**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation review and staff interview, the facility staff failed to implement their abuse policy for screening employees for 8 employees (Employee#1, Employee #4, Employee #5, Employee #8, Employee #9, Employee #10, Employee #16, Employee #23) in a sample size of 25 employees. The findings included: On [DATE], the facility staff provided a copy of their policy entitled, Abuse Prevention Program. In Section 2(a), it was documented, Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has (a) been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law . Section 2(b) documented, .had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property . On [DATE] at approximately 10:45 A.M., this surveyor and Employee E, the Human Resources Manager, reviewed 25 employee files which revealed the following: Employee #1, a housekeeper with a hire date of [DATE], did not have a criminal background check on file. Employee #4, a Licensed Practical Nurse (LPN) with a hire date of [DATE], had a license verification completed on [DATE]. The LPN license had an expiration date of [DATE]. There was not another license verification until [DATE], nearly 4 months after the license had expired. There was no evidence the license was verified to be renewed or evaluated for findings. Employee #5, a Certified Nursing Assistant (CNA) with a hire date [DATE], had a license verification completed on [DATE], over 4 months after the date of hire. Employee #8, a Certified Nursing Assistant (CNA) with a hire date of [DATE], had a license verification completed on [DATE]. The CNA license had an expiration date of [DATE]. The next license verification to verify active status was not completed until [DATE], nearly 3 months after the license was due to expire. Employee #9, a CNA with a hire date of [DATE], had a license verification on [DATE], one month after the date of hire. Employee #10, a CNA with a hire date of [DATE], had a certification verification on [DATE], nearly one month after the date of hire. Employee #16, a CNA with a hire date of [DATE], had a certification verification completed on [DATE]. The CNA license had an expiration date of [DATE]. The next license verification to verify active status was not completed until [DATE] months after the license was due to expire. Employee #23, a certified physical therapy assistant with a hire date of [DATE], had a license verification on [DATE], over one year after the date of hire. On [DATE] at approximately 11:30 A.M., when asked why many of the license/certification verifications were performed late, Employee E stated that licenses used to be checked prior to hire but due to a time crunch with the implementation of a new process and electronic system, some licenses did not get verified timely. On [DATE] at approximately 1:15 P.M., the administrator and Director of Nursing were notified of findings. The administrator indicated there was no further information or documentation to submit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident interview, clinical record review and staff interview, the facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed within 30 days of admission (prior to admission is being waived due to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency) for 1 resident (Resident #11) in a sample of 19 residents. For Resident #11, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed within 30 days of admission. The Findings included: Resident #11 was admitted on [DATE] with diagnoses including: Schizophrenia, Non-Alzheimer's dementia, and anxiety disorder. On 6-22-22 an observation, Resident interview, and review of Resident #11's record was conducted. Resident #11 was noted to have diagnoses including schizophrenia, and non-Alzheimer's dementia. Geriatric psychiatry notes, resident history, and admission information revealed that the illnesses were long standing. No previous to admission PASARR was found in the Electronic Health Record (EHR). The facility staff were asked to locate Resident #11's PASARR. On 6-23-22, an interview was conducted with the Director of Nursing (DON). The DON stated there was no PASARR completed for Resident #11, and stated that this error would be corrected. The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 6-23-22. The Administrator stated, we will correct this immediately and indicated they would be auditing all residents' PASARRs. No further documents were provided.

Based on staff interview, and facility documentation review, the facility staff failed to develop a procedure for unvaccinated and vaccinated staff who refuse or are unable to be tested for COVID-19 in accordance with the Centers for Disease Control and Prevention (CDC) guidance. The findings included: There were no COVID positive staff nor Residents present in the facility during the course of the survey, from 6-21-22 through 6-23-22. Staff were observed wearing eye protection and face masks during the survey in accordance with community transmission rates, and according to CDC guidance. Staff were interviewed and asked what the procedure was for those staff who are unable or unwilling to be tested. Two direct care staff members, and one house keeping staff member, were interviewed. Each of them stated they did not know, and would ask the Director of Nursing (DON). On 6-22-22 at 10:00 a.m., the DON was asked for policies regarding testing of staff. The document title was Universal COVID-19 Testing Policy. The policy was reviewed and revealed under General Considerations, Staff who decline COVID-19 testing will not be allowed to continue to work, removed from the work calendar and sent home immediately to self-quarantine for 14 days. This is the only mention of refusal or inability to test staff in all of the COVID-19 facility policies. On 6-22-22 at the end of day debriefing at 5:00 p.m., the Administrator and DON were asked what happened at the end of the 14 day quarantine? Was the staff member allowed to return to work? The DON stated I see what you mean. We need a contingency plan for staff refusals and those staff which can't be tested, for them to be able to return safely to work, or not to return. This will include what PPE to wear and what areas they may safely work in. We will be fixing this policy this week. On 6-23-22 at 2:00 p.m., the Administrator and DON were made aware of the facility need for a contingency plan for testing refusals. No further information was provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview facility documentation and clinical record review the facility staff failed to ensure one Residents was free from neglect for 1 of 25 sampled Residents (#34). For Resident #34 who had a recent history of falls with fracture, the facility staff left the Resident on the toilet without supervision, neglecting the Resident's known needs, and the Resident fell. The findings included: Resident #34 was admitted to the facility on [DATE] with diagnoses including; Dementia, glaucoma, lack of coordination, muscle weakness, and fall with fracture of the tibia, and fibula, and was non-weight bearing at the time of admission from the hospital for surgery related to that fracture on 12-26-18. The Resident was also hard of hearing and wore hearing aids. Resident #34's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 3-20-19. Resident #34 was coded with a Brief Interview of Mental Status score of 7, indicating moderate cognitive impairment. Resident #34 was extensively dependant on one staff member for assistance with activities of daily living care, such as bed mobility, transferring, and toileting. On the physician's progress notes, most described the Resident as hard of hearing (HOH). Nursing staff and the Resident's daughter indicated the Resident was very hard of hearing, and this could be a barrier to communication, and understanding instructions. On 2-25-19 the physician's progress notes indicated the Resident had fallen on 2-23-19 while trying to stand from a wheel chair. On 3-5-19 the nursing notes documented that the Resident had been left alone on the toilet and had fallen. On 5-14-19 at approximately 1:00 p.m., Resident #34's daughter was interviewed. The daughter stated I was not aware that mom fell from the toilet unattended. She can't be left alone on the toilet, she will try to get up and fall. She has an immobilizer on her ankle from her fracture, and pain in that leg that she receives pain medication for. She is not supposed to stand on it unassisted, and she doesn't remember that. The Resident's current care plan was reviewed and revealed no revision or update review, since admission on [DATE], and had a goal date of 7-5-19. The care plan stated as problems related to falls and fracture, the 3 following areas, and those interventions are below; 1. Falls - at risk for more falls related to recent fall and fracture - observe and anticipate or intervene with factors causing previous or potential for falls. Answer calls quickly, attempt to anticipate needs for prompt response, and decrease in attempts to ambulate without proper assist. 2. Impaired functional status - has impaired functional status with bed mobility, transfer, walking, toileting, etc - weight bear as tolerated with brace when out of bed, stand pivot for transfers with assist of 1 staff. 3. Medical condition Orthopedic - had a recent fracture, requires follow up care. - Assess immobilizer device cast to ensure intact, assess skin under/at edge of immobilizer to ensure no rubbing, friction or pressure is evident. Maintain imposed limitations of non-weight bear right lower extremity educate and remind (Resident) of limitations. At the time of survey no facility reported incident (FRI) or allegation of neglect was forwarded to the state agency, the Virginia Department of Health Office of Licensure and Certification (VDH/OLC). The facility abuse & neglect policy and procedure documents were requested from the administrator, and obtained. Review of the policy revealed that all allegations of abuse or neglect be reported within 24 hours after the (incident) allegation is made. Federal regulations describes neglect as: the failure of the facility , it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. On 5-16-19 at 10:30 a.m. the Director of Nursing (DON) was asked for any FRI's for this Resident. She stated there were none. In summary, the staff were aware of the Resident's fall history with attempts to stand alone, resulting in serious injury, and the Resident was demented, with memory impairment, hard of hearing, and was non-weight bearing. The Resident had a cast device on her left leg which was a fall hazard. she had pain in that leg, poor vision, lack of coordination and weakness. The facility staff placed her on the toilet and left her there alone, and when they returned she was sitting on the floor in the bathroom where she had fallen. Staff did not implement their care plan to intervene with factors causing previous falls or potential for falls, nor attempt to anticipate needs for prompt response, and decrease in attempts to ambulate without proper assist. The Administrator and Director of Nursing were notified at the end of day meeting on 5-16-19 at 2:00 p.m. that the staff was negligent in providing the care and services required by the Resident, and were deficient in investigating and reporting this incident. 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 staff failed to notify the ombudsman of transfer to the hospital for two Residents (Resident #339, Resident 89) in a survey sample of 25 Residents. 1. For Resident #339, the facility staff failed to notify the ombudsman of transfer to the hospital on two occasions. 2. For Resident #89, the facility staff failed to notify the ombudsman of transfer to hospital. The findings included: 1. For Resident #339, the facility staff failed to notify the ombudsman of transfer to the hospital on two occasions. Resident #339, was admitted to the facility on [DATE]. The Resident's diagnoses included but were not limited to: other symptoms and signs involving musculoskeletal system, lack of coordination, muscle weakness, unsteadiness on feet, dysphagia and cognitive communication deficit. Resident #339's most recent MDS (minimum data set) (an assessment tool), was coded as an admission assessment, with an ARD (assessment reference date) of 11/21/18. Resident #339, had a BIMS (brief interview for mental status) score of 9, which indicated moderately impaired cognition. Resident #339 was coded that extensive assistance of two staff members was required for ADL's (activities of daily living) which included, bed mobility, transfers, dressing and personal hygiene. On 5/15/19 during review of Resident #339's clinical record, nursing notes revealed that on 12/13/18, Resident #339 was sent to the hospital. The nursing note dated 12/13/18 at 23:51 read, Resident was found on the floor close to the bed in her room by Aide. A laceration noted on back of head, measured 2cm x 0.5 cm, with depth 0.3cm. Surrounding area appeared swollen and blood draining. In the incident scene there was a clock with front glass in pieces on the floor, blood on the carpet closer to the TV and two chairs on the side wall. She denied pain, no complain of drowsiness, dizziness, or lightheadedness noted. Injury area cleanse with NS, pressure applied to stop bleeding. According to assigned CNA, resident was put to bed after dinner and ADL care had been provided. Resident stated that she lost her balance and hit her head on the side wall while trying to go to the restroom. She believed that the clock fell to the ground resulting from the impact on the wall due to her hitting the wall. Vitals taken x 4 every 15 minutes, pressure applied to stop bleeding, cleanse injured with NS, pat dry and covered with dry gauze. MD notified and ordered to sent to ER for further evaluation and possible sutures to injured area Daughter was notified that walked in shortly after the incident occurred. Pt was sent out via medical transportation, accompanied by daughter. A nursing note dated 12/16/18 at 17:04 read, Patient was sent out per daughter/[name] request: approved by Dr. [Dr. name] d/t s/p fall trauma injury noted to right forearm (redness, swelling, pain, inflammation and warm to touch) and c/o pain to right hip. Pain managed with hydrocodone. Review of the clinical record for Resident #339 revealed no indication that the ombudsman was notified of her transfer to the hospital on [DATE] and 12/16/18. On 5/16/19 at approximately 11 am the facility Administrator was interviewed and asked for verification of the ombudsman notification of Resident #339's transfer to the hospital. The Administrator stated, we weren't doing it at that time. The facility administrator was made aware of the facility staff's failure to notify the ombudsman of hospital transfers on 5/16/19. No further information was provided. 2. For Resident #89, the facility staff failed to notify the ombudsman of transfer to hospital. Resident #89, a [AGE] year old female, was admitted to the facility on [DATE] and discharged on 05/01/2018 due to a transfer to the hospital. Therefore, this was a closed record review. Diagnoses included but not limited to diabetes, hypertension, and atherosclerotic heart disease. Resident #89's most recent Minimum Data Set with an Assessment Reference Date of 04/20/2018 was coded as an admission assessment. The Brief Interview for Mental Status was coded as a 15 out of possible 15 indicative of intact cognition. On 05/16/2019 at approximately 9:30 AM, the nurse's notes were reviewed. A nursing entry dated 05/01/2018 documented that [Resident #89] was sent to the hospital for hyperglycemia after unsuccessfully attempting to correct levels. On 05/16/2019 at approximately 9:45 AM, documentation of ombudsman notification associated with transfer to hospital on [DATE] was requested. On 05/16/19 at 1:45 PM, the Administrator stated, We have not been notifying ombudsman of transfers. On 05/16/2019, the facility staff provided a policy entitled, Transfer or Discharge, Emergency. In Section 4, it documented, Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's attending physician b. Notify the receiving facility that the transfer is being made c. Prepare the resident for transfer d. Prepare a transfer form to send with the resident e. Notify the sponsor or other family member f. Assist in obtaining transportation g. Others as appropriate or as is necessary. Notifying the ombudsman of hospital transfer was not addressed in the policy. On 05/16/2019 at approximately 2:30 PM, the Administrator stated they have no further documentation or information to offer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to notify the resident of bed hold policy before transfer to the hospital for one Resident (Resident #339) in a survey sample of 25 Residents. For Resident #339, the facility staff failed to notify the resident of the bed hold policy before transfer to the hospital on two occassions. The findings included: Resident #339, was admitted to the facility on [DATE]. The Resident's diagnoses included but were not limited to: other symptoms and signs involving musculoskeletal system, lack of coordination, muscle weakness, unsteadiness on feet, dysphagia and cognitive communication deficit. Resident #339's most recent MDS (minimum data set) (an assessment tool), was coded as an admission assessment, with an ARD (assessment reference date) of 11/21/18. Resident #339, had a BIMS (brief interview for mental status) score of 9, which indicated moderately impaired cognition. Resident #339, was coded that extensive assistance of two staff members was required for ADL's (activities of daily living) which included, bed mobility, transfers, dressing and personal hygiene. On 5/15/19 during review of Resident #339's clinical record, nursing notes revealed that on 12/13/18 Resident #339 was sent to the hospital. The nursing note dated 12/13/18 at 23:51 read, Resident was found on the floor close to the bed in her room by Aide. A laceration noted on back of head, measured 2cm x 0.5 cm, with depth 0.3cm. Surrounding area appeared swollen and blood draining. In the incident scene there was a clock with front glass in pieces on the floor, blood on the carpet closer to the TV and two chairs on the side wall. She denied pain, no complain of drowsiness, dizziness, or lightheadedness noted. Injury area cleanse with NS, pressure applied to stop bleeding. According to assigned CNA, resident was put to bed after dinner and ADL care had been provided. Resident stated that she lost her balance and hit her head on the side wall while trying to go to the restroom. She believed that the clock fell to the ground resulting from the impact on the wall due to her hitting the wall. Vitals taken x 4 every 15 minutes, pressure applied to stop bleeding, cleanse injured with NS, pat dry and covered with dry gauze. MD notified and ordered to sent to ER for further evaluation and possible sutures to injured area Daughter was notified that walked in shortly after the incident occurred. Pt was sent out via medical transportation, accompanied by daughter. A nursing note dated 12/16/18 at 17:04 read, Patient was sent out per daughter/[name] request: approved by Dr. [Dr. name] d/t s/p fall trauma injury noted to right forearm (redness, swelling, pain, inflammation and warm to touch) and c/o pain to right hip. Pain managed with hydrocodone. Review of the clinical record for Resident #339 revealed no indication that the resident or her responsible representative was notified of the bed hold policy prior to her transfer to the hospital on [DATE] and 12/16/18. On 5/16/18, the facility Administrator was asked where it is noted that Resident #339 was notified of the bed hold policy prior to her transfer and the Administrator stated, we weren't doing it at that time. The facility administrator was made aware on 5/16/19 of the facility staff's failure to notify the resident of the bed hold policy prior to transfer. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #34, the facility staff failed to develop a comprehensive care plan for hearing deficits. Resident #34 was admitted to the facility on [DATE] with diagnoses including; Dementia, glaucoma, lack of coordination, muscle weakness, fall with fracture of the tibia, and fibula, and was hard of hearing with hearing aid devices. Resident #34's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 3-20-19. Resident #34 was coded with a Brief Interview of Mental Status score of 7, indicating moderate cognitive impairment. Resident #34 was extensively dependant on one staff member for assistance with activities of daily living care, such as bed mobility, transferring, and toileting. On the physician's progress notes, it described the Resident as hard of hearing (HOH). Nursing staff and the Resident's daughter indicated the Resident was very hard of hearing, and this could be a barrier to communication, and understanding instructions. The Resident's current care plan was reviewed and revealed no care plan for hard of hearing deficits. The Administrator and Director of Nursing were notified at the end of day meeting on 5-16-19 at 2:00 p.m. No further information was provided by the facility. Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed develop a care plan for 2 of 25 sampled residents. 1. For Resident # 91, the facility staff failed to develop a care plan for a renal diet. 2. For Resident #34, the facility staff failed to develop a comprehensive care plan for hearing deficits. The Findings included: 1. For Resident # 91, the facility staff failed to develop a care plan for a renal diet. Resident #91 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #91's diagnoses included Hypertension, Chronic Kidney Disease, Stage 4 Type 2 Diabetes without Complications, Hyperlipidemia, and Obesity. On 5/14/19 at 3:15 P.M., an interview was conducted with Resident #91 and her son. Resident #91 was concerned that her diet order wasn't being followed. She stated that the facility served her canned peaches that morning, and continued to serve her orange juice for breakfast. She stated, and her son agreed that her potassium level increased and she had to take a new medication the previous night. Resident #91 gave the surveyor her meal ticket, which listed the following prohibited foods: No banana, orange juice, potato, sweet potato, tomato, apricots, peaches, pears, oranges, spinach, asparagus, Brussels sprouts, collard, turnips, deli meat sausage bacon. Resident #91 was dressed appropriately, and was oriented to person place, time and situation. On 5/15/19 at 8:20 A.M., an observation was conducted of Resident #91 eating breakfast. The breakfast tray contained mandarin oranges and orange juice. On 5/15/19, a review was conducted of Resident #91's clinical record. On 5/9/19 the Registered Dietician changed the resident's diet from a regular, no added salt diet, to a renal diet. Resident #91's lab reports were as follows: Potassium on 4/30/19 - 4.6 Potassium on 5/13/19 - 5.6 normal range is 3.5 - 5.1 According to a signed telephone order, on 5/13/19 at 2:23 P.M. the MD ordered Kayexalate 30 Grams by mouth x 1 dose (used to decrease elevated potassium). Resident #91's care plan was reviewed. It read, 5/8/19. No added salt diet. On the most recent care plan , dated 5/15/19, The Nutritional status, and Dietary Goals sections were left blank. On 5/14/19 at 2:27 P.M. an interview was conducted with the Registered Dietician (Employee L). She stated, If the potassium is high, she shouldn't get the foods high in potassium. The Regional Dietician (Employee M) was also present, and stated, A person who gets too much potassium, it could cause heart failure. On 5/15/19 at 10:42 A.M., an interview was conducted with the Director of Nursing (Employee B). She was asked to describe how the process works to change a diet order. She stated, the dietician can change the order in the computer system. The Dietician writes their own orders. The kitchen and nursing departments are automatically notified of the diet change. The kitchen staff is supposed to make sure that forbidden foods are not on the tray. The nursing staff should also read the ticket on the resident's tray to ensure that food restrictions are followed. 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 review and revise a careplan for one Resident (Resident #341) in a survey sample of 25 Residents. For Resident #341, the facility staff failed to review and revise the careplan after the Resident was diagnosed with a superficial vein thrombosis and was started on an anticoagulant. The findings included: Resident #341, was admitted to the facility on [DATE]. The Resident's diagnoses included but were not limited to: fracture of left humerus, fracture of left pubis, muscle weakness, lack of coordination, anemia, syncope and collapse, gastrointestinal hemorrhage, hypertension, hyperlipidemia, and gastro-esophageal reflux disease. Resident #341's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 4/30/19 was coded as an admission assessment. Resident #341, had a BIMS (brief interview for mental status) score of 13, which indicated the resident was cognitively intact. She was coded as requiring extensive assistance of staff for, bed mobility, transfers, dressing, toileting, and personal hygiene. Review of Resident #341's clinical record revealed a physician progress note on 4/29/19 that read, Chief Complaint NP visit per staff/son request for increased edema to LUE (left upper extremity). The provider noted under plan: LUE edema-venous doppler to LUE ordered, encouraged elevation with pillow. Review of the doppler report with a date of service of 5/10/19 revealed, acute superficial vein thrombosis in the left cephalic vein. Nursing notes dated 5/11/19 9:50am read, Resident have a new order for warm compress QID (four times a day) to L/U (left upper) arm. Warm compress to L/U/arm done and pain patch applied to L/arm as well. Resident started prednisone this morning and 2.5 mg Eliquis given as order. Pain management effective. Review of Resident #341's careplan reveals no indication of the edema, superficial vein thrombosis, warm compress order, or use of Eliquis (anticoagulant). On 5/16/19 the DON (director of nursing) was shown the careplan for Resident #341 and the DON stated, it is not in there. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident representative interview, clinical record review, and facility document review, the facility staff failed to ensure treatment services to maintain hearing were afforded one Resident, (Resident #34) in a sample of 25 Residents. For Resident #34, who was hard of hearing, and wore hearing aids, the facility staff failed to provide timely cerumen removal as ordered by a physician, to maintain hearing. The findings included; Resident #34 was admitted to the facility on [DATE] with diagnoses including; Dementia, glaucoma, lack of coordination, muscle weakness, fall with fracture of the tibia, and fibula, and was hard of hearing with hearing aid devices. Resident #34's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 3-20-19. Resident #34 was coded with a Brief Interview of Mental Status score of 7, indicating moderate cognitive impairment. Resident #34 was extensively dependant on one staff member for assistance with activities of daily living care, such as bed mobility, transferring, and toileting. On the physician's progress notes, most described the Resident as hard of hearing (HOH). Nursing staff and the Resident's daughter indicated the Resident was very hard of hearing, and this could be a barrier to communication, and understanding instructions. Review of the Physician's orders revealed that the doctor ordered cerumen removal from the Resident's ears which were completely occluded according to the doctor's order on 3-28-19. The order was not clarified, nor administered, and never transcribed onto the Medication and Treatment Administration Records (MARs/TARs), to be completed by staff, which were also reviewed. The physician again wrote two orders on 4-10-19 for the following; 1. Flush both ears for wax one time. 2. Debrox 6.5% ear drops 5 drops in both ears at bedtime for impacted cerumen. Review of the nursing notes, physician notes, and physician orders indicated that on 4-11-19 the Debrox treatment was completed by staff, however, not the flush (12 days after the first order was given). It is unknown if there was any effect, as no notes indicate whether cerumen was removed or not. The doctor again ordered Cerumen needs removed from both ears on 4-25-19, and as of the time of survey this order had not been completed, clarified, nor transcribed onto the MAR/TAR for completion by staff. The Resident's current care plan was reviewed and revealed no care plan for cerumen removal nor hearing aids, nor hard of hearing deficits. The Administrator and Director of Nursing were notified at the end of day meeting on 5-16-19 at 2:00 p.m. No further information was provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview facility documentation and clinical record review the facility staff failed to provide supervision for 2 of 25 sampled Residents (#189 and #34). 1. For Resident #189 the facility staff failed to utilize proper amount of staff while transferring a resident via Mechanical Lift. 2. For Resident #34 who had a recent history of falls with fracture, the facility staff left the Resident on the toilet without supervision, and the Resident fell. The findings included: 1. For Resident #189, the facility staff failed to utilize the proper amount of staff while transferring a resident via Mechanical Lift. Resident #189, a [AGE] year old woman was admitted to the facility on [DATE] with diagnoses of but not limited to Dementia, Hypertension, Diabetes, Hypothyroidism, Chronic ischemic heart disease, Congestive heart failure, and abnormal posture. Resident #189's most recent (Minimum Data Set) MDS a quarterly with an ARD date of 3/16/19 codes Resident #189 as having a (Brief Interview of Mental Status) BIMS score of 00/15 which indicates severe cognitive impairment. Resident is also coded as being total assistance for all aspects of (Activities of Daily Living) ADL's. She is coded as requiring 2 or more people to perform her care and the use of Mechanical Lift for transferring from bed to chair or wheelchair. Resident #189 was the subject of a (Facility Reported Incident) FRI that was submitted to the OLC (Office of Licensure and Certification) on 1/16/19. The FRI states that on 1/16/19 at approximately 11:30 AM the CNA that was working with Resident #189 reported to the LPN and Nursing supervisor that the resident was crying out in pain when she was touched on her right lower leg. The nurse examined and found swelling to the ankle area. The family and the MD (Medical Doctor) were notified and the MD ordered X-Rays. The FRI also states that at 4:30 PM the X-Ray results arrived with a diagnosis of Acute Non-displaced fracture of right distal fibula. The MD and family were notified of the diagnosis and the MD ordered continuation of stabilization and follow up with orthopedics/ podiatry the following morning. On 5/15/19 at 2:00 PM, an interview was conducted with the DON (Director of Nursing) who stated that once she was told that there was a fracture involved she initiated a Fracture (of unknown cause) Investigation Form The DON stated that the CNA (Certified Nursing Assistant) that was working with Resident #189 failed to obtain help from a coworker. She stated at all times there should be 2 persons operating the mechanical lift. The DON further stated that she did training on all direct care staff after the incident. According to the statement by the CNA who worked with Resident #189 on 1/15/19 from 3:00 PM to 11:00 PM, Requested assistance multiple times to help with residents transfer to bed- unable to obtain assistance-transferred via Hoyer lift / mechanical lift to bed. According to facility Policy for Full Body Lift: Policy: All CNA's will be trained in safe and appropriate use of the full body lift. Any time the full body lift is used, there must be 2 trained staff members present to ensure staff and resident safety. On 5/15/19 at the DON also asked for Past Non Compliance to be considered however, another resident was found to be deficient after the incident on 1/16/19. On 5/15/19 at 4:30 PM, an interview was conducted with Employee H who stated that When moving any Resident with a mechanical lift we always have to use two people. When asked how she knows this she stated that she was taught that in annual training. On 5/16/19, the Administrator was made aware of the issues involving the injury to Resident #189 and no further information was provided. 2. For Resident #34 who had a recent history of falls with fracture, the facility staff left the Resident on the toilet without supervision, and the Resident fell. Resident #34 was admitted to the facility on [DATE] with diagnoses including; Dementia, glaucoma, lack of coordination, muscle weakness, and fall with fracture of the tibia, and fibula, and was non-weight bearing at the time of admission from the hospital for surgery related to that fracture on 12-26-18. The Resident was also hard of hearing and wore hearing aids. Resident #34's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 3-20-19. Resident #34 was coded with a Brief Interview of Mental Status score of 7, indicating moderate cognitive impairment. Resident #34 was extensively dependant on one staff member for assistance with activities of daily living care, such as bed mobility, transferring, and toileting. On the physician's progress notes, most described the Resident as hard of hearing (HOH). Nursing staff and the Resident's daughter indicated the Resident was very hard of hearing, and this could be a barrier to communication, and understanding instructions. On 2-25-19 the physician's progress notes indicated the Resident had fallen on 2-23-19 while trying to stand from a wheel chair. On 3-5-19 the nursing notes documented that the Resident had been left alone on the toilet and had fallen. On 5-14-19 at approximately 1:00 p.m., Resident #34's daughter was interviewed. The daughter stated I was not aware that mom fell from the toilet unattended. She can't be left alone on the toilet, she will try to get up and fall. She has an immobilizer on her ankle from her fracture, and pain in that leg that she receives pain medication for. She is not supposed to stand on it unassisted, and she doesn't remember that. The Resident's current care plan was reviewed and revealed no revision or update review, since admission on [DATE], and had a goal date of 7-5-19. The care plan stated as problems related to falls and fracture, the 3 following areas, and those interventions are below; 1. Falls - at risk for more falls related to recent fall and fracture - observe and anticipate or intervene with factors causing previous or potential for falls. Answer calls quickly, attempt to anticipate needs for prompt response, and decrease in attempts to ambulate without proper assist. 2. Impaired functional status - has impaired functional status with bed mobility, transfer, walking, toileting, etc - weight bear as tolerated with brace when out of bed, stand pivot for transfers with assist of 1 staff. 3. Medical condition Orthopedic - had a recent fracture, requires follow up care. - Assess immobilizer device cast to ensure intact, assess skin under/at edge of immobilizer to ensure no rubbing, friction or pressure is evident. Maintain imposed limitations of non-weight bear right lower extremity educate and remind (Resident) of limitations. In summary, the staff were aware of the Resident's fall history with attempts to stand alone, the Resident was demented, with memory impairment, hard of hearing, and was non-weight bearing. The Resident had a cast device on her left leg which was a fall hazard. She had pain in that leg, poor vision, lack of coordination and weakness. The facility staff placed her on the toilet and left her there alone, and when they returned she was sitting on the floor in the bathroom where she had fallen. Staff did not implement their care plan to intervene with factors causing previous falls or potential for falls, nor attempt to anticipate needs for prompt response, and decrease in attempts to ambulate without proper assist. The Administrator and Director of Nursing were notified at the end of day meeting on 5-16-19 at 2:00 p.m. No further information was provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #290, the facility staff failed to provide a therapeutic diet as ordered by the healthcare provider on 05/14/2019. Resident #290, a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses to include but not limited to chronic obstructive pulmonary disease (COPD), shortness of breath, acute respiratory failure, and malnutrition. Resident #290's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/03/2019 was coded as admission from an acute hospital. A comprehensive MDS is pending and the physician's admitting assessment read, Cognition WNL (within normal limits), AOX4 (alert and oriented to person, place, time, and situation), pleasant, no agitation, able to answer all questions appropriately, able to follow simple commands. On 05/14/2019 at approximately 12:45 PM, Resident #290 was observed sitting in her room eating her lunch. She stated, The food here is good but I am concerned that I am not getting what the doctor has ordered for me. He wants me to try and gain weight and get my energy back because I only weigh 80 pounds; I was just in the hospital. He ordered a special Gelato for me that has additional nutrients but I have only received it one time since I have been here. They just tell me that it's not available and that they don't have it. The dietician has also recommended it for me. I really want to get better. There was no nutritional supplement observed on her lunch tray. On 05/14/2019 at approximately 1:40 PM, a staff interview was conducted with the Director of Dining Services (Employee K) who stated, I have never run out of the Thrive Gelato, it is always available for any resident that wants it, everyone likes it, it is like ice cream, I have 3 flavors. At approximately 2:00 PM, Resident #290 was observed eating the Gelato and stated, thank you so much, they just brought it to me. On 05/16/2019, a review was conducted of Resident #290's clinical record. A comprehensive nutritional evaluation dated 05/06/2019 read: current wt: 81 (pounds), BMI (body mass index): 14, Interpretation: severely underweight .RD (Registered Dietician) to order Thrive Gelato BID (twice per day) with lunch and dinner. The medication administration record and nursing note on 05/14/2019 at 12:32 PM indicated the Gelato was not given, supplement not available. Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain nutritional status. 1. For Resident #91, the facility staff failed to maintain nutritional status, resulting in an increased potassium level which required pharmacological intervention. 2. For Resident #290, the facility staff failed to provide a therapeutic diet as ordered by the healthcare provider on 05/14/2019. The Findings included: 1. For Resident #91, the facility staff failed to maintain nutritional status, resulting in an increased potassium level which required pharmacological intervention. Resident #91 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #91's diagnoses included Hypertension, Chronic Kidney Disease, Stage 4 Type 2 Diabetes without Complications, Hyperlipidemia, and Obesity. On 5/14/19 at 3:15 P.M., an interview was conducted with Resident #91 and her son. Resident #91 was concerned that her diet order wasn't being followed. She stated that the facility served her canned peaches that morning, and continued to serve her orange juice for breakfast. She stated, and her son agreed that her potassium level increased and she had to take a new medication the previous night. Resident #91 gave the surveyor her meal ticket, which listed the following prohibited foods: No banana, orange juice, potato, sweet potato, tomato, apricots, peaches, pears, oranges, spinach, asparagus, Brussels sprouts, collard, turnips, deli meat sausage bacon. Resident #91 was dressed appropriately, and was oriented to person place, time and situation. On 5/15/19 at 8:20 A.M., an observation was conducted of Resident #91 eating breakfast. The breakfast tray contained mandarin oranges and orange juice. On 5/15/19, a review was conducted of Resident #91's clinical record. On 5/9/19 the Registered Dietician changed the resident's diet from a regular, no added salt diet, to a renal diet. Resident #91's lab reports were as follows: Potassium on 4/30/19 - 4.6 Potassium on 5/13/19 - 5.6 normal range is 3.5 - 5.1 According to a signed telephone order, on 5/13/19 at 2:23 P.M., the MD ordered Kayexalate 30 Grams by mouth x 1 dose (used to decrease elevated potassium). Resident #91's care plan was reviewed. It read, 5/8/19. No added salt diet. On the most recent care plan , dated 5/15/19, The Nutritional status, and Dietary Goals sections were left blank. On 5/14/19 at 2:27 P.M. an interview was conducted with the Registered Dietician (Employee L). She stated, If the potassium is high, she shouldn't get the foods high in potassium. The Regional Dietician (Employee M) was also present, and stated, A person who gets too much potassium, it could cause heart failure. On 5/15/19 at 10:42 A.M., an interview was conducted with the Director of Nursing (Employee B). She was asked to describe how the process works to change a diet order. She stated, the dietician can change the order in the computer system. The Dietician writes their own orders. The kitchen and nursing departments. are automatically notified of the diet change. The kitchen staff is supposed to make sure that forbidden foods are not on the tray. The nursing staff should also read the ticket on the resident's tray to ensure that food restrictions are followed. No further information was received.

