Based on staff interview, clinical record review, and facility document review, it was determined that the facility failed to implement their abuse policy for investigating and reporting a resident to resident altercation for one of 28 residents in the survey sample, Resident #260. The findings include: For Resident #260 (R260), the facility staff failed to implement their abuse policy to investigate and report a resident to resident altercation that was reported to facility staff on 5/21/2021. On 5/21/2021, Resident #251 (R251) twisted R260's finger in their shared room. The facility policy Area of Focus: Abuse & Neglect dated 11/21/2022 documented in part, .Residents must not be subjected to abuse by anyone. This includes but is not limited to staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals .In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken . On R251's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/9/2022, the resident was assessed as being moderately impaired for making daily decisions. Section E documented R251 having physical and verbal behaviors directed towards others one to three days during the assessment period. On R260's most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 11/14/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. R260 no longer resided at the facility and could not be observed or interviewed during the survey dates. The record was reviewed as a closed record. The progress notes for R260 documented in part, - 5/21/2021 14:15 (2:15 p.m.) Resident was involved in an altercation with her roommate in which her roommate twisted her right pointer finger, the resident yelled for staff, staff attended to situation, the resident denied pain, no s/s (signs or symptoms) of injury from finger, full active ROM (range of motion), resident declined room change, resident placed on alert charting to monitor for any injury. The resident was safe prior to leaving the room. The progress notes for R251 documented in part, - 5/21/2021 14:16 (2:16 p.m.) The resident has had behaviors today, during lunch meal while in dining room the resident threw her glass cup on the floor in which broke the glass, the resident also had altercation with her roommate in which the resident twisted the roommate's finger, the resident was removed from situation to ensure safety, resident did write on white board she was sorry, resident placed on alert charting and RP (responsible party) was notified of behaviors. On 7/11/2023 at 4:10 p.m., a request was made to ASM (administrative staff member) #1, the executive director for evidence of reporting and investigation for the resident to resident altercation between R251 and R260 on 5/21/2021. On 7/12/2023 at 8:32 a.m., an interview was conducted with ASM #2, the director of nursing who stated that they did not have any evidence of reporting or investigation for the resident to resident altercation between R251 and R260 on 5/21/2021. ASM #2 presented progress notes for R251 dated 5/21/2021-5/24/2021 documenting monitoring for behaviors, and for R260 dated 5/21/2021-5/23/2021 assessing for injury to the finger. ASM #2 stated that they were unable to find documentation that the incident had been reported to administrative staff. She stated that R260 had a motherly relationship with R251 and had refused to move to another room when offered. She stated that if the nurse felt that the situation was abusive they should report it and they had never had staff not report anything to them before. ASM #2 stated that she did not recall the incident on 5/21/2021 being reported to her. On 7/12/2023 at 11:01 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that they remembered the incident they documented in the progress notes on 5/21/2021 but did not recall who reported it to them. She stated that she did not recall exactly what she did but the process was to go in and remove the resident from the situation to ensure that both residents were safe. She stated that the nurse assessed the resident for injury, notified the physician, the responsible party and the director of nursing and completed an incident report. When asked why they followed this process, she stated that it was to make sure everything was documented and to ensure follow through on the incident because they were pretty sure that it had to be reported. She stated that it would be considered a resident to resident altercation. On 7/12/2023 at 11:52 a.m., ASM #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility failed to report a resident to resident altercation to the facility administrator and the State Survey Agency, for one of 28 residents in the survey sample, Resident #260. The findings include: For Resident #260 (R260), the facility staff failed to report a resident to resident altercation on 5/21/2021. On 5/21/2021, Resident #251 (R251) twisted R260's finger in their shared room. On R251's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/9/2022, the was assessed as being moderately impaired for making daily decisions. Section E documented R251 having physical and verbal behaviors directed towards others one to three days during the assessment period. On R260's most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 11/14/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. R260 no longer resided at the facility and could not be observed or interviewed during the survey dates. The record was reviewed as a closed record. The progress notes for R260 documented in part, - 5/21/2021 14:15 (2:15 p.m.) Resident was involved in an altercation with her roommate in which her roommate twisted her right pointer finger, the resident yelled for staff, staff attended to situation, the resident denied pain, no s/s (signs or symptoms) of injury from finger, full active ROM (range of motion), resident declined room change, resident placed on alert charting to monitor for any injury. The resident was safe prior to leaving the room. The progress notes for R251 documented in part, - 5/21/2021 14:16 (2:16 p.m.) The resident has had behaviors today, during lunch meal while in dining room the resident threw her glass cup on the floor in which broke the glass, the resident also had altercation with her roommate in which the resident twisted the roommate's finger, the resident was removed from situation to ensure safety, resident did write on white board she was sorry, resident placed on alert charting and RP (responsible party) was notified of behaviors. On 7/11/2023 at 4:10 p.m., a request was made to ASM (administrative staff member) #1, the executive director for evidence of reporting and investigation for the resident to resident altercation between R251 and R260 on 5/21/2021. On 7/12/2023 at 8:32 a.m., an interview was conducted with ASM #2, the director of nursing who stated that they did not have any evidence of reporting or investigation for the resident to resident altercation between R251 and R260 on 5/21/2021. ASM #2 presented progress notes for R251 dated 5/21/2021-5/24/2021 documenting monitoring for behaviors, and for R260 dated 5/21/2021-5/23/2021 assessing for injury to the finger. ASM #2 stated that they were unable to find documentation that the incident had been reported to administrative staff. She stated that R260 had a motherly relationship with R251 and had refused to move to another room when offered. She stated that if the nurse felt that the situation was abusive they should report it and they had never had staff not report anything to them before. ASM #2 stated that she did not recall the incident on 5/21/2021 being reported to her. On 7/12/2023 at 11:01 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that they remembered the incident they documented in the progress notes on 5/21/2021 but did not recall who reported it to them. She stated that she did not recall exactly what she did but the process was to go in and remove the resident from the situation to ensure that both residents were safe. She stated that the nurse assessed the resident for injury, notified the physician, the responsible party and the director of nursing and completed an incident report. When asked why they followed this process, she stated that it was to make sure everything was documented and to ensure follow through on the incident because they were pretty sure that it had to be reported. She stated that it would be considered a resident to resident altercation. The facility policy Area of Focus: Abuse & Neglect dated 11/21/2022 documented in part, .Residents must not be subjected to abuse by anyone. This includes but is not limited to staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals .Reporting Allegations: In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken .All personnel will promptly report any incident or suspected incident of resident abuse and/or neglect, including injuries of unknown origin to their direct supervisor or Abuse Coordinator immediately . On 7/12/2023 at 11:52 a.m., ASM #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit.

