Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to follow physicians orders regarding oxygen therapy for 1 of 24 residents, Resident #34. The findings included: Resident #34's clinical record included a physician order for oxygen at 3 liters per minute. The surveyor observed the oxygen to be set at 6 liters per minute. Resident #34's diagnoses included, but were not limited to, obstructive sleep apnea, chronic obstructive pulmonary disease, and anxiety disorder. Section C (cognitive patterns) of Resident #34's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/09/22 included a brief interview for mental status (BIMS) score of 9 out of a possible 15 points. Section O (special treatments/procedures/programs) was coded to indicate Resident #34 was receiving oxygen therapy. Resident #34's comprehensive care plan included the intervention provide oxygen as ordered. Resident #34's physician orders included an order for oxygen at 3 liters per minute via nasal cannula diagnosis shortness of breath. The order date for the oxygen was documented as 01/09/23. 02/27/23 10:50 a.m., surveyor in room and observed oxygen to be set at 6 liters a minute. Resident stated oxygen should be set at 3 liters a minute. LPN (licensed practical nurse) #2 in room, checked oxygen and stated, they were not aware it was at 6 liters and adjusted the setting to 3 liters a minute. 02/27/23 4:15 p.m., the Administrator, Director of Nursing, Nurse Consultant #1 and #2, and the Assistant Administrator were made aware of the issue regarding Resident #34's oxygen. 02/28/23 11:05 a.m., Nurse Consultant #1 provided the surveyor with copies of in-service logs and stated they had inserviced 100% of the nursing staff regarding Resident #34's oxygen. No further information was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to maintain complete and accurate clinical records for 2 of 24 residents, Residents #34 and #118. The findings included: 1. For Resident #34, the facility staff documented they had administered Resident #34's medications. When in fact Resident #34 was in the hospital and not at the facility. Resident #34's diagnoses included, but were not limited to, obstructive sleep apnea, chronic obstructive pulmonary disease, and anxiety disorder. Section C (cognitive patterns) of Resident #34's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/09/22 included a brief interview for mental status (BIMS) summary score of 9 out of a possible 15 points. Section O (special treatments/procedures/programs) was coded to indicate Resident #34 was receiving oxygen therapy. The clinical record review revealed that Resident #34 had been admitted to the hospital on [DATE]-[DATE]. Licensed Practical nurses (LPN) #6, #7, and #8 documented they had administered Resident #34's medications on 11/26/22. Registered Nurse (RN) #3, LPN #6, #8, and #9 documented they had administered Resident #34's oxygen after they had been discharged to the hospital and before returning to the facility. 02/27/23 4:15 p.m., the Administrator, Director of Nursing, Nurse Consultant #1 and #2, and the Assistant Administrator were made aware of the issue regarding Resident #34's clinical record. Nurse Consultant #1 stated the Resident #34's admission was over a weekend, and they were not taken out of the system. No further information was provided to the survey team prior to the exit conference. 2. The facility staff failed to document a post-fall assessment for Resident #118. Resident #118's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 2/9/23, was dated as completed on 2/14/23. Resident #118 was documented as usually able to make self understood and as usually able to understand others. Resident #118's Brief Interview for Mental Status (BIMS) summary score of 12 out of 15; this indicated moderate cognitive impairment. Resident #118 was assessed as requiring limited assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #118 was assessed as having a history of falls without injuries. Resident #118 was care planned for being at risk for falls. The following information was found in a facility document titled Charting and Documentation (revised on July 2017): - All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. - The following information is to be documented in the resident medical record: a. Objective observations .e. Events, incidents or accidents involving the resident . - Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. On 2/26/23 at 3:50 p.m., Resident #118 was observed to be setting in the corridor near their room. Facility staff members were observed to be assessing Resident #118 and assisting the resident into a wheelchair via a lifting device. Resident #118 was heard to say they were not having pain after the fall. Review of Resident #118's medical documentation failed to reveal documentation of the resident's aforementioned fall. On 2/28/23 at 8:47 a.m., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) was asked about the absence of documentation of Resident #118's fall which occurred on 2/26/23; the surveyor requested copies of any documentation of the fall. On 2/28/23 at approximated 10:00 a.m., the surveyor interviewed Licensed Practical Nurse (LPN) #18 about Resident #118's fall. LPN #18 stated, at the time they were starting to document the fall, they were called away to care for another resident. LPN #18 confirmed they had not documented the fall. The surveyor was provided a copy of a LATE ENTRY note for the 2/26/23 fall; this LATE ENTRY note was documented on 2/28/23 at 10:39 a.m. On 2/28/23 at 1:50 p.m., the survey team met with the facility's Administrator, DON, ADON, Infection Preventionist, and Regional Nurse Consultant; the failure of facility staff to document Resident #118's fall and/or post-fall assessment in the clinical record was discussed for a final time.

Based on observation, staff interview, resident review, and family interview, the facility staff failed to maintain a clean and homelike environment on 2 of 2 wings. The findings included: 02/26/23 during initial tour of the facility the surveyors identified a pervasive smell of urine throughout the facility. 02/26/23 at approximately 2:50 p.m., during an interview with a family member of a resident of the facility the family member stated the facility always had an odor. 02/27/23 08:45 a.m., Licensed Practical Nurse (LPN) #1 stated the facility had an odor at times. The surveyor again identified a strong odor on the C hall of the building. 02/27/23 4:15 p.m., the Administrator, Director of Nursing, Nurse Consultant #1 and #2, and the Assistant Administrator were made aware of the issue regarding odors in the building. 02/28/23 8:35 a.m., Resident Council President stated the facility had an odor occasionally and if it did have one it seemed to be more likely to happen in the evening. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, facility document review and employee record review the facility staff failed to implement facility policy for the screening of new employees for 3 of 25 new employees, #14, #15, and #21. The findings included: For new employee #14 and #21 the facility staff failed to obtain reference checks and for new employee #15 the facility staff failed to obtain criminal background checks per the facility abuse policy. The surveyor reviewed 25 records for new hire employees on 03/17/21. The surveyor could not locate references for new employee #14, a CNA (certified nursing aide) with a hire date of 11/16/2020, and new employee #21, a CNA with a hire date of 01/15/21. The surveyor also could not locate a criminal background check for new employee #15, a CNA with a hire date of 06/04/2020. Surveyor spoke with the BOM (business office manager) on 03/17/21 at approximately 1:40 pm. Surveyor asked BOM if they could locate the missing reference checks and criminal background check. BOM stated they could not. Surveyor reviewed the facility policy entitled Abuse, Neglect and Exploitation Prevention and Reporting, which read in part The facility must: 3. Not employ or otherwise engage individuals who: d. Background, reference and credentials' checks should be conducted on employees prior to or at the time of employment, by facility administration, in accordance with applicable state and federal regulations. Any person having knowledge that an employee's license or certification is in question should report such information to the Administrator. The concern of the facilitiy not obtaining reference checks and a criminal background check was discussed with the administrative staff (administrator, DON [director of nursing], ADON [assistant director of nursing], RNC [regional nurse consultant]) during a meeting on 03/18/21 at approximatley 11:15 am. No further information provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to administer a routine narcotic and failed to follow their system of record keeping for a controlled narcotic in sufficient detail to enable an accurate reconciliation for 2 of 27 Residents, Resident's #85 and #90. The findings included: 1. For Resident #85, the facility staff failed to ensure the narcotic medication Valium was available for administration. Resident #85's clinical record included the diagnosis of anxiety disorder. Section C (cognitive patterns) of the residents quarterly (MDS) minimum data set assessment with an (ARD) assessment reference date of 02/15/2021 included a (BIMS) brief interview for mental status summary score of 15 indicating the resident was alert and orientated. The residents comprehensive care plan included the approach MEDICATE AS ORDERED. A review of Resident #85's (eMARs) electronic medication administration records revealed that the facility nursing staff had documented on 02/25/2021 at 9:19 p.m. that Resident #85's Valium was unavailable and not in the stat box .contacted pharmacy and spoke with .stated it would be on the night shift run . This same nurse had documented for the administration of this medication on 02/22-02/24/2021 and indicating they would have known how much Valium, the resident had on hand. A review of the facility policy titled, Receipt of Interim/Stat/Emergency Deliveries read in part, .Facility should immediately notify Pharmacy when Facility receives from a Physician/Prescriber a medication order that may require an interim/stat/emergency delivery. If a necessary medication is not contained within Facility's interim/stat/emergency supply, and Facility determines that in interim/stat/emergency delivery is necessary, Facility should arrange either: With pharmacy to include the interim/stat/emergency medication(s) in an earlier scheduled delivery or a special delivery, as required, or, For delivery by contract courier, or, For the medication to be dispensed and delivered by a Third Party Pharmacy to ensure timely receipt . On 03/17/2021 at 2:51 p.m., the administrator, (DON) director of nursing, (ADON) assistant director of nursing, and (RNC) regional nurse consultant were notified of the Valium not being available for administration on 02/25/2021. No further information regarding this issue was provided to the survey team prior to the exit conference on 03/18/2021. 2. For Resident #90, the facility failed to follow their policy in regards to wasting the narcotic pain medication Norco. Resident #90's clinical record included the diagnosis of pain. Section C (cognitive patterns) of the residents quarterly (MDS) minimum data set assessment with an (ARD) assessment reference date of 02/22/2021 had been coded 1/1/2 to indicate Resident #90 had problems with long and short term memory and was moderately impaired in cognitive skills for daily decision making. On 03/17/21 at 1:28 p.m., Resident #90 stated they had back pain. The resident later stated they would like to have their pain medication back. Resident #90's comprehensive care plan included the problem area's pain/alteration in comfort related to pain has neuropathy/nerve pain and arthritis and refuses meds at times. Approaches included medicate as ordered and be alert for refusing meds. A review of Resident #90's (eMARs) electronic medication administration records revealed that the nursing staff had documented an N for the pain medication Norco 10-325 mg tablet at 6:00 a.m. on 03/03, 03/05, 03/07, 03/09, 03/10, 03,11, 03/12, 03/13, 03/14, 03/16 and 03/17/2021. For the 2:00 p.m. administration time the staff had documented an N' on 03/03, 03/08, 03/09, 03/10, and 03/16/2021. For 10:00 p.m. administration time the facility staff had documented an N' on 03/02/2021. A review of the notes following the eMARs revealed that the nursing staff had documented this medication had been refused by Resident #90 for the administration times marked with an N. On 03/17/21 at 4:00 p.m., the (ADON) assistant director of nursing stated that Resident #90 refused their pain medication On 03/18/21 at 8:01 a.m., a review of Resident #90's INDIVIDUAL NARCOTIC RECORD for the pain medication Norco revealed that the nursing staff rarely had a second nurse or any witness sign the narcotic record when the pain medication was refused and discarded. The unit manager stated that the nurses should have a witness when narcotics are refused and discarded. On 03/18/21 at 8:29 a.m., (LPN) licensed practical nurse #1 stated that Resident #90 would come and go cognitively and refused their medications at times. This nurse stated that she had a second nurse witness when the resident refused their narcotic. A copy of the facility policy titled, Discarding and Destroying Medications was shared with the survey team on 03/18/21. This policy read in part, .Document the disposal on the medication disposition record. Include the signature(s) of at least two witnesses . On 03/18/2021 at 11:13 a.m., the administrator, (DON) director of nursing, ADON, and regional nurse consultant were made aware of the issue regarding the wasting of the narcotic Norco for Resident #90. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, and facility document review, facility staff failed to monitor by not following up on how pharmacy recommendations were acted up on regarding dose changes for 3 out of 3 unsampled residents (Residents #16, 51, and 91). The findings included: During clinical record reviews on 3/17/2021, surveyors were unable to find documentation of drug regimen reviews (DRR) in the clinical records. A surveyor interviewed the director of nursing (DON) on 3/17/2021. The DON reported being unaware that the pharmacy review reports were supposed to be reviewed, reported to the physician, and placed in the clinical records. From November 2020 through March 17 2021, staff did not review pharmacy recommendations or place reviews on the resident records. The administrator and the corporate consultant were notified of the concern. On 3/18/2021, surveyors were given copies of the DRR reports from November 2020 through 3/17/2021. Nursing staff reported reviewing the reports and passing recommendations to the nurse practitioner for action. For Resident #16, a DRR Consultation Report dated 12/22/2020 recommended increasing donepezil from 5 mg to 10 mg once daily. This recommendation was marked decline- psych to follow dated 3/18/2021. For Resident # 51, a DRR Consultation Report dated 2/18/2021 recommended increasing donepezil from 5 mg to 10 mg once daily. This recommendation had not been addressed prior to the surveyor receiving the copy on 3/18/2021. For Resident #91, a DRR Consultation Report dated 2/17/2021 recommended discontinuing Gliptizide (a diabetic medication). This recommendation was marked decline- psych to follow dated 3/18/2021.

