Based on interview clinical record review and facility documentation the facility staff failed to develop and implement a comprehensive care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 Resident (#1) in a survey sample of three (3) residents. The findings included: For Resident #1 the care plan does not have specific interventions for ADL (Activities of Daily Living) assistance. On 5/22/24 a review of the clinical record revealed the following excerpt from the care plan: FOCUS: Impaired Coping Date Initiated: 04/29/2024 GOAL: [This section was not filled in] INTERVENTIONS: Provide assistance with ADLs / IADLs as needed Date Initiated: 04/29/2024. Provide care in a calm and reassuring manner Date Initiated: 04/29/2024. On 5/24/24 at approximately 3:30 PM an interview was conducted with RN C who was asked the purpose of a care plan. RN C stated the purpose of a care plan is to direct the care of the Resident. When asked if this should include care that is individualized to each Resident, and she stated that it should. When asked if it should specify the exact ADL assistance that each Resident needs, she stated that All aspects of Resident care bathing, transferring, eating, incontinence care and any conditions like diabetes or seizures, and specific interventions like walker or wheelchair and Hoyer lift transfer, adaptive equipment anything that is used to care for that resident should be in the care plan. The following excerpts are from the facility policy entitled Care Plans, Comprehensive Person-Centered. Policy Statement: Comprehensive person-centered care plan that includes measurable objectives and timelines to meet the physical, psychosocial and functional needs is developed for each resident. 7. The comprehensive person-centered care plan: a. includes measurable objectives and timeframes. b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial wellbeing. On 5/23/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure that residents are free from significant medication errors for 1 Resident (#10) in a survey sample of 5 Residents. The findings included: For Resident #1 the facility staff failed to hold the blood pressure medications according to the parameters listed in the order. On 5/22/24 a review of the clinical record revealed that Resident #1 had the following orders: Hydralazine HCl Oral Tablet 25 MG Give 1 tablet by mouth every 8 hours related to essential hypertenson. Hold if SBP less than 110 -Start Date- 02/01/2024. Isosorbide Dinitrate Oral Tablet 20 MG (Isosorbide Dinitrate) Give 1 tablet by mouth every 8 hours related to essential hypertension. Hold if SBP [systolic blood pressure] less than 110 -Start Date- 02/01/2024. A review of the MAR (Medication Administration Record) Resident #1 was administered both hydralazine and Isosorbide Dinitrate on the following dates when his blood pressure was below 110: 3/13/24 -108/55 at 6 am 3/17/24 - 108/53 at 6 am 3/18/24 101/54 at 6 am 3/20/24 105/56 at 6 am 3/20/24 - 105/56 at 10 pm 3/21/24 - 104/55 at 6am 3/28/24 - 105/55 at 6 am 3/31/24 - 97/45 at 6am and 97/45 at 2pm (*Note the same blood pressure was entered twice) 4/3/24 - 108/54 6 am 4/12/24 102/58 at 6 am 4/17/24 108/53 at 6 am 4/25/24 104/50 at 10 pm 5/1/24 -106/55 at 6 am 5/5/24 - 108/55 at 6 am 5/11/24 - 101/54 at 6 am, 104/55 at 2 pm, and 106/72 at 10 pm 5/11/24 - 104/55 at 2 pm 5/12/24 - 108/60 at 10 pm On 5/23/24 at 2:00 pm an interview was conducted with LPN D who was asked what the significance of parameters on a blood pressure are and she stated it was to be sure that the Resident only received the medication when his or her blood pressure was high. When asked what the danger is if it is given out of the parameters, LPN D stated the Resident's blood pressure could drop suddenly and he or she could fall or faint or become dizzy. A review of the facility policy for Medication Administration read: Medication Administration Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders including any required timeframes. On 5/23/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided. 2. For Resident #2 the facility staff failed to administer midodrine (a medication that raises blood pressure) according to the parameters in the physician orders. On 5/23/24 a review of the clinical record revealed that Resident #2 had orders that read: Midodrine HCl Oral Tablet 10 MG Give 0.5 tablet by mouth three times a day for Hypotension Systolic BP less than 120. Start Date- 05/14/2024 On 5/22/24 the order was changed to read: Midodrine HCl Oral Tablet 10 MG (Midodrine HCl) Give 0.5 tablet by mouth three times a day for Hypotension Hold for SBP >139. Start Date- 05/22/2024. For the first order to give for systolic bp less than 120, midodrine was signed off in the MAR (Medication Administration Record) as being given as follows: 5/14/24 - 9am 125/68 and 1pm 144/58 5/16/24 - 9 am 134/69 5/19/24 - 1 pm 146/70 5/20/24 - 1pm 146/68 5/22/24 - 9 am 159/77 For the second order to hold midodrine for spb more than 139, midodrine was entered into the MAR as being given as follows: 5/22/24 - 9 pm 143/67 5/23/24 - 9 am 138/80 On 5/23/24 an interview was conducted with LPN D who was asked what the significance of parameters on a blood pressure are and she stated it was to be sure that the Resident only received the medication when his or her blood pressure was high. When asked what the danger is if it is given out of the parameters, LPN D stated the Resident's blood pressure could drop suddenly and he or she could fall or faint or become dizzy. A review of the facility policy for Medication Administration read: Medication Administration Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. On 5/23/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents receive services in the facility with reasonable accommodation of resident needs for 1 Resident in a survey sample of 4 Residents. The findings included: For Resident #1 the facility staff failed to ensure the Resident had transportation to appointments outside of the facility. On the afternoon of 4/9/24 an interview was held with the SW who stated, We do arrange transportation for the Resident, however, sometimes the company does not show up, so we then reschedule the appointment for the resident and reschedule transportation as well. The SW stated that on one occasion the ride did not show up to pick up the Resident up after the appointment and the Administrator had to go and pick her up. A review of the transportation logs revealed that Resident #1 missed the following appointments due to transportation issues: On 2/7/24 she missed the cardiology follow up at 9 AM. On 2/14/24 she missed the allergy follow up at 11 AM. On 2/24/24 she missed the cardiology follow up at 7:30 AM On 4/10/24 at approximately 10 AM an interview was conducted with the Administrator who confirmed that there was one occasion where transportation did not show up and she (the Administrator) had to go pick the Resident up at the doctor and transport her back to the facility. On 4/10/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review the facility staff failed to provide care and services that meet professional standards of quality for 2 Residents (# 1 and #2) in a survey sample of 4 Residents. The findings included: 1. The facility staff failed to ensure medications were given per physician orders for Resident #1. On 4/9/24 at approximately 3:00 PM an interview was conducted with Resident #1 who stated that she was, Happy at the facility there were some improvements that needed to be made. When asked about her medications and treatments she stated that she was not getting her medications right a while ago, but they are getting better. A review of the clinical record revealed the following: The MAR (Medication Administration Record) was reviewed, and it was found that on 2/9/24 Advair Diskus Inhaler marked as #9, Not given see nurses note. The nurses note read as follows: 2/9/2024 9:57 AM - Orders - Administration Note Text: Advair Diskus Inhalation Aerosol Powder Breath Activated 250-50 MCG/ACT 1 puff inhale orally two times a day Rinse mouth after use - unavail. -Reordered from pharmacy. (NP's name) notified. 3/29/2024 -3:23 PM - Nurses Note Text: 7-3 F/U pain 4/9. No complaints at this time. New order of Monistat 3 for Vulvovaginitis. Family notified. Nurses note reflect that the order put in for Monistat 3 was then discontinued at 9:52 PM as med was not available from the pharmacy. Order was received to start when available. 3/29/2024 -9:52 PM -Orders - Administration Note: Text: Monistat 3 Combination Pack Vaginal Kit 200 & 2 MG-% (9GM) - Insert 1 applicatorful vaginally at bedtime for Vulvovaginitis for 3 Days Start when available. Med not available. On 4/9/24 at approximately 11:45 AM an interview was conducted with LPN B who stated, If a medication is not available, we check the med bank system (Stat Box) and if it is not there, we then notify the pharmacy, the family member and the MD to see if we can get an order to hold till available. When asked does the physician specify how long you can hold it, she stated that the order will read. May hold till available. On 4/10/24 at 1:22 PM a telephone interview was conducted with the pharmacy representative for the facility. The pharmacy representative was asked if they have a system for back up medications or medications not available immediately from the pharmacy. The pharmacy representative stated that they utilize a backup pharmacy and they can also utilize the STAT order. If a physician orders a medication STAT, then the pharmacy will get it there within 4 hours. When asked about the cut off times for orders she stated, We have cut off times to get medications to the facility by the next run. If they do not meet that cut off time it will be on the one after that if it is available. If it is not available, we have to find a backup and get it to them. If they do not specify STAT order, we get it to them as soon as it is available to send. When asked about over the counter meds that may be unavailable she stated, We use [pharmacy name redacted] and [pharmacy name redacted] locally to fill medications we may not have or that may be OTC [over the counter]. She stated that Those local pharmacies can fill most medications however if it is an IV medication it will have to come from us, as the local pharmacies do not do IV meds. On 4/11/24 a review of the backup medication list revealed the above-mentioned medications were not available from the stat box. On 4/11/24 during the end of day meeting the Administrator was made aware of the findings and no further information was made available. 2. For Resident #2 the facility staff failed to ensure medications were administered per physician orders. On 4/10/24 a review of the clinical record revealed that Resident #2 had discharge orders dated 4/1/24 from the acute care hospital he was in for 6 days due to Osteomeylitits of the right heel. The orders included but were not limited to the following: Piperacillin Sod. Tazobactam Intravenous Solution Reconstituted 4.5 (4-0.5) GM (Piperacillin Sodium Tazobactam Sodium) Use 4.5 gram intravenously every 8 hours or (13.5 g in a continuous infusion pump). Duration of antibiotics 6 weeks total until 5/6/24. Symbicort Inhalation Aerosol 160-4.5 MCG/ACT 2 puff inhale orally two times a day for asthma rinse mouth with water after use. Gabapentin Oral Tablet 600 MG (Gabapentin) Give 1 tablet by mouth three times a day for neuropathy. Upon admission to the facility on 4/1/24 the orders were put into the system and it was discovered the IV antibiotic that the Resident was to receive was not in stock it would have to be ordered. The facility then entered the time to start on 4/2/24 at 6:00 AM., however the Resident did not receive the first dose of antibiotic until 4/3/24 at 10 PM. The antibiotics were scheduled for 6:00 AM, 2:00 PM, and 10:00 PM. The Resident arrived at the facility at 2:00 PM on 4/1/24 therefore he missed 4 doses of antibiotic therapy. A nursing note was placed in the chart 4/01/2024 10:47 PM - Note Text : Piperacillin Sod-Tazobactam So Intravenous Solution Reconstituted 4.5 (4-0.5) GM Use 4.5 gram intravenously every 8 hours for osteomyelitis 4.5 gm over 4 hrs at 25 ml/hr D/C to start 4/2/24. On 4/9/24 at approximately 11:45 AM an interview was conducted with LPN B who stated, If a medication is not available we check the med bank system (Stat Box) and if it is not there we then notify the pharmacy, the family member and the MD to see if we can get an order to hold till available. When asked does the physician specify how long you can hold it, she stated that the order will read.May hold till available. Gabapentin was ordered at 8:00 AM 1:00 PM and 9:00 PM, Resident #2 did not get his 9 PM dose on 4/1/24 and the following progress note was entered: 04/01/2024 10:47 PM -Note Text : Gabapentin Oral Tablet 600 MG Give 1 tablet by mouth three times a day for neuropathy Awaiting approval from pharm. Resident #2 received Gabapentin starting on 4/2/24 at 8 AM. Symbicort Inhalation -Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) 2 puff inhale orally two times a day for asthma rinse mouth with water after use. do not swallow Start Date 04/02/2024 800 AM D/C Date 04/03/2024 2:56 PM The following 2 notes were written about the Symbicort orders: 04/02/2024 4:24 PM - Note Text : Symbicort Inhalation Aerosol 160-4.5 MCG/ACT 2 puff inhale orally two times a day for asthma rinse mouth with water after use. do not swallow On hold til delivered. 04/03/2024 2:53 Type: Orders - Administration Note Note Text : Symbicort Inhalation Aerosol 160-4.5 MCG/ACT 2 puff inhale orally two times a day for asthma rinse mouth with water after use. do not swallow . Medication not available due to insurance coverage, Nurse notified NP (NP's name) on 4/3/2024 @ 2:55 pm. N/O received. Symbicort was not available and had to be ordered . The facility set the start date for 4/2/24 at 8:00 AM., however they actually did not get a replacement medication for the Symbicort until 4/4/24, causing the Resident to miss 5 doses (one dose on 4/1/24, 2 doses each on 4/2/24 and 4/3/24) of this medication that is used to manage his COPD (Chronic Obstructive Pulmonary Disease). Review of the back up med list (stat box) revealed that of the 3 above named medication only gabapentin 100 mg tabs were available however they were in the 100 mg dose form. Guidance for nursing standards for the administration of medication is provided by Fundamentals of Nursing, 7th Edition, Mosby's/ [NAME]-[NAME], p. 705: Professional standards, such as the American Nurses Association's Nursing Scope and Standards of Nursing Practice of (2004), apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation. On 4/11/24 during the end of day meeting the Administrator was made aware of the findings and no further information was made available.

Based on interview, clinical record review and facility documentation, the facility staff failed to ensure that Residents were free from unnecessary medications to include duplicate drug therapy for 1 Resident (#1) in a survey sample of 4 Residents. The findings included: For Resident #1 the facility staff failed to ensure the Resident was free from unnecessary medication to include duplicate medications. On 4/9/24 a review of the clinical record revealed that Resident #1 had following orders. GNP Mucus Relief DM Max Oral Liquid 5-100 MG/5ML (Dextromethorphan / Guaifenesin) Give 10 ml by mouth every 4 hours as needed for cough supervised self-administration -Start Date 02/01/2024 6:00 AM - PRN. Guaifenesin Oral Syrup 100 MG/5ML (Guaifenesin) Give 30 ml by mouth every 6 hours as needed for cough -Start Date 02/01/2024 6:00 AM. A review of the clinical records revealed that both medications have been valid orders available for use since 2/1/24. Since 2/1/24 both orders had been utilized for a total of 6 doses administered. 4/11/24 an interview was held with LPN D who stated she was familiar with Resident #1. When asked about the orders for her cough medicine she stated that she uses it when she needs it. When asked about the difference in the 2 medications she stated that they are both for cough and they both have guaifenesin in them so either one could be given. When asked if they should be given at the same time, she stated they should not. When asked if they can both be given in the same day, she stated that technically they could as long as they were at least 4 hours apart. LPN D then stated, I think it would be better if I get them clarified by the nurse practitioner. Per the manufacturer: Dextromethorphan HBR- cough suppressant, calms the cough reflex. Relieves the following symptoms: Cough. Guaifenesin -An expectorant that clears the airways by thinning and loosening excess mucus in the air passages, making it easier to cough up the mucus. Relieves the following symptoms: Chest Congestion. The prescriber did not make clear when to give the Guaifenesin and when to give the Guaifenesin / Dextromethorphan as both were prescribed for cough. On 4/11/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to facilitate Resident self-determination through support of Resident choice for one Resident (Resident #43) in a sample size of 38 Residents. For Resident #43, the facility staff failed to assist Resident #43 spend time outside in August 2022 as was her personal preference. The findings included: On 08/30/2022 at 8:30 A.M., Resident #43 was observed in her bed. When asked about concerns at the facility, Resident #43 stated she used to go outside sometimes but now she cannot go outside. When asked why, Resident #43 stated she didn't know why and would like to go outside again sometimes. On 08/31/2022, Resident #43's clinical record was reviewed. Resident #43's Minimum Data Set with an Assessment Reference Date of 07/07/2022 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 14 out of possible 15 indicative of intact cognition. An activity preference assessment was not completed with this quarterly review dated 07/07/2022. According to Resident #43's previous Minimum Data Set with an Assessment Reference Date of 04/08/2022 (which was coded as an annual assessment), the importance of going outside to get fresh air when the weather is good was coded as 1 meaning very important. Resident #43's care plan in the electronic health record was reviewed. A problem dated 07/07/2022 entitled, Resident (#43) has the potential for social isolation related to impaired mobility, depression, anxiety, and dementia. Interventions associated with this problem were as follows: Assist resident to and from activities as needed. Visit with resident to determine appropriate in-room activities that may be provided. Accommodate resident's limited mobility to enable participation in activity events outside of room when possible. Reinforce attendance at activities outside of room with verbal praise. Provide in-room activities and supplies for resident. Post activity calendar in room. The care plan did not address Resident #43's personal preference of going outside at times. Resident #43's progress notes were reviewed for August 2022. There was no evidence Resident #43 went outside for the month of August 2022. On 09/01/2022 at 8:25 A.M., Certified Nursing Assistant C (CNA C) was interviewed. When asked if there were any restrictions on Residents going outside, CNA C stated that Residents could go outside if they wanted to. When asked about Resident #43, CNA C stated that Resident #43 could go outside if she wanted to and would be assisted to go outside if Resident (#43) asked. On 09/01/2022 at 9:05 A.M., the Activities Director, Employee N, was interviewed. When asked about Resident #43 going outside, the Activities Director stated that it's not possible to allow Residents to go outside due to COVID. The Activities Director then stated that Once the facility allows me to take Residents outside, I will. When asked what activities Resident #43 participated in for August 2022, the Activities Director referred to 2 documents for Resident #43 in the Activity Binder. The list of Resident #43's Activities for August 2022 included playing Bingo (on 08/04/2022, 08/12/2022, and 08/30/2022) and drinking juice (on 08/04/2022, 08/05/2022, 08/06/2022, 08/07/2022, 08/08/2022, 08/11/2022, and 08/12/2022). There was no evidence Resident #43 went outside in August 2022 as was her personal preference. The Activities Calendar for August 2022 was reviewed. There was no evidence on the calendar any outside activities were planned. On 09/01/2022 at 10:35 A.M., the Director of Nursing and Administrator were notified of findings. The administrator provided a copy of Resident #43's updated Minimum Data Set with an Assessment Reference Date of 09/01/2022. In Section F0500 Part G entitled, How important is it to you to go outside to get fresh air when the weather is good?, it was coded as 1 meaning very important. The Administrator also provided a copy of Resident #43's updated care plan. One intervention dated 09/01/2022 documented, Assist Resident outside to courtyard as she desires, if all weather permits. The facility staff provided a copy of their policy entitled, Resident Rights. In Section 1(e) it documented, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . self-determination.

Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to revise the care plan for two Residents (Resident #43, Resident #59) in a sample size of 38 Residents. 1) For Resident #43, the facility staff failed to revise the care plan regarding Resident #43's personal preference to spend time outside. 2) For Resident #59, the facility staff failed to review and revise the care plan based on changing goals, preferences and needs of the resident and in response to current interventions. The findings included: On 08/30/2022 at 8:30 A.M., Resident #43 was observed in her bed. When asked about concerns at the facility, Resident #43 stated she used to go outside sometimes but now she cannot go outside. When asked why, Resident #43 stated she didn't know why and would like to go outside again sometimes. On 08/31/2022, Resident #43's clinical record was reviewed. Resident #43's Minimum Data Set with an Assessment Reference Date of 07/07/2022 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 14 out of possible 15 indicative of intact cognition. An activity preference assessment was not completed with this quarterly review dated 07/07/2022. According to Resident #43's previous Minimum Data Set with an Assessment Reference Date of 04/08/2022 (which was coded as an annual assessment), the importance of going outside to get fresh air when the weather is good was coded as 1 meaning very important. Resident #43's care plan in the electronic health record was reviewed. A problem dated 07/07/2022 entitled, Resident (#43) has the potential for social isolation related to impaired mobility, depression, anxiety, and dementia. Interventions associated with this problem were as follows: Assist resident to and from activities as needed. Visit with resident to determine appropriate in-room activities that may be provided. Accommodate resident's limited mobility to enable participation in activity events outside of room when possible. Reinforce attendance at activities outside of room with verbal praise. Provide in-room activities and supplies for resident. Post activity calendar in room. The care plan did not address Resident #43's personal preference of going outside at times. Resident #43's progress notes were reviewed for August 2022. There was no evidence Resident #43 went outside for the month of August 2022. On 09/01/2022 at 8:25 A.M., Certified Nursing Assistant C (CNA C) was interviewed. When asked if there were any restrictions on Residents going outside, CNA C stated that Residents could go outside if they wanted to. When asked about Resident #43, CNA C stated that Resident #43 could go outside if she wanted to and would be assisted to go outside if Resident (#43) asked. On 09/01/2022 at 9:05 A.M., the Activities Director, Employee N, was interviewed. When asked about Resident #43 going outside, the Activities Director stated that it's not possible to allow Residents to go outside due to COVID. The Activities Director then stated that Once the facility allows me to take Residents outside, I will. When asked what activities Resident #43 participated in for August 2022, the Activities Director referred to 2 documents for Resident #43 in the Activity Binder. The list of Resident #43's Activities for August 2022 included playing Bingo (on 08/04/2022, 08/12/2022, and 08/30/2022) and drinking juice (on 08/04/2022, 08/05/2022, 08/06/2022, 08/07/2022, 08/08/2022, 08/11/2022, and 08/12/2022). There was no evidence Resident #43 went outside in August 2022 as was her personal preference. The Activities Calendar for August 2022 was reviewed. There was no evidence on the calendar any outside activities were planned. On 09/01/2022 at 10:35 A.M., the Director of Nursing and Administrator were notified of findings. The Administrator provided a copy of Resident #43's updated Minimum Data Set with an Assessment Reference Date of 09/01/2022. In Section F0500 Part G entitled, How important is it to you to go outside to get fresh air when the weather is good?, it was coded as 1 meaning very important. The Administrator also provided a copy of Resident #43's updated care plan. One intervention dated 09/01/2022 documented, Assist Resident outside to courtyard as she desires, if all weather permits. The facility staff provided a copy of their policy entitled, Activity Evaluation. Under the header Policy Statement, it was documented, In order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities. In Section 1 it was documented, An activity evaluation is conducted as part of the comprehensive assessment to help develop an activities plan that reflects the choices and interests of the resident. In Section 6, it was documented The activity evaluation is used to develop an individual activities care plan separate from or as part of the comprehensive care plan that will allow the resident to participate in activities of his or her choice and interest. The facility staff provided a copy of their policy entitled, Care Plans, Comprehensive Person-Centered. In Section 13, it was documented, Assessments of residents are ongoing and care plans are revised as information about the residents' condition change. 2. For Resident #59, the facility staff failed to review and revise the care plan based on changing goals, preferences and needs of the resident and in response to current interventions. On 8/31/22 at approximately 2:10 PM an interview was conducted with Resident #59 who stated that the facility had removed her call bell from her room and given her a hand held bell that she has to ring. She stated that she felt she had Learned her lesson and would like her call bell back. When asked why the facility took her call bell she stated because I ring it too much. During an interview with the Unit Manager on 8/31/22 at approximately 3:15 PM the unit manager stated that the reason the call bell had been removed from Resident #59 was that she had attempted suicide by placing the call bell around her neck and she was found by the CNA and sent to the ER for evaluation. Upon return to the facility she was given another type of call bell without a cord. The unit manager stated this was for safety and not punitive in any way. A review of the care plan revealed that on 7/10/22 the following was written in Resident #59's care plan 7/10/22 - Q 15 min checks per orders. This was a hand written entry with no definite time frame as to when the 15 minute checks will start or end. On 8/31/22 an interview was conducted with the MDS Coordinator who stated that the care plans are reviewed and revised quarterly in the computer. Between quarterly reviews any changes are handwritten on the copy that is kept in the MDS office. When asked if the care plan book stays in the MDS office she stated that it did. When asked if her office was locked over weekends and evenings she stated that it was. When asked how the staff can access the care plans she stated that they have access to the copy in the computer. When asked is that copy always up to date she stated that it was not, the working copy is the one with the changes and that one is located in the MDS office. When asked about the entry of 7/10/22 she stated that it was hand written in the working copy on that date. When asked how the staff would know when to start and end the 15 minute checks she stated they would have to look at the orders. A review of the Care Plan Policy read: Page 8 The comprehensive person-centered care plan will: a. Include measurable objectives and time frames. On 9/1/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide an ongoing program to support residents in their choice of activities for one Resident (Resident #43) in a sample size of 38 Residents. For Resident #43, the facility staff failed to assist Resident #43 spend time outside in August 2022 as was her personal preference. The findings included: On 08/30/2022 at 8:30 A.M., Resident #43 was observed in her bed. When asked about concerns at the facility, Resident #43 stated she used to go outside sometimes but now she cannot go outside. When asked why, Resident #43 stated she didn't know why and would like to go outside again sometimes. On 08/31/2022, Resident #43's clinical record was reviewed. Resident #43's Minimum Data Set with an Assessment Reference Date of 07/07/2022 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 14 out of possible 15 indicative of intact cognition. An activity preference assessment was not completed with this quarterly review dated 07/07/2022. According to Resident #43's previous Minimum Data Set with an Assessment Reference Date of 04/08/2022 (which was coded as an annual assessment), the importance of going outside to get fresh air when the weather is good was coded as 1 meaning very important. Resident #43's care plan in the electronic health record was reviewed. A problem dated 07/07/2022 entitled, Resident (#43) has the potential for social isolation related to impaired mobility, depression, anxiety, and dementia. Interventions associated with this problem were as follows: Assist resident to and from activities as needed. Visit with resident to determine appropriate in-room activities that may be provided. Accommodate resident's limited mobility to enable participation in activity events outside of room when possible. Reinforce attendance at activities outside of room with verbal praise. Provide in-room activities and supplies for resident. Post activity calendar in room. The care plan did not address Resident #43's personal preference of going outside at times. Resident #43's progress notes were reviewed for August 2022. There was no evidence Resident #43 went outside for the month of August 2022. On 09/01/2022 at 8:25 A.M., Certified Nursing Assistant C (CNA C) was interviewed. When asked if there were any restrictions on Residents going outside, CNA C stated that Residents could go outside if they wanted to. When asked about Resident #43, CNA C stated that Resident #43 could go outside if she wanted to and would be assisted to go outside if Resident (#43) asked. On 09/01/2022 at 9:05 A.M., the Activities Director, Employee N, was interviewed. When asked about Resident #43 going outside, the Activities Director stated that it's not possible to allow Residents to go outside due to COVID. The Activities Director then stated that Once the facility allows me to take Residents outside, I will. When asked what activities Resident #43 participated in for August 2022, the Activities Director referred to 2 documents for Resident #43 in the Activity Binder. The list of Resident #43's Activities for August 2022 included playing Bingo (on 08/04/2022, 08/12/2022, and 08/30/2022) and drinking juice (on 08/04/2022, 08/05/2022, 08/06/2022, 08/07/2022, 08/08/2022, 08/11/2022, and 08/12/2022). There was no evidence Resident #43 went outside in August 2022 as was her personal preference. The Activities Calendar for August 2022 was reviewed. There was no evidence on the calendar any outside activities were planned. On 09/01/2022 at 10:35 A.M., the Director of Nursing and Administrator were notified of findings. The administrator provided a copy of Resident #43's updated Minimum Data Set with an Assessment Reference Date of 09/01/2022. In Section F0500 Part G entitled, How important is it to you to go outside to get fresh air when the weather is good?, it was coded as 1 meaning very important. The Administrator also provided a copy of Resident #43's updated care plan. One intervention dated 09/01/2022 documented, Assist Resident outside to courtyard as she desires, if all weather permits. The facility staff provided a copy of their policy entitled, Activity Evaluation. Under the header Policy Statement, it was documented, In order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities. In Section 1 it was documented, An activity evaluation is conducted as part of the comprehensive assessment to help develop an activities plan that reflects the choices and interests of the resident.

Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care according to professional standards for one Resident (Resident #38) in a sample size of 38 Residents. For Resident #38, the facility staff failed to re-valuate for leg prosthetics after a fitting for shrinkers socks was completed. The findings included: On 08/30/2022 at 8:45 A.M., Resident #38 was observed dressed, sitting on his bed covers. Resident #38 had bilateral above the knee amputations. When asked if he had any concerns about the care he received at the facility, Resident #38 stated that he wanted his prosthetic legs. When asked if he knew where they were located, Resident #38 stated that he doesn't have prosthetic legs yet, but wants to get them. On 08/31/2022, Resident #38's clinical record was reviewed. Resident #38's Minimum Data Set with an Assessment Reference Date of 07/05/2022 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of possible 15 indicative of intact cognition. On 09/01/2022 at 8:30 A.M., Employee P, an occupational therapist, was interviewed. When asked about Resident #38's most recent dates of service for therapy, Employee P referred to Resident #38's clinical record and stated that Resident #38 was seen by physical therapy from 08/25/202 through 11/24/2020. When asked the reason for the therapy, Employee P stated the reason for the evaluation was for mobility because Resident #38 wanted leg prosthetics. On the Physical Therapy Evaluation dated 08/25/2020 under Patient Goals it was documented, To be able to stand with prosthesis and get out of here. Under the section entitled, Potential for Achieving Rehab Goals it was documented, Patient demonstrates good rehab potential as evidenced by ability to follow 2-step directions, attentive to tasks and active participation in skilled treatment. Employee P stated that Resident #38 currently doesn't have leg prosthetics and gets around in a wheelchair. Employee P stated that Resident #38 transfers himself to the wheelchair independently and has a functional reach of 12 inches, meaning he is not at risk for falls. Employee P then stated that on 11/04/2020, Resident #38 was scheduled for a prosthetic assessment with an outside company for 12/04/2020. Employee P stated that Resident #38 was discharged from physical therapy services on 11/24/2020 because all of his goals were met. Employee P stated that physical therapy services would not be involved in his care again until after the prosthetic fitting occurred. When asked why Resident #38 did not have prosthetic legs currently, Employee P stated that she could not tell from the physical therapy documentation the results of the prosthetic assessment. On 09/01/2022 at 10:35 A.M., the Administrator was notified of findings. The Administrator stated that Resident #38 was seen by outside company twice and was deemed not a good candidate for prosthetics. The Administrator stated she would provide the documents for those visits. At approximately 11:45 A.M., the Administrator provided the following: 1) A handwritten physician's order dated 07/29/2021 which documented, Prosthetic consult for (B) [bilateral] stump shrinkers [compression socks to reduce swelling and help shape limb for prosthetic]. 2) A document entitled, Clinical Summary dated 07/30/2021 from a prosthetic company. The document indicated Resident #38 was seen to be evaluated for shrinker socks. 3) A document entitled, Clinical Summary dated 08/06/2021 from the same prosthetic company as dated 07/30/2021. The document indicated Resident #38 was successfully fitted for and provided bilateral shrinker socks. 4) A document from the prosthetic company dated 08/06/2021 entitled, Prescription - Letter/Certificate of Medical Necessity under the header Functional Capacity (from K0-K4) documented, K1-Ability or potential to transfer or ambulate on level surfaces with fixed cadence. Under the header Directions for use it was documented, Use with therapy at this time and re-eval [re-evaluate]. There was no evidence in the documentation that Resident #38 was not a candidate for leg prosthetics. On 09/01/2022 at approximately 7:30 P.M., the Administrator stated there was no further documentation to submit.

Based on staff interview and facility documentation review, the facility staff failed to have an accurate system to track the immunization status of all facility employees affecting one employee (Staff #5) in a sample of 11 employees reviewed, and the facility staff permitted one staff member (Staff #5) who was not fully immunized to continue to work; the facility staff's vaccination rate was 99.5% The findings included: The facility staff failed to have an accurate system to track the COVID immunization status of one employee Staff #5 and permitted her to work after being eligible to receive the second dose, which she didn't receive timely. On 8/30/22, the facility staff provided the survey team with a copy of the staff vaccination matrix and a document titled, COVID-19 Vaccination Record Log for Staff, which included dates of vaccination. These two documents were reviewed and a sample of 11 employees were selected for review. The staff vaccination matrix revealed the following: Staff #5 was listed as being partially vaccinated. The COVID-19 vaccination record log for staff, revealed that Staff #5 was listed as having received one dose on 6/28/22. On 8/31/22 at 2:14 PM, an interview was conducted with the Infection Preventionist (IP) Nurse. She stated that she oversees the COVID testing of Residents and staff but that Human Resources (HR) maintains the staff vaccination cards and staff vaccination matrix. The IP and Employee E, the Quality Assurance (QA) nurse confirmed that second doses of COVID vaccinations are given 30 days from the first dose. On the afternoon of 8/31/22, Surveyor E met with Employee F, the HR Director. The HR director looked through employee files and found the following: Staff #5's information on file indicated she received one dose of a multi-dose vaccine series on 6/28/22. Staff #5 was hired 7/13/22. During this interview, the HR director said, I do recruiting and onboarding. If they don't have the vaccine then they have to file for an exemption prior to hire. They bring their vaccination card when they come in for the drug test or orientation, they can't start without at least one [dose]. We had one or two that only had one dose and I put them on the COVID tracker. I put new hires on there and I send an email to the Administrator every week as to who was hired, terminated, received the booster, etc. I put the information on the tracker but I don't follow-up. On 8/31/22 at 4:24 PM, an interview was conducted with Employee E. Employee E was asked about COVID vaccine requirements for staff. Employee E said, They are required to have their first shot before hired and second when eligible. On 8/31/22 at 4:56 PM, during an end of day meeting, the facility Administrator and Corporate staff were made aware that Staff #5 was noted as being partially vaccinated, is eligible to receive the second dose, and has continued to work. The facility staff indicated they would look into this. On 9/1/22 at 10:53 AM, Surveyor E met with the facility Infection Preventionist and QA nurse. They were both shown Staff #5's information on the COVID-19 Vaccination Record Log for Staff that the facility provided. It indicated Staff #5 received 1 dose of a primary series on 6/28/22, and they were asked when she would be eligible for the second dose. The QA nurse said, 7/26/22. They were then shown Staff #5's time card, which revealed she had worked 7/26/22, 7/30/22, 7/31/22, 8/2/22, 8/3/22, 8/5/22, 8/8/22, 8/9/22, 8/11/22, 8/14/22, daily from 8/17/22-8/23/22, 8/25/22, 8/28/22, and 8/30/22. When asked if this is a problem, they both [the IP and QA nurse] stated, Yes. On the morning of 9/1/22, the facility Administrator provided Surveyor E with a document from CDC that read, Stay Up to Date with COVID-19 Vaccines Including Boosters. This document had a revision date of 8/23/22. The Administrator pointed out that it indicated the 2nd dose of the primary series for the Moderna is due 4-8 weeks after the first dose and stated that Staff #5 was within the 8 weeks of her first dose. Surveyor E then showed the Administrator a document from CDC that read, Stay Up to Date with Your Vaccines dated 1/16/22, that indicated Moderna vaccines are to be given 4 weeks (28 days) apart. On 9/1/22 at 11:02 AM, the Administrator provided Surveyor E with a copy of Staff #5's vaccination card that showed a second dose of the primary vaccination series was completed 8/15/22. The document had a printed date of 9/1/22, 10:50 AM. The Administrator was asked about this and she said, She [Staff #5] just sent it to HR this morning. On 9/1/22, the HR Director, Employee F, confirmed that Staff #5 had emailed her a photo of her COVID immunization card this morning and prior to receiving this at 10:50 AM, she was not aware that Staff #5 had been immunized. The facility staff's vaccination rate was 99.5%. A review was conducted of the facility policy titled, Covid-19 Vaccine Policy & Forms with a revision date of 5/10/22. This policy read, . Guidelines: 1. It is required that all affected individuals working within the center receive a COVID-19 vaccination as a condition of employment or access to the center unless a valid medical or religious exemption is granted. All affected individuals are expected to either receive the 2-shot series or a single dose of a one shot COVID-19 vaccine or obtain an approved exemption from the vaccination requirement. 5. New affected individuals are required to receive COVID-19 vaccination or provide proof of vaccination or provide adequate documentation of exemption at the time of hire or entry to the center. New applicants or affected individuals who have not provided documentation of compliance (or have failed to secure an approved exemption or immunization), will be listed as 'pending' hire and will not participate in the new Team member orientation program. Newly affected individuals who have not provided documentation of compliance (or have failed to secure an approved exemption or immunization) will not be allowed to enter the facility. a. New team member applicants will be given seven (7) business days from the date of the employment health screening to provide adequate documentation of exemption or vaccination before the facility rescinds the offer of employment; during this (7) day period the new applicant will not be allowed to work without proof of vaccination status or documentation of exemption. If documentation is not received, the facility Human Resources will advise the applicant they are not cleared for hire and may result in rescinding the offer of employment. b. Newly affected individuals who receive the initial dose of COVID -19 vaccine on day one of entering the facility and complete the medical exemption form under other stating they have initial dose and will wear Personal Protection Equipment, PPE of a N95 face mask until full vaccination status of 2 weeks after final vaccine will be allowed to enter facility and work. 6.Team members on leave of absence who return are required to be in compliance with this policy upon return and must provide documentation of policy compliance (approved exemption or immunization) prior to the scheduled return to work date. If no documentation is provided to the facility Human Resource office at the time of the return-to-work visit, the team member will be advised that he/she is not cleared to return to work until he/she is in compliance with this policy . CMS (Centers for Medicare and Medicaid Services) issued notice in the QSO Memo titled, Ref: QSO-22-09-ALL, DATE: January 14, 2022. This notice read, .CMS expects all providers' and suppliers' staff to have received the appropriate number of doses by the timeframes specified in the QSO-22-07 unless exempted as required by law, or delayed as recommended by CDC. Facility staff vaccination rates under 100% constitute non- compliance under the rule .Within 90 days and thereafter following issuance of this memorandum, facilities failing to maintain compliance with the 100% standard may be subject to enforcement action . On 9/1/22, during the end of day meeting, the facility staff were made aware of the above findings. No additional information was received.

Based on observation, staff interview, and facility documentation review, the facility staff failed to distribute food in accordance with professional standards for food service safety. Specifically, the facility staff failed to ensure a safe holding temperatures for 2 out of 2 milk containers on 08/31/2022 for the lunch tray line. The findings included: On 08/31/2022 at 11:00 A.M., this surveyor observed Employee K, a cook, obtain tray line temperatures. The cold beverages for the tray line were on cart shelves by the tray line. Employee K selected a carton of milk to check the holding temperature. The temperature was 50.8 degrees Fahrenheit. Employee K then selected another milk off the cart and checked the temperature. The temperature was 47.2 degrees Fahrenheit. The cook then stated the milk on the cart would be taken away. The Dietary Manager was informed of findings and stated that the milk should be on ice while serving on the tray line. On 08/31/2022, the facility staff provided a copy of their policy entitled, Food Production. In Section D(b)(1) entitled, Milk Production, an excerpt documented, During service, place on ice to maintain temperature below 41 degrees Fahrenheit. On 08/31/2022 at approximately 6:00 P.M., the administrator and Director of Nursing were notified of findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to conduct routine testing of staff who were not up to date with COVID immunizations for 6 staff (Staff #1, #2, #4, #5, #6, and #10) in a sample of 8 staff reviewed for COVID testing. On 8/31/22, a review was conducted of the staff vaccination matrix and a sample of 11 employees was selected. On 8/31/22 at 2:14 PM, Surveyor E met with the Infection Preventionist (IP) and the QA (Quality Assurance) Nurse to review staff COVID testing. The following testing dates were noted and confirmed by the IP nurse. The hire dates, work status and time card/punches were obtained from Employee F, Human Resources Manager. 2a. Staff #1 had testing occurrences of 8/9/22 and 8/11/22. Staff 1 was hired 3/2/22, and worked on an as needed basis. Staff #1 was noted on the staff vaccination matrix as being partially vaccinated. Review of the vaccination information Human Resources had on file revealed Staff #1 received one dose of a multi-dose, Moderna COVID vaccine on 2/22/22. Staff #1 worked 8/18 and 8/24, without having any testing completed. 2b. Staff #2 had no evidence of any testing conducted in July or August, 2022. Staff #2 was hired 5/20/22, and worked full time. Staff #2 was noted as having been granted a non-medical exemption from vaccination, which was approved on 5/24/22. 2c. Staff #4 was tested 7/4/22, 7/12/22, 7/15/22, 7/19/22, and 7/22/22. There was no testing occurrences for Staff #4 after 7/22/22. Staff #4 worked 6 additional shifts following 7/22, without any testing. 2d. Staff #5, was noted on the staff vaccination matrix as being partially vaccinated. Staff #5 was tested on ly twice in July, on 7/19 and 7/27. In August she was tested twice weekly from 8/1/22-8/17/22. Following the test on 8/17/22, the other testing occurrences were 8/23/22 and 8/30/22. She had not been tested twice weekly in July or for the last two weeks in August. Review of the time card revealed Staff #5 worked 10 shifts from 8/17-8/31. 2e. Staff #6, was noted on the staff vaccination matrix as having had been granted a non-medical exemption from immunization. Staff #6 was not tested twice weekly. Her testing occurrences for July and August were as follows: 7/19/22, 7/22/22, 7/23/22, 8/2/22, 8/4/22, 8/8/22, 8/11/22, 8/16/22, 8/18/22, 8/22/22, and 8/29/22. When Surveyor E asked if there was any testing between, 7/23/22-8/2/22, the IP said, No. 2f. Staff #10, was noted on the staff vaccination matrix as being partially vaccinated. Review of the testing for Staff #10 revealed that the facility staff had her marked as being boosted, therefore she was not conducting routine testing. She was not tested from July 20, 2022 until Aug. 21. Once they started testing Staff #10, she did not have twice weekly testing. She was tested 8/21/22, 8/26/22, and 8/31/22. Review of the time card for Staff #10 revealed she worked 17 days in July and 22 days in Aug. During the interview, Staff #10 identified as working at that time, she was called into the office and confirmed that she is not boosted for COVID-19. The Infection Preventionist was made aware that the staff who were not up-to-date were not being tested twice weekly. She confirmed the findings. 3. The facility staff failed to conduct outbreak testing of staff, regardless of their vaccination status. On 8/31/22 and again on 9/1/22, Surveyor E met with the facility Infection Preventionist (IP). The IP confirmed they had been in a COVID outbreak until 8/30/22. When staff testing records for August were reviewed, the IP stated that staff who are up-to-date do not have to be tested unless they are symptomatic. When asked if they are tested during an outbreak, the IP said, No. The testing records revealed no evidence of any staff who are up-to-date with COVID immunizations receiving any COVID testing. On 9/1/22 at approximately 5:45 PM, the Regional Director of Clinical Services (RDCS) stated, Per CMS definition, it says 1 staff or 1 Resident is an outbreak, but VDH (Virginia Department of Health) tells us often no, so we let VDH make the determination if we are in outbreak or not. The RDCS was asked which guidance they follow if there is a discrepancy between the two. The RDCS said, We follow VDH because they are in the area and are experts in their area. Review of the facility policy titled, Coronavirus (COVID-19) with a revision date of 5/10/22, was conducted. This policy read, . Routine testing of staff that are not up to date with all recommended vaccinations will be based on the extent of the virus in the community. Facilities should use their community transmission level as the trigger for staff testing frequency. Reports of COVID-19 level of community transmission are available on the CDC COVID-19 Integrated County View site: https://covid.cdc.gov/covid-data-tracker/#county-view (9.14.2021) see Covid 19 Testing Policy . The facility policy titled, COVID-19 Testing was reviewed. This policy read, .Testing Triggered by an Outbreak Investigation/Testing of Staff and Residents During an Outbreak Investigation: A new COVID-19 infection in any staff or any nursing home-onset COVID-19 infection in a resident triggers an outbreak investigation. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin. Facilities have the option to perform outbreak testing through two approaches, 1) contact tracing or 2) broad-based (e.g. facility-wide) testing. If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts. If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility). Broader approaches might also be required if the facility is directed to do so by the jurisdiction's public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission. When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. If testing of close contacts reveals additional HCP or residents with SARS-CoV-2 infection, contact tracing should be continued to identify residents with close contact or HCP with higher-risk exposures to the newly identified individual(s) with SARS-CoV-2 infection. A facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility) approach should be considered if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. If the outbreak investigation is broadened to either a facility-wide or unit-based approach, follow recommendations below for alternative approaches to individual contact tracing. Alternative, broad-based approach: If close contacts cannot be determined, the facility should investigate the outbreak at a facility-level or group-level (e.g., unit, floor, or other specific area(s) of the facility) . On 9/1/22, during an end of day meeting the facility Administrator and Director of Nursing were made aware of the above findings. No additional information was provided. Based on staff interview and facility documentation review, the facility staff failed to test Residents for COVID-19 in on one (A-unit) of two units accordance with The Centers for Disease Control and Prevention guidance. The findings included: Review of the CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated on 02/02/2022, was reviewed. An excerpt of the document read, Asymptomatic residents with close contact with someone with SARS-CoV-2 infection, regardless of vaccination status, should have a series of two viral tests for SARS-CoV-2 infection. In these situations, testing is recommended immediately (but generally not earlier than 24 hours after exposure) and, if negative, again 5-7 days after the exposure. On 08/31/2022 at approximately 5:00 P.M., the facility staff provided a copy of their staff line listing. According to the line listing, Staff #17, a nurse, had symptom onset (cough, temperature greater than 100 degrees Fahrenheit, chills/shaking, new malaise, dizziness, sore throat, and body aches) on 08/19/2022 and tested positive for COVID-19 on 08/19/2022. On 09/01/2022, the facility staff provided an as worked schedule for 08/18/2022. According to the schedule, Staff #17 was the only nurse assigned on the A unit to care for Residents from 11:00 P.M. (08/18/2022) to 7:00 A.M. (08/19/2022). On 09/01/2022 at 10:45 A.M., the Infection Preventionist (Employee D) was interviewed. When asked about the timeline for the current outbreak, the Infection Preventionist stated that they were no longer in outbreak. The Infection Preventionist explained that a Resident tested positive on 08/02/2022 and their policy is that outbreak is considered to extend 28 days after a Resident tests positive. The Infection Preventionist stated that Residents would be tested twice a week for the 28 days. This surveyor and the Infection Preventionist reviewed the facility's testing logs. According to the testing logs, Residents were tested on [DATE], 08/09/2022, 08/16/2022, 08/22/2022, 08/23/2022, and 08/26/2022. There was no evidence Residents exposed to Staff #17 on 08/19/2022 were tested until 3 days after exposure. On 09/01/2022, the Administrator was notified of findings.