Based on clinical record review, facility document review and staff interview, it was determined that the facility failed to investigate a resident to resident altercation for one of 28 residents in the survey sample, Resident #260. The findings include: For Resident #260 (R260), the facility staff failed to investigate a resident to resident altercation that was reported to facility staff on 5/21/2021. On 5/21/2021, Resident #251 (R251) twisted R260's finger in their shared room. On R251's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/9/2022, the was assessed as being moderately impaired for making daily decisions. Section E documented R251 having physical and verbal behaviors directed towards others one to three days during the assessment period. On R260's most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 11/14/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. R260 no longer resided at the facility and could not be observed or interviewed during the survey dates. The record was reviewed as a closed record. The progress notes for R260 documented in part, - 5/21/2021 14:15 (2:15 p.m.) Resident was involved in an altercation with her roommate in which her roommate twisted her right pointer finger, the resident yelled for staff, staff attended to situation, the resident denied pain, no s/s (signs or symptoms) of injury from finger, full active ROM (range of motion), resident declined room change, resident placed on alert charting to monitor for any injury. The resident was safe prior to leaving the room. The progress notes for R251 documented in part, - 5/21/2021 14:16 (2:16 p.m.) The resident has had behaviors today, during lunch meal while in dining room the resident threw her glass cup on the floor in which broke the glass, the resident also had altercation with her roommate in which the resident twisted the roommate's finger, the resident was removed from situation to ensure safety, resident did write on white board she was sorry, resident placed on alert charting and RP (responsible party) was notified of behaviors. On 7/11/2023 at 4:10 p.m., a request was made to ASM (administrative staff member) #1, the executive director for evidence of reporting and investigation for the resident to resident altercation between R251 and R260 on 5/21/2021. On 7/12/2023 at 8:32 a.m., an interview was conducted with ASM #2, the director of nursing who stated that they did not have any evidence of reporting or investigation for the resident to resident altercation between R251 and R260 on 5/21/2021. ASM #2 presented progress notes for R251 dated 5/21/2021-5/24/2021 documenting monitoring for behaviors, and for R260 dated 5/21/2021-5/23/2021 assessing for injury to the finger. ASM #2 stated that they were unable to find documentation that the incident had been reported to administrative staff. She stated that R260 had a motherly relationship with R251 and had refused to move to another room when offered. She stated that if the nurse felt that the situation was abusive they should report it and they had never had staff not report anything to them before. ASM #2 stated that she did not recall the incident on 5/21/2021 being reported to her. On 7/12/2023 at 11:01 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that they remembered the incident they documented in the progress notes on 5/21/2021 but did not recall who reported it to them. She stated that she did not recall exactly what she did but the process was to go in and remove the resident from the situation to ensure that both residents were safe. She stated that the nurse assessed the resident for injury, notified the physician, the responsible party and the director of nursing and completed an incident report. When asked why they followed this process, she stated that it was to make sure everything was documented and to ensure follow through on the incident because they were pretty sure that it had to be reported. She stated that it would be considered a resident to resident altercation. The facility policy Area of Focus: Abuse & Neglect dated 11/21/2022 documented in part, .Investigate/Prevent/Correct Alleged Violation. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Have evidence that all alleged violations are thoroughly investigated. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken .The facility does not condone resident abuse and/or neglect by anyone. This includes but is not limited to staff members, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, sponsors, friends, or other individuals. All personnel will promptly report any incident or suspected incident of resident abuse and/or neglect, including injuries of unknown origin to their direct supervisor or Abuse Coordinator immediately . On 7/12/2023 at 11:52 a.m., ASM #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit.

2. For Resident #98 (R98), the facility staff failed to monitor compliance and/or non-compliance with ordered daily fluid restrictions per the plan of care. The comprehensive care plan for R98 documented in part, At risk for weight fluctuation r/t (related to) current health status, sepsis, r (right) BKA (below the knee amputation), dyslipidema, DM II (type 2 diabetes mellitus), CKD III (chronic kidney disease stage 3), HTN (hypertension), CHF (congestive heart failure), Kidney stones, anemia, afib (atrial fibrillation), hypokalemia, Fluid restriction. Date Initiated: 06/28/2023. Revision on: 07/03/2023. Under Interventions/Tasks it documented in part, .Honor fluid restriction, encourage resident to adhere to restriction. Date Initiated: 07/03/2023. Revision on: 07/03/2023. The care plan further documented The resident has renal failure r/t ST (stage) III Kidney disease and kidney stones. Date Initiated: 07/03/2023. Revision on: 07/03/2023. Under Interventions/Tasks it documented in part, .Fluids as ordered. Restrict or give as ordered. Date Initiated: 07/03/2023 . The physician's orders for R98 documented in part, Fluid Restriction: 1500 ml (milliliter)/day From Dietary: breakfast 720ml, lunch 240ml, dinner 240ml. From Nursing: Days 150ml, Eves (evenings) 150ml, Nights 0ml every shift. Document amount consumed. Order Date: 06/28/2023. The eMAR (electronic medication administration record) for R98 dated 6/1/2023-6/30/2023 documented in part, Fluid Restriction: 1500 ml/day From Dietary: breakfast 720ml, lunch 240ml, dinner 240ml. From Nursing: Days 150ml, Eves 150ml, Nights 0ml. every shift. Document amount consumed. Order Date- 06/28/2023 1519 (3:19 p.m.). The eMAR documented R98 having 680ml on days, 680 on evening and 240 on nights on 6/29/2023 for a total of 1600ml. The eMAR for R98 dated 7/1/2023-7/31/2023 documented in part, Fluid Restriction: 1500 ml/day From Dietary: breakfast 720ml, lunch 240ml, dinner 240ml. From Nursing: Days 150ml, Eves 150ml, Nights 0ml. every shift. Document amount consumed. Order Date- 06/28/2023 1519 (3:19 p.m.). The eMAR documented the following: - on 7/1/2023, 960ml on days, 720 on evening and 0 on nights for a total of 1680ml. - on 7/2/2023, 1320ml on days, 720 on evening and 50 on nights for a total of 2090ml. - on 7/4/2023, 1320ml on days, 560 on evening and 0 on nights for a total of 1880ml. - on 7/5/2023, 960ml on days, 480 on evening and 240 on nights for a total of 1680ml. - on 7/7/2023, 960ml on days, 820 on evening and 180 on nights for a total of 1960ml. - on 7/10/2023, 960ml on days, 600 on evening and 240 on nights for a total of 1800ml. The clinical record failed to evidence documentation of resident non-compliance with the fluid restrictions or physician notification of the resident's non-compliance with the fluid restrictions. On 07/11/2023 at approximately 1:10 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the purpose of a resident's care plan was to address any issues the resident may be having, for discharge purposes and for total care. She stated that the care plan was not being implemented if a treatment or a procedure documented on the care plan was not provided. On 7/11/2023 at 3:51 p.m., an interview was conducted with RN (registered nurse) #2, unit manager. RN #2 stated that fluid restrictions were monitored by the physician's order. She stated that the order advised the staff what amount of fluids were allowed by dietary and by nursing and they documented the total amount of fluids taken in each shift on the eMAR. She stated that R98 was on fluid restrictions and was allowed 1500ml/day between dietary and nursing. She reviewed R98's eMAR for July 2023 with daily amounts totaling over 1500ml's and stated that there should be skilled notes documenting non-compliance if the resident was taking in more than the allotted amount and the physician or nurse practitioner should be notified. On 7/11/2023 at approximately 4:07 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to implement the comprehensive care plan for two of 28 residents in the survey sample, Resident #4 and Resident #98. The findings include: 1. For Resident #4 (R4), the facility staff failed to implement the comprehensive care plan for the administration of physician ordered oxygen. R4 was admitted to the facility with diagnoses that included but were not limited to respiratory failure (1). R4's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 05/10/2023, coded R4 as scoring a 9 out of 15 on the brief interview for mental status (BIMS) which indicated the resident was moderately impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded R4 as receiving oxygen. On 07/10/2023 at approximately 2:43 p.m., R4 was observed lying in bed receiving oxygen by nasal cannula. The flow meter on the oxygen concentrator was set at four liters per minute. The physician's order for R4 dated 01/17/2023 documented, Oxygen at 2 liters per minute PRN (as needed) per nasal cannula. The comprehensive care plan for R4 dated 02/28/2023 documented in part, Focus. The resident has altered respiratory status/difficulty breathing r/t (related to) sleep apnea. Date Initiated: 02/28/2023. Under Interventions / Tasks it documented in part, Administer medication/puffers as ordered. Date Initiated: 02/28/2023. On 07/11/23 at approximately 1:10 p.m., an interview was conducted with LPN (licensed practical nurse) #1. When asked what the prescribed oxygen flow rate was for R4, she reviewed the electronic order and stated that the physician's order was for two liters per minute. When informed of the above observation LPN #1 stated that it was incorrect. When asked to describe the purpose of a resident's care plan, LPN #1 stated that it was to address any issues the resident may be having, for discharge purposes and for total care. After being informed of the above observation LPN #1 was asked if the care plan was being implemented for the administration of (R4's) oxygen; LPN #1 stated no. On 07/11/2023 at approximately 4:00 p.m., ASM (administrative staff member) #1, executive director, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html.