Based on observation, staff interview, and facility documentation review, the facility staff failed to maintain an accurate record for a controlled medication. Facility staff failed to account for the receipt of a controlled medication from the pharmacy. The Findings included: On 05/15/2019 at approximately 10:30 AM, an inventory of refrigerated controlled medications was conducted with LPN C in the medication storage room. A partial bottle of lorazepam oral concentrate [syrup] 2mg/ml, prescription #9981672, contained 20 ml [millilters] but was documented as 24.50 ml on the individual inventory sheet. LPN C stated, I don't know how that happened, I see 20 in the bottle but the sheet is 24.5. Two unopened bottles of lorazepam suspension 2mg/ml, prescription #10018839 and #10073360, each containing 30 ml, were observed with seals intact, however there was no record of either bottle on inventory. LPN C had no response when asked about the accounting for the bottles. At approximately 10:40, the Assistant Director of Nursing (ADON, Employee C) and Employee P were informed of the findings. The ADON and Employee P conducted an inventory of the refrigerated lorazepam. The ADON stated, Our accounting is not accurate, we need to look into this and fix it. On 05/15/2019, a copy of the facility policy regarding controlled medications was requested and received. The facility policy entitled Storage and Expiration of Medications, Biologicals, Syringes and Needles, revision date 10/31/16, had Procedure item 12, Controlled Substances Storage:, item 12.2, After receiving controlled substances and adding to inventory . The facility policy entitled Inventory Control of Controlled Substances, revision date 01/01/13, had Procedure item 2, Facility should ensure that facility staff count all Schedule 111-V controlled substances in accordance with facility policy and applicable law and item 5, A facility representative should regularly check the inventory records to reconcile inventory.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview facility documentation and clinical record review the facility staff failed to ensure Residents are free from unnecessary medications for 1 Resident (#25) in a survey sample of 25 Residents. For Resident #25 the facility staff administered Tylenol 650 mg on three occasions when Resident has pain rating of 0/10. The findings include: Resident #25 is an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Dementia with behavioral disturbance, Hypertension, Use of Anti-Coagulants, diabetes and stage 3 chronic kidney disease, osteoporosis and feeding difficulties. Resident #25's most recent (Minimum Data Set) MDS was dated 4/3/19 and it was an annual. According to the most recent MDS Resident # 25 had a (Brief Interview of Mental Status) BIMS score of 00/15 indicating severe cognitive impairment. On 5/14/19 during clinical record review it was noted that Resident # 25 had received Tylenol 650 (milligrams) mg without indication for use on three separate occasions. The Medication Administration records read as follows: On 2/15/19 Resident has pain rating of 0 for entire month but Tylenol 650 mg was administered at 9:40 AM On 4/17/19 Resident has pain rating of 0 for all entire month but Tylenol 650 mg was administered at 8:19 PM On 5/9/19 Resident has pain rating of 0 every shift for entire month but Tylenol 650 mg was administered at 4:15 PM On 5/14/19 at 4:00 PM in an interview with the DON when asked why the pain ratings were all 0 yet the Resident was given Tylenol 650 mg. she stated well they must have entered the pain rating of 0 before they gave her the Tylenol. When asked for nurses notes to support the use of Tylenol she did not find any notes related to pain. During the end of day meeting on 5/16/19, the Administrator was made aware of the issue with unnecessary meds and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure resident's are free from unnecessary psychotropic medication use for one Resident (Resident #19) in a survey sample of 25 Residents . For Resident #19, the facility staff failed to ensure the medication regime was free from unnecessary psychotropic medications. The findings included: Resident #19, was admitted to the facility on [DATE]. The Resident's diagnoses included but were not limited to: UTI, retention of urine, unspecified lack of coordination, cognitive communication deficit, dysphagia, extend spec beta lactamase resistance, parkinsons, unspecified dementia without behavioral disorder, hypotension, and unspecified OA (osteoarthritis). Resident #19's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/20/19 was coded as a quarterly assessment. Resident #19 was coded as having a BIMS (brief interview for mental status) score of 11, which indicated moderately impaired cognition. The Resident was coded as requiring extensive assistance of staff for bed mobility, transfers, dressing, and personal hygiene. For toileting and bathing the Resident was totally dependent upon staff. Review of the physician orders for Resident #19 revealed that on 9/24/18 an order was written, that read seroquel 25 mg 1/2 tab po q hs [by mouth at bedtime] for hallucinations/nightmares. A physician progress note dated 9/24/18 read, Pt's history is supplemented by staff and RP [name redacted]. Pt is having recurrence of hallucinations per RP. She states she previously was on Seroquel to help and had been taken off when she had extreme AMS in July. RP requesting she be put back on medication. Pt denies any pain or dysuria. Pt has many UTI's and writer discussed she has completed recent course of abx 9/22 and will start prophylaxis with Hiprex and vitamin C. Review of the entire clinical record to include but not limited to, physician progress notes, nursing notes, social services notes, psychiatry notes, and careplan revealed no documentation of any behaviors or hallucinations. Review of the MAR (Medication administration record) for May 2019 revealed that Resident #19 continues to receive Seroquel 25mg, 1/2 tab at bedtime for hallucinations. On 5/16/19 during an interview with the DON, when asked about the use of Seroquel and documentation to support the use, the DON stated, there isn't any, activities said they had seen her hallucinate and I told them to document it. I am not aware of any behaviors and see your concern. The DON was made aware of the facility staff's failure to ensure Resident #19 was free of unnecessary psychotropic medication use on 5/16/19. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to provide an appropriate alternative to accommodate a food allergy for 1 resident (Resident #290) in a sample size of 25 residents. For Resident #290, the facility staff failed to provide any alternative dessert at the lunch meal on 05/14/2019 to accommodate her food allergies. The Findings included: Resident #290, a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses to include but not limited to chronic obstructive pulmonary disease (COPD), shortness of breath, acute respiratory failure, and malnutrition. Resident #290's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/03/2019 was coded as admission from an acute hospital. A comprehensive MDS is pending and the physician's admitting assessment read, Cognition WNL (within normal limits), AOX4 (alert and oriented to person, place, time, and situation), pleasant, no agitation, able to answer all questions appropriately, able to follow simple commands. On 05/14/2019 at approximately 12:45 PM, Resident #290 was observed sitting in her room eating her lunch. She stated, I filled out a menu with food selections but they did not give me any dessert. I had selected the regular almond cake and someone drew a frowning face on it with an arrow saying contains chocolate. I guess that's all they have because I didn't get anything else, no one offered anything different to me, and they didn't even give me the Gelato supplement that the doctor ordered for me. No dessert items or nutritional supplements were observed on her lunch tray. On 05/14/2019 at approximately 1:50 PM, a staff interview was conducted with the Registered Dietician (Employee L) who stated, If she (Resident #290) has allergies, we do not serve food that can harm her, we find a replacement for that item, I do not know why she wasn't offered a substitution, although looking at her tray ticket it also states that she is allergic to yellow dye and it just so happens that the other cake today contained yellow dye, so that's probably why she wasn't given anything else but we could have worked with her. No further information was received. On 05/16/2019, a review was conducted of Resident #290's clinical record. A comprehensive nutritional evaluation dated 05/06/2019 read: allergic to chocolate and yellow dye, current wt: 81 (pounds), BMI (body mass index): 14, Interpretation: severely underweight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. For Resident #20, the facility staff failed, for three hours to respond to the Resident's call bell and request for assistance. Resident # 20, was admitted to the facility on [DATE]. The resident's diagnoses included but were not limited to: constipation, MDD single episode, allergic rhinitis, heartburn, pruritus, hyperlipidemia, heart disease, obesity, chronic diastolic heart failure, pyridoxine deficiency, polyosteoarthritis, rheumatoid arthritis. Resident #20's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/20/19, was coded as a quarterly assessment. Resident #20 was coded as having a BIMS (brief interview for mental status) score of 15, which indicated being cognitively intact. Resident #20, was also coded as requiring extensive of assistance of staff for bed mobility, transfers, dressing, and personal hygiene. She was coded as being totally dependent upon staff for toileting and bathing. During an interview with Resident #20 on 05/14/19 at 01:33 PM, Resident #20 stated, I have called for help and waited over an hour. When asked how often this occurs, Resident #20 stated, it happens too often and indicated it is an ongoing concern. Review of the facility call bell response log on 5/15/19 revealed that on 5/8/19, Resident #20 used her call bell at 2:11pm to call for assistance. Three hours later, at 5:11pm her call bell was still sounding and had not been responded to. On 5/15/19 at 10:10am an interview was conducted with Employee J, Information Systems Director. Employee J stated, the system is programmed so when the call bell is pressed it notifies multiple people. If there is no response after 30 minutes, it resets and resends all of the notifications again. When Employee J was asked to interpret the call bell response log for Resident #20 on 5/8/19, Employee J stated, it tells me it wasn't responded to. When Employee J was asked what happens when a resident uses their call bell, Employee J and the DON stated, it activates a notification to the CNA, the supervisor and after a minute the DON and Administrator get a text on their phone. On 5/15/19 the DON (Director of Nursing, Employee B) was asked about the incident on 5/8/19 when Resident #20's call bell went off for 3 hours. The DON stated, I can tell you someone will check- people will come by and pop their heads in. On 5/15/19 the Administrator stated, an acceptable time and my expectation is for call bells to be answered within 15 minutes. We don't know what happened at that time, her care is exceptional. I know they get the care they need. Review of the facility policy titled, Call light with an effective date of May 2018, read Emergency call system will be made available to all residents in room, bathrooms and other areas as deemed necessary. Residents are to have a method to activate the emergency call system herein referred to as call lights in bedrooms and bathrooms. Review of the facility policy titled, Responding to call light with an effective date of, May 2018 read, All staff to respond to all lights. 1. Respond to location of call light. 2. Ask resident what assistance is needed. 3. If certified to perform care, render care 4. If not certified to render care, notify a member of the nursing team and/or supervisor 5. Please ensure call light is reset. On 5/15/19 the facility Administrator and DON were made aware of the facility staff's failure to respond to Resident #20's call light for 3 hours. No further information was provided. Based on observation, resident interviews, staff interviews, clinical record reviews, and facility documentation review, the facility staff failed to accommodate needs and preferences for 7 residents (Resident #12, Resident #15, Resident #5, Resident #28, Resident #190, Resident #20, Resident #6) in a sample size of 25 residents. 1. For Resident #12, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 2 of 14 opportunities the call light was activated. 2. For Resident #15, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 3 of 15 opportunities the call light was activated. 3. Resident #5 was not provided a hoyer lift sling to get out of bed in the morning on 5-14-19 due to lack of equipment. 4. For Resident # 28 the facility staff failed to answer call bells in timely manner for a Resident who requires assistance with transfer and ambulation. 5. For Resident #190 the facility staff failed to answer call bells in a timely manner for a Resident who needs assistance with transfer and ambulation. 6. For Resident #20, the facility staff failed, for three hours to respond to the Resident's call bell and request for assistance 7. For Resident #6, the facility staff failed to ensure that her call bell was within reach. The findings included: 1. For Resident #12, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 2 of 14 opportunities the call light was activated. Resident #12, an [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but not limited to spastic hemiplegia, paralytic syndromes, muscle weakness, depression, and flaccid neurogenic bladder. Cognitive disorders were not on the list of diagnoses. Resident #12's most recent Minimum Data set with Assessment Reference Date of 02/13/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as a 6 out of possible 15 indicative of severe cognitive impairment. Functional status for bed mobility, dressing, and personal hygiene were coded as requiring extensive assistance from staff. On 05/14/19 at approximately 12:00 PM, an interview with Resident #12 was conducted. Resident #12 was in bed with the head of the bed elevated approximately 45 degrees. When asked if the facility staff answered the call light promptly when he needed assistance, Resident #12 stated, Sometimes it seems like it takes forever for staff to come. Resident #12 stated that sometimes he needs help positioning in the bed and calls for assistance. On 05/14/19 at 2:55 PM, call logs for the past week for the health center were requested from Employee J from the information technology department. On 5/14/19 at 4:15 PM in an interview with the Administrator she stated that her expectation is for call bells to be answered within 15 minutes. She stated that she didn't know why they were longer perhaps staff forgot to cut off the call bell and was in the room doing care. On 05/15/2019 at approximately 9:00 AM, the facility staff provided call logs for Resident #12 with a date range of 05/08/2019 through 05/13/2019. Of the 14 times the call light was activated, there were 2 instances where the duration was longer than 15 minutes. On 05/12/2019 at 7:11 AM, the duration was 21 minutes and 7 seconds. On 05/12/2019 at 10:22 PM, the duration was 30 minutes and 2 seconds. On 05/15/19 at approximately 10:10 AM, an interview with Employee J was conducted. Employee J stated that the system is programmed to do certain things when the button is pushed. Employee J stated that the activated call bell routes to the certified nurse assistant (CNA) pager and if it isn't answered, it flows over to nurse pager. The facility staff provided a copy of their policy entitled, Responding to call light. The listed procedures documented, 1. Respond to location of call light. 2. Ask resident what assistance is needed. 3. If certified to perform care, render care. 4. If not certified to render care, notify a member of the nursing team and/or supervisor. 5. Please ensure call light is reset. On 05/16/2019 at approximately 2:30 PM, the Administrator stated they had no further documentation or information to offer. 2. For Resident #15, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 3 of 15 opportunities the call light was activated. Resident #15, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but not limited to chronic kidney disease, dementia without behavior disturbance, Parkinson's disease, cognitive communication deficit, muscle weakness, and difficulty in walking. Resident #15's most recent minimum Data set with an Assessment Reference Date of 02/20/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as 12 out of possible 15 indicative of moderate cognitive impairment. Functional status for bed mobility, transfers, dressing, and toileting was coded as requiring extensive assistance from staff. On 05/14/19 at approximately 1:55 PM, an interview with Resident #15 was conducted. When asked if the staff answer the call light promptly when she needs assistance, Resident #15 stated, Sometimes it's a long time before they come. Resident #15 stated that she needs help to get into her chair or to get positioned for a nap. Resident #15 also stated, I can't get up by myself. On 05/14/19 at 2:55 PM, call logs for the past week for the health center were requested from Employee J from the information technology department. On 5/14/19 at 4:15 PM in an interview with the Administrator she stated that her expectation is for call bells to be answered within 15 minutes. She stated that she didn't know why they were longer perhaps staff forgot to cut off the call bell and was in the room doing care. On 05/15/2019 at approximately 9:00 AM, the facility staff provided call logs for Resident #12 with a date range of 05/08/2019 through 05/14/2019. Of the 15 times the call light was activated, there were 3 instances where the duration was longer than 15 minutes. On 05/08/2019 at 9:23 AM, the duration was 28 minutes and 43 seconds. On 05/11/2019 at 7:56 PM, the duration was 23 minutes and 24 seconds. On 05/13/2019 at 4:26 PM, the duration was 15 minutes and 31 seconds. On 05/15/19 at approximately 10:10 AM, an interview with Employee J was conducted. Employee J stated that the system is programmed to do certain things when the button is pushed. Employee J stated that the activated call bell routes to the certified nurse assistant (CNA) pager and if it isn't answered, it flows over to nurse pager. The facility staff provided a copy of their policy entitled, Responding to call light. The listed procedures documented, 1. Respond to location of call light. 2. Ask resident what assistance is needed. 3. If certified to perform care, render care. 4. If not certified to render care, notify a member of the nursing team and/or supervisor. 5. Please ensure call light is reset. On 05/16/2019 at approximately 2:30 PM, the Administrator stated they had no further documentation or information to offer. 