care workers swab the scissors with alcohol after each use, they will virtually eliminate the risk of transmission of microorganisms. In the study, contaminated scissors were effectively disinfected after swabbing the scissors with alcohol. (6) ASM (administrative staff member) #1, the center executive director, and ASM #2, the center nurse executive, were made aware of the above concern on [DATE] at 5:15 p.m. No further information was provided prior to exit. COMPLAINT DEFICIENCY References: References: (1) Anemia: condition in which the hemoglobin content of the blood is below normal limits. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 33. (2) Congestive Heart Failure: abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 138. (3) COPD: Chronic Obstructive Pulmonary Disease is 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. (4) Leukemia: one of the major types of cancer, malignant neoplasm of blood forming tissues. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 332. (5) This information was obtained from the following website: https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf (6) Embil JM, [NAME] B, [NAME] J, et al. Scissors as a potential source of nosocomial infection? Presented at the 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections. Atlanta; [DATE]. (7) This information was obtained from the following website: https://hydrofera.com/ (8) Lippincott Manual of Nursing Practice, 11th Edition, Wolters and Kluwer, page 104. B. The facility staff failed to administer the wound treatment per the physician's order. The physician order dated, [DATE], documented, Betadine Swabsticks Swab; Apply to L (left) heel topically every day shift for wound care, cleanse w/ (with) NS (normal saline)/wound cleanser, apply betadine, apply foam dressing. The TAR (treatment administration record) for [DATE] documented the above physician's treatment order. The treatment was completed every day from [DATE] and [DATE] and [DATE]. There was a blank on the date of [DATE]. The resident was then transferred to the hospital on [DATE]. The physician order dated, [DATE], documented, Hydrofera Blue 4 (wound dressing) Apply to L heel topically every day shift for wound care cleanse L heel w/ NS/wound cleanser, skin prep wound edges, apply Hydrofera blue, cover w/ dry dressing. The TAR for [DATE], documented the above physician's treatment order. The wound care was documented on every day from [DATE] through [DATE] except [DATE] and [DATE]. There was a blank on the date of [DATE] and [DATE]. The TAR for [DATE], documented the above physician's treatment order. The wound care was documented every day from [DATE] through [DATE]. There was a blank for [DATE]. The TAR for [DATE], documented the above physician's treatment order. The wound care was documented every day from [DATE] through [DATE]. There were blanks on [DATE] and [DATE]. Review of the nurse's notes for the above blank dates on the TARs failed to evidence documentation as to why the treatment wasn't administered. An interview was conducted with LPN (licensed practical nurse) #6 on [DATE] at 7:51 a.m. When shown the above TARs with the blank spaces and asked what it means if there were blanks on the TAR, LPN #6 stated, It means the treatment wasn't done. An interview was conducted with ASM (administrative staff member) #2, the center nurse executive, on [DATE] at 8:09 a.m. regarding the above dates with blanks on the TAR, and what the blanks mean. ASM #2 stated an omission means it wasn't done. ASM #1, the center executive director, and ASM #2 were made aware of the above concerns on [DATE] at 8:14 a.m. No further information was provided prior to exit. COMPLAINT DEFICIENCY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care consistent with professional standards for three of 31 residents, Resident #19, Resident #25 and Resident #252. The facility staff failed to store Resident #19 and Resident #25's nasal cannula oxygen tubing in a sanitary manner when not in use, Resident #19's and #25's nasal cannula oxygen tubing laying over the oxygen concentrators uncovered when not in use and the facility staff administered oxygen to Resident #252 without a physician's order. The findings include: 1. The facility staff failed to ensure Resident #19's nasal cannula tubing was stored in a sanitary manner when not in use. Resident #19 was admitted to the facility on [DATE]. Resident #19's diagnoses included but were not limited to: congestive heart failure (circulatory congestion characterized by circulatory congestion and retention of salt and water by the kidneys) (1), chronic kidney disease (decreased function of the kidneys frequently as a complication of hypertension or diabetes) (2) and hypertension (high blood pressure) (3). Resident #19's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/20/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status: coded the resident as requiring supervision for mobility, transfers, locomotion, dressing, bathing, hygiene and eating. Walking did not occur. A review of MDS Section H- Bowel and Bladder: coded the resident as always continent for bowel and occasionally incontinent for bladder. Section O-Special Treatments and Procedures: coded the resident as oxygen 'yes'. During the initial resident observation of Resident #19 on 8/16/21 at 11:10 AM, the residents nasal cannula oxygen tubing was observed laying over the oxygen concentrator uncovered. Observation of the nasal cannula oxygen tubing revealed it was last changed on 8/12/21, per a date documented on a plastic bag observed hanging on the oxygen concentrator. Resident #19's nasal cannula was again observed laying over the oxygen concentrator uncovered on 8/16/21 at 4:04 PM and was observed in use on Resident #19 on 8/17/21 at 7:57 AM. When asked if he uses the oxygen, Resident #19 stated, I use it at night. A review of the comprehensive care plan dated 1/22/18 and revised 9/23/20 which documented in part, FOCUS: Resident exhibits or is at risk for respiratory complications r/t shortness of breath, Oxygen dependent at night while sleeping, CHF. INTERVENTIONS: Oxygen as ordered. A review of the physician orders dated 12/10/20, documented in part, Oxygen at 2L/min via Nasal Cannula at bedtime for shortness of breath. A review of the MAR (medication administration record) for August 2021, documented the following: Oxygen at 2 liters per minute via nasal cannula at bedtime each night August 1, 2021-August 17, 2021. An interview was conducted on 8/17/21 at 4:29 PM with CNA (certified nursing assistant) #1. When asked if nasal cannula tubing for oxygen should be uncovered when not in use, CNA #1 stated, No, it should be covered but the nurse is the one to ask about it. An interview and observation of Resident #19's nasal cannula was conducted on 8/17/21 at 4:45 PM with LPN (licensed practical nurse) #1. When asked if Resident #19's nasal cannula tubing for oxygen should be uncovered when not in use, LPN #1 stated, No, it should be placed in the plastic bag [plastic bag observed hanging on Resident #19's oxygen concentrator, with a documented date of 8/12/21] that is right here. On 8/18/21 at 7:21 AM, ASM (administrative staff member) #1, the executive director and ASM #2, the center nurse executive were made aware of the above findings. A review of the facility's policy Oxygen Nasal Cannula policy revised 6/1/21, which documents in part, Replace disposable set-up every seven days. Date and store in treatment bag when not in use. 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 119. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 282. 2. The facility staff failed to ensure Resident #25's nasal cannula tubing was stored in a sanitary manner when not in use. Resident #25 was admitted to the facility on [DATE]. Resident #25's diagnoses included but were not limited to: chronic obstructive pulmonary disease (chronic, non-reversible lung disease) (1), dementia (progressive state of mental decline especially memory function and judgement) (2) and atrial fibrillation (rapid, random contractions of the atria of the heart) (3). Resident #25's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/20/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status: coded the resident as requiring extensive assistance for mobility, transfers, dressing, bathing, and hygiene. Resident #25 was coded as requiring supervision for eating and locomotion. A review of MDS Section H- Bowel and Bladder: coded the resident as frequently incontinent for bowel and for bladder. Section O-Special Treatments and Procedures: coded the resident as 'yes' for oxygen. During the initial resident observation on 8/16/21 at 11:25 AM, Resident #25's nasal cannula oxygen tubing was observed laying over the oxygen concentrator uncovered. Further observation revealed the nasal cannula was last changed on 8/13/21, per a date documented on a plastic bag observed hanging on Resident #25's oxygen concentrator. Resident #25's nasal cannula was again observed laying over the oxygen concentrator uncovered on 8/16/21 at 4:15 PM and was observed in use on Resident #25 on 8/17/21 at 7:59 AM. When asked if she uses the oxygen, Resident #25 stated, I use it mainly at night, rarely during the day. A review of the comprehensive care plan dated 8/5/21, which documented in part, FOCUS: Chronic Obstructive Pulmonary Disease (COPD)-Clinical Management. INTERVENTIONS: Administer Oxygen as ordered/indicated. A review of the physician orders dated 4/8/21, documented in part, Oxygen at 2 liters for shortness of breath- every shift as needed, and at night for shortness of breath. A review of Resident #25's MAR (medication administration record) for August 202, documented Oxygen at 2 liters per minute via nasal cannula at bedtime each night August 5, 2021-August 17, 2021. An interview was conducted on 8/17/21 at 4:29 PM with CNA (certified nursing assistant) #1. When asked if nasal cannula tubing for oxygen should be uncovered when not in use, CNA #1 stated, No, it should be covered but the nurse is the one to ask about it. An interview and observation of Resident #25's nasal cannula was conducted on 8/17/21 at 4:45 PM with LPN (licensed practical nurse) #1. When asked if Resident #25's nasal cannula tubing for oxygen should be uncovered when not in use, LPN #1 stated, No, it should be placed in the plastic bag [plastic bag observed hanging on Resident #25's oxygen concentrator, with a documented date of 8/13/21] that is right here. On 8/18/21 at 7:21 AM, ASM (administrative staff member) #1, the executive director and ASM #2, the center nurse executive were made aware of the above findings. A review of the facility's policy Oxygen Nasal Cannula policy revised 6/1/21, which documents in part, Replace disposable set-up every seven days. Date and store in treatment bag when not in use. 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 120. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 154. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 54. 3. The facility staff administered oxygen to Resident #252 without a physicians order. Resident #252 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: COPD (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (1), lung cancer, high blood pressure and diabetes. A MDS (minimum data set) assessment had not yet been completed during the time of survey. The Nursing Documentation dated 8/10/2021 at 9:17 p.m. documented in part, Reason for note: admission/readmission. Under question 3. Additional details about the note, was documented, Pt (patient) is A&O (alert and oriented) X4 (person, place time and situation). Pt is on 2 liters of oxygen via nasal cannula. Documented under Respiratory was a check mark next to O2 (oxygen) at 2 L/min (liters per minute) by Nasal cannula. Observation was made of Resident #252 on 8/16/2021 at 12:05 p.m. The resident was sitting on the side of the bed with oxygen on via a nasal cannula (a two-pronged plastic tube that inserts into the nares) connected to an oxygen concentrator that was running. The oxygen concentrator flow meter was set at 3 LPM (liters per minute). A second observation was made of Resident #252 at 3:10 p.m. the resident was observed in her room with the oxygen on via a nasal cannula connected to an oxygen concentrator that was running. The oxygen concentrator flow meter was set at 3 LPM. The resident was again observed on 8/17/2021, at 8:15 a.m. in her bed with the oxygen on via a nasal cannula connected to an oxygen concentrator that was running and set at 3 LPM via nasal cannula. Review of the clinical record failed to evidence a physician order for the use of oxygen. The Medication List that was received by the facility upon transfer, documented in part, Oxygen - inhale 2 L/min at bed time via nasal cannula. The O2 saturations for Resident #252 between 8/11/2021 through 8/17/202 in the clinical record, documented the value of 94% to 98%. The care plan dated, 8/17/2021, documented in part, Focus: Resident exhibits or is at risk for respiratory complications related to COPD. The Interventions failed to document anything regarding the use of oxygen. An interview was conducted with LPN (licensed practical nurse) #7 on 8/17/2021 at 2:56 p.m. When asked if a physician's order is required for the use of oxygen, LPN # 4 stated yes. When asked what the prescribed oxygen flow rate was for Resident #252, LPN # 7 stated she was told in report that she [Resident #252] was supposed to be on 3 LPM. The physician orders for Resident #252 in the electronic medical record were reviewed with LPN #7. When LPN #7 was asked if she saw an order for Resident #252's oxygen, she stated, there was no order for the oxygen. The documents received from the hospital were reviewed with LPN #7. LPN #7 stated she would contact the nurse practitioner and get an order for Resident #252's oxygen. The facility policy, Oxygen - Nasal Cannula documented in part, 1. Verify order. According to Fundamentals of Nursing, Fifth Edition, [NAME] & [NAME], 2007, page 851, Because oxygen is a drug, its use requires a prescription. Policies and standing orders often permit the nurse to administer oxygen in emergency situations if the physician is not immediately available to write an order. Although oxygen is generally safe when used properly, certain precautions must be observed. As with all drugs, the potential exists for causing harm with misuse. ASM (administrative staff member) #1, the center executive director, and ASM #2, the center nurse executive, were made aware of the above concern on 8/17/2021 at 5:15 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review it was determined the facility staff failed to ensure implementation of a complete pain management program for three of 31 residents in the survey sample, Residents # 252, # 81, and # 250. The facility staff failed to assess the location of pain, pain level/intensity and failed to attempting/ offering non-pharmacological interventions prior to administering as needed narcotic pain medications to Resident #252, #81 and #250 on multiple dates in August 2021. The findings include: 1. Resident #252 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: COPD (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (1), lung cancer, high blood pressure and diabetes. There was no MDS (minimum data set) assessment completed during the time of survey. The Nursing Documentation dated 8/10/2021 at 9:17 p.m. documented in part, Reason for note: admission/readmission. Under question 3. Additional details about the note, it was documented, Pt (patient) is A&O (alert and oriented) X4 (person, place time and situation). In Section H - Pain: the resident was documented as having a pain level of 2 at the time of the assessment. The pain was described as soreness. The Pain Goal - acceptable pain level was documented as a 2. The physician order dated, 8/10/2021, documented, Percocet Tablet (used to relieve moderate to severe pain.)(2) 10-325 MG (milligrams) (oxycodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain. Review of Resident #252's MAR (medication administration record) for August documented the above physicians order for Percocet. The MAR documented the Percocet was administered on the following dates and times: 8/11/2021 at 9:31 p.m., 8/12/2021 at 8:37 p.m., 8/13/2021 at 6:38 p.m., 8/15/2021 at 5:03 a.m. and 6:50 p.m., 8/14/2021 at 6:15 a.m. and 7:28 p.m., 8/16/2021 at 6:37 p.m., and on 8/17/2021 at 3:28 a.m. Further review of the MAR revealed there was no documentation of a pain level rating for Resident #252's pain for any of the dates listed above. The nurse's notes for Resident #252 were reviewed for the above dates and times and revealed following: 8/11/2021 at 9:31 p.m., 8/12/2021 at 8:37 p.m., 8/13/2021 at 6:38 p.m., 8/15/2021 at 5:03 a.m., 8/15/2021 at 6:50 p.m., 8/16/2021 at 6:37 p.m. and 8/17/2021 at 3:28 a.m., there was no documentation of an assessed pain level, or pain location for Resident #252's pain and no documentation of attempted or refused non-pharmacological interventions prior to the administration of the prescribed as needed pain medication Percocet. The nurse's notes were reviewed for the above dates and times and documented the following: 8/11/2021 at 1:28 p.m. - Resident c/o (complained of) pain in back. Resting in bed not effective. There was no documentation of Resident #252's pain level. 8/14/2021 at 6:15 a.m. - c/o generalized body pain. There was no pain level for Resident #252's pain documented and no documentation of attempted or refused non-pharmacological interventions prior to administration of the as needed pain medication. 8/14/2021 at 7:28 p.m. -hip pain. There was no pain level for Resident #252's pain documented and no documentation of attempted or refused non-pharmacological interventions prior to administration of the as needed pain medication. 8/12/2021 at 8:37 p.m., 8/13/2021 at 6:38 p.m., 8/15/2021 at 5:03 a.m., 8/15/2021 at 6:50 p.m., 8/16/2021 at 6:37 p.m. and 8/17/2021 at 3:28 a.m., there was no documentation of an assessed pain level, or pain location for Resident #252's pain and no documentation of attempted or refused non-pharmacological interventions prior to the administration of the prescribed as needed pain medication Percocet. The comprehensive care plan dated, 8/17/2021, documented in part, Focus: Resident exhibits or is at risk for alteration in comfort related to acute pain. The Interventions documented in part, Utilize pain scale. Encourage and assist resident to eliminate additional stressors or sources of discomfort. An interview was conducted with Resident #252 on 8/17/2021 at 01:49 p.m. Resident #252 was asked if staff asks them where their pain is located. Resident #252 stated, No. When asked if the staff asks them to describe their pain level on a pain scale of one to ten, ten being the worse pain ever and zero equaling pain, Resident #252 stated, No. When asked if the staff offer something other than medication to relive pain before administering the pain medication, such as a back rub, ice pack or hot compress, Resident #252 stated, No, I hope they don't because when I want my pain medication I want it. An interview was conducted with LPN (licensed practical nurse) # 5 on 8/17/2021 at 2:19 p.m., regarding the process staff follows for residents' complaints of pain. LPN #5 stated, First she asks where the pain is, then asks them to tell her on a pain scale of one to ten, how bad the pain is. Once the resident tells her the level she checks for medication ordered for pain. When asked where the assessment of a resident's pain including location and pain scale rating is documented, LPN #5 stated, When you pull up the medication in the computer; it automatically pops up a window for you to put the pain scale and has a place for a nurse's note. When asked if staff offer non-pharmacological interventions prior to giving a pain medication, LPN #5 stated, Yes, that should be first after the assessment. When asked where that is documented, LPN #5 stated, in the progress notes. The facility policy, Pain Management documented in part, Policy: Patients will be evaluated as part of the nursing assessment process for the presence of pain upon admission/readmission, quarterly , with change in condition or change in pain status, and as required by the state thereafter. Pain management that is consist with profession standards of practice, the comprehensive person-centered care plan and the patient's goals and preferences is provided to patient who require such services. Fundamentals of Nursing, 6th Edition, [NAME] and [NAME], 2005, pages 1239-1287, Nurses need to approach pain management systematically to understand a client's pain and to provide appropriate intervention it is necessary to monitor pain on a consistent basis Assessment of common characteristics of pain helps the nurse form an understanding of the type of pain, its pattern, and types of interventions that may bring relief Onset and duration Location Intensity Quality Pain Pattern Relief Measures Contributing Symptoms Pain therapy requires an individualized approach According to Fundamentals of Nursing, Fifth Edition, 2007, [NAME] & [NAME], page 1176 to 1207. Assessment: An accurate assessment focusing on pain's cause is essential for determining proper therapy. Ongoing assessment also is important for implementing an effective pain management plan Document pain assessment information in an accessible location. Even the best pain assessment conducted by the one nurse is of limited value unless he or she shares the information with other healthcare professionals responsible for the client's care. Subjective Data: In an attempt to assess the client's pain, obtain answers to the following questions: Where is the pain located? What is the magnitude or intensity (level) of the pain? What level of pain would the client like to have? What level of pain would the client be willing to tolerate? How does the pain feel to the client; how is it described (its quality)? How does the pain change with rest, activity, or time (its temporal pattern) . ASM (administrative staff member) #1, the center executive director, and ASM #2, the center nurse executive, were made aware of the above concern on 8/17/2021 at 5:15 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. (2)This information was obtained from the following website:https://medlineplus.gov/druginfo/meds/a682132.html 2. Resident #81 was admitted to the facility on [DATE] with the most recent readmission on [DATE], with diagnoses that included but were not limited to: anemia (1), diabetes, high blood pressure, congestive heart failure (2), COPD [chronic obstructive pulmonary disease) (3), and leukemia (4). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/7/2021, coded Resident #81 as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. In Section J - Health Conditions, the resident was coded as not being on scheduled pain medication and not receiving as needed pain medications. It coded the resident as not having any pain in the past five days of the look-back period. The physician orders dated, 8/10/2021, documented, Oxycodone - Acetaminophen Tablet (used to relieve moderate to severe pain.) (5) 5-325 MG (milligrams) Give 1 tablet by mouth every 4 hours as needed for pain. The August MAR (medication administration record) for Resident #81 documented the above physician's order for Oxycodone-Acetaminophen and documented the medication was administered on the following dates and times: 8/10/2021 at 1:30 p.m. 8/11/2021 at 11:45 a.m. and 8:20 p.m. 8/12/2021 at 9:38 a.m. 8/13/2021 at 6:38 p.m. Review of the Resident #81's nurse's notes for the above administered doses of Oxycodone-Acetaminophen revealed the following: 8/10/2021 at 1:30 p.m., 8/11/2021 at 8:20 p.m., 8/13/2021 at 6:38 p.m., there was no documentation of Resident #81's location of pain, level of pain, and no documentation of attempted/ refused non-pharmacological interventions prior to the administration of the as needed Oxycodone-Acetaminophen narcotic pain medication. 8/11/2021 at 11:45 a.m. - c/o (complained of) pain in back. Resting in bed not effective. There was no documentation of the intensity or level of Resident #81's pain. 8/12/2021 at 9:38 p.m. - Resident complained of pain to right hand. Hand elevated on pillows. Did not relieve pain. There was no documentation of the intensity or level of Resident #81's pain. The comprehensive care plan dated, 8/2/2021, documented in part, Focus: Resident exhibits or is at risk for alteration in comfort related to acute pain, chronic pain. The Interventions documented in part, Offer the following non-pharmacological interventions (none were documented). Patient on Opioid therapy. Medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects of opioid medications, report to physician as indicated. Utilize pain scale. Encourage and assist resident to eliminated additional stressors or sources of discomfort. Manage pain by providing ice packs or cold compresses to applicable area. Manage pain by applying warm soaks to applicable area. An interview was conducted with Resident #81 on 8/17/2021 at 1:48 p.m. When asked if the nurses ask where her pain is located, Resident #81 stated sometimes. When asked if they ask what level or intensity her pain is, Resident #81 stated sometimes. When asked if the offer anything before giving the pain medication such as repositioning, back rub, ice pack, Resident #81 stated, No. An interview was conducted with LPN (licensed practical nurse) # 5 on 8/17/2021 at 2:19 p.m., regarding the process staff follows for residents' complaints of pain. LPN #5 stated, First she asks where the pain is, then asks them to tell her on a pain scale of one to ten, how bad the pain is. Once the resident tells her the level she checks for medication ordered for pain. When asked where the assessment of a resident's pain including location and pain scale rating is documented, LPN #5 stated, When you pull up the medication in the computer; it automatically pops up a window for you to put the pain scale and has a place for a nurse's note. When asked if staff offer non-pharmacological interventions prior to giving a pain medication, LPN #5 stated, Yes, that should be first after the assessment. When asked where that is documented, LPN #5 stated, in the progress notes. ASM (administrative staff member) #1, the center executive director, and ASM #2, the center nurse executive, were made aware of the above concern on 8/17/2021 at 5:15 p.m. No further information was provided prior to exit. References: (1) Anemia: condition in which the hemoglobin content of the blood is below normal limits. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 33. (2) Congestive heart failure: abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 138. (3) COPD: chronic obstructive pulmonary disease - 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. (4) Leukemia: one of the major types of cancer, malignant neoplasm of blood forming tissues. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 332. (5) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682132.html. 3. Resident #250 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: status post knee replacement, diabetes, high blood pressure and rheumatoid arthritis (A chronic, destructive disease characterized by joint inflammation. Symptoms are varied, often including fatigue, low-grade fever, loss of appetite, morning stiffness, tender, painful swelling of two or more joints, most commonly in fingers, ankles, feet, hips and shoulders.). (1) The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 8/9/2021, coded Resident #250 as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. In Section J - Health Conditions, the resident was coded as receiving scheduled pain medication. The resident was coded as having no pain at the time of the assessment. The physician order dated 8/8/2021, documented, Oxycodone HCL (hydrochloride) (used to relieve moderate to severe pain.) (2) Tablet 5 mg (milligrams) Give 1 tablet by mouth every 4 hours as needed for moderate pain. The August 2021 MAR (medication administration record) for Resident #250 documented the above physician's order for Oxycodone and documented the medication administered on the following days and times: 8/11/2021 at 10:53 a.m. 8/13/2021 at 9:23 a.m. 8/14/2021 at 8:36 p.m. 8/16/2021 at 8:35 a.m. Review of Resident #250's nurse's notes revealed the following for the above-administered doses of Oxycodone: 8/11/2021 at 10:53 a.m. - Resident c/o pain in right knee, ice pack not effective. There was no documentation of a pain level or intensity of the pain for Resident #250. 8/13/2021 at 9:23 a.m. - Resident complained of knee pain unrelieved by repositioning. There was no documentation of a pain level or intensity of the pain for Resident #250. 8/14/2021 at 8:36 p.m. and 8/16/2021 at 8:35 a.m., there was no documentation of Resident #250's location of pain, level of pain or documentation of attempted or refused non-pharmacological interventions offered prior to the administration of the prescribed as needed Oxycodone HCL narcotic pain medication. The comprehensive care plan dated, 8/9/2021, documented in part, Focus: Resident exhibits or is at risk for alterations in comfort related to recent illness and hospitalization resulting in fatigue and activity intolerance. The Interventions documented in part, Evaluate pain characteristics, quality, severity, location, precipitating/relieving factors. Evaluate resident's coping mechanism to determine what measures work best (relaxation, diversional activities, visualization). Encourage and assist resident to eliminate additional stressors or sources of discomfort. Medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated. An interview was conducted with Resident #250 on 08/17/2021 1:43 p.m. When asked if the staff ask about the location of pain, Resident #250 stated yes. When asked if the staff ask about the level of pain, Resident #250 stated yes. When asked if the staff offer to do anything before administering the pain medication like an ice pack, Resident #250 stated she can't tolerate the ice pack as it makes her cold. She stated, They just give me the pill. An interview was conducted with LPN (licensed practical nurse) # 5 on 8/17/2021 at 2:19 p.m., regarding the process staff follows for residents' complaints of pain. LPN #5 stated, First she asks where the pain is, then asks them to tell her on a pain scale of one to ten, how bad the pain is. Once the resident tells her the level she checks for medication ordered for pain. When asked where the assessment of a resident's pain including location and pain scale rating is documented, LPN #5 stated, When you pull up the medication in the computer; it automatically pops up a window for you to put the pain scale and has a place for a nurse's note. When asked if staff offer non-pharmacological interventions prior to giving a pain medication, LPN #5 stated, Yes, that should be first after the assessment. When asked where that is documented, LPN #5 stated, in the progress notes. ASM (administrative staff member) #1, the center executive director, and ASM #2, the center nurse executive, were made aware of the above concern on 8/17/2021 at 5:15 p.m. No further information was provided prior to exit. References: (1) Rheumatoid arthritis: a chronic, destructive disease characterized by joint inflammation. Symptoms are varied, often including fatigue, low-grade fever, loss of appetite, morning stiffness, tender, painful swelling of two or more joints, most commonly in fingers, ankles, feet, hips and shoulders. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 511. (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682132.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide dialysis services, consistent with professional standards of practice, the comprehensive person-centered care plan for two of 31 residents, Resident #29 and Resident #38. The facility staff failed to evidence of ongoing communication and collaboration with the dialysis facility for eight dialysis dates during May, June, and July 2021, for Resident #29 and for six dialysis dates during May and June 2021, for Resident #38. The findings include: 1. Resident #29 was admitted to the facility on [DATE]. Resident #29's diagnoses included but were not limited to: diabetes mellitus (inability of insulin to function normally in the body) (1), end stage renal disease (end stage of renal failure-inability of the kidneys to excrete wastes and function in the maintenance of electrolyte balance) (2) and chronic obstructive pulmonary disease (chronic, non-reversible lung disease) (3). Resident #29's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/4/21, coded the resident as scoring 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. MDS Section G- Functional Status: coded the resident as requiring extensive assistance for mobility, transfers, dressing, bathing, hygiene and locomotion. Supervision is required for eating and walking did not occur. A review of MDS Section H- Bowel and Bladder: coded the resident as always incontinent for bowel and for bladder. Section O-Special Treatments and Procedures: coded the resident as 'yes' for dialysis. A review of the comprehensive care plan revised 4/21/21, documented in part, FOCUS: Resident exhibits or is at risk for impaired renal function and is at risk for complications related to hemodialysis. INTERVENTION: Monitor external hemodialysis catheter and site for catheter integrity, excessive redness, swelling, pain at site, signs and symptoms of infection and excessive bleeding from site and report to physician as indicated. A review of the physician orders dated 4/21/21, documented in part, Dialysis center phone number is: 540.720.1225. Dialysis days: Monday, Wednesday, Friday Time for Pick up: 1030. Resident #29's dialysis binder containing the Hemodialysis Communication Record with top section to be completed by the facility and the bottom portion to be completed by the dialysis center was reviewed. The Hemodialysis Communication Record reviewed were from 5/4/21-8/16/21 and evidenced a total of eight missing communication forms for the following dialysis days: 5/5/21, 5/28/21, 6/4/21, 6/11/21, 6/30/21, 7/2/21, 7/19/21 and 7/30/21. An interview was conducted on 8/17/21 at 8:45 AM with LPN (licensed practical nurse) #2. When asked the purpose of the dialysis communication form, LPN #2 stated, To maintain communication between the dialysis center and us. LPN #2 stated, It is to be completed each time the resident goes out for dialysis. When asked what missing forms mean, LPN #2 stated, It could mean they got lost or they weren't filled out. On 8/18/21 at 7:21 AM, ASM (administrative staff member) #1, the executive director and ASM #2, the center nurse executive were made aware of the above findings. A review of the facility's Dialysis contract, which states, Mutual obligation: Both parties shall ensure that there is documented evidence of collaboration of care communication between the long term care facility and the ESRD end stage renal disease) dialysis unit. A review of the facility's Dialysis: Hemodialysis provided by a certified dialysis facility revised 6/1/21, documented in part, Shared communication between the center and the certified dialysis facility: the care of the patient receiving hemodialysis must reflect ongoing communication, coordination, and collaboration between the center and dialysis staff. On 8/18/21 at 8:55 AM, ASM #2, the center nurse executive provided dialysis communication forms for Resident #29 for the dates of 5/21/21 and 6/14/21. These two dates were not included in the eight missing communication forms listed above. 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 160. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 498. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 120. 2. Resident #38 was admitted to the facility on [DATE]. Resident #25's diagnoses included but were not limited to: diabetes mellitus (inability of insulin to function normally in the body) (1), end stage renal disease (end stage of renal failure-inability of the kidneys to excrete wastes and function in the maintenance of electrolyte balance) (2) and chronic obstructive pulmonary disease (chronic, non-reversible lung disease) (3). Resident #38's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/20/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status: coded the resident as requiring extensive assistance for mobility, transfers, dressing, bathing, and hygiene. Supervision is required for eating and locomotion is independent; walking did not occur. A review of MDS Section H- Bowel and Bladder: coded the resident as always incontinent for bowel and occasionally incontinent for bladder. Section O-Special Treatments and Procedures: coded the resident as dialysis 'yes'. A review of the comprehensive care plan revised 11/15/20, documented in part, FOCUS: Resident exhibits or is at risk for impaired renal function and is at risk for complications related to hemodialysis, CKD (chronic kidney disease). INTERVENTION: Monitor external hemodialysis catheter and site for catheter integrity, excessive redness, swelling, pain at site, signs and symptoms of infection and excessive bleeding from site and report to physician as needed. A review of the physician orders dated 7/7/21, documented in part, Dialysis center phone number is: [PHONE NUMBER]. Dialysis days: Tues, Thurs, Sat. Pick up time: 9:15am Chair time: 10:15am. A review of Resident #38's dialysis binder containing the Hemodialysis Communication Record with top section to be completed by the facility and the bottom portion to be completed by the dialysis center. The records reviewed were from 4/15/21-8/17/21 and evidenced a total of six missing communication forms for the dates of: 5/6/21, 5/13/21, 5/29/21, 6/10/21, 6/12/21 and 6/26/21. An interview was conducted on 8/17/21 at 8:45 AM with LPN (licensed practical nurse) #2. When asked the purpose of the dialysis communication form, LPN #2 stated, To maintain communication between the dialysis center and us. When asked when the form should be completed, LPN #2 stated, It is to be completed each time the resident goes out for dialysis. When asked what missing forms means, LPN #2 stated, It could mean they got lost or they weren't filled out. On 8/18/21 at 7:21 AM, ASM (administrative staff member) #1, the executive director and ASM #2, the center nurse executive were made aware of the above findings. On 8/18/21 at 8:55 AM, ASM #2, the center nurse executive state she was unable to provide any of the missing dialysis communication forms for Resident #38. 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 160. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 498. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 120.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of 31 residents was free of unnecessary psychotropic medications, Resident #252. There was no documentation as to why the medication Ativan was administered and no documentation any non-pharmacological interventions were attempted or provided prior to the administration of the medication to Resident #252. The findings include: Resident #252 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: COPD (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (1), lung cancer, high blood pressure and diabetes. A MDS (minimum data set) assessment had not yet been completed during the time of survey. The Nursing Documentation dated 8/10/2021 at 9:17 p.m. documented in part, Reason for note: admission/readmission. Under question 3. Additional details about the note, the following was documented, Pt (patient) is A&O (alert and oriented) X4 (person, place time and situation). The form documented, High Risk Medication Therapy with a check mark documented next to anti-anxiety medication. The physician order dated, 8/13/2021, documented, Lorazepam (Ativan) Tablet (used to treat anxiety)(2) 0.5 mg (milligram) Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 days. Review of the MAR (medication administration record) for August 2021, documented the above physician's order for Lorazepam. The MAR documented the medication had been administered on the following dates and times: 8/13/2021 at 8:24 p.m. 8/14/2021 at 1:39 a.m. 8/14/2021 at 10:58 p.m. 8/16/2021 at 6:42 a.m. Review of the nurse's notes for the dates above revealed on: 8/13/2021 at 8:24 p.m., 8/14/2021 at 1:39 a.m., 8/14/2021 at 10:58 p.m., 8/16/2021 at 6:42 a.m., there was no documentation as to the reason for the administration of the antianxiety medication and no documentation of any non-pharmacological interventions attempted or provided prior to the administration of the medication. The care plan was reviewed at the time of discovery and it did not address the use of an anti-anxiety medication for Resident #252. An updated care plan dated, 8/17/2021, documented in part, Focus: Resident is at risk for complications related to the use of psychotropic drugs, Buspar (used to treat anxiety disorders) (3), Wellbutrin (used to treat depressant) (4) and Ativan. An interview was conducted on 8/17/2021 at 4:17 p.m., with Resident #252. When asked if staff asks why she needs her Ativan, when she requests the medication, Resident #252 stated no. When asked if the staff offer to do something like talk, offer food, to put on music for her, Resident #252 stated, No, when I request my Ativan, I want my medication. An interview was conducted with LPN (licensed practical nurse) #5 on 8/17/2021 at 2:19 p.m. LPN #5 was asked about the process staff follows when a resident requests an as needed (PRN) anti-anxiety medication such as Ativan. LPN #5 stated she has never had a resident on PRN Ativan. But I would think that it would be similar to other PRN medications. Assess the resident. Try to redirect them with talking to them, see if there is something that will calm them down before giving the medication. When asked where the things attempted are documented, LPN #5 stated it should be documented in a progress note as to what you did to change the situation, how you redirected the resident and what you attempted to do to resolve the situation. The facility policy, Psychotropic Medication Use documented in part, Facility staff should monitor the resident's behavior pursuant to Facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving psychotropic medication for organic mental syndrome with agitate or psychotic behaviors. Facility staff should monitor behavioral triggers, episodes and symptoms. Facility staff should document the number and/or intensity of symptoms and the resident's response to staff interventions. ASM (administrative staff member) #1, the center executive director, and ASM #2, the center nurse executive, were made aware of the above concern on 8/17/2021 at 5:15 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/druginfo/meds/a682053.html (3) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a688005.html (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a695033.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide written notification to the resident and/or resident representative and ombudsman, upon transfer to the hospital for eight of 31 residents in the survey sample, (Resident #29, Resident #38, Resident #26, Resident #25, Resident #43, Resident #71, Resident #91 and Resident #81). The facility staff failed to evidence that a written notification was provided to the resident and or the resident representative and ombudsman upon hospital transfers for Resident #29, Resident #38, Resident #26, Resident #25, Resident #43, Resident #71, Resident #91 and Resident #81 The findings include: 1. The facility staff failed to provide Resident # 29 and Resident # 29's representative and the ombudsman written notification of a facility-initiated transfer on 04/05/2021 for Resident # 29. Resident #29 was admitted to the facility on [DATE]. Resident #29's diagnoses included but were not limited to: diabetes mellitus (inability of insulin to function normally in the body) (1), end stage renal disease (end stage of renal failure-inability of the kidneys to excrete wastes and function in the maintenance of electrolyte balance) (2) and chronic obstructive pulmonary disease (chronic, non-reversible lung disease) (3). Resident #29's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/4/21, coded the resident as scoring 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the eINTERACT (interventions to reduce acute care transfers) Transfer Form V5 dated 4/5/21, documented in part, Transfer to hospital. There were no additional progress notes addressing the transfer to hospital and no documented evidence Resident #29, or the RP and ombudsman were provided written notice for hospital transfer evidenced in the medical record. On 8/17/21 a request for evidence of the provision of written notice to the resident, RP and ombudsman for the hospital transfer of Resident #29 was made via written a request for documents to the facility. On 8/17/21 ASM (administrative staff member) #1, the administrator, provided a written note documenting New social worker, wasn't aware to notify. On 8/17/21 at 2:25 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the nurses call resident's representatives when residents are discharged to the hospital but do not provide a written notice of transfer. On 8/17/21 at 4:05 p.m., an interview was conducted with OSM (other staff member) #3 [social services director who has been employed at the facility for a little under two months]. OSM #3 stated she just found out on this day that she was responsible for providing written notice of transfer to residents/representatives and the ombudsman. OSM #3 stated she had not been doing this. On 8/18/21 at 7:21 AM, ASM (administrative staff member) #1, the executive director and ASM #2, the center nurse executive were made aware of the above findings. A review of the facility's policy Discharge and Transfer policy revised 2/1/19, which documents in part, For unplanned, acute transfers where it is planned for the patient to return to the Center, the patient and/or resident representative will be notified verbally followed by written notification using the 'Notice of Hospital Transfer' or state specific transfer form. Copies of notices for emergency transfers must also be sent to the Ombudsman. 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 160. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 498. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 120. 