Based on clinical record review, staff interview, and facility document review it was determined that the facility staff failed to implement interventions to monitor compliance with ordered fluid restrictions for one of 28 residents, Resident #98. The findings include: For Resident #98 (R98), the facility staff failed to monitor compliance and/or non-compliance with ordered daily fluid restrictions. R98 was admitted to the facility with diagnoses that included but were not limited to chronic kidney disease, stage 3 (1) and congestive heart failure (2). The physician's orders for R98 documented in part, Fluid Restriction: 1500 ml (milliliter)/day From Dietary: breakfast 720ml, lunch 240ml, dinner 240ml. From Nursing: Days 150ml, Eves (evenings) 150ml, Nights 0ml every shift. Document amount consumed. Order Date: 06/28/2023. The eMAR (electronic medication administration record) for R98 dated 6/1/2023-6/30/2023 documented in part, Fluid Restriction: 1500 ml/day From Dietary: breakfast 720ml, lunch 240ml, dinner 240ml. From Nursing: Days 150ml, Eves 150ml, Nights 0ml. every shift. Document amount consumed. Order Date- 06/28/2023 1519 (3:19 p.m.). The eMAR documented R98 having 680ml on days, 680 on evening and 240 on nights on 6/29/2023 for a total of 1600ml. The eMAR for R98 dated 7/1/2023-7/31/2023 documented in part, Fluid Restriction: 1500 ml/day From Dietary: breakfast 720ml, lunch 240ml, dinner 240ml. From Nursing: Days 150ml, Eves 150ml, Nights 0ml. every shift. Document amount consumed. Order Date- 06/28/2023 1519 (3:19 p.m.). The eMAR documented the following: - on 7/1/2023, 960ml on days, 720 on evening and 0 on nights for a total of 1680ml. - on 7/2/2023, 1320ml on days, 720 on evening and 50 on nights for a total of 2090ml. - on 7/4/2023, 1320ml on days, 560 on evening and 0 on nights for a total of 1880ml. - on 7/5/2023, 960ml on days, 480 on evening and 240 on nights for a total of 1680ml. - on 7/7/2023, 960ml on days, 820 on evening and 180 on nights for a total of 1960ml. - on 7/10/2023, 960ml on days, 600 on evening and 240 on nights for a total of 1800ml. The clinical record failed to evidence documentation of resident non-compliance with the fluid restrictions or notification of the physician of resident non-compliance with fluid restrictions. The comprehensive care plan for R98 documented in part,The resident has renal failure r/t (related to) ST (stage) III Kidney disease and kidney stones. Date Initiated: 07/03/2023. Revision on: 07/03/2023. Under Interventions/Tasks it documented in part, .Fluids as ordered. Restrict or give as ordered. Date Initiated: 07/03/2023 . On 7/11/2023 at 3:51 p.m., an interview was conducted with RN (registered nurse) #2, unit manager. RN #2 stated that fluid restrictions were monitored by the physician's order. She stated that the order advised the staff what amount of fluids were allowed by dietary and by nursing and they documented the total amount of fluids taken in each shift on the eMAR. She stated that R98 was on fluid restrictions and was allowed 1500ml/day between dietary and nursing. She reviewed R98's eMAR for July 2023 with daily amounts totaling over 1500ml's and stated that there should be skilled notes documenting non-compliance if the resident was taking in more than the allotted amount and the physician or nurse practitioner should be notified. The facility provided policy Fluid-Restriction Diet dated 4/24/2023 documented in part, .Indication: A fluid restriction diet is indicated in individuals with congestive heart failure, hypertension, fluid retention, pulmonary edema, hyponatremia, and renal failure . On 7/11/2023 at approximately 4:07 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: (1) chronic kidney disease Kidneys are damaged and can't filter blood as they should. This information was obtained from the website: https://medlineplus.gov/chronickidneydisease.html. (2) congestive heart failure A condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. This information was obtained from the website: https://medlineplus.gov/heartfailure.html

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care and services per physician's order for one of 28 residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff failed to maintain R4'S oxygen flow rate at two liters per minute according to the physician's orders. R4 was admitted to the facility with diagnoses that included but were not limited to respiratory failure (1). R4's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 05/10/2023, coded R4 as scoring a 9 out of 15 on the brief interview for mental status (BIMS) which indicated the resident was moderately impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded R4 as receiving oxygen. On 07/10/2023 at approximately 2:43 p.m., R4 was observed lying in bed receiving oxygen by nasal cannula. The flow meter on the oxygen concentrator was set at a flow rate of four liters per minute. The physician's order for R4 dated 01/17/2023 documented, Oxygen at 2 liters per minute PRN (as needed) per nasal cannula. The comprehensive care plan for R4 dated 02/28/2023 documented in part, Focus. The resident has altered respiratory status/difficulty breathing r/t (related to) sleep apnea. Date Initiated: 02/28/2023. Under Interventions / Tasks it documented in part, Administer medication/puffers as ordered. Date Initiated: 02/28/2023. On 07/11/23 at approximately 1:10 p.m., an interview was conducted with LPN (licensed practical nurse) #1. When asked if she was familiar with R4 she stated yes. When asked what the prescribed oxygen flow rate was ordered for R4 LPN #1 reviewed the electronic order and stated that the physician's order was for two liters per minute. When informed of the above observation LPN #1 stated that it was incorrect. On 07/11/2023 at approximately 4:00 p.m., ASM (administrative staff member) #1, executive director, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html.

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence documentation of current bed/side rail inspections for three of 28 residents in the survey sample, Residents #17, #64 and #4. The findings include: 1. Resident #17 (R17) was observed lying in bed with the right and left upper bed rails raised on 07/10/2023 at 2:35 p.m. R17 was admitted to the facility with diagnosis that included but was not limited to: a history of falls. Review of the facility's bed inspections dated 2022 failed to evidence a bed inspection for R17. On 7/11/2023 at 3:11 p.m., an interview was conducted with OSM (other staff member) #2 maintenance director. When asked about the 2022 bed inspection for R17, he stated that he was unable to locate documentation that a bed inspection was completed. The facility's policy Bed Inspection & Maintenance and Bed Rail Inspection documented in part, Procedure. 5. Quarterly inspections of the Seven Zones of Entrapment are required for all beds and when there are any changes to the bedframe, mattresses or side rails. On 07/11/2023 at approximately 4:00 p.m., ASM (administrative staff member) #1, executive director, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. 2. Resident #64 (R64) was observed lying in bed with the right and left upper bed rails raised on 07/10/2023 at 2:37 p.m. R64 was admitted to the facility with diagnosis that included but was not limited to: a history of falls. Review of the facility's bed inspections dated 2022 failed to evidence a bed inspection for R64. On 7/11/2023 at 3:11 p.m., an interview was conducted with OSM (other staff member) #2 maintenance director. When asked about the 2022 bed inspection for R64, he stated that he was unable to locate documentation that a bed inspection was completed. On 07/11/2023 at approximately 4:00 p.m., ASM (administrative staff member) #1, executive director, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. 3. Resident #4 (R4) was observed lying in bed with the right and left upper bed rails raised on 07/10/2023 at 2:42 p.m. Review of the facility's bed inspections dated 2022 failed to evidence a bed inspection for R4. On 7/11/2023 at 3:11 p.m., an interview was conducted with OSM (other staff member) #2 maintenance director. When asked about the 2022 bed inspection for R4, he stated that he was unable to locate documentation that a bed inspection was completed. On 07/11/2023 at approximately 4:00 p.m., ASM (administrative staff member) #1, executive director, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review it was determined facility staff failed to store food in a sanitary manner in one of one facility kitchens. The findings include: On 07/10/2023 at approximately 10:15 a.m., an observation of the facility's kitchen was conducted with OSM (other staff member) #1, assistant dietary manager. The following concerns were identified: 1. The facility staff failed to discard food that was available for use, found in the walk-in refrigerator located in the facility kitchen. On 07/10/2023 at approximately 10:20 a.m., an observation of the inside of the facility's walk-in refrigerator revealed the following. a. A food container on a shelf with approximately two cups of shredded jack cheese dated 06/20/2023. b. A food container on a shelf with approximately two quarts of cheddar cheese dated 07/03/2023. c. A food container on a shelf with approximately two quarts of ham salad dated 07/06/2023. On 07/10/2023 at approximately 11:00 a.m., an interview was conducted with OSM #1. When asked about the dates on the food containers stated above OSM #1 stated that the date indicated when the food was placed in the container and after three days from the date, the food should be discarded. He further stated that the above food items should have been discarded. When asked to describe the procedure they follow to prevent expired food from being used OSM #1 stated that the kitchen staff, including himself should be checking the dates daily. He further stated it was an oversight. The facility's policy Food Safety documented in part, Cold Food Storage. 10. Leftovers are dated properly and discarded after 72 hours unless otherwise indicated. 