3. For Resident #96 facility staff failed to address a drug regimen review completed by the pharmacist on 2/16/21 recommending a gradual dose reduction review for the psychotropic medication Bupropion, an antidepressant used to treat depression. Resident #96's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease Unspecified, Major Depressive Disorder Single Episode Unspecified, Anxiety Disorder Unspecified, and Unspecified Psychosis Not Due to a Substance or Known Physiological Condition, and Heart Failure Unspecified. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 2/16/21 assigned the resident a BIMS (brief interview for mental status) score of 99 indicating resident was unable to complete the interview. Resident #96 was coded as being severely impaired with cognitive skills for daily decision making with short-term and long-term memory problems in section C, Cognitive Patterns. In section N, Medications, Resident #96 was coded as receiving an antidepressant for 7 days during the last 7 days. Upon review of Resident #96's clinical record on 3/17/21, surveyor was unable to locate any pharmacy drug regimen reviews. On 3/17/21 at approximately 4:00 pm, surveyor spoke with the DON (director of nursing) and asked where the drug regimen reviews were filed in the clinical records, DON stated they were in their email but they have not printed them. On 3/17/21 at 4:21 pm, DON spoke with the survey team and stated they were unaware that the drug regimen reviews needed to be printed out right then and there were no recommendations. On 3/17/21 at approximately 4:30 pm, surveyor was provided with a copy of Resident #96's (Pharmacy name omitted) Consultation Report completed by the pharmacist on 2/16/21 stating in part, Comment: (Resident #96) has received Bupropion 150 mg twice daily and Escitalopram 5 mg daily for management of depressive symptoms since 1/03/20. Recommendation: Please consider a reduction of Bupropion to 100 mg twice daily while concurrently monitoring for re-emergence of depressive and/or withdrawal symptoms. If therapy is to continue at the current dose, please provide rationale describing a dose reduction as clinically contraindicated. The section of the consultation report provided for the physician's response to accept the recommendation, accept the recommendation with modification, or decline the recommendation has been left blank and there was a hand written note on the side of the form stating, No new orders 3/17/21 MS RN. No additional drug regimen reviews were provided to the surveyor for Resident #96. On 3/18/21 at approximately 11:15 am, the administrator, DON, assistant DON, and the regional nurse were notified of the concern regarding Resident #96's February 2021 pharmacy drug regimen review not being addressed until 3/17/21. No further information regarding this issue was presented to the survey team prior to the exit conference on 3/18/21. Based on staff interview clinical record review, and facility document review, facility staff failed to address gradual dose recommendations for 2 of 27 residents in the survey sample (Resident #68 and #96) and for 12 additional current residents not included in the survey sample. The findings included: 1. For Resident #68, facility staff failed to act upon a recommendation for a gradual dose reduction of Paroxetine (an antidepressant medication). Resident #68 was admitted to the facility with diagnoses including cerebrovascular accident, cardiac artery disease, hemiplegia, and depression. On the Minimum Data Set assessment with assessment reference date 2/8/2021, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. During clinical record reviews on 3/17/2021, surveyors were unable to find documentation of drug regimen reviews (DRR) in the clinical records. A surveyor interviewed the director of nursing (DON) on 3/17/2021. The DON reported being unaware that the pharmacy review reports were supposed to be reviewed, reported to the physician, and placed in the clinical records. From November 2020 through March 17 2021, staff did not review pharmacy recommendations or place reviews on the resident records. The administrator and the corporate consultant were notified of the concern. On 3/18/2021, surveyors were given copies of the DRR reports from November 2020 through 3/17/2021. Nursing staff reported reviewing the reports and passing recommendations to the nurse practitioner for action. After surveyors reported the concern, facility staff printed the pharmacy recommendations. Resident # 68's Consultation Report dated 2/17/2021 under Recommendation: Please attempt a gradual dose reduction (GDR) to Paroxetine 5 mg daily while concurrently monitoring for reemergence of depressive and/or withdrawal symptoms. A comment was hand-written noted 3/17/21 No new orders TH, RN. The portion of the Consultation Report under Physician's Response, where the physician accepts, accepts with modification, or declines the recommendation was blank. 2. Surveyors discovered GDR recommendations for 12 current residents who were not included in the survey sample. Facility staff had not acted on those recommendations prior to surveyors reporting the problem to the director of nursing on 3/17/2021.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure a complete and accurately documented clinical record for 2 of 27 residents in the survey sample, Resident's #34 and #85. The findings included: 1. For Resident #34, facility staff failed to accurately document the amount of tube feeding residual obtained on 3/16/21. Resident #34, diagnosis list indicated diagnoses, which included, but not limited to Parkinson's Disease, Gastrostomy Status, Dysphagia following Unspecified Cerebrovascular Disease, Unspecified Protein-Calorie Malnutrition, Unspecified Dementia with Behavioral Disturbance, and Chronic Kidney Disease Stage 3 Unspecified. The most recent significant change MDS (minimum data set) with an ARD (assessment reference date) of 3/09/21 assigned the resident a BIMS (brief interview for mental status) score of 99 indicating that the resident was unable to complete the interview. Resident #34 is coded as being severely impaired in cognitive skills for daily decision making with short-term and long term memory problems in section C, Cognitive Patterns. In section K, Swallowing/Nutritional Status, Resident #34 is coded as receiving 51% or more of total calories received through parenteral or tube feeding and 501 cc/day or more of average fluid intake per day by IV or tube feeding during the entire last 7 days. On 3/16/21 at 5:51 pm, surveyor observed Resident #34 in bed with an empty tube feeding formula bag hanging and attached to the pump, the pump was turned off. The formula bag was labeled 1.5 Nutren 60 ml/hr and dated 3/15/21 2000 (8:00 pm). On 3/17/21 at approximately 8:50 am, the surveyor observed Resident #34 in bed with the tube feeding running via pump set at 60 ml/hr. The formula bag was dated 3/16/21 2115 (9:15 pm). At 8:57 am, surveyor spoke with the UM (Unit Manager) and asked why the resident's tube feeding was turned off yesterday at 5:51pm, UM stated it was probably off because the nurse was getting ready to hang it. A review of Resident #34's clinical record revealed an order for tube feeding dated 12/21/20 stating, Nutren 1.5 liquid 60ml/hr cont. (continuous) via tube Dx (diagnosis): Nutritional Supplement and an order dated 12/26/21 to Check residual Q (every) 4 hrs hold feeding x 1 hour if residual >60ml. Resident #34's March 2021 MAR (medication administration record) was reviewed and the order for Nutren 1.5 liquid 60 ml/hr cont. via tube was signed off as being administered on 3/16/21 at 6:30 am, 2:30 pm, and 10:30 pm. The tube feeding residual was documented on the MAR for 3/16/21 as 0 at 4:00 pm and 0 at 8:00 pm. On 3/17/21 at 4:45 pm, surveyor spoke with LPN (licensed practical nurse) #1, who was caring for Resident #34 on 3/16/21 during the time the tube feeding formula was observed turn off, LPN #1 stated the resident's residual was in the 70s and there's an order that you cannot restart the feeding and have to hold it if the residual is 60 or greater. Surveyor asked LPN #1 if the residual was documented on the MAR and LPN #1 stated they probably forgot to document. Surveyor asked what the residual was when the tube feeding was restarted and LPN #1 stated it was probably somewhere in the 30s. According to Resident #34's weight documentation, on 2/11/21 resident weighed 101.2 pounds and on 3/10/21 resident weighed 100.4 which is a 0.79% loss. Resident #34's current care plan includes an approach stating, Check residual as ordered, hold feeding 1 hr if greater than 60. Surveyor requested and received the facility policy for tube feeding entitled, Enteral Nutrition which states in part: 12. The provider will consider the need for supplemental orders, including: g. Checks for gastric residual volume (GRV). On 3/18/21 at approximately 11:15 am, the administrator, director of nursing, assistant director of nursing, and the regional nurse were notified of the concern with Resident #34's residual not being correctly documented on the MAR. No further information regarding this issue was presented to the survey team prior to the exit conference on 3/18/21. 2. For Resident #85, the facility nursing staff failed to document that they had changed the residents foley catheter. This foley catheter was due to be changed every month and prn (as needed). Resident #85's clinical record included the diagnosis neurogenic bladder. Section C (cognitive patterns) of the residents quarterly (MDS) minimum data set assessment with an (ARD) assessment reference date of 02/15/2021 included a (BIMS) brief interview for mental status summary score of 15 indicating the resident was alert and orientated. Section H (bladder and bowel) was coded to indicate the resident had a foley catheter. Resident #85's comprehensive care plan included the problem area at risk for signs and symptoms of (UTI) urinary tract infection has indwelling foley catheter. Approaches included change foley catheter every month and prn. Resident #85's clinical record included a physician order for a 16 french (size) foley catheter change every month and prn. Diagnosis neurogenic bladder. A review of Resident #85's (eMARs) electronic medication administration records for 02/2021 and 03/2021 revealed that the nursing staff had documented an N for 02/25/2021 for the foley catheter change. This same nurse documented .can not find a 16 fr (french) size to change cath will pass it along to order some The surveyor was unable to locate any documentation in the clinical record to indicate when and if they foley catheter had been changed. On 03/17/21 at 10:33 a.m., (LPN) licensed practical nurse #1 reviewed the clinical record and was unable to determine when the foley catheter was last changed. On 03/17/21 at 10:40 a.m., the (DON) director of nursing and (ADON) assistant director of nursing made aware that the nursing staff had documented that they had not changed the residents foley catheter. On 03/17/21 at 11:35 a.m., Resident #85 stated their foley catheter had been changed, that the nurse had stated she did not have it and then obtained it and changed. Resident #85 was unable give the surveyor a date that the foley catheter had been changed. On 03/18/21 at 11:13 a.m., the administrator, DON, ADON, and regional nurse consultant were made aware of the issues regarding the residents foley catheter change. The surveyor requested a date when the foley catheter had been changed or would be changed. This date was never shared with the surveyor prior to the exit conference.

Based on staff interview and clinical record review, facility staff failed to ensure that Drug Regimen Review reports were addressed by the physician and that documentation concerning the reviews was placed in the clinical record while reviewing the sample of 24 records. The findings included: During clinical record reviews on 3/17/2021, surveyors were unable to find documentation of drug regimen reviews (DRR) in the clinical records. A surveyor interviewed the director of nursing (DON) on 3/17/2021. The DON reported being unaware that the pharmacy review reports were supposed to be reviewed, reported to the physician, and placed in the clinical records. From November 2020 through March 17 2021, staff did not review pharmacy recommendations or place reviews on the resident records. The administrator and the corporate consultant were notified of the concern. On 3/18/2021, surveyors were given copies of the DRR reports from November 2020 through 3/17/2021. Nursing staff reported reviewing the reports and passing recommendations to the nurse practitioner for action.

Based on resident council interview, staff interview, and facility document review, the facility staff failed to ensure a private location for the resident council to meet. Volunteers and residents interrupted the resident council meeting on three (3) different occasions. The findings included: Volunteers and residents not attending the resident council meeting interrupted the meeting on multiple occasions. On 3/20/19 at 11:00 a.m., the surveyor met with a group of the facility residents. Seven residents attended the resident council meeting. The assistant activity director placed signs on both entrances to the dining room at 11:07 a.m. Immediately after placing the signs on the door and before the activity assistant left the room, two residents came through the main dining room entrance, walked to the end of the room, and went to the outside deck area. At 11:11 a.m., a resident entered the resident council meeting from the rehab side entrance, pedaled the wheelchair through the dining room and exited the main entrance to the dining room with the help of a second resident who opened the door for the resident to let out. At 11:32 a.m., a third resident entered from the outside rehab entrance and walked to the area where crafts were set up. At 11:48 a.m., a volunteer entered the dining room from the main entrance. The volunteer came in, walked to the kitchen door, took the resident sitting in the Geri chair out through the main entrance door, then came back, and apologized for coming in. The surveyor informed the administrator, the director of nursing, and the corporate registered nurse of the above concern in the end of the day meeting on 3/20/19 at 5:40 p.m. No further information was provided prior to the exit conference.