Based on observation, staff interview, and facility documentation review, the facility staff failed to post daily staffing information for Residents, staff, and visitors to see, which has the potential to affect all Residents. The findings included: On 9/1/22 at approximately 11:00 AM, a faciltiy tour was conducted to look for daily staffing posted. Surveyor E was unable to locate it. On 9/1/22 at approximately 12:40 PM, the Director of Nursing (DON) was asked where the daily staffing is posted. The DON and Surveyor E went to the B unit and found the Daily Unit Assignment sheet posted in the hallway. This posting listed the date, staff's first names and their assigned shift. No census data or hours worked was noted. The DON and Surveyor E then went to the A unit. The Daily Unit Assignment was posted in the chart room, which was located behind the nursing station. On 9/1/22, the Director of Nursing (DON) was interviewed. The DON stated the scheduler posts the daily staffing and on the weekends posts for the entire weekend on Friday. When asked what the purpose of posting the daily staffing is, the DON said, For the staff to know where to go since we have two sides. On 9/1/22, the facility Administrator was asked where the staff posting is posted. She said, I will have to check, is it not posted out by the time clock. Surveyor E went and made an observation of the postings around employee time clock and didn't see a posting of daily staffing. On 9/1/22, the facilty staffing coordinator, Employee H was asked where she posts the daily staffing. She stated, On B unit across from the station, on A unit in the chart room. I know families are supposed to have access but A side doesn't really have any where to post it. On 9/1/22 at approximatey 12:55 PM, the faciltiy Administrator approached Surveyor E and asked if the posting in the lobby had been seen. Surveyor E and the Administrator went to the lobby and behind the reception desk in a case/shadow box, there was a posting that was not ligible. It was above eye level and at a distance that the text could not be read. On 9/1/22 at 1:30 PM, upon the survey team's return from lunch, Surveyor E pointed out the daily staff posting behind the receptionist. Surveyor E asked Surveyor D if she could read it and Surveyor D said, No. On 9/1/22 at 1:35 PM, an interview was conducted with Employee J, the business office assistant and receiptionist. The facility lobby had a door that was locked, which seperates the lobby from the Resident care areas and units. Facility staff have to enter a code to unlock the door for access to be gained to the Resident care unit and back to the lobby from the unit. When asked if Residents have access to the lobby, Employee J said they do not, a staff member would have to unlock the door for them to access the lobby. A review of the facility policy titled, Posting Direct Care Daily Staffing Numbers was conducted. This policy read, 1. Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. On 9/1/22, during an end of day meeting with the facility Administrator, Assistant Administrator, DON, and corporate staff were made aware of the above findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, resident interviews and clinical record review, the facility staff failed to ensure reasonable accommodation of resident needs and preferences for two Residents (Resident # 49 and # 68) in a survey sample of 30 residents. 1. For Resident # 49, the facility staff failed to make sure the clock in his room was correct. 2. For Resident # 68, the facility staff failed to make sure the clock in her room was correct. Findings included: 1. For Resident # 49, the facility staff failed to make sure the clock in his room was correct. Resident # 49, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Alzheimer's Disease, Hypertension, Malignant Neoplasm of Prostate, Gastroesophageal Reflux Disease, Dementia, Osteoarthritis, and Anxiety. Resident # 49's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 2/1/2019. The MDS coded Resident # 49 with a BIMS (Brief Interview for Mental Status) score of 3 out of 15, indicating severe cognitive impairment. Resident # 49 was coded as requiring limited to extensive assistance of one staff person for Activities of Daily Living except total assistance of one staff person for bathing. Resident # 49 was coded as occasionally incontinent of bowel and bladder. During the initial tour of the facility on 4/2/2019 at 12:17 PM, the white clock located above the closet in Resident # 49's room was observed to have the time 11:15. The second hand was not moving. On 4/2/2019 at 4:13 PM, the clock still had the time of 11:15. Resident # 49 was observed lying in bed. On 4/3/2019 at 8:30 AM, the observed time on the clock was 11:15. On 4/3/2019 at 2:45 PM, the observed time on the clock was 11:15. On 4/4/2019 at 3:15 PM, the observed time on the clock was 11:15. Resident # 49 was observed lying in bed. A review of Resident # 49's clinical record was conducted during the survey. Resident #49's care plan, revised on 02/27/2019, read that Resident # 49 had a diagnosis of Alzheimer's Disease and dementia resulting in confusion at times. One of the interventions listed was Reorient as needed. On 4/4/2019 during the end of day debriefing, the Director of Nursing was interviewed. The Director of Nursing stated Resident # 49 was confused and that clocks were used to help with orientation to time. The Director of Nursing went with the surveyor to Resident # 49's room to look at the clock. The Director of Nursing stated the clock in Resident # 49's room should have been accurate. 2. For Resident # 68, the facility staff failed to make sure the clock in her room was correct. Resident # 68, a [AGE] year old female was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Alzheimer's Disease, Hypertension, Major Depressive Disorder, Gastroesophageal Reflux Disease, Dementia, Cardiomegaly, and Anxiety. Resident # 68's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 2/21/2019. The MDS coded Resident # 68 with a BIMS (Brief Interview for Mental Status) score of 3 out of 15, indicating severe cognitive impairment. Resident # 68 was coded as requiring extensive assistance of one to two staff persons for Activities of Daily Living except total assistance of one staff person for Bathing. Resident # 68 was coded as frequently incontinent of bowel and bladder. On 4/2/2019 at 4:13 PM, the clock had the time of 11:15. Resident # 68 was observed lying in bed. On 4/3/2019 at 8:30 AM, the observed time on the clock was 11:15. On 4/3/2019 at 1:30 PM, Resident # 68 was observed lying in bed. Resident # 68 told the surveyor she was waiting to get some pain medicine. The surveyor asked when she last had pain medicine. Resident # 68 looked at the clock and stated I don't know but I need some medicine. On 4/3/2019 at 2:45 PM, the observed time on the clock was 11:15. On 4/4/2019 at 3:15 PM, the observed time on the clock was 11:15. Resident # 68 was observed walking in her room. Review of the clinical record was conducted on 4/4/2019. Review of care plan revealed: Page 1 of 8 Resident #68's care plan, revised on 02/27/2019, read that Resident #68 had a cognitive/communication deficit related to Alzheimer's Disease. On page diagnosis of Alzheimer's Disease and dementia resulting in confusion at times. One of the interventions listed was Reorient as needed. On 4/5/2019 during the end of day debriefing, the facility Administrator and Director of Nursing were informed of the findings. The Director of Nursing stated new batteries had been placed in the clock and that the clock should be accurate. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to accurately convey Advanced Directives preferences to the staff responsible for resident's care for one resident (Resident #63) in a sample size of 30 residents. The findings included: Resident #63, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include but not limited to Non-ST elevation (NSTEMI) myocardial infarction, heart failure, cerebral infarction, hypertension, diabetes, and hemiplegia. Resident #63's most recent Minimum Data Set had an Assessment Reference Date (ARD) of 02/18/2019 and was coded as a quarterly assessment. Resident #63 was coded with a Brief Interview of Mental Status (BIMS) score of 3 out of possible 15 indicative of severe cognitive impairment. Functional status for bed mobility, transfers, dressing, and personal hygiene were all coded as requiring extensive assistance from staff. Functional status for eating was coded as requiring supervision from staff. On 04/02/2019 at 4:15 PM, the current physician's orders in the electronic health record were reviewed. A physician's order dated 11/25/2018 documented, Resident Hospice care as of 11/16/18 [hospice company name]. A physician's order dated 11/26/2018 documented, DNR (do not resuscitate). The care plan in the electronic health record was reviewed. A problem onset dated 04/02/2015 documented, [Resident #63] has an inability to perform ADLs (Activities of Daily Living) independently secondary to muscle spasms, HTN (hypertension), CVA (cerebral vascular accident), hemiparesis, RAKA (right above-the-knee amputation), depression. Resident refuses meals & supplements at time. (sic) One approach documented for this problem documented, Full code. On 04/02/2019 at 4:40 PM, an interview with CNA C was conducted. When asked where a CNA would find out information about how to care for Resident #63, she stated she looks at the care plan that is posted on the inside of Resident #63's closet door. CNA C and this surveyor then entered Resident#63's room and CNA C then opened Resident #63's closet door to show a document entitled, CNA Care Plan which included Resident #63's name and room number (handwritten). It also included Resident #63's needs pertaining to ADLs. On the left hand side of the paper, it was documented, Information is current as of this date: 10-31-18. On the top left side of the CNA Care Plan, it was documented Full code. CNA C then closed the closet door. This surveyor then asked CNA C what Resident #63's code status was and she stated, She's a full code. A copy of the CNA Care Plan was requested and CNA C stated she would have to ask the nurse. On 04/02/2019 at approximately 4:45 PM, this surveyor and CNA C walked to the nurse's station. After speaking with a nurse, CNA C went to Resident #63's room to retrieve the CNA Care Plan on the closet door. The staff nurse got Resident #63's hard chart and displayed the Durable Do Not Resuscitate Order and stated to this surveyor, Do you realize this resident is on hospice and she's a DNR? CNA C returned with the CNA Care Plan and handed it to LPN B. LPN B looked at the document and stated, It (closet care plan) wasn't updated. A copy of the Durable Do Not Resuscitate order and the electronic care plan were requested. On 04/02/2019 at 4:55 PM, a Durable Do Not Resuscitate document was provided. It was dated 11/20/18 and signed by physician, responsible party, and a witness. A paper copy of the electronic care plan was provided. Under the problem entitled, [Resident #63] has an inability to perform ADLs (Activities of Daily Living) independently secondary to muscle spasms, HTN (hypertension), CVA (cerebral vascular accident), hemiparesis, RAKA (right above-the-knee amputation), depression. Resident refuses meals & supplements at time. ,Full Code was crossed out and DNR was added (handwritten and not dated or initialed). Employee L stated the most updated version of the care plan is on paper kept on the unit. Employee L stated electronic care plans (what is seen on the computer) are updated quarterly. On 04/05/19 at 10:10 AM, an interview with Employee H, the MDS, Care Plan Coordinator was conducted. When asked about how to determine when an intervention on a care plan was implemented, Employee H stated, We don't date interventions. She went on to say the intervention either continues or it would be resolved. When asked about a resolved intervention, Employee H stated, I would delete it. Employee H stated the paper copy care plans are kept in a book on the unit, updated on the paper, and eventually entered into the computer. When asked about the CNA (closet) care plans, Employee H stated closet care plans are also updated as needed. The facility policy entitled, Advanced Directives was reviewed. Section 7 documented, Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. Section 10 documented, The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive. In summary, there was conflicting information regarding Resident #63's Advanced Directives preferences on the electronic care plan, the paper copy care plan, and the CNA closet care plan. On 04/05/2019 at approximately 2:30 PM, the DON and Administrator were notified of findings and they offered no further information or documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility documentation review, the facility staff failed to notify resident/responsible party of termination of Medicare Part A benefits for one resident (Resident #77) in a sample of 3 residents. The findings included: Resident #77, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but not limited to diabetes, hypertension, and hyperlipidemia. Resident #77's most recent MDS (Minimum Data Set) assessment with an ARD (assessment reference date) of 02/22/2019 was coded as an annual assessment. The Brief Interview for Mental Status (BIMS) was coded as 9 out of possible 15 indicative of moderate cognitive impairment. Resident #77's Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) were reviewed. Neither form was signed. On 04/03/2019 at 3:00 PM, an interview with Employee N was conducted. When asked why there were no signatures on the forms, Employee N provided a copy of a page from a ledger dated 03/07/2019 . Employee N stated it shows that the documents were mailed to the responsible party on 03/07/2019. When asked how it is verified the recipient received the information, Employee N stated she knows they were received because they are her relatives. Employee N verified they do not have signed forms as evidence the responsible party was notified. On 04/04/2019 at 9:10 AM, Employee L confirmed that Resident #77 was admitted to skilled care on 02/15/2019, received physical therapy, and was discharged to long-term care status effective 03/15/2019. The facility policy entitled Advance Beneficiary Notices was provided by facility staff. Section 5 documented, A notice of Medicare non-coverage form CMS 10123, shall be issued to the resident/representative when medicare-covered services are ending, no matter if resident is leaving the facility or remaining in the facility. This informs the resident on how to request an appeal or expedited determination from their quality improvement organization. Section 6 documented, To ensure that the resident, or representative, has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided within two days of the last anticipated covered day. Section 12 entitled Delivery Requirements part (b) documented, The notice shall be hand-delivered as possible (sic) to obtain beneficiary signature. The facility shall retain the original and give a copy to the resident representative. On 04/05/2019 at approximately 2:30 PM, the Administrator and DON were notified of findings and offered no further information or documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility record review the facility staff failed to ensure one hospital bed was in good repair for one resident (Resident #71) in a survey sample of 30 residents. The facility staff failed to maintain a hospital bed in good repair for Resident #71. The findings included: Resident #71, a [AGE] year old, was admitted to the facility on [DATE]. Resident #71's diagnoses included but were not limited to: unspecified dementia with behavioral disturbance, hypothyroidism, essential hypertension, major depressive disorder, gastro-esophageal reflux disease without esophagitis, progressive bulbar palsy, and pseudobulbar affect. Resident #71's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/25/19, was coded as an Annual assessment. The resident was coded of having a BIMS (Brief Interview for Mental Status) score of 5, which indicated the resident's cognitive functioning was severely impaired. Resident #71 was coded as requiring extensive assistance of one staff member for dressing and eating; required extensive assistance of two staff members for transfers, toilet use and personal hygiene. During initial observation of the facility on 4/2/19 at approximately 2:25pm the foot board of the bed was noted to be broken. Facility rounds on 4/5/19 at 9:25am the footboard was observed to remain broken. On 4/5/19 at 9:35am an interview was conducted with Employee I; he stated, I didn't know about this footboard. I can't work on the bed while the resident is in it, but as soon as she is up I can put a replacement on. On 4/5/19 at 12:34pm an interview was conducted with Employee M who stated, all staff have access to enter work orders. Whoever broke that bed and noticed it should have filled out a work order. The Administrator and Director of Nursing were informed of the failure of staff to maintain furniture in good repair during end of day meeting on 4/5/19. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to notify the Ombudsman of a transfer to the hospital on 2 separate occasions for 1 resident (Resident #41) in a sample size of 30 residents. For Resident #41, the facility staff failed to notify the Ombudsman upon transfer to the hospital on [DATE] and 02/25/2019. The Findings included: Resident #41, a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses to include but not limited to diabetes, heart failure, kidney failure requiring dialysis, and depression. Resident #41's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/13/2019 was coded as re-entry from an acute hospital. Resident #41 was coded with a Brief Interview of Mental Status (BIMS) score of 11 out of possible 15 indicating moderately impaired cognition. On 04/04/2019 at approximately 9:15 AM, Resident #41 was observed awake and resting quietly in bed. Resident #41 stated that he had several recent hospitalizations in February 2019 but declined further interview. On 04/04/2019, the nurse's notes for February 2019 were reviewed and confirmed 2 hospital admissions on 02/19/2019 and 02/25/2019. On 04/04/2019, a copy of the Ombudsman Notification for both February hospital admissions was requested. The Social Worker (Employee G) stated I send the notifications to the Ombudsman at the end of each month, however I cannot explain why (Resident #41) is missing from my list and I cannot find the forms, he must have been overlooked. A copy of the facility policy regarding resident transfers was requested and provided by the Social Worker (Employee G). Line item #4 of the facility's policy entitled Transfer or Discharge Notice (revised December 2016) states that a copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman. On 04/04/2019 at approximately 5:30 PM, the Administrator (Employee A) and Director of Nursing (DON, Employee B) were notified of the findings. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to provide notice of the facility Bed Hold Policy on 2 separate occasions for 1 resident (Resident #41) in a sample size of 30 residents. For Resident #41, the facility staff failed to provide notice of the facility Bed Hold Policy upon transfer to the hospital on [DATE] and 02/25/2019. The Findings included: Resident #41, a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses to include but not limited to diabetes, heart failure, kidney failure requiring dialysis, and depression. Resident #41's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/13/2019 was coded as re-entry from an acute hospital. Resident #41 was coded with a Brief Interview of Mental Status (BIMS) score of 11 out of possible 15 indicating moderately impaired cognition. On 04/04/2019 at approximately 9:15 AM, Resident #41 was observed awake and resting quietly in bed. Resident #41 stated that he had several recent hospitalizations in February 2019 but declined further interview. On 04/04/2019, the nurse's notes for February 2019 were reviewed and confirmed 2 hospital admissions on 02/19/2019 and 02/25/2019. On 04/04/2019, a copy of the Bed Hold Notification for both February hospital admissions was requested. The Social Worker (Employee G) stated I cannot find any forms, they must not have been done. A copy of the facility policy regarding bed holds was requested and provided by the Director of Nursing (DON, Employee B). The facility's policy entitled Bed-Holds and Returns (revised 3/17, updated 1/19) states that prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. On 04/04/2019 at approximately 5:30 PM, the Administrator (Employee A) and DON (Employee B) were notified of the findings. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to conduct accurate assessment of resident's functional capacity for one resident (Resident #35) in a sample size of 30 residents. For Resident #35, the facility staff failed to accurately assess her visual functional capacity The findings included: Resident #35, 70-year female, was admitted to the facility on [DATE]. Diagnoses include but not limited to heart failure, hypertension, morbid obesity, and muscle weakness. Resident #35's most recent Minimum Data Set had an Assessment Reference Date (ARD) of 01/02/2019 and was coded as a significant change in status assessment. Resident #35 was coded with a Brief Interview of Mental Status (BIMS) score of 15 out of possible 15 indicative of intact cognition. Functional status for bed mobility, dressing, and personal hygiene were all coded as requiring extensive assistance from staff. Vision was coded as adequate - sees fine detail, including regular print in newspapers/books. On 04/02/2019 at 12:51 PM, an interview with Resident #35 was conducted. When asked if she had any concerns, Resident #35 stated she had an eye exam last year but never received glasses. Resident #35 stated she spoke with LPN B about it. Resident #35 also stated she loves to read but is unable to do so without her reading glasses. Resident #35 was not wearing glasses at the time of the interview. On 04/03/2019 at 9:10 AM, Resident #35 was observed in her bed sleeping with the head of the bed elevated approximately 30 degrees. On 04/04/2019 at 9:00 AM, Resident #35 was observed in bed, awake, with the head of her bed elevated approximately 45 degrees. The TV was on. Resident #35 was not wearing glasses. Resident #35 stated, my left eye is my good eye. She went on to say that if she closes her left eye, everything is blurry. On 04/04/2019 at 4:05 PM, LPN B was asked if she was aware Resident #35 needed glasses and LPN B stated, Yes. When asked about the process of getting glasses for Resident #35, LPN B stated, The social worker takes care of that. On 04/04/2019 at approximately 4:40 PM, Employee G, a social worker, was asked about the process for vision services and Employee G stated she visits with residents and asks them if they want to see the eye doctor and if so, their name is put on a list. Employee G then provided a list to show that Resident #35 was scheduled for vision services on 04/17/2019. On 04/05/2019 at 9:25 AM, Resident #35 was observed in her room, in bed, awake. When asked if a social worker had talked with her about getting glasses and she stated, No. She went on to say I miss being able to read. On 04/05/2019 at approximately 10:05 AM, Employee G was interviewed. When asked about the process if a resident has concerns pertaining to their glasses, she stated if the glasses are broken, she will try to fix them herself and used the example of applying superglue to the hinge. She also stated that if a resident needs reading glasses, she has a whole box of them in her office and will give them to the residents that need them. When asked if she knew why Resident #35 wanted to see the eye doctor, she stated she didn't know. On 04/05/2019 at approximately 10:15 AM, the MDS coordinator, Employee H, confirmed that Social Services completes Part B of the MDS assessment and then it is signed off by the nurse. Vision was coded as Adequate - sees fine detail, such as regular print in newspapers/books. The social service notes ranging from 06/15/2018 through 03/18/2019. Of the 15 social services entries by Employee G, there were no entries addressing vision services. The facility provided Summary Ocular Progress Notes dated 07/13/2018 for Resident #35. An optometrist documented the chief complaint, Blurred vision, hard to see at distance and near. Under Diagnosis and Treatments, it was documented, Age-related nuclear cataract, bilateral - cataracts - OU-Mild/stable - not visually significant - monitor 6 mos (months). The progress notes also included a glasses prescription that expires 7/13/19. The prescription documented, OD (right eye) -2.75 sph x .add +2.50 OS (left eye) -1.25 sph x .Add +2.50. In summary, Resident #35 was examined by an optometrist in July 2018 which included a prescription for glasses. Resident #35 loves to read but is unable to do so because she did not have glasses and did not receive glasses following the exam by the optometrist nearly 9 months ago. The most recent MDS assessment documented Resident #35's vision was adequate. On 04/05/2019 at approximately 2:30 PM, the DON and Administrator were notified of findings and they offered no further information or documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility documentation review and clinical record review, the facility staff failed to ensure the assessment of the resident accurately reflected the resident's status for one resident (Resident #55) in a survey sample of 30 residents. For Resident #55, the facility staff failed to accurately code the MDS (Minimum Data Set) (an assessment tool). The findings included: Resident #55, a [AGE] year old, was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: hypertension, Type 2 diabetes, and neuromuscular dysfunction of bladder. Resident #55's most recent MDS with an ARD (assessment reference date) of 2/8/19 was coded as an admission assessment. The resident was coded as having a BIMS (Brief Interview for Memory Status) score of 15, indicating the resident was cognitively intact. Functional status for transfers, dressing, toilet use and personal hygiene, was coded as Resident #55 required extensive assistance. Review of the Nursing admission Assessment, dated 2/1/19 revealed the resident had an indwelling catheter on admission. The hospital Discharge summary dated [DATE] indicated the resident had an indwelling catheter at the time of discharge from the hospital. A history and physical completed by a physician on 2/5/19 read that the resident had a foley catheter. Review of the Treatment Administration Record indicated Resident #55 received foley cath (catheter) care every shift from 2/3/19-4/3/19. Review of Resident #55's most recent MDS with an ARD of 4/3/19 was coded on section H0100 A. Indwelling catheter, as a catheter not being present. An interview was conducted with Resident #55 on 4/4/19 and when questioned about the catheter he stated, I've had that thing since I was in the hospital. The MDS, with an ARD of 2/8/19 was coded indicating the resident was incontinent of bowel. Review of the Nursing admission assessment dated [DATE] is coded that the resident is continent of bowel movements. Review of Fall Risk Assessments with dates of 2/1/19, 2/7/19, 2/15/19, and 2/22/19 stated that Resident #55 was, ambulatory and continent. In an Interview with Resident #55 on 4/5/19 at 9:34am the resident stated, I know when I need to go but it makes it easier for everyone if I use this diaper and let them know when it needs changing. I can get in my chair and go to the bathroom. Surveyor A conducted an interview with CNA M on 4/3/19 at approximately 2pm. During the interview, CNA M stated, [Resident #55's name] is continent, he has a foley, he will let me know when he needs changed, he just uses his brief. The Administrator and Director of Nursing were notified of the findings of facility staff failing to accurately code an assessment, on 4/4/19 at 5:30pm. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to complete a baseline care plan to provide behavioral health services for 1 resident (Resident #6) of the 30 residents in the survey sample. For Resident 6, the facility staff failed to develop a base line care plan for behavioral health services. The findings included: Resident #6, was admitted to the facility on [DATE]. Diagnoses included; depression, anxiety, heart disease, diabetes, high blood pressure, and chronic obstructive pulmonary disease (COPD). The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date (ARD) of 3-26-19. Resident #6 was coded with a Brief Interview of Mental Status (BIMS) score of 13 indicating little to no cognitive impairment and requiring assistance with physical activities of daily living. The full admission MDS assessment was also reviewed with an ARD date of 12-25-18 which revealed a BIMS score of 13, and both documents did not code depression nor anxiety as diagnoses to be treated or care planned for this Resident. An interview was conducted with Resident #6 on 4-2-19, at 1:00 p.m., and on 4-3-19 at 12:00 p.m. During the interviews, Resident #6 was tearful. The Resident stated that she did not get to see her family often, and had just moved to Virginia from another state, and had no friends here other than family. The Resident went on to say the family members lived quite a distance from the facility, and were busy raising children, and working. The Resident was asked if she had ever talked with the social worker about her feelings, and she stated no, I only saw her twice the first week I came here, and the day I had to move out of my room because my room mate was so disruptive. I haven't seen her since. When asked if she was interested in talking with the social worker, Resident #6 stated no, I would rather see a doctor. When asked if she meant a psychologist, or a psychiatrist, she stated yes. Resident #6's clinical record was reviewed. The social services notes indicated that the social services director (SSD) did visit the Resident on 12-19-18, and ten days later on 12-29-18 for routine admission, and 14 day follow up. The SSD did not document seeing the Resident again until 3-18-19 to prepare for the quarterly MDS submission. The SSD documented the following entry on 3-18-19; There has been no change to the resident during this quarter in behaviors or mood. The resident appears anxious, nervous in conversation but is very pleasant and nice. Residents son visits often, but tends to complain about little things or things of unimportance in regards to residents overall care and treatment. The resident tends to stay in room and is socially withdrawn by nature. On 3-19-19, the Resident was moved to another room. A review of all discipline notes in the clinical record did not reveal any documentation of the reason for the move, or how the Resident responded to the move. All behavior documents were reviewed, to include social work notes, physician notes, nursing notes, medication administration notes, and MDS documents, which revealed that the Resident had no aberrant behaviors. All physician notes were reviewed from admission to the dates of survey. There were 4 visits, and the documents revealed the first visit as a medical history, which was a 3 page form dated 12-20-18. This first visit document described the Resident as negative for psychiatric problems, and went on to document, alert and oriented to person/place/time. Depression and anxiety were not included in the diagnoses written on the form. On 2-7-19, 2-21-19, and 3-26-19 the doctor saw the Resident and documented the first 2 visits as recert visits for skilled care. The final visit on 3-26-19 was a sick visit, as the Resident had been diagnosed with pneumonia. None of these visits have any documentation under the psyche heading on the document, and they were left blank, as no assessment in this area was conducted. All other headings were assessed and documented as such. No psychiatric physician evaluation was ever conducted. Review of all nursing notes since admission, and to the time of survey revealed no assessment or interventions for depression or anxiety. Physician's orders, and Medication Administration Records (MAR's) were reviewed and revealed the following (4) psychoactive medications were ordered and administered during Resident #6's stay; 1. Zoloft 125 milligrams (mg) every day at 9:00 a.m. for depression. Ordered 12-19-18, and continued through survey. 2. Buspar 15 mg three times per day at 10:00 a.m., 2:00 p.m., and 9:00 p.m. for anxiety. Ordered 12-19-18, and continued through survey. 3. Xanax 0.5 mg every 6 hours as needed for anxiety. Ordered 12-19-18, discontinued 12-23-18, reordered 12-25-18 to stop 2-15-19. 4. Xanax 0.5 mg every day at 9:00 a.m. for anxiety. ordered 2-16-19, and continued through survey. The Residents care plan in the computer, and the paper copy with revisions from the care plan book on the nursing unit were reviewed. The 2 care plans revealed, no baseline initial care plan, nor comprehensive care plan was ever devised for the Resident's depression, anxiety, and behavioral health care needs. On 04/05/19 at 10:10 AM, an interview with Employee H, the MDS/ Care Plan Coordinator was conducted. When asked about how to determine when an intervention on the care was implemented, Employee H stated, We don't date interventions. She went on to say the intervention either continues or it would be resolved. When asked about a resolved intervention, Employee H stated, I would delete it. Employee H stated the paper copy care plans are kept in a book on the unit, updated on the paper, and eventually entered into the computer. At the end of day meeting on 4-3-19, the Director of Nursing (DON) and Administrator were notified that it did not appear that the facility staff were providing for Resident #6's behavioral health needs. It was reviewed that it did not appear that Resident #6's depression and anxiety were ever care planned, nor was there any formal psychiatric assessment, nor social work interventions. The administrative staff were asked to provide clarification in this matter, and they stated they would get back to the surveyors with any information found. The Administrator and DON were notified of the concern again on 4-4-19 at 11:00 a.m. regarding Resident #6, and the DON stated you have everything we have. No further information was able to be provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to develop a comprehensive resident-centered care plan for 3 residents (Resident #63, #35, #6) in a sample size of 30 residents. The findings included: 1. For Resident #63, the facility staff failed to date interventions and goals on the care plan in order to establish time frames and measurable objectives. 2. For Resident #35, the facility staff failed to include vision services/needs on the care plan. 3. For Resident #6, the facility staff failed to develop a comprehensive care plan for the behavioral health services needs of depression and anxiety. The findings include: 1. For Resident #63, the facility staff failed to date interventions and goals on the care plan in order to establish time frames and measurable objectives. Resident #63, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include but not limited to Non-ST elevation (NSTEMI) myocardial infarction, heart failure, cerebral infarction, hypertension, diabetes, and hemiplegia. Resident #63's most recent Minimum Data Set had an Assessment Reference Date (ARD) of 02/18/2019 and was coded as a quarterly assessment. Resident #63 was coded with a Brief Interview of Mental Status (BIMS) score of 3 out of possible 15 indicative of severe cognitive impairment. Functional status for bed mobility, transfers, dressing, and personal hygiene were all coded as requiring extensive assistance from staff. Functional status for eating was coded as requiring supervision from staff. The care plan in the electronic health record was reviewed. There were 12 problem areas. The interventions associated with each problem did not include dates of initiation and revision. Under Goal and Target Date, each goal would end with .through next review. There were no measurable timeframes, initiation, or target dates included. On 04/02/2019 at 4:55 PM, the facility provided a paper copy of the care plan. Employee L stated the most updated version of the care plan is on paper copy kept on the unit. Employee L stated electronic care plans (what is seen on the computer) are updated quarterly. Both the electronic and paper versions of the care plan did not have dates associated with interventions with the exception of one which documented (handwritten), Hospice as of 11/16/18 and an intervention that was crossed out and documented, D/C (discontinued) 1/15/19. On 04/05/19 at 10:10 AM, an interview with Employee H, the MDS/Care Plan Coordinator was conducted. When asked about how to determine when an intervention on a care plan was implemented, Employee H stated, We don't date interventions. She went on to say the intervention either continues or it would be resolved. When asked about a resolved intervention, Employee H stated, I would delete it. Employee H stated the paper copy care plans are kept in a book on the unit, updated on the paper, and eventually entered into the computer. When asked about the CNA (closet) care plans, Employee H stated closet care plans are also updated as needed. On 04/05/2019 at approximately 2:30 PM, the DON and Administrator were notified of findings and they offered no further information or documentation. 2. For Resident #35, the facility staff failed to include vision services/needs on the care plan. Resident #35, 70-year female, was admitted to the facility on [DATE]. Diagnoses include but not limited to heart failure, hypertension, morbid obesity, and muscle weakness. Resident #35's most recent Minimum Data Set had an Assessment Reference Date (ARD) of 01/02/2019 and was coded as a significant change in status assessment. Resident #35 was coded with a Brief Interview of Mental Status (BIMS) score of 15 out of possible 15 indicative of intact cognition. Functional status for bed mobility, dressing, and personal hygiene were all coded as requiring extensive assistance from staff. Vision was coded as adequate - sees fine detail, including regular print in newspapers/books. On 04/02/2019 at 12:51 PM, an interview with Resident #35 was conducted. When asked if she had any concerns, Resident #35 stated she had an eye exam last year but never received glasses. Resident #35 stated she spoke with LPN B about it. Resident #35 also stated she loves to read but is unable to do so without her reading glasses. Resident #35 was not wearing glasses at the time of the interview. On 04/03/2019 at 9:10 AM, Resident #35 was observed in her bed sleeping with the head of the bed elevated approximately 30 degrees. On 04/04/2019 at 9:00 AM, Resident #35 was observed in bed, awake, with the head of her bed elevated approximately 45 degrees. The TV was on. Resident #35 was not wearing glasses. Resident #35 stated, my left eye is my good eye. She went on to say that if she closes her left eye, everything is blurry. On 04/04/2019 at 4:05 PM, LPN B was asked if she was aware Resident #35 needed glasses and LPN B stated, Yes. When asked about the process of getting glasses for Resident #35, LPN B stated, The social worker takes care of that. On 04/04/2019 at approximately 4:40 PM, Employee G, a social worker, was asked about the process for vision services and Employee G stated she visits with residents and asks them if they want to see the eye doctor and if so, their name is put on a list. Employee G then provided a list to show that Resident #35 was scheduled for vision services on 04/17/2019. On 04/05/2019 at 9:25 AM, Resident #35 was observed in her room, in bed, awake. When asked if a social worker had talked with her about getting glasses and she stated, No. She went on to say I miss being able to read. The facility provided Summary Ocular Progress Notes dated 07/13/2018 for Resident #35. An optometrist documented the chief complaint, Blurred vision, hard to see at distance and near. Under Diagnosis and Treatments, it was documented, Age-related nuclear cataract, bilateral - cataracts - OU-Mild/stable - not visually significant - monitor 6 mos (months). The progress notes also included a glasses prescription that expires 7/13/19. The prescription documented, OD (right eye) -2.75 sph x .add +2.50 OS (left eye) -1.25 sph x .Add +2.50. The care plan was reviewed. A problem/need onset dated 04/11/2016 documented, [Resident #35] prefers to structure her own day, and stays in bed per her choice, enjoys reading Bible, listening to gospel music, keeping up with news, and participating with religious programs in her room. Enjoys reading and writing and getting to know new people. In past, loved to sing. Has dx (diagnosis) of DM2 (type 2 diabetes) and severe morbid obesity. Approaches associated with this focus included but not limited to offer and provide writing materials and other materials to promote continued independence; provide Bible for resident to use as requested. Resident #35's vision deficit and her need for glasses was not addressed on the care plan. In summary, Resident #35 was examined by an optometrist in July 2018 which included a prescription for glasses. Resident #35 loves to read but is unable to do so because she did not have glasses and did not receive glasses following the exam by the optometrist nearly 9 months ago. Vision needs are not included in the care plan. On 04/05/2019 at approximately 2:30 PM, the DON and Administrator were notified of findings and they offered no further information or documentation. 3. For Resident #6, the facility staff failed to develop a comprehensive care plan for the behavioral health services needs of depression and anxiety. Resident #6, was admitted to the facility on [DATE]. Diagnoses included; depression, anxiety, heart disease, diabetes, high blood pressure, and chronic obstructive pulmonary disease (COPD). The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date (ARD) of 3-26-19. Resident #6 was coded with a Brief Interview of Mental Status (BIMS) score of 13 indicating little to no cognitive impairment and requiring assistance with physical activities of daily living. The full admission MDS assessment was also reviewed with an ARD date of 12-25-18 which revealed a BIMS score of 13, and both documents did not code depression nor anxiety as diagnoses to be treated or care planned for this Resident. An interview was conducted with Resident #6 on 4-2-19, at 1:00 p.m., and on 4-3-19 at 12:00 p.m. During the interviews, Resident #6 was tearful. The Resident stated that she did not get to see her family often, and had just moved to Virginia from another state, and had no friends here other than family. The Resident went on to say the family members lived quite a distance from the facility, and were busy raising children, and working. The Resident was asked if she had ever talked with the social worker about her feelings, and she stated no, I only saw her twice the first week I came here, and the day I had to move out of my room because my room mate was so disruptive. I haven't seen her since. When asked if she was interested in talking with the social worker, Resident #6 stated no, I would rather see a doctor. When asked if she meant a psychologist, or a psychiatrist, she stated yes. Resident #6's clinical record was reviewed. The social services notes indicated that the social services director (SSD) did visit the Resident on 12-19-18, and ten days later on 12-29-18 for routine admission, and 14 day follow up. The SSD did not document seeing the Resident again until 3-18-19 to prepare for the quarterly MDS submission. The SSD documented the following entry on 3-18-19; There has been no change to the resident during this quarter in behaviors or mood. The resident appears anxious, nervous in conversation but is very pleasant and nice. Residents son visits often, but tends to complain about little things or things of unimportance in regards to residents overall care and treatment. The resident tends to stay in room and is socially withdrawn by nature. The SSD stated no change, yet describes anxiety and nervousness (which had not been documented before) without assessing for a reason. She also describes the family complaints as unimportant, and, without any psychological assessment, or physicians evaluation, describes the Resident as socially withdrawn by nature. On 3-19-19, the Resident was moved to another room. A review of all discipline notes in the clinical record did not reveal any documentation of the reason for the move, or how the Resident responded to the move. All behavior documents were reviewed, to include social work notes, physician notes, nursing notes, medication administration notes, and MDS documents, which revealed that the Resident had no aberrant behaviors. All physician notes were reviewed from admission to the dates of survey. There were 4 visits, and the documents revealed the first visit as a medical history, which was a 3 page form dated 12-20-18. This first visit document described the Resident as negative for psychiatric problems, and went on to document, alert and oriented to person/place/time. Depression and anxiety were not included in the diagnoses written on the form. On 2-7-19, 2-21-19, and 3-26-19 the doctor saw the Resident and documented the first 2 visits as recert visits for skilled care. The final visit on 3-26-19 was a sick visit, as the Resident had been diagnosed with pneumonia. None of these visits have any documentation under the psyche heading on the document, and they were left blank, as no assessment in this area was conducted. All other headings were assessed and documented as such. No psychiatric physician evaluation was ever conducted. Review of all nursing notes since admission, and to the time of survey revealed no assessment or interventions for depression or anxiety. Physician's orders, and Medication Administration Records (MAR's) were reviewed and revealed the following (4) psychoactive medications were ordered and administered during Resident #6's stay; 1. Zoloft 125 milligrams (mg) every day at 9:00 a.m. for depression. Ordered 12-19-18, and continued through survey. 2. Buspar 15 mg three times per day at 10:00 a.m., 2:00 p.m., and 9:00 p.m. for anxiety. Ordered 12-19-18, and continued through survey. 3. Xanax 0.5 mg every 6 hours as needed for anxiety. Ordered 12-19-18, discontinued 12-23-18, reordered 12-25-18 to stop 2-15-19. 4. Xanax 0.5 mg every day at 9:00 a.m. for anxiety. ordered 2-16-19, and continued through survey. The Residents care plan in the computer, and the paper copy with revisions from the care plan book on the nursing unit were reviewed. The 2 care plans revealed no comprehensive care plan was ever devised for the Resident's depression, anxiety, and behavioral health care needs. On 04/05/19 at 10:10 AM, an interview with Employee H, the MDS/ Care Plan Coordinator was conducted. When asked about how to determine when an intervention on the care was implemented, Employee H stated, We don't date interventions. She went on to say the intervention either continues or it would be resolved. When asked about a resolved intervention, Employee H stated, I would delete it. Employee H stated the paper copy care plans are kept in a book on the unit, updated on the paper, and eventually entered into the computer. At the end of day meeting on 4-3-19, the Director of Nursing (DON) and Administrator were notified that it did not appear that the facility staff were providing for Resident #6's behavioral health needs. It was reviewed that it did not appear that Resident #6's depression and anxiety were ever care planned, nor was there any formal psychiatric assessment, nor social work interventions. The administrative staff were asked to provide clarification in this matter, and they stated they would get back to the surveyors with any information found. The Administrator and DON were notified of the concern again on 4-4-19 at 11:00 a.m. regarding Resident #6, and the DON stated you have everything we have. No further information was able to be provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, clinical record reviews, and facility documentation, the facility staff failed to revise resident-centered care plans for 3 residents (Resident #63, Resident #49, Resident #68) in a sample size of 30 residents. 1. For Resident #63, the facility staff failed to revise the care plan to reflect current code status from Full Code to DNR 2. For Resident # 49, the facility staff failed to document the dates of problems and interventions listed on the careplan when revised. 3. For Resident # 68, the facility staff failed to document the dates of problems and interventions listed on the careplan when revised. The findings included: Resident #63, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include but not limited to Non-ST elevation (NSTEMI) myocardial infarction, heart failure, cerebral infarction, hypertension, diabetes, and hemiplegia. Resident #63's most recent Minimum Data Set had an Assessment Reference Date (ARD) of 02/18/2019 and was coded as a quarterly assessment. Resident #63 was coded with a Brief Interview of Mental Status (BIMS) score of 3 out of possible 15 indicative of severe cognitive impairment. Functional status for bed mobility, transfers, dressing, and personal hygiene were all coded as requiring extensive assistance from staff. Functional status for eating was coded as requiring supervision from staff. On 04/02/2019 at 4:15 PM, the current physician's orders in the electronic health record were reviewed. A physician's order dated 11/25/2018 documented, Resident Hospice care as of 11/16/18 [hospice company name]. A physician's order dated 11/26/2018 documented, DNR (do not resuscitate). The care plan in the electronic health record was reviewed. A problem onset dated 04/02/2015 documented, [Resident #63] has an inability to perform ADLs (Activities of Daily Living) independently secondary to muscle spasms, HTN (hypertension), CVA (cerebral vascular accident), hemiparesis, RAKA (right above-the-knee amputation), depression. Resident refuses meals & supplements at time. (sic) One approach documented for this problem documented, Full code. On 04/02/2019 at 4:40 PM, an interview with CNA C was conducted. When asked where a CNA would find out information about how to care for Resident #63, she stated she looks at the care plan that is posted on the inside of Resident #63's closet door. CNA C and this surveyor then entered Resident#63's room and CNA C then opened Resident #63's closet door to show a document entitled, CNA Care Plan which included Resident #63's name and room number (handwritten). It also included Resident #63's needs pertaining to ADLs. On the left hand side of the paper, it was documented, Information is current as of this date: 10-31-18. On the top left side of the CNA Care Plan, it was documented Full code. CNA C then closed the closet door. This surveyor then asked CNA C what Resident #63's code status was and she stated, She's a full code. A copy of the CNA Care Plan was requested and CNA C stated she would have to ask the nurse. On 04/02/2019 at approximately 4:45 PM, this surveyor and CNA C walked to the nurse's station. After speaking with a nurse, CNA C went to Resident #63's room to retrieve the CNA Care Plan on the closet door. The staff nurse got Resident #63's hard chart and displayed the Durable Do Not Resuscitate Order and stated to this surveyor, Do you realize this resident is on hospice and she's a DNR? CNA C returned with the CNA Care Plan and handed it to LPN B. LPN B looked at the document and stated, It (closet care plan) wasn't updated. A copy of the Durable Do Not Resuscitate order and the electronic care plan were requested. On 04/02/2019 at 4:55 PM, a Durable Do Not Resuscitate document was provided. It was dated 11/20/18 and signed by physician, responsible party, and a witness. A paper copy of the electronic care plan was provided. Under the problem entitled, Resident #63] has an inability to perform ADLs (Activities of Daily Living) independently secondary to muscle spasms, HTN (hypertension), CVA (cerebral vascular accident), hemiparesis, RAKA (right above-the-knee amputation), depression. Resident refuses meals & supplements at time. ,Full Code was crossed out and DNR was added (handwritten and not dated or initialed). Employee L stated the most updated version of the care plan is on paper kept on the unit. Employee L stated electronic care plans (what is seen on the computer) are updated quarterly. On 04/05/19 at 10:10 AM, an interview with Employee H, the MDS, Care Plan Coordinator was conducted. When asked about how to determine when an intervention on a care plan was implemented, Employee H stated, We don't date interventions. She went on to say the intervention either continues or it would be resolved. When asked about a resolved intervention, Employee H stated, I would delete it. Employee H stated the paper copy care plans are kept in a book on the unit, updated on the paper, and eventually entered into the computer. When asked about the CNA (closet) care plans, Employee H stated closet care plans are also updated as needed. The facility policy entitled, Advanced Directives was reviewed. Section 7 documented, Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. Section 10 documented, The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive. In summary, there was conflicting information regarding Advanced Directives on the electronic care plan, the paper copy care plan, and the CNA closet care plan for Resident #63. On 04/05/2019 at approximately 2:30 PM, the DON and Administrator were notified of findings and they offered no further information or documentation. 2. For Resident # 49, the facility staff failed to document the dates of problems and interventions listed on the careplan when revised. Resident # 49, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Alzheimer's Disease, Hypertension, Malignant Neoplasm of Prostate, Gastroesophageal Reflux Disease, Dementia, Osteoarthritis, and Anxiety. Resident # 49's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 2/1/2019. The MDS coded Resident # 49 with a BIMS (Brief Interview for Mental Status) score of 3 out of 15, indicating severe cognitive impairment. Resident # 49 was coded as requiring limited to extensive assistance of one staff person for Activities of Daily Living except total assistance of one staff person for bathing. Resident # 49 was coded as occasionally incontinent of bowel and bladder. On 04/04/2019 at 2:30 PM, review of the clinical record was conducted. Resident #49 was admitted to the facility on [DATE]. A review of Resident # 49's clinical record was conducted during the survey. Resident #49's care plan, revised on 02/27/2019, read that Resident # 49 had a diagnosis of Alzheimer's Disease and dementia resulting in confusion at times. One of the interventions listed was Reorient as needed. Under the problem: Has inability to perform ADLS (Activities of Daily Living) independently secondary to Alzheimer's disease, dementia . , there was a problem added by handwriting: occasionally refuses scheduled shower, become agitated and at times aggressive. There was no date of when that handwritten note was added. There were interventions that were handwritten: Encourage res (resident) to take showers. Approach Res (Resident) in a calm manner. There were other interventions handwritten on the care plan under other problems. There were no dates of when the problems or interventions were added. On 04/05/19 at 10:10 AM, an interview with Employee H, the MDS/ Care Plan Coordinator was conducted. When asked about how to determine when an intervention on the care was implemented, Employee H stated, We don't date interventions. Employee H state the intervention would either continue or it would be resolved. When asked about a resolved intervention, Employee H stated, I would delete it. Employee H stated the paper copy care plans were kept in a book on the unit, updated on the paper, and eventually entered into the computer. There was no way to determine when interventions were added to the care plan or if the care plan needed to be revised. On 4/5/2019 during the end of day debriefing, the facility Administrator and the Director of Nursing were informed of the findings. The Director of Nursing stated the interventions and revisions should be dated. No further information was provided. 