4. For Resident # 28 the facility staff failed to answer call bells in timely manner for a Resident who requires assistance with transfer and ambulation. Resident #28 is an [AGE] year old woman originally admitted to the facility with diagnoses of but not limited to Hypertension, History of hip fracture with artificial hip replacement, (Coronary Artery Disease), CAD, Congestive Heart failure and Asthma. On 3/19/19 Resident was admitted to the facility prior to admission to hospital for planned surgical repair of hardware from prior hip fracture. The Resident went out for surgery on 4/6/19 and was readmitted on [DATE]. Residents most recent (Minimum Data Set) MDS was dated 3/31/19 and it was a 14 -Day PPS. According to the most recent MDS Resident # 28 had a (Brief Interview of Mental Status) BIMS score of 15 / 15 indicating no cognitive impairment. On 5/14/19 at 2:15 PM an interview was conducted with Resident #28 who stated she had no problems with the facility other than the time it took for staff to answer the call bells. She further elaborated by saying If the staff would answer the call bells this place would be great! She relayed an incident where she had put the call bell on because she wanted something for her cough. She stated that someone came in and turned the call bell off and told her she would let the nurse know what she needed. She stated that happened three times and no nurse came. She stated after that I just got up by myself and walked to the nurses' station to tell her. On 5/14/19 at 3:00 P.M., an interview was conducted with Employee J (Information Technology), when asked if this surveyor could have a copy of the call bell response times he replied I don't think I can get that. When asked what company they use he stated Status Solutions and when asked what program he stated [NAME]. He was then informed by this surveyor that we request these logs from other facilities using the same system and are able to get them, he stated he would try to get them. On 5/14/19 at 4:15 PM in an interview with the Administrator she stated, my expectation is for call bells to be answered within 15 minutes. I know they get the care they need. According to the facility call logs provided by Status Solutions from 5/1/19 through 5/14/19 5/2/19 - Call bell rang from 4:33 PM to 4:56 PM - total 22 min. 21 sec. 5/3/19 - Call bell rang from 7:05 AM to 7:23 AM - total 18 min 10 sec. 5/3/19 - Call bell rang from 7:38 AM to 7:53 AM - total 14 min. 56 sec. 5/3/19 - Call bell rang from 1:33 PM to 1:56 PM - total 22 min 46 sec. 5/4/19 - Call bell rang from 7:59 AM to 8:15 AM - total 16 min. 19 sec 5/4/19 - Call bell rang from 8:24 PM to 8:50 PM - total 26 min. 5 sec 5/5/19 - Call bell rang from 8:10 AM to 8:24 AM - total 14 min. 15 sec 5/5/19 - Call bell rang from 8:43 AM to 9:18 AM - total 34 min 35 sec 5/6/19 - Call bell rang from 8:03 AM to 8:19 AM - total of 15 min 46 sec. 5/7/19 - Call bell rand from 7:01 AM to 7:30 AM - total 28 min 41 sec. 5/10/19 - Call bell rang from 7:35 AM to 7:53 AM total of 18 min 7 sec 5/11/19 Call bell rang from 7:01 AM to 7:44 AM - total 43 min 37 sec 5/11/19 Call bell rang from 12:30 PM to 12:50 PM total of 20 min 10 sec. 5/13/19 Call bell rang from 4:12 PM to 4:52 PM total of 20 min 40 sec. 5/13/19 Call bell rang from 9:10 PM to 9:27 PM total of 17 min 5 sec. On 5/15/19 at 4:30 PM in an interview with CNA A, CNA A stated that Resident # 98 needs assistance to get up and go to the bathroom and she needs help getting out of bed and to her chair. On 5/16/19 at the end of day meeting, the Administrator was made aware of the issues with answering call bells timely and no further information was provided. 5. For Resident #190 the facility staff failed to answer call bells in a timely manner for a Resident who needs assistance with transfer and ambulation. Resident # 190 a [AGE] year old woman was admitted to the facility on [DATE]. The Resident had no (Minimum Data Set) MDS information available as she was a new admission. The Resident was admitted to the facility with diagnoses of but not limited to recent Right hip replacement surgery, foot drop in Right foot, difficulty walking, general weakness, (Chronic Obstructive Pulmonary Disease) COPD, Atrial Fibrillation and Diabetes. On 5/14/19 at 2:25 PM an interview was conducted with Resident #190 who stated the staff take too long to answer call bells. She stated that the facility is nice but if you have to use the bathroom [ROOM NUMBER] minutes is way too long to wait. When asked what type of assistance she requires Resident #190 stated she had a hip replacement surgery but something went wrong and she ended up with foot drop as well so she is unable to ambulate or transfer alone. On 5/14/19 at 3:00 P.M. an interview was conducted with Employee J (Information Technology), when asked if this surveyor could have a copy of the call bell response times he replied I don't think I can get that. When asked what company they use he stated Status Solutions and when asked what program he stated [NAME]. He was then informed by this surveyor that we request these logs from other facilities using the same system and are able to get them. He stated he would try to get them. On 5/14/19 at 4:15 PM in an interview with the Administrator she stated, my expectation is for call bells to be answered within 15 minutes. I know they get the care they need. According to the facility call logs provided by Status Solutions from 5/1/19 through 5/14/19 5/9/19 - Call bell rang from 7:14 AM to 7:31 AM - total 17 min. 18 sec. 5/10/19 Call bell rang from 9:17 AM to 9:37 AM total 19 min 40 sec. 5/10/19 Call bell rang from 12:35 PM to 12:50 PM total 15 min 9 sec. 5/11/19 Call bell rang from 1:38 AM to 1:55 AM total 16 min 42 sec. 5/11/19 Call bell rang from 2:30 PM to 3:06 PM total 19 min 32 sec. 5/11/19 Call bell rang from 5:59 PM to 6:15 PM total 15 min 56 sec. 5/12/19 Call bell rang from 1:44 PM to 2:15 PM total 31 min 45 sec. 5/12/19 Call bell rang from 3:02 PM to 3:22 PM total 19 min 32 sec. 5/14/19 Call bell rang from 8:19 AM to 8:42 Am total 23 min 4 sec. On 5/15/19 at 4:30 PM, an interview was conducted with Employee H who stated that Resident # 98 needed assistance to get up and go to the bathroom and she needed help getting out of bed and to her chair. On 5/16/19 at the end of day meeting, the Administrator was made aware of the issues with answering call bells timely and no further information was provided. 3. Resident #5 was not provided a hoyer lift sling to get out of bed in the morning on 5-14-19 due to lack of equipment. Resident #5, was admitted to the facility on [DATE]. Diagnoses included diabetes, sarcoidosis, and abnormal posture. The Resident's neck was bent laterally to the right, so profoundly, that the Resident's right cheek laid on her right clavicle and shoulder. Resident #5's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-24-19 was coded as an annual assessment. Resident #5 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #5 was also coded as requiring extensive assistance to total dependence on one to two staff members to perform activities of daily living, such as hygiene, transferring, and bed mobility. On 5-14-19 at 12:00 noon, Resident #5 was observed in bed, with the head of the bed elevated, during initial tour of the facility. A Resident interview was conducted, and the Resident complained that this morning I couldn't even get up to get my lunch today because they had no strap clean for the hoyer lift for me. She explained that she got up for lunch and went back to bed around 4:00 p.m., which was her choice, because if I didn't go back at 4:00 p.m., I would be up til 9:00 p.m., or 10:00 p.m., and she stated that she could not sit up comfortably that long. She went on to say that today, I won't be able to get out of bed at all. That just makes no sense. Review of the resident's clinical record revealed the resident's current POS (physician order sheet), for May 2019. Contained was an order for Physical therapy evaluation for appropriate mechanical lift device ordered on 1-29-19. On 5-14-19 at approximately 4:00 p.m., Resident #5 was again interviewed and observed returning to bed from a wheel chair. CNA B was in the room with the Resident and stated the Resident did get up for about 2 hours after they found a hoyer lift sling for her, however, they were only able to get her up from 2:00 p.m., until 4:00 p.m., because there was no lift sling for the hoyer mechanical lift for her. Resident #5's care plan was reviewed and revealed that the document was last revised on 5-2-19, and noted that the resident was dependent on 2 staff members to provide mechanical lift for transferring. On 5-16-19 at end of day debrief the DON (director of nursing), and Administrator were notified of above findings. No further information was provided. 7. For Resident #6, the facility staff failed to ensure that the call bell was within reach. Resident #6 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #6's diagnoses included Generalized Muscle Weakness, History of Falls, Difficulty in walking, Arthritis, Polyneuropathy, Hypertension, and Unspecified Cataract. The Minimum Data Set, which was an Annual Assessment, with an Assessment Reference Date of 1/3/19 was reviewed. Resident #6 was coded as having a Brief Interview of Mental Status Score of 8, indicating moderate cognitive impairment. In addition, Resident #8 was coded as not having any mood or behavioral issues. On 5/15/19 at 8:31 A.M., an observation was conducted of Resident #6 in her bed. Resident #6's call bell was on the floor, out of reach. Resident #6 stated that she had no way to let the staff know what she needed. She said that due to the wound on the back of her knee, it was difficult for her to get up and use her walker when it was time for her to go to the bathroom. Resident #6 stated that she didn't remember the last time that the call bell was within reach. On 5/15/19 a review was conducted of facility documentation. The call bell response log was reviewed. During the previous 7 days, the call bell had not been activated during any shift. On 5/15/19 at 2:30 P.M., a Resident Group Interview was conducted. The group unanimously agreed that their call bells were not routinely answered in a timely manner. They stated that it usually took staff between 30 minutes and one hour to answer the call bell. They further stated that the facility had reduced the number of available Certified Nursing Assistants, and that additional staff were needed to meet their needs. On 5/15/19 at approximately 3:30 P.M., an interview was conducted with the facility Administrator (Employee A). The administrator stated, The resident probably knocked the call bell off the bed. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #7, the facility staff failed to administer 2 consecutive doses of insulin on 05/12/2019 as indicated by sliding scale per physician's orders. Resident #7, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but not limited to diabetes, peripheral vascular disease, hypertension, aphasia following cerebral infarction, and generalized muscle weakness. Resident #7's most recent Minimum Data Set with an Assessment Reference Date of 01/30/2019 was coded as an annual assessment. The Brief Interview for Mental Status was coded as 3 out of possible 15 indicative of severe cognitive impairment. Number of days insulin injections were received was coded as 7. On 05/14/2019 at approximately 3:00 PM, the current physician's orders were reviewed. An excerpt of an order dated 01/14/2019 documented, Humalog 100unit/ml subcutaneous solution sliding scale check QID (four times a day) FS (fasting sugar) 200 or less give 0 units; 201-250 give 2 units; 251-300 give 4 units; 301-350 give 6 units; 351-400 give 8 units; greater than 400 give 1 units, call MD, recheck in 1 hour. The Medication Administration Record for May 2019 was reviewed. On 05/12/2019 on the line BfrBrkfst (before breakfast), the blood sugar was recorded as 210. Just below it on the line units, it was documented 0 (units). On the line BfrLunch (before lunch), the blood sugar level was documented as 283. Just below it on the line units, it was documented 0 (units). The meal intake flowsheet was reviewed. It was documented that Resident #7 consumed 51-75% of her meal for dinner on 05/11/2019. For 05/12/2019, Resident #7 consumed 76-100% of her breakfast and 26-50% of her lunch. On 05/15/19 10:24 AM , the findings were shared with the DON. When asked about her expectations for insulin administration, she stated she expects insulin to be administered as ordered. The DON then looked at the electronic health record of Resident #7 and stated she was unable to find a reason why the insulin was not given. The facility staff provided a copy of their policy entitled, Sliding Scale Insulin. The policy documented, A physician protocol for the use of sliding scale insulin will be used in the nursing center. The procedure documented, The following scale will be initiated upon admission for residents of [physician names]: Regular human insulin finger sticks AC & HS (before meals and at bedtime) FS (fasting sugar) below 200 - 0 units; 201-250 - give 2 units; 251-300 - give 4 units; 301-350 - give 6 units; 351-400 - give 8 units; Above 400 - give 10 units, call MD, recheck in 1 hour. According to Lippincott Manual of Nursing Practice, 10th edition, in Box 2-1 entitled, Common Legal Claims for Departure from Standards of Care it is documented that a departure from standards of nursing care included, Failure to administer medications properly and in a timely fashion or to report and administer omitted doses appropriately. On 05/16/2019 at approximately 2:30 PM, the Administrator stated they had no further documentation or information to offer. Based on observation, staff interview, facility documentation and clinical record review the facility staff failed to provide care and services in accordance with professional standards of practice for 3 Residents (Residents # 7, # 190, #5) in a survey sample of 25 Residents. 1a. For Resident #190, the facility staff failed to administer medications per physicians order and; 1b. failed to document that an entry was a late entry. 2. For Resident #7, the facility staff failed to administer 2 consecutive doses of insulin on 05/12/2019 as indicated by sliding scale per physician's orders. 3. For Resident #5, the facility staff failed to ensure insulin was administered on 5-11-19 as ordered by a physician. The findings include: 1a. For Resident #190, the facility staff failed to administer medications per physicians order and; 1b. failed to document that an entry was a late entry. Resident # 190, a [AGE] year old woman admitted to the facility on [DATE] the Resident had no (Minimum Data Set) MDS information available as she was a new admission. The Resident was admitted to the facility with diagnoses of but not limited to recent Right hip replacement surgery, foot drop in Right foot, difficulty walking, general weakness, (Chronic Obstructive Pulmonary Disease) COPD, Atrial Fibrillation and Diabetes On 5/15/19, the clinical record was reviewed. During review of the May 2019 Medication Administration Record (MAR), it was noted that medications for Resident #190 had not been signed off for the following medications and dates: 5/10/19 - 1:00 PM- Simethicone 180 (milligrams) mg 1 capsule by mouth 3 times a day. 5/13/19 - 6:00 AM - Linzess 145 (microgram) mcg capsule- 2 Capsules by mouth every day 5/13/19 - 6:00 AM - Pantoprazole 40 mg. by mouth every day 5/14/19 Lunch- Thrive Gelato [Dietary Supplement] QD with lunch 5/15/19 - 6:00 AM - OxyContin 20 mg by mouth 3 times per day for pain On 5/15/19 at 1:43 PM, copies of (Medication Administration Record) MAR was submitted and reflected the missing medication administration signatures. On 5/16/19 at 8:30 AM during an interview with the DON (Director of Nursing), she stated that she checked with the LPN (Licensed Practical Nurse) who gave medications to that resident and that the LPN stated the meds were refused by the Resident. She then produced an MAR that was filled in with R meaning Refused and the last page stating Resident Refused and the dates of the missing medications. The DON was asked why the document did NOT say LATE ENTRY she said she didn't know. She stated that she told the LPN to put in a late entry. The documents were identical except the new MAR had all the missing medication signatures were filled in. When DON was asked how was someone to know by looking at that document that it was a late entry, she stated there was no way to know unless you look at the computer. According to the DON, the facility used [NAME] for Professional Standards. According to Lippincott Manual of Nursing Practice, 10th edition, in Box 2-1 entitled, Common Legal Claims for Departure from Standards of Care it is documented that a departure from standards of nursing care included, Failure to administer medications properly and in a timely fashion or to report and administer omitted doses appropriately. On 5/16/19 during the end of day conference, the Administrator was made aware of the issues with medication administration. No further documentation was provided. 3. For Resident #5, the facility staff failed to ensure insulin was administered on 5-11-19 as ordered by a physician. Resident #5, was admitted to the facility on [DATE]. Diagnoses included diabetes, sarcoidosis, and long time insulin use. Resident #5's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-24-19 was coded as an annual assessment. Resident #5 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #5 was also coded as requiring extensive assistance to total dependence on one to two staff members to perform activities of daily living, such as hygiene, and bed mobility. On 5-14-19 at 12:00 noon, Resident #5 was observed in her room in bed. A Resident interview was conducted, and the Resident stated she did not receive her insulin as she should from staff. Review of the resident's clinical record revealed the resident's current POS (physician order sheet), and MAR (Medication Administration Record) for May 2019. Contained was an order for Novolog insulin per sliding scale with fingerstick blood sugars (FSBS) three times per day. If the Resident's blood sugar was above 251 and below 300, give 4 units of the insulin by subcutaneous injection. On 5-11-19 the Resident's FSBS was 254, and no insulin was given, and was documented as such by the nurse. Review of the medication and nursing notes revealed no documentation as to why the insulin was not given. Review of the facility policy revealed that only trained nurses would administer insulin by the physician's orders. On 5-15-19 at 5:00 p.m., the DON (director of nursing) was notified of above findings. The DON stated, The medication should have been given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility documentation review, and clinical record review the facility staff failed to have sufficient nursing staff to meet the needs of seven Residents (Resident #20, Resident #190, Resident #28, Resident #189, Resident #12, Resident #15, Resident #6) in a survey sample of 25 Residents. 1. For Resident #20, the facility staff failed to have adequate staff to respond to the Resident's call bell and request for assistance for three hours. 2. For Resident #190, the facility staff failed to ensure adequate staff available to answer call bell in a timely manner. 3. For Resident #28, the facility staff failed to ensure adequate staff available to answer call bell in a timely manner. 4. For Resident #189, the facility staff failed to provide sufficient staff to safely lift Resident using Hoyer. 5. For Resident #12, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 2 of 14 opportunities the call light was activated. 