2. The facility staff failed to cover food that was prepared and available for use, found in the walk-in refrigerator located in the facility kitchen. On 07/10/2023 at approximately 10:20 a.m., an observation of the inside of the facility's walk-in refrigerator revealed 2 - three-shelf carts. One cart contained three trays of approximately 96 plated sliced cake for the residents, uncovered, and the other cart contained two trays of approximately 18, four-ounce cups of beverages for the residents, uncovered. On 07/10/2023 at approximately 11:00 a.m., an interview was conducted with OSM #1. When asked about the food items listed above, he stated that the dessert plates and beverages should have been covered to prevent contamination. 3. The facility staff failed to cover beverages that were prepared and available for use, found in the reach-in refrigerator located in the facility kitchen. On 07/10/2023 at approximately 10:30 a.m., an observation of the inside of the facility's reach-in refrigerator revealed 3 two-quart pitchers containing beverages for the residents, uncovered. When asked about the beverage items listed above, he stated that the beverages should have been covered to prevent contamination. On 07/11/2023 at approximately 4:00 p.m., ASM (administrative staff member) #1, executive director, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to assess 1 of 35 residents in the survey sample for safe self administration of medications, Resident #31. Resident #31 was observed with prescribed medications unsecured and unsupervised by staff in their room. The findings include: Resident #31 was admitted to the facility with diagnoses that include but were not limited to Parkinson's disease (1), dysphagia (2) and atrial fibrillation (3). Resident #31's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 11/12/2021 coded Resident #31 as scoring a 15 on the BIMS (brief interview for mental status) assessment, 15- being cognitively intact for making daily decisions. Resident #31 was observed on 1/4/2022 at approximately 3:13 p.m. Resident #31 was out of bed sitting in a motorized wheelchair. The overbed table was in front of Resident #31 with a medication cup containing two visible medication tablets, and a second medication cup containing applesauce. At that time an interview was conducted with Resident #31. Resident #31 stated that the nurse had left the medications for her earlier to take after eating. Resident #31 stated that she had recently visited the neurologist who had advised her to wait at least 30 minutes after eating any protein to take her medication for Parkinson's disease and proceeded to take the medications on the bed side table with the applesauce. The eMAR (electronic medication administration record) dated 1/1/2022-1/31/2022 for Resident #31 documented medications most recently administered to Resident #31 at 1:00 p.m. on 1/4/2022. The comprehensive care plan for Resident #31 failed to evidence documentation of self-administration of medications. Review of Resident #31's clinical record failed to evidence an assessment for self-administration of medications or a physician's order for medications to be safely left at Resident #31's bedside for her to take unsupervised. On 1/5/2022 at approximately 1:20 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated that Resident #31 had an order in place to give her medications as a bolus with applesauce but the medications were not supposed to be left unattended at the bedside. RN #2 stated that they were not aware that Resident #31 wished to take the medications 30 minutes after proteins until 1/4/2022. RN #2 stated that they should have brought the medication for Parkinson's back to Resident #31 after she had finished eating rather than leave them in the room. RN #2 stated that they completed self-administration of medication assessments on residents who could demonstrate taking their medications independently and normally did these on residents with inhalers or anyone who was leaving the facility with a medication. RN #2 stated that they did not have an assessment completed for Resident #31. On 1/5/2022 at approximately 4:00 p.m., a request was made for the facility policies on medication administration, medication storage and self administration of medication by residents. The facility policy, General Dose Preparation and Medication Administration dated 12/1/07 documented in part, .Facility staff should not leave medications or chemical unattended . The facility policy, Self Administration of Medications dated 11/28/16 documented in part, .2. Facility, in conjunction with the Interdisciplinary Care Team, should assess and determine, with respect to each resident, whether Self-Administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition .11. Facility should document the Self-Administration of medications in the resident's care plan. 12. Facility should document the self-storage of medications in the resident's care plan. The facility policy, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles dated 12/1/07 documented in part, .Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration . On 1/5/2022 at approximately 4:30 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were made aware of the above concern. No further information was provided prior to exit. References: 1. Parkinson's disease A type of movement disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/parkinsonsdisease.html. 2. dysphagia A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. 3. atrial fibrillation A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: <https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, the facility staff failed to evidence that the physician wrote a note, and comprehensive care plan goals were provided to the receiving facility upon a hospital transfer, for 1 of 35 residents in the survey sample, Resident #39. The findings include: Resident #39 was admitted to the facility on [DATE], hospitalized on [DATE] and readmitted on [DATE]. Resident #39 had the diagnoses of but not limited to high blood pressure, congestive heart failure, and stroke. The most recent MDS (Minimum Data Set) was 5-day readmission assessment with an ARD (Assessment Reference Date) of 11/17/21. The resident was coded as being severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring extensive assistance for all areas of activities of daily living except for eating, which required limited assistance. A review of the clinical record revealed the following nurse's notes: 11/7/21 at 2:47 AM: resident continues with confusion and lethargy this shift. resident had increased confusion, alert but not oriented to person, place, time and situation. resident repeating I dont (sic) know. resident's pupils reactive bilaterally, unable to follow simple commands like gripping fingers. resident states no to c/o (complaints of) pain. bil (bilateral) lung sounds clear, no respiratory distress noted. resident's BS (blood sugar): 201, Temp elevated at 101.6, room was very warm d/t (due to) roommate increasing temp (temperature) of room. resident given tylenol (1) per md (medical doctor) order, covid tested per facility protocol with negative results. resident's temp decreased to 99.5. resident now alert and oriented to person, able to answer simple questions appropriately, and follow commands. resident is resting quietly in bed with eyes closed with no pain or discomfort noted. 11/7/21 at 12:39 PM: Daughter (name) expressed concern about her dads confusion. This nurse called on call provider who ordered UA C&S (2 - urinalysis with culture and sensitivity) , CBC (3 - complete blood count), CMP (4 - complete metabolic panel), CXR (chest x-ray) and 1 gram of Rocephin (5) IM x 1 (intramuscularly for one dose). Daughter (name) informed about new orders. No concerns at this time. 11/7/21 at 2:56 PM: Resident was covid and flu tested during shift and was negative. MD/NP (nurse practitioner) aware, RP (responsible party) and resident aware of results. 11/7/21 at 7:01 PM: Resident is very lethargic and is unable to arouse at this time. Resident not eating or drinking d/t not being awake. UA in house done and looks positive. IM Rocephin administered @ (at) 1750 (5:50 PM) in right buttocks. Per Daughter requests, sending out to ER (emergency room) (name of hospital) for evaluation. 11/7/21 at 8:38 PM: RP-Daughter, (name), was in facility visiting resident when it was decided to send resident out to ER. RP aware are requested resident to be sent out @ 1930. On Call Dr (doctor) (name) aware of resident being sent out. 11/8/21 at 12:47 AM: resident admitted to (name of hospital) for urosepsis. The above notes did not evidence what documentation was provided to the receiving hospital. There was no note located in the clinical record from the physician regarding this hospitalization. Further review of the clinical record revealed the Nursing Home to Hospital Transfer Form. This form documented resident demographics information, contact person, primary care physician, code status, clinical information, allergies, precautions, alerts, devices, treatments, etc. However, it did not document that the comprehensive care plan goals were provided to the hospital. In addition, there was no evidence the physician wrote a note regarding this hospitalization. On 1/6/22 at 10:00 AM, an interview was conducted with LPN #5 (Licensed Practical Nurse). She stated that a check list is completed when residents are transferred and that a copy of the checklist is kept in the clinical record. She stated that upon a transfer, the facesheet, medication list, care plan, nurses notes, transfer form, and pertinent labs are sent to the hospital and that the physician should write a note. LPN #5 was asked for a copy of this checklist. On 1/6/22 at 10:17 AM, in a follow up interview with LPN #5, she provided the checklist. A review of this checklist revealed that comprehensive care plan goals were listed. However, when asked if a copy of a completed checklist was in the clinical record for Resident #39 regarding the hospital transfer of 11/7/21, she stated that it was not. When asked if the physician wrote a note, she stated that he had not. A review of the facility policy, Transfers and Discharges