Based on staff interview and clinical record review, the facility staff failed to complete a discharge minimum data set (MDS) assessment for 1 of 3 closed records, Resident #30. The findings included: For Resident #30, the facility staff failed to complete a discharge MDS assessment. Resident #30's diagnoses included, but were not limited to, arthritis, Gilbert Syndrome, and cerebral infarction. Resident #30's admission MDS assessment with an assessment reference date (ARD) of 06/29/23 included a brief interview for mental status (BIMS) summary score of 13 out of a possible 15 points. Resident #30 was discharged in 07/2023. The clinical record did not include a discharge MDS assessment. On 12/21/23 at 10:45 a.m., during an interview with the MDS coordinator this staff reviewed the clinical record and stated a discharge MDS had not been completed. On 12/21/23 at 1:50 p.m., during a meeting with the Administrator, Nurse Consultant, Director of Clinical Services, and Director of Nursing the issue with the discharge MDS assessment not being completed was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to complete a level II Preadmission Screening and Resident Review (PASARR) for 1 of 15 current residents, Resident #47. The findings included: The facility staff failed to complete a level II PASARR. A PASARR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Resident #47's diagnoses included but were not limited to, schizophrenia, depression, and unspecified dementia. Section C (cognitive patterns) of Resident #47's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] included a brief interview for mental status (BIMS) summary score of 15 out of a possible 15 points. Section A (identification information) was coded to indicate a level 2 PASARR had not been completed. A review of the clinical record revealed that Resident #47 had short term approval for a level II PASARR through [DATE]. On [DATE] at 3:30 p.m., during and end of the day meeting that included the Administrator and Director of Nursing the issue with the expired PASARR was reviewed. On [DATE] at 8:00 a.m., during an interview with Social Service Employee #1. This staff stated they generally received a notice when a PASARR needed to be redone and they had not received one for this resident. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan (CCP) for 1 of 15 current resident reviews, Resident #27. The findings included: The facility staff failed to review and revise Resident #27's CCP to include smoking. Resident #27's diagnoses included, but were not limited to, shortness of breath, tobacco use, weakness, and depression. Section C (cognitive patterns) of Resident #27's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/01/23 included a brief interview for mental status (BIMS) summary score of 15 out of a possible 15 points. The clinical record included a smoking assessment completed on 10/28/23 indicating this resident used tobacco products. Resident #27 was observed outside smoking with staff supervision on 12/20/23. A review of the CCP revealed that the facility staff had not revised the care plan to include smoking. On 12/20/23 at 10:36 a.m., the MDS staff reviewed the residents clinical record with the surveyor and stated the care plan did not include the residents smoking status. On 12/20/23 at 3:30 p.m., during an end of the day meeting that included the Administrator and Director of Nursing the issue with the CCP not including Resident #27's smoking status was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, facility document review, and during a medication pass and pour observation, the facility staff failed to follow the provider orders regarding medication administration for 1 of 4 residents reviewed during the medication pass, Resident #12. The findings included: Licensed Practical Nurse (LPN) #6 administered 10 mg of Pepcid when the provider order read Pepcid 20 mg one time a day. On 12/20/23 at 8:18 a.m., the surveyor observed LPN #6 prepare and administer Resident #12's morning medications. During this administration LPN #6 was observed to administer Resident #12 Pepcid 10 mg. The clinical record included an order for Pepcid 20 mg 1 tablet by mouth one time a day. The order date was documented as 08/14/23. On 12/20/23 at 9:10 a.m., LPN #6 was interviewed regarding the Pepcid order. LPN #6 opened the medication cart and pulled a bottle of Pepcid from the top drawer. This bottle read 10 mg LPN #6 stated they had administered 10 mg of Pepcid and had always administered 10 mg. On 12/20/23 at 3:30 p.m., during an end of the day meeting that included the Administrator and Director of Nursing the issue with the Pepcid dosage was reviewed. The administrative staff provided the survey team with a copy of their policy titled, Administering Medications. This policy read in part, .Medications are administered in accordance with prescriber orders . No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and clinical record review, the facility staff failed to treat a stage II pressure ulcer as ordered by the provider for 1 of 6 residents, Resident #2. The findings included: The facility staff discontinued Resident #2's treatment orders for a stage II pressure ulcer. This resulted in the pressure ulcer not being treated for 2 days. Resident #2's diagnoses included, but were not limited to, stage II pressure ulcer, age related debility, and muscle weakness. Section C (cognitive patterns) of Resident #2's quarterly minimum data set (MDS) assessment with an assessment reference date of 11/04/22 included a brief interview for mental status (BIMS) score of 6 out of a possible 15 points. Resident #2's comprehensive care plan included the problem/need area at risk for skin breakdown dressing to left hip as ordered. The clinical record included a provider order dated 10/27/22 for a foam dressing to be applied to the left hip every day. A review of the clinical record revealed that the dressing to the left hip had been discontinued by the nursing staff. The surveyor was unable to find any documentation indicating the stage II pressure ulcer had healed. 11/14/22 at 1:42 p.m., during an observation with Licensed Practical Nurse (LPN) #1 and #2 the surveyor observed a dressing in place to the residents left hip. Upon removal of the dressing the surveyor observed a red area to the left hip with the center being yellow in appearance. LPN #2 stated the dressing was dated 11/11/22. LPN #2 reviewed the clinical record with the surveyor and stated the dressing had been discontinued in error. Indicating Resident #2's treatment was not completed on 11/12/22 and 11/13/22 per the providers orders. A telemedicine follow up evaluation was completed on 11/14/22 per the request of the medical provider. LPN #2 provided the surveyor with a copy of the WOUND CARE TELEMEDICINE FOLLOW UP EVALUATION. This document was dated 11/14/22, identified the area to Resident #2's left hip as being a stage II pressure ulcer, and included the following information Asked to reevaluate wound due to an issue with treatment orders at the facility. The wound overall still appears to be improving, with a decrease in surface area since the last visit. This document included the following measurements wound size 3.2 cm length X 1.0 cm width X 0.1 cm depth. Surface area 3.20 cm. Wound Progress improved. The clinical record included a WOUND EVALUATION & MANAGEMENT SUMMARY dated 11/11/22 that included the following wound measurements 3.2 cm length X 1.5 cm width X 0.1 cm depth. Surface Area 4.80 cm. LPN #2 transcribed the following order on 11/14/22 Tx (treatment) to left hip-Cleanse with DWC (wound cleanser), apply alginate with foam dressing Q (every) day and PRN (as needed) until resolved. The Administrator and Nurse Consultant #1 were notified of the issue regarding Resident #2's stage II pressure ulcer treatment during an end of the day meeting with the survey team on 11/14/22 at 4:20 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference on 11/15/22.

Based on observation, staff interview, and facility document review, the facility staff failed to follow established infection control procedures during a wound care observation for 1 of 17 residents, Resident #44. The findings included: The facility staff failed to complete hand hygiene after removing gloves and after cleaning a sacral wound. Resident #44's clinical record included the diagnosis, atrial fibrillation, chronic obstructive pulmonary disease, edema, and cognitive communication deficit. Section C (cognitive patterns) of Resident #44's significant change in status (MDS) minimum data set assessment with an (ARD) assessment reference date of 05/07/2021 included a (BIMS) brief interview for mental status summary score of 12 out of a possible 15 points. Section M (skin) had been coded to indicate Resident #44 had a stage 2 pressure ulcer. Resident #44's clinical record included a physician order dated 05/20/2021 to cleanse stage 2 to sacrum with dermal wound cleanser, pat dry, apply calcium ag and comfort foam to wound every day and (PRN) as needed until resolved. 06/02/2021 2:14 p.m., wound care observation with (RN) registered nurse #1. RN #1 was observed to wash their hands and apply a clean pair of gloves, remove old dressing, wash their hands, apply a clean pair of gloves, clean the wound with dermal wound cleanser, change their gloves, cut a piece of calcium ag, predate the comfort foam border gauze, put the calcium ag into the wound bed, and apply the foam dressing. 06/02/2021, the (RNC) regional nurse consultant provided the surveyor with a copy of their policy titled Handwashing/Hand Hygiene. This policy read in part, .Use an alcohol-based hand rub .or, alternatively, soap .and water for the following situations .Before handling clean or soiled dressings, gauze pads .Before moving from a contaminated body site to a clean body side during resident care .After removing gloves . 