2. The facility staff failed to provide Resident # 38 and Resident # 38's representative and the ombudsman written notification of a facility-initiated transfer on 07/03/2021 for Resident # 38. Resident #38 was admitted to the facility on [DATE]. Resident #25's diagnoses included but were not limited to: diabetes mellitus (inability of insulin to function normally in the body) (1), end stage renal disease (end stage of renal failure-inability of the kidneys to excrete wastes and function in the maintenance of electrolyte balance) (2) and chronic obstructive pulmonary disease (chronic, non-reversible lung disease) (3). Resident #38's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/20/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the nursing progress note dated 7/3/21 at 8: 21 PM, documented in part, Resident went out to dialysis did not returned to facility in the evening time. This nurse called the family to inform that resident was not in the building at this time left message called [Name of Hospital] hospital and found out she was admitted .Supervisor made aware. On 8/17/21 a request for evidence of the provision of written notice to the resident, RP and ombudsman for the 7/3/21 hospital transfer of Resident #38 was made via a written request for documents to the facility. On 8/17/21 ASM (administrative staff member) #1, the administrator, provided a written note documenting New social worker, wasn't aware to notify. On 8/17/21 at 2:25 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the nurses call resident's representatives when residents are discharged to the hospital but do not provide a written notice of transfer. On 8/17/21 at 4:05 p.m., an interview was conducted with OSM (other staff member) #3 [social services director who has been employed at the facility for a little under two months]. OSM #3 stated she just found out on this day that she was responsible for providing written notice of transfer to residents/representatives and the ombudsman. OSM #3 stated she had not been doing this. On 8/18/21 at 7:21 AM, ASM (administrative staff member) #1, the executive director and ASM #2, the center nurse executive were made aware of the above findings. 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 160. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 498. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 120. 3. The facility staff failed to provide Resident # 26 and Resident # 26's representative and the ombudsman written notification of a facility-initiated transfer on 05/19/2021 for Resident # 26. Resident #26 was admitted to the facility on [DATE]. Resident #25's diagnoses included but were not limited to: congestive heart failure 'CHF' (circulatory congestion and retention of salt and water by the kidneys) (1), vascular dementia (progressive state of mental decline often caused by metabolic condition such as vascular supply to the brain) (2) and chronic kidney disease (decreased function of the kidneys) (3). Resident #26's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/6/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the eINTERACT (interventions to reduce acute care transfers) Transfer Form V5 dated 5/19/21, documented in part, Transfer to acute care hospital. A review of the nursing progress notes dated 5/19/21 at 4:05 PM, documented in part, The NP wanted resident [Resident #26] to see a cardio MD [cardiologist] but was not able to get an appointment. The NP decided to send to hospital for evaluation. On 8/17/21 a request for evidence of the provision of written notice to the resident, RP and ombudsman for the 7/3/21 hospital transfer of Resident #26 was made via a written request for documents to the facility. On 8/17/21 ASM (administrative staff member) #1, the administrator, provided a written note documenting New social worker, wasn't aware to notify. On 8/17/21 at 2:25 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the nurses call resident's representatives when residents are discharged to the hospital but do not provide a written notice of transfer. On 8/17/21 at 4:05 p.m., an interview was conducted with OSM (other staff member) #3 [social services director who has been employed at the facility for a little under two months]. OSM #3 stated she just found out on this day that she was responsible for providing written notice of transfer to residents/representatives and the ombudsman. OSM #3 stated she had not been doing this. On 8/18/21 at 7:21 AM, ASM (administrative staff member) #1, the executive director and ASM #2, the center nurse executive were made aware of the above findings. 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 154. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 119. 4. The facility staff failed to provide Resident # 25 and Resident # 25's representative and the ombudsman written notification of a facility-initiated transfer on 07/07/2021 for Resident # 25. Resident #25 was admitted to the facility on [DATE]. Resident #25's diagnoses included but were not limited to: chronic obstructive pulmonary disease (chronic, non-reversible lung disease) (1), dementia (progressive state of mental decline especially memory function and judgement) (2) and atrial fibrillation (rapid, random contractions of the atria of the heart) (3). Resident #25's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/20/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the eINTERACT (interventions to reduce acute care transfers) Transfer Form V5 dated 7/7/21, documented in part, Transfer to acute care hospital. A review of the nursing progress note dated 7/7/21 at 3:15 PM, documented in part, Send to [name of hospital] for evaluation. On 8/17/21 a request for evidence of the provision of written notice to the resident, RP and ombudsman for the 7/3/21 hospital transfer of Resident #38 was made via a written request for documents to the facility. On 8/17/21 ASM (administrative staff member) #1, the administrator, provided a written note documenting New social worker, wasn't aware to notify. On 8/17/21 at 2:25 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the nurses call resident's representatives when residents are discharged to the hospital but do not provide a written notice of transfer. On 8/17/21 at 4:05 p.m., an interview was conducted with OSM (other staff member) #3 [social services director who has been employed at the facility for a little under two months]. OSM #3 stated she just found out on this day that she was responsible for providing written notice of transfer to residents/representatives and the ombudsman. OSM #3 stated she had not been doing this. On 8/18/21 at 7:21 AM, ASM (administrative staff member) #1, the executive director and ASM #2, the center nurse executive were made aware of the above findings. 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 120. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 154. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 54. 7. Resident #91 was transferred to the hospital on 5/29/21. The facility staff failed to provide written notification of the transfer to the resident or representative and the ombudsman. Resident #91 was admitted to the facility on [DATE]. Resident #91's diagnoses included but were not limited to heart failure, diabetes and high cholesterol. Resident #91's quarterly minimum data set assessment with an assessment reference date of 7/22/21, coded the resident as being cognitively intact. Review of Resident #91's clinical record revealed the resident was transferred to the hospital on 5/29/21 for nausea and vomiting. Further review of the resident's clinical record, including nurses' notes and a transfer form, failed to reveal written notification of the transfer was provided to Resident #91, the resident's representative and the ombudsman. On 8/17/21 at 2:25 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated the nurses call residents' representatives when residents are discharged to the hospital but do not provide a written notice of transfer. On 8/17/21 at 4:05 p.m., an interview was conducted with OSM (other staff member) #3, the social services director who had been employed at the facility a little under two months. OSM #3 stated she just found out on this day that she was responsible for providing written notice of transfer to residents/representatives and the ombudsman. OSM #3 stated she had not been doing this. On 8/17/21 at 4:58 p.m., ASM (administrative staff member) #1 (the center executive director) and ASM #2 (the center nurse executive) were made aware of the above concern. ASM #1 stated the former social worker had been notifying the ombudsman of resident transfers via email and she was unable to obtain the emails. No further information was presented prior to exit. 5. The facility staff failed to provide Resident # 43 and Resident # 43's representative and the ombudsman written notification of a facility-initiated transfer on 06/07/2021 for Resident # 43. Resident # 43 was admitted to the facility with diagnoses that included but were not limited to: fractured femur [1] and high blood pressure. Resident # 43's most recent MDS [minimum data set], a significant change assessment with an ARD (assessment reference date) of 06/17/2021, coded Resident # 43 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 SNF/NF [skilled nursing facility/nursing facility] Hospital Transfer Form for Resident # 43 dated 06/07/2021 documented in part, Reason for transfer: fall. Review of the clinical record and the EHR (electronic health record) for Resident # 43 failed to evidence that a written notification of discharge was provided to the resident and resident's representative or notification to the ombudsman for the facility-initiated transfer on 06/07/2021 for Resident # 43. On 8/17/21 at 2:25 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the nurses call resident's representatives when residents are discharged to the hospital but do not provide a written notice of transfer. On 8/17/21 at 4:05 p.m., an interview was conducted with OSM (other staff member) #3 [social services director who has been employed at the facility for a little under two months]. OSM #3 stated she just found out on this day that she was responsible for providing written notice of transfer to residents/representatives and the ombudsman. OSM #3 stated she had not been doing this. On 8/17/21 at 4:58 p.m., ASM (administrative staff member) #1 (the center executive director) stated the former social worker had been notifying the ombudsman of resident transfers via email and she was unable to obtain the emails. On 08/17/2021 at approximately 5:00 p.m., ASM [administrative staff member] #1, center executive director, ASM # 2, center nurse executive, were made aware of the above concern. No further information was presented prior to exit. Reference: [1] The thigh bone, or femur, is the large upper leg bone that connects the lower leg bones (knee joint) to the pelvic bone (hip joint). This information was obtained from the website: https://medlineplus.gov/ency/imagepages/8844.htm. 6. The facility staff failed to provide Resident # 71 and Resident # 71's representative and the ombudsman written notification of a facility-initiated transfer on 06/21/2021 and 06/27/2021 for Resident # 71 Resident # 71 was admitted to the facility with diagnoses that included but were not limited to: heart failure and kidney failure. Resident # 71's most recent MDS [minimum data set], a significant change assessment with an ARD (assessment reference date) of 07/06/2021, coded Resident # 71 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 # 71 dated 06/21/2021 at 11:10 p.m. documented, Resident was taking [sic] to the hospital due to general weakness, and persistent headache at about 1545 [3:45 p.m.] this afternoon. The facility's progress note for Resident # 71 dated 06/27/2021 at 11:10 p.m. documented in part, Cardiovascular Status Evaluation: Chest pain/tightness. Recommendations: Sent to [Name of Hospital] for further observation. Review of the clinical record and the EHR (electronic health record) for Resident # 71 failed to evidence that a written notification of discharge was provided to the resident and resident's representative or notification to the ombudsman for the facility-initiated transfer on 06/21/2021 and 06/27/2021 for Resident # 71. On 8/17/21 at 2:25 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the nurses call resident's representatives when residents are discharged to the hospital but do not provide a written notice of transfer. On 8/17/21 at 4:05 p.m., an interview was conducted with OSM (other staff member) #3 [social services director who has been employed at the facility for a little under two months]. OSM #3 stated she just found out on this day that she was responsible for providing written notice of transfer to residents/representatives and the ombudsman. OSM #3 stated she had not been doing this. On 8/17/21 at 4:58 p.m., ASM (administrative staff member) #1 (the center executive director) stated the former social worker had been notifying the ombudsman of resident transfers via email and she was unable to obtain the emails. On 08/17/2021 at approximately 5:00 p.m., ASM [administrative staff member] #1, center executive director, ASM # 2, center nurse executive, were made aware of the above concern. No further information was presented prior to exit. 8. The facility staff failed to provide written notification of Resident #81's transfers to the hospital on 4/21/2021, 07/09/2021 and 07/28/2021 to the resident and/or responsible party and the ombudsman. Resident #81 was admitted to the facility on [DATE] with the most recent readmission on [DATE], with diagnoses that included but were not limited to: anemia (condition in which the hemoglobin content of the blood is below normal limits) (1), diabetes, high blood pressure, congestive heart failure (abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys) (2), COPD (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (3), and leukemia (one of the major types of cancer, malignant neoplasm of blood forming tissues) (4). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/7/2021, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. The SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer Form dated 4/21/2021, documented Resident #81's transfer to the hospital. There was no documentation related to providing the resident and/or responsible party a written notification of the transfer. The SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer Form dated 7/9/2021, documented Resident #81's transfer to the hospital. There was no documentation related to providing the resident and/or responsible party a written notification of the transfer. The SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer Form dated 7/28/2021, documented Resident #81's transfer to the hospital. There was no documentation related to providing the resident and/or responsible party a written notification of the transfer. On 8/17/21 at 2:25 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated the nurses call residents' representatives when residents are discharged to the hospital but do not provide a written notice of transfer. On 8/17/21 at 4:05 p.m., an interview was conducted with OSM (other staff member) #3 (the social services director who has been employed at the facility for a little under two months). OSM #3 stated she just found out on this day that she was responsible for providing written notice of transfer to residents/representatives and the ombudsman. OSM #3 stated she had not been doing this. On 8/17/21 at 4:58 p.m., ASM (administrative staff member) #1 (the center executive director) stated the former social worker had been notifying the ombudsman of resident transfers via email and she was unable to obtain the emails. ASM (administrative staff member) #1, and ASM #2, the center nurse executive, were made aware of the above concern on 8/17/2021 at 5:15 p.m.

**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 provide a written bed hold notice prior to an or upon a facility initiated transfer for eight of 31 residents in the survey sample, Resident #29, Resident #38, Resident #26, Resident #25, Resident #43, Resident #71, Resident #91 and Resident #81. The findings include: 1. Resident #29 was admitted to the facility on [DATE]. Resident #29's diagnoses included but were not limited to: diabetes mellitus (inability of insulin to function normally in the body) (1), end stage renal disease (end stage of renal failure-inability of the kidneys to excrete wastes and function in the maintenance of electrolyte balance) (2) and chronic obstructive pulmonary disease (chronic, non-reversible lung disease) (3). Resident #29's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/4/21, coded the resident as scoring 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the eINTERACT (interventions to reduce acute care transfers) Transfer Form V5 dated 4/5/21, documented in part, Transfer to hospital. No additional progress notes addressing transfer to the hospital on 4/5/21 was evidenced in the medical record. There was no documentation Resident #29 and or the resident representative was provided with a bed hold notice prior to and or upon transfer to the hospital on 4/5/21. On 8/17/21, a request for documented evidence a bed hold notice was provided to Resident #29 and or the resident RP at the time of discharge was made via a written request. On 8/17/21 at 11:24 AM, ASM (administrative staff member) #1, the administrator, returned the written request with the following documented note Bed holds not done. An interview was conducted on 8/17/21 at 3:52 PM with OSM (other staff member) #4, the admissions director, regarding resident transfers to the hospital. OSM #4 stated, We are supposed to contact the RP (responsible party) if they want to do bed hold, give them cost per day, and if they want to do bed hold, get signature when they come back in or the resident can sign it. We call and ask the resident or RP to sign. We call everybody. When asked if staff provide the resident and or resident representative with a written copy, OSM #4 stated, Yes if they would like it. No, it is not a standard to give a copy. The business office has binders with bed holds by month for every person that goes out. If the forms are not in the binder then they are not done. OSM #4 stated, We looked through the binder and the bed holds are not there and there is no other documentation. An interview was conducted on 8/17/21 at 4:07 PM with OSM #3, the social worker director. When asked about bed holds for resident transfers to the hospital, OSM #3 stated, I just found out today that the bed hold notice was my responsibility. I was not aware that this was part of my job. I have been here just short of two months, not even eight weeks. I will fix the process going forward. On 8/18/21 at 7:21 AM, ASM (administrative staff member) #1, the executive director and ASM #2, the center nurse executive were made aware of the above findings. A review of the facility's policy Discharge and Transfer policy revised 2/1/19, which documents in part, For unplanned, acute transfers where it is planned for the patient to return to the Center, the patient and/or resident representative will be notified verbally followed by written notification using the 'Notice of Hospital Transfer' or state specific transfer form. Copies of notices for emergency transfers must also be sent to the Ombudsman. 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 160. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 498. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 120. 2. Resident #38 was admitted to the facility on [DATE]. Resident #25's diagnoses included but were not limited to: diabetes mellitus (inability of insulin to function normally in the body) (1), end stage renal disease (end stage of renal failure-inability of the kidneys to excrete wastes and function in the maintenance of electrolyte balance) (2) and chronic obstructive pulmonary disease (chronic, non-reversible lung disease) (3). Resident #38's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/20/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the nursing progress note dated 7/3/21 at 8: 21 PM, documented in part, Resident went out to dialysis did not returned to facility in the evening time. This nurse called the family to inform that resident was not in the building at this time left message called [name of hospital] and found out she was admitted .Supervisor made aware. Further review of the clinical record failed to evidence any documentation Resident #38 and or the RP (resident representative) were provided with a bed hold notice prior to and or upon the residents transfer to the hospital on 7/3/21. On 8/17/21, a request for documented evidence a bed hold notice was provided to Resident #38 and or the resident RP at the time of discharge was made via a written request. On 8/17/21 at 11:24 AM, SAM (administrative staff member) #1, the administrator, returned the written request with the following documented note Bed holds not done. An interview was conducted on 8/17/21 at 3:52 PM with [NAME] (other staff member) #4, the admissions director, regarding resident transfers to the hospital. OSM #4 stated, We are supposed to contact the RP (responsible party) if they want to do bed hold, give them cost per day, and if they want to do bed hold, get signature when they come back in or the resident can sign it. We call and ask the resident or RP to sign. We call everybody. When asked if staff provide the resident and or resident representative with a written copy, OSM #4 stated, Yes if they would like it. No, it is not a standard to give a copy. The business office has binders with bed holds by month for every person that goes out. If the forms are not in the binder then they are not done. OSM #4 stated, We looked through the binder and the bed holds are not there and there is no other documentation. An interview was conducted on 8/17/21 at 4:07 PM with OSM #3, the social worker director. When asked about bed holds for resident transfers to the hospital, OSM #3 stated, I just found out today that the bed hold notice was my responsibility. I was not aware that this was part of my job. I have been here just short of two months, not even eight weeks. I will fix the process going forward. On 8/18/21 at 7:21 AM, ASM (administrative staff member) #1, the executive director and ASM #2, the center nurse executive were made aware of the above findings. 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 160. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 498. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 120. 3. Resident #26 was admitted to the facility on [DATE]. Resident #25's diagnoses included but were not limited to: congestive heart failure 'CHF' (circulatory congestion and retention of salt and water by the kidneys) (1), vascular dementia (progressive state of mental decline often caused by metabolic condition such as vascular supply to the brain) (2) and chronic kidney disease (decreased function of the kidneys) (3). Resident #26's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/6/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the eINTERACT (interventions to reduce acute care transfers) Transfer Form V5 dated 5/19/21, documented in part, Transfer to acute care hospital. A review of the nursing progress notes dated 5/19/21 at 4:05 PM, documented in part, The NP [nurse practitioner] wanted resident [Resident #26] to see a cardio MD [cardiologist] but was not able to get an appointment. The NP decided to send to hospital for evaluation. Further review of the clinical record failed to evidence any documentation regarding a bed hold being provided to the resident and or the resident representative prior to and or upon the Resident #26's transfer to the hospital on 5/19/21. On 8/17/21, a request for documented evidence a bed hold notice was provided to Resident #26 and or the resident RP at the time of discharge was made via a written request. On 8/17/21 at 11:24 AM, ASM (administrative staff member) #1, the administrator, returned the written request with the following documented note Bed holds not done. An interview was conducted on 8/17/21 at 3:52 PM with OSM (other staff member) #4, the admissions director, regarding resident transfers to the hospital. OSM #4 stated, We are supposed to contact the RP (responsible party) if they want to do bed hold, give them cost per day, and if they want to do bed hold, get signature when they come back in or the resident can sign it. We call and ask the resident or RP to sign. We call everybody. When asked if staff provide the resident and or resident representative with a written copy, OSM #4 stated, Yes if they would like it. No, it is not a standard to give a copy. The business office has binders with bed holds by month for every person that goes out. If the forms are not in the binder then they are not done. OSM #4 stated, We looked through the binder and the bed holds are not there and there is no other documentation. An interview was conducted on 8/17/21 at 4:07 PM with OSM #3, the social worker director. When asked about bed holds for resident transfers to the hospital, OSM #3 stated, I just found out today that the bed hold notice was my responsibility. I was not aware that this was part of my job. I have been here just short of two months, not even eight weeks. I will fix the process going forward. On 8/18/21 at 7:21 AM, ASM (administrative staff member) #1, the executive director and ASM #2, the center nurse executive were made aware of the above findings. 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 154. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 119. 4. Resident #25 was admitted to the facility on [DATE]. Resident #25's diagnoses included but were not limited to: chronic obstructive pulmonary disease (chronic, non-reversible lung disease) (1), dementia (progressive state of mental decline especially memory function and judgement) (2) and atrial fibrillation (rapid, random contractions of the atria of the heart) (3). Resident #25's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/20/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the eINTERACT (interventions to reduce acute care transfers) Transfer Form V5 dated 7/7/21, documented in part, Transfer to acute care hospital. A review of the nursing progress note dated 7/7/21 at 3:15 PM, documented in part, Send to [name of hospital] for evaluation. Further review of the clinical record failed to reveal any documentation evidencing a bed hold notice was provided to the resident and or RP prior to and or upon Resident #25's transfer to the hospital on 7/7/21. On 8/17/21, a request for documented evidence a bed hold notice was provided to Resident #25 and or the resident RP at the time of discharge was made via a written request. On 8/17/21 at 11:24 AM, ASM (administrative staff member) #1, the administrator, returned the written request with the following documented note Bed holds not done. An interview was conducted on 8/17/21 at 3:52 PM with OSM (other staff member) #4, the admissions director, regarding resident transfers to the hospital. OSM #4 stated, We are supposed to contact the RP (responsible party) if they want to do bed hold, give them cost per day, and if they want to do bed hold, get signature when they come back in or the resident can sign it. We call and ask the resident or RP to sign. We call everybody. When asked if staff provide the resident and or resident representative with a written copy, OSM #4 stated, Yes if they would like it. No, it is not a standard to give a copy. The business office has binders with bed holds by month for every person that goes out. If the forms are not in the binder then they are not done. OSM #4 stated, We looked through the binder and the bed holds are not there and there is no other documentation. An interview was conducted on 8/17/21 at 4:07 PM with OSM #3, the social worker director. When asked about bed holds for resident transfers to the hospital, OSM #3 stated, I just found out today that the bed hold notice was my responsibility. I was not aware that this was part of my job. I have been here just short of two months, not even eight weeks. I will fix the process going forward. On 8/18/21 at 7:21 AM, ASM (administrative staff member) #1, the executive director and ASM #2, the center nurse executive were made aware of the above findings. 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 120. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 154. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 54 7. The facility staff failed to provide Resident #91 and/or the resident's representative written notification of the bed hold policy when the resident was transferred to the hospital on 5/29/21. Resident #91 was admitted to the facility on [DATE]. Resident #91's diagnoses included but were not limited to heart failure, diabetes and high cholesterol. Resident #91's quarterly minimum data set assessment with an assessment reference date of 7/22/21, coded the resident as being cognitively intact. Review of Resident #91's clinical record revealed the resident was transferred to the hospital on 5/29/21 for nausea and vomiting. Further review of Resident #91's clinical record failed to reveal evidence that written notification of the bed hold policy was provided to the resident and/or the resident representative. On 8/17/21 at 3:52 p.m., an interview was conducted with OSM (other staff member) #4 (the admissions director). OSM #4 stated she is supposed to contact residents or their representatives when residents are transferred to the hospital, explain the bed hold process and ask if they would like a bed hold. OSM #4 stated she has residents or their representatives sign a bed hold form if they elect for a bed hold but a copy of the bed hold policy is not provided unless a bed hold is chosen. On 8/17/21 at 4:58 p.m., ASM (administrative staff member) #1 (the center executive director) and ASM #2 (the center nurse executive) were made aware of the above concern. No further information was presented prior to exit. 5. For Resident # 43, facility staff failed to send a copy of the bed hold policy to the hospital with the resident at the time of transfer on 06/07/2021. Resident # 43 was admitted to the facility with diagnoses that included but were not limited to: fractured femur [1] and high blood pressure. Resident # 43's most recent MDS [minimum data set], a significant change assessment with an ARD (assessment reference date) of 06/17/2021, coded Resident # 43 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 SNF/NF [skilled nursing facility/nursing facility] Hospital Transfer Form for Resident # 43 dated 06/07/2021 documented in part, Reason for transfer: fall. Review of the EHR [electronic health record] and the paper clinical record for Resident # 43 failed to evidence documentation that a bed hold policy was provided to Resident # 43 or Resident # 43's responsible party in regard to the facility-initiated transfer on 06/07/2021. On 8/17/21 at 3:52 p.m., an interview was conducted with OSM (other staff member) #4 (the admissions director). OSM #4 stated she is supposed to contact residents or their representatives when residents are transferred to the hospital, explain the bed hold process and ask if they would like a bed hold. OSM #4 stated she has residents or their representatives sign a bed hold form if they elect for a bed hold but a copy of the bed hold policy is not provided unless a bed hold is chosen. On 08/17/2021 at approximately 5:00 p.m., ASM [administrative staff member] #1, center executive director, ASM # 2, center nurse executive, were made aware of the above concern. No further information was presented prior to exit. Reference: [1] The thigh bone, or femur, is the large upper leg bone that connects the lower leg bones (knee joint) to the pelvic bone (hip joint). This information was obtained from the website: https://medlineplus.gov/ency/imagepages/8844.htm. 6. For Resident # 71, facility staff failed to send a copy of the bed hold policy to the hospital with the resident at the time of transfer on 06/27/2021. Resident # 71 was admitted to the facility with diagnoses that included but were not limited to: heart failure and kidney failure. Resident # 71's most recent MDS [minimum data set], a significant change assessment with an ARD (assessment reference date) of 07/06/2021, coded Resident # 71 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 # 71 dated 06/27/2021 at 11:10 p.m. documented in part, Cardiovascular Status Evaluation: Chest pain/tightness. Recommendations: Sent to [Name of Hospital] for further observation. Review of the EHR [electronic health record] and the paper clinical record for Resident # 71 failed to evidence documentation that a bed hold policy was provided to Resident # 71 or Resident # 71's responsible party in regard to the facility-initiated transfer on 06/27/2021. On 8/17/21 at 3:52 p.m., an interview was conducted with OSM (other staff member) #4 (the admissions director). OSM #4 stated she is supposed to contact residents or their representatives when residents are transferred to the hospital, explain the bed hold process and ask if they would like a bed hold. OSM #4 stated she has residents or their representatives sign a bed hold form if they elect for a bed hold but a copy of the bed hold policy is not provided unless a bed hold is chosen. On 08/17/2021 at approximately 5:00 p.m., ASM [administrative staff member] #1, center executive director, ASM # 2, center nurse executive, were made aware of the above concern. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 33. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 138. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 332.No further information was presented prior to exit. 8. The facility staff failed to provide written bed hold notification to the resident and/or responsible party for Resident #81's transfers to the hospital on 7/9/2021 and 7/28/2021. Resident #81 was admitted to the facility on [DATE] with the most recent readmission on [DATE], with diagnoses that included but were not limited to: anemia (condition in which the hemoglobin content of the blood is below normal limits) (1), diabetes, high blood pressure, congestive heart failure (abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys) (2), COPD (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (3), and leukemia (one of the major types of cancer, malignant neoplasm of blood forming tissues) (4). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/7/2021, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. The SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer Form dated 4/21/2021, documented the transfer to the hospital for Resident #81. There was no documentation related to providing the resident and/or responsible party a written notification of the transfer. The SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer Form dated 7/9/2021, documented the transfer to the hospital for Resident #81. There was no documentation related to providing the resident and/or responsible party a written notification of the transfer. The SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer Form dated 7/28/2021, documented the transfer to the hospital for Resident #81. There was no documentation related to providing the resident and/or responsible party a written notification of the transfer. ASM (administrative staff member) #1, the center executive director, presented one written behold notification for Resident #81's transfer to the hospital on 4/21/2021. ASM #1 stated there were no bed hold notifications for the transfers on 7/9/2021 and 7/28/2021. On 8/17/21 at 3:52 p.m., an interview was conducted with OSM (other staff member) #4 (the admissions director). OSM #4 stated she is supposed to contact residents or their representatives when residents are transferred to the hospital, explain the bed hold process and ask if they would like a bed hold. OSM #4 stated she has residents or their representatives sign a bed hold form if they elect for a bed hold but a copy of the bed hold policy is not provided unless a bed hold is chosen. ASM (administrative staff member) #1, and ASM #2, the center nurse executive, were made aware of the above concern on 8/17/2021 at 5:15 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility staff implemented bed rails for Resident #92 without a documented need and failed to obtain informed consent for the use of bed rails. Resident #92 was admitted to the facility on [DATE]. Resident #92's diagnoses included but were not limited to history of stroke, paralysis and anxiety disorder. Resident #92's quarterly minimum data set assessment with an assessment reference date of 7/24/21, coded the resident's cognitive skills for daily decision making as severely impaired. Section G coded Resident #92 as being totally dependent of two or more staff with bed mobility. Review of Resident #92's clinical record revealed a physician's order dated 3/21/21 for side rails (bed rails) as an enabler for bed mobility. Resident #92's comprehensive care plan initiated on 3/21/21 documented, Bed rails to the left and right side for bed mobility. A bed rail evaluation dated 3/21/21 documented Resident #92 was not able to move upper or lower extremities and no rail was recommended. Further review of Resident #92's clinical record failed to reveal informed consent for the use of bed rails was obtained from the resident's representative. On 8/16/21 at 11:48 a.m., Resident #92 was observed lying in bed. The right one half bed rail was up and the left one half bed rail was down. On 8/17/21 at 8:09 a.m., Resident #92 was observed lying in bed. Both one half bed rails were up. On 8/17/21 at 2:25 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated bed rail assessments are usually done on admission and she knew that a re-evaluation is completed but she was not sure when. LPN #3 stated a re-evaluation may be completed if a resident becomes stronger and no longer needs bed rails or when a resident becomes weaker and needs bed rails. LPN #3 was asked if a resident should have bed rails if they was assessed as not needing them. LPN #3 stated, You go by the assessment. LPN #3 stated Resident #92 was not able to use bed rails. On 8/17/21 at 4:58 p.m., ASM (administrative staff member) #1 (the center executive director) and ASM #2 (the center nurse executive) were made aware of the above concern. ASM #2 stated Resident #92 had recently been moved per her husband's request and the new bed contained bed rails. ASM #2 stated a work order had been submitted to remove the bed rails. No further information was presented prior to exit. Based on observation, staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement bed rail requirements for four of 31 residents in the survey sample, Residents # 68, #252, #250 and # 92. The findings include: 1. The facility staff implemented bed rails for Resident #68 without a documented need and failed to obtain informed consent for the use of bed rails. Resident #68 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: fracture of hip, high blood pressure and diabetes. The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 7/16/2021, coded Resident #68 as scoring a 12 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired to make daily cognitive decisions. In Section G the resident was coded for bed mobility as the activity did occur but only once or twice with the assistance of two or more staff members. Resident #68 was observed on 8/16/2021 at 3:42 p.m. in the bed, with half side rails up on both sides. A Bed Rail Evaluation for Resident #68 dated 7/12/2021, documented in part, Category: No Bed Rails to be used. Review of the physician orders failed to evidence documentation of a physician order for the use of bed rails. Further review of Resident #68's clinical record failed to reveal informed consent for the use of bed rails was obtained from the resident and or resident's representative. The comprehensive care plan dated, 7/12/2021, documented in part, Focus: Resident/Patient requires assistance for ADL (activities of daily living) care in specify: (bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to recent illness and hospitalization. There was no documentation related to the use of bed rails [also referred to as side rails]. On 8/17/21 at 2:25 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated bed rail assessments are usually done on admission and she knew that a re-evaluation is completed but she was not sure when. LPN #3 stated a re-evaluation may be completed if a resident becomes stronger and no longer needs bed rails or if a resident becomes weaker and needs bed rails. LPN #3 was asked if a resident should have bed rails if he or she was assessed as not needing them. LPN #3 stated, You go by the assessment. The facility policy, Bed Rails documented in part, (Name of Corporation) will only use bed rails as mobility enablers Prior to use of bed rails, staff will attempt the use of appropriate alternatives. If the alternatives were not adequate to meet the patient's needs, the patient will be evaluated for the use of bed rails. The Bed Rail Evaluation will be completed upon admission, re-admission, change in bed or mattress, and with a significant change in condition .If the Evaluation determines that a bed rail would not provide benefit as an enabler and bed rails are currently on the bed, notify Maintenance to remove the bed rail or secure the bed rail in the 'down' position. ASM (administrative staff member) #1, the center executive director, and ASM #2, the center nurse executive, were made aware of the above on 8/17/2021 at 5:15 p.m. No further information was provided prior to exit. 2. The facility staff implemented bed rails for Resident #252 without a documented need and failed to obtain informed consent for the use of bed rails. Resident #252 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: COPD (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (1), lung cancer, high blood pressure and diabetes. A MDS (minimum data set) assessment had not yet been completed during the time of survey. The Nursing Documentation dated 8/10/2021 at 9:17 p.m. documented in part, Reason for note: admission/readmission. Under question 3. Additional details about the note, the following was documented, Pt (patient) is A&O (alert and oriented) X4 (person, place time and situation). There was no documentation related to bed mobility. Observation was made of Resident #252 on 8/16/2021 at 3:08 p.m. The resident was in bed with quarter rails up on both sides of the bed. Resident #252's Bed Rail Evaluation dated, 8/10/2021, documented in part, Category: No Bed Rails to be used. Review of the physician orders failed to evidence documentation of a physician order for the use of side rails. Further review of Resident #252's clinical record failed to reveal informed consent for the use of bed rails was obtained from the resident and or resident's representative. The comprehensive care plan dated, 8/17/2021, documented in part, Resident/Patient requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to recent hospitalization resulting in decreased mobility, and activity intolerance. The Interventions documented in part, Provide resident/patient with limited assist of one for bed mobility. On 8/17/21 at 2:25 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated bed rail assessments are usually done on admission and she knew that a re-evaluation is completed but she was not sure when. LPN #3 stated a re-evaluation may be completed if a resident becomes stronger and no longer needs bed rails or if a resident becomes weaker and needs bed rails. LPN #3 was asked if a resident should have bed rails if he or she was assessed as not needing them. LPN #3 stated, You go by the assessment. ASM (administrative staff member) #1, the center executive director, and ASM #2, the center nurse executive, were made aware of the above on 8/17/2021 at 5:15 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. 3. The facility staff implemented bed rails for Resident #250 without a documented need and failed to obtain informed consent for the use of bed rails. Resident #250 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: status post knee replacement, diabetes, high blood pressure and rheumatoid arthritis (A chronic, destructive disease characterized by joint inflammation. Symptoms are varied, often including fatigue, low-grade fever, loss of appetite, morning stiffness, tender, painful swelling of two or more joints, most commonly in fingers, ankles, feet, hips and shoulders.). (1) The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 8/9/2021, coded Resident #250 as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. In Section G - Functional Status, the resident was coded as requiring limited assistance on two or more staff members for bed mobility. Observation was made of Resident #250 on 8/16/2021 at 4:45 p.m. in bed with quarter rails up on both sides of the bed. The Bed Rail Evaluation for Resident #250 dated 6/1/2021, documented in part, Category: No Bed Rails to be used. Review of the physician orders failed to evidence a physician order for the use of bed rails. Further review of Resident #92's clinical record failed to reveal informed consent for the use of bed rails was obtained from the resident and or resident's representative. The comprehensive care plan dated, 8/9/2021, documented in part, Focus: Resident/Patient requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to recent illness and hospitalization resulting in fatigue, activity intolerance. On 8/17/21 at 2:25 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated bed rail assessments are usually done on admission and she knew that a re-evaluation is completed but she was not sure when. LPN #3 stated a re-evaluation may be completed if a resident becomes stronger and no longer needs bed rails or if a resident becomes weaker and needs bed rails. LPN #3 was asked if a resident should have bed rails if he or she was assessed as not needing them. LPN #3 stated, You go by the assessment. ASM (administrative staff member) #1, the center executive director, and ASM #2, the center nurse executive, were made aware of the above on 8/17/2021 at 5:15 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 511.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store food in a sanitary manner. The facility staff failed to discard two (five pound) plastic containers of low fat cottage cheese with a manufacturer's best if used by date of 7/31/21, failed to cover and label a metal pan of mixed vegetables with broccoli, cauliflower and carrots, and failed to ensure a scoop was not stored in a bin of flour. The findings include: On 8/16/21 at 10:35 a.m., a tour of the facility kitchen was conducted with OSM (other staff member) #1 (dietary manager. The following was observed: -In the walk in refrigerator: two (five pound) plastic containers of low fat cottage cheese with a manufacturer's best if used by date of 7/31/21. -In the walk in freezer: a metal pan of mixed vegetables with broccoli, cauliflower and carrots that was not covered or labeled. -In the dry storage room: a scoop sitting in flour within the flour bin. In regards to the cottage cheese, OSM #1 stated he follows manufacturers' best if used by dates and the cottage cheese should be thrown away. OSM #1 removed the cottage cheese and stated he needed to call the food distribution company because the cottage cheese had recently been delivered. In regards to the metal pan of mixed vegetables, OSM #1 stated the dietary staff was in the process of cooling the vegetables but they should be covered to prevent germs and labeled. In regards to the scoop inside of the flour bin, OSM #1 stated the scoop is supposed to be stored on a rack in the dish room and placed back in the dish room after use. OSM #1 stated the scoop should not be stored inside the bin. On 8/17/21 at 4:58 p.m., ASM (administrative staff member) #1 (the center executive director) and ASM #2 (the center nurse executive) were made aware of the above concern. The facility policy titled, Food Storage: Dry Goods documented, All dry goods will be appropriately stored in accordance with the FDA (Food and Drug Administration) Food Code. The facility policy titled, Food Storage: Cold Foods documented, 5. All food will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. No further information was presented prior to exit.