**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 inform the resident representative of a change in condition for 1 of 26 residents (Resident #160). The findings included: The facility staff failed to inform Resident #160's responsible party of a new order for an antibiotic. The clinical record of Resident #160 was reviewed 3/21/19. Resident #160 was admitted to the facility 12/18/18 and readmitted [DATE] with diagnoses that included but not limited to cerebral infarction, hemiplegia following cerebral infarction affecting left non-dominant side, ST elevation, cardiomegaly, hypertension, dysphagia, hyperlipidemia, anxiety, obstructive and reflux uropathy, acute upper respiratory infection, and embolism and thrombosis of arteries of lower extremities. Resident #160's 30 day minimum data set (MDS) with an assessment reference date (ARD) of 2/5/19 assessed the resident with short term memory problems, long term memory problems, and moderately impaired cognitive skills for decision making-decisions poor; needs cues and supervision. Resident #160 had orders dated 1/10/19 for a UA (urinalysis) w (with) culture/sensitivity dx (diagnosis) hematuria. The surveyor located two results of the urine culture-one found in Resident #160's clinical record and one found in Resident #46's clinical record. The results found in Resident #46's record had an order written by the nurse practitioner (NP) for Cipro 500 mg (milligrams) q12 (every) 12 x 5 days and was dated 1-14-19. The culture result found in Resident #160's laboratory section read No new orders-NP signature and dated 1-15-18 (?19). The surveyor reviewed the 1/14/19 through 1/15/19 departmental notes and found no documentation the resident's responsible party was informed of the medication order. The surveyor informed the director of nursing of the above concern on 3/21/19 at 10:19 a.m. The surveyor requested the facility policy on change of condition/notification on 3/21/19. Asked if staff are responsible for notifying the resident's representative about medication changes, the director of nursing stated yes. The policy titled Change in a Resident's Condition or Status read in part 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when b. There is a significant change in the resident's physical, mental, or psychosocial status. No further information was provided prior to the exit conference on 3/21/19.

**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 follow professional standards of practice for the transcription of physician orders involving medications for 1 of 26 residents (Resident #160). The findings included: The facility staff incorrectly filed the results of Resident #160's laboratory test on Resident #46's clinical record. The laboratory test had physician orders for antibiotics for Resident #160. The physician orders were never implemented for Resident #160 because the facility staff filed the laboratory test results with orders in the wrong record. The 1/14/19 urine culture results had been noted by licensed practical nurse #1 (L.P.N. #1). L.P.N. #1 failed to write a telephone order for Resident #160's antibiotic. The clinical record of Resident #160 was reviewed 3/21/19. Resident #160 was admitted to the facility 12/18/18 and readmitted [DATE] with diagnoses that included but not limited to cerebral infarction, hemiplegia following cerebral infarction affecting left non-dominant side, ST elevation, cardiomegaly, hypertension, dysphagia, hyperlipidemia, anxiety, obstructive and reflux uropathy, acute upper respiratory infection, and embolism and thrombosis of arteries of lower extremities. Resident #160's 30 day minimum data set (MDS) with an assessment reference date (ARD) of 2/5/19 assessed the resident with short term memory problems, long term memory problems, and moderately impaired cognitive skills for decision making-decisions poor; needs cues and supervision. Resident #160 had orders dated 1/10/19 for a UA (urinalysis) w (with) culture/sensitivity dx (diagnosis) hematuria. The surveyor located two results of the urine culture-one found in Resident #160's clinical record and one found in Resident #46's clinical record. The results found in Resident #46's record had an order written by the nurse practitioner (NP) for Cipro 500 mg (milligrams) q12 (every) x 5 days, dated 1-14-19 and noted by L.P.N. #1. The culture result found in Resident #160's laboratory section read No new orders-NP signature and dated 1-15-18 (?19). The surveyor was unable to locate a telephone order for the Cipro 500 mg q12 h x 5 days in Resident #160's clinical record. The surveyor informed the director of nursing of the above concern on 3/21/19 at 10:19 a.m. The surveyor requested the facility standard of practice for the transcription of physician orders and the policy on documentation. The DON was asked if the order found on the urine culture result should be transcribed to a telephone order and the DON stated yes. The surveyor interviewed the family nurse practitioner (FNP) on 3/21/19 at 1:00 p.m. The FNP stated she was never made aware that Resident #160 did not receive the ordered antibiotic. You assume the residents get the medications that I prescribe. The FNP was asked about the medication orders. After reviewing the lab results, the FNP stated she wanted the resident to have the Cipro. The facility policy titled Medication and Treatment Orders read, 1.Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 3. Drugs and biologicals must be recorded on the Physician's Order Sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis. 4. All drugs and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order. The facility policy titled Charting and Documentation read in part 3. Documentation in the medical record will be objective, complete, and accurate. No further information was provided prior to the exit conference on 3/21/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, the facility staff failed to follow physician orders for 2 of 26 Residents, Resident's #30 and #160. The findings included: 1. For Resident #30, the facility staff failed to administer the medications atorvastatin (liptor) and carvedilol (coreg) as ordered by the physician. The clinical record review revealed that Resident #30 had been re-admitted to the facility 12/28/18. Diagnoses included, but were not limited to, weakness, atrial fibrillation, hypertension, chronic obstructive pulmonary disease, hypothyroidism, and gastro-esophageal reflux disease. Section C (cognitive patterns) of the Residents annual MDS (minimum data set) assessment with an ARD (assessment reference date) of 01/17/19 included a BIMS (brief interview for mental status) summary score of 11 out of a possible 15 points. A review of the Residents eMARs (electronic medication administration records) revealed that the facility nursing staff had documented that they had not administered the Residents atorvastatin 40 mg or the Residents carvedilol 3.125 mg on 03/01/19, as the medications were not available. A review of the facility stat box/emergency supply list revealed that the medications would have been available in the stat box/emergency supply for administration. The facility policy/procedure titled Medication Shortages/Unavailable Medications read in part, Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy .If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for an emergency delivery . The Residents CCP (comprehensive care plan) included the problem area at risk for complications related to hyperlipidemia approaches included, but were not limited to, medicate as ordered. The administrative staff were notified of the issue regarding the Resident not receiving their physician ordered medications on 03/20/19 at 3:55 PM. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. The facility staff incorrectly filed the results of Resident #160's laboratory test on Resident #46's clinical record. The laboratory test had physician orders for antibiotics for Resident #160. The physician orders were never implemented for Resident #160 because the facility staff filed the laboratory test results with orders in the wrong record. The 1/14/19 urine culture results had been noted by licensed practical nurse #1 (L.P.N. #1). L.P.N. #1 failed to write a telephone order for Resident #160's antibiotic-Cipro 500 mg (milligrams) q (every) 12 hours x 5 days. Resident #160 did not receive Cipro for a urinary tract infection. The clinical record of Resident #160 was reviewed 3/21/19. Resident #160 was admitted to the facility 12/18/18 and readmitted [DATE] with diagnoses that included but not limited to urinary tract infection, cerebral infarction, hemiplegia following cerebral infarction affecting left non-dominant side, ST elevation, cardiomegaly, hypertension, dysphagia, hyperlipidemia, anxiety, obstructive and reflux uropathy, acute upper respiratory infection, and embolism and thrombosis of arteries of lower extremities. Resident #160's 30 day minimum data set (MDS) with an assessment reference date (ARD) of 2/5/19 assessed the resident with short term memory problems, long term memory problems, and moderately impaired cognitive skills for decision making-decisions poor; needs cues and supervision. Resident #160 had orders dated 1/10/19 for a UA (urinalysis) w (with) culture/sensitivity dx (diagnosis) hematuria. The surveyor located two results of the urine culture-one found in Resident #160's clinical record and one found in Resident #46's clinical record. The results found in Resident #46's record had an order written by the nurse practitioner (NP) for Cipro 500 mg (milligrams) q12 (every) x 5 days, dated 1-14-19 and noted by L.P.N. #1. The culture result found in Resident #160's laboratory section read No new orders-NP signature and dated 1-15-18 (?19). The surveyor was unable to locate a telephone order for the Cipro 500 mg q12 h x 5 days in Resident #160's clinical record. The surveyor informed the director of nursing of the above concern on 3/21/19 at 10:19 a.m. The surveyor requested the facility standard of practice for the transcription of physician orders and the policy on documentation. The DON was asked if the order found on the urine culture result should be transcribed to a telephone order and the DON stated yes. The surveyor interviewed the family nurse practitioner (FNP) on 3/21/19 at 1:00 p.m. The FNP stated she was never made aware that Resident #160 did not receive the ordered antibiotic. You assume the residents get the medications that I prescribe. The FNP was asked about the medication orders. After reviewing the lab results, the FNP stated she wanted the resident to have the Cipro. The facility policy titled Medication and Treatment Orders read, 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 3. Drugs and biologicals must be recorded on the Physician's Order Sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis. 4. All drugs and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order. The facility policy titled Charting and Documentation read in part 3. Documentation in the medical record will be objective, complete, and accurate. No further information was provided prior to the exit conference on 3/21/19.

Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5%. There were 2 errors in 25 opportunities for a medication error rate of 8%. These medication errors effected Resident #29 and #46. The findings included: 1. For Resident #29, the facility staff failed to administer the correct dosage of the Resident sertraline. The clinical record review revealed that Resident #29 had been re-admitted to the facility 04/11/18. Diagnoses included, but were not limited to, major depressive disorder, dementia, atrial fibrillation, peripheral vascular disease, and gastroesophageal reflux disease. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 01/15/19 included a BIMS (brief interview for mental status) summary score of 7 out of a possible 15 points. On 03/20/19 beginning at approximately 7:53 a.m., the surveyor observed LPN (licensed practical nurse) #2 prepare and administer Resident #29's morning medications. After placing the medication, sertraline 50 mg into the Residents medication cup LPN #2 handed the medication card to the surveyor for the surveyor to review. The surveyor then recorded the preprinted information on the medication card label. After the medication pass and pour observation the surveyor reconciled the Residents medications. The clinical record included orders for sertraline 25 mg give one tab po (by mouth) daily. The Resident was previously on 50 mg of sertraline it had been changed on 01/25/19 to 25 mg. On 03/20/19 at 9:21 a.m., the surveyor and LPN #2 checked the medication cart for this medication. LPN #2 pulled 2 medication cards from the medication cart sertraline 25 mg (current dose) and sertraline 50 mg (previous dose). LPN #2 verbalized that she could not be sure but thought she had administered the 25 mg and handed the surveyor the wrong card. The administrator and nurse consultant were notified of the issue regarding the Residents sertraline on 03/20/19 at 9:49 a.m. No further information regarding this issue was provided to the survey team prior to the exit conference, 2. For Resident #46, the facility staff failed to administer the Residents zantac. The clinical record review revealed that Resident #46 had been re-admitted to the facility 09/21/07. Diagnoses included, but were not limited to, non-traumatic subdural hematoma, gastroesophageal reflux disease, hypertension, and diabetes. Section C (cognitive patterns) of the Residents significant change MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/06/19 had been coded 1/1/2 to indicate the Resident had problems with long and short term memory and was moderately impaired in cognitive skills for daily decision making. On 03/20/19 at 7:38 a.m., the surveyor observed LPN (licensed practical nurse) #1 prepare and administer Resident #46's morning medications. These medications included atenolol, enalapril, januvia, valsartan, hydrochlorothiazide, carbamazepine, senna, loratadine, and lactulose. When reviewing the Residents physician orders it was noted that the Resident also had orders for multivitamin, artificial tear eye drops, sodium chloride, and zantac. The surveyor did not see these medications administered. On 03/20/19 at 9:25 a.m., the surveyor interviewed LPN #1 regarding the missed medications. LPN #1 stated she had went back and administered everything but the zantac. LPN #1 stated, I don't remember the zantac. After reviewing the EHR (electronic health record) LPN #1 stated I missed the zantac. The administrator and nurse consultant were notified of the issue regarding the Residents zantac on 03/20/19 at 9:49 a.m. No further information regarding this issue was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility document review, the facility staff failed to ensure that medications were properly stored on 1 of 2 units, unit C. The findings included: 1. The facility staff failed to secure the medication omeprazole. LPN (licensed practical nurse) #2 left a bottle of omeprazole out of her view and on the top of the medication cart. On 03/20/19 at 7:53 a.m., during a medication pass and pour observation LPN #2 did not have a Residents stock medication esomeprazole for administration. After looking through the medication cart LPN #2 stated she would have to obtain the medication from the medication room. LPN #2 went to the medication room and obtained a bottle of omeprazole. Upon returning to the medication cart LPN #2 stated she did not know if this was the correct medication and stated she was going to check a drug book. LPN #2 left the bottle of omeprazole on top of the medication cart and went down the hall leaving her cart with the medication on top and out of her view. LPN #2 then returned to her cart with another bottle of medication for administration. The surveyor observed 3 different staff members in the hallway during the period that LPN #2 was out of the vicinity of the medication cart. On 03/20/19 at 9:21 a.m., LPN #2 was asked about leaving the medication unattended and out of their view, LPN #2 stated she had gotten nervous. The administrator and nurse consultant were notified of the issue regarding the medication being left on top of the medication cart on 03/20/19 at 9:49 a.m. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. The facility staff failed to store medications in a secured location in Resident #46's room. The clinical record of Resident #46 was reviewed 3/19/19 through 3/21/19. Resident #46 was admitted to the facility 6/27/17 and readmitted [DATE] with diagnoses that included non-displaced fracture of lateral malleolus right fibula, non-traumatic subdural hemorrhage, constipation, gastroesophageal reflux disease, hypertension, Vitamin deficiency, convulsions, benign prostatic hyperplasia, diabetes mellitus type 2, chronic hepatitis, dry eye syndrome, and anemia. Resident #46's significant change in minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/6/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. On 3/19/19 at 5:00 p.m., the surveyor entered the room of Resident #46 to interview the resident. Upon entrance to the room, the surveyor observed a syringe labeled Normal Saline 3cc (cubic centimeters) IV (intravenous). The syringe was in a plastic protective sleeve. The surveyor did not observe a needle on the syringe. The surveyor informed licensed practical nurse #2 of the above observation and gave the syringe to her. L.P.N. #2 stated Resident #46's roommate was transferred to the hospital this morning and the syringe was on hand for that resident. Resident #46 did not have March 2019 physician orders for Normal Saline 3 cc IV. The surveyor informed the administrator, the director of nursing and the corporate registered nurse on 3/19/19 at 5:40 p.m. and requested the facility policy on medication storage. The facility policy titled Storage of Medications read in part 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. No further information was provided prior to the exit conference on 3/21/19.