6. For Resident #15, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 3 of 15 opportunities the call light was activated. 7. For Resident #6, the facility staff failed to provide activities of daily living care in a timely manner. The findings included: 1. For Resident #20, the facility staff failed to have adequate staff to respond to the Resident's call bell and request for assistance for three hours. Resident # 20, was admitted to the facility on [DATE]. The resident's diagnoses included but were not limited to: constipation, MDD single episode, allergic rhinitis, heartburn, pruritus, hyperlipidemia, heart disease, obesity, chronic diastolic heart failure, pyridoxine deficiency, polyosteoarthritis, rheumatoid arthritis, . Resident #20's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/20/19, was coded as a quarterly assessment. Resident #20 was coded as having a BIMS (brief interview for mental status) score of 15, which indicated being cognitively intact. Resident #20, was also coded as requiring extensive of assistance of staff for bed mobility, transfers, dressing, and personal hygiene. She was coded as being totally dependent upon staff for toileting and bathing. During an interview with Resident #20 on 05/14/19 at 01:33 PM, Resident #20 stated, I have called for help and waited over an hour. When asked how often this occurs, Resident #20 stated, it happens too often and indicated it is an ongoing concern. Resident #20 stated, they need another aide on the unit, they don't have enough staff to help us. Review of the facility call bell response log on 5/15/19 revealed that on 5/8/19, Resident #20 used her call bell at 2:11pm to call for assistance. Three hours later, at 5:11pm her call bell was still sounding and had not been responded to. On 5/15/19 at 10:10am an interview was conducted with Employee J, Information Systems Director. Employee J stated, the system is programmed so when the call bell is pressed it notifies multiple people. If there is no response after 30 minutes, it resets and resends all of the notifications again. When Employee J was asked to interpret the call bell response log for Resident #20 on 5/8/19, Employee J stated, it tells me it wasn't responded to. When Employee J was asked what happens when a resident uses their call bell, Employee J and the DON stated, it activates a notification to the CNA, the supervisor and after a minute the DON and Administrator get a text on their phone. On 5/15/19 the DON (Director of Nursing, Employee B) was asked about the incident on 5/8/19 when Resident #20's call bell went off for 3 hours. The DON stated, I can tell you someone will check- people will come by and pop their heads in. On 5/15/19 the Administrator stated, an acceptable time and my expectation is for call bells to be answered within 15 minutes. We don't know what happened at that time, her care is exceptional. I know they get the care they need. Review of the facility policy titled, Call light with an effective date of May 2018, read Emergency call system will be made available to all residents in room, bathrooms and other areas as deemed necessary. Residents are to have a method to activate the emergency call system herein referred to as call lights in bedrooms and bathrooms. Review of the facility polity titled, Responding to call light with an effective date of, May 2018 read, All staff to respond to all lights. 1. Respond to location of call light. 2. Ask resident what assistance is needed. 3. If certified to perform care, render care 4. If not certified to render care, notify a member of the nursing team and/or supervisor 5. Please ensure call light is reset. On 5/15/19 the facility Administrator and DON were made aware of the facility staff's failure to respond to Resident #20's call light for 3 hours. No further information was provided. 5. For Resident #12, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 2 of 14 opportunities the call light was activated Resident #12, an [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but not limited to spastic hemiplegia, paralytic syndromes, muscle weakness, depression, and flaccid neurogenic bladder. Cognitive disorders were not on the list of diagnoses. Resident #12's most recent Minimum Data set with Assessment Reference Date of 02/13/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as a 6 out of possible 15 indicative of severe cognitive impairment. Functional status for bed mobility, dressing, and personal hygiene were coded as requiring extensive assistance from staff. On 05/14/19 at approximately 12:00 PM, an interview with Resident #12 was conducted. Resident #12 was in bed with the head of the bed elevated approximately 45 degrees. When asked if the facility staff answered the call light promptly when he needed assistance, Resident #12 stated, Sometimes it seems like it takes forever for staff to come. Resident #12 stated that sometimes he needs help positioning in the bed and calls for assistance. On 05/14/19 at 2:55 PM, call logs for the past week for the health center were requested from Employee J from the information technology department. On 5/14/19 at 4:15 PM in an interview with the Administrator she stated, my expectation is for call bells to be answered within 15 minutes. She stated that she didn't know why they were longer perhaps staff forgot to cut off the call bell and was in the room doing care. On 05/15/2019 at approximately 9:00 AM, the facility staff provided call logs for Resident #12 with a date range of 05/08/2019 through 05/13/2019. Of the 14 times the call light was activated, there were 2 instances where the duration was longer than 15 minutes. On 05/12/2019 at 7:11 AM, the duration was 21 minutes and 7 seconds. On 05/12/2019 at 10:22 PM, the duration was 30 minutes and 2 seconds. On 05/15/19 at approximately 10:10 AM, an interview with Employee J was conducted. Employee J stated that the system is programmed to do certain things when the button is pushed. Employee J stated that the activated call bell routes to the certified nurse assistant (CNA) pager. If it isn't answered, it flows over to nurse pager. The facility staff provided a copy of their policy entitled, Responding to call light. The listed procedures documented, 1. Respond to location of call light. 2. Ask resident what assistance is needed. 3. If certified to perform care, render care. 4. If not certified to render care, notify a member of the nursing team and/or supervisor. 5. Please ensure call light is reset. On 05/16/2019 at approximately 2:30 PM, the Administrator stated they had no further documentation or information to offer. 6. For Resident #15, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 3 of 15 opportunities the call light was activated. Resident #15, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but not limited to chronic kidney disease, dementia without behavior disturbance, Parkinson's disease, cognitive communication deficit, muscle weakness, and difficulty in walking. Resident #15's most recent minimum Data set with an Assessment Reference Date of 02/20/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as 12 out of possible 15 indicative of moderate cognitive impairment. Functional status for bed mobility, transfers, dressing, and toileting was coded as requiring extensive assistance from staff. On 05/14/19 at approximately 1:55 PM, an interview with Resident #15 was conducted. When asked if the staff answer the call light promptly when she needs assistance, Resident #15 stated, Sometimes it's a long time before they come. Resident #15 stated that she needs help to get into her chair or to get positioned for a nap. Resident #15 also stated, I can't get up by myself. On 05/14/19 at 2:55 PM, call logs for the past week for the health center were requested from Employee J from the information technology department. On 5/14/19 at 4:15 PM in an interview with the Administrator she stated, my expectation is for call bells to be answered within 15 minutes. She stated that she didn't know why they were longer perhaps staff forgot to cut off the call bell and was in the room doing care. On 05/15/2019 at approximately 9:00 AM, the facility staff provided call logs for Resident #12 with a date range of 05/08/2019 through 05/14/2019. Of the 15 times the call light was activated, there were 3 instances where the duration was longer than 15 minutes. On 05/08/2019 at 9:23 AM, the duration was 28 minutes and 43 seconds. On 05/11/2019 at 7:56 PM, the duration was 23 minutes and 24 seconds. On 05/13/2019 at 4:26 PM, the duration was 15 minutes and 31 seconds. On 05/15/19 at approximately 10:10 AM, an interview with Employee J was conducted. Employee J stated that the system is programmed to do certain things when the button is pushed. Employee J stated that the activated call bell routes to the certified nurse assistant (CNA) pager. If it isn't answered, it flows over to nurse pager. The facility staff provided a copy of their policy entitled, Responding to call light. The listed procedures documented, 1. Respond to location of call light. 2. Ask resident what assistance is needed. 3. If certified to perform care, render care. 4. If not certified to render care, notify a member of the nursing team and/or supervisor. 5. Please ensure call light is reset. On 05/16/2019 at approximately 2:30 PM, the Administrator stated they had no further documentation or information to offer. 2. For Resident #28 the facility staff failed to ensure adequate staff available to answer call bells in a timely manner. Resident #28 is an [AGE] year old woman originally admitted to the facility with diagnoses of but not limited to Hypertension, History of hip fracture with artificial hip replacement, (Coronary Artery Disease), CAD, Congestive Heart failure and Asthma. On 3/19/19 Resident was admitted to the facility prior to admission to hospital for planned surgical repair of hardware from prior hip fracture. The Resident went out for surgery on 4/6/19 and was readmitted on [DATE]. Residents most recent (Minimum Data Set) MDS was dated 3/31/19 and it was a 14 -Day PPS. According to the most recent MDS Resident # 28 had a (Brief Interview of Mental Status) BIMS score of 15/15 indicating no cognitive impairment. On 5/14/19 at 2:15 PM an interview was conducted with Resident #28 who stated she had no problems with the facility other than the time it took for staff to answer the call bells. She further elaborated by saying If the staff would answer the call bells this place would be great! She relayed and incident where she had put the call bell on because she wanted something for her cough. She stated that someone came in and turned the call bell off and told her she would let the nurse know what she needed. She stated that happened three times and no nurse came. She stated after that I just got up by myself and walked to the nurses' station to tell her. On 5/14/19 at 3:00 P.M. an interview was conducted with Employee J (Information Technology), when asked if this surveyor could have a copy of the call bell response times he replied I don't think I can get that. When asked what company they use he stated Status Solutions and when asked what program he stated [NAME]. He was then informed by this surveyor that we request these logs from other facilities using the same system and are able to get them, he stated he would try to get them. On 5/14/19 at 4:15 PM in an interview with the Administrator she stated, my expectation is for call bells to be answered within 15 minutes. I know they get the care they need. According to the facility call logs provided by Status Solutions from 5/1/19 through 5/14/19 5/02/19 - Call bell rang from 4:33 PM to 4:56 PM - total 22 min. 21 sec. 50/3/19 - Call bell rang from 7:05 AM to 7:23 AM - total 18 min 10 sec. 5/03/19 - Call bell rang from 7:38 AM to 7:53 AM - total 14 min. 56 sec. 50/3/19 - Call bell rang from 1:33 PM to 1:56 PM - total 22 min 46 sec. 5/04/19 - Call bell rang from 7:59 AM to 8:15 AM - total 16 min. 19 sec. 50/4/19 - Call bell rang from 8:24 PM to 8:50 PM - total 26 min. 5 sec. 5/05/19 - Call bell rang from 8:10 AM to 8:24 AM - total 14 min. 15 sec. 5/05/19 - Call bell rang from 8:43 AM to 9:18 AM - total 34 min 35 sec. 5/06/19 - Call bell rang from 8:03 AM to 8:19 AM - total of 15 min 46 sec. 5/07/19 - Call bell rand from 7:01 AM to 7:30 AM - total 28 min 41 sec. 5/10/19 - Call bell rang from 7:35 AM to 7:53 AM total of 18 min 7 sec. 5/11/19 - Call bell rang from 7:01 AM to 7:44 AM - total 43 min 37 sec. 5/11/19 - Call bell rang from 12:30 PM to 12:50 PM total of 20 min 10 sec. 5/13/19 - Call bell rang from 4:12 PM to 4:52 PM total of 20 min 40 sec. 5/13/19- Call bell rang from 9:10 PM to 9:27 PM total of 17 min 5 sec. On 5/15/19 at 4:30 PM in an interview with CNA A stated that Resident # 98 needs assistance to get up and go to the bathroom and she needs help getting out of bed and to her chair. On 5/16/19 at the end of day meeting the Administrator was made aware of the issues with answering call bells timely and no further information was provided. 3. The facility staff failed to ensure adequate staff available to answer call bells in a timely manner. Resident # 190 a [AGE] year old woman admitted to the facility on [DATE] the Resident has no (Minimum Data Set) MDS information available as she is a new admission. The Resident was admitted to the facility with diagnoses of but not limited to recent Right hip replacement surgery, foot drop in Right foot, difficulty walking, general weakness, (Chronic Obstructive Pulmonary Disease) COPD, Atrial Fibrillation and Diabetes. On 5/14/19 at 2:25 PM an interview was conducted with Resident #190 who stated the staff take too long to answer call bells. She stated that the facility is nice but if you have to use the bathroom [ROOM NUMBER] minutes is way too long to wait. When asked what type of assistance she requires Resident #190 stated she had a hip replacement surgery but something went wrong and she ended up with foot drop as well so she is unable to ambulate or transfer alone. On 5/14/19 at 3:00 P.M. an interview was conducted with Employee J (Information Technology), when asked if this surveyor could have a copy of the call bell response times he replied I don't think I can get that. When asked what company they use he stated Status Solutions and when asked what program he stated [NAME]. He was then informed by this surveyor that we request these logs from other facilities using the same system and are able to get them, he stated he would try to get them. On 5/14/19 at 4:15 PM in an interview with the Administrator she stated, my expectation is for call bells to be answered within 15 minutes. I know they get the care they need. According to the facility call logs provided by Status Solutions from 5/1/19 through 5/14/19 5/9/19 - Call bell rang from 7:14 AM to7:31 AM - total 17 min. 18 sec. 5/10/19 Call bell rang from 9:17 AM to 9:37 AM total 19 min 40 sec. 5/10/19 Call bell rang from 12:35 PM to 12:50 PM total 15 min 9 sec. 5/11/19 Call bell rang from 1:38 AM to 1:55 AM total 16 min 42 sec 5/11/19 Call bell rang from 2:30 PM to 3:06 PM total 19 min 32 sec. 5/11/19 Call bell rang from 5:59 PM to 6:15 PM total 15 min 56 sec. 5/12/19 Call bell rang from 1:44 PM to 2:15 PM total 31 min 45 sec. 5/12/19 Call bell rang from 3:02 PM to 3:22 PM total 19 min 32 sec. 5/14/19 Call bell rang from 8:19 AM to 8:42 Am total 23 min 4 sec. On 5/16/19 at the end of day meeting the Administrator was made aware of the issues with answering call bells timely and no further information was provided. 4. For Resident #189 the facility staff failed to provide sufficient staff to safely lift Resident using Hoyer which resulted in an injury. Resident #189 a [AGE] year old woman was admitted to the facility on [DATE] with diagnoses of but not limited to Dementia, Hypertension, Diabetes, Hypothyroidism, Chronic ischemic heart disease, Congestive heart failure, and abnormal posture. Resident #189's most recent (Minimum Data Set) MDS a quarterly with an ARD date of 3/16/19 codes Resident #189 as having a (Brief Interview of Mental Status) BIMS score of 00/15 which indicates severe cognitive impairment. Resident is also coded as being total assistance for all aspects of (Activities of Daily Living) ADL's. She is coded as requiring 2 or more people to perform her care and the use of Mechanical Lift for transferring from bed to chair or wheelchair. Resident #189 is the subject of a (Facility Reported Incident) FRI that was submitted to the OLC on 1/16/19. The FRI states that on 1/16/19 at approximately 11:30 AM the CNA that was working with Resident #189 reported to the LPN and Nursing supervisor that the resident was crying out in pain when she was touched on her right lower leg. The nurse examined and found swelling to the ankle area. The family and the MD were notified and the MD ordered X-Rays. The FRI also states that at 4:30 PM the X-Ray results arrived with a diagnosis of Acute Non-displaced fracture of right distal fibula. The MD and family were notified of the diagnosis and the MD ordered continuation of stabilization and follow up with orthopedics/ podiatry the following morning. On 5/15/19 at 2:00 PM an interview was conducted with the DON who stated that once she was told that there was a fracture involved she initiated a Fracture (of unknown cause) Investigation Form The DON submitted all of the statements and results of her investigation and also stated that the cause of the fracture was improper use of the mechanical lift. She elaborated to say that the CNA that was working with Resident #189 failed to obtain help from a coworker. She stated at all times there should be 2 persons operating the mechanical lift. The DON further stated that she did training on all direct care staff after the incident. According to the statement by the CNA who worked with Resident #189 on 1/15/19 from 3:00 PM to 11:00 PM Requested assistance multiple times to help with residents transfer to bed- unable to obtain assistance-transferred via Hoyer lift / mechanical lift to bed. According to facility Policy for Full Body Lift Policy: All CNA's will be trained in safe and appropriate use of the full body lift. Any time the full body lift is used, there must be 2 trained staff members present to ensure staff and resident safety. On 5/16/19 the Administrator was made aware of the issues involving the transfer without adequate number of staff and subsequent injury to Resident #189 and no further information was provided. 7. For Resident #6, the facility staff failed to provide activities of daily living care in a timely manner. Resident #6 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #6's diagnoses included Generalized Muscle Weakness, History of Falls, Difficulty in walking, Arthritis, Polyneuropathy, Hypertension, and Unspecified Cataract. The Minimum Data Set, which was an Annual Assessment, with an Assessment Reference Date of 1/3/19 was reviewed. Resident #6 was coded as having a Brief Interview of Mental Status Score of 8, indicating moderate cognitive impairment. In addition, Resident #8 was coded as not having any mood or behavioral issues. On 5/15/19 at 8:31 A.M., an observation was conducted of Resident #6 in her bed. Resident #6's call bell was on the floor, out of reach. Resident #6 stated that she had no way to let the staff know what she needed. She said that due to the wound on the back of her knee, it was difficult for her to get up and use her walker, when it was time for her to go to the bathroom. Resident #6 stated that she didn't remember the last time that the call bell was within reach. On 5/15/19 a review was conducted of facility documentation. The call bell response log was reviewed. During the previous 7 days, the call bell had not been activated during any shift. On 5/15/19 at 2:30 P.M., a Group Interview was conducted. The group unanimously agreed that their call bells were not routinely answered in a timely manner. They stated that it usually took staff between 30 minutes and one hour to answer the call bell. They further stated that the facility had reduced the number of available Certified Nursing Assistants, and that additional staff were needed to meet their needs. On 5/15/19 at approximately 3:30 P.M., an interview was conducted with the facility Administrator (Employee A). The administrator stated, The resident probably knocked the call bell off the bed. 