Based on staff interview and facility document review, it was determined that the facility staff failed to maintain an effective Quality Assurance program. The findings include: On 08/17/2021 at approximately 8:00 a.m., a review of the facility's QAPI [quality assurance performance improving] Committee Meeting Sign-In Sheets dated October 2020 through December 2020, January 2021 through March 2021 and April 2021 through June 2021 were reviewed. The QAPI sign-in sheets listed above failed to evidence the signature of the facility's medical director. On 08/17/2021 at approximately 9:09 a.m., an interview was conducted with ASM [administrative staff member] # 1, center executive director regarding the missing signature of the medical director for the dates listed above. When asked how the members of the QAPI committee were notified of the meet times and dates, ASM # 1 stated they send out a Zoom invitation [allows you to send invites by email, contact or phone number] to all members. When asked about the missing signature of the medical director, ASM # 1 stated that the medical director does not attend nor do they respond to the zoom invitations. When asked if the medical director was aware of their responsibility regarding QAPI, ASM # 1 stated yes. ASM # 1 further stated, He does not communicate well and will refuse to meet with nurses when he is in the facility. The facility's Medical Director Agreement dated 09/01/2018 documented in part, [Name of Physician Services] [Name of Medical Director] (Physician) who is duly licensed to practice medicine in the State of Virginia and has the background, training, education and experience to provide the medical direction and supervision the Center requires. Under (iv) Physician and Center compliance it documented, Objective: To ensure effective physician compliance with pertinent laws and regulations, so the Center can meet overall requirements. The Medical Director will ensure that the medical and overall care at the Center is consistent with applicable laws and regulations. In addition, Medical Director shall ensure that appropriate policies and procedures exist and are being followed. The Medical Director will provide appropriate feedback to physicians about their care and overall performance. Methods may include (but are not limited to) written rules and guidelines for physicians; patient rounds; review of feedback from nursing staff, letters, phone calls, and faxes to attending physicians; use of quality indicators; and review of new and revised regulations, when issued. (v) Care quality improvement. Objective: To help the physician and the Center assess and improve the care quality. The Medical Director will help evaluate and try to improve care quality. The Medical Director will help define or clarify quality standards, based on broad professional consensus or current medical knowledge. Methods for doing this may include (but not limited to) rounds; consultation in individual cases (especially those with complications or specific staff, patient or family concerns); review of specific aspects of care; screening of care through various measures, participation in quality assurance committee; reporting of findings to physicians individually and collectively; provision of education and information to physicians; review of high risk aspects of care ; review of selected admissions and discharges to help with problems; review of selected aspects of physician documentation; meeting with administrator, director of nursing and other key staff; review of performance contractual or external providers (lab, x-ray, etc.). The facility's policy Medical Director Responsibilities documented in part, The Medical Director participates in the Quality Assurance and Performance Improvement (QAPI) Committee or assigns a designee to represent him/her. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview and clinical record review, it was determined that the facility staff failed to provide accommodation of resident needs for one of 55 residents in the survey sample, Resident # 7. The facility staff failed to ensure Resident #7's call bell (a device with a button that can be pushed to alert staff when assistance is needed), was within the resident's reach. The findings include: Resident # 7 was admitted to the facility on [DATE] with diagnoses that included but were not limited to lack of coordination, rheumatoid arthritis (1), Alzheimer's disease (2), gastroesophageal reflux disease (3) and hypertension (4). Resident # 7's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 10/20/18, coded Resident # 7 as scoring an eight on the brief interview for mental status (BIMS) of a score of 0 - 15, eight - being moderately impaired of cognition for making daily decisions. Resident # 7 was coded as requiring extensive assistance of one staff member for activities of daily living. Section G0400 Functional Limitation in Range of Motion coded Resident # 7 as being impaired on both sides of her upper extremities (shoulder, elbow, wrist, hand). On 02/05/19 at 11:08 a.m., an observation of Resident # 7 revealed she was lying in bed, awake, neat and clean, watching television. The head of the bed was slightly raised and a pillow was under the upper part of Resident # 7's back. Further observation of Resident # 7 revealed she was leaning toward her left side. Observation of the call bell revealed it was a flat pressure switch. Observation of the call bell's placement revealed it was lying on top of the mattress in the upper right corner, behind Resident # 7's head. When asked if she could locate the call bell Resident # 7 moved her head slightly to the right and left and struggled to remove her right arm from under the blanket covering her. Resident # 7 stated, I don't know where it is. Observation of Resident # 7's movements revealed there was decreased range of motion. On 02/05/19 at 3:22 p.m., an observation of Resident # 7 revealed she was lying in bed, awake, neat and clean, watching television. The head of the bed was slightly raised and a pillow was under the upper part of Resident # 7's back. Further observation of Resident # 7 revealed she was leaning slightly to her left side. Observation of the call bell's placement revealed it was hanging off the side of the mattress in the upper right corner, behind Resident # 7's head. When asked if she could locate the call bell Resident # 7 stated, I don't know where it is. On 02/06/19 at 8:01 a.m., an observation of Resident # 7 was lying in bed, watching television. The head of the bed was slightly raised and a pillow was under the upper part of Resident # 7's back. Further observation of Resident # 7 revealed she was leaning slightly to her left side. Observation of the call bell's placement revealed it was lying on the bed, on Resident # 7's right side just below her shoulder. When asked if she could locate the call bell Resident # 7 stated, I don't know where it is. On 02/07/19 at 8:15 a.m., an observation of Resident # 7 was lying in bed, watching television. The head of the bed was slightly raised and a pillow was under the upper part of Resident # 7's back. Further observation of Resident # 7 revealed she was leaning slightly to her left side. Observation of the call bell's placement revealed it was lying on the bed, on Resident # 7's right side just below her shoulder. When asked if she could locate the call bell Resident # 7 stated, No. The comprehensive care plan for Resident # 7 dated 10/25/2017, with a revision date of 12/12/2018 documented, Focus. Resident is at risk for falls related to cognitive impairment, lack of safety awareness and impaired mobility. Date initiated 10/25/2017. Revision date: 12/12/2018. Under Interventions, it documented Place call light within reach while in bed or close proximity to the bed. Date initiated: 10/25/2017. On 02/07/19 at 8:15 a.m., an observation of Resident # 7's call bell placement was conducted with CNA (certified nursing assistant) # 2. When asked if the call bell was placed in, a position that Resident # 7 could reach and activate, CNA #2 sated, It's not in reach, she has limited range of motion. When asked to describe the procedure for the placement of a cell bell for a resident, CNA # 2 stated, They should be placed in reach. It should have been placed on her gown where she can reach it. When asked why it was important for a resident to have access to their call bell, CNA # 2 stated, In case they have an accident, if they are in pain to get a hold of the staff for assistance, to have their needs met. When asked how often the placement of the call bell should be checked, CNA # 2 stated, (At least every two hour during rounds and when you go into the room. On 02/07/19 at 8:30 a.m., an observation of Resident # 7's call bell placement was conducted with RN (registered nurse) # 8, unit manager. When asked if the call bell was placed in a position that Resident # 7 could reach and activate, RN # 8 sated, No and immediately repositioned the call bell within reach of Resident # 7's right hand. When asked to describe the procedure for the placement of a cell bell for a resident, RN # 8 stated, Should be in reach within the resident's ability. When asked why it was important for a resident to have access to their call bell, RN # 8 stated, For dignity, to be able to get a hold of staff for assistance and help. When asked how often the placement of the call bell should be checked, RN # 8 stated, Every time we (staff) go into the resident's room. On 02/07/19 at approximately 3:45 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, executive nurse, were made aware of the above findings. No further information was provided prior to exit. References: (1) A long-term disease. It leads to inflammation of the joints and surrounding tissues. It can also affect other organs. This information was obtained from the website: https://medlineplus.gov/ency/article/000431.htm. (2) A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. (3) Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary. (4) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, it was determined that the facility staff failed to clarify a physician's order for code status for one of 55 residents in the survey sample, Resident #26. The facility staff failed to ensure Resident #26's current active physician's order form signed by the physician on 2/5/19 contained the resident's code status (whether or not to perform cardiopulmonary resuscitation in the event of cardiac arrest). The findings include: Resident #26 was admitted to the facility on [DATE]. Resident #26's diagnoses included but were not limited to fractured vertebra, acute kidney failure and urinary tract infection. Resident #26's most recent MDS (minimum data set), a 30 day Medicare assessment with an ARD (assessment reference date) of 11/25/18, coded the resident's cognition as severely impaired. Review of Resident #26's clinical record revealed a Virginia Department of Health Durable Do Not Resuscitate Order form dated 2/5/18. Resident #26's comprehensive care plan dated 10/31/18 documented, Resident has established advanced directive and/or DNR (do not resuscitate) order in place .DO NOT RESUSCITATE (DNR) . Review of Resident #26's current active physician's order form (a listing of all active physician's orders), signed by the physician on 2/5/19 failed to reveal documentation of the resident's code status. On 2/6/19 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 was asked where nurses reference a resident's code status. LPN #3 stated, Sometimes in the computer or in the chart under the admissions records or the advance directives. When asked if a resident should have a physician's order for his or her code status, LPN #3 stated, Well yeah. Resident #26's current active physician's order form signed by the physician on 2/5/19 was reviewed with LPN #3. LPN #3 stated the form should reflect the resident's current active physician's orders. When asked to confirm that the form did not contain a current active order reflecting Resident #26's code status, LPN #3 stated, According to this no. On 2/6/19 at 5:39 p.m., ASM (administrative staff member) #1 (the executive director), ASM #2 (the nurse executive) and ASM #3 (the clinical quality specialist) 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 resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to notify and consult with the physician regarding a possible need to alter treatment for two of 55 residents in the survey sample, Resident #71, and #35. 1. The facility staff failed to notify Resident #71's physician when the resident's medication Advair was not administered on multiple dates in November 2018 and January 2019. 2. The facility staff failed to evidence the physician was notified, consulted regarding, the need to administer prescribed medications to Resident #35 late, when the resident returned to the facility late, over an hour past the scheduled time for the 8:00 p.m., administration of two medications on 8/30/18 and 10/3/18. The findings include: 1. Resident #71 was admitted to the facility on [DATE]. Resident #71's diagnoses included but were not limited to chronic obstructive pulmonary disease (2), low back pain and anxiety disorder. Resident #71's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/8/19, coded the resident as being cognitively intact. Review of Resident #71's clinical record revealed a physician's order dated 10/17/18, for, Advair 500 mcg (micrograms)/50 mcg and to inhale one puff every 12 hours. Review of Resident #71's November 2018 and January 2019 MARs (medication administration records) failed to reveal Advair was administered to the resident (as evidenced by blank spaces with no documented nurses' initials) on the following dates and times: - 11/1/18 at 9:00 p.m., - 11/3/18 at 9:00 a.m., - 11/30/18 at 9:00 p.m., - 1/9/19 at 9:00 p.m., - 1/23/19 at 9:00 p.m. Nurses' notes for those dates failed to reveal the medication was administered. Further review of Resident #71's January 2019 MAR revealed Advair was not administered to the resident on the following dates and times: -1/6/19 at 9:00 a.m. and 9:00 p.m., -1/18/19 at 9:00 a.m. and 9:00 p.m., -1/19/19 at 9:00 a.m. and - 1/29/19 at 9:00 a.m. On these dates above, the nurses circled their initials and documented the medication was not available on the back of the MAR. Resident #71's comprehensive care plan dated 10/2/18 documented, Resident exhibits or is at risk for respiratory complications related to Asthma, COPD .Medicate as ordered and monitor for effectiveness and observe for signs/symptoms of side effects. Report to physician as indicated. On 2/5/19 at 12:20 p.m., an interview was conducted with Resident #71. The resident stated he was not getting his Advair as he was supposed to for a while but that had straightened itself out. On 2/6/19 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 was asked how nurses evidence the medications and treatments they administer. LPN #3 stated, They sign off on the MAR (medication administration record) and TAR. When asked what is meant if there are blank, spaces on the MAR or TAR and the nurses did not sign off, LPN #3 stated, In reality it means that they didn't do it. LPN #3 was asked what is meant if nurses sign and circle their initials on the MAR. LPN #3 stated, Usually if signed and circled, either they held it, or couldn't give it, they are supposed to explain on the back of the MAR. LPN #3 was asked if Advair is contained in the facility STAT (immediate) box (a box containing various medications that can be accessed for any resident if needed). LPN #3 stated Advair is contained in the facility omnicell (a machine provided by that pharmacy, containing many various medications that can be accessed for each resident). LPN #3 was asked about the facility process for ensuring Advair is available for administration, if not in the medication cart. LPN #3 stated, They can check the omnicell. If it's the right dose, the omnicell will let you pull it. If not, let the physician know it's not here, let the patient know, call the pharmacy and ask to send (the medication) from backup (a backup pharmacy) and let the rp (responsible party) know that you didn't give it. When asked why the physician should be notified, LPN #3 stated, Cause it's a med (medication) they ordered and they need to know if they got it or not. Complications could happen so they need to be aware. On 2/6/19 at 5:39 p.m., ASM (administrative staff member) #1 (the executive director), ASM #2 (the nurse executive) and ASM #3 (the clinical quality specialist) were made aware of the above concern. The facility policy titled, Medication Administration: General documented, A licensed nurse, Med Tech, or medication aide, per state regulations, will administer medications to patients .If discrepancies, including medication not available, notify physician/advanced practice provider (APP) and/or pharmacy as indicated . No further information was obtained prior to exit. (1) Advair is used to treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by asthma. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a699063.html (2) COPD (chronic obstructive pulmonary disease) makes it hard for you to breathe. The two main types are chronic bronchitis and emphysema. The main cause of COPD is long-term exposure to substances that irritate and damage the lungs. This is usually cigarette smoke. Air pollution, chemical fumes, or dust can also cause it. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=copd&_ga=2.95971676.178186840.1550160688-1667741437.1550160688 2. The facility staff failed to evidence the physician was notified, consulted regarding, the need to administer prescribed medications to Resident #35 late, when the resident returned to the facility late, over an hour past the scheduled time for the 8:00 p.m., administration of two medications on 8/30/18 and 10/3/18. Resident #35 was admitted to the facility on [DATE] with the diagnoses of but not limited to hip fracture, atrial fibrillation, high blood pressure, falls, inguinal hernia, and cardiomyopathy. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 11/23/18. The resident was coded as being cognitively intact in ability to make daily life decisions. The resident was coded as being independent for transfers, locomotion, dressing, eating, and toileting and as requiring supervision for hygiene. A review of the clinical record revealed a physician's order dated 8/22/18 that documented the resident may go on LOA [leave of absence] for 4 hours daily. A review of the nurse's notes revealed the following: A nurse's note dated 8/30/18 documented, Resident signed out at 1:30pm, today and stated that he was going to (name of bank) and not going to church tonight. Cousin and friend were contacted at 10pm today because resident was not back at facility. Unit manager on call was contacted. Resident made contact with facility soon after and was reported to unit manager on call. Unit manager will pick up resident from Firestone off of (location) A nurse's note dated 8/31/18 documented, Late entry: This RN was contacted by nursing staff of residents (Sic.) failure to return to the facility following his departure for the bank earlier in the afternoon. Nursing staff was advised to make contact with RP to see if they knew where resident was located. This RN was advised that contact was made with residents (Sic.) cousin and friend, neither of which knew of his whereabouts. DON was notified of incident. Nursing staff was advised to call the sheriffs (Sic.) office non emergency number to report the residents (Sic.) failure to return. At approximately 10:30pm, this RN was notified by staff that (resident) had called the facility and stated he was at the Firestone and was unable to get back due to not having enough money for the cab ride. This writer went to pick up resident shortly after. Resident was found in front of the Firestone (location) sitting on the ground. Resident stated he left his bank card (Sic.) back at the facility and was unable to get a ride back. Resident returned to facility. This RN stressed the importance to the resident of returning in a timely manner and the need to be able to take his evening medicine. Resident expressed understanding. Resident was asked where he usually goes when he leaves the facility so if another incident occurs we know where to look. Resident stated that he goes to the (name of bank) on (location) and is usually in the shopping center above or below the hospital. Resident returned to facility at approximately 11:30pm. A nurse's note dated 10/3/18 documented, Patient left facility at 2:10 p.m., for LOA was supposed to return by 6:10 p.m. Patient called facility at 7:50 p.m., to say he was at the Bus Station in (location) with no way back. Patient returned at 9:30PM He stated, Someone from the Bus Station gave me a ride back. Patient education given on Safety and if Patient is going out alone he must have money for Cab fare both ways and he must return back on time. A review of the clinical record revealed an order dated 5/23/18 for Cal-Gest {1}, 1 tab (tablet) twice daily for calcium supplement; and a Metoprolol {2} 50 mg (milligrams) twice daily for high blood pressure. A review of the August 2018 MAR (Medication Administration Record) documented that the resident was to receive the above medications at 8:00 p.m. On 8/30/18, these medications were documented as administered at 8:00 p.m., when the resident was documented in nurses' notes, as not present in the building between 1:30 p.m., and 11:30 p.m. There was no evidence that the physician was notified, consulted for orders to administer the medications late. A review of the October 2018 MAR documented that the resident was to receive the same two medications above at 8:00 p.m. On 10/3/18, these medications were documented as administered at 8:00 p.m., when the resident was documented in nurses' notes as not being in the building between 2:10 p.m. and 9:30 p.m. There was no evidence that the physician was notified, consulted for orders to administer the medications late. On 2/7/19 at 1:24 p.m., in an interview with LPN #4, was asked about the process staff follows when a resident is out on leave long enough to miss medications. LPN #4 stated the physician should be called to verify if the medications can be given or not. On 2/7/19 at 2:20 p.m., in an interview with the Executive Director (ASM [administrative staff member] #1) and Nurse Executive, ASM #2. When asked about the resident's unsupervised outings into the community and issues he had of returning to the facility timely, ASM #1 stated that he was alert and oriented, his BIMS (Brief Interview for Mental Status exam) was a 15 (cognitively intact). She stated the physician was aware of the resident's outings and that it was his right to go out if he wanted to. When asked about the resident's missed medications when he was late returning to the facility, ASM #1 stated that the doctor should have been notified and direction provided whether or not to administer them (medications) late. A review of the facility policy, Leave of Absence/Therapeutic Leave did not include direction on procedures if the resident was out past a medication time and missed medications. A review of the facility policy, Leave of Absence, Resident Discharge with Medication or Other Change of Status documented, When a Facility physician/prescriber provides an order for the resident to take a leave of absence, the physician/prescriber should specify the medications the resident is to take with them while on leave If the resident is taking a leave of absence for less than 24 hours, consider a change in the time for administration of a medication, if appropriate, to avoid the need to send that dose of medication with the resident The policy did not address what the procedure should be if the resident's leave was to be brief, but the resident missed the medications due to a late return. No further information was provided. {1} Cal-Gest Antacid - Calcium carbonate is a dietary supplement used when the amount of calcium taken in the diet is not enough. Calcium is needed by the body for healthy bones, muscles, nervous system, and heart. Calcium carbonate also is used as an antacid to relieve heartburn, acid indigestion, and upset stomach. It is available with or without a prescription. Information obtained from https://medlineplus.gov/druginfo/meds/a601032.html {2} Metoprolol - Metoprolol is used alone or in combination with other medications to treat high blood pressure. It also is used to prevent angina (chest pain) and to improve survival after a heart attack. Metoprolol also is used in combination with other medications to treat heart failure. Metoprolol is in a class of medications called beta blockers. It works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a682864.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility policy review and clinical record review, it was determined the facility staff failed to ensure resident mail was received unopened for one of 55 residents in the survey sample, Resident #50. The facility staff failed to ensure Resident #50 received unopened mail. The findings include: Resident #50 was admitted to the facility on [DATE]. Diagnosis included but were not limited to: high blood pressure, depression, chronic obstructive pulmonary disease (1) and obstructive sleep apnea (2). The most recent MDS (minimum data set), an annual assessment, with an assessment reference date of 7/24/18, coded the resident as having a score of 15 of 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact to make daily decisions. On 02/05/19 at approximately 11:09 a.m., an interview was conducted with Resident #50. Resident #50 was asked if he felt the facility offered him privacy. Resident #50 replied, For the most part. A couple of months ago I was supposed to get a package in the mail, but when it got to me, someone had opened it. I was pretty- mad about that, and I let the administration know about it (Sic). I had ordered some batons from Amazon. They (the facility administration) thought it was a weapon. I have a 'bum' shoulder, and I was going to use them to stretch my arms. After I complained about this, they said they would ask me before they opened my packages. The social worker note dated 8/21/18 at 3:07 p.m., documented (name of Resident #50) has a rotator cuff pain and goals will focus on improving his flexibility and pain level. (Name of Resident #50) continues to order equipment from Amazon that might not be appropriate for our facility (i.e. gym equipment, karate gear, etc.). He is aware that anything he wants to order should be reviewed first so that he does not bring anything inappropriate to the facility. On 02/07/19 at approximately 8:43 a.m., an interview was conducted with OSM (other staff member) #2, Activities director. OSM #2 was asked how residents are supposed to receive their mail, OSM #2 replied, We usually receive mail every day, and try to give it to the residents. We have a mail day on Saturday. OSM #2 was asked if residents were supposed to get their mail unopened, OSM #2 replied Yes. OSM #2 was asked if any resident had complained about receiving opened mail, OSM #2 replied Yes, (name of the Resident #50), I don't know who opened it. I remember asking around about it but no one said they opened it. But I, the activities assistant and the receptionist all were educated that a resident's mail was supposed to be unopened. On 02/07/19 at approximately 8:52 a.m., an interview was conducted with ASM (administrative staff member) #1, the Executive Director. ASM #1 was asked if any residents had complained of getting opened mail. ASM #1 replied, Yes (name of Resident #50), told me while I made a tour, that a while back before I got here, he had received an opened package. The resident had a history of getting weapons in the mail, so the previous administrator opened his package. However when I found out about this I educated the staff on not opening a residents mail. We also told him that he can't have any weapons here. And now staff are not to open any of his package unless he consents and they open it in his presence. On 02/07/19 at approximately 11:00 a.m., the facility provided this surveyor with a document titled Recreation Staff Education dated 1/8/19, which documented, Resident mail will be delivered unopened. The document was signed by OSM #12, activities assistant, OSM #13, activities, and OSM #2, activities assistant. The comprehensive care plan dated February 2019 failed to mention how Resident #50's mail should be delivered. On 02/07/19 at approximately 5:45 p.m., ASM #1, the Executive Director and ASM #2, the Nurse Executive, and ASM #3, Clinical Quality Specialist, were made aware of the findings. The facility policy titled Privacy Rights: Patient with a most recent revision date of 11/28/16, documented, Personal privacy includes accommodations, medical treatment, written, telephone and electronic communication. No further information was obtained prior to exit. 1. Disease that makes it difficult to breath that can lead to shortness of breath). The two main types are chronic bronchitis and emphysema. The main cause of COPD is long-term exposure to substances that irritate and damage the lungs. This is usually cigarette smoke. Air pollution, chemical fumes, or dust can also cause it. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 2. Obstructive sleep apnea (OSA) is a problem in which your breathing pauses during sleep. This occurs because of narrowed or blocked airways. This information was obtained from the website: https://medlineplus.gov/ency/article/000811.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the facility abuse policy for three of 55 residents in the survey sample, Residents #3, #261 and #262. 1. The facility staff failed to implement the facility abuse policy for reporting Resident #3's allegation of abuse to the state agency within the required two-hour timeframe. 2. The facility staff failed to implement the facility abuse policy for reporting Resident #261's and Resident #262's allegations of abuse to the SA (state agency) within the required two-hour timeframe. On 9/23/18, Resident #261 reported an allegation of abuse to RN (registered nurse) #11. The allegation was not reported to the SA until 9/24/18. On 9/22/18, Resident #262 reported an allegation of abuse to CNA (certified nursing assistant) #9. The allegation was not reported to the SA until 9/24/18. Both allegations were submitted to the SA in one FRI (facility reported incident) on 9/24/18. The findings include: 1. The facility staff failed to implement the facility abuse policy for reporting Resident #3's allegation of abuse to the state agency within the required two hour timeframe. Resident #3 was admitted to the facility on [DATE]. Resident #3's diagnoses included but were not limited to diabetes, major depressive disorder and end stage kidney disease. Resident #3's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/5/18, coded the resident's cognition as severely impaired. The facility policy titled, Abuse Prohibition documented, 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED (center executive director) or designee will perform the following: 6.1 Enter allegation into the Risk Management System (RMS). 6.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made . A FRI (facility reported incident) submitted to the state agency (Office of Licensure and Certification) on 1/18/19 documented, Incident Date: 1/17/2019. Report date: 1/18/2019. Residents involved: (name of Resident #3). Injuries: (an X beside No). Incident type: (an X beside Allegation of abuse/mistreat). No further information regarding the incident was documented on the FRI. The final report dated 1/23/19 documented, On 1/17/19 (name of Resident #3) reported that 'a CNA (certified nursing assistant) with red hair was rough when putting me back to bed, they picked me up around my breast and threw me into bed' this statement was made to the resident's son (name) when he came to visit .(Name of Resident #3's son) later than evening arrived to the facility to visit with (name of Resident #3) at this time the resident reported rough care to her son. The charge nurse returned to the resident's room with (name of son) to interview the resident. (Name of Resident #3) stated the CNA threw her into bed. An investigation was initiated and it was found to be a lack of education with transfers . A witness statement dated 1/17/19 and signed by the nurse caring for Resident #3 during the evening shift of 1/17/19 documented, Around 6:45 p.m. resident son arrived to the building to visit his mom. He reported to this nurse that (name of Resident #3) told him a CNA with red hair grabbed her and threw her in bed. When asked the resident what happened in front of the son resident stated that: a CNA grab (sic) me and throw (sic) me in bed. Supervisor 3-11 shift made aware and told me to call the DON (director of nursing). DON unable to reach. Call placed to the unit manager and informed about incident and she stated she will call the DON to follow up on this matter. A note was left at the unit manager office to follow up. A witness statement signed by the on-call manager on 1/17/19 documented, As on call mgr (manager) I received call from facility (name of nurse caring for Resident #3) at 7:02 p.m. concerning resident in room (number) had fallen on the floor with no injuries at about 3:20 p.m. Also patient stated that aid with red hair had grabbed her and threw her on the bed. I placed call to (name of ASM [administrative staff member] #2 [nurse executive- also known as director of nursing]) and after talking with (ASM #2) we decided to interview patient in morning concerning her transfer from wheelchair to bed. The nurse who cared for Resident #3 during the evening shift on 1/17/19, and was made aware of the allegation by Resident #3's son was not available for interview during the survey. On 2/6/19 at 4:32 p.m., an interview was conducted with RN (registered nurse) #10. RN #10 was asked what nurses should do if an allegation of resident abuse is reported to them. RN #10 stated she would ensure the patient's safety, separate the staff member and notify her direct supervisor. RN #10 stated she would contact the director of nursing then the executive director if her direct supervisor was not available. On 2/6/19 at 5:39 p.m., ASM #1 (the executive director), ASM #2 and ASM #3 (the clinical quality specialist) were made aware of the above concern. ASM #2 was asked the facility process for reporting allegations of abuse to the state agency. ASM #2 stated allegations of abuse should be reported to the state agency within two hours. ASM #2 stated training had recently been completed with staff and they have been told to report allegations of abuse to her and ASM #1. ASM #2 stated that ASM #1 was the abuse coordinator and ultimately needed to know about any allegations. (Note- not all staff had recently been provided abuse training). No further information was presented prior to exit. 2. The facility staff failed to implement the facility abuse policy for reporting Resident #261's and Resident #262's allegations of abuse to the SA (state agency) within the required two-hour timeframe. On 9/23/18, Resident #261 reported an allegation of abuse to RN (registered nurse) #11. The allegation was not reported to the SA until 9/24/18. On 9/22/18, Resident #262 reported an allegation of abuse to CNA (certified nursing assistant) #9. The allegation was not reported to the SA until 9/24/18. Both allegations were submitted to the SA in one FRI (facility reported incident) on 9/24/18. Resident #261 was admitted to the facility on [DATE]. Resident #261's diagnoses included but were not limited to arthritis, high blood pressure and morbid obesity. Resident #261's most recent MDS (minimum data set) (prior to discharge) a 60 day Medicare assessment with an ARD (assessment reference date) of 10/19/18, coded the resident as being cognitively intact. Resident #262 was admitted to the facility on [DATE]. Resident #262's diagnoses included but were not limited to paralysis, major depressive disorder and diabetes. Resident #262's most recent MDS (minimum data set) (prior to discharge), a 14 day Medicare assessment with an ARD (assessment reference date) of 12/18/18, coded the resident's cognition as moderately impaired. The facility policy titled, Abuse Prohibition documented, 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED (center executive director) or designee will perform the following: 6.1 Enter allegation into the Risk Management System (RMS). 6.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made . A FRI (facility reported incident) submitted to the state agency (Office of Licensure and Certification) on 9/24/18 documented, Report date: September 24, 2018. Incident date: 9/20/18 and 9/22/18. Residents involved: (name of Resident #261 [9/20/18] and name of Resident #262 [9/23/18]). Injuries: None. Incident type: (a check mark beside Allegation of abuse/mistreat). Describe incident, including location and action taken: (name of Resident #261) reported that she asked the aide on 11-7 shift 9/20/18 to put her on the bedpan. She stated she advised the aide she was not positioned correctly on the bedpan and was left to 'soil all over herself and the bed' due to the bedpan not positioned correctly. She also stated that she was 'rough' while positioning her on the bedpan, pushing her hard to get her on the bedpan since patient was unable to assist. She advised the CNA that she was unable to assist with positioning and that she was uncomfortable during the process. On the same date, (name of Resident #262) advised nursing supervisor that the 11-7 aide on 9/22/18 used 'force' when changing her diaper. Patient stated the aide was 'pushing and pulling me so hard and rough.' She asked the aide to stop due to the aide hurting her and the aide rolled her eyes and continued to provide care. (Name of Resident #262) went on to state the aide grabbed her right leg while getting her comfortable in bed which caused her pain due to that being her 'bad leg.' A witness statement signed by CNA #9 on 9/23/18 documented, To Whom It may concerned (sic). On Saturday September 22, 2018 at 3:30 p.m. when I went into (Resident #262's room) she reported to me that the 11-7 cna who had given care to her was very rude and abusive to her. She throw (sic) the diapers on the other bed, calling her names and was upset because she was unable to reached (sic) the call bell and had wet on herself. So I reported the incident to the charged (sic) nurse (name of RN #11) who told me she could not deal with the situation. So I then reported it to (name of RN #10) Sunday morning on the 7-3 shift. A witness statement signed by RN #11 on 9/23/18 documented, To whom this may concern, (name of CNA #9) told me about an encounter related to her by a resident (name of Resident #262). (Name of CNA #9) stated that I told her I could not deal with it right now and that she should tell the supervisor. I had seen the resident several times during the shift later on but I had forgotten about the incident and did not ask the resident or anyone else about it. A witness statement documented by RN #10 on 9/23/18, documented, At the start of my 7am shift on Sunday 9/23/2018, (name of CNA #9) reported to me that she was told last night (3-11 9/22/2018) by (name of Resident #262) in Room (number) that the CNA the night before (Friday night 11-7 9/21/2018) was being very rude and rough with her, the most abusive person shes (sic) ever had to deal with. (Name of CNA #9) said she reported it to me this morning because she said she tried to notify (name of RN #11) on 3-11 Saturday when the patient reported it to her, but (name of RN #11's) response back to (name of CNA #9) was 'Im (sic) too busy and don't have time to deal with that.' Upon interviewing patient, she gave a recollection of her account of events from the night of the concern. I forwarded her statement to the Unit Manager, ADON (assistant director of nursing) for her assigned unit. I was the charge nurse on 11-7, the night of patients (sic) admission. I rounded multiple times throughout the shift, for the most part, patient was sleeping peacefully so I did not wake her. There were no concerns reported to me throughout the shift I was assigned to work with her, nor did the CNA report any issues to me. A statement verbally obtained from Resident #262 by RN #10 on 9/23/18 documented, I came here Friday night and the CNA in the middle of the night was very rough with me. I knew she was pissed off because she came in with an attitude and slammed the closet door. She also used force when she was changing my diaper. She was pushing and pulling me so hard and rough. I asked her to stop because it was hurting me and she rolled her eyes and kept doing it until she was done. Her attitude and body language was cold and scary. Please don't make me have to deal with her again, I am scared to be around her. She grabbed my right leg while getting me comfortable in bed and it was so painful because it is my bad leg. She isn't a nice or gentle person. She threw a pack of my diapers across the room to the empty bed on the other side of the room. She didn't speak or talk to me much, Real grumpy and quiet. Didn't seem to acknowledge anything I said. I finally decided to report what happened to one of the girls last night because I need to help keep the other people here safe too. A patient statement obtained from Resident #261 by RN #10 on 9/23/19 documented, Patient reported to this nurse that a CNA she had a few nights ago was very rude and hurtful for her. She said she reported it to her nurse around 6am that same shift and asked the nurse that the CNA in question doesn't go back in the room again, and the nurse told her she would make sure that CNA doesn't go back to her room. Patient said the CNA came in with a nasty attitude and seemed like she didn't really like her job. Also stated that she seemed very angry and was throwing things, anything she picked up and needed to place somewhere or put down, she threw it and was very rough and abrupt. Patient stated she was put on a bedpan by CNA and told her it wasn't positioned right, but she left patient that way and she was forced to soil all over herself and the bed because the bedpan was not positioned correctly. Patient also stated that she was very rough with her while positioning her on the bedpan. She told CNA that the side she was laying on restricted her movement and she couldn't help the CNA with repositioning her, however she pushed patient really hard to get her in the position she wanted to, and it wasn't comfortable during the whole process. Patient asked to never have the CNA in her room ever again. She described the CNA as (name), an agency CNA. She described her nurse as the one she has every night almost, but couldn't remember her name. A final report sent to the SA on 9/27/18 documented, Resident (name of Resident #261) reported that she asked the aide on 11-7 shift 9/20/18 to put her on the bedpan. She stated she advised the aide she was not positioned correctly on the bedpan and was left to 'soil all over herself and the bed' due to the bedpan not positioned correctly. She also stated that she was 'rough' while positioning her on the bedpan, pushing her hard to get her on the bedpan since patient was unable to assist. She advised the CNA that she was unable to assist with positioning and that she was uncomfortable during the process. On the same date, (name of Resident #262) advised nursing supervisor that the 11-7 aide on 9/22/18 used 'force' when changing her diaper. Patient stated the aide was 'pushing and pulling me so hard and rough.' She asked the aide to stop due to the aide hurting her and the aide rolled her eyes and continued to provide care. (Name of Resident #262) went on to state the aide grabbed her right leg while getting her comfortable in bed which caused her pain due to that being her 'bad leg.' CONCLUSION: Unable to Substantiate allegation of abuse. Allegations to be unsubstantial due to interviewed Staff, alert and orient (sic) residents in the care of alleged perpetrator with no allegations of roughness during ADL (activities of daily living) care. Accused employee denies allegations. Per accused employee states she was not aware of residents (sic) concern and voicing she was rough. She states she forgot her hearing aids the day of the incident. CNA is contract agency and is no longer working at Facility. Staff in service on the 'Abuse policy and Abuse Prohibition' with the Center Nursing Executive. Current Status of Resident: Stable. On 2/6/19 at 3:37 p.m., an interview was conducted with CNA #9. When asked what a CNA should do if a resident verbalizes an allegation of abuse, CNA #9 stated, I am supposed to report it to the charge nurse. When asked if she does anything after she reports the allegation to the charge nurse, CNA #9 stated, I follow up to see if she does anything about it. If not, I report to the supervisor above her. CNA #9 stated she would follow up the next day if the allegation occurred on her 3:00 p.m. to 11:00 a.m. shift. CNA #9 was asked to explain the situation regarding Resident #262's allegation of abuse. CNA #9 stated on 9/22/18 she went into Resident #262's room and the resident did not look happy. CNA #9 stated she asked Resident #262 what was wrong, and the resident explained the 11:00 p.m. to 7:00 a.m. shift CNA had thrown a diaper and said verbal things to her that was out of place. CNA #9 stated she went straight to RN #11 and told RN #11 the information reported to her by Resident #262. CNA #9 stated RN #11 told her to tell the supervisor but the supervisor was not in the building so she told RN #10 when she came to the facility. On 2/6/19 at 4:32 p.m., an interview was conducted with RN (registered nurse) #10. RN #10 was asked what nurses should do if an allegation of resident abuse is reported to them. RN #10 stated she would ensure the patient's safety, separate the staff member and notify her direct supervisor. RN #10 stated she would contact the director of nursing then the executive director if her direct supervisor was not available. RN #10 was asked to explain the situation regarding Resident #262's allegation. RN #10 stated she made sure Resident #262 was okay, interviewed the resident, interviewed staff and contacted the ADON (assistant director of nursing) as soon as she was made aware of the allegation. On 2/6/19 at 5:39 p.m., ASM #1 (the executive director), ASM #2 and ASM #3 (the clinical quality specialist) were made aware of the above concern. (Note- ASM #1 and ASM #2 were not employed at the facility in September 2018). ASM #2 was asked the facility process for reporting allegations of abuse to the state agency. ASM #2 stated allegations of abuse should be reported to the state agency within two hours. ASM #2 stated training had recently been completed with staff and they have been told to report allegations of abuse to her and ASM #1. ASM #2 stated that ASM #1 was the abuse coordinator and ultimately needed to know about any allegations. (Note- not all staff had recently been provided abuse training). On 2/7/19 at 9:22 a.m., an interview was conducted with RN #11. RN #11 was asked what should be done if she is made aware of a resident's allegation of abuse. RN #11 stated, Right away you are supposed to tell your supervisor and the supervisor must tell the manager. When asked about the period of time this should be done, RN #11 stated it must be done, timely within 24 hours but the allegation should be reported to the supervisor right away. RN #11 was asked to explain the situation regarding Resident #262's allegation. RN #11 stated a CNA came to her and stated Resident #262 reported an allegation but the alleged event did not occur on her shift so she told the CNA to tell the supervisor. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to report allegations of abuse to the SA (state agency) within a timely manner for three of 55 residents in the survey sample, Residents #3, #261 and #262. 1. The facility staff failed to report Resident #3's allegation of abuse to the SA within the two-hour timeframe. Resident #3's allegation of abuse was reported to staff on 1/17/19 and was not reported to the SA until 1/18/19. 2. The facility staff failed to report Resident #261's and Resident #262's allegations of abuse to the SA within the two-hour timeframe. Resident #261's allegation of abuse was reported to staff on 9/23/18 and was not reported to the SA until 9/24/18. Resident #262's allegation of abuse was reported to staff on 9/22/18 and was not reported to the SA until 9/24/18. Both allegations were submitted to the SA in one FRI (facility reported incident) on 9/24/18. The findings include: 1. The facility staff failed to report Resident #3's allegation of abuse to the SA within the two-hour timeframe. Resident #3's allegation of abuse was reported to staff on 1/17/19 and was not reported to the SA until 1/18/19. Resident #3 was admitted to the facility on [DATE]. Resident #3's diagnoses included but were not limited to diabetes, major depressive disorder and end stage kidney disease. Resident #3's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/5/18, coded the resident's cognition as severely impaired. A FRI (facility reported incident) submitted to the state agency (Office of Licensure and Certification) on 1/18/19 documented, Incident Date: 1/17/2019. Report date: 1/18/2019. Residents involved: (name of Resident #3). Injuries: (an X beside No). Incident type: (an X beside Allegation of abuse/mistreat). No further information regarding the incident was documented on the FRI. The final report dated 1/23/19, documented, On 1/17/19 (name of Resident #3) reported that 'a CNA (certified nursing assistant) with red hair was rough when putting me back to bed, they picked me up around my breast and threw me into bed' this statement was made to the resident's son (name) when he came to visit .(Name of Resident #3's son) later than evening arrived to the facility to visit with (name of Resident #3) at this time the resident reported rough care to her son. The charge nurse returned to the resident's room with (name of son) to interview the resident. (Name of Resident #3) stated the CNA threw her into bed. An investigation was initiated and it was found to be a lack of education with transfers . A witness statement dated 1/17/19 and signed by the nurse caring for Resident #3 during the evening shift of 1/17/19 documented, Around 6:45 p.m. resident son arrived to the building to visit his mom. He reported to this nurse that (name of Resident #3) told him a CNA with red hair grabbed her and threw her in bed. When asked the resident what happened in front of the son resident stated that: a CNA grab (sic) me and throw (sic) me in bed. Supervisor 3-11 shift made aware and told me to call the DON (director of nursing). DON unable to reach. Call placed to the unit manager and informed about incident and she stated she will call the DON to follow up on this matter. A note was left at the unit manager office to follow up. A witness statement signed by the on-call manager on 1/17/19 documented, As on call mgr (manager) I received call from facility (name of nurse caring for Resident #3) at 7:02 p.m. concerning resident in room (number) had fallen on the floor with no injuries at about 3:20 p.m. Also patient stated that aid with red hair had grabbed her and threw her on the bed. I placed call to (name of ASM [administrative staff member] #2 [nurse executive- also known as director of nursing]) and after talking with (ASM #2) we decided to interview patient in morning concerning her transfer from wheelchair to bed. The nurse who cared for Resident #3 during the evening shift on 1/17/19, and was made aware of the allegation by Resident #3's son was not available for interview during the survey. On 2/6/19 at 4:32 p.m., an interview was conducted with RN (registered nurse) #10. RN #10 was asked what nurses should do if an allegation of resident abuse is reported to them. RN #10 stated she would ensure the patient's safety, separate the staff member and notify her direct supervisor. RN #10 stated she would contact the director of nursing then the executive director if her direct supervisor was not available. On 2/6/19 at 5:39 p.m., ASM #1 (the executive director), ASM #2 and ASM #3 (the clinical quality specialist) were made aware of the above concern. ASM #2 was asked the facility process for reporting allegations of abuse to the state agency. ASM #2 stated allegations of abuse should be reported to the state agency within two hours. ASM #2 stated training had recently been completed with staff and they have been told to report allegations of abuse to her and ASM #1. ASM #2 stated that ASM #1 was the abuse coordinator and ultimately needed to know about any allegations. (Note- not all staff had recently been provided abuse training). The facility policy titled, Abuse Prohibition documented, 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED (center executive director) or designee will perform the following: 6.1 Enter allegation into the Risk Management System (RMS). 6.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made . No further information was presented prior to exit. 2. The facility staff failed to report Resident #261's and Resident #262's allegations of abuse to the SA within the two-hour timeframe. Resident #261's allegation of abuse was reported to staff on 9/23/18 and was not reported to the SA until 9/24/18. Resident #262's allegation of abuse was reported to staff on 9/22/18 and was not reported to the SA until 9/24/18. Both allegations were submitted to the SA in one FRI (facility reported incident) on 9/24/18. Resident #261 was admitted to the facility on [DATE]. Resident #261's diagnoses included but were not limited to arthritis, high blood pressure and morbid obesity. Resident #261's most recent MDS (minimum data set) (prior to discharge) a 60 day Medicare assessment with an ARD (assessment reference date) of 10/19/18, coded the resident as being cognitively intact. Resident #262 was admitted to the facility on [DATE]. Resident #262's diagnoses included but were not limited to paralysis, major depressive disorder and diabetes. Resident #262's most recent MDS (minimum data set) (prior to discharge), a 14 day Medicare assessment with an ARD (assessment reference date) of 12/18/18, coded the resident's cognition as moderately impaired. A FRI (facility reported incident) submitted to the state agency (Office of Licensure and Certification) on 9/24/18 documented, Report date: September 24, 2018. Incident date: 9/20/18 and 9/22/18. Residents involved: (name of Resident #261 [9/20/18] and name of Resident #262 [9/23/18]). Injuries: None. Incident type: (a check mark beside Allegation of abuse/mistreat). Describe incident, including location and action taken: (name of Resident #261) reported that she asked the aide on 11-7 shift 9/20/18 to put her on the bedpan. She stated she advised the aide she was not positioned correctly on the bedpan and was left to 'soil all over herself and the bed' due to the bedpan not positioned correctly. She also stated that she was 'rough' while positioning her on the bedpan, pushing her hard to get her on the bedpan since patient was unable to assist. She advised the CNA that she was unable to assist with positioning and that she was uncomfortable during the process. On the same date, (name of Resident #262) advised nursing supervisor that the 11-7 aide on 9/22/18 used 'force' when changing her diaper. Patient stated the aide was 'pushing and pulling me so hard and rough.' She asked the aide to stop due to the aide hurting her and the aide rolled her eyes and continued to provide care. (Name of Resident #262) went on to state the aide grabbed her right leg while getting her comfortable in bed which caused her pain due to that being her 'bad leg.' A witness statement signed by CNA #9 on 9/23/18 documented, To Whom It may concerned (sic). On Saturday September 22, 2018 at 3:30 p.m. when I went into (Resident #262's room) she reported to me that the 11-7 cna who had given care to her was very rude and abusive to her. She throw (sic) the diapers on the other bed, calling her names and was upset because she was unable to reached (sic) the call bell and had wet on herself. So I reported the incident to the charged (sic) nurse (name of RN #11) who told me she could not deal with the situation. So I then reported it to (name of RN #10) Sunday morning on the 7-3 shift. A witness statement signed by RN #11 on 9/23/18 documented, To whom this may concern, (name of CNA #9) told me about an encounter related to her by a resident (name of Resident #262). (Name of CNA #9) stated that I told her I could not deal with it right now and that she should tell the supervisor. I had seen the resident several times during the shift later on but I had forgotten about the incident and did not ask the resident or anyone else about it. A witness statement documented by RN #10 on 9/23/18, documented, At the start of my 7am shift on Sunday 9/23/2018, (name of CNA #9) reported to me that she was told last night (3-11 9/22/2018) by (name of Resident #262) in Room (number) that the CNA the night before (Friday night 11-7 9/21/2018) was being very rude and rough with her, the most abusive person shes (sic) ever had to deal with. (Name of CNA #9) said she reported it to me this morning because she said she tried to notify (name of RN #11) on 3-11 Saturday when the patient reported it to her, but (name of RN #11's) response back to (name of CNA #9) was 'Im (sic) too busy and don't have time to deal with that.' Upon interviewing patient, she gave a recollection of her account of events from the night of the concern. I forwarded her statement to the Unit Manager, ADON (assistant director of nursing) for her assigned unit. I was the charge nurse on 11-7, the night of patients (sic) admission. I rounded multiple times throughout the shift, for the most part, patient was sleeping peacefully so I did not wake her. There were no concerns reported to me throughout the shift I was assigned to work with her, nor did the CNA report any issues to me. A statement verbally obtained from Resident #262 by RN #10 on 9/23/18 documented, I came here Friday night and the CNA in the middle of the night was very rough with me. I knew she was pissed off because she came in with an attitude and slammed the closet door. She also used force when she was changing my diaper. She was pushing and pulling me so hard and rough. I asked her to stop because it was hurting me and she rolled her eyes and kept doing it until she was done. Her attitude and body language was cold and scary. Please don't make me have to deal with her again, I am scared to be around her. She grabbed my right leg while getting me comfortable in bed and it was so painful because it is my bad leg. She isn't a nice or gentle person. She threw a pack of my diapers across the room to the empty bed on the other side of the room. She didn't speak or talk to me much, Real grumpy and quiet. Didn't seem to acknowledge anything I said. I finally decided to report what happened to one of the girls last night because I need to help keep the other people here safe too. A patient statement obtained from Resident #261 by RN #10 on 9/23/19 documented, Patient reported to this nurse that a CNA she had a few nights ago was very rude and hurtful for her. She said she reported it to her nurse around 6am that same shift and asked the nurse that the CNA in question doesn't go back in the room again, and the nurse told her she would make sure that CNA doesn't go back to her room. Patient said the CNA came in with a nasty attitude and seemed like she didn't really like her job. Also stated that she seemed very angry and was throwing things, anything she picked up and needed to place somewhere or put down, she threw it and was very rough and abrupt. Patient stated she was put on a bedpan by CNA and told her it wasn't positioned right, but she left patient that way and she was forced to soil all over herself and the bed because the bedpan was not positioned correctly. Patient also stated that she was very rough with her while positioning her on the bedpan. She told CNA that the side she was laying on restricted her movement and she couldn't help the CNA with repositioning her, however she pushed patient really hard to get her in the position she wanted to, and it wasn't comfortable during the whole process. Patient asked to never have the CNA in her room ever again. She described the CNA as (name), an agency CNA. She described her nurse as the one she has every night almost, but couldn't remember her name. A final report sent to the SA on 9/27/18 documented, Resident (name of Resident #261) reported that she asked the aide on 11-7 shift 9/20/18 to put her on the bedpan. She stated she advised the aide she was not positioned correctly on the bedpan and was left to 'soil all over herself and the bed' due to the bedpan not positioned correctly. She also stated that she was 'rough' while positioning her on the bedpan, pushing her hard to get her on the bedpan since patient was unable to assist. She advised the CNA that she was unable to assist with positioning and that she was uncomfortable during the process. On the same date, (name of Resident #262) advised nursing supervisor that the 11-7 aide on 9/22/18 used 'force' when changing her diaper. Patient stated the aide was 'pushing and pulling me so hard and rough.' She asked the aide to stop due to the aide hurting her and the aide rolled her eyes and continued to provide care. (Name of Resident #262) went on to state the aide grabbed her right leg while getting her comfortable in bed which caused her pain due to that being her 'bad leg.' CONCLUSION: Unable to Substantiate allegation of abuse. Allegations to be unsubstantial due to interviewed Staff, alert and orient (sic) residents in the care of alleged perpetrator with no allegations of roughness during ADL (activities of daily living) care. Accused employee denies allegations. Per accused employee states she was not aware of residents (sic) concern and voicing she was rough. She states she forgot her hearing aids the day of the incident. CNA is contract agency and is no longer working at Facility. Staff in service on the 'Abuse policy and Abuse Prohibition' with the Center Nursing Executive. Current Status of Resident: Stable. On 2/6/19 at 3:37 p.m., an interview was conducted with CNA #9. When asked what a CNA should do if a resident verbalizes an allegation of abuse, CNA #9 stated, I am supposed to report it to the charge nurse. When asked if she does anything after she reports the allegation to the charge nurse, CNA #9 stated, I follow up to see if she does anything about it. If not, I report to the supervisor above her. CNA #9 stated she would follow up the next day if the allegation occurred on her 3:00 p.m. to 11:00 a.m. shift. CNA #9 was asked to explain the situation regarding Resident #262's allegation of abuse. CNA #9 stated on 9/22/18 she went into Resident #262's room and the resident did not look happy. CNA #9 stated she asked Resident #262 what was wrong, and the resident explained the 11:00 p.m. to 7:00 a.m. shift CNA had thrown a diaper and said verbal things to her that was out of place. CNA #9 stated she went straight to RN #11 and told RN #11 the information reported to her by Resident #262. CNA #9 stated RN #11 told her to tell the supervisor but the supervisor was not in the building so she told RN #10 when she came to the facility. On 2/6/19 at 4:32 p.m., an interview was conducted with RN (registered nurse) #10. RN #10 was asked what nurses should do if an allegation of resident abuse is reported to them. RN #10 stated she would ensure the patient's safety, separate the staff member and notify her direct supervisor. RN #10 stated she would contact the director of nursing then the executive director if her direct supervisor was not available. RN #10 was asked to explain the situation regarding Resident #262's allegation. RN #10 stated she made sure Resident #262 was okay, interviewed the resident, interviewed staff and contacted the ADON (assistant director of nursing) as soon as she was made aware of the allegation. On 2/6/19 at 5:39 p.m., ASM #1 (the executive director), ASM #2 and ASM #3 (the clinical quality specialist) were made aware of the above concern. (Note- ASM #1 and ASM #2 were not employed at the facility in September 2018). ASM #2 was asked the facility process for reporting allegations of abuse to the state agency. ASM #2 stated allegations of abuse should be reported to the state agency within two hours. ASM #2 stated training had recently been completed with staff and they have been told to report allegations of abuse to her and ASM #1. ASM #2 stated that ASM #1 was the abuse coordinator and ultimately needed to know about any allegations. (Note- not all staff had recently been provided abuse training). On 2/7/19 at 9:22 a.m., an interview was conducted with RN #11. RN #11 was asked what should be done if she is made aware of a resident's allegation of abuse. RN #11 stated, Right away you are supposed to tell your supervisor and the supervisor must tell the manager. When asked about the time period this should be done, RN #11 stated it must be done timely within 24 hours but the allegation should be reported to the supervisor right away. RN #11 was asked to explain the situation regarding Resident #262's allegation. RN #11 stated a CNA came to her and stated Resident #262 reported an allegation but the alleged event did not occur on her shift so she told the CNA to tell the supervisor. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed provide required documentation to a receiving provider for Resident #90's facility initiated hospital transfer dated 11/28/18 and 1/5/18. Resident #90 was admitted to the facility on [DATE] with a most recent readmission date of 1/10/19. Diagnoses included but were not limited to: syncope and collapse (1), depression, urinary tract infection and bradycardia (2). The most recent MDS (minimum data set), a Medicare fourteen day assessment, with an ARD (assessment reference date) of 1/24/19 coded the resident as having a score of five on the BIMS (brief interview for mental status), indicating the resident had severe cognitive impairment. Resident #90's clinical record revealed that she was sent to the hospital on [DATE]. A nurse's note dated 11/28/18 at 3:31 p.m., documented (name of resident) had an unplanned transfer. Contact person notified of transfer. Resident #90's clinical record revealed that she was sent to the hospital on 1/5/19. Nurse's note dated 1/5/19 at 7:18 p.m., documented This writer F/U (followed up) with (name of hospital) on pt. (patient) status and noted resident admitted with diagnosis of AMS (altered mental status) and acute cystitis (urinary tract infection). There was no evidence in the clinical record that the required information was provided to the hospital for Resident #90's facility initiated hospital transfers dated 11/28/18 and 1/5/18. On 02/07/19 at approximately 11:18 a.m., an interview was conducted with ASM (administrative staff member) #2, the Nurse Executive. ASM #2 was asked what documents the facility provides to receiving providers when a resident is transferred to the hospital. ASM #2 replied, We usually give a face sheet with the resident's demographics, history and physical and also some labs [laboratory tests results]. We also have a transfer form with a list of required documents that we started to use a couple of months ago, however, nursing is not using it consistently. ASM #2 was asked if the facility had evidence that the required documentation such as but not limited to: Contact information of the residents, resident representative information including contact information, Advance Directive, all special instructions or precautions for ongoing care and comprehensive care plan goals, was provided for Resident #90's hospital transfer dated 11/28/18 and 1/5/18. ASM #2 replied, No. On 02/07/19 at approximately 5:45 p.m., ASM #1, the Executive Director and ASM #2, the Nurse Executive, and ASM #3, Clinical Quality Specialist, were made aware of the findings. The facility policy titled Discharge and Transfer with a most recent revision date of 11/28/16 documented, 5.3 Patient's advance directives and/or health care instructions will be sent to the hospital with the resident. No further information was provided prior to exit. 1. Fainting is a temporary loss of consciousness. If you're about to faint, you'll feel dizzy, lightheaded, or nauseous. Your field of vision may white out or black out. Your skin may be cold and clammy. You lose muscle control at the same time, and may fall down. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=syncope. Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to evidence that required documentation was sent with residents to the Hospital at the time of transfer, for three of 55 residents, Residents #208, #90, and #51. 1. The facility staff failed to evidence that Resident #208's comprehensive care plan goals were sent with the resident to the hospital at the time of the facility-initiated transfer on 05/25/2018. 2. The facility staff failed provide required documentation to a receiving provider for Resident #90's facility initiated hospital transfer dated 11/28/18 and 1/5/18. 3. The facility staff failed to provide evidence that all required information (including physician contact information, resident representative contact information, special instructions for ongoing care, advance directives and comprehensive care plan goals) was provided to the hospital staff when Resident #51 was transferred to the hospital on 1/24/19. The Findings Included: 1. The facility staff failed to evidence that Resident #208's comprehensive care plan goals were sent with the resident to the hospital at the time of the facility-initiated transfer on 05/25/2018. Resident #208 was reviewed as a closed record. Resident #208 was admitted to the facility on [DATE]. Her diagnoses included right hip fracture, muscle weakness, hyperlipidemia (high levels of fat/cholesterol in the blood), and hypertension (high blood pressure). Her most recent Minimum Data Set (MDS) Assessment was a Medicare 14 Day Assessment with and Assessment Reference Date (ARD) of 05/16/2018. Resident #208 was scored as a six (6) on the Brief Interview for Mental Status (BIMS), indicating severe impairment. Resident #208 was coded as requiring extensive assistance of two or more people for transfers and bed mobility; and extensive assistance of one person for ambulation, dressing, eating, hygiene, and toileting. A review of Resident #208's closed record revealed that Resident #208 was transferred to the hospital on [DATE]. According to the nurse's note dated 05/25/2018 8:59 p.m., Resident #208 was discovered on the floor of her room at 5:45 p.m. Resident #208 complained of pain to her right hip at that time. Facility staff notified the Provider, who ordered a mobile x ray of the right hip. However, according to the nurse's note, Resident #208's daughter, upon being informed of the fall, stated she wished for her mother to be sent to the ER (emergency room) immediately. A review of the Physician's Orders revealed an order dated 05/25/2018 reading Send Resident to [HOSPITAL] ER for Tx (treatment) and Eval (evaluation) per family request. A review of the nurse's notes for 05/25/2019 revealed no description of what documentation, if any, was sent to the hospital with Resident #208. At the End of Day Meeting on 02/06/2019, ASM (Administrative Staff Member) #1, the Executive Director, and ASM #2, the Center Nurse Executive, were informed of the concerns regarding Resident #208's transfer, and were asked to provide documentation of what was sent with her to the hospital. ASM #2 replied, We usually give a face sheet with the resident's demographics, history and physical and also some labs [laboratory tests results]. We also have a transfer form with a list of required documents that we started to use a couple of months ago, however, nursing is not using it consistently. ASM #2 was asked if the facility had evidence that Resident #208's comprehensive care plan goals were provided to the hospital for the facility initiated hospital transfer on 05/25/18. ASM #2 replied, No. No further information was provided prior to exit. 3. The facility staff failed to provide evidence that all required information (including physician contact information, resident representative contact information, special instructions for ongoing care, advance directives and comprehensive care plan goals) was provided to the hospital staff when Resident #51 was transferred to the hospital on 1/24/19. Resident #51 was admitted to the facility on [DATE]. Resident #51's diagnoses included but were not limited to diabetes, high blood pressure and pneumonia. Resident #51's most recent MDS (minimum data set), a 14 day Medicare assessment with an ARD (assessment reference date) of 12/13/18, coded the resident's cognition as severely impaired. Review of Resident #51's clinical record revealed the resident was transferred to the hospital on 1/24/19 due to a fall. Further review of Resident #51's clinical record (including nurses' notes) failed to reveal evidence that the facility staff provided the required information to hospital staff when the resident was transferred. On 2/6/19 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 was asked to describe the information that is provided to hospital staff when a resident is transferred to the hospital. LPN #3 stated, Their name, I usually go by their name, date of birth , the reasoning as to why we are sending them, their history, code status, last set of vitals, last time seen normal, face sheet, labs [laboratory tests], medication list, H&P (history and physical). When asked if the resident representative's contact information, physician's contact information and special instructions for care are provided, LPN #3 stated that information is documented on an eInteract form. LPN #3 stated the eInteract form is sometimes but not always provided to the hospital staff. LPN #3 stated that information is provided via phone if the eInteract form is not sent to the hospital. When asked if residents' comprehensive care plan goals are provided to hospital staff, LPN #3 stated, No. LPN #3 was asked how nurses evidence the information that is provided to hospital staff. LPN #3 stated, We know that stuff goes but are not able to evidence. They started off with a form that we check off with, with an envelope but it's new and I'm not sure everyone is using it. Further review of Resident #51's clinical record failed to reveal an eInteract form or check off list containing all the required information. On 2/6/19 at 5:39 p.m., ASM (administrative staff member) #1 (the executive director), ASM #2 (the nurse executive) and ASM #3 (the clinical quality specialist) 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 clinical record review, staff interview and review of facility documentation the facility staff failed to ensure professional standards for the administration of medications for one resident (Resident #35) in the survey sample of 55 residents. The facility staff failed to evidence the physician was notified, consulted and that orders were obtained to administer two medications late to Resident #35, when the resident returned to the facility late, over an hour past the scheduled time for administering two prescribed medications. The facility staff initialed/documented two 8:00 p.m., schedule medications as administered when the clinical record documented the resident was out of the facility on 8/30 and 10/3/18. The findings include: Resident #35 was admitted to the facility on [DATE] with the diagnoses of but not limited to hip fracture, atrial fibrillation, high blood pressure, falls, inguinal hernia, and cardiomyopathy. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 11/23/18. The resident was coded as being cognitively intact in ability to make daily life decisions. The resident was coded as being independent for transfers, locomotion, dressing, eating, toileting and as requiring supervision for hygiene. A review of the clinical record revealed a physician's order dated 8/22/18 that documented the resident may go on LOA (leave of absence) for 4 hours daily. A review of the nurse's notes revealed the following: A nurse's note dated 8/30/18 documented, Resident signed out at 1:30pm, today and stated that he was going to (name of bank) and not going to church tonight. Cousin and friend were contacted at 10pm today because resident was not back at facility. Unit manager on call was contacted. Resident made contact with facility soon after and was reported to unit manager on call. Unit manager will pick up resident from Firestone off of (location) A nurse's note dated 8/31/18 documented, Late entry: This RN was contacted by nursing staff of residents (Sic.) failure to return to the facility following his departure for the bank earlier in the afternoon. Nursing staff was advised to make contact with RP to see if they knew where resident was located. This RN was advised that contact was made with residents (Sic.) cousin and friend, neither of which knew of his whereabouts. DON was notified of incident. Nursing staff was advised to call the sheriffs (Sic.) office non emergency number to report the residents (Sic.) failure to return. At approximately 10:30pm, this RN was notified by staff that (resident) had called the facility and stated he was at the Firestone and was unable to get back due to not having enough money for the cab ride. This writer went to pick up resident shortly after. Resident was found in front of the Firestone (location) sitting on the ground. Resident stated he left his bank card (Sic.) back at the facility and was unable to get a ride back. Resident returned to facility. This RN stressed the importance to the resident of returning in a timely manner and the need to be able to take his evening medicine. Resident expressed understanding. Resident was asked where he usually goes when he leaves the facility so if another incident occurs we know where to look. Resident stated that he goes to the (name of bank) on (location) and is usually in the shopping center above or below the hospital. Resident returned to facility at approximately 11:30pm. A nurse's note dated 10/3/18 documented, Patient left facility at 2:10 p.m., for LOA was supposed to return by 6:10 p.m. Patient called facility at 7:50 p.m., to say he was at the Bus Station in (location) with no way back. Patient returned at 9:30p.m., He stated, Someone from the Bus Station gave me a ride back. Patient education given on Safety and if Patient is going out alone he must have money for Cab fare both ways and he must return back on time. A review of the clinical record revealed an order dated 5/23/18 for Cal-Gest {1}, 1 tab (tablet) twice daily for calcium supplement; and a Metoprolol {2} 50 mg (milligrams) twice daily for high blood pressure. A review of the August 2018 MAR (Medication Administration Record) documented that the resident was to receive the above medications at 8:00 p.m. On 8/30/18, these medications were documented as administered at 8:00 p.m., when the resident was documented in nurses' notes, as not present in the building between 1:30 p.m., and 11:30 p.m. There was no evidence that the physician was notified, consulted and orders were obtained to administer the medications late. A review of the October 2018 MAR documented that the resident was to receive the same two medications above at 8:00 p.m. On 10/3/18, these medications were documented as administered at 8:00 p.m., when the resident was documented in nurses' notes as not being in the building between 2:10 p.m. and 9:30 p.m. There was no evidence that the physician was notified, consulted and orders were obtained to administer the medications late. On 2/7/19 at 1:24 p.m., in an interview with LPN #4, was asked about the process staff follows when a resident is out on leave long enough to miss medications. LPN #4 stated the physician should be called to verify if the medications can be given or not. On 2/7/19 at 2:20 p.m., in an interview with the Executive Director (ASM [administrative staff member] #1) and Nurse Executive, ASM #2. When asked about the resident's unsupervised outings into the community and issues he had of returning to the facility timely, ASM #1 stated that he was alert and oriented, his BIMS (Brief Interview for Mental Status exam) was a 15 (cognitively intact). She stated the physician was aware of the resident's outings and that it was his right to go out if he wanted to. When asked about the resident's missed medications when he was late returning to the facility, ASM #1 stated that the doctor should have been notified and direction provided whether or not to administer them (medications) late. When asked what standard of practice the facility follows, she stated the facility policies and procedures. A review of the facility policy, Leave of Absence/Therapeutic Leave did not include direction on procedures if the resident was out past a medication time and missed medications. A review of the facility policy, Leave of Absence, Resident Discharge with Medication or Other Change of Status documented, When a Facility physician/prescriber provides an order for the resident to take a leave of absence, the physician/prescriber should specify the medications the resident is to take with them while on leave If the resident is taking a leave of absence for less than 24 hours, consider a change in the time for administration of a medication, if appropriate, to avoid the need to send that dose of medication with the resident The policy did not address what the procedure should be if the resident's leave was to be brief, but the resident missed the medications due to a late return. The facility policy titled, Medication Administration: General documented, A licensed nurse, Med Tech, or medication aide, per state regulations, will administer medications to patients .If discrepancies, . notify physician/advanced practice provider (APP) and/or pharmacy as indicated . No further information was provided. {1} Cal-Gest Antacid - Calcium carbonate is a dietary supplement used when the amount of calcium taken in the diet is not enough. Calcium is needed by the body for healthy bones, muscles, nervous system, and heart. Calcium carbonate also is used as an antacid to relieve heartburn, acid indigestion, and upset stomach. It is available with or without a prescription. Information obtained from https://medlineplus.gov/druginfo/meds/a601032.html {2} Metoprolol - Metoprolol is used alone or in combination with other medications to treat high blood pressure. It also is used to prevent angina (chest pain) and to improve survival after a heart attack. Metoprolol also is used in combination with other medications to treat heart failure. Metoprolol is in a class of medications called beta blockers. It works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a682864.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, facility staff failed to ensure one resident, Resident #61, was free of unnecessary psychotropic medications. Resident #61 had a PRN (as-needed) order for Lorazepam (1) more than 14 days old and with no stop date. The Findings Included: Resident #61 was admitted on [DATE]. Her diagnoses included Hyperlipidemia (high levels of fat/cholesterol in the blood), Anxiety, Alzheimer's disease (2), and Dementia. Resident #61's most recent Minimum Data Set (MDS) Assessment was a 14-Day Assessment with an Assessment Reference Date (ARD) of 01/01/2019. Resident #61 was scored as a 5 on the Brief Interview for Mental Status (BIMS), indicating severe impairment. Resident #61 was coded as requiring total assistance of two or more people for transfers and toileting; total assistance of one person for ambulation; extensive assistance of two or more people for dressing, and as requiring extensive assistance of one person for eating, bed mobility, and hygiene. A review of the Physician Order Sheet dated 02/01/2019 revealed the following under PRN (as needed) Medications: Lorazepam 0.5MG tablet (WF: Ativan) 1 tab [tablet] by mouth every day as needed. To the left of that order, in the column labeled date, 01/20/19 was typed. To the right of the order, the column labeled Discontinue by was left blank. A review of Resident #61's Medication Administration Record (MAR) revealed that she received the PRN dose of Ativan on February 2nd, 2019. On 02/07/2019 at 1:55p.m., an interview was conducted with ASM (Administrative Staff Member) #5, the Nurse Practitioner. ASM #5 was asked to describe why a resident might be prescribed Ativan. She stated that it is a drug used to treat anxiety. ASM #5 also stated that it is sometimes used in people with dementia for behaviors, but that that is not an approved use. When asked about what restrictions might be in place when prescribing Ativan for a resident, ASM #5 stated that, aside from considering things like the resident's allergies, orders for drugs like Ativan are usually written to be given on a schedule. She stated that when writing an order for one to be given as needed, it cannot be written for greater than 14 days. She went on to state that if the prescriber believes that the resident needs the medication to be given as needed for more than 14 days, he or she must re-assess the patient, as well as document the justification for extending the order. A resident on Hospice care, for example, might be one who would benefit from a greater than 14 day course. On 02/07/2019 at 2:02p.m., an interview was conducted with ASM #3, the Facility Medical Director. When asked why a resident might be taking Ativan, ASM #3 stated that very often they would get patients from the Hospital who already have an as-needed order for Ativan in place. He stated that in many cases, the hospital does this to treat agitation or disruptive behaviors. ASM #3 went on to state that for these residents arriving from the hospital with a PRN order already in place, he usually leaves it in place at the facility because many residents have difficulty adjusting to their new environment and can benefit from anti-anxiety medication. ASM #3 stated that the maximum time he uses the as-needed order is 14 days. After that, he will either discontinue the medication or ask Psychiatric services to see the resident and decide if the medication should be extended. When asked, if, in either case, described the initial order should only be 14 days, ASM #3 responded, yes, that is correct. A review of the facility policy 3.9 Psychotheraputic Medication Use revealed the following under the heading Purpose: To ensure patients are prescribed psychotherapeutic drugs for appropriate indications, dosages, lengths of treatment, and duration. No further information in the policy elaborated on lengths of treatment, and duration. The Executive Director, ASM #1and Center Nurse Executive, ASM #2, were informed of the findings at the End of Day Meeting on 02/07/2019. No further information was provided. 