**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 ensure a complete and accurate clinical record for 2 of 26 residents (Resident #46 and Resident #94). The findings included: 1. The facility staff incorrectly filed the results of Resident #160's laboratory test on Resident #46's clinical record. The 1/14/19 urine culture results had physician orders for antibiotics for Resident #160 and had been noted by licensed practical nurse #1 (L.P.N. #1). The clinical record of Resident #46 was reviewed 3/19/19 through 3/21/19. Resident #46 was admitted to the facility 6/27/17 and readmitted [DATE] with diagnoses that included non-displaced fracture of lateral malleolus right fibula, non-traumatic subdural hemorrhage, constipation, gastroesophageal reflux disease, hypertension, Vitamin deficiency, convulsions, benign prostatic hyperplasia, diabetes mellitus type 2, chronic hepatitis, dry eye syndrome, and anemia. Resident #46's significant change in minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/6/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. The surveyor reviewed Resident #46's laboratory section on 3/21/19. During the review, the surveyor found the results of a urine culture dated 1/12/19 0838 for Resident #160. The urine culture results also had specific orders for an antibiotic-Cipro 500 mg (milligrams) q (every) 12 x 5 days-dated 1/14/19 written by the family nurse practitioner and noted by licensed practical nurse #1. Resident #46 did not have an order for a urine culture and sensitivity in January 2019. The clinical record of Resident #160 was reviewed 3/21/19. Resident #160 was admitted to the facility 12/18/18 and readmitted [DATE] with diagnoses that included but not limited to cerebral infarction, hemiplegia following cerebral infarction affecting left non-dominant side, ST elevation, cardiomegaly, hypertension, dysphagia, hyperlipidemia, anxiety, obstructive and reflux uropathy, acute upper respiratory infection, and embolism and thrombosis of arteries of lower extremities. Resident #160's 30 day minimum data set (MDS) with an assessment reference date (ARD) of 2/5/19 assessed the resident with short term memory problems, long term memory problems, and moderately impaired cognitive skills for decision making-decisions poor; needs cues and supervision. Resident #160 had orders dated 1/10/19 for a UA (urinalysis) w (with) culture/sensitivity dx (diagnosis) hematuria. The surveyor informed the director of nursing (DON) of the above concern on 3/21/19 at 10:19 a.m. The surveyor asked the director of nursing who was responsible for filing laboratory results in the medical record. The DON stated (other #1) and the nurses look at the laboratory results. The surveyor requested the facility policy on charting. The facility policy titled Charting and Documentation read in part 3. Documentation in the medical record will be objective, complete, and accurate. No further information was provided prior to the exit conference on 3/21/19. 2. The facility staff failed to ensure Resident #94's DNR (do not resuscitate) was located in the clinical record. The clinical record of Resident #94 was reviewed 3/19/19 through 3/21/19. Resident #94 was admitted to the facility 12/23/15 and readmitted [DATE] with diagnoses that included but not limited to acute on chronic combined systolic and diastolic heart failure, atherosclerotic heart disease, atrial fibrillation, hemiplegia following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus, and hypertension. Resident #94's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/5/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #94's March 2019 physician's orders read Do Not Resuscitate (DNR) start date 1/15/18. The surveyor reviewed the clinical record and was unable to locate the DNR. The surveyor informed the assistant director of nursing of the above concern on 3/21/19 at 11:49 a.m. The assistant director of nursing (ADON) informed the surveyor that she was not able to locate the DDNR (durable do not resuscitate) in the clinical record. The ADON stated the hospital was called and the hospital faxed a copy of the DDNR to the facility. The facility policy titled Charting and Documentation read in part 3. Documentation in the medical record will be objective, complete, and accurate. No further information was provided prior to the exit conference on 3/21/19.

Based on observation, Resident interview, and staff interview, the facility staff failed to maintain a safe and hazard free environment. The findings included: The deck outside the back of the facility was observed with rotted and warped boards. On 3/19/19 at 3:00 p.m., during an interview with Resident #108, outside the dining area, this Resident expressed a concern over not being able to use the outside deck, as the deck was rotten. The surveyor immediately checked the deck area. The facility had placed a park bench across the entryway to this deck. However, the surveyor was able to push the park bench out of the way and gain access to the deck. The surveyor checked the deck and identified two boards that were rotten, boards that were warped, and boards that were uneven. The surveyor asked the facility administrator, maintenance director, and nurse consultant to accompany them to the outside deck. During this observation two decking boards were identified that were rotten, spongy, and moveable. Other boards were identified that were warped and uneven. The facility administrator and maintenance director stated they would place a barrier across the entryway. The nurse consultant stated she would stay in the area until it was addressed. Two ambulatory Residents were observed in the vicinity and another Resident came out into the area during this observation period. The facility dietician was able to visualize the Residents outside from where she was sitting in the dining area. There was no staff present outside during the initial observation. On 3/19/19 at 3:51 p.m., the maintenance director verbalized to the survey team that the deck was 7 inches off the ground at the lowest point and 2 foot at the highest. When asked who had placed the park bench across the entranceway to the deck the facility identified this person as being the activity director. The facility administrator and maintenance director stated that they had blocked off the entryway by nailing boards across the entrance. The surveyor checked the area and observed the boards to be secure and in place. The administrator stated they would either replace all the boards or may just demolish the deck. The administrator and maintenance director stated the deck was inspected in October/November and a couple of boards had been replaced. The surveyor interviewed the activity assistant on 03/21/19 at 9:52 a.m., during this interview the activity assistant verbalized to the surveyor that the activity director was out of town and that the boy scouts had redone the deck but that the winter had been rough on the deck. The activity assistant also stated there was caution tape across the deck and she was not sure what had happened to it and she was unsure as to who had placed the park bench across the entrance. The activity assistant then added I had never seen a Resident out there before without staff. They never go outside without supervision. No further information regarding this issue was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility staff failed to provide the hospital with the required paper work concerning Resident #110's medical information. Resident #110 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, heart failure, high blood pressure, pneumonia and dementia. On the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE], the resident was coded as having short term and long-term memory problems and being moderately impaired in daily decision-making. Resident #110 was also coded as requiring extensive assistance of 2 staff members for dressing, personal hygiene and bathing. During the closed record review on [DATE], the surveyor noted that Resident #110 had been transferred to the hospital on [DATE]. The surveyor could not find any documentation that the facility provided to the hospital concerning the resident's medical condition and/or list of medications. Since the resident expired at the hospital on [DATE], the facility was not required to offer the bed hold policy in writing to the resident's representative. The director of nursing and social worker was notified of the above documented findings on [DATE] at 3:55 pm. The social worker stated, We didn't send any paperwork with the resident to the hospital when he was transferred. No further information was provided to the surveyor prior to the exit conference on [DATE]. Based on staff interview, facility document review and clinical record review, the facility staff failed to provide the receiving provider with information that included the contact information of the practitioner responsible for the care of the resident, Resident representative information including contact information, Advance Directive information, all special instructions or precautions for ongoing care, as appropriate, comprehensive care plan goals, and all other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care for 5 of 26 residents (Resident #2, Resident #44, Resident #46, Resident #72, and Resident #110). The findings included: 1. The facility staff failed to provide the receiving provider information for care of Resident #2-the name of the practitioner at the nursing home, the resident representative contact information, advanced directive information, instructions for ongoing care, the comprehensive care plan goals, and the discharge summary. The facility staff failed to document in the clinical record what information was provided to the receiving provider for Resident #2. The clinical record of Resident #2 was reviewed [DATE] through [DATE]. Resident #2 was admitted to the facility [DATE] and readmitted [DATE]. Diagnoses included but not limited to acute cellulitis right foot with infected ulceration of right great toe, probable peripheral vascular disease, diabetes mellitus type II, atrial fibrillation, esophageal reflux, hypertension, dysphagia, convulsions, anxiety, dementia without behavioral disturbances, hyperlipidemia, anemia, Alzheimer's disease, and seizure disorder. Resident #2's quarterly minimum data set (MDS) with an assessment reference date (ARD) of [DATE] assessed the resident with short-term memory problems, long-term memory problems, and severely impaired cognitive skills for daily decision-making. The departmental note dated [DATE] at 2:34 p.m. read LE (late entry) from 0900: Rescue 33 here to transport res (resident) to (name of hospital omitted). Informed by night shift nurse that MD (medical doctor) wants res (resident) sent to (name of hospital omitted) for direct admit due to cellulitis of Rt. (right) leg. Called for transport and hospital was notified.__ The surveyor was unable to locate information sent to the receiving provider from the facility. The surveyor spoke with the corporate registered nurse on [DATE] at 10:24 a.m. what information was sent to the hospital when residents are transferred. The corporate RN stated the social worker completes that. The surveyor interviewed the social worker. The social worker was asked what information was sent with the resident when the resident was admitted to the hospital on [DATE]. The social worker provided the surveyor a form titled Heritage Hall [NAME] Discharge/Transfer Form. The form read, I understand that I am being discharged from Heritage Hall [NAME]. I understand that the reason for the transfer is recommendation of physician for direct admission to hospital. Resident in (name of hospital omitted) [DATE]. Copy mailed to RP (responsible party) on [DATE]. The social worker stated he provided no information to the hospital when Resident #2 was transferred [DATE]. Bed hold acceptance/declination located at the bottom of the page was blank. The corporate RN informed the surveyor [DATE] at 10:30 a.m. a transfer/discharge report was not done. The surveyor requested the facility policy on transfers/discharges. The facility policy titled Transfer or Discharge Notice read in part 3. The resident and/or resident representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge b. The effective date of the transfer or discharge c. The location to which the information is being transferred or discharged d. A statement of the resident's rights to appeal the transfer or discharge, including; (1) the name, address, email and telephone number of the entity which receives such requests; (2) information about how to obtain, complete and submit an appeal form; and (3) how to get assistance completing the appeal process; e. The facility bed-hold policy; The surveyor informed the administrator, the director of nursing, and the corporate registered nurse of the above information on [DATE]. No further information was provided prior to the exit conference on [DATE]. 2. The facility staff failed to provide the receiving provider with contact information of the practitioner caring for the resident, the resident representative contact information, advanced directive information, any special instructions for ongoing care, the comprehensive care plan goals and a copy of the discharge summary and failed to document what information was provided to the receiving provider for Resident #44. The clinical record of Resident #44 was reviewed [DATE] through [DATE]. Resident #44 was admitted to the facility [DATE], readmitted [DATE] and [DATE] with diagnoses that included but not limited to hemiplegia following cerebral infarction affecting left non-dominant side, hepatomegaly, dysphagia, gastro-esophageal reflux disease, arthopathy, diabetic ketoacidosis with new onset type 1 diabetes, sepsis due to multifocal pneumonia, acute renal failure secondary to volume depletion, hypertension, hyperlipidemia, urinary tract infection with methicillin sensitive Staph aureus, hyponatremia, and history of seizure disorder. Resident #44's 30-day minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] assessed the resident with a brief interview for mental status as 15/15. The clinical record revealed a departmental note dated [DATE] that read in part Resident #44 vomited a large amount of brown substance. Call to nurse practitioner who ordered the resident to be transferred to the hospital. The order dated [DATE] read Transfer to ____ (name of hospital) ER (emergency room) for eval (evaluation) of congestion, N/V (nausea/vomiting) x 2 days. BP (blood pressure) 130/76, T (temperature) 97.7, P (pulse) 110, 94%. The surveyor was unable to locate documentation in the clinical record of information provided to the receiving provider when Resident #44 was transferred to the emergency room. The surveyor interviewed the director of nursing on [DATE] at 11:29 a.m. of the above concern when Resident #44 was transferred to the emergency room. The surveyor requested Resident #44's face sheet, MDS, care plan, [DATE] departmental notes, [DATE] departmental notes and the facility policy for transfer/discharges. The facility policy titled Transfer or Discharge Notice read in part 3. The resident and/or resident representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge b. The effective date of the transfer or discharge c. The location to which the information is being transferred or discharged d. A statement of the resident's rights to appeal the transfer or discharge, including; (1) the name, address, email and telephone number of the entity which receives such requests; (2) information about how to obtain, complete and submit an appeal form; and (3) how to get assistance completing the appeal process; e. The facility bed-hold policy; No further information was provided prior to the exit conference on [DATE]. 