06/02/2021 3:45 p.m., RN #1 stated they did not wash their hands after cleansing the wound. 06/02/2021 4:35 p.m., the infection control issue was reviewed with the regional vice president of operations, RNC, administrator, and (DON) director of nursing during an end of the day meeting. No further information regarding this issue was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, the facility staff failed to notify the physician when medications were refused by the resident or not administered by the nurse for 2 of 18 residents (Resident #53 and Resident #25). The findings included: 1. The facility staff failed to notify the physician when Resident #53 refused insulin (Victoza) on two dates (4/5/19 and 4/9/19). Victoza was held on 4/5/19 and 4/9/19. There was no evidence the physician was informed of the insulin held on 4/5/19 and 4/9/19. Resident #53 was admitted to the facility 5/21/07 and readmitted [DATE] with diagnoses that included but not limited to type 2 diabetes mellitus with diabetic neuropathy, sepsis, multiple sclerosis, hyperlipidemia, hypertension, anemia, age related osteoporosis, chronic kidney disease, idiopathic scoliosis, paranoid schizophrenia, depressive disorder, chronic obstructive pulmonary disease, and pressure ulcer of sacrum. Resident #53's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 4/9/19 assessed the resident with a BIMS (brief interview for mental status) Summary Score as 15/15. There were no signs or symptoms of delirium or behaviors affecting others. Resident #53 did exhibit delusions. Problem for nutrition was care planned with onset date of 4/10/19. Resident #53 has significant weight loss, was at risk for hypoglycemia/hyperglycemia type 2 diabetes mellitus. Approaches: Administer meds (medications) per MD (medical doctor) orders. The April 2019 physicians orders read in part Victoza 3-pak 18 mg/3ml (milligrams/milliliter) pen Inj (inject) 1.8 mg (milligrams) subq (subcutaneously) daily DM (diabetes mellitus). The surveyor reviewed the April medication administration record (eMAR). There were Ns in the boxes for 4/1/19, 4/5/19, 4/7/19 and 4/9/19. N=not administered. The surveyor reviewed the notes at the end of the eMAR. Resident #53 had refused the insulin Victoza on 4/1/19 and 4/5/19; however the RP (responsible party) and MD had been informed. Resident #53 also refused the insulin Victoza on 4/5/19 and 4/9/19. The documentation for 4/5/19 read Inj 1.8 scheduled for 04/05/19 7:30 a.m. was held and the documentation for 4/9/19 read Inj 1.8 scheduled for 4/9/19 7:30a.m. was held. The surveyor reviewed the departmental noted for 4/5/19 timed 2:42 a.m., 8:45 a.m., 2:28 p.m., and 9:01 p.m. There was no documentation the physician was made aware the resident had refused the insulin and the surveyor was unable to locate a physician order to hold the Victoza insulin on 4/5/19 and 4/9/19. The departmental notes for 4/9/19 timed at 12:52 a.m., 9:36 a.m., 1:52 p.m., 2:30p.m., 4:38 p.m., and 11:52 p.m. did not have documentation the physician was informed that Victoza had been held. The timed note of 7:44 a.m. did document the Victoza had been held but no documentation that the physician had been informed., The surveyor informed the interim director of nursing of the above concern on 4/25/19 11:42 a.m. and requested the facility policy on notification/change of condition, diabetes mellitus, and physician's orders. The interim DON stated she would expect the nursing staff to inform the physician when medications were refused x2. The facility policy titled Change in a Resident's Condition or Status read in part 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an) e. need to alter the resident's medical treatment significantly and f. refusal of treatment or medications two (2) or more consecutive times. The facility policy titled Medication and Treatment Orders read in part 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. The surveyor informed the administrator, the interim director of nursing, the minimum data set coordinator and the corporate registered nurse of the above concern on 4/25/19 at 12:51 p.m. No further information was provided prior to the exit conference on 4/25/19. 