1. Lorazepam is used to relieve anxiety. Lorazepam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow for relaxation. - https://medlineplus.gov/druginfo/meds/a682053.html 2. Alzheimer's disease (AD) is the most common form of dementia among older people. Dementia is a brain disorder that seriously affects a person's ability to carry out daily activities. AD begins slowly. It first involves the parts of the brain that control thought, memory and language. People with AD may have trouble remembering things that happened recently or names of people they know. - https://medlineplus.gov/alzheimersdisease.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to provide a dignified dining experience for Resident #8 and Resident #24. The facility staff failed to address Resident #97's loud cursing at staff for approximately 29 minutes, during which time Resident #8 and #24 both expressed a dislike of Resident #97's cursing. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to: diabetes, history of falls, anxiety, depression and dementia (1). The most recent MDS (minimum data set), a quarterly assessment, with an ARD (assessment reference date) of 10/23/18 coded the resident as having a 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact to make daily decisions. The resident was coded as requiring supervision while eating. The resident was also coded as being on a diabetic therapeutic diet. Resident #24 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included but were not limited to: diabetes, atrial fibrillation (5) heart failure (6), and cerebral infarction (4). The most recent MDS (minimum data set), an annual day assessment, with an ARD (assessment reference date) of 3/28/18 coded the resident as having a 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact to make daily decisions. The resident was coded as requiring supervision with eating. The resident was also coded as requiring a diabetic therapeutic diet. Resident #97 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: diabetes, high blood pressure, hemiplegia (2) and hemiparesis (3) following cerebral infarction (4). The most recent MDS (minimum data set), a Medicare thirty day assessment, with an ARD (assessment reference date) of 1/18/19 coded the resident as having a 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact to make daily decisions. The resident was coded as requiring limited assistance with eating. On 02/05/19 at approximately 12:20 p.m., an observation was conducted in the main dining room, where lunch was being served. Resident #97 was observed cursing loudly and continuously at staff. He was also observed complaining to other residents in the dining hall about the food and service in the lunchroom. On 02/05/19 at approximately 12:22 p.m., Resident #8 was heard and observed telling Resident #97, Can you please stop using that language. Resident #8 then turned to this surveyor and said, He always does this, and they (the facility staff) need to do something. On 02/05/19 at approximately 12:32 p.m., Resident #24 was heard and observed telling Resident #97, Watch your language please. However, Resident #97 continued cursing loudly. On 02/05/19 at approximately 12:49 p.m., (29 minutes after the initial observation of Resident #97 cursing in the dining room), Resident #97 was told by CNA (certified nursing assistant) #1, Mr. (name of Resident #97) you can't use that type of language in the dining room. On 02/05/19 at approximately 12:45 p.m., an interview was conducted with Resident #24. When asked about a dignified dining experience, Resident #24 stated, No, the language that some people use in here should not be allowed. On 02/06/19 at approximately 1:47 p.m., an interview was conducted with CNA #1. CNA #1 was asked if Resident #97 had a habit of cursing in the dining room, CNA #1 replied, Yes, he is known for cursing we have told him in the past to stop but sometimes he does not listen. CNA #1 was asked if the dining room experience for the other residents in the dining room was dignified, with Resident #97 cursing. CNA #1 stated, I don't think so. On 02/05/19 at approximately 3:53 p.m., an interview was conducted with Resident #8. Resident #8 was asked if she is treated with dignity and respect by the facility. Resident #8 replied, The dining room has been a problem. There is a person that curses in there constantly. I have told the staff to do something about it, but nothing gets done. I'm not use to that type of language. Review of Resident #97's comprehensive care plan initiated on 12/24/18 and revised on 1/8/19 failed to document the residents' behavior of cursing in the dining room. Review of the facility's document titled, Residents Rights Under Federal Law dated 11/28/16 documented, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. On 02/07/19 at approximately 5:45 p.m., ASM (administrative staff member) #1, the Executive Director and ASM #2, the Nurse Executive, and ASM #3, Clinical Quality Specialist, were made aware of the findings. No further information was provided prior to exit. 1. A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. 2. Also called: Hemiplegia, Palsy, Paraplegia, and Quadriplegia. Paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. This information was obtained from the website: https://medlineplus.gov/paralysis.html. 3. Paralysis is the loss of muscle function in part of your body. This information was obtained from the website: https://medlineplus.gov/paralysis.html. 4. A stroke. When blood flow to a part of the brain stops. A stroke is sometimes called a brain attack. If blood flow is cut off for longer than a few seconds, the brain cannot get nutrients and oxygen. Brain cells can die, causing lasting damage. This information was obtained from the website: https://medlineplus.gov/ency/article/000726.htm. 5. An arrhythmia is a problem with the speed or rhythm of the heartbeat. Atrial fibrillation (AF) is the most common type of arrhythmia. The cause is a disorder in the heart's electrical system. This information was obtained from the website:https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=atrial+fibrillation 3. The facility staff failed to serve Resident #40 lunch on 2/5/19 at the same time her roommate received lunch. Resident #40 did not receive lunch until at least 16 minutes after her roommate was served. Resident #40 was admitted to the facility on [DATE]. Resident #40's diagnoses included but were not limited to diabetes, major depressive disorder and retention of urine. Resident #40's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/4/18, coded the resident as being cognitively intact. Section G coded Resident #40 as requiring supervision/set up help only with eating. Resident #40's comprehensive care plan dated 12/11/17 failed to document information regarding a dignified dining experience. On 2/5/19 at 12:58 p.m., Resident #40 was observed sitting up in bed with no lunch tray. The resident's roommate was observed sitting up in the room and eating lunch. On 2/5/19 at 1:08 p.m., LPN (licensed practical nurse) #1 was observed entering and exiting the room. On 2/5/19 at 1:11 p.m., this surveyor attempted to interview Resident #40 regarding lunch but the resident refused to talk. On 2/5/19 at 1:14 p.m., RN (registered nurse) #1 entered the room and served Resident #40 a meal tray. An interview was conducted with RN #1 and RN #2 in the hall, immediately after RN #1 served Resident #40's meal tray. RN #1 confirmed Resident #40's meal tray was not on the food cart used to serve meal trays in resident rooms. RN #1 stated she went to the dining room to obtain the resident's meal tray. RN #2 stated Resident #40 usually eats in the dining room. On 2/6/19 at 3:02 p.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 was asked if both residents in a room are supposed to be served their meal trays at the same time. CNA #2 stated, They should be served at the same time. CNA #2 stated serving residents who reside in the same room at the same time has been an issue because of the way the meal trays are organized in the food carts. CNA #2 stated the meal trays are not organized in the food carts in order of the rooms. CNA #2 stated a resident's meal tray might be in one place in the food cart while the roommate's tray may be placed somewhere else in the food cart. CNA #2 was asked how she would feel if she had not been served her meal while her roommate was eating. CNA #2 stated she would be hurt and embarrassed. On 2/6/19 at 5:39 p.m., ASM (administrative staff member) #1 (the executive director), ASM #2 (the nurse executive) and ASM #3 (the clinical quality specialist) were made aware of the above concern. The facility policy titled, Treatment: Considerate and Respectful documented, (Name of company) Centers will promote care for patients in a manner and in an environment that maintains or enhances each patient's dignity and respect in full recognition of his or her individuality. No further information was presented prior to exit. 4. The facility staff failed to assist Resident# 61 with eating on 2/5/19 at the same time her roommate received lunch. Resident #61 did not receive assistance with eating until at least 15 minutes after her roommate was served. Resident #61 was admitted to the facility on [DATE]. Resident #61's diagnoses included but were not limited to dementia, repeated falls and high cholesterol. Resident #61's most recent MDS (minimum data set), a 14 day Medicare assessment with an ARD (assessment reference date) of 1/29/19, coded the resident's cognition as severely impaired. Section G coded Resident #61 as requiring extensive assistance of one staff with eating. Resident #61's care plan dated 12/29/18 failed to document information regarding a dignified dining experience. On 2/5/19 at 1:25 p.m., Resident #61 was observed sitting in a wheelchair beside her bed. The resident's meal tray was on a table positioned over the bed. Resident #61's roommate was sitting up and eating lunch. On 2/5/19 at 1:28 p.m., a male and a female visitor entered Resident #61's room and were observed talking to the resident. On 2/5/19 at 1:31 p.m., OSM (other staff member) #8 (a speech therapist) entered Resident #61's room, spoke to the resident's roommate and exited the room. On 2/5/19 at 1:40 p.m., an interview was conducted with CNA (certified nursing assistant) #3 in the hall outside of Resident #61's room. CNA #3 confirmed Resident #61 required assistance with eating. When asked if the resident had eaten lunch, CNA #3 stated, We feed her if her family isn't here. We just finished serving trays. CNA #3 looked into Resident #61's room and stated family was present in the room. At this time, CNA #3 entered Resident #61's room. The resident's meal tray remained on the table over the bed. CNA #3 asked the resident's visitors if they were feeding her (Resident #61). The female visitor stated, No. This surveyor asked the female visitor if she or the male visitor was family; she stated they were Resident #61's friends. This surveyor asked the female visitor if she or the male visitor ever assists Resident #61 with eating; the female visitor stated they never had. CNA #3 stated she was obtaining meal trays for a few other residents who did not receive a tray then she would assist Resident #61 with eating (note- after this interview, Resident #61 was observed receiving assistance with eating). On 2/6/19 at 3:02 p.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 was asked if both residents in a room are supposed to be served their meal trays at the same time. CNA #2 stated, They should be served at the same time. CNA #2 stated serving residents who reside in the same room at the same time has been an issue because of the way the meal trays are organized in the food carts. CNA #2 stated the meal trays are not organized in the food carts in order of the rooms. CNA #2 stated a resident's meal tray might be in one place in the food cart while the roommate's tray may be placed somewhere else in the food cart. CNA #2 was asked if a meal tray should be left beside a resident who requires assistance while the roommate is eating. CNA #2 stated, No. CNA #2 was asked how she would feel if she had not been served her meal while her roommate was eating. CNA #2 stated she would be hurt and embarrassed. On 2/6/19 at 5:39 p.m., ASM (administrative staff member) #1 (the executive director), ASM #2 (the nurse executive) and ASM #3 (the clinical quality specialist) were made aware of the above concern. No further information was presented prior to exit. Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide a dignified dining experience for fifteen of 55 residents in the survey sample; Residents #74, #13, #34, #62, #500, #36, #59, #49, #48, #55, #33, #24, #8, #40, and #61. 1. The facility staff failed to provide a dignified dining experience for Residents #74, #13, #34, #62, #500, #36, #59, #49, #48, #55, and #33. Residents were observed sitting at three tables in the small café dining room without food while another resident at the table was served their meal and eating. 2. The facility staff failed to provide a dignified dining experience for Resident #8 and Resident #24. The facility staff failed to address Resident #97's loud cursing at staff for approximately 29 minutes, during which time Resident #8 and #24 both expressed a dislike of Resident #97's cursing. 3. The facility staff failed to serve Resident #40 lunch on 2/5/19 at the same time her roommate received lunch. Resident #40 did not receive lunch until at least 16 minutes after her roommate was served. 4. The facility staff failed to assist Resident# 61 with eating on 2/5/19 at the same time her roommate received lunch. Resident #61 did not receive assistance with eating until at least 15 minutes after her roommate was served The findings include: 1. The facility staff failed to provide a dignified dining experience for Residents #74, #13, #34, #62, #500, #36, #59, #49, #48, #55, and #33. Residents were observed sitting at three tables in the small café dining room without food while another resident at the table was served their meal and eating. On 2/5/19 at 12:17 p.m., a dining observation in the small cafe dining room was conducted. There were three (3) tables of residents. Table 1, closest to the door, had 3 (three) residents (#62, #48, and #59). Table 2, closest to the courtyard windows, had 4 (four) residents (#74, #500, #36, and #55). Table 3, closest to the sink and counter area, had 4 (four) residents (#13, #49, #33, and #34). The following was observed on 2/5/19 during the dining observations: Table 1: - At 12:55 p.m., Resident #62 at table 1 was served. The remaining two residents (Residents #48, and #59) at this table were not served at this time. - At 12:56 p.m., Resident 59 at table 1 was served. The third resident (Resident #48) at this table was still not served at this time. - At 1:02 p.m., Resident #48 at table 1 was served. This was 7 minutes after Resident #62 at the same table was served. Table 2: - At 12:46 p.m., Resident #74 at table 2 was served. The remaining three residents at this table (Residents #500, #36, and #55) were not served at this time. - At 12:55 p.m., Resident #500 at table 2 was served. This was 9 minutes after Resident #74 at the same table was served their meal. The remaining two residents (Residents#36, and #55) at this table were not served. - At 12:56 PM, Resident #36 at table 2 was served. This was 10 minutes after Resident #74 was served at the same table. - At 1:03 p.m., Resident #55 at table 2 was served. This was 17 minutes after the meal for Resident #74 at the same table, was served. Table 3: - At 12:49 p.m., Residents #13 and #34 at table 3 were served. The remaining two residents (Residents #49 and #33) at this table were not served at this time. - At 12:58 p.m., Resident #49 at table 3 was served. This was 9 minutes after Residents #13 and #34 at the same table were served. - At 1:05 p.m., Resident #33 at table 3 was served. This was 16 minutes after Residents #13 and #34 at the same table were served. On 2/7/19 at 10:40 a.m., during an interview conducted with CNA #1 (Certified Nursing Assistant). CNA#1 stated that residents are served depending on when their tray is brought to the dining room from the kitchen; or when it is brought to the dining from a cart that went out to the unit for residents who are being served in their rooms. CNA #1 stated residents should not be served this way; residents at a table should all be served at the same time, but that this happens all the time. A review of the facility policy, Dining Service Standards documented, Patients/Residents are provided a positive meal experience Meals are served table by table Restaurant style dining is encouraged in the primary dining locations On 2/7/19 at approximately 2:20 p.m., the Executive Director and Nurse Executive (ASM [Administrative Staff Member] #1 and #2) were made aware of the findings. No further information was provided by the end of the survey. Resident #74 was admitted to the facility on [DATE] with the diagnoses of but not limited to chronic obstructive pulmonary disease, high blood pressure, and dementia. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 1/8/19. The resident was coded as being moderately impaired in ability to make daily life decisions. The resident was coded as supervision for eating. Resident #13 was admitted to the facility on [DATE] with the diagnoses of but not limited to Alzheimer's disease, high blood pressure, and arthritis. The most recent MDS (Minimum Data Set) was an admission assessment with an ARD (Assessment Reference Date) of 11/7/18. The resident was coded as severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring limited assistance for eating. Resident #34 was admitted to the facility on [DATE] with the diagnoses of but not limited to renal insufficiency, stroke, high blood pressure, and dementia. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 1/11/19. The resident was coded as being severely impaired in ability to make daily life decisions. The resident was coded as requiring extensive assistance for eating. Resident #62 was admitted to the facility on [DATE], acute kidney failure, and bladder cancer. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 1/1/19. The resident was coded as being significantly impaired in ability to make daily life decisions. The resident was coded as requiring total care for eating. Resident #500 was admitted to the facility on [DATE] with diagnoses including but not limited to: systemic inflammatory response syndrome, and dementia. The MDS had not yet been completed. The admission nursing assessment dated [DATE] documented the resident was alert and oriented to person, place, and time. The assessment form did not include documentation about the resident's level of assistance required to attend to any areas of activities of daily living. Resident #36 was admitted to the facility on [DATE] with diagnoses including but not limited to: urinary retention, and encephalopathy. The most recent MDS (Minimum Data Set) was an annual assessment with an ARD (Assessment Reference Date) of 11/21/18. The resident was coded as being severely impaired in ability to make daily life decisions. The resident was coded as requiring extensive assistance for transfers and eating. Resident #59 was admitted to the facility on [DATE] with diagnoses including but not limited to: cerebral palsy, asthma, and mood disorder. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 12/29/18. The resident was coded as being severely impaired in ability to make daily life decisions. The resident was coded as requiring supervision for eating. Resident #49 was admitted to the facility on [DATE] with diagnoses including but not limited to: pelvic fracture, wrist fracture, distal radius fracture, frontal scalp hematoma, head injury, and dementia MDS was a quarterly assessment with an ARD (Assessment Reference Date) of 12/12/18. The resident was coded as being severely cognitively impaired in ability to make daily life decisions. The resident required total care for all areas of activities of daily living, including eating. Resident #48 was admitted to the facility on [DATE] with diagnoses including but not limited to: with diagnoses that included but are not limited to diabetes, high blood pressure, and stroke. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 12/12/18. The resident was coded as being moderately impaired in ability to make daily life decisions. The resident was coded as independent for eating. Resident #55 was admitted to the facility on [DATE], with diagnoses including but not limited to: renal mass, macular degeneration, frequent falls, and dementia. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 12/19/18. The resident was coded as being severely impaired in ability to make daily life decisions. The resident was coded as requiring limited assistance for eating. Resident #33 was admitted to the facility on [DATE] with diagnoses that included but are not limited to hip fracture, Alzheimer's disease, and dysphagia. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 11/10/18. The resident was coded as being severely impaired in ability to make daily life decisions. The resident was coded as requiring extensive assistance for transfers, eating and hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop and implement the comprehensive care plan for eight of 55 residents in the survey sample, Resident #50, #52, #97, #7, #99, #309, #71, and #29. 1. The facility staff failed to develop a comprehensive care plan regarding Resident #50's mail delivery. 2. The facility staff failed to implement the comprehensive care plan for the administration of oxygen for Resident #52. 3. The facility staff failed to develop a behavior care plan for Resident #97 to address the residents cursing. 4. The facility staff failed to follow Resident # 7's comprehensive care plan for the placement of the call bell. 5. The facility staff failed to develop a comprehensive care plan for Resident # 99's tube feeding and tracheostomy care. 6. The facility staff failed to develop a comprehensive care plan for Resident # 309's oxygen. 7. The facility staff failed to implement Resident #71's care plan for respiratory medication administration. 8. The facility staff failed to implement Resident #29's care plan for pressure injury treatment. The findings include: 1. Resident #50 was admitted to the facility on [DATE]. Diagnosis included but were not limited to: high blood pressure, depression, chronic obstructive pulmonary disease (1) and obstructive sleep apnea (2). The most recent MDS (minimum data set), an annual assessment, with an assessment reference date of 7/24/18, coded the resident as having a score of 15 of 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact to make daily decisions. On 02/05/19 at approximately 11:09 a.m., an interview was conducted with Resident #50. Resident # 50 was asked if he felt the facility offered him privacy. Resident #50 replied For the most part. A couple of months ago I was supposed to get a package in the mail but when it got to me, someone had opened it. I was pretty mad about that and I let the administration know about it (Sic). Resident #50 was asked what was in the package. Resident #50 replied Some batons that I ordered from Amazon. They (the facility administration) thought it was a weapon. I have a 'bum' shoulder, and I was going to use them to stretch my arms. After I complained about this, they said they would ask me before they opened my packages. The social worker note dated 8/21/18 at 3:07 p.m., documented (name of Resident #50) has a rotator cuff pain and goals will focus on improving his flexibility and pain level. (Name of Resident #50) continues to order equipment of (sic) amazon that might not be appropriate for our facility (i.e. gym equipment, karate gear, etc.). He is aware that anything he wants to order should be reviewed first so that he does not bring anything inappropriate to the facility. The comprehensive care plan dated February 2019, failed to address how Resident #50's history of ordering in appropriate items and how his mail should be delivered. On 2/6/19 at approximately 1:47 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 was asked what the purpose of a care plan is. CNA #1 replied, It contains all the basic information about how to care for a resident. On 02/07/19 at approximately 8:52 a.m., an interview was conducted with ASM (administrative staff member) #1, the Executive Director. ASM #1 was asked if any residents had complained of getting opened mail. ASM #1 replied, Yes (name of Resident #50), told me while I made a tour, that a while back before I got here, he had received an opened package. The resident had a history of getting weapons in the mail, so the previous administrator opened his package. However when I found out about this I educated the staff on not opening a residents mail. We also told him that he can't have any weapons here. And now staff are not to open any of his package unless he consents and they open it in his presence. On 2/7/19 at approximately 11:27 a.m., an interview was conducted with RN (registered nurse) #5, Nurse Practice Educator. RN #5 was asked if Resident #50's care plan documented how his mail should be delivered. RN #5 replied, No. RN #5 was asked if Resident #50's care plan should include his history of ordering inappropriate items, and if it should address how to handle his mail. RN #5 replied, Yes. On 2/7/18 at approximately 5:45 p.m., ASM (administrative staff member) #1, the Executive Director and ASM #2, the Nurse Executive, and ASM #3, Clinical Quality Specialist, were made aware of the findings. No further information was obtained prior to exit. 1. Disease that makes it difficult to breath that can lead to shortness of breath). The two main types are chronic bronchitis and emphysema. The main cause of COPD is long-term exposure to substances that irritate and damage the lungs. This is usually cigarette smoke. Air pollution, chemical fumes, or dust can also cause it. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 2. Obstructive sleep apnea (OSA) is a problem in which your breathing pauses during sleep. This occurs because of narrowed or blocked airways. This information was obtained from the website: https://medlineplus.gov/ency/article/000811.htm. 2. The facility staff failed to implement Resident #52's comprehensive care plan for the administration of oxygen. Resident #52 was admitted to the facility on [DATE]. Diagnoses included but were not limited to: chronic obstructive pulmonary disease (COPD) (1), myelodysplastic syndrome (2), anemia (3), depression, and shortness of breath. The most recent MDS (minimum data set), an annual assessment, with an ARD (assessment reference date) of 12/15/18, coded the resident as having a score of 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact to make daily decisions. Section O-Special Treatments, documented that Resident #52 receives oxygen therapy. The physician order sheet dated January 2019 documented Oxygen at 2 liters per minute via nasal cannula (a plastic tube with two prongs that inserts in the nose) continuously. The comprehensive care plan dated 7/13/18 documented, O2 (oxygen) as ordered. On 2/5/19 at approximately 8:34 a.m., an observation was made of Resident #52. Resident #52 was observed receiving oxygen via a nasal cannula connect to an oxygen concentrator. Observation of the flow meter on Resident #52's oxygen concentrator revealed the oxygen flow rate was set with the ball between the 2.0L/min (liters per minute) and 2.5L/min lines. On 2/5/19 at approximately 3:30 p.m., a second observation was made of Resident #52's oxygen concentrator. Observation of the flow meter on Resident #52's oxygen concentrator revealed the oxygen flow rate was set with the ball between the 2.0L/min (liters per minute) and 2.5L/min lines. On 2/5/19 at approximately 3:40 p.m., a third observation was made with of Resident 52's oxygen concentrator flow meter with LPN (licensed practical nurse) #1. LPN #1 was asked to read the flow meter on Resident #52's oxygen concentrator. After observing Resident #52's oxygen concentrator flow meter, LPN #1 stated, its set at 2.5L (liters). On 2/5/19 at approximately 3:41 p.m., an interview was conducted with LPN #1. When asked was asked how an oxygen flow meter is read, LPN #1 replied, The top of the ball is supposed to be on the line. On 2/5/19 at approximately 3:45 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 was asked how the rate on an oxygen flow meter is set. RN #2 replied, You turn the dial until the line is in the middle of the ball. On 2/6/19 at approximately 1:47 p.m., an interview was conducted with CNA (certified nursing assistant) #1, regarding the purpose of a care plan. CNA #1 replied, It's all the basic information about how to care for a resident. CNA #1 was asked residents' care plans should be followed. CNA #1 replied, Yes. On 2/6/19 at approximately 2:17 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 was asked the purpose of resident care plans. LPN #2 replied, It has all the information you need so you can care for a particular resident. LPN #2 was asked if Resident #52's care plan in regards to oxygen administration be followed. LPN #2 replied, Yes. On 2/7/19 at approximately 5:45 p.m., ASM (administrative staff member) #1, the Executive Director and ASM #2, the Nurse Executive, and ASM #3, Clinical Quality Specialist, were made aware of the findings. No further information was provided prior to exit. 1. A disease that makes it difficult to breath that can lead to shortness of breath. The two main types are chronic bronchitis and emphysema. The main cause of COPD is long-term exposure to substances that irritate and damage the lungs. This is usually cigarette smoke. Air pollution, chemical fumes, or dust can also cause it. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 2. Your bone marrow is the spongy tissue inside some of your bones, such as your hip and thigh bones. It contains immature cells, called stem cells. The stem cells can develop into the red blood cells that carry oxygen through your body, the white blood cells that fight infections, and the platelets that help with blood clotting. If you have a myelodysplastic syndrome, the stem cells do not mature into healthy blood cells. Many of them die in the bone marrow. This means that you do not have enough healthy cells, which can lead to infection, anemia, or easy bleeding. This information was obtained from the website: https://medlineplus.gov/myelodysplasticsyndromes.html 3. If you have anemia, your blood does not carry enough oxygen to the rest of your body. The most common cause of anemia is not having enough iron. Your body needs iron to make hemoglobin. Hemoglobin is an iron-rich protein that gives the red color to blood. It carries oxygen from the lungs to the rest of the body. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=anemia&_ga=2.71282640.1704263304.1542638661-1154288035.1542638661 3. The facility staff failed to develop a behavior care plan for Resident #97 to address the residents cursing. Resident #97 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: diabetes, high blood pressure, hemiplegia (1) and hemiparesis (2) following cerebral infarction (3). The most recent MDS (minimum data set), a Medicare thirty day assessment, with an ARD (assessment reference date) of 1/18/19 coded the resident as having scored a 15 out of 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact to make daily decisions. The resident was coded as requiring limited assistance with eating. On 02/05/19 at approximately 12:20 p.m., an observation was conducted in the main dining room, where lunch was being served. Resident #97 was observed cursing loudly and continuously at staff. He was also observed complaining to other residents in the dining hall about the food and service in the lunchroom. On 02/05/19 at approximately 12:22 p.m., Resident #8 told Resident #97, Can you please stop using that language. Resident #8 then turned to this surveyor and stated, He always does this, and they (the facility staff) need to do something. On 02/05/19 at approximately 12:32 p.m., Resident #24 told Resident #97, Watch your language please. However, Resident #97 continued cursing loudly. On 02/05/19 at approximately 12:49 p.m., (29 minutes after the initial observation of cursing in the dining room), an observation was conducted in the main dining room, where lunch was being served. Resident #97 was told by CNA (certified nursing assistant) #1, Mr. (name of resident) you can't use that type of language in the dining room. On 02/06/19 at approximately 1:47 p.m., an interview was conducted with CNA #1. CNA #1 was asked if Resident #97 had a habit of cursing in the dining room. CNA #1 replied, Yes, he is known for cursing we have told him in the past to stop but sometimes he does not listen. CNA #1 was asked about the purpose of resident care plans. CNA #1 replied, It contains all the basic information about how to care for a resident. CNA #1 was asked if Resident #97's behavior of cursing in the dining room was addressed in his care plan, CNA #1 replied No. CNA #1 was asked how all staff would know how to care for Resident #97 in regards to his behavior, if they were not familiar with him. CNA #1 replied, If something else is not written down anywhere else in his chart, I don't know. On 02/07/19 at approximately 11:27 a.m., an interview was conducted with RN (registered nurse) #5, Nurse Practice Educator. RN #5 was asked about the purpose of residents' care plans, RN #5 replied, It communicates with all staff about how to care for a specific resident's needs. RN #5 was asked if a resident has behaviors; should that be a part of the residents care plan, RN #5 replied, Yes. Review of Resident #97's care plan initiated on 12/24/18 and revised on 1/8/19 failed to document the residents' behavior of cursing in the dining room. On 02/07/19 at approximately 5:45 p.m., ASM (administrative staff member) #1, the Executive Director and ASM #2, the Nurse Executive, and ASM #3, Clinical Quality Specialist, were made aware of the findings. No further information was given to surveyor prior to exit. 1. Also called: Hemiplegia, Palsy, Paraplegia, and Quadriplegia. Paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. This information was obtained from the website: https://medlineplus.gov/paralysis.html. 2. Paralysis is the loss of muscle function in part of your body. This information was obtained from the website: https://medlineplus.gov/paralysis.html. 3. A stroke. When blood flow to a part of the brain stops. A stroke is sometimes called a brain attack. If blood flow is cut off for longer than a few seconds, the brain cannot get nutrients and oxygen. Brain cells can die, causing lasting damage. This information was obtained from the website: https://medlineplus.gov/ency/article/000726.htm. 2. Bradycardia is a slower than normal heart rate. The hearts of adults at rest usually beat between 60 and 100 times a minute. If you have bradycardia ([NAME]-e-[NAME]-[NAME]-uh), your heart beats fewer than 60 times a minute. Bradycardia can be a serious problem if the heart doesn't pump enough oxygen-rich blood to the body. For some people, however, bradycardia doesn't cause symptoms or complications. This information was obtained from the website: https://www.mayoclinic.org/diseases-conditions/bradycardia/symptoms-causes/syc-20355474?p=1 7. The facility staff failed to implement Resident #71's care plan for respiratory medication administration. Resident #71 was admitted to the facility on [DATE]. Resident #71's diagnoses included but were not limited to chronic obstructive pulmonary disease (2), low back pain and anxiety disorder. Resident #71's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/8/19, coded the resident as being cognitively intact. Review of Resident #71's clinical record revealed a physician's order dated 10/17/18, for Advair 500 mcg (micrograms)/50 mcg and to inhale one puff every 12 hours. Review of Resident #71's November 2018 and January 2019 MARs (medication administration records) failed to reveal Advair was administered to the resident (as evidenced by blank spaces with no documented nurses' initials) on the following dates and times: - 11/1/18 at 9:00 p.m., - 11/3/18 at 9:00 a.m., - 11/30/18 at 9:00 p.m., - 1/9/19 at 9:00 p.m., - 1/23/19 at 9:00 p.m. Nurses' notes for those dates failed to reveal the medication was administered. Further review of Resident #71's January 2019 MAR revealed Advair was not administered to the resident on the following dates and times: -1/6/19 at 9:00 a.m. and 9:00 p.m., -1/18/19 at 9:00 a.m. and 9:00 p.m., -1/19/19 at 9:00 a.m. and - 1/29/19 at 9:00 a.m. On these dates above, the nurses circled their initials and documented the medication was not available on the back of the MAR. Resident #71's comprehensive care plan dated 10/2/18 documented, Resident exhibits or is at risk for respiratory complications related to Asthma, COPD .Medicate as ordered . On 2/5/19 at 12:20 p.m., an interview was conducted with Resident #71. The resident stated he was not getting his Advair as he was supposed to for a while but that had straightened itself out. On 2/6/19 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 was asked the purpose of a care plan. LPN #3 stated, So the nursing staff can know how to really care for the resident and if they require any equipment or anything really. When asked how nurses ensure they implement residents' care plans, LPN #3 stated, Usually most, they honestly go by the orders; the physician orders, and their MARs (medication administration records) and stuff. LPN #3 confirmed residents' care plans are available if nurses need to review them. LPN #3 was asked how nurses evidence the medications and treatments they administer. LPN #3 stated, They sign off on the MAR (medication administration record) and TAR. When asked what is meant if there are blank spaces on the MAR, or TAR and the nurses did not sign off, LPN #3 stated, In reality it means that they didn't do it. LPN #3 was asked what is meant if nurses sign and circle their initials on the MAR. LPN #3 stated, Usually if signed and circled, either they held it, or couldn't give it, they are supposed to explain on the back of the MAR. LPN #3 was asked if Advair is contained in the facility STAT (Immediate) box (a box containing various medications that can be accessed for any resident if needed). LPN #3 stated Advair is contained in the facility omnicell (a machine provided by that pharmacy, containing many various medications that can be accessed for each resident). LPN #3 was asked the facility process for ensuring Advair is available for administration, if not in the medication cart. LPN #3 stated, They can check the omnicell. If it's the right dose, the omnicell will let you pull it. If not, let the physician know it's not here, let the patient know, call the pharmacy and ask to send (the medication) from backup (a backup pharmacy) and let the rp (responsible party) know that you didn't give it. When asked if Resident #71 missed doses of his Advair, LPN #3 stated, Yes. He would tell us he got it (the disk) and it was empty; then I further investigated. LPN #3 was asked if the Advair disk displays how many doses are left in the device. LPN #3 confirmed it did. LPN #3 was asked if nurses should have addressed a pharmacy refill for the medication before the medication ran out and stated nurses should have addressed the refill when there were four doses left. On 2/6/19 at 5:39 p.m., ASM (administrative staff member) #1 (the executive director), ASM #2 (the nurse executive) and ASM #3 (the clinical quality specialist) were made aware of the above concern. No further information was obtained prior to exit. 8. The facility staff failed to implement Resident #29's care plan for pressure injury treatment. Resident #29 was admitted to the facility on [DATE]. Resident #29's diagnoses included but were not limited to urinary tract infection, arthritis and abnormal posture. Resident #29's most recent MDS (minimum data set), a 30 day Medicare assessment with an ARD (assessment reference date) of 11/21/18, coded the resident's cognition as moderately impaired. Section G coded Resident #29 as requiring extensive assistance of one staff with bed mobility, toilet use and personal hygiene. Section M coded Resident #29 as having one stage three-pressure injury (1) that was present upon admission. Review of a skin integrity report dated 10/29/18 revealed Resident #29 presented with a stage three-pressure injury. A physician's order dated 10/29/18 documented, Cleanse open area L (left) buttock (with) NS (normal saline), apply skin prep to wound edges, santyl (2) to wound bed & cover (with) dry dressing QD (every day) & PRN (as needed) (illegible word). Review of Resident #29's October 2018 and November 2018 TARs (treatment administration records) failed to reveal evidence that the treatment ordered on 10/29/18 was provided for Resident #29 on 10/30/18, 11/4/18, 11/10/18, 11/11/18, 11/12/18, 11/24/18, 11/25/18, 11/26/18, 11/27/18, 11/28/18, 11/29/18 and 11/30/18. This was evidenced by blank spaces on the TARs. No nurses' initials were signed off to indicate the treatment had been performed. Review of nurses' notes for the above dates failed to reveal Resident #29's pressure injury