3. For Resident #68, the facility staff failed to document the dates of problems and interventions listed on the careplan when revised. Resident # 68, a [AGE] year old female was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Alzheimer's Disease, Hypertension, Major Depressive Disorder, Gastroesophageal Reflux Disease, Dementia, Cardiomegaly, and Anxiety. Resident # 68's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 2/21/2019. The MDS coded Resident # 68 with a BIMS (Brief Interview for Mental Status) score of 3 out of 15, indicating severe cognitive impairment. Resident # 68 was coded as requiring extensive assistance of one to two staff persons for Activities of Daily Living except total assistance of one staff person for Bathing. Resident # 68 was coded as frequently incontinent of bowel and bladder. Review of the clinical record was conducted on 4/4/2019. A review of Resident # 68's clinical record was conducted during the survey. Resident #68's care plan, revised on 02/27/2019, read that Resident # 68 had a diagnosis of Alzheimer's Disease and dementia resulting in confusion at times. One of the interventions listed was Reorient as needed. Another problem listed was: Bunion to right inner foot and (L) (left) foot skin integrity Treat as ordered to bunion on right inner foot. [NAME] hose per order, treat as ordered to left foot to maintain skin integrity, weekly weights, Aquaphor to BLE (Bilateral Lower Extremities) every other day. There was no documentation of when the problems or interventions were added to the careplan. There were other interventions handwritten on the care plan under other problems. There were no dates of when the problems or interventions were added. On 04/05/19 at 10:10 AM, an interview with Employee H, the MDS/ Care Plan Coordinator ,was conducted. When asked about how to determine when an intervention on the care was implemented, Employee H stated, We don't date interventions. Employee H state the intervention would either continue or it would be resolved. When asked about a resolved intervention, Employee H stated, I would delete it. Employee H stated the paper copy care plans were kept in a book on the unit, updated on the paper, and eventually entered into the computer. There was no way to determine when interventions were added to the care plan or if the care plan needed to be revised. On 4/5/2019 during the end of day debriefing, the facility Administrator and Director of Nursing were informed of the findings. The Director of Nursing stated the interventions and revisions should be dated. The facility provided no further information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review the facility staff failed to maintain professional standards when administering medications for 1 Resident (#97) in a survey sample of 30 Residents. For Resident #97 the facility staff failed to administer Heparin (an anti-coagulant) ,Daily, as ordered by the Physician. The findings include: Resident #97 is an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Anemia, Hypertension, Dementia (Alzheimer's Type) History of Stroke, Anxiety and Depression. The most recent Minimum Data Set assessment was a PPI 5 Day assessment with an assessment reference date (ARD) of 3/12/19 Resident #97 was coded as having a (Brief Interview of Mental Status) BIMS score of 3, indicating severe cognitive impairment. Resident # 97 was coded as requiring 1 person physical assistance for all aspects of ADL's and a physical assist of 2 staff for transfers. On 4/5/19 during clinical record review it was noted that Resident #97 had orders for Flushing Midline Catheter (Intravenous Line for medication administration.). The orders began on 3/17/18 at 2:30 PM. The orders read: Heparin flush 10 Units/ML [10 Units per Milliliter] Flush midline with Heparin [an Anti-Coagulant] & Normal Saline QD [Every Day] The order appears on the (Medication Administration Record) MAR signed off and timed for 6:30 AM, 2:30 PM and 10:30 PM (3 times daily) The first dose was signed off at 2:30 PM on 3/17/19 and continued to be signed off as administered three (3) times a day for the duration of the month of March. A second order was initiated on 3/17/19 in addition to the original Heparin Flush order. The order stated: Normal Saline Flush Syringe Flush Midline with saline & Heparin QD [Every Day] Discontinue Date 3/18/19 - That order was timed for 2:00 PM (daily) and signed off on 3/17/19 and 3/18/19 at 2:00 PM then it was discontinued. A third order was initiated on 3/18/19 in addition to the Heparin Flush order. That order stated: Clarification order: Normal Saline Flush Syringe 10 ML Flush Midline with 10 ML NS [normal saline] Q 12 hours [Every 12 hours] This order was written on the 18th but not imitated until the 19th and timed for 9:00 AM and 9:00 PM. This order was signed off as administered twice daily for the duration of the month of March. The Physicians order sheet for April read: Heparin flush 10 Units/ML Flush midline with Heparin [an Anti-Coagulant] & Normal Saline QD [Every Day] [Once again the Heparin order was timed and signed off at 6:30 AM 2:30 PM and 10:30 PM for April 1st-5th] Also on April Physicians Orders was: Clarification order: Normal Saline Flush Syringe 10 ML Flush Midline with 10 ML NS [normal saline] Q 12 hours [Every 12 hours] The Normal Saline order was signed off at 9:00 AM and 9:00 PM. On 4/5/19 at 1:45 PM LPN E was asked how many times a day does the Residents Midline get flushed and stated that it was done every shift. She then elaborated that Night shift does it at 6:30 AM, Day shift at 2:30 PM and Evening shift does it at 10:30 PM. The facility cited [NAME] as the resource used for professional nursing standards. Guidance was given from [NAME], Fundamentals of Nursing, which reads: To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to these rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation review and clinical record review, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay. For Resident #104, the facility staff failed to complete a discharge summary that accurately described the clinical status of the resident and a recapitulation of the resident's stay. The findings included: Resident #104, [AGE] year old, admitted to the facility on [DATE] and discharged on 1/10/19. The resident's diagnoses included but were not limited to, legal blindness, muscle weakness, encephalopathy, dysphagia, cognitive communication deficit and athscl [sic] heart disease. Resident #104's most recent MDS (Minimum Data Set) (an assessment tool) with an ARD (assessment reference date) of 1/1/19 was coded as a 60 day assessment. Resident #104 was coded as having a BIMS (brief interview for memory status) score of 4, indicating severe cognitive impairment. Functional status for Resident #104 was coded as being totally dependent on staff for transfers, locomotion, eating, toilet use and personal hygiene. Review of the Recapitulation of resident stay dated 1/10/19 by various members of the interdisciplinary team to include, social services director, director of nursing and certified dietary manager was incomplete. The following items had no response written: 1. the reason for admission 2. treatment provided 3. progress 4. reason for discharge/discharge diagnosis 5. mental and psychosocial status 6. cognitive status 7. clinical lab values or diagnostic tests 8. weight trend 9. eating habits/preferences Drug therapy required had P.O.S. (physician's order sheet) noted on the line. Review of the discharge summary signed by the physician on 1/15/19 and signed by the director of nursing on 1/10/19 revealed the following: 1. functional status: alert to self 2. dental condition: blank 3. cognitive status: limited with no explanation 4. activities potential: limited with no explanation 5. drug therapy : P.O.S. [sic] (physician's order sheet) 6. Condition at the time of discharge: blank Review of the facility policy titled, Discharge Summary and Plan revised December 2016 read: The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: a. current diagnosis, b. medical history, c. course of illness, treatment and/or therapy since entered the facility, d. current laboratory, radiology, consultation, and diagnostic test results; e. physical and mental functional status, f. ability to perform activities of daily living, g. sensory and physical impairments, h. nutritional status and requirements, i. special treatments or procedures, j. mental and psychosocial status (ability to deal with life, interpersonal relationships and goals, make healthcare decisions, and indicators of resident behavior and mood); k. discharge potential, l. dental condition, m. activities potential (the ability and desire to take part in activity pursuits which maintain or improve physical, mental, and psychosocial well-being); n. rehabilitation potential (the ability to improve independence in functional status through restorative care programs); o. cognitive status (the ability to problem solve, decide, remember, and be aware of and respond to safety hazards) and p. medication therapy (all prescription and over-the-counter medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident). The Administrator and Director of Nursing were informed of the facility staff to complete a discharge summary that accurately describes the current clinical status of the resident and a recapitulation of the resident's stay on 4/4/19 at 5:30pm. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview and clinical record review, the facility staff failed to provide necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish for one resident (Resident #55) in a survey sample of 30 residents. The facility staff failed to provide care and assistance in ADL's (Activities of daily living) to maintain a resident's continence for Resident #55. The findings included: Resident #55, a [AGE] year old, was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: hypertension, Type 2 diabetes, and neuromuscular dysfunction of bladder. Resident #55's most recent MDS with an ARD (assessment reference date) of 2/8/19 was coded as an admission assessment. The resident was coded as having a BIMS (Brief Interview for Memory Status) score of 15, indicating the resident was cognitively intact. Functional status for transfers, dressing, toilet use and personal hygiene, was coded as Resident #55 required extensive assistance of staff. Review of the Nursing admission assessment dated [DATE] is coded that the resident is continent of bowel movements. In an interview with Resident #55 on 4/5/19 at 9:34am the resident stated, I know when I need to go but it makes it easier for everyone if I use this diaper and let them know when it needs changing. I can get in my chair and go to the bathroom. The baseline careplan indicates resident requires assistance of one staff person for transfers and toileting and is continent of bowel. The CNA careplan dated 2/1/19 indicates resident needs assisted toileting. Review of the Bowel & Bladder Report from 2/2/19-4/4/19 showed Resident #55 had a bowel movement on 70 of those days. Of the 70 occurrences 66 of those were incontinent, using an adult brief. Surveyor A conducted an interview with CNA M on 4/3/19 at approximately 2pm. During the interview, CNA M stated, [Resident #55's name] is continent, he has a foley, he will let me know when he needs changed, he just uses his brief. The Administrator and Director of Nursing were made aware of the findings of staff failing to provide ADL assistance to maintain bowel continence for Resident #55 during end of the day meeting on 4/4/19. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide needed care and services for one resident (Resident #45) in a sample size of 30 residents. 1. For Resident #45, the facility failed to identify, assess, and notify provider for a potential change in condition. It was documented in the clinical record Resident #45 weighed 226.4 pounds on 03/25/2019 and 199.6 pounds on 04/01/2019 (11.84% weight loss in 6 days). The findings include: Resident #45, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but not limited to atherosclerotic heart disease, diabetes, cerebral infarction, hypertension, atrial fibrillation, and dementia. Resident #45's most recent MDS (minimum data set) with an ARD (assessment reference date) of 01/25/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as 9 out of possible 15 indicative of moderate cognitive impairment. Weight gain or weight loss of more than 10% in the past 6 months was coded as No or unknown. On 04/03/2019 at 9:10 AM, Resident #45 was observed in his room seated in his wheelchair watching TV in no apparent distress. On 04/03/2019 at 11:43 AM, the electronic clinical record was reviewed for weight status. An entry dated 03/25/2019 at 1:49 PM documented the value 226.4 pounds. An entry dated 04/01/2019 at 11:32 AM documented the value 199.6 pounds indicative of an 11.84% weight loss in 6 days. The nurse's notes for 04/01/2019 were reviewed. There was no documentation addressing or assessing the weight loss. The active physician's orders were reviewed. An entry dated 03/18/2019 documented, Weight monitor weekly. An entry dated 03/14/2019 documented, Lasix 40 mg by mouth BID (twice a day). A provider's visit dated 03/14/2019 under the section Subjective documented, Left axillary 3x3 cm mass with pain; bilateral leg edema. On the bottom of the form under the section Diagnosis part (2) documented, Bilateral leg edema. Under the section Plan part (2) documented, Lasix 40 mg po BID (by mouth twice daily) and part (3) weight monitor weekly. On 04/04/2019 at 11:10 AM, an interview with CNA L was conducted. When asked about the process for weighing residents, CNA L stated there is one scale in the facility and 2 she is one of two CNA's that weigh most of the residents. CNA L stated that weights are recorded in the weight book. CNA L stated she writes weekly weights on a form that is kept in the back office. CNA L and this surveyor went to that office and CNA L retrieved a clipboard from the shelf with documents on it entitled Weekly Weight Tracking System. It contained the weekly weights for residents in the month of March 2019. Resident #45 was not listed. CNA L stated since Resident #45 was scheduled for weekly weights every Monday instead of Wednesdays, it would be completed by the CNA assigned to care for him that day. CNA L stated that the CNA would report to the nurse what the value was and the nurse would enter it into the computer. When asked about weight changes, CNA L stated they compare weights and if there is a 5 pound weight change, more or less, they tell the nurse and the QA nurse who is responsible for monitoring weights. On 04/04/2019 at 11:30 AM, an interview with LPN F was conducted. When asked about the expectation of the nurse if there was a significant weight change, LPN F stated it would depend on the parameters. LPN F went on to say if it exceeded parameters, she would notify the physician, the responsible party, and the QA nurse. When asked specifically about Resident #45 being on Lasix and losing 27 pounds in 6 days, she stated, That's desirable weight loss to get rid of extra fluid. On 04/04/2019 at 12:25 PM, an interview with the QA nurse was conducted. She confirmed that she monitors weights on all residents. When asked about the process for recording weights, she stated monthly weights go in the weight book and weekly weights go on the weight tracking sheet. She stated that no one puts weekly weights in the computer because weekly weight sheets in the weight book eventually go into the hard charts as part of the clinical record. The QA nurse stated that daily weights are done by the assigned CNA and reported to the assigned nurse. When asked about how she tracks residents' weights, she stated she gets a monthly weight tracking form from the electronic health record and also uses a Microsoft excel spreadsheet. When asked about the expectation for weight changes, the QA nurse stated that if there is a weight change 3 pounds, more or less, we notify the doctor and investigate what we need to do. When asked if she checks for weight values in resident's electronic health record, she stated, No. The QA nurse and this surveyor looked at Resident #45's weight values in the electronic health record. When the QA nurse saw the weight values for 03/25/2019 and 04/01/2019, she stated, That weight (199.6 pounds) should've been rechecked. On 04/04/2019 at 3:40 PM, the QA nurse provided a copy of a clinical note entry dated 04/04/2019 at 3:31 PM: weighed resident due to last weekly weight was incorrect; resident current weight 235.2#; resident has not lost weight but has gained 8.8#; nurse practitioner made aware and she stated just to monitor him and continue weekly weights at this time; call placed to [family member name]; and made aware; [family member name] stated I guess I gotta quit bringing him in all those snacks. In summary, Resident #45 had a potentially significant weight loss that was not identified or assessed by facility staff. On 04/05/2019 at approximately 2:30 PM, the Administrator and the DON were notified of findings and offered no further information or documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident interview, staff interview, and clinical record review the facility staff failed to provide proper treatment and hearing assistive devices for 2 residents (Resident #57 and #35) in a sample size of 30 residents. 1. For Resident #57, the facility staff failed to provide proper treatment and assistive devices to maintain and/or enhance his hearing ability. 2. For Resident #35, the facility staff failed to assist with procurement of eye glasses as prescribed by optometrist. The Findings included: Resident #57, an [AGE] year old male who was admitted to the facility on [DATE] with diagnoses to include but not limited to diabetes, right leg amputation, high blood pressure, peripheral vascular disease, and depression. Resident #57's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/01/2019 was coded as an Annual assessment. Resident #57 was coded with a Brief Interview of Mental Status (BIMS) score of 14 out of possible 15 indicating no cognitive impairment. He was also coded as having moderate hearing difficulty with no hearing aids used. On 04/02/2019 at approximately 2:00 PM an interview was conducted with Resident #57. He stated if I had hearing aids, I would use them .I had to choose between teeth or hearing aids and I chose teeth I have had two sets of hearing aids and they don't last long .I don't know what else to do. During the course of the interview, Resident #57 appeared to have difficulty hearing by cupping his right hand around his right ear and asking for questions to be repeated frequently. He was able to comprehend the questions and was apologetic for not being able to hear better. On 04/02/2019 a review was conducted of Resident #57's clinical record. A copy of Resident #57's current Care Plan was requested and received (Care Plan was undated). On page 9 it read, Wears glasses and is HOH [hard of hearing] ENT [ear, nose, throat] consult. No evidence of ENT consultation was provided. On 04/03/2019 at approximately 4:00 PM, an interview was conducted with the Social Worker (Employee G). When asked about Resident #57's remark with regard to having to choose between teeth or hearing aids, she replied, It has not been brought to my attention .I never knew he had hearing aids, I know he is hard of hearing. When asked if she had professionally assessed him, she replied Nobody has ever told me that he needed anything .I do review the MDS quarterly but he only has a moderate hearing loss .Nursing needs to tell me if he needs anything .I have resources available to me to get him hearing aids. On 04/04/2019 at approximately 5:30 PM, the Administrator (Employee A) and Director of Nursing (DON, Employee B) were notified of the findings. No further information was received, including a policy on Assistive Devices. 2. For Resident #35, the facility staff failed to assist with procurement of eye glasses as prescribed by optometrist. Resident #35, 70-year female, was admitted to the facility on [DATE]. Diagnoses include but not limited to heart failure, hypertension, morbid obesity, and muscle weakness. Resident #35's most recent Minimum Data Set had an Assessment Reference Date (ARD) of 01/02/2019 and was coded as a significant change in status assessment. Resident #35 was coded with a Brief Interview of Mental Status (BIMS) score of 15 out of possible 15 indicative of intact cognition. Functional status for bed mobility, dressing, and personal hygiene were all coded as requiring extensive assistance from staff. Vision was coded as adequate - sees fine detail, including regular print in newspapers/books. On 04/02/2019 at 12:51 PM, an interview with Resident #35 was conducted. When asked if she had any concerns, Resident #35 stated she had an eye exam last year but never received glasses. Resident #35 stated she spoke with LPN B about it. Resident #35 also stated she loves to read but is unable to do so without her reading glasses. Resident #35 was not wearing glasses at the time of the interview. On 04/03/2019 at 9:10 AM, Resident #35 was observed in her bed sleeping with the head of the bed elevated approximately 30 degrees. On 04/04/2019 at 9:00 AM, Resident #35 was observed in bed, awake, with the head of her bed elevated approximately 45 degrees. The TV was on. Resident #35 was not wearing glasses. Resident #35 stated, my left eye is my good eye. She went on to say that if she closes her left eye, everything is blurry. On 04/04/2019 at 4:05 PM, LPN B was asked if she was aware Resident #35 needed glasses and LPN B stated, Yes. When asked about the process of getting glasses for Resident #35, LPN B stated, The social worker takes care of that. On 04/04/2019 at approximately 4:40 PM, Employee G, a social worker, was asked about the process for vision services and Employee G stated she visits with residents and asks them if they want to see the eye doctor and if so, their name is put on a list. Employee G then provided a list to show that Resident #35 was scheduled for vision services on 04/17/2019. On 04/05/2019 at 9:25 AM, Resident #35 was observed in her room, in bed, awake. When asked if a social worker had talked with her about getting glasses and she stated, No. She went on to say I miss being able to read. On 04/05/2019 at approximately 10:05 AM, Employee G was interviewed. When asked about the process if a resident has concerns pertaining to their glasses, she stated if the glasses are broken, she will try to fix them herself and used the example of applying superglue to the hinge. She also stated that if a resident needs reading glasses, she has a whole box of them in her office and will give them to the residents that need them. When asked if she knew why Resident #35 wanted to see the eye doctor, she stated she didn't know. The social service notes ranging from 06/15/2018 through 03/18/2019. Of the 15 social services entries by Employee G, there were no entries addressing vision services. The facility provided Summary Ocular Progress Notes dated 07/13/2018 for Resident #35. An optometrist documented the chief complaint, Blurred vision, hard to see at distance and near. Under Diagnosis and Treatments, it was documented, Age-related nuclear cataract, bilateral - cataracts - OU-Mild/stable - not visually significant - monitor 6 mos (months). The progress notes also included a glasses prescription that expires 7/13/19. The prescription documented, OD (right eye) -2.75 sph x .add +2.50 OS (left eye) -1.25 sph x .Add +2.50. The care plan was reviewed. A problem/need onset dated 04/11/2016 documented, [Resident #35] prefers to structure her own day, and stays in bed per her choice, enjoys reading Bible, listening to gospel music, keeping up with news, and participating with religious programs in her room. Enjoys reading and writing and getting to know new people. In past, loved to sing. Has dx (diagnosis) of DM2 (type 2 diabetes) and severe morbid obesity. Approaches associated with this focus included but not limited to offer and provide writing materials and other materials to promote continued independence; provide Bible for resident to use as requested. Resident #35's vision deficit and her need for glasses was not addressed on the care plan. The policy entitled, Social Services the facility staff provided was reviewed. In Section 4, it is documented, The social worker, or social services designee, will pursue the provision of any identified need for medically-related social services of the resident. Attempts to meet the needs of the resident will be handled by the appropriate discipline(s). Services to meet the resident's needs may include: Under part (d) of Section 4, it is documented, Making arrangement for obtaining items, such as adaptive equipment, clothing, and personal items. In summary, Resident #35 was examined by an optometrist in July 2018 which included a prescription for glasses. Resident #35 loves to read but is unable to do so because she did not have glasses and did not receive glasses following the exam by the optometrist nearly 9 months ago. On 04/05/2019 at approximately 2:30 PM, the DON and Administrator were notified of findings and they offered no further information or documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review and clinical record review, the facility staff failed to provide adequate supervision to prevent accidents for one resident (Resident #55) in a survey sample of 30 residents . For Resident #55 the facility staff failed to implement interventions and provide supervision to reduce fall risks and hazards following falls on 2/6/19 and 3/28/19. The findings included: Resident #55, was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: hypertension, Type 2 diabetes, and neuromuscular dysfunction of bladder. Resident #55's most recent MDS with an ARD (assessment reference date) of 2/8/19 was coded as an admission assessment. The resident was coded as having a BIMS (Brief Interview for Memory Status) score of 15, indicating the resident was cognitively intact. Functional status for transfers, dressing, toilet use and personal hygiene, was coded as Resident #55 required extensive assistance of staff. Clinical record review of nursing notes dated 2/1/19-4/3/19, revealed that Resident #55 sustained falls on 2/6/19, 2/11/19, and twice on 3/28/19. During an interview with the Director of Nursing on 4/5/19 at approximately 9am when asked how they define a fall, she stated, any change in elevation. When asked if a resident was assisted or lowered to the floor by staff, is this a fall? She stated, yes. When asked how often Fall Risk Assessments are completed, she said, on admission, quarterly and with each fall. Review of nursing notes, physician progress notes, physical therapy notes, occupational therapy notes, nursing assessments and careplan, all with dates of 2/1/19-4/3/19, reveal that no action or supervision was provided to Resident #55 following his fall on 2/6/19 or 3/28/19. In the nursing notes dated 3/28/19 at 2:38pm the nurse wrote, Resident stated that it was in his room and while trying to reach over to turn on his light causing to slip r/t (related to) regular socks with out grips.[sic] The DON provided a post-incident actions form with an incident date of 3/28/19 at 1pm that grippy socks were provided to the resident. The nursing notes dated 3/28/19 at 11:36pm following his second fall, the nurse wrote, This writer went down to assess the resident and resident again stated that while attempting to turn on the light switch he slid to the floor because his socks were slippery. Review of the Fall Risk Assessment dated 2/1/19 indicated that Resident #55 was alert (oriented x 3) and had no falls in the past 3 months. Repeat Fall Risk Assessments completed on 2/7/19, 2/15/19 and 2/22/19 all indicated that Resident #55 had no falls in the past 3 months and as a result gave a score of less than 10, indicating he was not at high risk for falls. Review of the facility policy titled Falls and Fall Risk, Managing with a revision date of March 2018 was reviewed and read: Resident-Centered Approaches to Managing Falls and Fall Risk: The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. The administrator and DON were made aware of the failure of the facility staff to provide supervision to a resident to prevent accidents during the end of day meeting on 4/4/19 at 5:30pm. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview,facility record review, and clinical record review, the facility staff failed to provide necessary care and services to ensure that a resident who was continent of bowel on admission receives services to maintain continence for one resident (Resident #55) in a survey sample of 30 residents. The facility staff were not assisting Resident #55 to have bowel movements in the toilet. The findings included: Resident #55, a [AGE] year old, was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: hypertension, Type 2 diabetes, and neuromuscular dysfunction of bladder. Resident #55's most recent MDS with an ARD (assessment reference date) of 2/8/19 was coded as an admission assessment. The resident was coded as having a BIMS (Brief Interview for Memory Status) score of 15, indicating the resident was cognitively intact. Functional status for transfers, dressing, toilet use and personal hygiene, was coded as Resident #55 required extensive assistance of staff. Review of the Nursing admission assessment dated [DATE] is coded that the resident is continent of bowel movements. Interview with Resident #55 on 4/5/19 at 9:34am the resident stated, I know when I need to go but it makes it easier for everyone if I use this diaper and let them know when it needs changing. I can get in my chair and go to the bathroom. Baseline careplan indicates resident requires assistance of one staff person for transfers and toileting and is continent of bowel. CNA careplan dated 2/1/19 indicates resident needs assisted toileting. Review of the Bowel & Bladder Report from 2/2/19-4/4/19 indicates Resident #55 had a bowel movement on 70 days. Of the 70 occurrences 66 of those were incontinent, using an adult brief. Surveyor A conducted an interview with CNA M on 4/3/19 at approximately 2pm. During the interview, CNA M stated, [Resident #55's name] is continent, he has a foley, he will let me know when he needs changed, he just uses his brief. The Administrator and Director of Nursing were made aware of the findings of staff failing to provide ADL assistance to maintain bowel continence for Resident #55 during end of the day meeting on 4/4/19. No further information was provided.