2. The facility staff failed to inform the physician when Resident #25 refused sliding scale insulin (Novolog). The clinical record of Resident #25 was reviewed 4/23/19 through 4/25/19. Resident #25 was admitted to the facility 11/28/15 and readmitted [DATE] with diagnosis that included but not limited to type 2 diabetes mellitus, fracture of right pubis, heart failure, atrial fibrillation, edema, chronic ischemic heart disease, chronic obstructive pulmonary disease, and chronic kidney disease (stage III). Resident #25's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/18/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #25 had no signs or symptoms of delirium, psychosis, or behaviors affecting others. Resident #25's current comprehensive care plan was reviewed. The problem nutrition with onset date of 3/20/19 identified the resident to be at risk for hypo/hyperglycemia due to type 2 diabetes. Approaches: Administer meds (medications) per MD (medical doctor) order. The March 2019 physician's orders read in part Novolog 100 units/ml (milliliter) flexpen SSI (sliding scale insulin) with accuchecks AC/HS (before meals and at bedtime) 150-200=3 units 201-250=5 units 251-300=7 units 301-350=9 units 351-400=11 units, > (greater than) 400=13 units less than 60 or greater than 500 on 2 occasions 6 hours apart. The March 2019 electronic medication administration records (eMARs) were reviewed. The following date/times had N in the administration box: 3/12/19 4:30 p.m. BS was 171 3/13/19 6:00 a.m. BS was 161. 3/15/19 6:00 a.m. BS was 223 3/16/19 6:00 a.m. BS was 201 3/16/19 at 4:30 p.m. BS was not recorded-resident was not available. 3/17/19 6:00 a.m. BS was 180 3/19/19 at 4:30 p.m. BS was 219 3/19/19 at 8:30 p.m. BS was 262 3/20/19 6:00 a.m. BS was 193 3/20/19 at 4:30 p.m. BS was 231. 3/21/19 6:00 a.m. BS was 209 3/21/19 at 11:30 a.m. BS was 212. The above blood sugar results did not have evidence that the sliding scale insulin was administered. There was no documentation on the eMAR that the sliding scale insulin had been administered. The 3/12/19 4:30 p.m. insulin was refused by the resident. There was no evidence the physician had been informed. Resident #25 should have been administered 3 units of SSI. The 3/13/19 6:00 a.m. insulin was refused by the resident. There was no evidence the physician had been informed of the refusal. The 3/15/19 6:00 a.m. insulin was refused by the resident. There was no evidence the physician had been informed of the refusal. The 3/16/19 6:00 a.m. insulin was refused by the resident. There was no evidence the physician had been informed of the refusal. The 3/17/19 6:00 a.m. insulin was refused by the resident. There was no evidence the physician had been informed of the refusal. The 3/19/19 4:30 p.m. and 8:30 p.m. insulin was refused by the resident. There was no evidence the physician had been informed of the refusal. The 3/20/19 6:00 a.m. and 4:30 p.m. insulin was refused by the resident. There was no evidence the physician had been informed of the refusal. The 3/21/19 6:00 a.m. and 11:30 a.m. insulin was refused by the resident. There was no evidence the physician had been informed of the refusal. The surveyor informed the interim director of nursing of the above concern on 4/25/19 at 10:43 a.m. and requested the physician's orders for March and April 2019, March and April departmental notes, the most recent MDS and care plan and the facility policy on notification, diabetes and physician's orders. The interim DON stated she would expect the nursing staff to notify the physician when the resident refused medications or blood sugars 2 times. The surveyor reviewed the March departmental notes and found no evidence the physician had been made aware of Resident #25's refusal to take the sliding scale insulin on the above dates and times. The surveyor was unable to locate any physician's orders to hold the sliding scale insulin. The facility policy titled Change in a Resident's Condition or Status read in part 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an) e. need to alter the resident's medical treatment significantly and f. refusal of treatment or medications two (2) or more consecutive times. The facility policy titled Medication and Treatment Orders read in part 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. The surveyor informed the administrator, the interim director of nursing, the minimum data set coordinator and the corporate registered nurse of the above concern on 4/25/19 at 12:51 p.m. No further information was provided prior to the exit conference on 4/25/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to follow the physician's orders for the size of an indwelling Foley catheter balloon for 1 of 18 residents (Resident #54). The findings included: The facility staff failed to follow physician's orders for the size of the indwelling Foley catheter balloon for Resident #54. The clinical record of Resident #54 was reviewed 4/23/19 through 4/25/19. Resident #54 was admitted to the facility 6/5/15 and readmitted [DATE] with diagnoses that included but not limited to acute respiratory failure, hypomagnesemia, protein-calorie malnutrition, urine retention, hydronephrosis, bipolar disorder, major depressive disorder, hypertension, anxiety, arthritis, dorsalgia, and pneumonia. Resident #54's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/19/19 assessed the resident with a BIMS (brief interview for mental status) Summary Score as 