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 prevent significant medication errors. The facility failed to administer insulin on 5 separate occasions for 3 of 25 sampled residents. 1. For Resident #7, the facility staff failed to administer 2 consecutive doses of insulin on 05/12/2019 as indicated by sliding scale per physician's orders. 2. For Resident # 190 the facility staff omitted giving insulin at 4:30 PM on two consecutive days. 3. For Resident #5, the facility staff failed to ensure insulin was administered on 5-11-19 as ordered by a physician. The findings included: 1. For Resident #7, the facility staff failed to administer 2 consecutive doses of insulin on 05/12/2019 as indicated by sliding scale per physician's orders. Resident #7, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but not limited to diabetes, peripheral vascular disease, hypertension, aphasia following cerebral infarction, and generalized muscle weakness. Resident #7's most recent Minimum Data Set with an Assessment Reference Date of 01/30/2019 was coded as an annual assessment. The Brief Interview for Mental Status was coded as 3 out of possible 15 indicative of severe cognitive impairment. Number of days insulin injections were received was coded as 7. On 05/14/2019 at approximately 3:00 PM, the current physician's orders were reviewed. An excerpt of an order dated 01/14/2019 documented, Humalog 100unit/ml subcutaneous solution sliding scale check QID (four times a day) FS (fasting sugar) 200 or less give 0 units; 201-250 give 2 units; 251-300 give 4 units; 301-350 give 6 units; 351-400 give 8 units; greater than 400 give 1 units, call MD, recheck in 1 hour. The Medication Administration Record for May 2019 was reviewed. On 05/12/2019 on the line BfrBrkfst (before breakfast), the blood sugar was recorded as 210. Just below it on the line units, it was documented 0 (units). On the line BfrLunch (before lunch), the blood sugar level was documented as 283. Just below it on the line units, it was documented 0 (units). The meal intake flowsheet was reviewed. It was documented that Resident #7 consumed 51-75% of her meal for dinner on 05/11/2019. For 05/12/2019, Resident #7 consumed 76-100% of her breakfast and 26-50% of her lunch. On 05/15/19 10:24 AM , the findings were shared with the DON. When asked about her expectations for insulin administration, she stated she expects insulin to be administered as ordered. The DON then looked at the electronic health record of Resident #7 and stated she was unable to find a reason why the insulin was not given. The facility staff provided a copy of their policy entitled, Sliding Scale Insulin. The policy documented, A physician protocol for the use of sliding scale insulin will be used in the nursing center. The procedure documented, The following scale will be initiated upon admission for residents of [physician names]: Regular human insulin finger sticks AC & HS (before meals and at bedtime) FS (fasting sugar) below 200 - 0 units; 201-250 - give 2 units; 251-300 - give 4 units; 301-350 - give 6 units; 351-400 - give 8 units; Above 400 - give 10 units, call MD, recheck in 1 hour. On 05/16/2019 at approximately 2:30 PM, the Administrator stated they had no further documentation or information to offer. 2. For Resident # 190, the facility staff omitted giving insulin at 4:30 PM on two consecutive days. Resident # 190, a [AGE] year old woman admitted to the facility on [DATE]. The Resident had no (Minimum Data Set) MDS information available as she was a new admission. The Resident was admitted to the facility with diagnoses of but not limited to recent Right hip replacement surgery, foot drop in Right foot, difficulty walking, general weakness, (Chronic Obstructive Pulmonary Disease) COPD, Atrial Fibrillation and Diabetes. On 5/15/19 during clinical record review, it was noted that Resident #190 had orders for the following insulin : Humalog Mix 75/25 Insulin 100 Units/ (Milliliter) ml subcutaneous suspension [Insulin lispro protamine-lispro] give 10 Units subcutaneously twice daily HOLD FOR BLOOD SUGAR [LESS THAN] < 125 It was noted that : 5/12/19 at 4:30 PM the Resident's blood sugar was 133 and insulin was not given 5/13/19 at 4:30 PM the Resident's blood sugar was 159 and insulin was not given On 5/15/19 at 1:43 PM, copies of (Medication Administration Record) MAR was submitted and reflected the insulin not being given. On 5/16/19 at 8:30 AM during an interview with the DON (Director of Nursing), she stated that she checked with the LPN (Licensed Practical Nurse) who gave medications to that resident and that the LPN stated the insulin was refused by the Resident. She then produced another MAR with the last page stating Resident refused Insulin on 5/9/19 at 8:30 AM, 5/11/19 at 8:10 AM, 5/12/19 at 8:21, 5/14/19 at 8:10 and 5/15/19 at 8:09AM. She produced nothing to address the insulin on 5/12/19 at 4:30 or 5/13/19 at 4:30 PM. On 5/16/19 during the end of day conference, the Administrator was made aware of the issues with medication administration. No further documentation was provided. 3. For Resident #5, the facility staff failed to ensure insulin was administered on 5-11-19 as ordered by a physician. Resident #5, was admitted to the facility on [DATE]. Diagnoses included diabetes, sarcoidosis, and long time insulin use. Resident #5's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-24-19 was coded as an annual assessment. Resident #5 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #5 was also coded as requiring extensive assistance to total dependence on one to two staff members to perform activities of daily living, such as hygiene, and bed mobility. On 5-14-19 at 12:00 noon, Resident #5 was observed in her room in bed. A Resident interview was conducted, and the Resident stated she did not receive her insulin as she should from staff. Review of the resident's clinical record revealed the resident's current POS (physician order sheet), and MAR (Medication Administration Record) for May 2019. Contained was an order for Novolog insulin per sliding scale with fingerstick blood sugars (FSBS) three times per day. If the Resident's blood sugar was above 251 and below 300, give 4 units of the insulin by subcutaneous injection. On 5-11-19 the Resident's FSBS was 254, and no insulin was given, and was documented as such by the nurse. Review of the medication and nursing notes revealed no documentation as to why the insulin was not given. Review of the facility policy revealed that only trained nurses would administer insulin by the physician's orders. On 5-15-19 at 5:00 p.m., the DON (director of nursing) was notified of above findings. The DON stated, The medication should have been given.

**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 follow infection prevention protocols. The dietary manager was observed not wearing personal protective equipment (PPE) in the room of a resident on contact isolation for clostridium difficile. The dietary manager then exited the room without washing hands and entered two other resident rooms without performing hand hygiene. The findings included: On 05/16/19 at 08:35 AM, the dietary manager was observed in the room of Resident #92. There was personal protective equipment stationed outside the room door and a Stop sign posted next to the door. The dietary manager was observed standing inside the room talking with Resident #92 (seated in a chair) and a family member (standing next to Resident #92). The dietary manager and the family member were not wearing PPE. The dietary manager was observed shaking the family member's hand then stooped down next to Resident #92, leg touching the side of the chair, and placed his hand on Resident #92's back/shoulder. LPN A was observed to pass by the room [ROOM NUMBER] times, looked in the room once, then kept walking past the room without comment. The dietary manager then left the room of Resident #92 and entered the room of Resident #91 and spoke briefly to her without making physical contact. The dietary manager then exited Resident #91's room and entered the room of Resident #239. The dietary manager was observed touching the left bedrail as he spoke to Resident #239 who was lying in bed at the time. The dietary manager then exited Resident #239's room, walked down the hall, activated 2 sets of doors by pressing the door plates, touched the doorknob to open the dietary manager's office, then turned around and got on the elevator. The dietary manager did not perform hand hygiene from the time he left Resident #92's room to the time he got on the elevator. On 05/16/19 at 08:49 AM, the DON was asked if Resident #92 was on isolation and she stated she would need to check. On 05/16/19 at 09:03 AM, the ADON was asked if Resident #92 was on isolation and she stated, Yes, he is on contact precautions for C diff. When asked about the process for observing contact precaution, the ADON stated that staff should wash their hands, don PPE before entering room, remove PPE in room, and immediately wash hands before leaving room. When the ADON was updated on the observations made of dietary manager, the ADON stated the dietary staff was supposed to be mindful of that (policy) and report to the nurse first so they will use appropriate PPE when entering a resident's room. On 05/16/2019, an interview with the dietary manager was conducted. When asked about the process for entering a room of a resident on isolation, he stated he normally won't enter an isolation room but if required, he would first stop and ask the nurse what proper equipment to wear before entering room. When shared concerns about not donning PPE before entering Resident #92's room, the dietary manager stated he didn't know Resident #92 was still on isolation because he was scheduled to be discharged today (05/16/2019). The facility staff provided a policy entitled, Handwashing/Hand Hygiene. In Section 5 (e), it was documented, Employees must wash their hands for at least twenty seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: Before and after entering isolation precaution settings. On 05/16/2019 at approximately 2:30 PM, the Administrator stated they had no further documentation or information to offer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview and clinical record review, the facility staff failed for 1 resident (Resident #44) of 19 residents in the survey sample to ensure the resident was assessed to self administer medications and have physician orders for the medications the resident administered. For Resident #44, a bottle of Tums and and bottle of vitamin B12 was observed on the counter in the bathroom. There was no physician order for the medications and the resident could not describe the reason why she took these medications. The findings included: Resident #44, a [AGE] year old, was admitted to the facility on [DATE]. Her diagnoses included constipation, reflux, rheumatoid arthritis, dysphagia, hyperlipidemia, and congestive heart failure. He most recent Minimum Data Set (MDS) assessment was a comprehensive assessment with an assessment reference date of 1/17/18. She was coded with a Brief Interview of Mental Status score of 11 indicating moderate cognitive impairment and required extensive assistance with her activities of daily living. On 2/5/18 at 2:50 p.m., a bottle of Tums and a bottle of vitamin B12 were observed on the counter in Resident #44's bathroom. The medications were observed on the counter again on 2/6/18 at 11:00 a.m Resident #44's physician orders were reviewed on 2/6/18. There was no physician order for Tums or vitamin B12. Resident #44's February 2018 Medication Administration Record (MAR) was reviewed. The MAR did not include Tums or the vitamin B12. Resident #44's care plan was reviewed. Included was the Problem I would like to and have demonstrated my ability to self administer my Nitroglycerin tablets for Chest Pain medication. Start date 1/23/18. The Approaches read Assess my ability to self-medicate per facility policy. Review Quarterly. Start date 5/16/17 and Educate me on how to self administer, review name of medication, dose, action, purpose and side effects. Start date 5/16/17. On 2/7/18 at 4:00 p.m., a meeting was held with the Administrator and Assistant Director of Nursing (ADON). At this time, the Administrator was asked if he found Resident #44 to be reliable. He stated no. He was informed that Resident #44 stated that the nursing staff administered her medications at 5:30 a.m. and she did not like to receive medications that early. He was also informed that the Tums and vitamin B12 were observed on the bathroom counter on two occasions. The facility staff were asked to provide documentation that Resident #44 had been screened to self administer medications. On 2/8/18 at 8:30 a.m., the ADON provided the form Assessment of Self-Administration of Medication for Resident #44. The initial review was dated 10/31/16. The medication Nitro Tabs was written on the form and had been crossed out. The word Tums was also written on the form. Resident #44 was assessed as satisfactory in the category Appropriate to self administer medications for the date of 10/31/16. The review date of 2/15/17 was written on the form. The medication Nitro was written on the form and had been crossed out. All pieces of the assessment for the date of 2/15/17 were crossed out. She was not indicated to be satisfactory to self administer medications. The review date of 1/11/18 was written on the form. The section Appropriate to self administer medications was not completed. It was reviewed with the ADON that there were not physician orders for the Tums or the vitamin B12. When asked how the nurses know when Resident #44 takes the medications and how the medications are documented as having been administered, the ADON stated the resident should tell the nurse. On 2/8/18 at 8:40 a.m., Resident #44 was interviewed. When asked why she keeps Tums in her bathroom, Resident #44 stated she could not provide a reason. She stated that she just likes to have them. When asked when she is supposed to take them, she stated she takes them sometimes. At the end of day meeting on 2/8/18, the issue was reviewed with the Administrator, ADON, corporate staff and the MDS coordinator. At this time, the MDS coordinator stated that Resident #44's daughter probably put the medications in the bathroom. It was reviewed that the medications were observed in the room for two days and facility staff had not identified that they were there or removed them.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility staff failed to accurately complete an MDS for one resident ( Resident #19) in a survey sample of 19 residents. For Resident # 19, the facility staff inaccurately coded the MDS Section H as having an Ostomy. The Findings Included: Resident # 19 was an [AGE] year old male admitted to the facility on [DATE] with the diagnoses of, but not limited to, Hypertension, Diabetes, Peripheral Vascular Disease, Dyspnea, Anxiety, Pain and Coronary Artery Disease. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 12/27/17. The MDS coded Resident # 19 with a BIMS (Brief Interview for Mental Status) of 11/15 indicating moderate cognitive impairment. Resident # 19 required extensive assistance of one staff person to two staff persons with activities of daily living except required supervision and set up only for eating. He was also coded as having an Ostomy and frequently incontinent of bowel and bladder. On 2/6/2018 at 9:30 AM, review of the clinical record was conducted. Review of the clinical record revealed the MDS Section H-Bladder and Bowel H0 100 C coded Resident # 19 as having an Ostomy. Review of the Nurses Notes revealed no documentation of an Ostomy. On 2/6/2018 at 10:30 AM, an interview was conducted with Resident # 19 who stated he goes to the bathroom normally. Resident # 19 denied having an Ostomy. On 2/6/2018 at 2:35 PM, an interview was conducted with the RN (Registered Nurse) Supervisor (Registered Nurse A) who stated Resident # 19 did not have an Ostomy. RN A stated he did not know the MDS had been coded with Resident # 19 having an Ostomy. RN A stated he did not have access to the MDS system and the MDS Coordinator was out sick. RN A stated the coding must have been a mistake. On 2/6/2018 at 2:37 PM, an interview was conducted with LPN (Licensed Practical Nurse) A who stated he regularly cared for Resident # 19 and was sure he did not have an Ostomy. On 2/6/2018 at 2:40 PM, an interview was conducted with the Assistant Director of Nursing who stated Resident # 19 did not have an Ostomy. The Assistant Director of Nursing stated the expectation was that the MDS should be accurate. Guidance from CMSs RAI instructions: CMS ' s RAI Version 3.0 Manual CH 3: MDS Items [H] May 2013 Page H-2 H0100: Appliances (cont.) · Care planning should be based on an assessment and evaluation of the resident ' s history, physical examination, physician orders, progress notes, nurses ' notes and flow sheets, pharmacy and lab reports, voiding history, resident ' s overall condition, risk factors and information about the resident ' s continence status, catheter status, environmental factors related to continence programs, and the resident ' s response to catheter/continence services. Steps for Assessment 1. Examine the resident to note the presence of any urinary or bowel appliances. 