treatment was administered except for a note dated 11/4/18 that documented treatments were administered as ordered. Resident #29's comprehensive care plan dated 11/8/18 documented, Resident has actual skin breakdown related to limited mobility, stage 3 pressure wound to left buttock .Provide wound treatment as ordered . On 2/6/19 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 was asked the purpose of a care plan. LPN #3 stated, So the nursing staff can know how to really care for the resident and if they require any equipment or anything really. When asked how nurses ensure they implement residents' care plans, LPN #3 stated, Usually most, they honestly go by the orders; the physician orders, and their MARs (medication administration records) and stuff. LPN #3 confirmed residents' care plans are available if nurses need to review them. LPN #3 was asked how nurses evidence the medications and treatments they administer. LPN #3 stated, They sign off on the MAR and TAR. When asked what is meant if there are blank spaces on the MAR, or TAR and the nurses did not sign off, LPN #3 stated, In reality it means that they didn't do it. On 2/6/19 at 5:39 p.m., ASM (administrative staff member) #1 (the executive director), ASM #2 (the nurse executive) and ASM #3 (the clinical quality specialist) were made aware of the above concern. No further information was presented prior to exit. (1) Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. This information was obtained from the website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (2) SANTYL Ointment is an FDA-approved prescription medicine that removes dead tissue from wounds so they can start to heal. This information was obtained from the website: https://www.santyl.com/ 4. The facility staff failed to follow Resident # 7's comprehensive care plan for the placement of the call bell. Resident # 7 was admitted to the facility on [DATE] with diagnoses that included but were not limited to lack of coordination, rheumatoid arthritis (1), Alzheimer's disease (2), gastroesophageal reflux disease (3) and hypertension (4). Resident # 7's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 10/20/18, coded Resident # 7 as scoring an eight on the brief interview for mental status (BIMS) of a score of 0 - 15, eight - being moderately impaired of cognition for making daily decisions. Resident # 7 was coded as requiring extensive assistance of one staff member for activities of daily living. Section G0400 Functional Limitation in Range of Motion coded Resident # 7 as being impaired on both sides of her upper extremities (shoulder, elbow, wrist, hand). On 02/05/19 at 11:08 a.m., an observation of Resident # 7 revealed she was lying in bed, awake, neat and clean, watching television. The head of the bed was slightly raised and a pillow was under the upper part of Resident # 7's back. Further observation of Resident # 7 revealed she was leaning toward her left side. Observation of the call bell revealed it was a flat pressure switch. Observation of the call bell's placement revealed it was lying on top of the mattress in the upper right corner, behind Resident # 7's head. When asked if she could locate the call bell Resident # 7 moved her head slightly to the right and then left and struggled to remove her right arm from under the blanket covering her. Resident # 7 stated, I don't know where it is. Observation of Resident # 7's movements revealed there was decreased range of motion. On 02/05/19 at 3:22 p.m., an observation of Resident # 7 revealed she was lying in bed, awake, neat and clean, watching television. The head of the bed was slightly raised and a pillow was under the upper part of Resident # 7's back. Further observation of Resident # 7 revealed she was leaning slightly to her left side. Observation of the call bell's placement revealed it was hanging off the side of the mattress in the upper right corner, behind Resident # 7's head. When asked if she could locate the call bell Resident # 7 stated, I don't know where it is. On 02/06/19 at 8:01 a.m., an observation of Resident # 7 was lying in bed, awake, neat and clean, watching television. The head of the bed was slightly raised and a pillow was under the upper part of Resident # 7's back. Further observation of Resident # 7 revealed she was leaning slightly to her left side. Observation of the call bell's placement revealed it was lying on the bed, on Resident # 7's right side just below her shoulder. When asked if she could locate the call bell Resident # 7 stated, I don't know where it is. On 02/07/19 at 8:15 a.m., an observation of Resident # 7 was lying in bed, awake, neat and clean, watching television. The head of the bed was slightly raised and a pillow was under the upper part of Resident # 7's back. Further observation of Resident # 7 revealed she was leaning slightly to her left side. Observation of the call bell's placement revealed it was lying on the bed, on Resident # 7's right side just below her shoulder. When asked if she could locate the call bell Resident # 7 stated, No. The comprehensive care plan for Resident # 7 dated 10/25/2017 with a revision date of 12/12/2018 documented, Focus. Resident is at risk for falls related to cognitive impairment, lack of safety awareness and impaired mobility. Date initiated 10/25/2017. Revision date: 12/12/2018. Under Interventions, it documented Place call light within reach while in bed or close proximity to the bed. Date initiated: 10/25/2017. On 02/06/19 at 1:47 p.m., an interview was conducted with CNA (certified nursing assistant) # 1 When asked to describe the purpose of the care plan, CNA # 1 stated, All the basic information about how to care for a resident. When asked if they had access to the resident's care plans, CNA # 1 stated, Yes, it's on our tablet. On 02/06/19 at 2:17 p.m., an interview was conducted with LPN, (licensed practical nurse) # 2. When asked to describe the purpose of the care plan, LPN # 2 stated, It has all you need so you know what to do for a particular resident. On 02/07/19 at 8:15 a.m., an observation of Resident # 7's call bell placement was conducted with CNA (certified nursing assistant) # 2. When asked if the call bell was placed in a position that Resident # 7 could reach and activate, CNA #2 sated, It's not in reach, and she has limited range of motion. On 02/07/19 at 8:30 a.m., an observation of Resident # 7's call bell placement was conducted with RN (registered nurse) # 8, unit manager. When asked if the call bell was placed in a position that Resident # 7 could reach and activate, RN # 8 sated, No and immediately repositioned the call bell within reach of Resident # 7's right hand. On 02/07/19 at 11:27 a.m., an interview was conducted with RN (registered nurse) # 5. When asked to describe the purpose of the care plan, RN # 5 stated, Communicate with all staff about the needs of a resident, its updated constantly as the residents needs change. On 02/07/19 at approximately 3:45 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, executive nurse, were made aware of the above findings. No further information was provided prior to exit. References: (1) A long-term disease. It leads to inflammation of the joints and surrounding tissues. It can also affect other organs. This information was obtained from the website: https://medlineplus.gov/ency/article/000431.htm. (2) Gastroesophageal reflux disease (GERD) happens when your stomach contents come back up into your esophagus causing heartburn (also called acid reflux). This information was obtained from the website: https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults (3) Alzheimer's disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks. It is the most common cause of dementia in older adults. While dementia is more common as people grow older, it is not a normal part of aging. This information was obtained from the website: https://www.nia.nih.gov/health/alzheimers/basics. (4) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. 5. The facility staff failed to develop a comprehensive care plan for Resident # 99's tube feeding and tracheostomy care. Resident # 99 was admitted to the facility on [DATE] with diagnoses that included but were not limited to aphasia (1), tracheostomy status (2), hemiplegia (3) and cerebral vascular disease (4). Resident # 99's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/216/19, coded Resident # 99 as scoring a three on the brief interview for mental status (BIMS) of a[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility staff failed to review and revise Resident #1's care plan to include oxygen administration. Resident #1 was admitted to the facility on [DATE]. Resident #1's diagnoses included but were not limited to low back pain, bladder cancer and high blood pressure. Resident #1's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/1/19, coded the resident as being cognitively intact. Section G coded Resident #1 as requiring extensive assistance of one staff with bed mobility, transfers and personal hygiene. Section O coded the resident as receiving oxygen therapy during the last 14 days. Review of Resident #1's clinical record revealed a physician's order dated 1/25/19 for continuous oxygen, at two liters per minute via nasal cannula. Resident #1's care plan dated 1/29/19 failed to reveal documentation regarding oxygen administration. On 2/5/19 at 9:24 a.m. and 10:58 a.m., Resident #1 was observed sitting up in bed receiving oxygen via a nasal cannula. On 2/6/19 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 was asked the purpose of a care plan. LPN #3 stated, So the nursing staff can know how to really care for the resident and if they require any equipment or anything really. When asked if an oxygen dependent resident's care plan should be reviewed and revised to include oxygen administration, LPN #3 stated, Yes. When asked why, LPN #3 stated, That's what he is being treated with here and he has it; so what he has should be care planned. On 2/6/19 at 5:39 p.m., ASM (administrative staff member) #1 (the executive director), ASM #2 (the nurse executive) and ASM #3 (the clinical quality specialist) were made aware of the above concern. No further information was obtained prior to exit. 6. The facility staff failed to review and/or revise Resident # 309's care plan to reflect the physician's order to discontinue a Foley catheter. Resident # 309 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: edema (2), respiratory failure (3), hypertension (4) and anxiety (5). Resident # 309's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/30/19, coded Resident # 309 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. Resident # 309 was coded as requiring limited assistance of one staff member for activities of daily living. Under section H Bladder and Bowel Resident # 309 was coded for Indwelling catheter. On 02/05/19 at 9:45 a.m., an observation of Resident 309 revealed she was lying in her bed receiving oxygen by nasal cannula. Further observation failed to evidence a catheter. When asked if she had a catheter Resident # 309 stated no. The Physician Telephone Order dated 02/01/19 for Resident # 309 documented, D/C (discontinue Foley. The comprehensive care plan for Resident # 309 dated 02/04/2019 with a revision date of 02/04/2019 documented, Focus. Resident requires indwelling catheter due to: neurogenic bladder. Under Interventions it documented, Assess continued need of catheter. Date Initiated: 02/04/2019. On 02/06/19 at 2:56 p.m., an interview was conducted with RN (registered nurse) # 6, MDS coordinator and LPN (licensed practical nurse) # 6, MDS nurse. After reviewing the Physician Telephone Order dated 02/01/19 for Resident # 309 and the comprehensive care plan dated 02/04/2019 for a Foley catheter, RN # 6 and LPN # 6 stated, When the catheter was discontinued nursing should have revised or updated the care plan. When there is a change in the resident's status or there are new, orders nursing should revise/update the care plan. It wasn't done. On 02/06/19 at approximately 5:50 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, executive nurse, were made aware of the above findings. No further information was provided prior to exit. Reference: (1) A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm. (2) A swelling caused by fluid in your body's tissues. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/edema.html. (3) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. (4) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. (5) Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary. Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to review and/or revise the comprehensive care plan for six out of 55 residents in the survey sample; Residents #39, #31, #15, #35, #1, and #309. 1. The facility staff failed to evidence that Resident #39's comprehensive care plan was reviewed and/or revised after a fall on 11/8/18, 12/24/18, 1/1/19, 1/6/19, and 2/3/19. 2. The facility staff failed to evidence that Resident #31's comprehensive care plan was reviewed and/or revised after a fall on 1/18/19. 3. The facility staff failed to evidence that Resident #15's comprehensive care plan was reviewed and/or revised after a fall on 1/28/19. 4. The facility staff failed to evidence that Resident #35's comprehensive care plan was updated to include the resident's behaviors of going on leave of absences from the facility unsupervised, and his non-compliance with returning within the specified 4-hour window as ordered. 5. The facility staff failed to review and revise Resident #1's care plan to include oxygen administration. 6. The facility staff failed to review and/or revise Resident # 309's care plan to reflect the physician's order to discontinue a Foley catheter. The findings include: 1. The facility staff failed to evidence that Resident #39's comprehensive care plan was reviewed and/or revised after a fall on 11/8/18, 12/24/18, 1/1/19, 1/6/19, and 2/3/19. Resident #39 was most recently readmitted to the facility on [DATE] with the diagnoses of but not limited to dementia, diabetes, chronic back pain, high blood pressure, history of femur fracture, overactive bladder, adjustment disorder with anxiety, and osteoarthritis. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 12/3/18. The resident was coded as being moderately impaired in ability to make daily life decisions. The resident was coded as requiring extensive care for bathing; limited assistance for eating; and supervision for hygiene, toileting, dressing, and transfers. A review of the nurse's notes revealed one dated 11/8/18, which documented, A change in condition has been noted. The symptoms include: Falls 11/8/18 in the afternoon .Orders obtained include: NNO (no new orders) . This note did not document the circumstances surrounding the fall, if there were any injuries, and what, if any, new interventions were added to the care plan. Subsequent nurses' notes over the following days failed to reveal any additional information regarding the details of the fall. A review of the Event Summary Report dated 11/8/18 documented, Resident feel {sic} in dining room trying to reach across the table to get her stuffed cats. Resident fell to floor and hit her head. Resident stated that her head no long {sic} hurt after a few mins (minutes) and was able to get up from the floor with assistance. Resident was assessed for any injuries and none were found Interventions added immediately after fall and care plan updated: Resident was educated on not leaning while in chair. A review of the comprehensive care plan failed to reveal any evidence that the care plan was reviewed and/or revised following this fall. A review of the nurse's notes revealed one dated 12/24/18, which documented, A change in condition has been noted. The symptoms include: Falls 12/24/18 in the morning Change reported to Primary Care Clinician This note did not document the circumstances surrounding the fall, if there were any injuries, and what, if any, new interventions were added to the care plan. Subsequent nurses' notes over the following days failed to reveal any additional information regarding the details of the fall. A review of the Event Summary Report dated 12/24/18 documented, Resident was found on the floor beside her bed with no injuries, tolerated ROM (range of motion) well with no difficulty, vital signs were taken and neuro (neurological) checks initiated Interventions added immediately after fall and care plan updated: Resident had disabled alarm prior to fall, alarm was replaced. A review of the comprehensive care plan failed to reveal any evidence that the care plan was reviewed and/or revised following this fall. A review of the nurse's notes revealed one dated 1/1/19, which documented, A change in condition has been noted. The symptoms include: Falls Change reported to Primary Care Clinician Orders obtained included: Continue to monitor aware of the complaints of buttocks pain no bruising present This note did not document the circumstances surrounding the fall and if there were any injuries, and what, if any, new interventions were added to the care plan. Subsequent nurses' notes over the following days failed to reveal any additional information regarding the details of the fall. A review of the Event Summary Report dated 1/1/19 documented, The resident was toileted by the CNA (Certified Nursing Assistant) was instructed to pull call bell when she was done. The resident did not was noted to be lying on the floor near her bed Interventions added immediately after fall and care plan updated: Staff to remain with the resident while in the bathroom. A review of the comprehensive care plan failed to reveal any evidence that the care plan was reviewed and/or revised following this fall. A review of the nurse's notes revealed one dated 1/6/19, which documented, A change in condition has been noted. The symptoms include: Falls 1/6/19 in the morning. A second note dated 1/6/19 documented, The resident has no new changes in the ROM, usual complaints of general body ache A third note dated 1/6/19 documented, NP (nurse practitioner) .aware of the falls this am there are no new orders. There was no incident report related to this fall provided. These notes did not document the circumstances surrounding the fall and what, if any, new interventions were added to the care plan. Subsequent nurses' notes over the following days failed to reveal any additional information regarding the details of the fall. A review of the comprehensive care plan failed to reveal any evidence that the care plan was reviewed and/or revised following this fall. A review of the nurse's notes revealed one dated 2/3/19, which documented, A change in condition has been noted. The symptoms include: Falls in the morning Change reported to Primary Care Clinician Orders obtained included: Continued observation This note did not document the circumstances surrounding the fall, if there were any injuries, and what, if any, new interventions were added to the care plan. Subsequent nurses' notes over the following days failed to reveal any additional information regarding the details of the fall. A review of the Event Summary Report dated 2/3/19 documented, The resident had just been toileted and wanted to make her bed which was already done by the CNA (Certified Nursing Assistant). She wanted to place her blankets and had taken her shoes off and her feet slipped and she was found in a kneeling position next to her bed. The residents shoes were placed on and she was assisted via a gait belt which she pushed herself up and placed into her w/c (wheelchair). Neuro checks were initiated Interventions added immediately after fall and care plan updated: Continued education and encouragement to be compliant. A review of the comprehensive care plan failed to reveal any evidence that the care plan was reviewed and/or revised following this fall. On 2/06/19 at 1:47 p.m., an interview was conducted with CNA #1 (Certified Nursing Assistant). When asked what a care plan is, CNA #1 stated, All the basic information about how to care for a resident. When asked if she has access to the residents care plan, CNA #1 stated, Yes, it's on our tablet. On 2/06/19 at 2:17 p.m., in an interview with LPN #2 (Licensed Practical Nurse), when asked what the purpose of a care plan, LPN #2stated, It has all you need so you know what to do for a particular resident. When asked what information is on a care plan, LPN #2 stated, diagnoses, skin integrity, UTI (urinary tract infection). When asked who has access to the care plan, LPN #2 stated, nursing and administration. When asked who can review and revise the care plan, LPN #2 stated, the unit manager, DON (director of nursing - Nurse Executive at this facility) On 2/07/19 at 11:27 a.m., in an interview with RN #5 (Registered Nurse), when asked about the purpose of a care plan, RN #5 stated, Communicate with all staff about the needs of a resident, its updated constantly as the residents needs change. When asked what information is found on a care plan, RN #5 stated, Care needs, adl (activities of daily living), diagnoses, oxygen, and skin care. On 2/7/19 at approximately 2:20 p.m., the Executive Director (ASM [Administrative Staff Member] #1) and the Executive Nurse (ASM #2) were made aware of the concern. ASM #2 stated that the Event Summary Report is an internal document and is not part of the legal clinical record. At this time, she was notified that the legal clinical record did not reflect the above data regarding how the fall occurred, if there were any injuries, and if there were any care plan reviews or revisions. A review of the facility policy, Person-Centered Care Plan documented, A comprehensive, individualized care plan will be developed within 7 days after completion of the comprehensive assessment for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments 7. Care plans will be: .7.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals No further information was provided by the end of the survey. 2. The facility staff failed to evidence that Resident #31's comprehensive care plan was reviewed and/or revised after a fall on 1/18/19. Resident #31 was admitted to the facility on [DATE] with the diagnoses of but not limited to high blood pressure, cardiomyopathy, stroke, atrial fibrillation, pacemaker, dementia, contracture, seizures, chronic kidney disease and acute kidney failure. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 11/5/18. The resident was coded as being cognitively intact in ability to make daily life decisions. The resident was coded as requiring total care for bathing; extensive care for transfers, dressing, toileting and hygiene; and limited assistance for eating. A review of the nurse's notes revealed one dated 1/18/19, which documented, A change in condition has been noted. The symptoms include: Falls 1/18/19 at night Change reported to Primary Care Clinician This note did not document the circumstances surrounding the fall, if there were any injuries, and what, if any, new interventions were added to the care plan. Subsequent nurses' notes over the following days failed to reveal any additional information regarding the details of the fall. A review of the Event Summary Report dated 1/18/19 documented, Resident was found face down beside his bed with no injuries, tolerated ROM [range of motion] well, res [resident] stated I am trying to grab something from the floor denies any pain/discomfort Interventions added immediately after fall and care plan updated: Educated resident to use call bell at all times. A review of the comprehensive care plan failed to reveal any evidence that the care plan was reviewed and/or revised following this fall. On 2/7/19 at approximately 2:20 p.m., the Executive Director (ASM [Administrative Staff Member] #1) and the Executive Nurse (ASM #2) were made aware of the concern. ASM #2 stated that the Event Summary Report is an internal document and is not part of the legal clinical record. At this time, she was notified that the legal clinical record did not reflect the above data regarding how this fall occurred, if there were any injuries, if there were any care plan reviews or revisions. No further information was provided by the end of the survey. 3. The facility staff failed to evidence that Resident #15's comprehensive care plan was reviewed and/or revised after a fall on 1/28/19. Resident #15 was admitted to the facility on [DATE] with the diagnoses of but not limited to atrial fibrillation, high blood pressure, hypothyroidism, acute kidney injury, pacemaker, and congestive heart failure. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 10/18/18. The resident was coded as mildly cognitively impaired in ability to make daily life decisions. The resident was coded as requiring extensive care for bathing; supervision for transfers and toileting; and was independent for dressing, eating, and hygiene. A review of the clinical record revealed a nurse's note dated 1/28/19, which documented, A change in condition has been noted. The symptoms include: Fall on 1/28/19 at night Change reported to Primary Care Clinician Orders obtained include: Have PT (physical therapy) eval (evaluate) for functional status. This note did not document the circumstances surrounding the fall, if there were any injuries, and what, if any, new interventions were added to the care plan. Subsequent nurses' notes over the following days failed to reveal any additional information regarding the details of the fall. A review of the Event Summary Report dated 1/28/19 documented, heard res (resident) calling help, entered res room and observed her sitting on the floor between w/c [wheelchair] and bed., holding on to bed and w/c, on neuro [neurological] checks, abrasion to upper mid-back, no bleeding. NP (nurse practitioner) made aware and ordered PT [physical therapy] to eval [evaluate], res rp (responsible party) made aware of fall with abrasion and res need for more assist with ADLs (activities of daily living) Interventions added immediately after fall and care plan updated: Refer to PT, enc (encourage) res to call for assist before getting oob (out of bed). A review of the comprehensive care plan failed to reveal any evidence that the care plan was reviewed and/or revised following this fall. On 2/7/19 at approximately 2:20 p.m., the Executive Director (ASM [Administrative Staff Member] #1) and the Executive Nurse (ASM #2) were made aware of the concern. ASM #2 stated that the Event Summary Report is an internal document and is not part of the legal clinical record. At this time, she was notified that the legal clinical record did not reflect the above data regarding how the fall occurred and if there were any injuries, and if there were any care plan reviews or revisions. No further information was provided by the end of the survey. 4. The facility staff failed to evidence that Resident #35's comprehensive care plan was updated to include the resident's behaviors of going on leave of absences from the facility unsupervised, and his non-compliance with returning within the specified 4-hour window as ordered. Resident #35 was admitted to the facility on [DATE] with the diagnoses of but not limited to hip fracture, atrial fibrillation, high blood pressure, falls, inguinal hernia, and cardiomyopathy. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 11/23/18. The resident was coded as being cognitively intact in ability to make daily life decisions. The resident was coded as being independent for transfers, locomotion, dressing, eating, toileting and required supervision for hygiene. A review of the clinical record revealed the following: • A physician's order dated 8/2/18 that the resident might go on LOA (leave of absence) for 4 hours on 8/3/18 to go to the bank. • A physician's order dated 8/13/18 that the resident might go on LOA for 4 hours on 8/13/18. • A physician's order dated 8/15/18 that the resident might go on LOA for 4 hours on 8/15/18. • A physician's order dated 8/21/18 that the resident might go on LOA for 2 hours on 8/21/18. • A physician's order dated 8/22/18 that the resident might go on LOA for 4 hours daily. A review of the nurse's notes revealed the following: A nurse's note dated 8/15/18 that documented, Resident has order for LOA for 4 hrs [hours], resident left the facility at 99:45 {sic} but not back at 3pm. Safety maintained will continue to monitor. A nurse's note dated 8/15/18 that documented, A change in condition has been noted. The symptoms include: Behavioral symptoms (e.g. agitation, psychosis) 8/15/18 in this afternoon No further information was documented. A nurse's note dated 8/16/18 documented, Late Entry for 8-15-18 resident was observe by this writer and other staff news paper (sic.) on the floor resident pouring A-[NAME] / urine on the news paper (sic.) and pouring A [NAME] in urinal full of urine. This writer ask why and resident stated I wanted to see what dish detergent works the best. Call NP (nurse practitioner) to make aware of the altered mental status N.O. (new order) CBC {1} and BMP {2} in the AM resident own RP [responsible party]. A nurse's note dated 8/30/18 documented, Resident signed out at 1:30pm, today and stated that he was going to (name of bank) and not going to church tonight. Cousin and friend were contacted at 10pm today because resident was not back at facility. Unit manager on call was contacted. Resident made contact with facility soon after and was reported to unit manager on call. Unit manager will pick up resident from Firestone off of (location) A nurse's note dated 8/31/18 documented, Late entry: This RN was contacted by nursing staff of residents (Sic.) failure to return to the facility following his departure for the bank earlier in the afternoon. Nursing staff was advised to make contact with RP to see if they knew where resident was located. This RN was advised that contact was made with residents (Sic.) cousin and friend, neither of which knew of his whereabouts. DON was notified of incident. Nursing staff was advised to call the sheriffs (Sic.) office non emergency number to report the residents (Sic.) failure to return. At approximately 10:30pm, this RN was notified by staff that (resident) had called the facility and stated he was at the Firestone and was unable to get back due to not having enough money for the cab ride. This writer went to pick up resident shortly after. Resident was found in front of the Firestone (location) sitting on the ground. Resident stated he left his bank card (Sic.) back at the facility and was unable to get a ride back. Resident returned to facility. This RN stressed the importance to the resident of returning in a timely manner and the need to be able to take his evening medicine. Resident expressed understanding. Resident was asked where he usually goes when he leaves the facility so if another incident occurs we know where to look. Resident stated that he goes to the (name of bank) on (location) and is usually in the shopping center above or below the hospital. Resident returned to facility at approximately 11:30pm. A nurse's note dated 10/3/18 documented, Patient left facility at 2:10p.m., for LOA was supposed to return by 6:10p.m Patient called facility at 7:50p.m., to say he was at the Bus Station in (location) with no way back. Patient returned at 9:30p.m. He stated, Someone from the Bus Station gave me a ride back. Patient education given on Safety and if Patient is going out alone he must have money for Cab fare both ways and he must return back on time. A social services note dated 10/5/18 documented, Met with patient, (OSM #14 - Other Staff Member - the Ombudsman) CNE (former Center Nurse Executive) to discuss resident's community visits. He has had two instances where he was out in the community and unable to get a ride home after 10pm. Discussed safety and need to be in building when he is scheduled to get his meds. Resident does not have a cell phone at this time. SW (social worker) is working to get him a Medicaid phone. After discussion (resident) is willing to agree to the following. Until he has a cell phone he will not leave the property of (the facility). An exception will be to attend church on Sunday as they will provide transportation both ways. Once he has a phone we will reopen the discussion of his trips into the community. Discussed changing his check to come to (facility) therefore eliminating his need to go to the bank. This would also allow him to have access to his money daily if he wants to purchase a snack. He was agreeable to do this. (Resident) was able to state what the outcome of the meeting was in his own words. He will contact social work and the ombudsman as needed. A review of the care plan failed to reveal any evidence that the resident's community visits unsupervised, or his non-compliance with returning timely was care planned. On 2/7/19 at 1:24 p.m., in an interview with LPN (licensed practical nurse) #4, when asked if the resident's activity of leaving the facility unsupervised, and noncompliance with returning timely should be care planned, LPN #4stated it should have been. On 2/7/19 at 2:20 p.m., an interview was conducted with the Executive Director (ASM [Administrative Staff Member] #1) and the Executive Nurse (ASM #2). When asked about the resident's unsupervised outings into the community and issues he had of returning to the facility timely, ASM #1 stated that he was alert and oriented, his BIMS (Brief Interview for Mental Status exam) was a 15 (cognitively intact). She stated the physician was aware of the resident's outings and that it was his right to go out if he wanted to. When asked about the lack of care planning of his unsupervised outings and noncompliance with returning timely, ASM #1 stated it should have been care planned. No further information was provided. {1} CBC - A CBC (complete blood count) is a commonly performed lab test. It can be used to detect or monitor many different health conditions. Your health care provider may order this test: · As part of a routine check-up · If you are having symptoms, such as fatigue, weight loss, fever or other signs of an infection, weakness, bruising, bleeding, or any signs of cancer · When you are receiving treatments (medicines or radiation) that may change your blood count results · To monitor a long-term (chronic) health problem that may change your blood count results, such as chronic kidney disease. Information obtained from https://medlineplus.gov/ency/article/003642.htm {2} BMP - The basic metabolic panel (BMP) is a frequently ordered panel of 8 tests that gives a healthcare practitioner important information about the current status of a person's metabolism, including health of the kidneys, blood glucose level, and electrolyte and acid/base balance. Abnormal results, and especially combinations of abnormal results, can indicate a problem that needs to be addressed. Information obtained from https://labtestsonline.org/tests/basic-metabolic-panel-bmp

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to follow physician's orders and professional standards of practice for one of 55 residents in the survey sample, Residents #71. The facility staff failed to administer the medication Advair to Resident #71 per physician's order on multiple dates in November 2018 and January 2019. The findings include: The facility staff failed to administer the medication Advair (1) to Resident #71 per physician's order on multiple dates in November 2018 and January 2019. Resident #71 was admitted to the facility on [DATE]. Resident #71's diagnoses included but were not limited to chronic obstructive pulmonary disease (2), low back pain and anxiety disorder. Resident #71's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/8/19, coded the resident as being cognitively intact. Review of Resident #71's clinical record revealed a physician's order dated 10/17/18 for Advair 500 mcg (micrograms)/50 mcg and to inhale one puff every 12 hours. Review of Resident #71's November 2018 and January 2019 MARs (medication administration records) failed to reveal Advair was administered to the resident (as evidenced by blank spaces with no documented nurses' initials) on 11/1/18 at 9:00 p.m., 11/3/18 at 9:00 a.m., 11/30/18 at 9:00 p.m., 1/9/19 at 9:00 p.m., and 1/23/19 at 9:00 p.m. Nurses' notes for those dates failed to reveal the medication was administered. Further review of Resident #71's January 2019 MAR revealed Advair was not administered to the resident on 1/6/19 at 9:00 a.m. and 9:00 p.m., 1/18/19 at 9:00 a.m. and 9:00 p.m., 1/19/19 at 9:00 a.m. and on 1/29/19 at 9:00 a.m. On these dates, the nurses circled their initials and documented the medication was not available on the back of the MAR. Resident #71's comprehensive care plan dated 10/2/18 documented, Resident exhibits or is at risk for respiratory complications related to Asthma, COPD .Medicate as ordered . On 2/5/19 at 12:20 p.m., an interview was conducted with Resident #71. The resident stated he was not getting his Advair as he was supposed to for a while but that had straightened itself out. On 2/6/19 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 was asked how nurses evidence the medications and treatments they administer. LPN #3 stated, They sign off on the MAR (medication administration record) and TAR. When asked what is meant if there are blank spaces on the MAR, or TAR and the nurses did not sign off, LPN #3 stated, In reality it means that they didn't do it. LPN #3 was asked what is meant if nurses sign and circle their initials on the MAR. LPN #3 stated, Usually if signed and circled, either they held it, or couldn't give it, they are supposed to explain on the back of the MAR. LPN #3 was asked if Advair is contained in the facility STAT (Immediate) box (a box containing various medications that can be accessed for any resident if needed). LPN #3 stated Advair is contained in the facility omnicell (a machine provided by that pharmacy, containing many various medications that can be accessed for each resident). LPN #3 was asked about the facility process for ensuring Advair is available for administration, if not in the medication cart. LPN #3 stated, They can check the omnicell. If it's the right dose, the omnicell will let you pull it. If not, let the physician know it's not here, let the patient know, call the pharmacy and ask to send (the medication) from backup (a backup pharmacy) and let the rp (responsible party) know that you didn't give it. At this time, LPN #3 was made aware of this surveyor's concern regarding Resident #71's Advair. LPN #3 stated in the past, nurses would run out of Resident #71's Advair really quick because the disk device containing the medication only contained 14 doses as opposed to a typical device that contains 60 doses. LPN #3 stated nurses used to attempt to get the Advair out of the omnicell but the omnicell would not release the medication because it was too soon for a refill (except for one time when someone maintaining the omnicell was in the building). LPN #3 stated nurses would have to call the pharmacy, and authorize the pharmacy to bill the facility and send the medication. When asked if Resident #71 missed doses of his Advair, LPN #3 stated, Yes. He would tell us he got it (the disk) and it was empty; then I further investigated. LPN #3 was asked if the Advair disk displays how many doses are left in the device. LPN #3 confirmed it did. LPN #3 was asked if nurses should have addressed a pharmacy refill for the medication before the medication ran out and stated nurses should have addressed the refill when there were four doses left. On 2/6/19 at 5:39 p.m., ASM (administrative staff member) #1 (the executive director), ASM #2 (the nurse executive) and ASM #3 (the clinical quality specialist) were made aware of the above concern. The facility policy titled, Medication Administration: General documented, A licensed nurse, Med Tech, or medication aide, per state regulations, will administer medications to patients .If discrepancies, including medication not available, notify physician/advanced practice provider (APP) and/or pharmacy as indicated . No further information was obtained prior to exit. (1) Advair is used to treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by asthma. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a699063.html (2) COPD (chronic obstructive pulmonary disease) makes it hard for you to breathe. The two main types are chronic bronchitis and emphysema. The main cause of COPD is long-term exposure to substances that irritate and damage the lungs. This is usually cigarette smoke. Air pollution, chemical fumes, or dust can also cause it. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=copd&_ga=2.95971676.178186840.1550160688-1667741437.1550160688

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and services for the treatment of a pressure injury for one of 55 residents in the survey sample, Resident #29. The facility staff failed to provide Resident #29's pressure injury treatment as prescribed by the physician on multiple dates in October 2018 and November 2018. The findings include: Resident #29 was admitted to the facility on [DATE]. Resident #29's diagnoses included but were not limited to urinary tract infection, arthritis and abnormal posture. Resident #29's most recent MDS (minimum data set), a 30 day Medicare assessment with an ARD (assessment reference date) of 11/21/18, coded the resident's cognition as moderately impaired. Section G coded Resident #29 as requiring extensive assistance of one staff with bed mobility, toilet use and personal hygiene. Section M coded Resident #29 as having one stage three pressure injury (1) that was present upon admission. Review of a skin integrity report dated 10/29/18 revealed Resident #29 presented with a stage three-pressure injury. A physician's order dated 10/29/18 documented, Cleanse open area L (left) buttock (with) NS (normal saline), apply skin prep to wound edges, santyl (2) to wound bed & cover (with) dry dressing QD (every day) & PRN (as needed) (illegible word). Review of Resident #29's October 2018, and November 2018, TARs (treatment administration records) failed to reveal evidence that the treatment ordered on 10/29/18 was provided for Resident #29 on 10/30/18, 11/4/18, 11/10/18, 11/11/18, 11/12/18, 11/24/18, 11/25/18, 11/26/18, 11/27/18, 11/28/18, 11/29/18 and 11/30/18. This was evidenced by blank spaces on the TARs. No nurses' initials were signed off to indicate the treatment had been performed. Review of nurses' notes for the above dates failed to reveal Resident #29's pressure injury treatment was administered except for a note dated 11/4/18 that documented treatments were administered as ordered. Further review of Resident #29's skin integrity report for October 2018 and November 2018 revealed the resident's pressure injury did not deteriorate during those months. Resident #29's comprehensive care plan dated 11/8/18 documented, Resident has actual skin breakdown related to limited mobility, stage 3 pressure wound to left buttock .Provide wound treatment as ordered . On 2/6/19 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 was asked how nurses evidence the medications and treatments they administer. LPN #3 stated, They sign off on the MAR (medication administration record) and TAR. When asked what is meant if there are blank spaces on the MAR, or TAR and the nurses did not sign off, LPN #3 stated, In reality it means that they didn't do it. On 2/6/19 at 5:39 p.m., ASM (administrative staff member) #1 (the executive director), ASM #2 (the nurse executive) and ASM #3 (the clinical quality specialist) were made aware of the above concern. The facility policy titled, Skin Integrity Management documented, 4.7 Implement Special Wound Care treatments/techniques, as indicated and ordered. No further information was presented prior to exit. (1) Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. This information was obtained from the website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (2) SANTYL Ointment is an FDA-approved prescription medicine that removes dead tissue from wounds so they can start to heal. This information was obtained from the website: https://www.santyl.com/