3. The facility staff failed to provide the receiving provider information for care of Resident #46-the name of the practitioner at the nursing home, the resident representative contact information, advanced directive information, instructions for ongoing care, the comprehensive care plan goals, and the discharge summary. The facility staff failed to document in the clinical record what information was provided to the receiving provider for Resident #46. The clinical record of Resident #46 was reviewed [DATE] through [DATE]. Resident #46 was admitted to the facility [DATE] and readmitted [DATE] with diagnoses that included non-displaced fracture of lateral malleolus right fibula, non-traumatic subdural hemorrhage, constipation, gastroesophageal reflux disease, hypertension, Vitamin deficiency, convulsions, benign prostatic hyperplasia, diabetes mellitus type 2, chronic hepatitis, dry eye syndrome, and anemia. Resident #46's significant change in minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] assessed the resident with a BIMS (brief interview for mental status) as 15/15. The surveyor interviewed Resident #46 on [DATE]. When asked if the resident had any falls, Resident #46 raised his right leg, pointed to his ankle, and stated he slipped in the snow and broke his ankle. The surveyor reviewed the departmental note dated [DATE] at 12:00 p.m. The note read LE (late entry) from 0900: Res (resident) came [NAME] (sic) down hall to nurse and stated I was walking outside and slipped and hurt my ankle but I'm okay. Assessment reveals swollen area to RT (right) ankle. Instructed res to elevate leg and FNP (family nurse practitioner) was notified and gave order for x-ray. Instructed rest to not be outside walking due to inclement weather. FNP notified and res is own RP (responsible party). The [DATE] 6:06 p.m. departmental note read Late entry for 1700 (5:00 p.m.) FNP notified of x-rays and gave orders to send resident to ER (emergency room) for further eval (evaluation). @ (at) 1712 (5:12 p.m.) Rescue 33 ambulance services here @ this time to transport resident to (name of hospital ER) omitted. ER staff given report. Resident clean and dry upon departure and no visible signs of distress noted. The surveyor was unable to locate documentation in the clinical record of information sent to the hospital when Resident #46 was transferred there on [DATE]. The surveyor informed the corporate registered nurse of the above concern on [DATE] at 2:01 p.m. and asked where the information was located when the resident was sent to the emergency room. The corporate RN stated the transfer forms had not been started yet. The surveyor requested the facility policy on transfers/discharges. The facility policy titled Transfer or Discharge Notice read in part 3. The resident and/or resident representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge b. The effective date of the transfer or discharge c. The location to which the information is being transferred or discharged d. A statement of the resident's rights to appeal the transfer or discharge, including; (1) the name, address, email and telephone number of the entity which receives such requests; (2) information about how to obtain, complete and submit an appeal form; and (3) how to get assistance completing the appeal process; e. The facility bed-hold policy; No further information was provided prior to the exit conference on [DATE]. 4. The facility staff failed to provide the receiving provider information for care of Resident #72-the name of the practitioner at the nursing home, the resident representative contact information, advanced directive information, instructions for ongoing care, the comprehensive care plan goals, and the discharge summary. The facility staff failed to document in the clinical record what information was provided to the receiving provider for Resident #72. The clinical record of Resident #72 was reviewed [DATE] through [DATE]. Resident #72 was admitted to the facility [DATE] and readmitted [DATE] with diagnoses that included but not limited to above the knee amputation, acute diastolic heart failure, chronic obstructive pulmonary disease, insomnia, psoriasis, gastro-esophageal reflux disease, hypothyroidism, Vitamin deficiency, anemia, muscle weakness, obesity, hypertension, varicose veins of left lower extremity, type 2 diabetes mellitus, and mononeuropathy. Resident #72's significant change in minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] assessed the resident with a BIMS (brief interview for mental status) as 15/15. The clinical record revealed a Discharge summary dated [DATE]. The surveyor reviewed the departmental notes for [DATE]. The departmental note dated [DATE] at 8:23 a.m. read Upon administering res (resident) am (morning) medication, res lethargic, opens eyes a few times and goes back to sleep. O2 (oxygen) 86%. V/S (vital signs): BP (blood pressure) 157/105, P (pulse) 86, R (respirations) 20, T (temperature) 98.5. Edema noted to face/eyes and hands. Notified FNP (family nurse practitioner). Stated to send res to (name of hospital emergency room omitted) for eval (evaluation). Called 911. Upon arrival of Rescue 33, res nonresponsive. Res LOA (leave of absent) to hospital at 0525, res clean and dry upon departure. Notified ER and gave report given. Res is own RP (responsible person). Attempted to notify 2nd contact without success. Notified niece-she stated her mother is out of town for a few days, to contact her if needed anything. The departmental note dated [DATE] at 9:58 a.m. read Resident admitted to hospital ICU (intensive care unit) with dx (diagnosis) of acute hypoxemia and resp (respiratory) distress. The surveyor was unable to locate transfer/discharge form or documentation of pertinent information sent with Resident #72 when transported to the hospital on [DATE]. The surveyor informed the administrator, director of nursing, and the corporate registered nurse of the above concern on [DATE] at 4:18 p.m. The surveyor requested the face sheet, MDS, care plan, September progress notes and the policy for transfers/discharges. The facility policy titled Transfer or Discharge Notice read in part 3. The resident and/or resident representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge b. The effective date of the transfer or discharge c. The location to which the information is being transferred or discharged d. A statement of the resident's rights to appeal the transfer or discharge, including; (1) the name, address, email and telephone number of the entity which receives such requests; (2) information about how to obtain, complete and submit an appeal form; and (3) how to get assistance completing the appeal process; e. The facility bed-hold policy; No further information was provided prior to the exit conference on [DATE].

**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 provide written notice of transfer/discharge to include the effective date of transfer or discharge; the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman and documentation in the medical record that the notice was sent to the Ombudsman for 4 of 26 residents (Resident #2, Resident #44, Resident #46, and Resident #72). The findings included: 1. The facility staff failed to provide written notice of transfer to the resident and the resident representative when the resident was transferred to the hospital, failed to provide a statement of the resident's appeal rights, failed to provide information on how to obtain an appeal form and assistance in completion of such and failed to document in the medical record ombudsman notification when Resident #2 was transferred to the hospital. The clinical record of Resident #2 was reviewed 3/19/19 through 3/21/19. Resident #2 was admitted to the facility 10/11/12 and readmitted [DATE]. Diagnoses included but not limited to acute cellulitis right foot with infected ulceration of right great toe, probable peripheral vascular disease, diabetes mellitus type II, atrial fibrillation, esophageal reflux, hypertension, dysphagia, convulsions, anxiety, dementia without behavioral disturbances, hyperlipidemia, anemia, Alzheimer's disease, and seizure disorder. Resident #2's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 12/11/18 assessed the resident with short-term memory problems, long-term memory problems, and severely impaired cognitive skills for daily decision-making. The departmental note dated 2/26/19 at 2:34 p.m. read LE (late entry) from 0900: Rescue 33 here to transport res (resident) to (name of hospital omitted). Informed by night shift nurse that MD (medical doctor) wants res (resident) sent to (name of hospital omitted) for direct admit due to cellulitis of Rt. (right) leg. Called for transport and hospital was notified. The surveyor was unable to locate the above information in Resident #2's clinical record. The surveyor spoke with the corporate registered nurse on 3/20/19 at 10:24 a.m. what information was sent to the hospital when residents are transferred. The corporate RN stated the social worker completes that. The surveyor interviewed the social worker. The social worker was asked what information was sent with the resident when the resident was admitted to the hospital on [DATE]. The social worker provided the surveyor a form titled Heritage Hall [NAME] Discharge/Transfer Form. The form read, I understand that I am being discharged from Heritage Hall [NAME]. I understand that the reason for the transfer is recommendation of physician for direct admission to hospital. Resident in (name of hospital omitted) 2/27/19. Copy mailed to RP (responsible party) on 2/28/19. The social worker stated he provided no information to the hospital when Resident #2 was transferred 2/26/19. Bed hold acceptance/declination located at the bottom of the page was blank. The corporate RN informed the surveyor 3/20/19 at 10:30 a.m. a transfer/discharge report was not done. The surveyor requested the facility policy on transfers/discharges. The facility policy titled Transfer or Discharge Notice read in part 3. The resident and/or resident representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge b. The effective date of the transfer or discharge c. The location to which the information is being transferred or discharged d. A statement of the resident's rights to appeal the transfer or discharge, including; (1) the name, address, email and telephone number of the entity which receives such requests; (2) information about how to obtain, complete and submit an appeal form; and (3) how to get assistance completing the appeal process; e. The facility bed-hold policy; The surveyor informed the administrator, the director of nursing, and the corporate registered nurse of the above information on 3/21/19. No further information was provided prior to the exit conference on 3/21/19. 2. The facility staff failed to provide written notice of transfer to the resident and the resident representative when the resident was transferred to the hospital, failed to provide a statement of the resident's appeal rights, failed to provide information on how to obtain an appeal form and assistance in completion of such and failed to document in the medical record ombudsman notification when Resident #44 was transferred to the hospital. The clinical record of Resident #44 was reviewed 3/19/19 through 3/21/19. Resident #44 was admitted to the facility 9/23/09, readmitted [DATE] and 1/5/19 with diagnoses that included but not limited to hemiplegia following cerebral infarction affecting left non-dominant side, hepatomegaly, dysphagia, gastro-esophageal reflux disease, arthopathy, diabetic ketoacidosis with new onset type 1 diabetes, sepsis due to multifocal pneumonia, acute renal failure secondary to volume depletion, hypertension, hyperlipidemia, urinary tract infection with methicillin sensitive Staph aureus, hyponatremia, and history of seizure disorder. Resident #44's 30-day minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/3/19 assessed the resident with a brief interview for mental status as 15/15. The clinical record revealed a departmental note dated 12/31/18 that read in part resident #44 vomited a large amount of brown substance. Call to nurse practitioner who ordered the resident to be transferred to the hospital. The order dated 12/31/18 read Transfer to ____ (name of hospital) ER (emergency room) for eval (evaluation) of congestion, N/V (nausea/vomiting) x 2 days. BP (blood pressure) 130/76, T (temperature) 97.7, P (pulse) 110, 94%. The surveyor was unable to locate documentation in the clinical record of the above information when Resident #44 was transferred to the emergency room. The surveyor interviewed the director of nursing on 3/21/19 at 11:29 a.m. of the above concern when Resident #44 was transferred to the emergency room. The surveyor requested Resident #44's face sheet, MDS, care plan, December 2018 departmental notes, January departmental notes and the facility policy for transfer/discharges. The facility policy titled Transfer or Discharge Notice read in part 3. The resident and/or resident representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge b. The effective date of the transfer or discharge c. The location to which the information is being transferred or discharged d. A statement of the resident's rights to appeal the transfer or discharge, including; (1) the name, address, email and telephone number of the entity which receives such requests; (2) information about how to obtain, complete and submit an appeal form; and (3) how to get assistance completing the appeal process; e. The facility bed-hold policy; No further information was provided prior to the exit conference on 3/21/19. 