2. Review the medical record, including bladder and bowel records, for documentation of current or past use of urinary or bowel appliances. Coding Instructions Check next to each appliance that was used at any time in the past 7 days. Select none of the above if none of the appliances A-D were used in the past 7 days. · H0100A, indwelling catheter (including suprapubic catheter and nephrostomy tube) · H0100B, external catheter · H0100C, ostomy (including urostomy, ileostomy, and colostomy) · H0100D, intermittent catheterization · H0100Z, none of the above Coding Tips and Special Populations · Suprapubic catheters and nephrostomy tubes should be coded as an indwelling catheter (H0100A) only and not as an ostomy (H0100C). · Condom catheters (males) and external urinary pouches (females) are often used intermittently or at night only; these should be coded as external catheters. · Do not code gastrostomies or other feeding ostomies in this section. Only appliances used for elimination are coded here. · Do not include one time catheterization for urine specimen during look back period as intermittent catheterization. DEFINITIONS EXTERNAL CATHETER Device attached to the shaft of the penis like a condom for males or a receptacle pouch that fits around the labia majora for females and connected to a drainage bag. OSTOMY Any type of surgically created opening of the gastrointestinal or genitourinary tract for discharge of body waste. UROSTOMY A stoma for the urinary system used in cases where long-term drainage of urine through the bladder and urethra is not possible, e.g., after extensive surgery or in case of obstruction. ILEOSTOMY A stoma that has been constructed by bringing the end or loop of small intestine (the ileum) out onto the surface of the skin. COLOSTOMY A stoma that has been constructed by connecting a part of the colon onto the anterior abdominal wall. https://www.aanac.org/docs/mds-3.0-rai-users-manual/11123_mds_3-0_chapter_3_-_section_h_v1-12.pdf?sfvrsn=6 The facility Administrator, Assistant Director of Nursing, and corporate manager were informed of the failure of the staff to complete Section H0 100 accurately for an annual MDS with the ARD of 12/27/2017 during the end of day debriefing on 2/7/2018. On 2/8/2018 at 11:30 AM, an interview was conducted with the MDS Coordinator (RN C) who stated she had submitted a modification to the MDS to correct section H0 100. RN C stated the information about the Ostomy had transferred from incorrect information submitted by the Certified Nursing Assistants. RN C stated I missed it. He does not have an Ostomy. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure professional standards for three residents (Residents # 397, 19 and 398) in a survey sample of 19 residents. ( The staff failed to ensure and implement a method of disposition of written prescriptions for narcotics was followed to prevent potential diversion of controlled drugs.) 1. For Resident # 397, the facility staff failed to send a hard copy script dated 12/30/2017 for Oxycodone 5 milligrams to the Pharmacy. 2. For Resident # 19, the facility staff failed to send a hard copy script dated 1/16/2017 for Oxycodone 5 milligrams to the Pharmacy. 3. For Resident # 398, the facility staff failed to send a hard copy script dated 5/24/2017 for Norco 5/325 to the Pharmacy. Findings Included: 1. For Resident # 397, the facility staff failed to send a hard copy script dated 12/30/2017 for Oxycodone 5 milligrams to the Pharmacy. Resident # 397 was a [AGE] year old female admitted to the facility originally on 4/21/2015 and readmitted on [DATE] with the diagnoses of, but not limited to, Hypertension, Diabetes, Peripheral Vascular Disease, Dyspnea, Anxiety, Pain and Coronary Artery Disease. The most recent Minimum Data Set (MDS) was a Significant Change Assessment with an Assessment Reference Date (ARD) of 1/7/2018. The MDS coded Resident # 3 with a BIMS (Brief Interview for Mental Status) of 15/15 indicating no cognitive impairment. Resident # 397 required extensive assistance of one staff person to two staff persons with activities of daily living except required total assistance of one staff person for bathing and was coded for supervision and set up only for eating; She was also coded as frequently incontinent of bowel and bladder. On 2/6/2018 at 9:30 AM, review of the clinical record was conducted. Review of the clinical record revealed a hard copy of a written prescription for a narcotic dated 12/30/2017 from the hospital There was a hard script dated 12/30/2017 for Oxycodone (Roxicodone) 5 milligrams immediate release tablet, take 0.5 (2.5 milligrams) total by mouth every 4 hours as needed for pain. Route: Oral. Quantity 70 (Seventy) tablets. There was no line drawn through the prescription to indicate the prescription had been filled. Review of the Physicians Orders Summary for 2/7/ 2018 revealed an order written on 1/27/2018 Oxycodone 5 milligrams tablet, take 0.5 total by mouth every 4 hours as needed for pain. Route: Oral. On 2/7/2018 at 2:45 PM, an interview was conducted with the RN (Registered Nurse) Supervisor (RN A) who stated prescriptions for narcotics should be faxed to the Pharmacy. RN A stated a copy of the prescription should be left inside the chart, with a line drawn through the prescription. On 2/7/2018 at 3:05 PM, an interview was conducted with the Assistant Director of Nursing who stated after faxing a copy, the hard scripts should be sent to the Pharmacy and a copy should be left in the chart. On 2/7/2018 at 3:30 PM, an interview was conducted via the telephone with the Consultant Pharmacist who stated the facility had a procedure in place to handle prescriptions for narcotic. The Consultant Pharmacist (Admin F) stated the nursing staff should fax the order for narcotics, a copy of the prescription should be kept at the facility in the clinical record and the actual prescription should be sent to the Pharmacy. There was a poor telephone connection and the Pharmacist stated she was at another facility at that moment but would call the surveyor the next morning at 9 AM from a different telephone to clarify. During the end of day debriefing on 2/7/2018 at 4:15 PM, the facility Administrator, Assistant Director of Nursing (Admin B) and the corporate representative were informed of the findings. Admin B stated the professional guidance was provided by [NAME]. On 2/8/2018 at 8:55 AM, the Pharmacy Consultant (Admin F) came to the conference room to talk with the surveyor. Admin F apologized about the telephone connection on the previous day but stated she decided to come to the facility to clarify any concerns. Admin F stated the nursing staff should fax the order for narcotics, a copy of the prescription should be kept at the facility in the clinical record, a line should be drawn through the copy of the prescription and the actual prescription should be sent to the Pharmacy. Admin F stated the Pharmacy delivers to the facility twice a day. Admin F stated her supervisor, the Pharmacist in Charge, wanted to talk with the surveyor about the procedures regarding narcotics. Admin F reviewed Resident # 397's clinical record and saw the hard script for Oxycodone. Admin F stated the prescription should have been sent to the Pharmacy by facility staff. Admin F agreed that the prescription was not secure as filed in the clinical record. On 2/8/2018 at 9:06 AM, a telephone interview was conducted with the Pharmacist in charge (Admin G) stated the facility was supposed to forward the hard copies of narcotics to the Pharmacy in a bag and that the Pharmacy delivery person comes twice a day to the facility. During the end of day debriefing on 2/8/2018, the facility Administrator, Assistant Director of Nursing and Corporate Manager were informed of the failure of the staff to ensure the implementation of a method of safekeeping of hard scripts for narcotics. The nursing staff did not forward the hard copy of the narcotic prescription to the Pharmacy and the Pharmacy did not make sure it received the hard copy of the narcotic prescription. There was the potential of diversion of controlled drugs. There was the potential of diversion of controlled drugs. No further information was provided. 2. For Resident # 19, the facility staff failed to send a hard copy script dated 1/16/2017 for Oxycodone 5 milligrams to the Pharmacy. Resident # 19 was a [AGE] year old male admitted to the facility on [DATE] with the diagnoses of, but not limited to, Hypertension, Diabetes, Peripheral Vascular Disease, Dyspnea, Anxiety, Pain and Coronary Artery Disease. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 12/27/17. The MDS coded Resident # 19 with a BIMS (Brief Interview for Mental Status) of 11/15 indicating moderate cognitive impairment; Resident # 19 required extensive assistance of one staff person to two staff persons with activities of daily living except required supervision and set up only for eating; He was also coded as having an Ostomy and frequently incontinent of bowel and bladder. On 2/6/2018 at 9:30 AM, review of the clinical record was conducted. Review of the clinical record revealed a hard copy of a written prescription dated 1/16/17 for Oxycodone 5 milligrams one tablet oral every 4 hours as needed for pain Dispense/supply 30 tablets with no refills. Review of the signed Physicians Order Summary dated 1/10/2018 revealed no current order for Oxycodone. On 2/7/2018 at 2:45 PM, an interview was conducted with the RN (Registered Nurse) Supervisor (RN A) who stated prescriptions for narcotics should be faxed to the Pharmacy. RN A stated a copy of the prescription should be left inside the chart, with a line drawn through the prescription. On 2/7/2018 at 3:05 PM, an interview was conducted with the Assistant Director of Nursing who stated after faxing a copy, the hard scripts should be sent to the Pharmacy and a copy should be left in the chart. On 2/7/2018 at 3:30 PM, an interview was conducted via the telephone with the Consultant Pharmacist who stated the facility had a procedure in place to handle prescriptions for narcotic. The Consultant Pharmacist (Admin F) stated the nursing staff should fax the order for narcotics, a copy of the prescription should be kept at the facility in the clinical record and the actual prescription should be sent to the Pharmacy. There was a poor telephone connection and the Pharmacist stated she was at another facility at that moment but would call the surveyor the next morning at 9 AM from a different telephone to clarify. During the end of day debriefing on 2/7/2018 at 4:15 PM, the facility Administrator, Assistant Director of Nursing (Admin B) and the corporate representative were informed of the findings. Admin B stated the professional guidance was provided by [NAME]. On 2/8/2018 at 8:55 AM, the Pharmacy Consultant (Admin F) came to the conference room to talk with the surveyor. Admin F apologized about the telephone connection on the previous day but stated she decided to come to the facility to clarify any concerns. Admin F stated the nursing staff should fax the order for narcotics, a copy of the prescription should be kept at the facility in the clinical record, a line should be drawn through the copy of the prescription and the actual prescription should be sent to the Pharmacy. Admin F stated the Pharmacy delivers to the facility twice a day. Admin F stated her supervisor, the Pharmacist in Charge, wanted to talk with the surveyor about the procedures regarding narcotics. Admin F reviewed the Resident # 19's clinical record and saw the hard script for Oxycodone. Admin F stated the prescription should have been sent to the Pharmacy by facility staff. Admin F agreed that the prescription was not secure as filed in the clinical record. On 2/8/2018 at 9:06 AM, a telephone interview was conducted with the Pharmacist in charge (Admin G) stated the facility was supposed to forward the hard copies of narcotics to the Pharmacy in a bag and that the Pharmacy delivery person comes twice a day to the facility. Per the surveyor's request, Admin B provided a copy of the pharmacy delivery summary. Review of the Pharmacy Proof of Delivery Shipment Summary revealed Oxycodone 5 milligrams tablets quantity 30 was filled on 1/16/2017. Admin B stated the nursing staff should have faxed a copy of the prescription, made a copy for the chart with a line drawn through it and forward the hard copy to the Pharmacy in the bag. During the end of day debriefing on 2/8/2018, the facility Administrator, Assistant Director of Nursing and Corporate Manager were informed of the failure of the staff to ensure the implementation of a method of safekeeping of hard scripts for narcotics. The nursing staff did not forward the hard copy of the narcotic prescription to the Pharmacy and the Pharmacy did not make sure it received the hard copy of the narcotic prescription. There was the potential of diversion of controlled drugs. There was the potential of diversion of controlled drugs. No further information was provided. 3. Resident # 398 was a [AGE] year old female admitted to the facility on [DATE] with the diagnoses of, but not limited to, Fracture of Neck of Left Femur, History of Falling, Chronic Obstructive Pulmonary Disease, Dementia, Hypothyroidism and Hyperlipidemia. The most recent Minimum Data Set (MDS) was a Significant Change Assessment with an Assessment Reference Date (ARD) of 1/7/2018. The MDS coded Resident # 398 with a BIMS (Brief Interview for Mental Status) of 10/15 indicating moderate cognitive impairment; Resident # 398 required extensive assistance of one staff person to two staff persons with activities of daily living except required supervision and set up only for eating; She was also coded as frequently incontinent of bowel and bladder. Resident # 398 was coded as requiring oxygen therapy. On 2/6/2018 at 9:30 AM, review of the clinical record was conducted. On the inside of the clinical record were plastic sleeves covering several sheets of papers. Under one plastic sleeve that included a document about Code Status, there were several hand written prescriptions. One of the prescriptions was a hard copy of a written prescription for a narcotic dated 5/24/17 for Norco 5/325 one tablet by mouth every 4 hours as needed Quantity 100. There were no marks on the prescription indicating the disposition of whether the prescription had been filled or was no longer valid. There was no indication the prescription had ever been filled. On 2/7/2018 at 2:45 PM, an interview was conducted with the RN (Registered Nurse) Supervisor (RN A) who stated prescriptions for narcotics should be faxed to the Pharmacy. RN A stated a copy of the prescription should be left inside the chart, with a line drawn through the prescription. On 2/7/2018 at 3:05 PM, an interview was conducted with the Assistant Director of Nursing who stated after faxing a copy, the hard scripts should be sent to the Pharmacy and a copy should be left in the chart. After reviewing the record, the Assistant Director of Nursing (Admin B) stated Resident # 398 was supposed to be discharged to home in May 2017 and the prescriptions were supposed to be given to her at discharge. Admin B stated the staff should have forwarded the prescription for the narcotic to the pharmacy or marked as voided if it was not to be filled. Admin B agreed that the prescription was not secure in the clinical record. On 2/8/2018 at 8:55 AM, the Pharmacy Consultant (Admin F) came to the conference room to talk with the surveyor. Admin F apologized about the telephone connection on the previous day but stated she decided to come to the facility to clarify any concerns. Admin F stated the nursing staff should fax the order for narcotics, a copy of the prescription should be kept at the facility in the clinical record, a line should be drawn through the copy of the prescription and the actual prescription should be sent to the Pharmacy. Admin F stated the Pharmacy delivers to the facility twice a day. Admin F stated her supervisor, the Pharmacist in Charge, wanted to talk with the surveyor about the procedures regarding narcotics. Admin F reviewed the Resident # 398's clinical record and saw the hard script for Norco. Admin F stated the prescription should have been sent to the Pharmacy by facility staff. Admin F agreed that the prescription was not secure as filed in the clinical record. On 2/8/2018 at 9:06 AM, a telephone interview was conducted with the Pharmacist in charge (Admin G) stated the facility was supposed to forward the hard copies of narcotics to the Pharmacy in a bag and that the Pharmacy delivery person comes twice a day to the facility. During the end of day debriefing on 2/8/2018, the facility Administrator, Assistant Director of Nursing and Corporate Manager were informed of the failure of the staff to ensure the implementation of a method of safekeeping of hard scripts for narcotics. The nursing staff did not forward the hard copy of the narcotic prescription to the Pharmacy and the Pharmacy did not make sure it received the hard copy of the narcotic prescription. There was the potential of diversion of controlled drugs. There was the potential of diversion of controlled drugs. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation review, clinical record review, the facility staff failed to to administer oxygen in a manner to prevent the spread of infection for one Resident (Resident # 398) in a survey sample of 19 Residents. For Resident # 398, the oxygen tubing was not changed from 1/27/18 until 2/6/2018. The findings included: Resident # 398 was a [AGE] year old female admitted to the facility on [DATE] with the diagnoses of, but not limited to, Fracture of Neck of Left Femur, History of Falling, Chronic Obstructive Pulmonary Disease, Dementia, Hypothyroidism and Hyperlipidemia. The most recent Minimum Data Set (MDS) was a Significant Change Assessment with an Assessment Reference Date (ARD) of 1/7/2018. The MDS coded Resident # 398 with a BIMS (Brief Interview for Mental Status) of 10/15 indicating moderate cognitive impairment; Resident # 398 required extensive assistance of one staff person to two staff persons with activities of daily living except required supervision and set up only for eating. She was also coded as frequently incontinent of bowel and bladder. Resident # 398 was coded as requiring oxygen therapy. On 2/6/2018 at 9:30 AM, review of the clinical record was conducted. During the initial tour on 2/5/2018 at 2:30 PM, Resident # 398 was not in her room. A red Oxygen in Use sign was noted on the outside of the door. An oxygen concentrator was located on the right side of the bed. The oxygen tubing and bag connected to an oxygen concentrator were dated 1/27/2018 -11-7 shift. As the initial tour continued, Resident # 398 was observed 2/5/18 at 3:21 p.m. sitting in a wheelchair in the Activity Room. Resident # 398 was participating in the activity and did not have any oxygen on. Review of the Physicians Orders revealed the following orders for oxygen therapy: 9/30/2017 for Oxygen at 2 Liters per minute via nasal cannula PRN (as needed) for Shortness of Breath 9/30/2017 Check oxygen saturations every shift. Notify the MD (Medical Doctor) if below 90 % room air, give oxygen- every shift. 11/19/2017 Change oxygen tubing and bag weekly 11-7 (Saturday)- every week 12/3/2017 Change oxygen concentrator filter weekly 11-7 (Saturday) 12/3/2017 Change oxygen humidifier water weekly 11-7 (Saturday)and PRN -Every Week as needed Resident # 398 was observed 2/6/18 at 10:22 a.m. The bag and tubing from the oxygen concentrator was dated 1/27/18. Review of the facility policy entitled Oxygen Administration did not include the frequency of changing tubing once the therapy has been initiated. The policy also did not include that the tubing should be dated. On 2/6/2018 at 3:20 PM, the facility Administrator and Nursing Supervisor observed the date on the oxygen tubing and bag was dated 1/27/2018. The Administrator stated the tubing should have been changed on 2/3/17 when all of the oxygen equipment was scheduled to be changed. The Registered Nurse (RN) Supervisor (RN A) stated the standard for the facility was for all of the oxygen tubing to be changed weekly on 11-7 shift. RN A stated Resident # 398 had an order for PRN (as needed) use of oxygen. RN A opened the outside zip lock bag dated 1/27/2018 and noted the tubing bag was open with a date of 1/27/2018 on the end of the tubing. RN A stated the staff should not have opened the bag of tubing. RN A stated the facility staff should change the tubing weekly and staff should check the date on the tubing prior to using it to make sure it is not longer than a week. When interviewed 2/7/18 at 4:55 p.m., the Assistant Director of Nursing (Admin B) stated oxygen tubing should be changed weekly. During the end of day debriefing on 2/7/2018, the Administrator, Corporate and Assistant Director of Nursing were informed of the failure of the staff to change the oxygen tubing weekly for Resident # 398. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure professional standards for three residents (Residents # 397, 19 and 398) in a survey sample of 19 residents. ( Failed to ensure and implement a method of disposition of written prescriptions for narcotics was followed to prevent potential diversion of controlled drugs.) 1. For Resident # 397, the facility staff failed to send a hard copy script dated 12/30/2017 for Oxycodone 5 milligrams to the Pharmacy. 2. For Resident # 19, the facility staff failed to send a hard copy script dated 1/16/2017 for Oxycodone 5 milligrams to the Pharmacy. 3. For Resident # 398, the facility staff failed to send a hard copy script dated 5/24/2017 for Norco 5/325 to the Pharmacy. Findings Included: 1. For Resident # 397, the facility staff failed to send a hard copy script dated 12/30/2017 for Oxycodone 5 milligrams to the Pharmacy. Resident # 397 was a [AGE] year old female admitted to the facility originally on 4/21/2015 and readmitted on [DATE] with the diagnoses of, but not limited to, Hypertension, Diabetes, Peripheral Vascular Disease, Dyspnea, Anxiety, Pain and Coronary Artery Disease. The most recent Minimum Data Set (MDS) was a Significant Change Assessment with an Assessment Reference Date (ARD) of 1/7/2018. The MDS coded Resident # 3 with a BIMS (Brief Interview for Mental Status) of 15/15 indicating no cognitive impairment; Resident # 397 required extensive assistance of one staff person to two staff persons with activities of daily living except required total assistance of one staff person for bathing and was coded for supervision and set up only for eating; She was also coded as frequently incontinent of bowel and bladder. On 2/6/2018 at 9:30 AM, review of the clinical record was conducted. Review of the clinical record revealed a hard copy of a written prescription for a narcotic dated 12/302017 from the hospital There was a hard script dated 12/30/2017 for Oxycodone (Roxicodone) 5 milligrams immediate release tablet, take 0.5 (2.5 milligrams) total by mouth every 4 hours as needed for pain. Route: Oral. Quantity 70 (Seventy) tablets. There was no line drawn through the prescription to indicate the prescription had been filled. Review of the Physicians Orders Summary for 2/7/ 2018 revealed an order written on 1/27/2018 Oxycodone 5 milligrams tablet, take 0.5 total by mouth every 4 hours as needed for pain. Route: Oral. On 2/7/2018 at 2:45 PM, an interview was conducted with the RN (Registered Nurse) Supervisor (RN A) who stated prescriptions for narcotics should be faxed to the Pharmacy. RN A stated a copy of the prescription should be left inside the chart, with a line drawn through the prescription. On 2/7/2018 at 3:05 PM, an interview was conducted with the Assistant Director of Nursing who stated after faxing a copy, the hard scripts should be sent to the Pharmacy and a copy should be left in the chart. On 2/7/2018 at 3:30 PM, an interview was conducted via the telephone with the Consultant Pharmacist who stated the facility had a procedure in place to handle prescriptions for narcotic. The Consultant Pharmacist (Admin F) stated the nursing staff should fax the order for narcotics, a copy of the prescription should be kept at the facility in the clinical record and the actual prescription should be sent to the Pharmacy. There was a poor telephone connection and the Pharmacist stated she was at another facility at that moment but would call the surveyor the next morning at 9 AM from a different telephone to clarify. During the end of day debriefing on 2/7/2018 at 4:15 PM, the facility Administrator, Assistant Director of Nursing (Admin B) and the corporate representative were informed of the findings. Admin B stated the professional guidance was provided by [NAME]. On 2/8/2018 at 8:55 AM, the Pharmacy Consultant (Admin F) came to the conference room to talk with the surveyor. Admin F apologized about the telephone connection on the previous day but stated she decided to come to the facility to clarify any concerns. Admin F stated the nursing staff should fax the order for narcotics, a copy of the prescription should be kept at the facility in the clinical record, a line should be drawn through the copy of the prescription and the actual prescription should be sent to the Pharmacy. Admin F stated the Pharmacy delivers to the facility twice a day. Admin F stated her supervisor, the Pharmacist in Charge, wanted to talk with the surveyor about the procedures regarding narcotics. Admin F reviewed the Resident # 397's clinical record and saw the hard script for Oxycodone. Admin F stated the prescription should have been sent to the Pharmacy by facility staff. Admin F agreed that the prescription was not secure as filed in the clinical record. On 2/8/2018 at 9:06 AM, a telephone interview was conducted with the Pharmacist in charge (Admin G) stated the facility was supposed to forward the hard copies of narcotics to the Pharmacy in a bag and that the Pharmacy delivery person comes twice a day to the facility. During the end of day debriefing on 2/8/2018, the facility Administrator, Assistant Director of Nursing and Corporate Manager were informed of the failure of the staff to ensure the implementation of a method of safekeeping of hard scripts for narcotics. The nursing staff did not forward the hard copy of the narcotic prescription to the Pharmacy and the Pharmacy did not make sure it received the hard copy of the narcotic prescription. There was the potential of diversion of controlled drugs. No further information was provided. 2. For Resident # 19, the facility staff failed to send a hard copy script dated 1/16/2017 for Oxycodone 5 milligrams to the Pharmacy. Resident # 19 was a [AGE] year old male admitted to the facility on [DATE] with the diagnoses of, but not limited to, Hypertension, Diabetes, Peripheral Vascular Disease, Dyspnea, Anxiety, Pain and Coronary Artery Disease. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 12/27/17. The MDS coded Resident # 19 with a BIMS (Brief Interview for Mental Status) of 11/15 indicating moderate cognitive impairment; Resident # 19 required extensive assistance of one staff person to two staff persons with activities of daily living except required supervision and set up only for eating; He was also coded as having an Ostomy and frequently incontinent of bowel and bladder. On 2/6/2018 at 9:30 AM, review of the clinical record was conducted. Review of the clinical record revealed a hard copy of a written prescription dated 1/16/17 for Oxycodone 5 milligrams one tablet oral every 4 hours as need for pain Dispense/supply 30 tablets with no refills. Review of the signed Physicians Order Summary dated 1/10/2018 revealed no current order for Oxycodone. On 2/7/2018 at 2:45 PM, an interview was conducted with the RN (Registered Nurse) Supervisor (RN A) who stated prescriptions for narcotics should be faxed to the Pharmacy. RN A stated a copy of the prescription should be left inside the chart, with a line drawn through the prescription. On 2/7/2018 at 3:05 PM, an interview was conducted with the Assistant Director of Nursing who stated after faxing a copy, the hard scripts should be sent to the Pharmacy and a copy should be left in the chart. On 2/7/2018 at 3:30 PM, an interview was conducted via the telephone with the Consultant Pharmacist who stated the facility had a procedure in place to handle prescriptions for narcotic. The Consultant Pharmacist (Admin F) stated the nursing staff should fax the order for narcotics, a copy of the prescription should be kept at the facility in the clinical record and the actual prescription should be sent to the Pharmacy. There was a poor telephone connection and the Pharmacist stated she was at another facility at that moment but would call the surveyor the next morning at 9 AM from a different telephone to clarify. During the end of day debriefing on 2/7/2018 at 4:15 PM, the facility Administrator, Assistant Director of Nursing (Admin B) and the corporate representative were informed of the findings. Admin B stated the professional guidance was provided by [NAME]. On 2/8/2018 at 8:55 AM, the Pharmacy Consultant (Admin F) came to the conference room to talk with the surveyor. Admin F apologized about the telephone connection on the previous day but stated she decided to come to the facility to clarify any concerns. Admin F stated the nursing staff should fax the order for narcotics, a copy of the prescription should be kept at the facility in the clinical record, a line should be drawn through the copy of the prescription and the actual prescription should be sent to the Pharmacy. Admin F stated the Pharmacy delivers to the facility twice a day. Admin F stated her supervisor, the Pharmacist in Charge, wanted to talk with the surveyor about the procedures regarding narcotics. Admin F reviewed the Resident # 19's clinical record and saw the hard script for Oxycodone. Admin F stated the prescription should have been sent to the Pharmacy by facility staff. Admin F agreed that the prescription was not secure as filed in the clinical record. On 2/8/2018 at 9:06 AM, a telephone interview was conducted with the Pharmacist in charge (Admin G) stated the facility was supposed to forward the hard copies of narcotics to the Pharmacy in a bag and that the Pharmacy delivery person comes twice a day to the facility. Per the surveyor's request, Admin B provided a copy of the pharmacy delivery summary. Review of the Pharmacy Proof of Delivery Shipment Summary revealed Oxycodone 5 milligrams tablets quantity 30 was filled on 1/16/2017. Admin B stated the nursing staff should have faxed a copy of the prescription, made a copy for the chart with a line drawn through it and forward the hard copy to the Pharmacy in the bag. During the end of day debriefing on 2/8/2018, the facility Administrator, Assistant Director of Nursing and Corporate Manager were informed of the failure of the staff to ensure the implementation of a method of safekeeping of hard scripts for narcotics. The nursing staff did not forward the hard copy of the narcotic prescription to the Pharmacy and the Pharmacy did not make sure it received the hard copy of the narcotic prescription. There was the potential of diversion of controlled drugs. There was the potential of diversion of controlled drugs. No further information was provided. 3. Resident # 398 was a [AGE] year old female admitted to the facility on [DATE] with the diagnoses of, but not limited to, Fracture of Neck of Left Femur, History of Falling, Chronic Obstructive Pulmonary Disease, Dementia, Hypothyroidism and Hyperlipidemia. The most recent Minimum Data Set (MDS) was a Significant Change Assessment with an Assessment Reference Date (ARD) of 1/7/2018. The MDS coded Resident # 398 with a BIMS (Brief Interview for Mental Status) of 10/15 indicating moderate cognitive impairment; Resident # 398 required extensive assistance of one staff person to two staff persons with activities of daily living except required supervision and set up only for eating; She was also coded as frequently incontinent of bowel and bladder. Resident # 398 was coded as requiring oxygen therapy. On 2/6/2018 at 9:30 AM, review of the clinical record was conducted. On the inside of the clinical record were plastic sleeves covering several sheets of papers. Under one plastic sleeve that included a document about Code Status, there were several hand written prescriptions. One of the prescriptions was a hard copy of a written prescription for a narcotic dated 5/24/17 for Norco 5/325 one tablet by mouth every 4 hours as needed Quantity 100. There were no marks on the prescription indicating the disposition of whether the prescription had been filled or was no longer valid. There was no indication the prescription had ever been filled. On 2/7/2018 at 2:45 PM, an interview was conducted with the RN (Registered Nurse) Supervisor (RN A) who stated prescriptions for narcotics should be faxed to the Pharmacy. RN A stated a copy of the prescription should be left inside the chart, with a line drawn through the prescription. On 2/7/2018 at 3:05 PM, an interview was conducted with the Assistant Director of Nursing who stated after faxing a copy, the hard scripts should be sent to the Pharmacy and a copy should be left in the chart. After reviewing the record, the Assistant Director of Nursing (Admin B) stated Resident # 398 was supposed to be discharged to home in May 2017 and the prescriptions were supposed to be given to her at discharge. Admin B stated the staff should have forwarded the prescription for the narcotic to the pharmacy or marked as voided if it was not to be filled. Admin B agreed that the prescription was not secure in the clinical record. On 2/8/2018 at 8:55 AM, the Pharmacy Consultant (Admin F) came to the conference room to talk with the surveyors. Admin F stated her supervisor, the Pharmacist in Charge, wanted to talk with the surveyor about the procedures regarding narcotics. Admin F reviewed the Resident # 398's clinical record and saw the hard script for Norco. Admin F stated the prescription should have been sent to the Pharmacy by facility staff. Admin F agreed that the prescription was not secure as filed in the clinical record. On 2/8/2018 at 9:06 AM, a telephone interview was conducted with the Pharmacist in charge (Admin G) stated the facility was supposed to forward the hard copies of narcotics to the Pharmacy in a bag and that the Pharmacy delivery person comes twice a day to the facility. During the end of day debriefing on 2/8/2018, the facility Administrator, Assistant Director of Nursing and Corporate Manager were informed of the failure of the staff to ensure the implementation of a method of safekeeping of hard scripts for narcotics. The nursing staff did not forward the hard copy of the narcotic prescription to the Pharmacy and the Pharmacy did not make sure it received the hard copy of the narcotic prescription. There was the potential of diversion of controlled drugs. There was the potential of diversion of controlled drugs. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Staff Interview, and Clinical Record Review, facility staff failed to ensure expired medication was not available for use, for one resident (Resident #21) out of 19 residents in the survey sample. Facility staff failed to dispose of expired Novolog Insulin and left it labeled for use in Medication Cart #3. The Findings included: On [DATE] at 10:00am an inspection of the facility Medication Carts was conducted. In Medication Cart #3, a vial of Novolog insulin prescribed for Resident #21 was found with a date of [DATE] written on the bottle. RN (Registered Nurse) C, who was assigned Medication Cart #3, was asked what the dates on the medications represented. RN C stated that the date written on the bottle was the date the medication was opened. RN C was asked how long opened insulin was to be used. RN C stated 28 days. RN C was asked about the date on the vial of insulin and responded Its old. Resident #21, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, diabetes type 2, high blood pressure, and depression. Resident #21's most recent MDS (minimum data set) with an ARD (assessment reference date) of [DATE] was coded as a significant change in status assessment. The resident was coded as having a BIMS (brief interview of mental status) of 9 out of a possible 15, or moderate cognitive impairment. Resident #21 was also coded as requiring extensive assistance of one staff member to perform activities of daily living (ADL's), but requires supervision of one staff member for eating. Resident #21 had a physician order for Novolog dated [DATE]. Review of Resident #21's MAR revealed they had most recently received a dose of 4 units of Novolog Insulin on [DATE]. The Facility Administrator and ADON were made aware of the finding at the End-of-Day meeting on [DATE].

Based on observation, staff interview, facility documentation and clinical record review, the facility Administrator failed to ensure the facility was administered in a manner to ensure the safety of residents with hot liquids. Resident #21 received second degree burns on her abdomen from spilling hot coffee on 1/28/18. Following the event, the Administrator did not ensure temperatures of hot liquids were monitored and assessments for safety with hot liquids were not conducted; residents had access to a hot coffee machine dispensing hot liquids at 177 degrees Fahrenheit. The findings included: The Administrator stated that after Resident #21 was burned on 1/28/18, the dietary staff began to monitor the temperatures of the hot beverages served. The Administrator was asked to provide the coffee temperature logs. Another surveyor and the Administrator entered the main kitchen on 2/6/18 at 7:05 p.m. to review the hot beverage temperature logs. The Administrator asked the Kitchen Manager (Employee B) for the logs. She stated that the log for the dinner meal that evening had not been returned from the floor yet. She was asked to provide the log and all of the logs since 1/28/18. Employee B stated that the dietary department did not have temperature logs from 1/28/18 because they just started taking the temperatures of hot liquids on 2/5/18 after the survey team asked about hot liquid temperatures during the initial tour of the kitchen. She was asked to provide the temperature log for the dinner meal on 2/6/18 once it was located. As of the conclusion of the survey on 2/8/18, the temperature log for the 2/6/18 dinner meal was not provided. During tour on 2/5/18 at 2:48 PM, food /temperature logs were reviewed. No hot beverage temperatures were taken. Kitchen manager stated that it was the nursing staff's responsibility to take the coffee temperatures. He said that there were currently no residents who were using special cups with two handles. He further stated that no residents had ever been burned. 2/6/18: 6:20 PM: The facility Administrator and acting DON were notified of needed information. The Administrator stated the facility had a mock survey completed and had identified there was no policy for hot liquids and had also reviewed this on their QA (quality assurance meeting) monthly meeting on 1/26/18 (prior to Resident #21's burn). On 2/6/18 at 6:45 p.m. the Administrator and Director of Therapy (Employee F) were interviewed regarding the plan put into place after Resident #21 was burned by the hot coffee. The Administrator stated that all residents were screened by therapy. The Director of Therapy stated that the residents were screened for the need of adaptive equipment during self feeding. She stated that all residents were screened to use a cup without a lid. When asked if the screening she completed was a hot liquid assessment, the Director of Therapy stated no. When asked if her screen was to assess the physical ability versus the cognitive ability of the residents to drink hot liquids, the Director of Therapy stated that her assessment was of physical ability only. They were dated 1/10/18 to 1/11/18, prior to Resident #21's burn. On 2/8/18, prior to the end of the day meeting, the Administrator and Executive Director were notified of above findings.