Based on staff interview and facility documentation review the facility failed to ensure certified nurse aides (CNA's) receive regular in-service education for 2 of 5 employees. (CNA F and CNA H) The facility staff failed to ensure CNA's receive 12 hours of in-service training annually for CNA F and CNA H. The findings included. On 4/4/19 a review of employee records was conducted and revealed that CNA F and CNA H had no recorded in-service training for 2018. An interview with Employee F on 4/4/19 at 10:14am she stated, they have no training on file. The Administrator and Director of Nursing were made aware of the findings on 4/4/19 at 5:30pm. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide behavioral health services for 1 resident (Resident #6) of the 30 residents in the survey sample. Resident 6's clinical record documented that the Resident had anxiety and depression on admission. Continued behavioral health services assessment, care planning, physician evaluation, and non-pharmacologic nursing interventions, were not performed by facility staff. The findings included: Resident #6, was admitted to the facility on [DATE]. Diagnoses included; depression, anxiety, heart disease, diabetes, high blood pressure, and chronic obstructive pulmonary disease (COPD). The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date (ARD) of 3-26-19. Resident #6 was coded with a Brief Interview of Mental Status (BIMS) score of 13 indicating little to no cognitive impairment and requiring assistance with physical activities of daily living. The full admission MDS assessment was also reviewed with an ARD date of 12-25-18 which revealed a BIMS score of 13, and both documents did not code depression nor anxiety as diagnoses to be treated or care planned for this Resident. An interview was conducted with Resident #6 on 4-2-19, at 1:00 p.m., and on 4-3-19 at 12:00 p.m. During the interviews, Resident #6 was tearful. The Resident stated that she did not get to see her family often, and had just moved to Virginia from another state, and had no friends here other than family. The Resident went on to say the family members lived quite a distance from the facility, and were busy raising children, and working. The Resident was asked if she had ever talked with the social worker about her feelings, and she stated no, I only saw her twice the first week I came here, and the day I had to move out of my room because my room mate was so disruptive. I haven't seen her since. When asked if she was interested in talking with the social worker, Resident #6 stated no, I would rather see a doctor. When asked if she meant a psychologist, or a psychiatrist, she stated yes. Resident #6's clinical record was reviewed. The social services notes indicated that the social services director (SSD) did visit the Resident on 12-19-18, and ten days later on 12-29-18 for routine admission, and 14 day follow up. The SSD did not document seeing the Resident again until 3-18-19 to prepare for the quarterly MDS submission. The SSD documented the following entry on 3-18-19; There has been no change to the resident during this quarter in behaviors or mood. The resident appears anxious, nervous in conversation but is very pleasant and nice. Residents son visits often, but tends to complain about little things or things of unimportance in regards to residents overall care and treatment. The resident tends to stay in room and is socially withdrawn by nature. On 3-19-19, the Resident was moved to another room. A review of all discipline notes in the clinical record did not reveal any documentation of the reason for the move, or how the Resident responded to the move. All behavior documents were reviewed, to include social work notes, physician notes, nursing notes, medication administration notes, and MDS documents, which revealed that the Resident had no aberrant behaviors. All physician notes were reviewed from admission to the dates of survey. There were 4 visits, and the documents revealed the first visit as a medical history, which was a 3 page form dated 12-20-18. This first visit document described the Resident as negative for psychiatric problems, and went on to document, alert and oriented to person/place/time. Depression and anxiety were not included in the diagnoses written on the form. On 2-7-19, 2-21-19, and 3-26-19 the doctor saw the Resident and documented the first 2 visits as recert visits for skilled care. The final visit on 3-26-19 was a sick visit, as the Resident had been diagnosed with pneumonia. None of these visits have any documentation under the psyche heading on the document, and they were left blank, as no assessment in this area was conducted. All other headings were assessed and documented as such. No psychiatric physician evaluation was ever conducted. Review of all nursing notes since admission, and to the time of survey revealed no assessment or interventions for depression or anxiety. Physician's orders, and Medication Administration Records (MAR's) were reviewed and revealed the following (4) psychoactive medications were ordered and administered during Resident #6's stay; 1. Zoloft 125 milligrams (mg) every day at 9:00 a.m. for depression. Ordered 12-19-18, and continued through survey. 2. Buspar 15 mg three times per day at 10:00 a.m., 2:00 p.m., and 9:00 p.m. for anxiety. Ordered 12-19-18, and continued through survey. 3. Xanax 0.5 mg every 6 hours as needed for anxiety. Ordered 12-19-18, discontinued 12-23-18, reordered 12-25-18 to stop 2-15-19. 4. Xanax 0.5 mg every day at 9:00 a.m. for anxiety. ordered 2-16-19, and continued through survey. The Residents care plan in the computer, and the paper copy with revisions from the care plan book on the nursing unit were reviewed. The 2 care plans revealed, no baseline initial care plan, nor comprehensive care plan was ever devised for the Resident's depression, anxiety, and behavioral health care needs. At the end of day meeting on 4-3-19, the Director of Nursing (DON) and Administrator were notified that the facility staff were not providing for Resident #6's behavioral health needs. It was reviewed that Resident #6's depression and anxiety were not care planned, nor was there any formal psychiatric assessment, nor social work interventions. The administrative staff were asked to provide clarification in this matter, and they stated they would get back to the surveyors with any information found. The Administrator and DON were notified of the concern again on 4-4-19 at 11:00 a.m. regarding Resident #6, and the DON stated you have everything we have. No further information was able to be provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility documentation the facility failed to provide 2 doses of medication ordered daily for 1 Resident (Resident #7) in a survey sample of 30 Residents. The findings included: Resident # 7 is a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Bipolar Disorder, Acute Kidney Failure, Repeated Falls, Pacemaker implant, Major Depressive Disorder, and Seizure Disorder On 4/3/19 during a clinical record review it was discovered that Resident #7 had missed 2 doses of a scheduled anti-anxiety medication Alprazolam (Generic Xanax) 0.25 MG daily. The medication was scheduled for 9:00 AM On 3/30/19 the (Medication Administration Record) MAR was marked N which indicates it has not been given. Under the comments it states Awaiting Pharmacy. On 3/31/19 the MAR was marked again with N indicating not given and under comments it states Received new script from Doctors Office. On 4/4/19 the DON was asked why the Resident missed 2 doses of the Alprazolam. The DON stated that they needed a new prescription to get it from the pharmacy on March 30th. On March 31st they had obtained the script but the pharmacy was in the process of filling it. They received the medication on the night of the 31st and were able to give it on April 1st. On 4/4/19 at the end of day meeting the Administrator was made aware and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and facility documentation the facility failed to ensure Resident is free from unnecessary meds for 1 Resident (#97) in a survey sample of 30 Residents. For Resident #97 the facility staff failed to follow Physicians Order for Heparin (an anti-coagulant) Flush to be administered daily, but instead, administered the Heparin Flush three times per day thus administering unnecessary amount of Heparin. The findings include Resident #97 is an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Anemia, Hypertension, Dementia (Alzheimer's Type) History of Stroke, Anxiety and Depression. On 4/5/19 during clinical record review it was noted that Resident #97 had orders for Flushing Midline Catheter (Intravenous Line for medication administration.). The orders began on 3/17/18 at 2:30 PM. The orders read: Heparin flush 10 Units/ML [10 Units per Milliliter] Flush midline with Heparin [an Anti-Coagulant] & Normal Saline QD [Every Day] The order appears on the (Medication Administration Record) MAR signed off and timed for 6:30 AM, 2:30 PM and 10:30 PM (3 times daily) The first dose was signed off at 2:30 PM on 3/17/19 and continued to be signed off as administered three (3) times a day for the duration of the month of March. A second order was initiated on 3/17/19 in addition to the original Heparin Flush order. The order stated: Normal Saline Flush Syringe Flush Midline with saline & Heparin QD [Every Day] Discontinue Date 3/18/19 - That order was timed for 2:00 PM (daily) and signed off on 3/17/19 and 3/18/19 at 2:00 PM then it was discontinued. A third order was initiated on 3/18/19 in addition to the Heparin Flush order. That order stated: Clarification order: Normal Saline Flush Syringe 10 ML Flush Midline with 10 ML NS [normal saline] Q 12hours [Every 12 hours] This order was written on the 18th but not imitated until the 19th and timed for 9:00 AM and 9:00 PM. This order was signed off as administered twice daily for the duration of the month of March. The Physicians order sheet for April read: Heparin flush 10 Units/ML Flush midline with Heparin [an Anti-Coagulant] & Normal Saline QD [Every Day] [Once again the Heparin order was timed and signed off at 6:30 AM 2:30 PM and 10:30 PM for April 1st-5th] Also on April Physicians Orders was: Clarification order: Normal Saline Flush Syringe 10 ML Flush Midline with 10 ML NS [normal saline] Q 12hours [Every 12 hours] The Normal Saline order was signed off at 9:00 AM and 9:00 PM. On 4/5/19 at 1:45 PM LPN E was asked how many times a day does the Residents Midline get flushed and stated that it was done every shift. She then elaborated that Night shift does it at 6:30 AM, Day shift at 2:30 PM and Evening shift does it at 10:30 PM. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and observation, the facility staff failed to serve food in accordance with professional standards for food service safety, for two residents (Resident #63, Resident #98) in a survey sample of 30 residents. 1. For Resident #63, the facility staff failed to serve food in a sanitary manner. 2. For Resident #98, the facility staff failed to serve food in a sanitary manner. The findings included: 1. For Resident #63, the facility staff failed to serve food in a sanitary manner. Resident #63, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included but were not limited to Non-ST elevation (NSTEMI) myocardial infarction, heart failure, cerebral infarction, hypertension, diabetes, and hemiplegia. Resident #63 ' s most recent Minimum Data Set had an Assessment Reference Date (ARD) of 02/18/2019 and was coded as a quarterly assessment. Resident #63 was coded with a Brief Interview of Mental Status (BIMS) score of 3 out of possible 15 indicative of severe cognitive impairment. Functional status for bed mobility, transfers, dressing, and personal hygiene were all coded as requiring extensive assistance from staff. Functional status for eating was coded as requiring supervision from staff. On 4/3/19 at 11:38pm during observation of lunch service in the dining room, CNA A removed Resident #63's sandwich from the bag with her ungloved hands. Employee C, Dietary Manager then walked over to CNA A and talked to her. When Employee C was asked what she told her, Employee C stated I told her to dump the bread out, we don't touch their food. On 4/4/19 at 3:44pm, an interview was conducted with the Director of Nursing regarding meal service and she stated her expectation is that staff wash their hands and put gloves on if they are going to touch food. The Administrator and DON were made aware of the facility staff failing to serve food in a sanitary manner during the end of day meeting held on 4/4/19 at 5:30pm. No further information was provided. 2. For Resident #98, the facility staff failed to serve food in a sanitary manner. Resident #98, was admitted to the facility on [DATE]. The resident's diagnoses included but were not limited to: heart failure, diabetes, CVA (cardiovascular accident), dementia and depression. Resident #98's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/22/19 was coded as an admission assessment. The resident was coded as requiring limited assistance with transfers and personal hygiene. Resident #98 was coded as requiring extensive assistance for toileting and totally dependent on staff for bathing. On 4/3/19 at 11:41am, during observation of lunch in the dining room, CNA B was observed to remove Resident #98's plate from the tray with her thumb on the top of the plate, where food was located. On 4/4/19 at 3:44pm an interview was conducted with the Director of Nursing regarding meal service and she stated her expectation is that staff wash their hands and put gloves on if they are going to touch food. The Administrator and DON were made aware of the facility staff failing to serve food in a sanitary manner during the end of day meeting held on 4/4/19 at 5:30pm. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to maintain an accurate clinical record for one resident (Resident #63) in a sample size of 30 residents. The Resident #63's DNR status was inaccurate. The findings included: Resident #63, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include but not limited to Non-ST elevation (NSTEMI) myocardial infarction, heart failure, cerebral infarction, hypertension, diabetes, and hemiplegia. Resident #63's most recent Minimum Data Set had an Assessment Reference Date (ARD) of 02/18/2019 and was coded as a quarterly assessment. Resident #63 was coded with a Brief Interview of Mental Status (BIMS) score of 3 out of possible 15 indicative of severe cognitive impairment. Functional status for bed mobility, transfers, dressing, and personal hygiene were all coded as requiring extensive assistance from staff. Functional status for eating was coded as requiring supervision from staff. On 04/02/2019 at 4:15 PM, the current physician's orders in the electronic health record were reviewed. A physician's order dated 11/25/2018 documented, Resident Hospice care as of 11/16/18 [hospice company name]. A physician's order dated 11/26/2018 documented, DNR (do not resuscitate). The care plan in the electronic health record was reviewed. A problem onset dated 04/02/2015 documented, [Resident #63] has an inability to perform ADLs (Activities of Daily Living) independently secondary to muscle spasms, HTN (hypertension), CVA (cerebral vascular accident), hemiparesis, RAKA (right above-the-knee amputation), depression. Resident refuses meals & supplements at time. (sic) One approach documented for this problem documented, Full code. On 04/02/2019 at 4:40 PM, an interview with CNA C was conducted. When asked where a CNA would find out information about how to care for Resident #63, she stated she looks at the care plan that is posted on the inside of Resident #63's closet door. CNA C and this surveyor then entered Resident#63's room and CNA C then opened Resident #63's closet door to show a document entitled, CNA Care Plan which included Resident #63's name and room number (handwritten). It also included Resident #63's needs pertaining to ADLs. On the left hand side of the paper, it was documented, Information is current as of this date: 10-31-18. On the top left side of the CNA Care Plan, it was documented Full code. CNA C then closed the closet door. This surveyor then asked CNA C what Resident #63's code status was and she stated, She's a full code. A copy of the CNA Care Plan was requested and CNA C stated she would have to ask the nurse. On 04/02/2019 at approximately 4:45 PM, this surveyor and CNA C walked to the nurse's station. After speaking with a nurse, CNA C went to Resident #63's room to retrieve the CNA Care Plan on the closet door. The staff nurse got Resident #63's hard chart and displayed the Durable Do Not Resuscitate Order and stated to this surveyor, Do you realize this resident is on hospice and she's a DNR? CNA C returned with the CNA Care Plan and handed it to LPN B. LPN B looked at the document and stated, It (closet care plan) wasn't updated. A copy of the Durable Do Not Resuscitate order and the electronic care plan were requested. On 04/02/2019 at 4:55 PM, a Durable Do Not Resuscitate document was provided. It was dated 11/20/18 and signed by physician, responsible party, and a witness. A paper copy of the electronic care plan was provided. Under the problem entitled, Resident #63] has an inability to perform ADLs (Activities of Daily Living) independently secondary to muscle spasms, HTN (hypertension), CVA (cerebral vascular accident), hemiparesis, RAKA (right above-the-knee amputation), depression. Resident refuses meals & supplements at time. ,Full Code was crossed out and DNR was added (handwritten and not dated or initialed). Employee L stated the most updated version of the care plan is on paper kept on the unit. Employee L stated electronic care plans (what is seen on the computer) are updated quarterly. On 04/05/19 at 10:10 AM, an interview with Employee H, the MDS/Care Plan Coordinator was conducted. When asked about how to determine when an intervention on a care plan was implemented, Employee H stated, We don't date interventions. She went on to say the intervention either continues or it would be resolved. When asked about a resolved intervention, Employee H stated, I would delete it. Employee H stated the paper copy care plans are kept in a book on the unit, updated on the paper, and eventually entered into the computer. When asked about the CNA (closet) care plans, Employee H stated closet care plans are also updated as needed. The facility policy entitled, Advanced Directives was reviewed. Section 7 documented, Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. Section 10 documented, The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive. In summary, there was conflicting information regarding Advanced Directives on the electronic care plan, the paper copy care plan, and the CNA closet care plan for Resident #63. On 04/05/2019 at approximately 2:30 PM, the DON and Administrator were notified of findings and they offered no further information or documentation.

Based on staff interview, facility documentation review and in the course of a complaint investigation, the facility staff failed to implement their abuse and neglect policy for 5 of 25 employees. (Employee D, Employee E, LPN C, CNA E and CNA F) The facility staff failed to implement their abuse and neglect policy by failing to pre-screen employees prior to hire by failing to obtain reference checks and verifying licenses/certification. The findings included: A review of employee records was conducted on 4/3/19. The facility failed to conduct license verification prior to hire for 2 of 25 employees, (employees LPN C and CNA E). During employee record review, LPN C was hired 3/5/19 and her nursing license was not verified until 3/8/19. This nurse did have findings against her license for a complaint of misconduct, which the facility was not aware of prior to her hire. During an interview with (Employee F), Human Resources Coordinator, on 4/4/19 at 9:37am, when asked if this is something the facility would want to know prior to hire, she replied, I would assume so, when I saw that I spoke with the DON. Review of CNA E's file revealed no certification verification prior to hire could be found. On 4/4/19, an interview with Employee F was conducted and she stated, it's not in here, it should have been done. The facility failed to check references prior to hire for 3 of 25 employees. References were not checked prior to hire for employees (Employee D, Employee E, and CNA F). Employee D's reference checks were not dated as to when they were obtained. Employee E's reference checks were incomplete, the form had multiple omissions. CNA F had a reference check that had no date to indicate when it was obtained. On 4/4/19 at 9:37am, an interview was conducted with Employee F, when asked about the process for reference checks she stated, I call the people on the application, I ask the questions on the paper. I have to have them before the person can enter orientation. Review of the facility policy titled Guidelines for the prevention of abuse with a revision date of 7/2016 states the standard as, The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy reads, 4. Careful screening of all employees, physicians, and contracted professionals. All information provided by the applicant is verified and at least two references are contacted with documentation maintained in the personnel file. 6. License verification performed for all licensed staff prior to employment. The Administrator and Director of Nursing were made aware of the findings on 4/4/19 at 5:30pm. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation and clinical record review the facility failed ensure Residents had (Pre admission Screening And Resident Review) PASARR screening prior to admission for five residents, Residents (#7, #28, #97, #49, and #68) in a survey sample of 30 residents. 1. For Resident # 7 the facility staff failed to obtain a PASARR prior to admission to the facility. 2. For Resident # 28 the facility staff failed to obtain a PASARR prior to admission to the facility. 3. For Resident # 97 the facility staff failed to obtain a PASARR prior to admission to the facility. 4. For Resident # 49, the facility staff failed to obtain a PASARR screening prior to admission to the facility. 5. For Resident # 68, the facility staff failed to obtain a PASARR screening prior to admission to the facility. The findings include: 1. For Resident # 7 the facility staff failed to obtain a PASARR prior to admission to the facility. Resident # 7 is a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Bipolar Disorder, Acute Kidney Failure, Repeated Falls, Pacemaker implant, Major Depressive Disorder, and Seizure Disorder. On 4/2/19 a clinical record review was done and no PASARR Level 1 was found in hard copy of chart or electronic medical record. A request then made for PASARR Level I and or II depending on what the Resident's diagnoses required. On 4/3/19 at 11:30 AM, an interview was conducted with the Social Worker who stated that the usual process for obtaining a PASARR is that the Resident comes in and is admitted and the PASARR is a part of the admissions process. During end of day conference on 4/3/19 the Administrator was made aware of the issue of obtaining a PASARR prior to admission no further information was provided. 2. For Resident # 28 the facility staff failed to obtain a PASARR prior to admission to the facility. Resident # 28 a [AGE] year old man, admitted to the facility on [DATE] with diagnoses of but not limited to Unspecified Psychosis, Altered Mental Status, Cerebral Infarction (stroke), Hemiplegia and Hemiparesis following cerebral infarction, Major Depressive Disorder and Diabetes Type II. On 4/2/19 a clinical record review was done and no PASARR Level 1 was found in hard copy of chart or electronic medical record. A request then made for PASARR Level I and or II depending on what the Resident's diagnoses required. On 4/3/19 facility staff submitted PASARR LEVEL I screening signed by facility Social Worker and dated 5/11/18. The PASARR was completed after admission. On 4/3/19 at 11:30 AM, an interview was conducted with the Social Worker who stated that the usual process for obtaining a PASARR is that the Resident comes in and is admitted and the PASARR is a part of the admissions process. During end of day conference on 4/3/19 the Administrator was made aware of the issue of obtaining a PASARR prior to admission no further information was provided. 3. For Resident # 97 the facility staff failed to obtain a PASARR prior to admission to the facility. Resident #97 is an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Anemia, Hypertension, Dementia (Alzheimer's Type) History of Stroke, Anxiety and Depression. On 4/2/19 a clinical record review was done and no PASARR Level 1 was found in hard copy of chart or electronic medical record. A request then made for PASARR Level I and or II depending on what the Resident's diagnoses required. On 4/3/19 facility staff submitted PASARR LEVEL I screening signed by facility Social Worker and dated 6/8/18. The PASARR was completed after admission. On 4/3/19 at 11:30 AM an interview was conducted with the Social Worker who stated that the usual process for obtaining a PASARR is that the Resident comes in and is admitted and the PASARR is a part of the admissions process. During end of day conference on 4/3/19 the Administrator was made aware of the issue of obtaining a PASARR prior to admission no further information was provided. 4. For Resident # 49, the facility staff failed to obtain a PASARR (Preadmission Screening and Resident Review) prior to admission to the facility. Resident # 49, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Alzheimer's Disease, Hypertension, Malignant Neoplasm of Prostate, Gastroesophageal Reflux Disease, Dementia, Osteoarthritis, and Anxiety. Resident # 49's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 2/1/2019. The MDS coded Resident # 49 with a BIMS (Brief Interview for Mental Status) score of 3 out of 15, indicating severe cognitive impairment. Resident # 49 was coded as requiring limited to extensive assistance of one staff person for Activities of Daily Living except total assistance of one staff person for bathing. Resident # 49 was coded as occasionally incontinent of bowel and bladder. On 04/04/2019 at 2:30 PM, review of the clinical record was conducted. Review of the clinical record revealed there was no PASARR Level 1 Screening in the electronic or paper clinical record. On 04/4/2019 at 11:08 AM, an interview was conducted with the Social Worker who stated the facility process was for the PASARR to be completed by the Social Worker on the day of admission. The Social Worker stated she did not see a PASARR screening in the clinical Record for Resident # 49. The Social Worker stated she was aware that the PASARR should be done prior to admission but stated I am not a part of the admission team. I don't see them (residents) until they get here. The Social Worker stated the Admissions Committee at the facility was responsible for seeing residents prior to admission and the Social Worker was responsible for the PASARR on the day of admission. On 4/4/2019 at 11:55 AM, the Social Worker stated that she reviewed the record and talked with the Admissions staff. The Social Worker stated she was told a PASARR screening was not done for Resident # 49 because he had been admitted to the facility as a private pay resident and a PASARR screening was not required for him. The Social Worker was advised that residents must have a Level 1 PASARR screening done prior to admission. On 04/04/2019, during the end of day debriefing, the Administrator and the Director of Nursing were informed of the findings of no PASARR for Resident # 49. The Administrator and the Director of Nursing were advised that residents admitted to nursing facilities must have a Level 1 screening prior to admission. The Administrator stated the facility staff would ensure all future admissions had a PASARR prior to admission. No further information was provided. 5. For Resident # 68, the facility staff failed to obtain a PASARR (Preadmission Screening and Resident Review) prior to admission to the facility. Resident # 68, a [AGE] year old female was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Alzheimer's Disease, Hypertension, Major Depressive Disorder, Gastroesophageal Reflux Disease, Dementia, Cardiomegaly, and Anxiety. Resident # 68's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 2/21/2019. The MDS coded Resident # 68 with a BIMS (Brief Interview for Mental Status) score of 3 out of 15, indicating severe cognitive impairment. Resident # 68 was coded as requiring extensive assistance of one to two staff persons for Activities of Daily Living except total assistance of one staff person for Bathing. Resident # 68 was coded as frequently incontinent of bowel and bladder. Review of the clinical record was conducted on 4/4/2019. Review of the Screening for Mental Illness, Mental Retardation/Intellectual Disability, or Related Conditions, PASARR (Preadmission Screening and Resident Review) form revealed a signature and a date of 5/11/2018. The spaces for Screening Committee, Telephone number, and Street Address were left blank. On 04/4/2019 at 11:08 AM, an interview was conducted with the Social Worker who stated the facility process was for the PASARR to be completed by the Social Worker on the day of admission. The Social Worker stated there was a PASARR screening in the clinical Record for Resident # 68 that was dated on 5/11/2018. The Social Worker stated the signature on the form was hers and she had completed the PASARR on 5/11/2018 because she noticed one was not in the record. The Social Worker stated she was aware that the PASARR should be done prior to admission but stated I am not a part of the admission team. I don't see them (residents) until they get here. The Social Worker stated the Admissions Committee at the facility was responsible for seeing residents prior to admission and the Social Worker was responsible for the PASARR on the day of admission. On 04/04/2019, during the end of day debriefing, the Administrator and Director of Nursing were informed of the findings of no PASARR for Resident # 49. The Administrator and Director of Nursing were advised that residents admitted to nursing facilities must have a Level 1 screening prior to admission. The Administrator stated the facility staff would ensure all future admissions had a PASARR prior to admission. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #69, the facility staff failed to ensure he was free from Seroquel (an antipsychotic) which is not indicated for use in residents with dementia. Resident #69, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses listed on Resident #69's facility face sheet included but not limited to cerebral infarction, major depressive disorder (recurrent, severe with psych symptoms), unspecified psychosis not due to a substance or known physical condition, and vascular dementia. Resident #69's most recent MDS assessment with an ARD date of 02/22/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as 15 out of possible 15 indicative of intact cognition. The Mood Severity Score was 00 and there were no behaviors documented in MDS Section E - Behaviors. On 04/02/2019 at 12:25 PM, Resident #69 was observed in his room, fully dressed, seated in wheelchair watching TV. Resident #69 appeared calm and neat in appearance. On 04/03/2019 at 9:00 AM, Resident #69 was observed resting in bed with the head of the bed up approximately 60 degrees. The current physician's orders were reviewed. An active entry dated 04/19/2018 documented, Quetiapine (Seroquel, an antipsychotic) 25 mg by mouth at bedtime, dx (diagnosis) psychosis. According to the National Institute of Mental Health, The word psychosis is used to describe conditions that affect the mind, where there has been some loss of contact with reality. The Medication Administration Record for February 2019 was reviewed. Quetiapine 25 mg was signed off as administered each evening in February. Pre-administration behavior count, behavior types, and pre-and-post admin of antipsychotic side effects all documented, None. The Medication Administration Record for March 2019 was reviewed. Quetiapine 25 mg was signed off as administered at 8:00 PM each evening. Pre-administration behavior types and pre-and-post antipsychotic side effects were documented as none for March 2019 with the exception of March 3, 21, and 28. For each of those days, pre-administration behavior count documented 1 but no further information was documented. On 04/03/2019 at 1:55 PM, an interview with a CNA familiar with Resident #69, CNA D, was conducted. When asked if Resident #69 had any behaviors, she stated, No, he's a nice guy. She then went on to say but he can be cranky sometimes. On 04/04/2019 at 9:00 AM, Resident #69 was observed eating breakfast in his room. He appeared calm. The nurse's notes ranging from 01/31/2019 through 03/21/2019 were reviewed. An entry dated 01/21/2019 at 10:14 PM documented, Resident was cussing at aides and refusing shower. He stated that he had a shower on 7-3(shift), this was not true. His shower is 3-11 (shift). Resident continued to yell and cuss at staff and insist on being put to bed. Resident was put to bed and shower was refused. There were no entries associated with psychotic behaviors. The care plan was reviewed. An undated problem area documented, [Resident #69] has a diagnosis of psychosis, insomnia and depression and is currently receiving psychotropic meds and is at risk for complications. The goal associated with this problem documented [Resident #69] will be on therapeutic dose through next review. Approaches associated with this problem included but not limited to Meds as ordered. Monitor for adverse reactions. Notify MD/NP as needed. Labs as ordered. Results to MD/NP. Allow [Resident #69] to verbalize thoughts/feelings. Monitor for behaviors during med pass and PRN (as needed) for types of behaviors, frequency, response to interventions and notify MD/NP if occur. Non-pharmacologic interventions will be attempted by staff with resident to attempt to alleviate any negative behaviors/emotions. Diversion, right direction, validation, toileting, outside consultation, calm approach, allow to vent feeling. A problem area (undated) documented, [Resident # 69] will be receiving long-term care services. He has the diagnosis of major depressive disorder recurrent, severe with psych symptoms and psychosis. He can state his own goals and structures his own days. Prefers to have an unrestricted diet. Approaches associated with this problem included but not limited to Mental health referrals as needed, redirect from unsafe practices as needed, educate on possible consequences for non-compliance behaviors when dealing with personal care/hygiene issues as needed, redirect and help identify triggers from periods of agitation as needed. Directly engage with [Resident #69] and seek positive resolutions during periods of emotional distress as needed. There were no psychotic symptoms or triggers listed on the care plan. Social Services notes ranging from 9/04/2018 through 1/10/2019 were reviewed. An entry dated 9-4-2018 at 11:54 a.m. documented Quarterly: There has been no change to the resident during this quarter in behaviors or mood the resident continues to participate in selected activities and socialize with others at times. The residents family is actively involved in visits the residence on a regular basis. Social Services will continue to provide 1:1 visits and complete referrals as needed for the resident. SSD (Social Services Department) will continue to monitor the resident for changes in behaviors or mood on a daily basis and will make staff aware to notify Social Services if any should occur. An entry dated 12-3-2018 at 10:46 a.m. documented Annual: There has been no change to the resident during this quarter in behaviors or mood during a look back over the past year. The resident has remained consistent/stable for behaviors and mood. The resident continues to participate and selected activities and socialize with others at times. The resident's family is actively involved and visits the resident on a regular basis. The resident is pleasant with SSD in interaction. Resident is very close with his sister [name]. Social Services will continue to provide one to one visits and complete referrals as needed for the resident. Social Services will continue to monitor the resident for changes in behaviors are mood on a daily basis and will make staff aware to notify Social Services if any should occur. An entry dated 1/10/2019 4:43 PM documented, SSD and unit manager met with resident and discussed his alcohol orders. Resident can have alcohol per orders but SSD will monitor his behavior on alcohol from staff reporting/feedback. SSD explained to resident the policies and rights of patients and staff. Resident stated that he will try to not get angry at CNAs and staff and work on his anger control in a more healthy way. A pharmacy consultation report dated 9-19-2018 documented in the Comments section [Resident 69] has received Seroquel 50 mg qd (daily), Sertraline 50 mg qd (daily), Temazepam 30 mg at bedtime, and trazodone 100 milligrams for depression insomnia. CMS regulations require periodic antipsychotic evaluation for clinical appropriateness of a gradual dose reduction. Under the section entitled, Recommendation, it was documented, if appropriate, please consider a gradual dose reduction (perhaps Seroquel 37.5 mg at bedtime, and/or Temazepam 15 mg at bedtime, and/or Sertraline 25 mg daily and/or trazodone 75 mg at bedtime), while monitoring for a re-emergence of target and/or withdrawal symptoms. Thank you. For antipsychotic therapy, it is recommended that a) the prescriber document and assessment of risk vs benefit, indicating that it continues to be a valid therapeutic intervention for this individual, and b) the facility dinner disciplinary team ensure that the care plan includes ongoing monitor of specific target behaviors; documentation of 1) a danger to self or others 2) desired outcome 3) the efficacy of individualized non-pharmacologic approaches for potential adverse consequences. Update and adapt the care plan as needed to provide person centered care. Under the section Physicians response, the following response was selected: I decline the recommendation above because GDR (gradual dose reduction) is clinically contraindicated for this individual as indicated below. Part two was selected which documented, The residents target symptoms returned or worsened after the most recent GDR attempt within the facility and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder as documented below. In the space provided, it was handwritten, Pt (patient) got Sig (significantly) worse. A time line was requested pertaining to the use of Seroquel and Resident #69's behaviors. The DON provided a timeline on 04/04/2019 at approximately 5:00 PM. The time line indicated that on 04/18/2018, Seroquel was reduced from 50 mg to 25 mg at bedtime. A GDR was declined on 09/2018 due to behaviors. The time line also documented a statement at the bottom of the page: Behaviors: yells, curses, hits staff, insomnia. Dx (diagnosis): Psychosis. In summary, Resident #69 does not have a diagnosis or behaviors to support the use of an antipsychotic. On 04/05/2019 at approximately 2:30 PM, the Administrator and DON were notified of findings and they offered no further information or documentation. 4. For Resident #39, the facility staff failed to ensure she was free from Seroquel, an antipsychotic, which is not indicated in residents with the diagnosis of dementia. Resident #39, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses listed on the face sheet were silent myocardial ischemia, adult failure to thrive, unspecified dementia with behavioral disturbance, and hypokalemia. Resident #39's most recent MDS (Minimum Data Set) with an ARD (assessment reference date) of 01/21/2019 was coded as a quarterly review. The Brief Interview for Mental Status was not coded but cognitive skills for daily decision-making was coded as severely impaired. Mood Severity score was coded as 00 indicative of no depressive symptoms. Psychosis and other behavioral symptoms were coded as not exhibited. The current physician's orders were reviewed. An entry dated 04/30/2018 documented, Quetiapine fumarate 12.5 mg by mouth every other day at bedtime for dementia/psychosis. The Medication Administration Record for March 2019 was reviewed. Quetiapine 12.5 mg by mouth every other day at bedtime was signed off administered as ordered. Pre-administration behavior counts and types were documented at 0 meaning none. A pharmacy consultation report dated 2/11/2019 documented in the Comments section, [Resident #39 has dementia and receives an anti-psychotic, Quetiapine 12.5 mg QOD (very other day). Under the header Recommendation, it was documented, If clinically appropriate, please consider a trial discontinuation, while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. Thank you. Under the header Rationale for recommendation, it was documented, An FDA box warning identifies an increased risk of mortality and elderly individuals receiving an anti-psychotic for behavior or psychiatric symptoms of dementia (BPSD). The 2012 Beers Criteria recommend avoiding antipsychotics for BPSD due to an increase risk for stroke and mortality unless non-pharmacological options have failed and the patient's behaviors are documented as a threat to self or others. Under the header Physician's Response, it was documented, I decline the recommendation above and do not wish to implement any changes due to the reasons below. In the space provided, a handwritten note documented, Pt stable at present dose signed by physician dated 02/12/2019. On 04/04/2019 at 10:35 AM, Resident #39 was observed in activity room seated in her Broda chair. Resident #39's eyes were closed and head was slightly tipped to one side. An interview with Employee J in Activities was conducted. When asked about activities for Resident #39, Employee J stated Resident #39 does small group activities, listens to music, sensory stimulation, and one-on-ones. She also stated it is usual that Resident #39 would sleep during activity time like she is sleeping now. CNA J entered the Activity room joined the conversation and stated she was familiar with Resident #39. When asked if she usually sleeps like this, CNA J stated, No, not really. Her eyes are bright and she will talk to you. When asked if Resident #39 had any behaviors, she stated Resident #39 had no acting out. Employee J added [Resident #39] is funny. CNA J attempted to talk with Resident #39, held her hand, and attempted to wake her up but was unable to do so. Employee J told CNA J to take her back to her room so she can rest. On 04/04/2019 at approximately 10:40 AM, CNA J returned Resident #39 to her room. An interview in the hall near Resident #39's room with LPN E was conducted. LPN E stated she was familiar with Resident #39. When asked about behaviors, she stated Resident #39 does not have behaviors and stated, She sleeps a lot. LPN E also stated that years ago, Resident #39 had to wear a helmet because she would bang her head on things but not deliberately. LPN E stated Resident #39 no longer does that. When asked what medications Resident #39 had recently, LPN E and this surveyor looked at the Medication Administration Record. Resident #39 had received two anti-hypertensives, a supplement, a proton pump inhibitor, and a laxative this A.M. and Resident #39 received Seroquel 12.5 mg by mouth at bedtime last evening. On 04/04/2019 at 10:50 AM, CNA J exited Resident #39's room and stated that Resident #39 woke up a bit when she transferred her back to bed and went back to sleep again. LPN E and this surveyor entered Resident #39's room. Resident #39 was sleeping supine with head of bed elevated approximately 30 degrees. LPN E was unable to wake Resident #39 up. LPN E stated, I'll check her vital signs. LPN E took Resident #39's blood pressure and pulse (123/75, 50, respectively). When asked if Resident #39 is sometimes difficult to wake up like this, she stated, Yes. On 04/04/2019 at 3:30 PM, an interview with the DON was conducted. When asked if Resident #39 exhibited any behaviors, she stated that in the past, Resident #39 had to wear a helmet because she would hit her head on the wall. She also wore elbow pads and knee pads. When asked about current behaviors, she stated that Resident #39 can be combative and refuses care. A medical management note completed by a nurse practitioner dated 3/30/2019 documented under Mental status exam, Upon arrival, patient sitting upright in wheelchair upon arrival. Patient has eyes closed but appears awake with body movements. Patient dressed appropriately and appears hygienically clean. Has flat appearing mood demeanor. Patient engaged in conversation with soft irrelevant mumbling that is mostly not understandable. Patient did provide a few one word answers. Oriented to self only. Insight limited judgment is impaired thought process he's a logical rambling unable to focus or follow interview effect flat no evidence of abnormal or psychotic thinking, perceptual disturbances, suicidal, violent or homicidal thoughts Under the header Plan of care, it was documented, Please see GDR recommendation. Please continue to monitor patient. Suggest assisting patient with good sleep hygiene practices. For example, try to keep patient mentally occupied during the day, it here to a structured daily schedule, and provide opportunities for physical exercise. Also suggest assisting patient and physical needs, addressing pain, constipation, and other physical discomfort is crucial in preventing agitation, confusion, and other behavioral disturbances. Under the header GDR Rationale, it was documented, Pt history of psychotic symptoms that are difficulty to control. Pt seem stable at this time. GDR are not recommended. Under the header Threat Statement, it was documented, Patient currently NOT a danger to self or others. On 04/05/2019 at approximately 2:30 PM, the Administrator and DON were notified of concerns and offered no further information or documentation. Based on staff interview, clinical record review and facility documentation the facility staff failed to ensure freedom from unnecessary psychotropic medications for 4 Residents (Resident #24, Resident # 86, #69, and #39) in a survey sample of 30 Residents. 1. For Resident #24 the facility doctor gave orders for Ativan 0.5 (Milligrams) MG every 6 hours (as needed) PRN for 90 days at a time. 2. For Resident #86 the facility staff gave anti-psychotic medication to a Dementia Resident without a proper diagnosis for use. 3. For Resident #69, the facility staff failed to ensure he was free from Seroquel (an antipsychotic) which is not indicated for use in residents with dementia. 4. For Resident #39, the facility staff failed to ensure she was free from Seroquel, an antipsychotic which is not indicated for use in residents with dementia. The findings include: 1. For Resident #24 the facility doctor gave orders for Ativan 0.5 (Milligrams) MG every 6 hours (as needed) PRN for 90 days at a time. Resident # 24 is an [AGE] year old woman admitted to facility on 8/1/16 with diagnoses of but not limited to Major Depressive Disorder, Dementia without Behavioral Disturbance, Anxiety Disorder, Diabetes Type II, Congestive Heart Failure, History of Aortocoronary Bypass Graft and Chronic Obstructive Pulmonary Disease. Her most recent (Minimum Data Set) MDS coded as a Quarterly with an (Assessment Reference Date) ARD of 1/10/19 codes Resident as having a (Brief Interview of Mental Status) BIMS score of 15 indicating no cognitive impairment. She is also coded as needing 1 person physical assistance with most of her (Activities of Daily Living) ADL's and she uses a wheelchair for locomotion on unit. On 4/3/19 during a clinical record review, it was noted that Resident #24 was receiving 2 psychotropic medications concomitantly including a PRN anti-anxiety medication. The Physician Order Sheets are as follows: Sertraline (generic Zoloft) 150 MG [Anti-Depressant] Lorazepam (generic Ativan) 0, 5 MG [Anti-Anxiety] X 30 days Review of care plan indicated Psych consult PRN. Review of Physicians Orders state Psych Consult PRN. On 4/4/19 at 2:40 PM any Psychiatry or Psychology notes for the Resident was requested. The DON stated she doesn't see a psychiatrist or psychologist she went on to say the facility Physician and/or Nurse Practitioner prescribes the Resident's psychotropic medications. According to the Pharmacy Consult dated [DATE]st - [DATE]th 2019- [Resident Name Redacted] has a PRN order for an anxiolytic, which has been in place for greater than 14 days without a stop date: Lorazepam Recommendation: If the medication cannot be discontinued at this time, current regulations require that the prescriber document the indication for use, the intended duration of therapy, and the rationale for the extended time period. Thank You Response Required [Box marked with X] I decline the recommendations above and do not wish to implement any changes due to the reason below Rationale: Pt is very anxious. DON provided the last Physician note dated 3/25/19 under Assessment & Plan the NP wrote: 1. Chronic Anxiety- Patient with a history of Dementia, however does contribute to exam. Patient with occasional episodes where she becomes anxious and staff are unable to calm patient or redirect. Patient requires the use of Ativan for chronic anxiety. Will continue the current dose of Ativan 0.5 MG 1 tablet (by mouth) PO (Every) Q6 hours PRN X 90 DAYS. MD/NP to re-evaluate for continued need in 90 days. It should be noted that on the (Medication Administration Record) MAR the Resident received the PRN dose 34 times in the month of March and out of those 34 times, 19 were documented on the MAR under behavior as 0 indicating no behaviors. In addition, the care plan did not address Non-pharmacological interventions. The Administrator was made aware of this on 4/4/19 at the end of day conference. No further information was provided. 2. For Resident #86 the facility staff gave anti-psychotic medication to a Dementia Resident without a proper diagnosis for use. Resident # 86 is an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Cardiac Arrhythmia, Hypertension, Myocardial Infarction (heart attack), and Dementia with behavioral disturbance, and Dysphasia. Resident's most recent (Minimum Data Set) MDS coded as a significant change coded Resident as having a BIMS of 3 indicating severe cognitive impairment. Resident was also coded as needing physical assist of 1 for ADL activities and is uses a wheelchair for locomotion on unit. On 4/4/19, a clinical record review was conducted and it was noted that Resident # 86 had a diagnosis of Dementia and received anti-psychotic medications. The Physicians Orders read: Quetiapine Fumarate [generic Seroquel] 100 MG by mouth every morning for Dementia with Behaviors. Quetiapine Fumarate 25 MG Give 3 tabs PO [by mouth] to equal 75 MG Q [every] Evening for Dementia with Behaviors. On 4/4/19 at 3:00 PM, an interview was conducted with the DON who stated that Resident # 89 has been on Seroquel for a while because of her behaviors. When asked about Pharmacy Reviews and recommendations she provided some from 2018 through 2019. The Pharmacy Review addressing Seroquel from a year ago (dated 4/1/2018) showed the attending physician agreed with Gradual Dose Reduction The Pharmacist Recommendation was as follows: [Resident name redacted] has dementia and receives Quetiapine Fumarate 100 MG by mouth twice daily for dementia with Behavioral Disturbances. Recommendation: If clinically appropriate please attempt a Gradual Dose Reduction of Quetiapine Fumarate perhaps 100 MG q am[100 MG every morning] and 75 q pm [75 MG every Evening] with the eventual goal of discontinuation, while concurrently monitoring for re-emergence of target behaviors and or withdrawal symptoms. Thank You Rationale for Recommendation: The FDA has issued a black box warning for anti-psychotics posing and increased risk of mortality in elderly individuals with dementia retaliated psychosis. The Beers criteria recommends avoiding anti-psychotics for the behavioral or psychological symptoms of dementia due to increased risk for stroke and mortality unless non-pharma logical options have failed and the residents behaviors are documented as a threat to self or others. For Antipsychotic therapy, it is recommended that a) The prescriber document an assessment of risk verses benefit indicating that it continues to be a valid therapeutic intervention. and b) The facility Interdisciplinary Team ensures ongoing monitoring of specific target behaviors documentation of 1) a danger to self or others including indications of resident distress 2) desired outcome 3) the efficacy of individualized, non-pharmacological approaches 4) potential adverse consequences and 5) History and outcome of previous attempts. [The box was checked] I accept the recommendations above please implement with the following modifications [Physician wrote] Reduce from 100 MG BID [twice a day] to 50 MG BID [twice daily] No GDR has been attempted since April 2018 According to the (Medication Administration Record) MAR for February 2019 under the nurses initials there is a line for Behaviors they are marked 0 indicating no behaviors for the entire month. According to the (Medication Administration Record) MAR for March 2019 under the nurses initials there is a line for Behaviors they are marked 0 indicating no behaviors for the entire month. According to the (Medication Administration Record) MAR for April 2019 under the nurses initials there is a line for Behaviors they are marked 0 indicating no behaviors thus far this month. The MDS dated [DATE] reads: Section E Behavioral Symptoms: E 0200- A Physical Behavioral symptoms directed toward others (e.g. hitting kicking, pushing, scratching grabbing abusing others sexually) coded O Behavior was not exhibited E 0200 - B Verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others) E 0200- C other behavioral symptoms not directed toward others E 0500 - Impact on Resident Did any identified behaviors put resident at risk for physical illness or injury? Coded No E 0800 Rejection of care Did the resident reject evaluation or care (e.g. bloodwork, taking medicine, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? Do not include behaviors that have already Been addressed 0- Behavior not exhibited E 0900 Wandering Presence and Frequency Has the Resident Wandered? 2- Behavior of this type occurred 4-6 days a week but less than daily. E 1000 does the wandering place the Resident at significant risk of getting into a potentially dangerous place? 1- Yes E 1100 - Does the wandering significantly intrude on the privacy and activities of others? 0- No It should be noted that wandering was the only behavior listed for this Resident on the MDS. The Administrator was made aware of this on 4/4/19 at the end of day conference. No further information was provided

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, Resident interview, clinical record review, and facility documentation review, the facility staff failed to accommodate the needs of 2 Residents, (Resident #487, and #26) of the 22 Residents in the survey sample. 1. For Resident #487, the facility staff failed to have a call system in place. 2. For Resident #26, the facility staff failed to accommodate her preference to attend worship activity within the facility. The findings included: 1. Resident #487 was recently admitted to the facility, on 11-20-17, with diagnoses that included; Hypertension, heart failure, urine retention, pneumonia, dementia, anxiety, dysphagia, and major recurrent depression. On 12-4-17 at 12:30 p.m., an initial tour was conducted of the facility, and the Resident was observed, and interviewed. The Resident was sitting in a wheel chair, on the side of her bed at the foot end. The Resident was wrapped in a blanket that she was sitting on, in the chair, and the blanket extended from her neck to her knees. The Resident was complaining of being cold. The Resident was asked if she could use her call bell to summon staff assistance, and she stated I don't know where it is. The call bell cord was noted to be plugged into the wall behind the head of the bed, and dangling down behind the head of the bed, resting on the floor. A staff member came to the door and stated Ms. (name), we will be carrying you to lunch in just a minute. The staff member was asked if the Resident could self-propel in the wheel chair, and she stated no, she is too weak, we have to push her. The Resident was wearing a nasal cannula with oxygen infusing at 4 liters per minute. The Resident was physically unable to come out of the room to ask for help. During Resident record review, Resident #487's full admission MDS (minimum data set) was found to be not yet submitted to CMS (Centers for Medicare and Medicaid Services). The Resident had only been a resident in the facility for 13 days at the time of survey. During the clinical record review, an admission nursing care plan was found, and it was reviewed. The care plan revealed that Resident #487 was documented as requiring assistance for all activities of daily living. The Resident was documented as requiring oxygen at 2 liters per minute via nasal cannula. Facility Policy & Procedure on the call bell system documented, All call lights will be answered promptly. Resident #487 was not able to summon help. On 12-6-17, and 12-7-17, the Administrator and Director of nursing were made aware of the lack of call bell accommodation for Resident #487. No further information was provided by the facility. 2. For Resident #26, the facility staff failed to accommodate her preference to attend worship activity within the facility. Resident #26 was [AGE] years old when admitted to the facility on [DATE]. Resident #26's diagnoses included Hypertension, Diabetes Mellitus, Neurogenic Bladder, Anxiety, and Depression. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 10/4/17, coded Resident #26 as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. Resident #26 was also coded as requiring the extensive physical assistance of two persons for bathing, dressing, transfers, and mobility. On 12/04/17 at 12:01 P.M., an interview was conducted with Resident #26. She stated that she has asked repeatedly to be assisted to attend church on Saturday and Sunday at 10 A.M., and that facility staff consistently bring her in late when the worship service is almost over. On 12/6/17 a Group Interview was conducted with approximately 20 residents. The majority of residents agreed that they often miss church service on the weekends because staff don't get them dressed and ready to attend timely. This happens on Saturday and Sunday because staff take residents outside of the facility to smoke earlier and that the official time, was 10:30 A.M. Resident #26 stated that she was upset because this also happened when her brother came from out of town to visit with her and attend the worship service. She often does not arrive until 10:45 when the worship activity is about to conclude. On 12/6/17 at 1:30 P.M. an interview was conducted with the Activities Coordinator (Employee G). She confirmed that Resident #26 regularly attended the worship activity on the weekends. She also confirmed that residents arrive late for the activity. On 12/6/17 at 4:30 P.M. the facility Administrator (Administration A), and Director of Nursing (DON- Administration B) were informed of the findings. The DON stated that the facility staff would get the residents dressed earlier. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure an accurate and complete MDS (minimum data set) for one Resident (Resident #58) of 22 Residents in the survey sample. For Resident #58, the facility staff inaccurately coded the special treatments status at Section O for the MDS assessment with Transfusions were received while a Resident. The findings included: 1. Resident #58 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, pressure ulcer, kidney disorder, dysphagia, irritable bowel syndrome, contractures both ankles, anxiety, depression, manic depression, anemia, neurogenic bladder, diabetes, wound infection, and quadriplegia. Resident #58's most recent MDS (minimum data set) with an ARD (assessment reference date) of 11-2-17 was coded as a quarterly assessment. Resident #58 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15 points, revealing no cognitive impairment. Resident #58 was also coded as requiring total dependence on one to two staff members for all activities of daily living, such as bed mobility and hygiene. In Section O-Special procedures, Resident #58 was coded as having blood transfusions while in the long term care facility. Review of the clinical record revealed no history of the Resident receiving a blood transfusion while in the facility. No physician's order existed in the clinical record for this procedure, and no documentation existed for this procedure in the nursing care plan. On 12-6-17 at approximately 10:00 a.m. an interview was conducted with Registered Nurse (RN) A, and Employee A, the MDS coordinators. The 2 staff members stated, It was coded incorrectly. No transfusions have been done in this facility, we don't do that. On 12-6-17, and 12-7-17, at the end of day debriefs, the Administrator and Director of Nursing were made aware of findings. No further information was provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility failed for one Resident, Resident 86, in a survey sample of 22 residents, to ensure a baseline care plan was initiated within 48 hours. Resident #86's initial care plan was initiated 8 days after his admission. The findings included: Resident #86 was admitted to the facility on [DATE]. Diagnoses included, but not limited to, stroke with hemiparesis, alcohol abuse. The resident has had no MDS (minimum data set) completed as he was a new admission. Care notes documented the resident required extensive to maximum assistance of two staff members. Resident # 86's initial care plan completed 8 days after admission. DON stated, Should be done 24 hours after admission. The only date on the document was the completion date. On 12/07/17 at 9:05 AM an interview was conducted with RN (registered nurse) A, the MDS coordinator, regarding interim care plans. She stated, The interim care plan form is included in the admission packet. The admit date is the initiation date. On 12/7/17 at approximately 11:15 AM, the Administrator and DON (director of nursing) were notified of above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review the facility staff failed for 1 resident (Resident #52) of 22 residents in the survey sample to review and revise the care plan. For Resident #52, the care plan did not include interventions to prevent the development of the pressure ulcer to the right heel. The findings included: Resident #52, an [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included stroke, aphasia, dementia, atrial fibrillation, hypertension. The most recent minimum data set assessment was a quarterly assessment with an assessment reference date of 10/20/17. Resident #52 was coded with a Brief Interview of Mental Status score of 3 indicating severe cognitive impairment. He required assistance with his activities of daily living (ADL) and was coded to have 1 stage 3 wound. Resident #52 had a right heel wound measuring 3.0 x 2.5 x. 0.1 centimeters when first assessed by the wound care doctor on 9/20/17. Resident #52's care plan was dated 8/31/17. The problem read potential for impaired skin integrity due to right sided hemiparesis. HX (history) of pressure ulcers. HX (history) of being non compliant with interventions and treatment plans. Refuses showers at times Open wound to right lateral ankle- resolved. HX (history) of cellulitis. Handwritten under this section read ref. (refuse) to elevate lower ext (extremities) @ times. The Approaches section read assist with turning, pressure reducing cushion to wheel chair, lift sheet for positioning, bowel and bladder program every 2 hours, wound consult as needed. There is no documentation of interventions specific to the feet and ankles. The CNA Care Plan was hung on the resident's closet door. The care plan read Information is current as of this date: 9/26/17. The interventions elevate heels off surface, turn & reposition, and pressure relieving boots were pre-printed on the care plan. None of these interventions were circled or identified to be care interventions for Resident #52. During the interview with the NP, DON and Assistant DON (ADON) on 12/7/17 at 9:15 a.m., the ADON stated that Resident #52 was known to refuse care. It was reviewed with the ADON that there were no interventions specific to prevention of foot and ankle wounds documented on the care plan. The ADON stated that she needed to take a look at the clinical record. The ADON provided a copy of an old care plan dated 2/2/17 that included the intervention 7/13/17 Float heels as resident will tolerate. Resident #52's care plans were discussed with LPN C. LPN C stated that the care plan dated 2/2/17 was old and had been thinned. She stated the care plan dated 8/31/17 was the current care plan. When asked if the intervention, Float heels as resident will tolerate, should have been included on the 8/31/17 care plan, she stated yes. When asked if a doctor's order was needed for pressure relieving boots, LPN C stated yes. LPN C stated that she also updated the CNA Care Plan and was responsible for keeping it up to date. The CNA care plan did not indicate that Resident #52's heels were supposed to be floated. LPN C stated that the CNA Care plan that was in place prior to 9/26/17 would have been discarded. The care plan issue was reviewed with the Administrator, DON and corporate staff at the end of day meeting on 12/7/17.