3. The facility staff failed to provide written notice of transfer to the resident and the resident representative when the resident was transferred to the hospital, failed to provide a statement of the resident's appeal rights, failed to provide information on how to obtain an appeal form and assistance in completion of such and failed to document in the medical record ombudsman notification when Resident #46 was transferred to the hospital. The clinical record of Resident #46 was reviewed 3/19/19 through 3/21/19. Resident #46 was admitted to the facility 6/27/17 and readmitted [DATE] with diagnoses that included non-displaced fracture of lateral malleolus right fibula, non-traumatic subdural hemorrhage, constipation, gastroesophageal reflux disease, hypertension, Vitamin deficiency, convulsions, benign prostatic hyperplasia, diabetes mellitus type 2, chronic hepatitis, dry eye syndrome, and anemia. Resident #46's significant change in minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/6/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. The surveyor interviewed Resident #46 on 3/20/19. When asked if the resident had any falls, Resident #46 raised his right leg, pointed to his ankle, and stated he slipped in the snow and broke his ankle. The surveyor reviewed the departmental note dated 1/24/19 at 12:00 p.m. The note read LE (late entry) from 0900: Res (resident) came [NAME] (sic) down hall to nurse and stated I was walking outside and slipped and hurt my ankle but I'm okay. Assessment reveals swollen area to RT (right) ankle. Instructed res to elevate leg and FNP (family nurse practitioner) was notified and gave order for x-ray. Instructed rest to not be outside walking due to inclement weather. FNP notified and res is own RP (responsible party). The 1/24/19 6:06 p.m. departmental note read Late entry for 1700 (5:00 p.m.) FNP notified of x-rays and gave orders to send resident to ER (emergency room) for further eval (evaluation). @ (at0 1712 (5:12 p.m.) Rescue 33 ambulance services here @ this time to transport resident to (name of hospital ER) omitted. ER staff given report. Resident clean and dry upon departure and no visible signs of distress noted. The surveyor was unable to locate documentation in the clinical record of the above information when Resident #46 was transferred there on 1/24/19. The surveyor informed the corporate registered nurse of the above concern on 3/20/19 at 2:01 p.m. and asked where the information was located when the resident was sent to the emergency room. The corporate RN stated the transfer forms had not been started yet. The surveyor requested the facility policy on transfers/discharges. The facility policy titled Transfer or Discharge Notice read in part 3. The resident and/or resident representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge b. The effective date of the transfer or discharge c. The location to which the information is being transferred or discharged d. A statement of the resident's rights to appeal the transfer or discharge, including; (1) the name, address, email and telephone number of the entity which receives such requests; (2) information about how to obtain, complete and submit an appeal form; and (3) how to get assistance completing the appeal process; e. The facility bed-hold policy; No further information was provided prior to the exit conference on 3/21/19. 4. The facility staff failed to provide written notice of transfer to the resident and the resident representative when the resident was transferred to the hospital, failed to provide a statement of the resident's appeal rights, failed to provide information on how to obtain an appeal form and assistance in completion of such and failed to document in the medical record ombudsman notification when Resident #72 was transferred to the hospital. The clinical record of Resident #72 was reviewed 3/19/19 through 3/21/19. Resident #72 was admitted to the facility 3/8/16 and readmitted [DATE] with diagnoses that included but not limited to above the knee amputation, acute diastolic heart failure, chronic obstructive pulmonary disease, insomnia, psoriasis, gastro-esophageal reflux disease, hypothyroidism, Vitamin deficiency, anemia, muscle weakness, obesity, hypertension, varicose veins of left lower extremity, type 2 diabetes mellitus, and mononeuropathy. Resident #72's significant change in minimum data set (MDS) assessment with an assessment reference date (ARD) of2/25/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. The clinical record revealed a Discharge summary dated [DATE]. The surveyor reviewed the departmental notes for September 2018. The departmental note dated 9/20/18 at 8:23 a.m. read Upon administering res (resident) am (morning) medication, res lethargic, opens eyes a few times and goes back to sleep. O2 (oxygen) 86%. V/S (vital signs): BP (blood pressure) 157/105, P (pulse) 86, R (respirations) 20, T (temperature) 98.5. Edema noted to face/eyes and hands. Notified FNP (family nurse practitioner). Stated to send res to (name of hospital emergency room omitted) for eval (evaluation). Called 911. Upon arrival of Rescue 33, res nonresponsive. Res LOA (leave of absent) to hospital at 0525, res clean and dry upon departure. Notified ER and gave report given. Res is own RP (responsible person). Attempted to notify 2nd contact without success. Notified niece-she stated her mother is out of town for a few days, to contact her if needed anything. The departmental note dated 9/20/18 at 9:58 a.m. read Resident admitted to hospital ICU (intensive care unit) with dx (diagnosis) of acute hypoxemia and resp (respiratory) distress. The surveyor was unable to locate transfer/discharge form or documentation of pertinent information when Resident #72 was transported to the hospital on 9/20/18. The surveyor informed the administrator, director of nursing, and the corporate registered nurse of the above concern on 3/20/19 at 4:18 p.m. The surveyor requested the face sheet, MDS, care plan, September progress notes and the policy for transfers/discharges. The facility policy titled Transfer or Discharge Notice read in part 3. The resident and/or resident representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge b. The effective date of the transfer or discharge c. The location to which the information is being transferred or discharged d. A statement of the resident's rights to appeal the transfer or discharge, including; (1) the name, address, email and telephone number of the entity which receives such requests; (2) information about how to obtain, complete and submit an appeal form; and (3) how to get assistance completing the appeal process; e. The facility bed-hold policy; No further information was provided prior to the exit conference on 3/21/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility staff failed to provide the bed hold policy in writing due to Resident #86 being transferred to emergency room. Resident #86 was originally admitted to the facility on [DATE] but was readmitted on [DATE]. On the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/1/19, coded the resident as having a BIMS (Brief Interview for Mental Status) score of 12 out of a possible score of 15. Resident #86 was also coded as requiring extensive assistance of 2 staff members for dressing, personal hygiene and bathing. The surveyor reviewed Resident #86's clinical record on 3/20/19 and 3/21/19. During this review, the surveyor noted that Resident #86 had been transferred to the hospital, on 3/8/19, to receive a blood transfusion. The surveyor could not find documentation in the clinical record of the bed hold policy being given to the resident and/or resident representative in written form. The surveyor requested and received the policy titled Transfer or Discharge Notice which read in part, .The resident and/or representative (sponsor) will be notified in writing of the following information .The facility bed hold policy . The surveyor notified the administrative team of the above documented findings on 3/20/19 at 3:55 pm in the conference room. On 3/21/19 at 9:06 am, the social worker came to the surveyor and stated, We didn't give the resident the bed hold policy when he was transferred to the hospital. No further information was provided to the surveyor prior to the exit conference on 3/21/19. Based on staff interview, facility document review and clinical record review, the facility staff failed to provide to the resident and the resident representative at the time of transfer/discharge written notice which specifies the duration of the bed-hold policy for 5 of 26 residents (Resident #2, Resident #44, Resident #46, Resident #72, and Resident #86). The findings included: 1. The facility staff failed to provide Resident #2 and the resident representative written information about bed-hold when the resident was transferred to the hospital 2/26/19. The clinical record of Resident #2 was reviewed 3/19/19 through 3/21/19. Resident #2 was admitted to the facility 10/11/12 and readmitted [DATE]. Diagnoses included but not limited to acute cellulitis right foot with infected ulceration of right great toe, probable peripheral vascular disease, diabetes mellitus type II, atrial fibrillation, esophageal reflux, hypertension, dysphagia, convulsions, anxiety, dementia without behavioral disturbances, hyperlipidemia, anemia, Alzheimer's disease, and seizure disorder. Resident #2's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 12/11/18 assessed the resident with short-term memory problems, long-term memory problems, and severely impaired cognitive skills for daily decision-making. The departmental note dated 2/26/19 at 2:34 p.m. read LE (late entry) from 0900: Rescue 33 here to transport res (resident) to (name of hospital omitted). Informed by night shift nurse that MD (medical doctor) wants res (resident) sent to (name of hospital omitted) for direct admit due to cellulitis of Rt. (right) leg. Called for transport and hospital was notified.__ The clinical record did not have documentation that written notice of bed hold information was provided to the resident and the resident representative when Resident #2 was transferred to the hospital 2/26/19. The surveyor spoke with the corporate registered nurse on 3/20/19 at 10:24 a.m. what information was sent to the hospital when residents are transferred. The corporate RN stated the social worker completes that. The surveyor interviewed the social worker. The social worker was asked what information was sent with the resident when the resident was admitted to the hospital on [DATE]. The social worker provided the surveyor a form titled Heritage Hall [NAME] Discharge/Transfer Form. The form read, I understand that I am being discharged from Heritage Hall [NAME]. I understand that the reason for the transfer is recommendation of physician for direct admission to hospital. Resident in (name of hospital omitted) 2/27/19. Copy mailed to RP (responsible party) on 2/28/19. The social worker stated he provided no information to the hospital when Resident #2 was transferred 2/26/19. Bed hold acceptance/declination located at the bottom of the page was blank. The surveyor informed the administrator, the director of nursing, and the corporate registered nurse of the above concern on 3/20/19 at 3:50 p.m. and requested the facility policy on bed hold. The surveyor reviewed the facility policy titled Bed-Holds and Returns on 3/21/19. The policy read in part Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. No further information was provided prior to the exit conference on 3/21/19. 2. The facility staff failed to provide Resident #44 and the resident representative written information about bed-holds when the resident was transferred to the hospital 12/31/18. The clinical record of Resident #44 was reviewed 3/19/19 through 3/21/19. Resident #44 was admitted to the facility 9/23/09, readmitted [DATE] and 1/5/19 with diagnoses that included but not limited to hemiplegia following cerebral infarction affecting left non-dominant side, hepatomegaly, dysphagia, gastro-esophageal reflux disease, arthopathy, diabetic ketoacidosis with new onset type 1 diabetes, sepsis due to multifocal pneumonia, acute renal failure secondary to volume depletion, hypertension, hyperlipidemia, urinary tract infection with methicillin sensitive Staph aureus, hyponatremia, and history of seizure disorder. Resident #44's 30-day minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/3/19 assessed the resident with a brief interview for mental status as 15/15. The clinical record revealed a departmental note dated 12/31/18 that read in part Resident #44 vomited a large amount of brown substance. Call to nurse practitioner who ordered the resident to be transferred to the hospital. The order dated 12/31/18 read Transfer to ____ (name of hospital) ER (emergency room) for eval (evaluation) of congestion, N/V (nausea/vomiting) x 2 days. BP (blood pressure) 130/76, T (temperature) 97.7, P (pulse) 110, 94%. The clinical record did not have documentation that written notice of bed hold information was provided to the resident and the resident representative when Resident #44 was transferred to the hospital 12/31/18. The surveyor interviewed the director of nursing on 3/21/19 at 11:29 a.m. of the above concern when Resident #44 was transferred to the emergency room and admitted to the hospital. The surveyor requested Resident #44's face sheet, MDS, care plan, December 2018 departmental notes, January 2019 departmental notes and the bed hold policy. The surveyor reviewed the facility policy titled Bed-Holds and Returns on 3/21/19. The policy read in part Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. No further information was provided prior to the exit conference on 3/21/19. 