documented, The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by- (A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident. (B) Resident representative information including contact information (C) Advance Directive information (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals; (F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. On 1/5/22 at the end of day meeting at approximately 4:30 PM, ASM #1 and ASM #2 (Administrative Staff Member), the Executive Director and Director of Nursing, respectively, were made aware of the findings. No further information was provided by the end of the survey. References: (1) Tylenol: is used to relieve mild to moderate pain. Information obtained from https://medlineplus.gov/druginfo/meds/a681004.html (2) Urinalysis and Culture and Sensitivity: Urinalysis is the examination of urine for certain physical properties, solutes, cells, casts, crystals, organisms, or particulate matter. Because urinalysis is easy, cheap, and productive, it is recommended as part of the initial examination of all patients and should be repeated as clinically warranted. A urine culture is a lab test to check for bacteria or other germs in a urine sample. Sensitivity analysis determines the effectiveness of antibiotics against microorganisms (germs) such as bacteria that have been isolated from cultures. Information obtained from https://www.ncbi.nlm.nih.gov/books/NBK302/ Information obtained from https://medlineplus.gov/ency/article/003751.htm Information obtained from https://medlineplus.gov/ency/article/003741.htm (3) CBC: The CBC can help detect blood diseases and disorders, such as anemia, infections, clotting problems, blood cancers, and immune system disorders. This test measures many different parts of your blood. Information obtained from https://www.nhlbi.nih.gov/health-topics/blood-tests (4) CMP: A comprehensive metabolic panel is a group of blood tests. They provide an overall picture of your body's chemical balance and metabolism. Metabolism refers to all the physical and chemical processes in the body that use energy. Information obtained from https://medlineplus.gov/ency/article/003468.htm (5) Rocephin: is used to treat certain infections Information obtained from https://medlineplus.gov/druginfo/meds/a685032.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview, and facility document review, the facility staff failed to develop a care plan for side rail use for 1 of 35 residents in the survey sample; Resident #50. The findings include: Resident #50 was admitted to the facility on [DATE] with the diagnoses of but not limited to dementia, depression, osteoporosis, and COVID-19. The most recent MDS (Minimum Data Set) was a significant change assessment with an ARD (Assessment Reference Date) of 11/23/21. The resident was coded as being severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing and extensive assistance for all other areas of activities of daily living. On 1/4/22 at 3:35 PM, Resident #50 was observed in bed asleep, with the head of the bed elevated, and the half length side rails up bilaterally. A review of the clinical record revealed an Evaluation For Use of Bed Rails form dated 2/1/21 that documented, Bed rail(s) are recommended at all times when resident is in bed. A review of the comprehensive care plan failed to reveal any evidence that it was reviewed and revised to include the use of side rails. On 1/6/22 at 10:00 AM, an interview was conducted with LPN #5 (Licensed Practical Nurse). She stated that the purpose of the care plan was to set goals for the resident and to guide care for the resident. She stated that any nurse can update the care plan. When asked if side rails should be care planned, she stated that they should be. A review of the facility policy Care Planning - Baseline, Comprehensive, and Routine Updates documented, The comprehensive Care Plan must be updated with each MDS assessment and periodically. It was noted in the electronic clinical record that the resident had 4 MDS's completed between the date of the side rail evaluation of 2/1/21 and the observation on 1/4/22. On 1/5/22 at the end of day meeting at approximately 4:30 PM, ASM #1 and ASM #2 (Administrative Staff Member), the Executive Director and Director of Nursing, respectively, were made aware of the findings. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow a physician's order to administer a medication for one of 35 residents in the survey sample, Resident #35. The facility staff failed to follow a physician's order to limit a resident's Tylenol dosage to 3000 mgs (millligrams) in a 24 hour period on 10/27/21, 10/29/21, 10/31/21, 11/1/21, 11/9/21, and 12/5/21. The findings include: Resident #35 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including arthritis, diabetes, bilateral below the knee amputations, and peripheral vascular disease. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/15/21, the resident was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). A review of Resident #35's clinical record revealed the following order, dated 7/16/21: Tylenol 8 Hour Arthritis Pain Tablet Extended Release 650 mg (milligrams) Give 2 tablets by mouth every 6 hours as needed for pain. DO NOT EXCEED 3 GMS (grams/1000 mgs) in 24 hours. A review of Resident #15's MARs (medication administration records) for October, November, and December 2021 revealed that on the following dates, Resident #35 received three doses of this medication in 24 hours, totaling 3900 milligrams (3.9 grams): 10/27/21, 10/29/21, 10/31/21, 11/1/21, 11/9/21, and 12/5/21. A review of Resident #35's comprehensive care plan dated 10/11/19 and updated 3/3/20 revealed, in part: Resident is at risk for pain/discomfort .Pain meds (medications) as ordered. On 1/5/22 at 1:21 p.m., LPN (licensed practical nurse) #1 was interviewed. When asked to review Resident #35's orders and the MARs referenced above, she stated: It looks like he sometimes got more [Tylenol] than he should. When asked if the physician's order was being followed, she stated: No. She stated when she administers an as-needed medication, she looks back to determine the last time it was administered. She stated the order is clear; the resident is able to get two doses six hours apart in 24 hours; but should not receive any more than that. She stated the nurse is responsible for doing the math and ensuring the resident does not get too much medicine. She stated too much Tylenol can put the resident's liver function at risk. On 1/05/22 4:29 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were notified of these concerns. A review of the facility policy, General Dose Preparation and Medication Administration, revealed, in part: Prior to administration of medication, facility staff should .verify .that it is the correct medication, at the correct dose, at the correct route, at the correct time . A review of the facility policy, Physician Orders, revealed no information related to the responsibility of the facility staff to follow the physician's orders. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility failed to store respiratory treatment equipment in a sanitary manner for one of 35 residents in the survey sample, Resident #90. On two separate occasions, Resident #90's CPAP (continuous positive airway pressure) (1) mask was observed uncovered, and lying in contact with his pillows. The findings include: Resident #90 was admitted to the facility on 9//24/18 with diagnoses including a traumatic brain injury, a stroke, and diabetes. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/27/21, the resident was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). On 1/4/22 at 2:56 p.m. and 1/5/22 at 10:22 a.m. Resident #90's CPAP mask was observed uncovered, and in direct contact with his bed pillows. Resident #90 was sitting up in the wheelchair in his room. He stated the staff always cleans the CPAP mask and places it on his pillow, uncovered. A review of Resident #90's physician's orders revealed the following order, dated 4/9/20: CPAP/BIPAP: Pressure setting 13-16. Full face mask .on while sleeping/napping and off while awake .Clean CPAP mask with warm soapy water, rinse and air dry as needed daily. A review of Resident #90's MARs (medication administration records) for October, November, and December 2021 and for January 2022 revealed Resident #90 wore his CPAP as ordered, and that the mask was cleaned daily. A review of Resident #90's comprehensive care plan dated 7/15/19 and updated 3/30/20 revealed, in part: The resident has altered respiratory status/difficulty breathing related to sleep apnea .Clean CPAP per protocol .Store CPAP per protocol. On 1/5/22 at 1:19 p.m., CNA (certified nursing assistant) #1 was interviewed. When asked how a CPAP mask should be stored when not in use, she stated it should be stored in a plastic bag, and preferably placed inside a drawer. When asked why the mask should be stored this way, she stated: We don't want to have germs on it. She added the mask goes on the resident's face, and it needs to be clean to prevent infection. On 1/5/22 at 1:21 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the facility has specific bags for storage of all respiratory equipment in resident rooms. She stated it after the mask is washed, it should be air dried, and then placed in the bag. She stated CPAP mask storage is all about infection control. On 1/05/22 4:29 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were notified of these concerns. A review of the facility policy, CPAP Administration Policy, failed to reveal an information related to sanitary storage of the CPAP mask when not in use by the resident. No further information was provided prior to exit. (1) CPAP (Continuous Positive Airway Pressure) is a treatment that uses mild air pressure to keep your breathing airways open .It involves using a CPAP machine that includes a mask or other device that fits over your nose or your nose and mouth, straps to position the mask, a tube that connects the mask to the machine's motor, and a motor that blows air into the tube. CPAP is used to treat sleep-related breathing disorders including sleep apnea. This information is taken from the website https://www.nhlbi.nih.gov/health-topics/cpap.