14/15. Resident #54 was assessed with inattention, disorganized thinking but without evidence of psychosis or behaviors that affected others. Resident #54's current comprehensive care plan identified the problem of urinary incontinency. Interventions read in part 3/25/19 Clarification Foley cath (catheter) 18 Fr (French) Change every month and as needed (prn). The April 2019 physician's orders included an order dated 3/25/19 for Foley cath 18 Fr/10 cc (cubic centimeters) balloon change q (every) month and prn (as needed). The surveyor observed Resident #54 on 4/23/19 at 12:30 p.m. Resident #54 was in bed. Certified nursing assistant #1 was asked to check the resident for anchorage and size of the Foley catheter. C.N.A. #1 stated the Foley catheter was anchored. Both the surveyor and C.N.A. #1 noted the size of the catheter was 18 Fr with a 30 cc balloon-not a 10 cc balloon as ordered. The surveyor and the interim director of nursing checked the indwelling Foley catheter on 4/24/19 at 4:06 p.m. The Foley size was 18 Fr with a 30 cc balloon. The interim DON stated the balloon size was wrong and then stated, I hope I didn't put it in. The surveyor requested the April 2019 physician's orders, MDS, care plan and the facility policy on Foley catheters. The surveyor informed the administrator, the interim director of nursing, the minimum data set coordinator, and the corporate registered nurse of the above concern on 4/25/19 at 12:51 p.m. The facility policy titled Foley Catheter Insertion, Female Resident was reviewed 4/25/19. The policy read in part Preparation 1. Verify that there is a physician's order for this procedure. No further information was provided prior to the exit conference on 4/25/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, the contracted pharmacist failed to document whether or not there was any change for psychotropic medications ordered for prn (as needed) use for 14 days for 1 of 18 residents (Resident #33). The findings included: Resident #33 was readmitted to the facility on [DATE] with the following diagnose of, but not limited to high blood pressure, heart failure, urinary tract infection, diabetes, stroke, anxiety disorder, depression and psychotic disorder. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/26/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 7 out of a possible score of 15. Resident #33 was also coded as requiring extensive assistance of 2 staff members for dressing and personal hygiene and being totally dependent on 2 staff members for bathing. During the clinical record review on 4/25/19, the surveyor noted the following physician order's for Resident #33: o .Haldol 1 mg po (by mouth) q (every) 4 hours prn (as needed) anxiety. May repeat X (times) 1 hour o .Ativan 0.5 mg (milligram) SL (sublingual) q 2 hours prn anxiety may repeat X 1 in 30 minutes if patient remains anxiety . The Hospice physician gave these orders to the facility staff on 3/19/19. The contracted pharmacist performed a Medication Regimen Review on 4/8/19. There was a written in notation that stated hospice. The surveyor noted no further recommendations from the contracted pharmacist. The surveyor notified the administrative team of the above documented findings on 4/25/19 at 12:50 pm. No further information was provided to the surveyor prior to the exit conference on 4/25/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility document review, staff interview and clinical record review, the facility staff failed to ensure that 1 of 18 residents in the survey sample was free from receiving prn/as-needed psychotropic medications for longer than 14 days (Resident #33). The findings included: The facility staff failed to ensure Resident #33 was free from receiving prn/as-needed psychotropic medications for longer than 14 days. Resident #33 was readmitted to the facility on [DATE] with the following diagnose of, but not limited to high blood pressure, heart failure, urinary tract infection, diabetes, stroke, anxiety disorder, depression and psychotic disorder. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/26/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 7 out of a possible score of 15. Resident #33 was also coded as requiring extensive assistance of 2 staff members for dressing and personal hygiene and being totally dependent on 2 staff members for bathing. During the clinical record review on 4/25/19, the surveyor noted the following physician order's for Resident #33: • .Haldol 1 mg po (by mouth) q (every) 4 hours prn (as needed) anxiety. May repeat X (times) 1 hour • .Ativan 0.5 mg (milligram) SL (sublingual) q 2 hours prn anxiety may repeat X 1 in 30 minutes if patient remains anxiety . • The Hospice physician gave these orders to the facility staff on 3/19/19. The Corporate Nurse and DON (director of nursing) was notified of the above documented findings on 4/25/19 at 9:16 am. The surveyor