3. The facility staff failed to provide Resident #46 and the resident representative written information about bed-hold when the resident was transferred to the hospital 1/24/19. The clinical record of Resident #46 was reviewed 3/19/19 through 3/21/19. Resident #46 was admitted to the facility 6/27/17 and readmitted [DATE] with diagnoses that included non-displaced fracture of lateral malleolus right fibula, non-traumatic subdural hemorrhage, constipation, gastroesophageal reflux disease, hypertension, Vitamin deficiency, convulsions, benign prostatic hyperplasia, diabetes mellitus type 2, chronic hepatitis, dry eye syndrome, and anemia. Resident #46's significant change in minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/6/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. The surveyor interviewed Resident #46 on 3/20/19. When asked if the resident had any falls, Resident #46 raised his right leg, pointed to his ankle, and stated he slipped in the snow and broke his ankle. The surveyor reviewed the departmental note dated 1/24/19 at 12:00 p.m. The note read LE (late entry) from 0900: Res (resident) came [NAME] (sic) down hall to nurse and stated I was walking outside and slipped and hurt my ankle but I'm okay. Assessment reveals swollen area to RT (right) ankle. Instructed res to elevate leg and FNP (family nurse practitioner) was notified and gave order for x-ray. Instructed rest to not be outside walking due to inclement weather. FNP notified and res is own RP (responsible party). The 1/24/19 6:06 p.m. departmental note read Late entry for 1700 (5:00 p.m.) FNP notified of x-rays and gave orders to send resident to ER (emergency room) for further eval (evaluation). @ (at) 1712 (5:12 p.m.) Rescue 33 ambulance services here @ this time to transport resident to (name of hospital ER) omitted. ER staff given report. Resident clean and dry upon departure and no visible signs of distress noted. The clinical record did not have documentation that written notice of bed hold information was provided to the resident and the resident representative when Resident #46 was transferred to the hospital 1/24/19. The surveyor informed the corporate registered nurse of the above concern on 3/20/19 at 2:01 p.m. and asked about bed-hold information. The corporate registered nurse stated the social worker completes that. The surveyor interviewed the social worker. The social worker did not have information about bed hold policy for Resident #46. The surveyor informed the administrator, the director of nursing, and the corporate registered nurse of the above concern on 3/20/19 at 3:50 p.m. and requested the bed hold policy. The surveyor reviewed the facility policy titled Bed-Holds and Returns on 3/21/19. The policy read in part Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. No further information was provided prior to the exit conference on 3/21/19. 4. The facility staff failed to provide Resident #72 and the resident representative written information about bed-hold when the resident was transferred to the hospital 9/20/18. The clinical record of Resident #72 was reviewed 3/19/19 through 3/21/19. Resident #72 was admitted to the facility 3/8/16 and readmitted [DATE] with diagnoses that included but not limited to above the knee amputation, acute diastolic heart failure, chronic obstructive pulmonary disease, insomnia, psoriasis, gastro-esophageal reflux disease, hypothyroidism, Vitamin deficiency, anemia, muscle weakness, obesity, hypertension, varicose veins of left lower extremity, type 2 diabetes mellitus, and mononeuropathy. Resident #72's significant change in minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/25/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. The clinical record revealed a Discharge summary dated [DATE]. The surveyor reviewed the departmental notes for September 2018. The departmental note dated 9/20/18 at 8:23 a.m. read Upon administering res (resident) am (morning) medication, res lethargic, opens eyes a few times and goes back to sleep. O2 (oxygen) 86%. V/S (vital signs): BP (blood pressure) 157/105, P (pulse) 86, R (respirations) 20, T (temperature) 98.5. Edema noted to face/eyes and hands. Notified FNP (family nurse practitioner). Stated to send res to (name of hospital emergency room omitted) for eval (evaluation). Called 911. Upon arrival of Rescue 33, res nonresponsive. Res LOA (leave of absent) to hospital at 0525, res clean and dry upon departure. Notified ER and gave report given. Res is own RP (responsible person). Attempted to notify 2nd contact without success. Notified niece-she stated her mother is out of town for a few days, to contact her if needed anything. The departmental note dated 9/20/18 at 9:58 a.m. read Resident admitted to hospital ICU (intensive care unit) with dx (diagnosis) of acute hypoxemia and resp (respiratory) distress. The clinical record did not have documentation that written notice of bed hold information was provided to the resident and the resident representative when Resident #72 was transferred to the hospital 9/20/18. The surveyor informed the administrator, the director of nursing, and the corporate registered nurse of the above concern on 3/20/19 at 3:50 p.m. and requested the bed hold policy. The surveyor reviewed the facility policy titled Bed-Holds and Returns on 3/21/19. The policy read in part Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. No further information was provided prior to the exit conference on 3/21/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #73 the facility staff failed to ensure respiratory equipment was bagged. Resident #73 was admitted to the facility on [DATE]. Diagnoses included anemia, congestive heart failure, hypertension, diabetes mellitus and chronic obstructive pulmonary disease. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/25/19 coded the Resident as 15 of 15 in section C, cognitive patterns. This is a quarterly MDS. Resident #73's clinical record was reviewed on 03/20/19. It contained a signed physician's order summary, which read in part Albuterol 2.5 mg/05 ml solution. Give 1 UD packet via nebulizer q (every) 6 hrs and Ipratropium BR 0.02% solution. Take 1 UD packet via nebulizer q 6 hrs. On 03/20/19 at approximately 1300, surveyor observed Resident #73's nebulizer mouthpiece lying on his nightstand. The mouthpiece was not bagged. The surveyor spoke with the infection control nurse on 03/20/19 at approximately 1325 regarding Resident #73's nebulizer mouthpiece. The infection control nurse accompanied the surveyor to Resident's room. The infection control nurse observed the Resident's nebulizer mouthpiece and stated to the surveyor that the mouthpiece should not be lying on the nightstand, but should be bagged. The surveyor requested and was provided with a policy entitled Departmental (Respiratory Therapy)-Prevention of Infection which read in part Infection Control Considerations related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag, marked with date and Resident's name, between uses. The concern of not having the Resident's nebulizer mouthpiece bagged was discussed with the administrative staff during a meeting on 03/20/19 at approximately 1555. No further information was provided prior to exit.Based on observation, staff interview, facility document review and clinical record review the facility staff failed to ensure respiratory equipment was stored properly and the oxygen tubing changed every 7 days for 5 of 26 residents in the survey sample (Resident #13, #73, #72, #159, and #23). The findings included: 1. The facility staff failed to date the oxygen tubing for Resident #13 when changed. Resident #13 was originally admitted to the facility on [DATE] and then readmitted to the facility on [DATE]. On the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/3/19, the resident was coded as to having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #13 was also coded as requiring extensive assistance of 2 staff members for dressing, personal hygiene and bathing. During the initial tour of the facility on 3/19/19 at 10:15 am, the surveyor noted Resident #13 was wearing oxygen. Upon further investigation, the surveyor could not find a date on the oxygen tubing to indicate when it had been changed. On 3/20/19 at 10 am, the surveyor again observed the resident wearing oxygen but there was no date on the oxygen tubing to indicate when it had been changed. At 5:41 pm, the surveyor notified the administration team of the above documented findings. The surveyor requested a copy of the facility's policy in regards to the administration of oxygen. The director of nursing stated that the staff was to change the oxygen tubing once a week and when this done, they will mark the tubing with a date in a black sharpie pen. On 3/21/19 at 8 am, the director of nursing provided a copy of the policy titled Departmental (Respiratory Therapy) Prevention of Infection. The policy read in part .Change the oxygen cannulae (sic) and tubing every (7) days, or as needed . No further information was provided to the surveyor prior to the exit conference on 3/21/19. 3. The facility staff failed to ensure Resident #23's bipap mask and headgear were stored in a plastic bag when not in use and failed to date when the oxygen tubing was changed. Resident #23's clinical record was reviewed 3/19/19 through 3/21/19. Resident #23 was admitted to the facility 8/17/17 with diagnoses that included but not limited to cerebrovascular disease, dysphagia, hemiplegia following cerebral infarct affecting right non-dominant side, hypertension, major depressive disorder, hyperlipidemia, anxiety, gastroesophageal reflux disease, hypothyroidism, urine retention, dysarthria and anarthria, aphasia, chronic kidney disease, and unspecified intellectual disabilities. Resident #23's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/14/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #23's current comprehensive care plan was reviewed. Problem onset dated 1/18/19 read Dx (diagnosis): SOB (shortness of breath). Approaches: Provide Bi-Pap as ordered. During the initial tour on 3/19/19 at 8:57 a.m., the surveyor observed a bipap mask and face gear lying on Resident #23's nightstand. Neither one were secured in a plastic bag. The oxygen concentrator in the room was turned off; however, the oxygen tubing was not dated. The surveyor interviewed licensed practical nurse #2 on 3/19/19 at 9:00 a.m. L.P.N. #2 was shown the mask and the oxygen tubing and stated the bipap mask should be in a bag. L.P.N. #2 stated oxygen tubing was supposed to be changed weekly and dated with a marker or with tape. The surveyor informed the corporate registered nurse of the above concern on 3/19/19 at 5:14 p.m. and requested the facility policy on storage of bipap masks and dating of oxygen tubing. The facility policy titled Departmental (Respiratory Therapy)-Prevention of Infection read in part Steps in the Procedure Infection Control Considerations Related to Oxygen Administration. 7. Change the oxygen cannulae and tubing every seven (7) days, or as needed. 8. Keep the oxygen cannulae and tubing used prn (as needed) in a plastic bag when not in use. Steps in the Procedure Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol-7. Store the circuit in plastic bag, marked with date and resident's name, between uses. No further information was provided prior to the exit conference on 3/21/19. 4. The facility staff failed to ensure Resident #72's bipap mask, headgear, and nebulizer mask were stored in a plastic bag when not in use. The facility staff also failed to ensure Resident #72 received the physician ordered amount of oxygen. The clinical record of Resident #72 was reviewed 3/19/19 through 3/21/19. Resident #72 was admitted to the facility 3/8/16 and readmitted [DATE] with diagnoses that included but not limited to above the knee amputation, acute diastolic heart failure, chronic obstructive pulmonary disease, insomnia, psoriasis, gastro-esophageal reflux disease, hypothyroidism, Vitamin deficiency, anemia, muscle weakness, obesity, hypertension, varicose veins of left lower extremity, type 2 diabetes mellitus, and mononeuropathy. Resident #72's significant change in minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/25/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Section O Special Treatments, Procedures and Programs was marked for oxygen use while a resident. Resident #72's current comprehensive care plan identified a problem with onset date of 3/1/19 that read resident was at risk for c/o (complaints of) SOB (shortness of breath) r/t (related to) dx (diagnosis): COPD (chronic obstructive pulmonary disease), has dx: allergies and dx: obstructive sleep apnea. Approaches: Provide O2 (oxygen) as ordered. The surveyor observed Resident #72 during the initial tour on 3/19/19 at 8:57 a.m. Resident #72 was observed sitting in his wheelchair with an oxygen canister attached to the wheelchair. The liter amount was turned to 3 liters. Resident #72 was in the process of being transported to an appointment and the emergency medical services staff were in attendance. The surveyor asked one of the members to read the oxygen amount and the EMS staff stated 3. Also during the initial tour, Resident #72 was observed to have bipap headgear and a facemask on the nightstand as well as a nebulizer machine with facemask. None were stored in a plastic bag. The nebulizer machine was covered with a towel. The surveyor informed licensed practical nurse #2 of the above and asked the nurse to come to Resident #72's room. L.P.N. #2 was shown the bipap machine and nebulizer and was asked if these were properly stored. L.P.N. #2 stated they needed to be in a plastic bag. L.P.N. #2 stated the facility only covers the nebulizer machines with a towel. Resident #72's March 2019 physician's orders were reviewed. Orders read Apply BIPAP QHS (at bedtime) with settings of 18/10 with rate of 20, Remove bipap (at 7:00 a.m.), O2 at 3 L/min (liters per minute) via nasal cannula, prn (as needed) dx: SOB (shortness of breath), and Albuterol sul (sulfate) 2.5mg/3ml (milliliter) soln (solution) Give 1 via neb (nebulizer) q (every) 8 hrs (hours) dx: SOB. The surveyor observed Resident #72 again on 3/19/19 at 4:01 p.m. Resident #72 was sitting in his wheelchair with oxygen at 2 liters/nc-not 3 liters as ordered. The surveyor informed the administrator, the director of nursing, and the corporate registered nurse of the above concerns on 3/19/19 at 6:00 p.m. and again on 3/20/19 at 4:34 p.m. and requested the facility policy on oxygen/nebulizer care. The facility policy titled Departmental (Respiratory Therapy)-Prevention of Infection read in part Steps in the Procedure Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol-7. Store the circuit in plastic bag, marked with date and resident's name, between uses. No further information was provided prior to the exit conference on 3/21/19. 