**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 prevent a resident from receiving unnecessary pain medication for one of 35 residents in the survey sample, Resident #35. The facility staff failed to follow a physician's order to limit a resident's Tylenol dosage to 3000 mgs in a 24 hour period on 10/27/21, 10/29/21, 10/31/21, 11/1/21, 11/9/21, and 12/5/21. The findings include: Resident #35 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including arthritis, diabetes, bilateral below the knee amputations, and peripheral vascular disease. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/15/21, the resident was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). A review of Resident #35's clinical record revealed the following order, dated 7/16/21: Tylenol 8 Hour Arthritis Pain Tablet Extended Release 650 mg (milligrams) Give 2 tablets by mouth every 6 hours as needed for pain. DO NOT EXCEED 3 GMS (grams/1000 mgs) in 24 hours. A review of Resident #15's MARs (medication administration records) for October, November, and December 2021 revealed that on the following dates, Resident #35 received three doses of this medication in 24 hours, totaling 3900 milligrams (3.9 grams): 10/27/21, 10/29/21, 10/31/21, 11/1/21, 11/9/21, and 12/5/21. A review of Resident #35's comprehensive care plan dated 10/11/19 and updated 3/3/20 revealed, in part: Resident is at risk for pain/discomfort .Pain meds (medications) as ordered. On 1/5/22 at 1:21 p.m., LPN (licensed practical nurse) #1 was interviewed. When asked to review Resident #35's orders and the MARs referenced above, she stated: It looks like he sometimes got more [Tylenol] than he should. When asked if the physician's order was being followed, she stated: No. She stated when she administers an as-needed medication, she looks back to determine the last time it was administered. She stated the order is clear; the resident is able to get two doses six hours apart in 24 hours; but should not receive any more than that. She stated the nurse is responsible for doing the math and ensuring the resident does not get too much medicine. On 1/05/22 4:29 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were notified of these concerns. A review of the facility policy, General Dose Preparation and Medication Administration, revealed, in part: Prior to administration of medication, facility staff should .verify .that it is the correct medication, at the correct dose, at the correct route, at the correct time . No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to treat one out of 47 residents in the survey sample, Resident #12, with dignity and respect. The findings include: Resident #12 was admitted to the facility on [DATE]. Diagnoses include but not limited to, high blood pressure, heart disease, edema, atrial fibrillation, congestive heart failure, and diabetes. The annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/11/19 coded the resident as being severely impaired in ability to make daily life decisions, scoring a 3 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. The resident was coded as requiring total care for bathing; extensive assistance for transfers, dressing, toileting and hygiene; and was coded as independent for eating. A nurse's notes dated 10/12/19 at 3:46 AM that documented, Resident came out of activities this evening and was sitting in her doorway moaning and pointing to her legs. she (sic) was told to stop her moaning if she was not going to be compliant with taking her medications and getting into bed to elevate her legs Resident has refused to go to bed tonight. She has been sleeping in WC (wheel chair) with legs down. On 10/23/19 at 3:02 PM, an interview was conducted with RN (registered nurse) #1, who wrote the note. RN #1 stated, Other residents complain about her moaning. She [Resident #12] wants you to fix her legs but doesn't want to take her meds (medications) for the edema or elevate them. She [Resident # 12] doesn't want to be compliant but she wants you to fix it. She [Resident #12] is alert and oriented [Resident has a BIMS of 3]. When asked if it is appropriate to tell a resident to stop your moaning if you are not going to be compliant, RN #1 stated, I don't know, I guess not. It wasn't meant to be disrespectful. My main goal with her moaning was not to keep other residents awake. When asked is that how was how it was documented and reflected in the note, RN #1 stated, It is not relayed in any way in the note. It probably wasn't worded appropriately. It wasn't meant as disrespectful. This was probably written after about 3 hours of trying to get her into bed. I just ran out of ideas on how to persuade her to help herself. On 10/23/19 at 4:16 PM, in an interview with RN #2, when asked how would it make her feel to be told to stop moaning if you are going to be non-compliant, RN #2 stated, I would feel like my needs are not being met, my needs are being over looked. That is kind of like stop you're whining. I think that is a dignity thing. The comprehensive care plan dated 7/30/19, documented, The resident has impaired cognition the interventions, dated 7/30/19, documented, Allow for extra time for resident to respond to questions and instructions, Ask yes or no questions in order to determine the resident's needs, Cue, reorient and supervise as needed, Face and speak clearly when communicating with resident A review of the facility policy, Dignity documented, Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as, honor and value their input. On 10/24/19 at 12:16 AM, ASM #1 (Administrative Staff Member) the Executive Director, and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, it was determined that the facility staff failed maintain a comfortable and homelike environment for one of 47 residents in the survey sample, Resident # 85. The facility staff failed to maintain Resident # 85's over-the-bed-table was in good repair. The findings include: Resident # 85 was admitted to the facility on [DATE] and a readmission of 04/08/2019 with diagnoses that included but were not limited to chronic obstructive pulmonary disease [1], chronic kidney disease [2] and anxiety [3]. Resident # 85's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/02/19, coded Resident # 85 as scoring a nine on the brief interview for mental status (BIMS) of a score of 0 - 15, nine - being moderately impaired of cognition for making daily decisions. On 10/22/19 at approximately 12:45 p.m., and 2:45 p.m., Resident # 85's over-the-bed-table was observed. The edges were chipped and peeling, the trim surrounding the edges of the table was separated from the table exposes the bare wood fiber edges. On 10/23/19 at approximately 2:47 p.m., an interview was conducted with Resident # 85. When asked about the condition of his over-the-bed-table, Resident # 85 stated, It needs to be fixed. On 10/24/19 at approximately 7:30 a.m., Resident # 85's over-the-bed-table was observed. The edges were chipped and peeling, the trim surrounding the edges of the table was separated from the table exposes the bare wood fiber edges. On 10/24/19 at approximately 7:30 a.m., Resident # 85's over-the-bed-table was observed with OSM [other staff member] # 1, director of maintenance. After observing the over-the-bed-table, OSM # 1 stated that it was in poor condition and in need of repair. OSAM # 1 was asked to measure the damaged edge of the table. Using a standardized carpenter's measuring tape, OSM # 1 stated that approximately twenty-five inches of the table edge was damaged. OSM #1 was asked to describe the process for identifying repairs in the facility's resident rooms. OSM # 1 stated, We [maintenance department] inspect five rooms a week and but if a staff member sees something in need of a repair or fixing, they complete a work order and we check them and address them throughout the day OSM # 1 stated that the condition of Resident # 1's over-the-bed-table should have been identified during rounds and replaced. On 10/24/19 at 12:10 p.m. ASM [administrative staff member] # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. [2] Kidneys are damaged and can't filter blood as they should. This information was obtained from the website: https://medlineplus.gov/chronickidneydisease.html. [3] Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement the abuse policy for immediately reporting an allegation of abuse to the state agency for one of 47 residents in the survey sample, Resident #33. The facility staff failed to report an allegation of abuse from Resident #33 to the state agency immediately and or within the required two hours after learning of the allegation. The findings include: A review of the facility policy, Protection of Residents; Reducing the Threat of Abuse and Neglect, revealed, in part, the following: Reporting and Response .All associates are mandated to immediately report suspected resident abuse and/or neglect to their immediate supervisor and/or facility representative. All alleged or suspected violations involving mistreatment, abuse, neglect, injuries of unknown origin .will be immediately reported to the administrator and/or director of nursing .Facilities must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Resident #33 was admitted to the facility on [DATE] with diagnoses that include, but are not limited to recent right great toe removal, diabetes, and heart failure. He was discharged on 10/18/19. On the most recent MDS (minimum data set), an admission assessment with an assessment reference date of 817/19, Resident #33 was coded as being moderately impaired for making daily decisions, having scored nine out of 15 on the BIMS (brief interview for mental status). A review of a Facility Reported Incident (FRI) report related to Resident #33 revealed, in part, the following: Report date: 10/8/18 .Incident date: 10/4/18 [Resident #33] stated CNA (certified nursing assistant) was 'rough' with him during care and words she used was (sic) hurtful. The fax timestamp for this report to the state agency was 10/8/18. A review of Resident #33's clinical record revealed a progress note dated 10/6/18 at 11:20 a.m. This nurse's note documented, in part, the following: Resident continues with SNF (skilled nursing facility care) following right great toe amputation and right foot diabetic ulcer. Alert and oriented .Resident tearful over treatment last night stating that CNA (certified nursing assistant) told him that 'just because he had a bigger bed now did not mean that he owned the room' when she moved his bed over. Also reported that she was rough in repositioning him and his neck is sore today. DON (director of nursing) and unit manager notified and witness form filled out by resident. [The nurse who wrote this note was unavailable for interview at the time of survey. The CNA named in the allegation was also not available for interview at the time of survey.] On 10/23/19 at 3:19 p.m., CNA (certified nursing assistant) # 3 was interviewed regarding reporting abuse allegations. She stated that all allegations of abuse should be immediately reported to the supervisor. On 10/24/19 at 9:05 a.m., LPN (licensed practical nurse) #1 was interviewed regarding reporting abuse allegations. She stated, Any allegation should be reported as soon as possible to the DON (director of nursing) or whoever is on call for the facility for administration. On 10/24/19 at 11:05 a.