requested and received the facility's policy titled Antipsychotic Medication Use which read in part: • .Residents will not receive PRN (as needed) doses for psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record . • The need to continue PRN orders for psychotropic medications beyond 14 days unless the healthcare practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. • PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of the medication . The surveyor notified the administrative team of the above documented findings at 12:50 pm. No further information was provided to the surveyor prior to the exit conference on 4/25/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for 1 of 18 residents (Resident #25). The findings included: The facility staff failed to ensure the clinical record of Resident #25 was accurate. The facility staff failed to document in the clinical record when the physician was notified of weight changes for Resident #25. The clinical record of Resident #25 was reviewed 4/23/19 through 4/25/19. Resident #25 was admitted to the facility 11/28/15 and readmitted [DATE] with diagnosis that included but not limited to type 2 diabetes mellitus, fracture of right pubis, heart failure, atrial fibrillation, edema, chronic ischemic heart disease, chronic obstructive pulmonary disease, and chronic kidney disease (stage III). Resident #25's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/18/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #25 had no signs or symptoms of delirium, psychosis, or behaviors affecting others. Resident #25's current comprehensive care plan was reviewed. The care plan identified nutrition with weight fluctuations as a risk and approaches were in part to monitor weights, labs, and intakes. The April 2019 physician's orders read Daily weights report weight gain of 3-5 lb. (pound) to Doctor. The surveyor reviewed the April 2019 daily weights. Resident #25 gained from 131.7 pounds on 4/11/19 to 139.7 pounds on 4/12/19-a difference of 8 pounds. The surveyor found no documentation of the weight change reported to the physician in the departmental notes for 4/12/19. There was a note dated 4/12/19 at 5:28 p.m. that the resident was seen by the nurse practitioner on that day with medication changes for anemia but for diuresis. Resident #25 gained from 130.2 pounds on 4/14/19 to 138.9 pounds on 4/15/19-a difference of 7.7 pounds. The surveyor found no documentation that the physician was made aware of the weight gain. The MD was made aware of that day's laboratory results but there was no documentation about the resident's weight gain as per the physician's orders. Resident #25 gained from 132.1 pounds on 4/18/19 to 139.8 pounds on 4/19/19 - a difference of 7.7 pounds. The 4/19/19 1:37 p.m. note stated the resident was seen on rounds and a new order to increase Lasix to 60 mg (milligrams) q am (every morning). Resident #25 gained weight from 132.1 pounds on 4/20/19 to 139.1 pounds on 4/21/19-a difference of 7 pounds. There was no documentation in the departmental notes that the physician had been informed of the weight gain. Resident #25gained from 131.9 pounds on 4/22/19 to 140.3 pounds on 4/23/19-a difference of 8.4 pounds. Resident #25 was seen by the nurse practitioner and changes to the diuretic were made. The surveyor informed the administrator, the interim director of nursing, the minimum data set coordinator and the corporate registered nurse of the above concern with failure to document/notify the physician of weight changes on 4/25/19 at 12:51 p.m. No further information was provided prior to the exit conference on 4/25/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to follow physician orders for 2 of 18 residents (Resident #54 and Resident #25). The findings included: 1. The facility staff failed to follow physician's orders for TED hose (TED is an abbreviation for thromboembolic disease) for Resident #54. The clinical record of Resident #54 was reviewed 4/23/19 through 4/25/19. Resident #54 was admitted to the facility 6/5/15 and readmitted [DATE] with diagnoses that included but not limited to acute respiratory failure, hypomagnesemia, protein-calorie malnutrition, urine retention, hydronephrosis, bipolar disorder, major depressive disorder, hypertension, anxiety, arthritis, dorsalgia, and pneumonia. Resident #54's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/19/19 assessed the resident with a BIMS (brief interview for mental status) Summary Score as 14/15. Resident #54 was assessed with inattention, disorganized thinking but without evidence of psychosis or behaviors that affected others. Resident #54's current comprehensive care plan identified ADL (activities of daily living) as a potential concern with interventions listed to include TED hose-on in am (morning), off in pm (evening). The April 2019 physician's orders included an order dated 3/26/19 for