5. The facility staff failed to obtain an order for the bipap settings and oxygen administration and failed to ensure Resident #159's bipap mask and nebulizer mask were stored in a plastic bag when not in use. Both were observed lying on the night stand during the resident interview on 3/19/19. The clinical record of Resident #159 was reviewed 3/19/19 through 3/21/19. Resident #159 was admitted [DATE] with diagnoses that included but not limited to severe bilateral chronic lymphedema, morbid obesity, obstructive sleep apnea, obstructive and reflux uropathy, hypertension, type 2 diabetes mellitus, hypothyroidism, hyperlipidemia, gastroesophageal reflux disease, and methicillin resistant staphylococcus aureus and MDRO (multi-drug resistant organism) to bilateral lower extremities. Resident #159 was on contact precautions. Resident #159's admission minimum data set (MDS) assessment had not yet been completed. The surveyor observed Resident #159 on 3/19/19 at 5:00 p.m. Resident #159 was observed in bed with oxygen concentrator at 2 liters via nasal cannula. O2 concentrator did not have a date on the tubing. Bipap mask was observed lying on the nightstand. The facemask was not secured in a plastic bag. The surveyor informed licensed practical nurse #2 of the above. The surveyor was unable to locate an order for the oxygen or the bipap settings for Resident #159. An order written 3/17/19 read to please call for settings on Bipap. The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above concern on 3/19/19 at 5:56 p.m. The surveyor reviewed the facility policy for oxygen concentrators on 3/21/19. The facility policy titled Departmental (Respiratory Therapy)-Prevention of Infection read in part Steps in the Procedure Infection Control Considerations Related to Oxygen Administration. 7. Change the oxygen cannulae and tubing every seven (7) days, or as needed. 8. Keep the oxygen cannulae and tubing used prn (as needed) in a plastic bag when not in use. Steps in the Procedure Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol-7. Store the circuit in plastic bag, marked with date and resident's name, between uses. No further information was provided prior to the exit conference on 3/21/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #81 the facility staff failed to maintain an effective infection control program. Resident #81 was admitted to the facility on [DATE]. Diagnoses included but not limited to cancer, coronary artery disease, hypertension, gastroesophageal reflux disease, benign prostatic hyperplasia, hyperlipidemia, hypothyroidism, depression, chronic obstructive pulmonary disease, and pseudomonas bronchitis. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/05/19 coded the Resident as 5 out of 15 in section C, cognitive patterns. This is an admission MDS. Resident #81's CCP (comprehensive care plan) was reviewed and contained a care plan for At risk for complaints of SOB (shortness of breath) and acute upper resp. (respiratory) infections related to DX: (diagnosis) bronchitis. Approaches for this care plan included Requires droplet isolation r/t (related to) pseudomonas of sputum. On 03/2019 at approximately 1230, surveyor observed LPTA (licensed physical therapy assistant) assisting with lunch trays. LPTA took the lunch tray for the Resident's roommate, and entered the room without donning any PPE (personal protective equipment). Surveyor spoke with the infection control nurse on 03/20/19 at approximately 1325. Surveyor asked infection control nurse if the LPTA should have entered the room without donning PPE, and the infection control nurse stated that he should not have. The surveyor requested and was provided with a facility policy entitled Isolation-Categories of Transmission-Based Precautions, which read in part Droplet Precautions 3. Masks will be worn when entering the room. The concern of not following infection control was discussed with the administrative team during a meeting on 03/20/19 at approximately 1555. No further information was provided prior to exit.Based on observation, clinical record review, staff interview and facility document review the facility staff failed to follow established infection control procedures for 5 of 26 Residents,#63, #259, #310, #81 and #159. The findings included: 1. For Resident #63, the facility staff failed to ensure that dirty linen was kept off the floor. The clinical record review revealed that Resident #63 had been admitted to the facility 09/20/17. Diagnoses included, but were not limited to, weakness, heart failure, Alzheimer's disease, dementia, and hypertension. Section C (cognitive patterns) of the Residents annual MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/18/19 had been coded 1/1/2 to indicate the Resident had problems with long and short term memory and was moderately impaired in cognitive skills for daily decision making. On 03/19/19 at 8:59 a.m., during initial tour of the facility, the surveyor observed a large pile of crumpled up linen in floor of the Residents room. The Resident was up in their wheelchair and the Residents bed was observed to be bare of any linen. During this observation CNA (certified nursing assistant) #1 entered the room and picked up the linen from the floor. When asked if linen was supposed to be in floor she stated no it is not and placed the linen in a closed barrel out on the hall. On 03/20/19 at 11:28 a.m., during an interview with the infection control nurse this nurse verbalized to the surveyor that they discussed linen in the floor during CNA meetings. The administrative staff were notified of the issue regarding the Residents linen during a meeting with the survey team on 03/19/19 at 5:40 p.m. and again on 03/20/19 at 3:55 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #259, the facility staff failed to ensure the Resident was in the correct isolation and failed to provide a container for disposal of PPE (personal protective equipment). The clinical record review revealed that the Resident had been admitted to the facility on [DATE]. Diagnoses included, but were not limited to, weakness, insomnia, benign prostatic hyperplasia, heart failure, and hypertension. There was no completed MDS (minimum data set) assessment on this Resident. However, the Resident was alert and orientated to person and place. During initial tour of the facility on 03/19/19 at approximately 8:45 a.m., the facility staff identified this Resident as being in contact isolation. Upon approaching the Resident room, the surveyor observed a plastic container that contained PPE (gloves, gown, and mask) and a sign outside the Residents door that stated to see the nurse. Prior to entering the room, the surveyor dressed out in the PPE provided by the facility. Upon removing the PPE and preparing to exit the room, the surveyor was unable to locate any infection control container to place the used PPE. The surveyor looked outside in the hallway and asked the staff in the hall about a container. The staff placed a closed barrel in the Residents room to discard the used PPE. On 03/19/19 at 9:34 a.m., the ADON (assistant director of nursing) identified the infection, as being in the Residents sputum and stated there should have been a barrel in the room. During an interview with the infection control nurse on 03/19/19 at 12:08 p.m., the designated infection control nurse stated the Resident was on contact isolation, they had spoken with the doctor, and they were going to discontinue the isolation. The infection control nurse stated the Resident should have had a barrel in their room to place the dirty PPE. The infection control nurse was also asked to confirm the type of isolation the Resident should have been placed in. On 03/20/19 at 11:28 a.m., the infection control nurse verbalized to the surveyor that the she had messed up and the Resident should have been in droplet isolation. However, he had been in contact at the hospital. A review of the Residents clinical record revealed that the Resident was placed on contact isolation on 03/14/19. This had been discontinued on 03/19/19. The Resident was in a private room. The Residents comprehensive care plan included the problem area contact isolation related to enterobacter of sputum. The facility policy titled Isolation-Categories of Transmission-Based Precautions included the following, .Droplet Precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets .that can be generated by the individual coughing, sneezing, talking . The administrative staff were notified of the issue regarding the Residents infection control status on 03/19/19 at 5:40 p.m. and again on 03/20/19 at 3:55 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #310, the facility staff failed to initiate the appropriate infection control guidelines and failed to provide a container for disposal of PPE (personal protective equipment). The clinical record review revealed that the Resident had been admitted to the facility on [DATE]. Diagnoses included, but were not limited to, weakness, Parkinson's disease, diabetes, dementia, and hypertension. There was no completed MDS (minimum data set) assessment on this Resident. The Resident was orientated to self. On 03/19/19 at 8:50 a.m., the surveyor observed an isolation sign on the outside of the Resident's door this sign directed any person that would be entering the room to see the nursing staff. The surveyor dressed out in the PPE provided in the cart outside the Residents room. Upon removing the PPE, the surveyor was unable to locate any infection control container to place the used PPE. The surveyor looked out into the hallway and CNA (certified nursing assistant) #1 approached the Resident's room stated the Resident was not on isolation and that the signage was from the previous Resident that was in this room. CNA #1 then removed the isolation sign, repositioned the cart from between the two rooms, and placed it further up the hall. After the signage and PPE equipment had been removed, a second surveyor entered this room with no PPE in place. During an interview with the infection control nurse, this nurse identified this Resident as being on contact isolation due to enterobacter in their urine. The clinical record included a physicians order dated 03/15/19 that read PROVIDE CONTACT ISOLATION RELATED TO ENTEROBACTER IN URINE. The Residents comprehensive care plan included the problems area UTI (urinary tract infection). Approaches included, but were not limited to, PROVIDE CONTACT ISOLATION RELATED TO ENTEROBACTER IN URINE, PLACE SIGN ON DOOR, PROVIDE GOWN, GLOVES, MASK . On 03/19/19 at 12:25 p.m., during an interview with CNA #1 this CNA verbalized to the surveyor that they had thought the previous Resident that was in this room was on isolation. CNA #1 acknowledged she had removed the sign and stated they had been off the weekend and that is when the Resident had been admitted . CNA #1 stated no one told me yesterday she was on isolation. I was in the room yesterday. The administrative staff were notified of the issues regarding the Residents infection control status during a meeting with the survey team on 03/19/19 at 5:40 p.m. The Residents isolation was discontinued on 03/19/19. No further information regarding this issue was provided to the survey team prior to the exit conference. 5. The facility staff failed to educate visitors on the use of PPE (personal protective equipment) and the staff failed to perform hand hygiene after removing gloves after assisting with wound care for Resident #159. Resident #159 was on contact isolation. The clinical record of Resident #159 was reviewed 3/19/19 through 3/21/19. Resident #159 was admitted [DATE] with diagnoses that included but not limited to severe bilateral chronic lymphedema, morbid obesity, obstructive sleep apnea, obstructive and reflux uropathy, hypertension, type 2 diabetes mellitus, hypothyroidism, hyperlipidemia, gastroesophageal reflux disease, and methicillin resistant staphylococcus aureus and MDRO (multi-drug resistant organism) to bilateral lower extremities. Resident #159 was on contact precautions. Resident #159's admission minimum data set (MDS) assessment had not yet been completed. The surveyor observed Resident #159 on 3/19/19 at 2:11 p.m. Resident #159 had a sign on the door directing staff/visitors to see nurse before entering the room. Also at the entrance to the room was a 3-drawer cart containing gloves, gowns, and masks. The surveyor observed a visitor sitting in the chair at the end of Resident #159's bed. The surveyor did not observe any PPE on the visitor. The surveyor observed Resident #159 again on 3/19/19 at 4:53 p.m. The 3-drawer cart did not have any gloves. The visitor was observed again without PPE in use-no gloves or gowns. The surveyor informed the administrator, the director of nursing, and the corporate registered nurse of the above concern on 3/19/19 at 5:55 p.m. and requested the infection control policy on contact precautions. The surveyor interviewed Resident #159's visitor on 3/20/19. The visitor was asked if any staff had explained the signage on the door. The visitor stated no. The surveyor observed wound care on 3/20/19 at 12:49 p.m. with licensed practical nurse #4. Certified nursing assistant #1 had gloved and gowned prior to entering the room. Upon completion of the wound care, L.P.N. #4 placed soiled bandages in the barrel, removed gloves and gowns and hands were washed. CNA #1 removed gloves and gown and left the room. No hand-washing observed or hand hygiene done. The surveyor spoke with L.P.N. #4 about the C.N.A. observation. L.P.N. #4 stated, She didn't wash her hands. The surveyor informed the administrator, the director of nursing, and the corporate registered nurse of the above concern on 3/20/19 at 3:54 p.m. and interviewed the infection control registered nurse on 3/21/19 at 1:07 p.m. The infection control nurse stated she was informed of C.N.A. #1 not washing her hands after removing gloves. She stated she expected staff to wash hands or use purell. The surveyor reviewed the facility policy titled, Isolation-Categories of Transmission-Based Precautions on 3/21/19. The policy read in part 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and type of precaution. Contact Precautions 4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room. 5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated environmental surfaces with clothing after gown is removed. The surveyor reviewed the facility policy titled Handwashing/Hand Hygiene on 3/21/19. The policy read in part: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternately, soap and water for the following situations: f. before donning sterile gloves m. after removing gloves. n. Before and after entering isolation precaution settings. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. No further information was provided prior to the exit conference on 3/21/19.