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure that four of 55 residents in the survey sample (Resident #35, 31, #15 and #39) were provided a safe enviorment and adequate supervision to prevent potential accidents, injuries, or harm. 1. The facility staff failed to ensure Resident #35 was assessed to determine if the resident was able to go out into the community unsupervised safely, and allowed the resident to have unsupervised, unmonitored leaves of absences, alone, without a friend of family with him, putting him at risk of potential accidents, injuries. Resident #35 was documented as being excessively late returning to the facility at times and did not have a cell phone so the facility could contact him to check on his safety, and was documented as contacting the facility on 2 occasions in which he did not have a ride or money to return to the facility late at night. 2. Resident #31 sustained a fall on 1/18/19. The facility staff failed to implement interventions identified at the time of the fall to prevent further falls for Resident #31. 3. Resident #15 sustained a fall on 1/28/19. The facility staff failed to implement interventions identified at the time of each fall to prevent further falls for Resident #15. 4. Resident #39 sustained falls on 11/8/18, 12/24/18, 1/1/19, 1/6/19, and 2/3/19. The facility staff failed to implement interventions identified at the time of each fall to prevent further falls for Resident #39. The findings include: 1. Resident #35 was admitted to the facility on [DATE] with the diagnoses of but not limited to hip fracture, atrial fibrillation, high blood pressure, falls, inguinal hernia, and cardiomyopathy. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 11/23/18. The resident was coded as being cognitively intact in ability to make daily life decisions. The resident was coded as being independent for transfers, locomotion, dressing, eating, toileting; and required supervision for hygiene. A review of the clinical record revealed the following: • A physician's order dated 8/2/18 that the resident may go on LOA (leave of absence) for 4 hours on 8/3/18 to go to the bank. • A physician's order dated 8/13/18 that the resident may go on LOA for 4 hours on 8/13/18. • A physician's order dated 8/15/18 that the resident may go on LOA for 4 hours on 8/15/18. • A physician's order dated 8/21/18 that the resident may go on LOA for 2 hours on 8/21/18. • A physician's order dated 8/22/18 that the resident may go on LOA for 4 hours daily. A review of the nurse's notes revealed the following: A nurse's note dated 8/15/18 that documented, Resident has order for LOA for 4 hrs, resident left the facility at 99:45 {sic} but not back at 3pm. Safety maintained will continue to monitor. A nurse's note dated 8/15/18, that documented, A change in condition has been noted. The symptoms include: Behavioral symptoms (e.g. agitation, psychosis) 8/15/18 in this afternoon No further information was documented. A nurse's note dated 8/16/18, documented, Late Entry for 8-15-18 resident was observe by this writer and other staff news paper (Sic.) on the floor resident pouring A-[NAME] / urine on the news paper (Sic.) and pouring A [NAME] in urinal full of urine. This writer ask why and resident stated I wanted to see what dish detergent works the best. Call NP (nurse practitioner) to make aware of the altered mental status N.O. (new order) CBC {1} and BMP {2} in the AM resident own RP [responsible party]. A nurse's note dated 8/30/18 documented, Resident signed out at 1:30pm, today and stated that he was going to (name of bank) and not going to church tonight. Cousin and friend were contacted at 10pm today because resident was not back at facility. Unit manager on call was contacted. Resident made contact with facility soon after and was reported to unit manager on call. Unit manager will pick up resident from Firestone off of (location) A nurse's note dated 8/31/18 documented, Late entry: This RN [registered nurse] was contacted by nursing staff of residents (Sic.) failure to return to the facility following his departure for the bank earlier in the afternoon. Nursing staff was advised to make contact with RP to see if they knew where resident was located. This RN was advised that contact was made with residents (Sic.) cousin and friend, neither of which knew of his whereabouts. DON was notified of incident. Nursing staff was advised to call the sheriffs (Sic.) office non emergency number to report the residents (Sic.) failure to return. At approximately 10:30pm, this RN was notified by staff that (resident) had called the facility and stated he was at the Firestone and was unable to get back due to not having enough money for the cab ride. This writer went to pick up resident shortly after. Resident was found in front of the Firestone (location) sitting on the ground. Resident stated he left his bank card (Sic.) back at the facility and was unable to get a ride back. Resident returned to facility. This RN stressed the importance to the resident of returning in a timely manner and the need to be able to take his evening medicine. Resident expressed understanding. Resident was asked where he usually goes when he leaves the facility so if another incident occurs we know where to look. Resident stated that he goes to the (name of bank) on (location) and is usually in the shopping center above or below the hospital. Resident returned to facility at approximately 11:30pm. A nurse's note dated 10/3/18 documented, Patient left facility at 2:10p.m., for LOA was supposed to return by 6:10p.m. Patient called facility at 7:50p.m., to say he was at the Bus Station in (location) with no way back. Patient returned at 9:30p.m., He stated, Someone from the Bus Station gave me a ride back. Patient education given on Safety and if Patient is going out alone he must have money for Cab fare both ways and he must return back on time. A social services note dated 10/5/18 documented, Met with patient, (OSM #14 - Other Staff Member - the Ombudsman) CNE (former Center Nurse Executive) to discuss resident's community visits. He has had two instances where he was out in the community and unable to get a ride home after 10pm. Discussed safety and need to be in building when he is scheduled to get his meds (medication). Resident does not have a cell phone at this time. SW (social worker) is working to get him a Medicaid phone. After discussion (resident) is willing to agree to the following. Until he has a cell phone he will not leave the property of (the facility). An exception will be to attend church on Sunday as they will provide transportation both ways. Once he has a phone we will reopen the discussion of his trips into the community. Discussed changing his check to come to (facility) therefore eliminating his need to go to the bank. This would also allow him to have access to his money daily if he wants to purchase a snack. He was agreeable to do this. (Resident) was able to state what the outcome of the meeting was in his own words. He will contact social work and the ombudsman as needed. A review of the care plan failed to reveal any evidence that the resident's community visits unsupervised, or his non-compliance with returning timely was care planned. On 2/6/19 at approximately 2:00 p.m., in an interview with RN #1 (Registered Nurse) she stated that she was not aware of the Ajax incident. She stated that the resident used to go out of the facility but has not in a long time unless a friend is with him. She did not recall anything else about the resident's incidents about being away from the facility and unable to get back. On 2/7/19 at 1:05 p.m., in an interview with LPN #3 (Licensed Practical Nurse) when asked about the resident going out unsupervised, LPN #3 stated, He would just call a cab or a friend would take him out. He would either have cab money to come back or he wouldn't and would call the facility to let them know where he was at so he could get back. When asked what assessment was done to ensure the resident was safe to leave the facility unsupervised, LPN #3 stated, I don't know what, if any assessment was done to ensure he was safe to go unsupervised. When asked process is followed if Resident #35 called and said he could not get back, LPN #3 stated, The Facility finds him a way to get back When asked about the incident as documented in the 8/31/18 nurse's note, LPN #3 stated, We could not get in contact with the bus station. We called the cab to get him. I'm not sure why he didn't get the cab. The cab would not go in (the bus station) to find him and the bus station would not go looking for him to notify him of a cab. When asked what the facility did to ensure Resident #35's safety outside the facility, LPN #3 stated, I don't know. He no longer goes out without a friend. LPN #3 stated she did not know anything about the AJax incident. On 2/7/19 at 1:24 p.m., in an interview with LPN #4, when asked how the resident was assessed to determine that, he was safe to leave the facility unsupervised, LPN #4 stated, I don't recall how or if he was assessed as being safe to go out unsupervised. When asked about the incidents of the resident leaving and then being unable to get back to the facility, LPN #4 stated, I know that it was discussed about him having issues getting back but I don't know what happened. When asked if the resident's activity of leaving the facility unsupervised, and noncompliance with returning timely should be care planned, LPN #4 stated it should have been. When asked about the process followed when the resident is out long enough to miss medications, LPN #4 stated that the physician should be called and verify if the medications can be given or not. When asked about the AJax incident, LPN #4 stated she did not know anything about it. On 2/7/19 at 2:20 p.m., an interview was conducted with the Executive Director (ASM [administrative staff member] #1) and Nurse Executive, ASM #2. When asked about the resident's unsupervised outings into the community and the issues he had of returning to the facility timely, ASM #1 stated that he was alert and oriented, his BIMS (Brief Interview for Mental Status exam) was a 15 (cognitively intact). She stated the physician was aware of the resident's outings and that it was his right to go out if he wanted to. When asked what assessment was done to ensure that the resident was safe to go out unsupervised, ASM #1 stated that if the IDT (Interdisciplinary team) felt he was safe to do so that is what they chose to do. ASM #1 was not employed at the facility at the time of the incidents when the resident came back late to the facility and was unable to provide any documented evidence of an assessment of the resident or discussions of his unsupervised activities by the IDT team. When asked about the A-[NAME] incident ASM #1 stated the facility does not use A-[NAME] and presumed he brought the cleaner in with him from one of his outings, but she was unable to find any administrative documentation or soft file of the incident. When asked about the lack of care planning of his unsupervised outings and noncompliance with returning timely, ASM #1 stated it should have been care planned. When asked about the resident's missed medications when he was late returning to the facility, ASM #1 stated that the doctor should have been notified and provided direction whether to administer them late. ASM #1 was informed that it was documented in the clinical record that the resident had an episode of psychosis and behaviors after one outing (the AJax incident dated 8/16/18), bringing question to his mental capacity to be safe when unsupervised. ASM #1 was asked if anything was done after the incidents of Resident #35 being out excessively late without means of transportation or communication with the facility on at least two occasions. ASM #1 again restated it is his (Resident #35's) right to go out if he wanted because he was cognitively intact and made his own decisions. ASM #1 stated that maybe he (Resident #35) brought in the Ajax because he might have thought he could clean his own equipment and property, although, she was unable to locate any information on the incident (administrative file, etc.) and was not employed at the facility at the time of the incident to speak on it. When asked about the assessment criteria that was used to determine Resident #35 was safe unsupervised, ASM #1 stated she did not know. She stated that it may have been an informal conversation and was not documented and a formal assessment tool used. ASM #1 stated that the facility apparently determined that he was mentally able to leave unsupervised and that he did not have a diagnoses to prevent him from making decisions and that the facility felt he was safe to do so. ASM #1 stated that she was not employed at the facility at that time, but that he (Resident #35) has since had a physical decline in health and no longer went out of the facility without supervision of friend or family. On 2/7/19 at 2:49 p.m., a phone interview was conducted with RN #12, (who the facility called to speak with the survey team, because she worked at the facility but was not on duty at the time of the resident's leave when he was late returning and no longer worked at the facility at the time of survey). RN #12 stated that regarding the night of 8/31/18, that when the resident called and stated he was at the bus station and was unable to return, an Uber was called for the resident to return to center, arrived at the bus station and waited 10 minutes and left. She stated the facility notified the ombudsman next day. RN #12 stated that the resident did not have cell phone with him and the facility was not able to let him know that the Uber was called and waiting for him. On 2/7/19 at 3:21 p.m., in an interview with OSM #14, the Ombudsman, she stated that she has worked with the resident since before he ever came to this facility. She stated she met with the facility and talked about his history because he was calling her saying the facility would not let him leave. OSM #14 stated he had a high BIMS to make decisions to go out into the community. She stated that he likes to go out into the community, even when at prior facilities, to go shopping, and that there is a community area, where he has friends he liked to go to and would come back. OSM #14 stated he knew he had to be back and could not stay out over night. OSM #14 stated that when he initially came to the facility, it was a concern for the facility. However, measures were put in place for him to go out with a friend, so it would be safe and he would not need money for cabs (this was after 2 incidents of being away from the facility without a means to return). She stated it was addressed with the resident to have funds for cab or transportation. OSM #14 stated the facility does have the responsibility to keep him safe, and that I know that him (Resident #35) not having a ride a couple of times looks bad and there is no way to excuse that. OSM #14 stated that she is working with him now for discharge to a subsidized housing setting. She stated that his friend says there is a house available and have been looking at it to ensure a safe discharge and that this just happened today (2/7/19). She stated that since has he been at the facility, she had been helping with placement. She stated, We put things in place to ensure if he wanted to leave he was safe to do so. The social worker who was at the facility during the above incidents was no longer at the facility as of a few days before the survey and therefore could not be interviewed. No further information could be provided, and staff who were employed at the time either, no longer were at the facility, or did not recall there being concerns with his safety. During the days of the survey the resident was not observed going out of the facility unsupervised. {1} CBC - A CBC (complete blood count) is a commonly performed lab test. It can be used to detect or monitor many different health conditions. Your health care provider may order this test: · As part of a routine check-up · If you are having symptoms, such as fatigue, weight loss, fever or other signs of an infection, weakness, bruising, bleeding, or any signs of cancer · When you are receiving treatments (medicines or radiation) that may change your blood count results · To monitor a long-term (chronic) health problem that may change your blood count results, such as chronic kidney disease. Information obtained from https://medlineplus.gov/ency/article/003642.htm {2} BMP - The basic metabolic panel (BMP) is a frequently ordered panel of 8 tests that gives a healthcare practitioner important information about the current status of a person's metabolism, including health of the kidneys, blood glucose level, and electrolyte and acid/base balance. Abnormal results, and especially combinations of abnormal results, can indicate a problem that needs to be addressed. Information obtained from https://labtestsonline.org/tests/basic-metabolic-panel-bmp 2. Resident #31 sustained a fall on 1/18/19. The facility staff failed to implement interventions identified at the time of the fall to prevent further falls for Resident #31. Resident #31 was admitted to the facility on [DATE] with the diagnoses of but not limited to high blood pressure, cardiomyopathy, stroke, atrial fibrillation, pacemaker, dementia, contracture, seizures, chronic kidney disease and acute kidney failure. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 11/5/18. The resident was coded as being cognitively intact in ability to make daily life decisions. The resident was coded as requiring total care for bathing; extensive care for transfers, dressing, toileting and hygiene; and limited assistance for eating. On 2/5/19 at 10:07 a.m., and on 2/6/19 at 1:14 p.m., a observations were made of Resident #31. There were no concerns identified. A review of the nurse's notes revealed one dated 1/18/19, which documented, A change in condition has been noted. The symptoms include: Falls 1/18/19 at night Change reported to Primary Care Clinician This note did not document the circumstances surrounding the fall, if there were any injuries, and what, if any, new interventions were added to the care plan. Subsequent nurses' notes over the following days failed to reveal any additional information regarding the details of the fall. A review of the Event Summary Report dated 1/18/19 documented, Resident was found face down beside his bed with no injuries, tolerated ROM well, res stated I am trying to grab something from the floor denies any pain/discomfort Interventions added immediately after fall and care plan updated: Educated resident to use call bell at all times. A review of the comprehensive care plan failed to reveal any evidence Resident # 31's care plan was reviewed and/or updated following this fall to prevent further falls. The intervention documented in the Event Summary Report above was not included/documented and implemented on the care plan. The resident's care plan documented as follows: Resident is at risk for falls: CVA (stroke), Impaired mobility, cognitive loss, lack of safety awareness, syncopal episode. This care plan was dated 10/13/15, and most recently revised on 12/10/18. The interventions were as follows: • 12/17/18 - Offer/assist resident with urinal/commode as requested/needed. (Created on 12/10/18). • Place bedside table within reach on left side. (Created on 12/9/15 and revised on 3/9/18). • Medication evaluation as needed. (Created on 9/20/17). • 8/10/18 Provide resident/caregiver education for safe techniques. (Created on 8/13/18). • Place call light within reach at all times. (Created on 10/13/15). • Remind resident to use call light when attempting to ambulate or transfer. (Created on 10/13/15). • When resident is in bed, place all necessary personal items within reach. (Created on 10/13/15). • Monitor for and assist toileting needs. (Created on 10/13/15). There was no evidence that after the fall on 1/18/19, that the effectiveness of the above interventions were reviewed and modifications made if necessary to include interventions implemented to prevent further falls for Resident #31. On 2/06/19 at 1:47 p.m., an interview was conducted with CNA #1 (Certified Nursing Assistant). When asked what a care plan is, CNA #1 stated, All the basic information about how to care for a resident. When asked if she has access to the residents care plan, CNA #1 stated, Yes, its on our tablet. On 2/06/19 at 2:17 p.m., in an interview with LPN #2 (Licensed Practical Nurse), when asked what the purpose of a care plan, LPN #2 stated, It has all you need so you know what to do for a particular resident. When asked what information is on a care plan, LPN #2 stated, diagnoses, skin integrity, UTI (urinary tract infection). When asked who has access to the care plan, LPN #2 stated, nursing and administration. When asked who can review and revise the care plan, LPN #2 stated, the unit manager, DON (director of nursing - Nurse Executive at this facility) On 2/07/19 at 11:27 a.m., in an interview with RN #5 (Registered Nurse), when asked about the purpose of a care plan, RN #5 stated, Communicate with all staff about the needs of a resident, its updated constantly as the residents needs change. When asked what information is found on a care plan, RN #5 stated, Care needs, adl (activities of daily living), diagnoses, oxygen, and skin care. On 2/7/19 at approximately 2:20 p.m., the Executive Director (ASM [Administrative Staff Member] #1) and the Executive Nurse (ASM #2) were made aware of the concern. ASM #2 stated that the Event Summary Report is an internal document and is not part of the legal clinical record. At this time, ASM #2 was notified that the legal clinical record did not reflect the above data regarding how the fall occurred, if there were any injuries, and if there were any care plan reviews or revisions and any interventions implemented to prevent further falls A review of the facility policy, Person-Centered Care Plan documented, A comprehensive, individualized care plan will be developed within 7 days after completion of the comprehensive assessment for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments 7. Care plans will be: .7.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals No further information was provided by the end of the survey. 3. Resident #15 sustained a fall on 1/28/19. The facility staff failed to implement interventions identified at the time of each fall to prevent further falls for Resident #15. Resident #15 was admitted to the facility on [DATE] with the diagnoses of but not limited to atrial fibrillation, high blood pressure, hypothyroidism, acute kidney injury, pacemaker, and congestive heart failure. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 10/18/18. The resident was coded as mildly cognitively impaired in ability to make daily life decisions. The resident was coded as requiring extensive care for bathing; supervision for transfers and toileting; and was independent for dressing, eating, and hygiene. On 2/5/19 at 9:15 a.m., and at 11:26 a.m., observations were made of Resident #15. There were no concerns identified. A review of the clinical record revealed a nurse's note dated 1/28/19, which documented, A change in condition has been noted. The symptoms include: Fall on 1/28/19 at night Change reported to Primary Care Clinician Orders obtained include: Have PT (physical therapy) eval (evaluate) for functional status. This note did not document the circumstances surrounding the fall, if there were any injuries, and what, if any, new interventions were added to the care plan. Subsequent nurses' notes over the following days failed to reveal any additional information regarding the details of the fall. A review of the Event Summary Report dated 1/28/19 documented, heard res (resident) calling help, entered res room and observed her sitting on the floor between w/c [wheelchair] and bed., holding on to bed and w/c, on neuro [neurological] checks, abrasion to upper mid-back, no bleeding. NP (nurse practitioner) made aware and ordered PT to eval, res rp (responsible party) made aware of fall with abrasion and res need for more assist with ADLs (activities of daily living) Interventions added immediately after fall and care plan updated: Refer to PT [physical therapy], enc (encourage) res to call for assist before getting oob (out of bed). A review of the comprehensive care plan failed to reveal any evidence Resident # 15's care plan was reviewed and/or updated following this fall to prevent further falls. The interventions documented in the Event Summary Report above, were not included/documented and implemented on the care plan. The resident's care plan documented as follows: Resident is at risk for falls R/T (related to) Diagnosis of vertigo, Impaired mobility, cognitive loss, lack of safety awareness, history of falls and requires assistance with transfers. This care plan was dated 1/26/15, and most recently revised on 3/15/18. The interventions were as follows: • 3/15/18 OT (occupational therapy) evaluation for w/c (wheel chair) positioning. (Created 3/15/18). • Assist resident in getting in and out of bed per lift assessment. (Created 2/4/15, revised on 3/9/18). • Place call light within reach at all times. (Created on 1/26/15, revised on 7/11/15). • Remind resident to use call light when attempting to ambulate or transfer. (Created on 1/26/15, revised on 7/11/15). • Monitor for and assist toileting needs. (Created on 1/26/15, revised on 7/11/15). • 1/2 side rails x 2 for functional mobility. (Created on 2/4/15, revised on 3/7/18). There was no evidence that after the fall on 1/28/19, that the effectiveness of the above interventions were reviewed and modifications made if necessary to include interventions implemented to prevent further falls for Resident #15. On 2/06/19 at 1:47 p.m., an interview was conducted with CNA #1 (Certified Nursing Assistant). When asked what a care plan is, CNA #1 stated, All the basic information about how to care for a resident. When asked if she has access to the residents care plan, CNA #1 stated, Yes, it's on our tablet. On 2/06/19 at 2:17 p.m., in an interview with LPN #2 (Licensed Practical Nurse), when asked what the purpose of a care plan, LPN #2 stated, It has all you need so you know what to do for a particular resident. When asked what information is on a care plan, LPN #2 stated, diagnoses, skin integrity, UTI (urinary tract infection). When asked who has access to the care plan, LPN #2 stated, nursing and administration. When asked who can review and revise the care plan, LPN #2 stated, the unit manager, DON (director of nursing - Nurse Executive at this facility) On 2/07/19 at 11:27 a.m., in an interview with RN #5 (Registered Nurse), when asked about the purpose of a care plan, RN #5 stated, Communicate with all staff about the needs of a resident, its updated constantly as the residents needs change. When asked what information is found on a care plan, RN #5 stated, Care needs, adl (activities of daily living), diagnoses, oxygen, and skin care. On 2/7/19 at approximately 2:20 p.m., the Executive Director (ASM [Administrative Staff Member] #1) and the Executive Nurse (ASM #2) were made aware of the concern. ASM #2 stated that the Event Summary Report is an internal document and is not part of the legal clinical record. At this time, ASM #2 was notified that the legal clinical record did not reflect the above data regarding how the fall occurred, if there were any injuries, and if there were any care plan reviews or revisions, including any interventions implemented to prevent further falls. No further information was provided by the end of the survey. 4. Resident #39 sustained falls on 11/8/18, 12/24/18, 1/1/19, 1/6/19, and 2/3/19. The facility staff failed to implement interventions identified at the time of each fall to prevent further falls for Resident #39. Resident #39 was most recently readmitted to the facility on [DATE] with the diagnoses of but not limited to dementia, diabetes, chronic back pain, high blood pressure, history of femur fracture, overactive bladder, adjustment disorder with anxiety, and osteoarthritis. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 12/3/18. The resident was coded as being moderately impaired in ability to make daily life decisions. The resident was coded as requiring extensive care for bathing; limited assistance for eating; and supervision for hygiene, toileting, dressing, and transfers. On 2/5/19 at 9:25 a.m., and on 2/6/19 at 2:11 p.m., observations were made of Resident #39. There were no concerns identified. A review of the nurse's notes revealed one dated 11/8/18, which documented, A change in condition has been noted. The symptoms include: Falls 11/8/18 in the afternoon .Orders obtained include: NNO (no new orders) . This note did not document the circumstances surrounding the fall, if there were any injuries, and what, if any, new interventions were added to the care plan. Subsequent nurses' notes over the following days failed to reveal any additional information regarding the details of the fall. A review of the Event Summary Report dated 11/8/18 documented, Resident feel {sic} in dining room trying to reach across the table to get her stuffed cats. Resident fell to floor and hit her head. Resident stated that her head no long {sic} hurt after a few mins (minutes) and was able to get up from the flo[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to provide oxygen to Resident #52, according to the physicians order. Resident #52 was admitted to the facility on [DATE]. Diagnoses included but were not limited to: chronic obstructive pulmonary disease (COPD) (1), myelodysplastic syndrome (2), anemia (3), depression and shortness of breath. The most recent MDS (minimum data set), an annual assessment, with an ARD (assessment reference date) of 12/15/18 coded the resident as having a score of 14 of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact to make daily decisions. Section O-Special Treatment, documented that Resident #52 receives oxygen therapy. The physician order sheet dated January 2019 documented Oxygen at 2 liters per minute via nasal cannula (A plastic tube with two prongs that inserts in the nose) continuously. Resident #52's comprehensive care plan dated 7/13/18 documented, O2 (oxygen) as ordered. Review of the MAR (medication administration record) dated January 2019, for Resident #52 documented, Oxygen at 2 liters per minute via nasal cannula continuously. The oxygen was signed off as administered to Resident #52 as evidenced by staff initials. On 2/5/19 at approximately 8:34 a.m., an observation was made of Resident #52. Resident #52 was observed receiving oxygen via a nasal cannula connect to an oxygen concentrator. Observation of the flowmeter on Resident #52's oxygen concentrator revealed the oxygen flow rate was set with the ball between the 2.0L/min (liters per minute) and 2.5L/min lines. On 2/5/19 at approximately 3:30 p.m., a second observation was made of Resident #52's oxygen concentrator. Observation of the flowmeter on Resident #52's oxygen concentrator revealed the oxygen flow rate was set with the ball between the 2.0L/min (liters per minute) and 2.5L/min lines. On 2/5/19 at approximately 3:40 p.m., a third observation was made with of Resident 52's oxygen concentrator flowmeter with LPN (licensed practical nurse) #1. LPN #1 was asked to read the flowmeter on Resident #52's oxygen concentrator. After observing Resident #52's oxygen concentrator flowmeter, LPN #1 stated, its set at 2.5L (liters). On 2/5/19 at approximately 3:41 p.m., an interview was conducted with LPN #1. When asked was asked how an oxygen flowmeter is read, LPN #1 replied, The top of the ball is supposed to be on the line. On 2/5/19 at approximately 3:45 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 was asked how the rate on an oxygen flowmeter is set. RN #2 replied, You turn the dial until the line is in the middle of the ball. The manufacturer's instructions for Resident #52's oxygen concentrator documented on page 19, Center the ball on the L/min (liters per minute) line prescribed. On 2/07/19 at approximately 4:30 p.m., ASM (administrative staff member) # 3, Clinical Quality Specialist, provided copies of requested facility polices. ASM # 3 informed this surveyor the facility did have a policy for oxygen administration. On 2/7/18 at approximately 5:45 p.m., ASM #1, the Executive Director and ASM #2, the Nurse Executive, and ASM #3 were made aware of the findings. No further information was provided prior to exit. 1. A disease that makes it difficult to breath that can lead to shortness of breath. The two main types are chronic bronchitis and emphysema. The main cause of COPD is long-term exposure to substances that irritate and damage the lungs. This is usually cigarette smoke. Air pollution, chemical fumes, or dust can also cause it. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 2. Your bone marrow is the spongy tissue inside some of your bones, such as your hip and thigh bones. It contains immature cells, called stem cells. The stem cells can develop into the red blood cells that carry oxygen through your body, the white blood cells that fight infections, and the platelets that help with blood clotting. If you have a myelodysplastic syndrome, the stem cells do not mature into healthy blood cells. Many of them die in the bone marrow. This means that you do not have enough healthy cells, which can lead to infection, anemia, or easy bleeding. This information was obtained from the website: https://medlineplus.gov/myelodysplasticsyndromes.html 3. If you have anemia, your blood does not carry enough oxygen to the rest of your body. The most common cause of anemia is not having enough iron. Your body needs iron to make hemoglobin. Hemoglobin is an iron-rich protein that gives the red color to blood. It carries oxygen from the lungs to the rest of the body. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=anemia&_ga=2.71282640.1704263304.1542638661-1154288035.1542638661 Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide respiratory care and services according to physician's order for four of 55 residents in the survey sample, Residents #1, #51, #52 and #309. 1. The facility staff failed to administer oxygen to Resident #1 at two liters per minute, per physician's order. 2. The staff failed to discontinue Resident #51's oxygen per physician's order. 3. The facility staff failed to provide respiratory services according to the physicians order for Resident #52. 4. The facility staff failed to administer Resident # 309's oxygen according to the physician's orders. The findings include: 1. The facility staff failed to administer oxygen to Resident #1 at two liters per minute, per physician's order. Resident #1 was admitted to the facility on [DATE]. Resident #1's diagnoses included but were not limited to low back pain, bladder cancer and high blood pressure. Resident #1's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/1/19 coded the resident as cognitively intact. Section G coded Resident #1 as requiring extensive assistance of one staff with bed mobility, transfer and personal hygiene. Section O coded the resident as receiving oxygen therapy during the last 14 days. Review of Resident #1's clinical record revealed a physician's order dated 1/25/19 for continuous oxygen, at two liters per minute via nasal cannula. Resident #1's care plan dated 1/29/19 failed to reveal documentation regarding oxygen administration. On 2/5/19 at 9:24 a.m. and 10:58 a.m., Resident #1 was observed sitting up in bed receiving oxygen via a nasal cannula. During each observation, the oxygen concentrator was set at a rate between two and a half and three liters as evidenced by the ball in the concentrator flowmeter positioned between the two and a half and three-liter lines. On 2/6/19 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 was asked to describe where the ball in an oxygen concentrator flowmeter should be if a resident has a physician's order for two liters. LPN #3 stated the two-liter line should run through the middle of the ball. On 2/6/19 at 5:39 p.m., ASM (administrative staff member) #1 (the executive director), ASM #2 (the nurse executive) and ASM #3 (the clinical quality specialist) were made aware of the above concern. On 2/7/19 at approximately 4:30 p.m., ASM #3 confirmed the facility did not have a policy regarding oxygen administration. The oxygen concentrator manufacturer's manual documented, Note: To properly read the flowmeter, locate the prescribed flowrate line on the flowmeter. Next, turn the flow knob until the ball rises to the line. Now, center the ball on the L/min (liter per minute) line prescribed. No further information was obtained prior to exit. 2. The staff failed to discontinue Resident #51's oxygen per physician's order. Resident #51 was admitted to the facility on [DATE]. Resident #51's diagnoses included but were not limited to diabetes, high blood pressure and pneumonia. Resident #51's most recent MDS (minimum data set), a 14 day Medicare assessment with an ARD (assessment reference date) of 12/13/18, coded the resident's cognition as severely impaired. Section G coded Resident #51 as requiring extensive assistance of two or more staff with bed mobility and extensive assistance of one staff with personal hygiene. Section O did not coded the resident as receiving oxygen during the last 14 days. Review of Resident #51's clinical record revealed a physician's order form signed by the physician on 1/15/19 that documented an order for oxygen, at two liters per minute as needed. On 2/5/19 at 9:21 a.m., Resident #51 was observed sitting up in bed receiving oxygen via a nasal cannula. On 2/5/19 at 4:43 p.m., Resident #51 was observed lying in bed receiving oxygen via a nasal cannula. During each observation, the oxygen concentrator was set at a rate between one and a half and two liters as evidenced by the ball in the concentrator flowmeter positioned between the one and a half and two-liter lines. On 2/6/19 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 was asked to describe where the ball in an oxygen concentrator flowmeter should be if a resident has a physician's order for two liters. LPN #3 stated the two-liter line should run through the middle of the ball. On 2/6/19 at 5:39 p.m., ASM (administrative staff member) #1 (the executive director), ASM #2 (the nurse executive) and ASM #3 (the clinical quality specialist) were made aware of the above concern. On 2/7/19 at 4:25 p.m., ASM #2 and ASM #3 presented a copy of a separate physician's order for Resident #51 that was dated 2/4/19. The order documented to discontinue the resident's oxygen. ASM #2 and ASM #3 also presented a copy of Resident #51's resolved oxygen care plan. ASM #2 and ASM #3 confirmed oxygen was administered to Resident #51 on 2/5/19 when it should not have been administered because the physician's order had been discontinued. No further information was presented prior to exit. 4. The facility staff failed to administer Resident # 309's oxygen according to the physician's orders. Resident # 309 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: edema (1), respiratory failure (2), hypertension (3) and anxiety (4). Resident # 309's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/30/19, coded Resident # 309 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. Resident # 309 was coded as requiring limited assistance of one staff member for activities of daily living. Under section O. Special Treatment, Procedures and Programs Resident # 309 was coded for C. Oxygen therapy. On 02/05/19 at 9:45 a.m., an observation of Resident 309 revealed she was lying in her bed receiving oxygen by nasal cannula connected to an oxygen concentrator that was running. Observation of the flowmeter on the oxygen concentrator revealed an oxygen flow rate between three-and-a-half liters and four liters per minute. The POS (physician's order sheet) for Resident # 309 dated 01/23 2019documented, O2 (oxygen) at 2/L (two liters) via (by) N/C (nasal cannula) continuous. The comprehensive care plan for Resident # 309 dated 01/25/2019 failed to evidence documentation for oxygen use. On 02/05/19 at 4:48 p.m., an observation of Resident 309 was conducted with LPN (licensed practical nurse) # 4. Resident 309 was lying in her bed receiving oxygen by nasal cannula connected to an oxygen concentrator that was running. Observation of the flowmeter on the oxygen concentrator revealed an oxygen flow rate of two liters per minute. At this time in an interview LPN # 4, LPN #4 stated that she needed to readjust the oxygen for Resident # 309 because it was up at four liters per minute. When asked what time she adjusted the oxygen flow rate, LPN # 4 stated, I don't remember. When asked how often a resident's oxygen flow rate is checked, LPN # 4 stated, Every time I go into the room, and at the beginning of the shift. When asked to describe how to read the oxygen flow rate on the oxygen concentrator LPN # 4 stated, The liter line should go through the middle of the ball. On 02/06/19 at approximately 5:50 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, executive nurse, were made aware of the above findings. No further information was provided prior to exit. Reference: (1) A swelling caused by fluid in your body's tissues. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/edema.html. (2) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. (3) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. (4) Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary.