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review the facility staff failed for 1 resident (Resident #52) of 22 residents in the survey sample to prevent and assess a pressure ulcer to the right heel. For Resident #52, no interventions were in place to prevent the development of the pressure ulcer. Once the ulcer was identified, it was not correctly assessed by facility staff. The findings included: Resident #52, an [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included stroke, aphasia, dementia, atrial fibrillation, hypertension. The most recent minimum data set assessment was a quarterly assessment with an assessment reference date of 10/20/17. Resident #52 was coded with a Brief Interview of Mental Status score of 3 indicating severe cognitive impairment. He required assistance with his activities of daily living (ADL) and was coded to have 1 stage 3 wound. Resident #52 was first observed on 12/04/17 at 2:30 PM. Resident #52 was lying in bed with his feet flat on the mattress. A purple pressure relieving boot was observed on the floor behind the head of the bed. When asked if he ever wears the boot, the resident stated yes. On 12/5/17, morning, the purple pressure relieving boot was observed in the same spot on the floor behind the head of the bed. On 12/7/17 at 12:40 p.m., Resident #52's right heel was observed in the presence of another surveyor and Certified Nursing Assistant B (CNA B). CNA B removed Resident #52's shoe and sock. Resident #52's right heel wound was closed and healed. According to the nursing notes, the right heel wound was first observed on 9/16/17. The nursing note read, open area noted to right heel during ADL care by CNA. Small amount of bloody drainage. Assessed by this nurse and NP notified and treatment applied. RP called and message left to call facility. A treatment was started on 9/16/17. The order read medi honey to R heel post cleansing w DWC (Dakins wound cleanser) and apply coveusite drsg (dressing). The order was implemented according to the September 2017 Treatment Administration Record (TAR). On 9/18/17, a wound consult was ordered. On 9/20/17, the wound doctor assessed the wound. The evaluation note read He presents with a stage 3 pressure wound of the right heel of at least 1 days duration. The wound was measured 3.0 x 2.5 x. 0.1 centimeters. It was described as 100% granulation tissue with moderate sero-sanguineous drainage. Recommendations included float heels while in bed, off-load wound, reposition per facility protocol. A new dressing was ordered dry protective dressing- once daily, silver alginate- once daily. Licensed Practical Nurse F (LPN F), quality assurance nurse, completed the Wound Assessment Report on 9/20/17. It included the exact same information from the wound doctor's assessment. During an interview with the Director of Nursing (DON) on 12/7/17 at 9:15 a.m., the DON stated that it was the facility process for LPN F to directly copy the information from the wound doctor note into the facility's wound assessment reports. The DON was asked to explain the process for assessing and documenting pressure ulcers. She stated that when the nurse was notified that a wound was present, the nurse was supposed to document the wound description, measurements, treatment order and notifications of doctor and responsible party. It was reviewed with the DON that the nurse that completed the nursing note on 9/16/17 did not measure the wound or describe the wound bed. The DON agreed that this information was not documented as it should have been. It was reviewed with the DON that the wound care doctor documented Resident #52's wound as a stage 3 on first assessment (4 days after the wound was found by facility staff). At this time, the Nurse Practitioner (NP) stated that she had reviewed the wound care doctor's assessments of the wound (on this day, 12/7/17) and was in disagreement with the documentation and staging. The NP was asked if she ever saw the wound. She stated no. The NP stated that she felt the wound doctor incorrectly staged the wound. The NP stated that she felt that a wound with the depth of 0.1 centimeters was a partial thickness wound (stage 1-2) rather than a full thickness wound (stage 3-4). She stated that the wound doctor's staging of the wound as a stage 3 was incorrect. The NP also questioned the description of the wound being 100% granulation tissue. When asked if they had identified issues with other residents regarding the wound care doctor's staging of wounds, the DON stated that Resident #52's wound was the first that they had reviewed. The DON stated that the wound care doctor assessed all pressure wounds. The DON stated that a nurse was present with the wound doctor during his rounds, but the nurse did not assess the wound. The nurse was there to document changes in treatment orders. For Resident #52, the nurse who first documented the wound on 9/16/17 did not measure the wound or describe the wound bed in her note. The NP and DON stated during their interview that the wound care doctor did not accurately describe or stage Resident #52's wound. The DON stated that the quality assurance nurse used the wound care doctor's assessment to complete the facility wound assessment report. As a result, there was no accurate assessment of Resident #52's pressure ulcer in his clinical record. Resident #52's care plan was dated 8/31/17. The problem read potential for impaired skin integrity due to right sided hemiparesis. HX (history) of pressure ulcers. HX (history) of being non compliant with interventions and treatment plans. Refuses showers at times Open wound to right lateral ankle- resolved. HX (history) of cellulitis. Handwritten under this section read ref. (refuse) to elevate lower ext (extremities) @ times. The Approaches section read assist with turning, pressure reducing cushion to wheel chair, lift sheet for positioning, bowel and bladder program every 2 hours, wound consult as needed. There is no documentation of interventions specific to skin care of the feet and ankles. The CNA Care Plan was hung on the resident's closet door. The care plan read Information is current as of this date: 9/26/17. The interventions elevate heels off surface, turn & reposition, and pressure relieving boots were pre-printed on the care plan. None of these interventions were circled or identified to be care interventions for Resident #52. During the interview with the NP, DON and Assistant DON (ADON) on 12/7/17, the ADON stated that Resident #52 was know to refuse care. It was reviewed with the ADON that there were no interventions specific to prevention of foot and ankle wounds documented on the care plan. The ADON stated that she needed to take a look at the clinical record. The ADON provided a copy of an old care plan dated 2/2/17 that included the intervention 7/13/17 Float heels as resident will tolerate. Resident #52's care plans were discussed with LPN C. LPN C stated that the care plan dated 2/2/17 was old and had been thinned. She stated the care plan dated 8/31/17 was the current care plan. When asked if the intervention, Float heels as resident will tolerate, should have been included on the 8/31/17 care plan, she stated yes. When asked if a doctor's order was needed for pressure relieving boots, LPN C stated yes. LPN C stated that she also updated the CNA Care Plan and was responsible for keeping it up to date. The CNA care plan did not indicate that Resident #52's heels were supposed to be floated. LPN C stated that the CNA Care plan that was in place prior to 9/26/17 would have been discarded. The issue was reviewed with the Administrator, DON, and corporate staff at the end of day meeting on 12/7/17.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and clinical record review, the facility staff failed, for 1 resident (Resident #38) in the survey sample of 22 residents, to provide a safe form of transport within the facility. The facility staff failed to provide Resident #38 a safe form of transport, after her ankle was fractured in 2 places while being transported by staff in a standard wheelchair without leg rests/food petals. The Findings included: Resident #38 was [AGE] years old when admitted to the facility on [DATE]. Resident #38's diagnoses included Altered Mental Status, Encephalopathy, Heart Failure, Hypertension, and Diabetes Mellitus. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 10/12/17, coded Resident #38 as being able to understand and be understood by others. She was also coded as having fluctuating inattention and disorganized thinking. She was coded as requiring the extensive physical assistance of one staff person for locomotion, dressing and personal hygiene. On 12/5/17 an interview was conducted with Resident #38. She stated, Aides took me to the beauty parlor to get my hair washed. They said we had to move fast because the the beauty parlor was closing. One aide pushed me fast while the other one walked with us and said to hurry up. I didn't have foot rests. My foot went down and my left ankle broke in 2 places. It happened in the hallway. I screamed, and was sent to the hospital. On 12/5/17 a review was conducted of Resident #38's clinical record, revealing that on 4/27/16, she sustained a fractured ankle while being transported by staff in a wheelchair without leg rests/ foot petals. On 12/7/17 at 1:30 P.M. an interview was conducted with Resident #38. Resident #38's wheelchair was next to her bed. It didn't have leg rests/ foot petals. There were no leg rests/ foot petals in her closet. According to the clinical record, and the statement by Resident #38, prior to the ankle fracture, she used her feet to ambulate around the facility in her wheelchair. After the fracture, Resident #38 had spent the majority of her time in bed. She stated that staff take her out of her room for showers, and that she doesn't feel safe in the wheelchair without leg rests/foot petals. When asked if the staff had installed leg rests/foot pedals on her wheelchair after the fracture, she stated, They threw something together that was unsteady. They didn't hold my feet properly. They tried to crunch up my foot. The pedal was wobbly. My feet would just slip right off the pedals. When they put me in the wheelchair, I could feel myself leaning forward at the gap between my lower back and the back of the wheelchair. I would always slide forward I was sometimes afraid of falling out. On 12/7/17 a review of Resident #38's clinical record was conducted. The Care Plan read, 7/3/17. Requires extensive assist/total assistance with ADL (Activities of Daily Living) care. Prefers to stay in bed majority of the time. Will attend at least 2 out of room activities of interest through next review. On 12/7/17 at 1:30 P.M. an interview was conducted with the Director of Rehabilitation (Employee F). When asked why Resident #38 did not have a safe form of transport, the Director of Rehabilitation stated that Resident #38 had refused to get out of bed. When asked if Resident #38's wheelchair had been altered, or adapted or adjusted in any manner since the ankle fracture occurred, she stated, No. The Director of Nursing was also present (DON -Administration B). They both agreed that Resident #38 is taken via her wheelchair twice weekly for showers, and to have her hair washed. They both were unable to state a specific plan to ensure a safe form of transport to engage in activities of daily living. On 12/7/17, the Administrator was informed of the findings. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation review and clinical record review, the facility staff failed to ensure that a urinary catheter drainage bag was maintained in a manner to prevent the spread of infection for one resident (Resident # 29) in a survey sample of 22 residents. For Resident # 29, the facility staff failed to ensure the urinary catheter bag was not resting the floor. Resident # 29 was observed to be sitting in a wheelchair in the dining room with his urinary drainage bag touching the floor. The findings included: Resident # 29 was a [AGE] year-old male who was admitted to the facility on [DATE], readmitted on [DATE] and 9/29/2017 with diagnoses of but not limited to: Hypertension, Diabetes, Acute Kidney Failure, Gastroesophageal Reflux Disease, Venous Insufficiency, Fluid Overload, Pulmonary Hypertension, Peripheral Vascular Disease, Neurogenic Bladder and Edema. The most recent Minimum Data Set (MDS) was a Significant Change Assessment with an Assessment Reference Date (ARD) of 10/6/2017. The MDS coded Resident # 29 with a BIMS (Brief Interview for Mental Status) of 15/15 indicating no cognitive impairment; the resident required extensive assistance of 1 staff person with Activities of Daily Living except required supervision and set up for eating; and coded as always incontinent of bowel and an indwelling catheter for bladder. 12/04/17 2:25 PM Observed Resident sitting in Dining Room in wheelchair. Indwelling catheter bag resting on the floor. 12/05/17 10:00 AM Observed Resident sitting in Dining Room in wheelchair. Indwelling catheter bag resting on floor 12/05/17 12:45 PM Observed Resident sitting in Dining Room in wheelchair. Indwelling catheter resting on floor. 12/05/17 2:00 PM-3:05 PM Resident sitting in Dining Room in wheelchair during Group Interview. Catheter bag resting on floor throughout meeting. 12/5/17 3:10 PM, the Director of Nursing was in the Dining Room checking on another resident. When the surveyor asked about Resident # 29's catheter bag, the DON stated the catheter bag was on the floor and should not rest on the floor. The DON stated the catheter bag kept dropping lower and that she had to lift it higher twice the night before because it had begun to touch the floor. The DON stated she thought the catheter bag would shift periodically. The Corporate Consultant (Admin D) came into the Dining Room and stated the drainage bag should not rest on the floor. Admin D stated she was going to take Resident # 29 to his room to correct the issue. Admin D began to turn Resident # 29's wheelchair. The DON stopped Admin D and instructed her to raise the catheter bag prior to transporting the resident. Review of the clinical record revealed Resident # 29 had a Suprapubic Catheter. Review of the Physicians Orders revealed orders to Monitor Suprapubic Foley output every shift and Cleanse Suprapubic area with wound cleanser, pat dry, apply sponge to area twice a day. On 12/6/2017 at 4:00 PM, observed nurse, (Licensed Practical Nurse E) providing treatment to the Suprapubic site as ordered by the physician. Suprapubic site appeared clean and dry. No issues were noted with the administration of the treatment. Review of the Facility Document entitled Catheter Care, Urinary revised 9/2017, Under Infection Control stated: 2. b. Be sure the catheter tubing and drainage bag are kept off the floor. During the end of day debriefing on 12/6/2017 at approximately 4:45 PM, the Director of Nursing, Administrator and Corporate Consultants were informed of the findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident # 41, the facility staff failed to ensure the oxygen tank was not empty on 12/5/2017. Resident # 41 was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of but not limited to: Neuromuscular scoliosis occipito atlantis axial region, Neuromuscular scoliosis of thoracic region, Abnormal posture, Gastroesophageal Reflux Disease, Chronic Heart Failure, and Malignant Neoplasm of Prostate. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 10/11/2017. The MDS coded Resident # 41 with a BIMS (Brief Interview for Mental Status) of 15/15 indicating no cognitive impairment; the resident required extensive assistance of 1 staff person with Activities of Daily Living except for bed mobility and bathing. For Bed mobility, he required extensive assistance of two staff persons and required total assistance of one staff person for bathing; Resident # 41 was coded as frequently incontinent of bowel and bladder. The Resident Council Group Interview was conducted on 12/5/2017 at 2:00 PM. At the end of the Group Interview, one resident in the Group stated she noticed the night before (12/4/17) that Resident # 41's oxygen tubing had come off and when she told the nurse and the nurse checked it, the oxygen tank was empty. Resident # 41 attended the Group Interview. The Group Interview ended at 2:55 PM. Resident # 41 was in the Dining Room during the entire Group Interview. He had oxygen tubing via nasal cannula in his nostrils. The surveyor checked Resident # 41's oxygen container after the Group interview was over. The oxygen tank was observed to be in the red zone indicating it was empty. The gauge indicated the oxygen rate was set at 2 liters per minute. Observations: 12/05/17 2:00-2:55 PM- Resident # 41 attended the entire Group Interview meeting. He was sitting in his wheelchair with oxygen tubing via nasal cannula. 12/05/17 3:05 PM, The surveyor observed Resident # 41 had Oxygen via nasal cannula set at 2 Liters/min. The Oxygen tank gauge was in the red zone indicating the tank was empty. The Director of Nursing (DON) came to the Dining Room, looked at the oxygen tank, removed the tubing, felt for a flow of air and found no oxygen coming out of tank. The DON stated the tank is empty. I will change it immediately. 12/05/17 3:10 PM- Oxygen tank was replaced by DON who showed surveyor the tank gauge was then reading the tank was half full. DON removed the tubing from the tank and felt the oxygen coming out of the tank. 12/05/17 3:15 PM-Facility Staff was asked to obtain a Pulse Oximetry reading on Resident # 41. Employee C checked the Pulse Oximetry reading which was 97. 12/05/17 3:30 PM-Interview conducted with DON who stated the nurse assigned to work with Resident # 41 told her she was going to check the resident's oxygen tank earlier but he was in the Group interview meeting with the surveyor and the nurse did not want to interrupt the meeting. The DON stated the expectation was for nurses to make sure residents receive oxygen as ordered by the physician. The DON also stated the nurses should check the amount of oxygen in the tank prior to a resident attending activities. The surveyor reiterated that any meeting held by a surveyor could be interrupted for Residents to receive care. 12/5/17 at 4:00 PM-Review of the clinical record revealed a Physician's Order for Oxygen at 2 liters continuously via nasal cannula with Oxygen saturation on Oxygen every shift. 12/6/17 at 9:00 AM, Review of the Facility Policy on Oxygen Administration dated October 2017 revealed statements under Steps in the Procedure .6. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened . 7. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. 12/6/2017 at 11:25 AM, Resident # 41 was observed sitting in the dining room with Oxygen via nasal cannula at 2 liters per minute. The portable oxygen tank gauge showed the tank was half full. During the end of day debriefing on 12/6/17, the Director of Nursing, Administrator and Corporate Consultant were informed of the findings. No further information was provided. Based on observation, staff interview, resident interview, and clinical record review, the facility staff failed to ensure a correct oxygen infusion rate for 2 Residents (Resident #487, and #41 ) of 22 residents in the survey sample. 1. Resident #487 failed to have 2 liters of oxygen infusing, and instead, had 4 liters of oxygen infusing. 2. For Resident # 41, the facility staff failed to ensure the oxygen tank was not empty on 12/5/2017. The findings included: 1. Resident #487 failed to have 2 liters of oxygen infusing, and instead had 4 liters of oxygen infusing. Resident #487 was recently admitted to the facility, on 11-20-17, with diagnoses that included; Hypertension, heart failure, urine retention, pneumonia, dementia, anxiety, dysphagia, and major recurrent depression. On 12-4-17 at 12:00 p.m., an initial tour was conducted of the facility, and the Resident was observed, and interviewed. The Resident was sitting in a wheel chair, on the side of her bed at the foot end. The Resident was wrapped in a blanket that she was sitting on, in the chair, and the blanket extended from her neck to her knees. The Resident was complaining of being cold. The Resident was asked if she could use her call bell to summon staff assistance, and she stated I don't know where it is. The call bell cord was noted to be plugged into the wall behind the head of the bed, and dangling down behind the head of the bed, resting on the floor. A staff member came to the door and stated Ms. (name), we will be carrying you to lunch in just a minute. The staff member was asked if the Resident could self-propel in the wheel chair, and she stated no, she is too weak, we have to push her. The Resident was wearing a nasal cannula with oxygen infusing at 4 liters per minute. The Resident was physically unable to come out of the room to ask for help. On 12-4-17 two further observations were conducted of the Resident at 2:51 p.m., and 3:25 p.m., during all three observations from 12:00 p.m. to 3:30 p.m., the Resident was receiving 4 liters of oxygen infusing via nasal cannula continuously. During Resident record review, on 12-4-17, and 12-5-17, Resident #487's full admission MDS (minimum data set) was found to be not yet submitted to CMS (Centers for Medicare and Medicaid Services). The Resident had only been a resident in the facility for 13 days at the time of survey. During the clinical record review, an admission nursing care plan was found, and it was reviewed. The care plan revealed that Resident #487 was documented as requiring assistance for all activities of daily living. The Resident was documented as requiring oxygen at 2 liters per minute via nasal cannula continuously. During the clinical record review physician's orders were reviewed and revealed a current order for oxygen 2 liters per minute via nasal cannula continuously. During the clinical record review, the Medication Administration record (MAR) was reviewed. The MAR revealed signatures that the Resident was receiving 2 liters of oxygen per minute via nasal cannula continuously. On 12-6-17, and 12-7-17, the Administrator and Director of nursing were made aware of the oxygen error for Resident #487. No further information was provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and clinical record review, the facility staff failed, for 1 resident (Resident #38) in the survey sample of 22 residents, to provide appropriate equipment to maintain or improve mobility. The facility staff failed to provide Resident #38 with appropriate equipment to maintain or improve mobility, after her ankle was fractured in 2 places while being transported by staff in a standard wheelchair without leg rests/food petals. Prior to the fracture, Resident #38 was able to use her feet to ambulate independently with a wheelchair. The Findings included: Resident #38 was [AGE] years old when admitted to the facility on [DATE]. Resident #38's diagnoses included Altered Mental Status, Encephalopathy, Heart Failure, Hypertension, and Diabetes Mellitus. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 10/12/17, coded Resident #38 as being able to understand and be understood by others. She was also coded as having fluctuating inattention and disorganized thinking. She was coded as requiring the extensive physical assistance of one staff person for locomotion, dressing and personal hygiene. On 12/5/17 an interview was conducted with Resident #38. She stated, Aides took me to the beauty parlor to get my hair washed. They said we had to move fast because the the beauty parlor was closing. One aide pushed me fast while the other one walked with us and said to hurry up. I didn't have foot rests. My foot went down and my left ankle broke in 2 places. It happened in the hallway. I screamed, and was sent to the hospital. On 12/5/17 a review was conducted of Resident #38's clinical record, revealing that on 4/27/16, she sustained a fractured ankle while being transported by staff in a wheelchair without leg rests/ foot petals. On 12/7/17 at 1:30 P.M. an interview was conducted with Resident #38. Resident #38's wheelchair was next to her bed. It didn't have leg rests/ foot petals. There were no leg rests/ foot petals in her closet. According to the clinical record, and the statement by Resident #38, prior to the ankle fracture, she used her feet to ambulate around the facility in her wheelchair. After the fracture, Resident #38 had spent the majority of her time in bed. She stated that staff take her out of her room for showers, and that she doesn't feel safe in the wheelchair without leg rests/foot petals. When asked if the staff had installed leg rests/foot pedals on her wheelchair after the fracture, she stated, They threw something together that was unsteady. They didn't hold my feet properly. They tried to crunch up my foot. The pedal was wobbly. My feet would just slip right off the pedals. When they put me in the wheelchair, I could feel myself leaning forward at the gap between my lower back and the back of the wheelchair. I would always slide forward I was sometimes afraid of falling out. On 12/7/17 a review of Resident #38's clinical record was conducted. The Care Plan read, 7/3/17. Requires extensive assist/total assistance with ADL (Activities of Daily Living) care. Prefers to stay in bed majority of the time. Will attend at least 2 out of room activities of interest through next review. On 12/7/17 at 1:30 P.M. an interview was conducted with the Director of Rehabilitation (Employee F). When asked why Resident #38 did not have a safe form of transport, the Director of Rehabilitation stated that Resident #38 had refused to get out of bed. When asked if Resident #38's wheelchair had been in altered, or adapted or adjusted in any manner since the ankle fracture occurred, she stated, No. The Director of Nursing was also present (DON -Administration B). They both agreed that Resident #38 is taken via her wheelchair twice weekly for showers, and to have her hair washed. They both were unable to state a specific plan to ensure a safe form of transport to engage in activities of daily living. On 12/7/17, the Administrator was informed of the findings. No further information was received.

Based on observation, staff interview, and facility documentation review, the facility staff failed to implement an effective infection control program. 1. The facility staff failed to assure that fingernails were cut to a short length on five direct care staff. The findings included: Licensed Practical Nurse (LPN) F, the Infection Control nurse was observed to have artificial multicolored nails about ½ in length on 12/6/2017 at 1:00 PM. Employee C, Medical Records, was observed pushing a resident in a wheel chair on 12/6/2017 at 2:30 PM. She was seen to have long natural, unpainted nails approximately ¾ in length. LPN A was noticed on 12/6/2017 at 2:45PM to have had long blue speckled artificial nails approximately 1 long. She was unable to type in a normal manner, having to use the pads of her fingers to touch the keyboard. RN B, Director of Nursing was seen to have artificial nails approximately 1/2 in length on 12/6/2017 at 4:45 PM. RN C, Assistant Director of Nursing was seen to have painted nails approximately 3/8 long. On 12/6/2017. LPN F, Infection Control nurse stated that her nails were inappropriate for a healthcare setting. The facility did not have a policy regulating nail length however there was a statement on page 21 of the Employee Handbook that stated Hair, beard, and nails must be clean and neatly trimmed. Extreme styles and colors should be avoided. Guidance was given at www.cdc.gov, Whether artificial nails contribute to transmission of health-care-associated (HCW) infections is unknown. However, HCWs who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than are those who have natural nails, both before and after handwashing (347--349). Whether the length of natural or artificial nails is a substantial risk factor is unknown, because the majority of bacterial growth occurs along the proximal 1 mm (millimeter) of the nail adjacent to subungual skin (345,347,348). Recently, an outbreak of P. aeruginosa in a neonatal intensive care unit was attributed to two nurses (one with long natural nails and one with long artificial nails) who carried the implicated strains of Pseudomonas spp. on their hands (350). Patients were substantially more likely than controls to have been cared for by the two nurses during the exposure period, indicating that colonization of long or artificial nails with Pseudomonas spp. may have contributed to causing the outbreak. Personnel wearing artificial nails also have been epidemiologically implicated in several other outbreaks of infection caused by gram-negative bacilli and yeast (351--353). Although these studies provide evidence that wearing artificial nails poses an infection hazard, additional studies are warranted. Administration were informed of the findings on 12/8/2017 at 3:00 PM-COMPLAINT RELATED DEFICIENCY