TEDs on qam (every morning) and off qpm (every evening). The surveyor observed Resident #54 on 4/24/19 at 2:21 p.m. Resident #54 was sitting in the activity area near the television doing a word search. The surveyor did not observe TED hose on the resident and the resident stated they were not on. The surveyor observed Resident #54 again at 4:22 p.m. Licensed practical nurse #1 was asked to check for the TED hose. L.P.N. #1 stated, No TED hose on. Resident #54 stated again the TED hose had not been put on. They are put on at bedtime. The surveyor informed the administrator, the interim director of nursing, the minimum data set coordinator, and the corporate registered nurse of the above concern on 4/25/19 at 12:51 p.m. No further information was provided prior to the exit conference on 4/25/19. 2. The facility staff failed to follow physician's orders for TED hose, failed to obtain orthostatic blood pressures for Resident #25, and failed to inform the physician of weight gain of 3-5 pounds. The clinical record of Resident #25 was reviewed 4/23/19 through 4/25/19. Resident #25 was admitted to the facility 11/28/15 and readmitted [DATE] with diagnosis that included but not limited to type 2 diabetes mellitus, fracture of right pubis, heart failure, atrial fibrillation, edema, chronic ischemic heart disease, chronic obstructive pulmonary disease, and chronic kidney disease (stage III). Resident #25's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/18/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #25 had no signs or symptoms of delirium, psychosis, or behaviors affecting others. Resident #25's current comprehensive care plan was reviewed. Blood pressures or TED hose were not addressed on the current care plan. Resident #25's current comprehensive care plan was reviewed. The care plan identified nutrition with weight fluctuations as a risk and approaches were in part to monitor weights, labs, and intakes. (A) Resident #25's clinical record included a telephone order dated 4/23/19 at 2:00 p.m. that read in part TEDs qam (every morning)and off qpm (every evening). The surveyor observed Resident #25 on 4/23/19 through 4/25/19. On 4/24/19 at 2:55 p.m., the surveyor observed Resident #25 sitting in a wheelchair with both feet on the ground. The surveyor did not observe TED hose on the resident. The surveyor and the interim director of nursing observed Resident #25 on 4/24/19 at 4:03 p.m. Resident #25 did not have TED hose on and stated she had not had them all day. The resident stated nobody put them on her. (B). Resident #25's April 2019 physician's orders read in part Orthostatic blood pressure to be taken daily-start date 3/11/19. A review of the April 2019 medication administration record found that the results for blood pressures obtained while the resident was lying only. The surveyor was unable to locate blood pressures for the sitting and standing positions. The vital signs summary form was reviewed for April 2019. One summary form had no type of blood pressure documented, another form had blood pressure-lying documented, and a third form had lying blood pressures and then a blood pressure of unknow type documented. The time difference on this third form between the lying BP and the second BP was an hour or greater. The surveyor informed the interim director of nursing and the corporate registered nurse on 4/25/19 at 9:07 a.m. The surveyor asked the interim DON when orthostatic blood pressures were ordered what blood pressures should be obtained. The interim DON stated lying, sitting and standing. The interim DON stated after reviewing the clinical record that the order had been placed as orthostatic blood pressure but that only the lying blood pressure had been obtained. The surveyor requested the facility guidance for obtaining orthostatic blood pressures. The MDS coordinator provided the following to the surveyor on 4/25/19 at 10:36 a.m. from the National High Blood Pressure Education Program, National Institute of Health (2003) and read Orthostatic hypotension (postural hypotension) refers to a sudden drop of 25 mm (millimeters) Hg (mercury) in systolic pressure and 10 mm Hg in diastolic pressure when the client moves from a lying to a sitting or a sitting to a standing position. Orthostatic hypotension usually occurs with aging and is a common antiadrenergic side effect of several medications such as chlorpromazine hydrochloride. When measuring orthostatic blood pressure: Place the client in a supine position for 5 minutes to allow for equilibrium of the blood pressure, and measure the pulse and blood pressure. Assist the client to a standing position, and wait 1 minute to obtain a full evaluation of the initial orthostasis, then recheck the pulse and blood pressure. Reassess the vital signs after 2 minutes to allow for an evaluation of the client's mechanisms to compensate for the presence of any orthostasis. (C). The