Based on staff interview and facility document review, it was determined the facility staff failed to conduct annual performance reviews for 10 of 23 CNAs (certified nursing assistants) who were employed for at least one year. The facility staff failed to complete annual performance reviews for CNA #1, CNA #2, CNA #3, CNA #4, CNA #5, CNA #6, CNA #7, CNA #8. CNA #9, and CNA #10. The findings include: On 2/6/19 at approximately 9:00a.m., a request for the annual performance reviews and associated training's for the CNAs was made to ASM (administrative staff member) #2, the nurse executive. On 2/6/19 at 5:30 p.m., a second request made for the annual performance reviews and associated training's for the CNAs to ASM #2, ASM #1, the executive director, and ASM #3, the clinical quality specialist. On 2/7/19 at 9:41 a.m., ASM #2 informed this surveyor that the facility could not find any performance reviews. When asked where they would be located, ASM #2 stated in the HR (human resources) files. ASM #2 stated, We searched the files last night and can't find anything. CNA #1 was hired on 9/6/17 CNA #2 was hired on 5/28/15 CNA #3 was hired on 8/21/17 CNA #4 was hired on 3/5/12 CNA #5 was hired on 3/14/16 CNA #6 was hired on 8/11/11 CNA #7 was hired on 5/12/14 CNA #8 was hired on 7/22/08 CNA #9 was hired on 4/2/15 CNA #10 was hired on 2/1/18. The facility policy, Performance Appraisal Program: Employee documented in part, Policy: Managers will meet with their regular full-time, regular part-time and regular casual employees at least annually to conduct a performance appraisal. In-service education will be provided based on the outcome of these reviews. ASM #1, ASM #2 and ASM #3 were made aware of the above concern on 2/7/19 at 3:46 p.m. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review it was determined that the facility staff failed to store, prepare and serve food in a sanitary manner. 1. The facility staff failed to label containers of tartar sauce and sour cream with a use-by date. 2. The facility staff failed to maintain a mixer and meat slicer in a clean and sanitary manner. 3. The facility staff failed to keep used alcohol swabs off the food-preparation sheet pan and place clean soup bowls on a clean surface before serving. The findings include: 1. The facility staff failed to label containers of tartar sauce and sour cream with a use-by date. On 02/05/19 at 9:15 a.m., an observation of the kitchen was conducted with OSM (other staff member) # 7, dining services manager. Observation of the inside of the reach-in refrigerator revealed a tray with 12 small plastic containers with approximately two ounces of tartar sauce in each container and three plastic containers with approximately two ounces of sour cream in each one. Further observation of the tray of containers failed to evidence a use-by-date. When asked about the missing date, OSM # 7 stated, They were prepared and used for dinner last night. There should be a date on them. OSM # 7 then removed the tray of containers from the reach in refrigerator. The facility's policy Food and Nutrition Services Policies and Procedures documented in part, 25. Use-By Dating Guidelines. Foods that are marked with the manufacturer's 'use-by' date that are properly stored can be used until that date as long as the product has not been combined with any other food or prepared in any way including proportioning. Once a product has been prepared or portioned, a new 'use-by' date is established. On 02/06/19 at approximately 5:50 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, executive nurse, were made aware of the above findings. No further information was provided prior to exit. 2. The facility staff failed to maintain a mixer and meat slicer in a clean and sanitary manner. On 02/05/19 at 9:15 a.m., an observation of the kitchen was conducted with OSM (other staff member) # 7, dining services manager. Observation of the mixer revealed it was covered with a plastic bag. When asked if the mixer was clean and ready for use OSM # 7 stated, Yes. OSM # 7 then removed the bag covering the mixer. Further observation of the mixer revealed food debris splattered on the splashguard of the mixer above the mixing bowl and food debris around the mounting pins for the cage. OSM # 7 agreed the mixer was not clean. Observation of the meat slicer revealed it was covered with a plastic bag. When asked if the meat slicer was clean and ready for use, OSM # 7 stated, Yes. OSM # 7 then removed the bag covering the meat slicer. Further observation of the meat slicer revealed debris on the surface of the base under the gauge plate and under the slice deflector. OSM # 7 was asked to observe the debris on the meat slicer. When asked if the debris was food debris, OSM # 7 stated he could not be sure if it was food debris or debris from the surrounding environment where work had been done in the kitchen. OSM # 7 agreed the meat slicer was not clean. On 02/06/19 at 1:32 p.m., an interview was conducted with OSM # 7. When asked how often the meal slicer and mixer should be cleaned, OSM # 7 stated, It should be washed and sanitized after each use. The facility policy Equipment documented in part, Procedures: 3. All food contact equipment will be cleaned and sanitized after every use. On 02/06/19 at approximately 5:50 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, executive nurse, were made aware of the above findings. No further information was provided prior to exit. 3. The facility staff failed to keep used alcohol swabs off the food-preparation sheet pan and place clean soup bowls on a clean surface before serving. On 02/05/19 at 11:55 a.m., an observation was made of the holding temperatures of the food on the steam table in the kitchen. An observation of steam table revealed a food preparation table at the end and in line with the steam table. Observation of the food preparation table revealed a sheet pan sitting on top of the food preparation table. Observation of the sheet pan revealed the bottom of the pan was covered with parchment paper. On top of the parchment paper was a stack of sliced cheese, 12 slices of bread, and a small stack of 4 grilled cheese sandwiches ready for grilling. Observation of OSM (other staff member) # 11, the cook taking the food temperatures revealed that she would open an alcohol swab package, clean the thermometer after taking the temperature of each food item and set the used alcohol swabs on the sheet pan that contained the cheese, bread and prepped grilled cheese sandwiches. Further observation of the tray line revealed a kitchen staff member placing six clean soup bowls, upside down on the food preparation table above the sheet pan. Further observation of the area on the food preparation table above the sheet pan revealed it was not cleaned before the soup bowls were placed there and there was food debris under the bowls. Further observation of the food line service revealed OSM # 11, the cook, picking up the six soup bowls, one at a time, fill them with soup, and placing a plastic cover over the bowl and then placing them on the resident's lunch trays. On 02/05/19 at 2:20 p.m., an interview was conducted with OSM # 7, dining services manager. When informed of the observation of the placement of the used alcohol swabs and the clean soup bowls, OSM # 7 stated, The swabs should have been placed in the trash and not on the food prep (preparation) sheet pan and the clean soup bowls should have been placed on a clean serving tray. The facility policy Food: Preparation documented in part, 2. Dining Services staff will be responsible for food preparation that avoid contamination by potentially physical, biological and chemical contamination. On 02/06/19 at approximately 5:50 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, executive nurse, were made aware of the above findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review and in the course of a complaint investigation, it was determined the facility staff failed to maintain a complete and accurate clinical record for four of 55 residents in the survey sample, Residents #312, # 35, #39 and #31. 1. The facility staff inaccurately documented Resident 312's comprehensive care plan with a diagnosis of dementia. 2. The facility staff failed to ensure an accurate clinical record for the administration of medications to Resident #35. The facility staff documented two medications were administered to Resident #35 at 8:00 p.m., on 8/30/18 and 10/3/18, when the clinical record documented the resident was out of the facility. 3. The facility staff failed to evidence that the clinical record documented the details of Resident #39's fall on 11/8/18, 12/24/18, 1/1/19, 1/6/19, and 2/3/19. 4. The facility staff failed to evidence that the clinical record documented the details of Resident #31's falls on 12/7/18 and 1/18/19. The findings include: 1. The facility staff inaccurately documented Resident 312's comprehensive care plan with a diagnosis of dementia. Resident # 312 was admitted to the facility on [DATE] with diagnoses that included but were not limited to pneumonia, fracture (break) of right humerus (1) urinary tract infection (2), dysphagia, (3), and hypokalemia (4). Resident # 312's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 08/06/18, coded Resident # 312 as scoring an (11) eleven on the brief interview for mental status (BIMS) of a score of 0 - 15, (11) eleven - being moderately impaired of cognition for making daily decisions. Resident # 312 was coded as requiring limited assistance of one staff member for activities of daily living. The comprehensive care plan for Resident # 312 dated 07/30/2018, documented, Focus: Resident/patient has impaired/decline in cognitive function or impaired thought processes related to a condition other than delirium: Dementia (other than Alzheimer's disease). Date initiated: 07/30/2018. The Assessment & Plan dated 07/25/18 from (Name of Hospital) for Resident # 312 documented, (Resident # 312) is a 93 y.o. (year old) female admitted under the hospitalist service with Pneumonia. Patient Active Problem List: Diagnosis: Pneumonia, Diarrhea, UTI (urinary tract infection), Failure to Thrive, CAD (coronary artery disease), Diabetes mellitus, Hypertension, Hyperlipidemia, and recent right humerus fracture. The Assessment & Plan dated 07/28/18 from (Name of Hospital) for Resident # 312 documented, (Internal Medicine Daily Progress Note. Principal Problem Pneumonia. Active Problems: Diarrhea, Pneumonia left lower lobe due to infectious organism. (Resident # 312) is a 93 y.o. (year old) female with a PM Hx (past medical history) of coronary artery disease, diabetes mellitus, hypertension, hyperlipidemia who presents here from assisted living facility accompanied by multiple family members secondary to fever. The facility's POS (physician order sheet) dated 7/30/18 for Resident # 312 documented, PNA (pneumonia), UTI (urinary tract infection), CAD (coronary artery disease), HTN (hypertension), HLD (high-lipid disorder), FTT (failure to thrive), DM II (type two diabetes), HX (history of): C-Diff (clostridium difficile), hyperkalemia, hx: fall, R (right) humerus fx (fracture). Further review of the clinical record for Resident # 312 failed to evidence documentation of a diagnosis of dementia. On 02/07/19 at 11:21 a.m., an interview was conducted with RN (registered nurse) # 6, MDS coordinator and LPN (licensed practical nurse) # 6, MDS nurse. LPN #6 was asked where the diagnosis of dementia documented on the comprehensive care plan for Resident # 312 came from. RN # 6 and LPN # 6 reviewed the clinical for Resident # 312. RN # 6 stated, It is not documented anywhere else, then the care plan is inaccurate in terms of the diagnosis of dementia. When the assistant director of nursing (who was no long employed with the facility) did the initial care plan, she put the diagnosis of dementia on the care plan. I don't know where she got that diagnosis from. When asked to describe the process for obtaining a resident's diagnosis, RN # 6 and LPN # 6 stated, We get the diagnoses from the hospital discharge summary and any other information from the hospital. On 02/07/19 at approximately 3:45 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, executive nurse, were made aware of the above findings. No further information was provided prior to exit. Complaint Deficiency References: (1) The humerus is the long bone in the upper arm. It is located between the elbow joint and the shoulder. This information was obtained from the website: https://www.healthline.com/human-body-maps/humerus-bone#1. (2) An infection in the urinary tract. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/000521.htm. (3) A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. (4) Low potassium level is a condition in which the amount of potassium in the blood is lower than normal. This information was obtained from the website: https://medlineplus.gov/ency/article/000479.htm. 2. The facility staff failed to ensure an accurate clinical record for the administration of medications to Resident #35. The facility staff documented two medications were administered to Resident #35 at 8:00 p.m., on 8/30/18 and 10/3/18, when the clinical record documented the resident was out of the facility. Resident #35 was admitted to the facility on [DATE] with the diagnoses of but not limited to hip fracture, atrial fibrillation, high blood pressure, falls, inguinal hernia, and cardiomyopathy. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 11/23/18. The resident was coded as being cognitively intact in ability to make daily life decisions. The resident was coded as being independent for transfers, locomotion, dressing, eating, and toileting and as requiring supervision for hygiene. A review of the clinical record revealed a physician's order dated 8/22/18 that documented the resident may go on LOA [leave of absence] for 4 hours daily. A review of the nurse's notes revealed the following: A nurse's note dated 8/30/18 documented, Resident signed out at 1:30pm, today and stated that he was going to (name of bank) and not going to church tonight. Cousin and friend were contacted at 10pm today because resident was not back at facility. Unit manager on call was contacted. Resident made contact with facility soon after and was reported to unit manager on call. Unit manager will pick up resident from Firestone off of (location) A nurse's note dated 8/31/18 documented, Late entry: This RN was contacted by nursing staff of residents failure to return to the facility following his departure for the bank earlier in the afternoon. Nursing staff was advised to make contact with RP to see if they knew where resident was located. This RN was advised that contact was made with residents cousin and friend, neither of which knew of his whereabouts. DON was notified of incident. Nursing staff was advised to call the sheriffs office non emergency number to report the residents failure to return. At approximately 10:30pm, this RN was notified by staff that (resident) had called the facility and stated he was at the Firestone and was unable to get back due to not having enough money for the cab ride. This writer went to pick up resident shortly after. Resident was found in front of the Firestone (location) sitting on the ground. Resident stated he left his bank card back at the facility and was unable to get a ride back. Resident returned to facility. This RN stressed the importance to the resident of returning in a timely manner and the need to be able to take his evening medicine. Resident expressed understanding. Resident was asked where he usually goes when he leaves the facility so if another incident occurs we know where to look. Resident stated that he goes to the (name of bank) on (location) and is usually in the shopping center above or below the hospital. Resident returned to facility at approximately 11:30pm. A nurse's note dated 10/3/18 documented, Patient left facility at 2:10 p.m., for LOA was supposed to return by 6:10 p.m. Patient called facility at 7:50 p.m., to say he was at the Bus Station in (location) with no way back. Patient returned at 9:30 p.m. He stated, Someone from the Bus Station gave me a ride back. Patient education given on Safety and if Patient is going out alone he must have money for Cab fare both ways and he must return back on time. A review of the clinical record revealed an order dated 5/23/18 for Cal-Gest {1}, 1 tab (tablet) twice daily for calcium supplement; and a Metoprolol {2} 50 mg (milligrams) twice daily for high blood pressure. A review of the August 2018 MAR (Medication Administration Record) documented that the resident was to receive the above medications at 8:00 p.m. On 8/30/18, these medications were initialed and documented as administered at 8:00 p.m., when the nurses' notes, documented the resident was not present in the building between 1:30 p.m., and 11:30 p.m. There was no evidence that the physician was notified, consulted for orders to administer the medications late. A review of the October 2018 MAR documented that the resident was to receive the same two medications above at 8:00 p.m. On 10/3/18, these medications were initialed and documented as administered at 8:00 p.m., when the nurses' notes, documented the resident was not present in the building between 2:10 p.m. and 9:30 p.m. There was no evidence that the physician was notified, consulted for orders to administer the medications late. On 2/7/19 at 1:24 p.m., in an interview with LPN #4, was asked about the process staff follows when a resident is out on leave long enough to miss medications. LPN #4 stated the physician should be called to verify if the medications could be given or not. On 2/7/19 at 2:20 p.m., an interview was conducted with the Executive Director (ASM [administrative staff member] #1) and Nurse Executive, ASM #2. When asked about the resident's unsupervised outings into the community and issues he had of returning to the facility timely, ASM #1 stated that he was alert and oriented, his BIMS (Brief Interview for Mental Status exam) was a 15 (cognitively intact). She stated the physician was aware of the resident's outings and that it was his right to go out if he wanted to. When asked about the resident's missed medications when he was late returning to the facility, ASM #1 stated that the doctor should have been notified and direction provided whether or not to administer them (medications) late. No further information was provided. {1} Cal-Gest Antacid - Calcium carbonate is a dietary supplement used when the amount of calcium taken in the diet is not enough. Calcium is needed by the body for healthy bones, muscles, nervous system, and heart. Calcium carbonate also is used as an antacid to relieve heartburn, acid indigestion, and upset stomach. It is available with or without a prescription. Information obtained from https://medlineplus.gov/druginfo/meds/a601032.html {2} Metoprolol - Metoprolol is used alone or in combination with other medications to treat high blood pressure. It also is used to prevent angina (chest pain) and to improve survival after a heart attack. Metoprolol also is used in combination with other medications to treat heart failure. Metoprolol is in a class of medications called beta blockers. It works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a682864.html 3. The facility staff failed to evidence that the clinical record documented the details of Resident #39's fall on 11/8/18, 12/24/18, 1/1/19, 1/6/19, and 2/3/19. Resident #39 was most recently readmitted to the facility on [DATE] with the diagnoses of but not limited to dementia, diabetes, chronic back pain, high blood pressure, history of femur fracture, overactive bladder, adjustment disorder with anxiety, and osteoarthritis. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 12/3/18. The resident was coded as being moderately impaired in ability to make daily life decisions. The resident was coded as requiring extensive care for bathing; limited assistance for eating; and supervision for hygiene, toileting, dressing, and transfers. A review of the nurse's notes revealed one dated 11/8/18, which documented, A change in condition has been noted. The symptoms include: Falls 11/8/18 in the afternoon .Orders obtained include: NNO (no new orders) . This note did not document the circumstances surrounding the fall, if there were any injuries, and what, if any, new interventions were added to the care plan. Subsequent nurses' notes over the following days failed to reveal any additional information regarding the details of the fall. A review of the Event Summary Report dated 11/8/18 documented, Resident feel {sic} in dining room trying to reach across the table to get her stuffed cats. Resident fell to floor and hit her head. Resident stated that her head no long {sic} hurt after a few mins (minutes) and was able to get up from the floor with assistance. Resident was assessed for any injuries and none were found Interventions added immediately after fall and care plan updated: Resident was educated on not leaning while in chair. A review of the nurse's notes revealed one dated 12/24/18, which documented, A change in condition has been noted. The symptoms include: Falls 12/24/18 in the morning Change reported to Primary Care Clinician This note did not document the circumstances surrounding the fall, if there were any injuries, and what, if any, new interventions were added to the care plan. Subsequent nurses' notes over the following days failed to reveal any additional information regarding the details of the fall. A review of the Event Summary Report dated 12/24/18 documented, Resident was found on the floor beside her bed with no injuries, tolerated ROM (range of motion) well with no difficulty, vital signs were taken and neuro checks initiated Interventions added immediately after fall and care plan updated: Resident had disabled alarm prior to fall, alarm was replaced. A review of the nurse's notes revealed one dated 1/1/19, which documented, A change in condition has been noted. The symptoms include: Falls Change reported to Primary Care Clinician Orders obtained included: Continue to monitor aware of the complaints of buttocks pain no bruising present This note did not document the circumstances surrounding the fall and what, if any, new interventions were added to the care plan. Subsequent nurses' notes over the following days failed to reveal any additional information regarding the details of the fall. A review of the Event Summary Report dated 1/1/19 documented, The resident was toileted by the CNA (Certified Nursing Assistant) was instructed to pull call bell when she was done. The resident did not was noted to be lying on the floor near her bed Interventions added immediately after fall and care plan updated: Staff to remain with the resident while in the bathroom. A review of the nurse's notes revealed one dated 1/6/19, which documented, A change in condition has been noted. The symptoms include: Falls 1/6/19 in the morning. A second note dated 1/6/19 documented, The resident has no new changes in the ROM, usual complaints of general body ache A third note dated 1/6/19 documented, NP (nurse practitioner) .aware of the falls this am there are no new orders. These notes did not document the circumstances surrounding the fall and what, if any, new interventions were added to the care plan. Subsequent nurses' notes over the following days failed to reveal any additional information regarding the details of the fall. There was no incident report related to this fall provided. A review of the nurse's notes revealed one dated 2/3/19, which documented, A change in condition has been noted. The symptoms include: Falls in the morning Change reported to Primary Care Clinician Orders obtained included: Continued observation This note did not document the circumstances surrounding the fall, if there were any injuries, and what, if any, new interventions were added to the care plan. Subsequent nurses' notes over the following days failed to reveal any additional information regarding the details of the fall. A review of the Event Summary Report dated 2/3/19 documented, The resident had just been toileted and wanted to make her bed which was already done by the CNA (Certified Nursing Assistant). She wanted to place her blankets and had taken her shoes off and her feet slipped and she was found in a kneeling position next to her bed. The residents shoes were placed on and she was assisted via a gait belt which she pushed herself up and placed into her w/c (wheelchair). Neuro [neurological] checks were initiated Interventions added immediately after fall and care plan updated: Continued education and encouragement to be compliant. On 2/7/19 at approximately 2:20 p.m., the Executive Director (ASM [administrative staff member] #1) and the Executive Nurse (ASM #2) were made aware of the concern. ASM #2 stated that the Event Summary Report is an internal document and is not part of the legal clinical record. At this time, she was notified that the legal clinical record did not reflect the above data regarding how these falls occurred, if there were any injuries, and if there were any care plan reviews or revisions. No further information was provided by the end of the survey. 4. The facility staff failed to evidence that the clinical record documented the details of Resident #31's falls on 12/7/18 and 1/18/19. Resident #31 was admitted to the facility on [DATE] with the diagnoses of but not limited to high blood pressure, cardiomyopathy, stroke, atrial fibrillation, pacemaker, dementia, contracture, seizures, chronic kidney disease and acute kidney failure. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 11/5/18. The resident was coded as being cognitively intact in ability to make daily life decisions. The resident was coded as requiring total care for bathing; extensive care for transfers, dressing, toileting and hygiene; and limited assistance for eating. A review of the nurse's notes revealed one dated 1/18/19, which documented, A change in condition has been noted. The symptoms include: Falls 1/18/19 at night Change reported to Primary Care Clinician This note did not document the circumstances surrounding the fall, if there were any injuries, and what, if any, new interventions were added to the care plan. Subsequent nurses' notes over the following days failed to reveal any additional information regarding the details of the fall. A review of the Event Summary Report dated 1/18/19 documented, Resident was found face down beside his bed with no injuries, tolerated ROM well, res stated I am trying to grab something from the floor denies any pain/discomfort Interventions added immediately after fall and care plan updated: Educated resident to use call bell at all times. On 2/7/19 at approximately 2:20 p.m., the Executive Director (ASM [administrative staff member] #1) and the Executive Nurse (ASM #2) were made aware of the concern. ASM #2 stated that the Event Summary Report is an internal document and is not part of the legal clinical record. At this time, she was notified that the legal clinical record did not reflect the above data regarding how this fall occurred, if there were any injuries, and if there were any care plan reviews or revisions. No further information was provided by the end of the survey.

Based on staff interview and facility document review, it was determined the facility staff failed to provide the required annual in-service training's for 10 CNAs (certified nursing assistants) who were employed for at least one year. The facility staff failed to provide the required annual 12 hours and/or dementia management training's for CNA #1, CNA #2, CNA #3, CNA #4, CNA #5, CNA #6, CNA #7, CNA #8, CNA #9, and CNA #10. The findings include: On 2/6/19 at approximately 9:00 a.m., a request was made to administrative staff member (ASM) #2, the nurse executive, for the training transcripts, for all CNAs who were employed at the facility for at least one year. For six of the above listed CNAs, an In-service Record was provided. The following was documented: CNA #2 - last training's completed - 1/5/18 CNA # 3 - last training's completed - 1/5/18 CNA # 1 - last training's completed - 1/8/18 CNA #6 - last training's completed - 1/5/18 CNA # 7 - last training's completed - 1/8/18 CNA # 9 - last training's completed - 1/8/18. There were no training records for CNA #4, CNA #5, CNA #8 and CNA #10. An interview was conducted with RN (registered nurse) #5, the nurse practice educator, on 2/7/19 at 11:36 a.m. When asked if she had any other documentation of training's provided to the above listed CNAs, RN #5 stated, I have reviewed all the files in my office and I haven't been able to find any other documented training's since January 2018. ASM #1, the executive director, ASM #2 and ASM #3, the clinical quality specialist, were made aware of the above concern on 2/7/19 at 3:46 p.m. No further information was provided prior to exit.

Based on observation and staff interview, it was determined that the facility staff failed to maintain the dumpster area in a sanitary manner. The facility staff failed to close the sliding doors on the facility's two dumpsters and maintain the area behind the dumpsters free of trash. The findings include: On 02/05/19 at 2:27 p.m., an observation of the facility's dumpsters was conducted with OSM (other staff member) # 7, dining services manager and OSM # 1, director of environmental services. The facility had two dumpsters located behind the facility on a concrete pad. Behind the dumpsters was a lawn area with small shrubs. Observation of both dumpsters revealed one sliding door located on the side was open on each dumpster. Further observation of the lawn area behind the two dumpsters revealed the following: approximately three old clear plastic trash bags, approximately four soda cans and bottles, a clear old plastic trash bag hanging from a branch in one of the shrubs. Approximately 24 plastic bowl covers, numerous pieces of paper, several Styrofoam cups, several plastic spoons and plastic cups, approximately four pairs of used plastic gloves and several plastic straws. An interview was then conducted with OSM # 1 and # 7. When asked who was responsible for keeping the dumpster's door closed and maintaining the dumpsters in a clean and sanitary manner, OSM # 1 and # 7 stated they were. When asked to describe the procedure for maintaining the dumpsters, OSM # 1 stated, Environmental services is responsible for checking the dumpsters on Tuesdays and dietary on Thursdays and both department monitor it during the rest of the week. When asked about all the debris and trash observed behind the dumpsters, OSM # 1 stated, I was going to take care of it the other day but there were some animals around it and I didn't want to deal with them. OSM # 7 stated, I always check the front and the sides of the dumpsters. When asked about the sliding doors being open on the sides of the dumpster, OSM # 1 and # 7 stated that the doors should be kept closed. On 02/06/19 at approximately 5:50 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, executive nurse, were made aware of the above findings. No further information was provided prior to exit.