facility staff failed to follow the physician order to notify the physician when the resident gained 3-5 pounds. The April 2019 physician's orders read Daily weights report weight gain of 3-5 lb. (pound) to Doctor. The surveyor reviewed the April 2019 daily weights. Resident #25 gained from 131.7 pounds on 4/11/19 to 139.7 pounds on 4/12/19-a difference of 8 pounds. The surveyor found no documentation of the weight change reported to the physician in the departmental notes for 4/12/19. There was a note dated 4/12/19 at 5:28 p.m. that the resident was seen by the nurse practitioner on that day with medication changes for anemia but for diuresis. Resident #25 gained from 130.2 pounds on 4/14/19 to 138.9 pounds on 4/15/19-a difference of 7.7 pounds. The surveyor found no documentation that the physician was made aware of the weight gain. The MD was made aware of that day's laboratory results but there was no documentation about the resident's weight gain as per the physician's orders. Resident #25 gained from 132.1 pounds on 4/18/19 to 139.8 pounds on 4/19/19 - a difference of 7.7 pounds. The 4/19/19 1:37 p.m. note stated the resident was seen on rounds and a new order to increase Lasix to 60 mg (milligrams) q am (every morning). Resident #25 gained weight from 132.1 pounds on 4/20/19 to 139.1 pounds on 4/21/19-a difference of 7 pounds. There was no documentation in the departmental notes that the physician had been informed of the weight gain. Resident #25gained from 131.9 pounds on 4/22/19 to 140.3 pounds on 4/23/19-a difference of 8.4 pounds. Resident #25 was seen by the nurse practitioner and changes to the diuretic were made. The surveyor informed the administrator, the interim director of nursing, the minimum data set coordinator and the corporate registered nurse of the above concern with TED hose, orthostatic blood pressures and failure to document/notify the physician of weight changes on 4/25/19 at 12:51 p.m. No further information was provided prior to the exit conference on 4/25/19.

Based on observation, facility document review and staff interview, the facility staff failed to date spices when opened and failed to discard expired spices. The findings included: The facility staff failed to date spices when opened and failed to discard spices that had expired. The surveyor toured the kitchen on 4/23/19 beginning at 10:15 a.m. with the assistant dietary manager and the dietary manager. The surveyor, the dietary manager and assistant dietary manager observed a shelf with spices. The first spice observed was 28 ounces of Lemon and Pepper spice that had no date when opened. Further observation revealed 6 ounces of Whole [NAME] that had no date when opened. The surveyor asked both dietary staff what their expectations were with dating food when opened. The assistant dietary manager stated food including spices were to be dated and labeled when opened. The surveyor observed the contents of the spice shelf and noted the following: Dill weed-5.5.ounces. No date when opened. Onion powder 20 ounces-No date when opened. Ground oregano 11 ounces. No date when opened. Hungarian Paprika 18 ounces-No date when opened. Garlic powder 20 ounces. No date when opened. Date on the container read Sent 4/16/19. Seasoning salt 38 ounces. No date when opened. Ginger 15 ounces. No date when opened. Cumin 16 ounces. Dated to be used by 2/9/16. Sage 6 ounces with a use by date of 8/4/18. Ground mustard 15 ounces with a use by date of 7/5/18. Thyme 13 ounces with use by date of 7/1/18. Chili powder 18 ounces. No date when opened. Black pepper 18 ounces. No date when opened. Many of the spices did not have a sticker on them as to when they were sent or the sticker was torn or unreadable. The surveyor requested the facility policy for dating of food from the managers on 4/23/19. The surveyor reviewed the facility policy titled Section CIII-Food Storage, Policy: Covering, Labeling, Dating Food on 4/23/19. The policy read in part under Dry Storage 1. All foods are to be dated upon receipt. The date shall reflect when the food has been received. The date upon receipt should be recorded as dd/mm/yy. (03/02/15). 2. Follow manufacturer's expiration dates or use by dates, when available to determine when a food should be discarded. 3. See attached food storage chart for expiration guidelines when the manufacturer does not have the use by date or expiration date clearly labeled on the container or packaging. The surveyor reviewed the Spices, Herbs, Condiments, Extracts chart on 4/23/19. Spices, whole good at room temperature for 1-2 years. Spices, ground at room temperature good for 6 months. The surveyor informed the administrator, the interim director of nursing, minimum data set coordinator and the corporate registered nurse of the above concern on 4/24/19 at 3:00 p.m. No further information was provided prior to the exit conference on 4/25/19.