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the DON (director of nursing), were interviewed. ASM #1 stated that the staff should report all allegations of abuse immediately, and that he or his designee should report them to the state agency within two hours of learning of the allegation. ASM #2 reviewed the FRI file regarding Resident #33 and stated, I don't remember this at all. I don't know why it took so long for us to report this. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to report an allegation of abuse to the state agency in a timely manner for one of 47 residents in the survey sample, Resident #33. The facility staff failed to immediately report an allegation of abuse from Resident #33 to the state agency after learning of the allegation. The findings include: Resident #33 was admitted to the facility on [DATE] with diagnoses including, but not limited to recent right great toe removal, diabetes, and heart failure. He was discharged on 10/18/19. On the most recent MDS (minimum data set), an admission assessment with an assessment reference date of 817/19, Resident #33 was coded as being moderately impaired for making daily decisions, having scored nine out of 15 on the BIMS (brief interview for mental status). A review of a Facility Reported Incident (FRI) report related to Resident #33 revealed, in part, the following: Report date: 10/8/18 .Incident date: 10/4/18 [Resident #33] stated CNA (certified nursing assistant) was 'rough' with him during care and words she used was (sic) hurtful. The fax timestamp for this report to the state agency was 10/8/18. A review of Resident #33's clinical record revealed a progress note dated 10/6/18 at 11:20 a.m. This nurse's note documented, in part, the following: Resident continues with SNF (skilled nursing facility care) following right great toe amputation and right foot diabetic ulcer. Alert and oriented .Resident tearful over treatment last night stating that CNA (certified nursing assistant) told him that 'just because he had a bigger bed now did not mean that he owned the room' when she moved his bed over. Also reported that she was rough in repositioning him and his neck is sore today. DON (director of nursing) and unit manager notified and witness form filled out by resident. [The nurse who wrote this note was unavailable for interview at the time of survey. The CNA named in the allegation was also not available for interview at the time of survey.] On 10/23/19 at 3:19 p.m., CNA (certified nursing assistant) # 3 was interviewed regarding reporting abuse allegations. She stated that all allegations of abuse should be immediately reported to the supervisor. On 10/24/19 at 9:05 a.m., LPN (licensed practical nurse) #1 was interviewed regarding reporting abuse allegations. She stated, Any allegation should be reported as soon as possible to the DON (director of nursing) or whoever is on call for the facility for administration. On 10/24/19 at 11:05 a.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the DON, were interviewed. ASM #1 stated that all allegations of abuse should be reported immediately by the staff, and that they should be reported to the state agency by him or his designee within two hours of learning of the allegation. ASM #2 reviewed the FRI file regarding Resident #33 and stated, I don't remember this at all. I don't know why it took so long for us to report this. A review of the facility policy, Protection of Residents; Reducing the Threat of Abuse and Neglect, revealed, in part, the following: Reporting and Response .All associates are mandated to immediately report suspected resident abuse and/or neglect to their immediate supervisor and/or facility representative. All alleged or suspected violations involving mistreatment, abuse, neglect, injuries of unknown origin .will be immediately reported to the administrator and/or director of nursing .Facilities must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence the required information was provided to the receiving hospital on transfer for one of 47 residents in the survey sample, Residents #36. The facility staff failed to evidence what, if any, paperwork and information was provided to the receiving facility upon Resident #36's transfer to the hospital on 8/10/19. The findings include: Resident #36 was admitted to the facility on [DATE]. readmitted on [DATE], with the diagnoses of but not limited to atrial fibrillation, chronic kidney disease, anxiety disorder, spinal stenosis, and intervertebral disc degeneration of the lumbar region. The significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/20/19 coded the resident as being cognitively intact in ability to make daily life decisions. A review of the clinical record revealed a nurse's note dated 8/10/19 that documented, Resident complained of increased lower back pain unresolved with prn (as needed) pain medication. MD (medical doctor) made aware and new orders received to send resident to ED (emergency department) for eval (evaluation). Resident's daughter (name of daughter) notified of increased back pain and new MD orders. (Name of daughter) stated that she would meet her at (name of hospital). Resident transported via EMT (emergency medical technician) around [PHONE NUMBER] (3:45 AM to 4:00 AM). Another nurse's note dated 8/10/19 documented, Residents daughter called and stated that resident was admitted to the hospital for UTI (urinary tract infection). Further review of the clinical record failed to evidence what, if any, paperwork and information was provided to the hospital upon Resident #36's transfer on 8/10/19. On 10/23/19 at 3:15 p.m., an interview was conducted with RN #2 (Registered Nurse). When asked to explain the process for transferring a resident to the hospital, RN #2 stated the nurses call the doctor, obtain an order to send the resident to the hospital and prepare the paperwork that is necessary to transfer a resident to the hospital. RN #2 was asked to describe the information that is provided to the hospital staff. RN #2 stated nurses are supposed to send an eInteract form, the care plan, and the bed hold policy. RN #2 stated nurses are supposed to write a note that documents all the information that is provided. On 10/24/19 at 9:10 AM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. ASM #2 was asked to review the note and if what is written in the note evidenced sufficient information of what was provided to the hospital. ASM #2 stated, No, it's missing the eInteract, which was not done. I'm not sure if they may have sent it in paper format and did not make a copy, but per the note, there is no documentation of what was sent. A review of the facility policy, Transfers and Discharges documented, Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident. (B) Resident representative information including contact information. (C) Advance Directive Information. (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals; (F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. On 10/24/19 at 12:16 AM, ASM #1 (Administrative Staff Member) the Executive Director, and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to evidence written notification of discharge was provided to the ombudsman and the resident or resident's representative for a facility-initiated transfer of Resident #31 on 10/11/2019. Resident #31was admitted to the facility on [DATE]. readmission on [DATE] with diagnoses that included but were not limited to chronic respiratory failure (1) and traumatic brain injury (2). Resident #31's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 08/09/19, coded Resident #31 in a persistent vegetative state/no discernible consciousness. The nurse's Progress Notes, dated 10/11/2019 12:26 (12:26 p.m.) for Resident #31 documented, Respiratory therapist in to do trach (tracheostomy) (3) change. Upon trying to suction resident prior to trach change RT (respiratory therapist) was unable to advance catheter in to inner cannula to suction resident d/t (due to) resistance. Trach was not changed. Inner cannula changed. RT spoke with NP (nurse practitioner) and order received to send resident to ER (emergency room) for eval (evaluation) and tx (treatment) r/t (related to) fever and trach malfunction. Resident continues with orange/red color drainage with inner cannula changes noted with foul odor. VSS (vital signs stable). O2 (oxygen) sat (saturation) 98% (percent). Report called to [Name of Hospital] and 911 called to transport resident. The nurse's Progress Notes, dated 10/11/2019 17:11 (5:11 p.m.) for Resident #31 documented, Called [Name of Hospital] for update. Per [Name of Staff member] resident is going to be admitted overnight for possible procedure in the morning for trach change. The nurse's Progress Notes, dated 10/16/2019 03:41 (3:41 a.m.) for Resident #31 documented, Adjusting well to readmission into facility without any noted problems . Review of Resident #31's clinical record failed to evidence that written notification of discharge was provided to the resident or representative and the ombudsman for the facility initiated transfer on 10/11/19. On 10/23/19 at 3:15 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 was asked to explain the facility process for transferring a resident to the hospital. RN #2 stated the nurses call the doctor, obtain an order to send the resident to the hospital and prepare the paperwork that is necessary to transfer a resident to the hospital. RN #2 was asked to describe the information that is provided to the hospital staff. RN #2 stated nurses are supposed to send an e-interact form, the care plan, and the bed hold policy. RN #2 stated nurses are supposed to write a note that documents all the information that is provided. On 10/23/19 at approximately 4:00 p.m., a request was made via a list provided to ASM (administrative staff member) #2, the director of nursing for evidence that written notification of discharge was provided to Resident #31 or representative and the ombudsman for the facility initiated transfer on 10/11/2019. On 10/24/19 at 8:35 a.m., an interview was conducted with OSM (Other Staff Member) #4, the front desk, staff member. When asked for the evidence of written notification regarding the facility-initiated transfer of Resident #31 on 10/11/19, OSM #4 stated that she did not have any evidence for that date. OSM #4 stated the only transfer information she had for Resident #31 was prior to July 2019. On 10/24/19 at approximately 12:15 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit. References: 1. Respiratory failure is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide. Sometimes you can have both problems. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=respiratory+failure&_ga=2.10765815.252353412.1572267082-1838772440.1562936034 2. Traumatic brain injury- Happens when a bump, blow, jolt, or other head injury causes damage to the brain. Symptoms of a TBI may not appear until days or weeks following the injury. A concussion is the mildest type. It can cause a headache or neck pain, nausea, ringing in the ears, dizziness, and tiredness. People with a moderate or severe TBI may have those, plus other symptoms: A headache that gets worse or does not go away, repeated vomiting or nausea, Convulsions or seizures, Inability to awaken from sleep, Slurred speech, Weakness or numbness in the arms and legs, dilated eye pupils. This information was obtained from the website: https://medlineplus.gov/traumaticbraininjury.html 3. Tracheostomy- A surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is most often placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube This information was obtained from the website: https://medlineplus.gov/ency/article/002955.htm. 3. Resident #99 was transferred to the hospital on 8/7/19. The facility staff failed to evidence that written notification regarding the transfer was provided to the resident, resident representative and/or the ombudsman. Resident #99 was admitted to the facility on [DATE]. Resident #99's diagnoses included but were not limited to heart attack, high blood pressure and shortness of breath. Resident #99's most recent MDS (minimum data set), a five day Medicare assessment with an ARD (assessment reference date) of 8/5/19, coded the resident's cognition as moderately impaired. Review of Resident #99's clinical record revealed the resident was transferred to the hospital on 8/7/19 due to an episode of vomiting bright blood and pressure to the chest. Further review of Resident #99's clinical record failed to reveal documentation to evidence the resident, resident representative and/or the ombudsman was provided written notification regarding the transfer. On 10/24/19 at 8:35 a.m., in an interview with OSM (Other Staff Member) #4, the front desk staff. OSM #4 stated she could not provide written notice of transfer when Resident #99 was transferred to the hospital on 8/7/19. On 10/24/19 at 12:24 p.m., ASM #1 (the executive director) and ASM #2 were made aware of the above concern. No further information was provided prior to exit. Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence that written notification of a hospital transfer was provided to the Resident Representative and/or Ombudsman, for three out of 47 residents in the survey sample, Residents #36, #31, and #99. The facility staff failed to evidence that written notification of a hospital transfer was provided to Resident #36 and/or Resident Representative and the Ombudsman, for a hospital transfer on 8/10/19. The facility staff failed to evidence written notification of discharge was provided to the ombudsman and the resident or resident's representative for a facility-initiated transfer to the hospital of Resident #31on 10/11/2019 and Resident #99 on 8/7/19. The findings include: 1. Resident #36 was admitted to the facility on [DATE]. readmitted on [DATE], with the diagnoses of but not limited to atrial fibrillation, chronic kidney disease, anxiety disorder, spinal stenosis, and intervertebral disc degeneration of the lumbar region. The significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/20/19 coded the resident as being cognitively intact in ability to make daily life decisions. A review of the clinical record revealed a nurse's note dated 8/10/19 that documented, Resident complained of increased lower back pain unresolved with prn (as needed) pain medication. MD (medical doctor) made aware and new orders received to send resident to ED (emergency department) for eval (evaluation). Resident's daughter (name of daughter) notified of increased back pain and new MD orders. (Name of daughter) stated that she would meet her at (name of hospital). Resident transported via EMT (emergency medical technician) around [PHONE NUMBER] (3:45 AM to 4:00 AM). Another nurse's note dated 8/10/19 documented, Residents daughter called and stated that resident was admitted to the hospital for UTI (urinary tract infection). Further review of the clinical record failed to evidence that written notification of the hospital transfer was provided to the Resident #36 and/or Resident Representative and the Ombudsman. On 10/24/19 at 8:13 AM, in an interview with ASM #2 (Administrative Staff Member) the Director of Nursing, she stated that before switching computer systems, the front desk was sending out the notifications. ASM #3 stated that when the facility switched to the new computer system, it was dropped because front desk was provided with a paper of who was discharged before and when the system was changed, the form that was provided to the front desk was no longer being done and so the notifications were not done. On 10/24/19 at 8:35 AM, in an interview with OSM #4 (Other Staff Member), the front desk staff, she stated that the new system went into effect 7/1/19. OSM #4 stated, We send documentation to the family and the Ombudsman. We generate a letter and we mail that and copy the envelope, the notice of transfer and discharge, notice of non-coverage form. All of this is generated and copied and sent to the Ombudsman and the family and is kept all together. If they go to the hospital and come back, I send the letter and bed hold to the family. When asked about the 8/10/19 hospital transfer for Resident #36, OSM #4 stated, I have no evidence of Ombudsman or written family notification. A review of the facility policy, Transfers and Discharges documented, Emergency Transfers: When as resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable, according to 42 CFR 483.15(c)(4)(ii)(D). Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as a list of residents on a monthly basis. Residents who are sent emergently to the hospital are considered facility-initiated transfers because the resident's return is generally expected. On 10/24/19 at 12:16 AM, ASM #1 (Administrative Staff Member) the Executive Director, and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility document review it was determined facility staff failed to evidence that written bed hold notice was provided to the resident or resident's representative for a facility-initiated transfer for two of 47 residents in the survey sample, Resident #31 and Resident #99. The facility staff failed to evidence that written bed hold notice was provided to Resident #31 or the resident's representative for a facility-initiated transfer of the resident on 10/11/2019 and to Resident #99 or the resident's representative when the resident was discharged to the hospital on 8/7/19. The findings include: 1. Resident #31 was admitted to the facility on [DATE]. readmitted on [DATE] with diagnoses that included but were not limited to chronic respiratory failure (1) and traumatic brain injury (2). Resident #31's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 08/09/19, coded Resident #31 in a persistent vegetative state/no discernible consciousness. The nurse's Progress Notes, dated 10/11/2019 12:26 (12:26 p.m.) for Resident #31 documented, Respiratory therapist in to do trach (tracheostomy) (3) change. Upon trying to suction resident prior to trach change RT (respiratory therapist) was unable to advance catheter in to inner cannula to suction resident d/t (due to) resistance. Trach was not changed. Inner cannula changed. RT spoke with NP (nurse practitioner) and order received to send resident to ER (emergency room) for eval (evaluation) and tx (treatment) r/t (related to) fever and trach malfunction. Resident continues with orange/red color drainage with inner cannula changes noted with foul odor. VSS (vital signs stable). O2 (oxygen) sat (saturation) 98% (percent). Report called to [Name of Hospital] and 911 called to transport resident. The nurse's Progress Notes, dated 10/11/2019 17:11 (5:11 p.m.) for Resident #31 documented, Called [Name of Hospital] for update. Per [Name of Staff member] resident is going to be admitted overnight for possible procedure in the morning for trach change. Review of Resident #31's clinical record failed to evidence that written bed hold notification was provided to the resident or representative for the facility initiated transfer on 10/11/19. On 10/23/19 at approximately 4:00 p.m., a request was made via a list provided to ASM (administrative staff member) #2, the director of nursing for evidence that written bed hold notice was provided to Resident #31 or the resident representative for the facility initiated transfer on 10/11/2019. On 10/24/19 at approximately 8:00 a.m., ASM #2 provided a document SBAR (situation, background, assessment, recommendations) Communication Form and Progress Note for RNs/LPN/LVNs [registered nurse, licensed practical nurse, licensed vocational nurse] dated 10/11/2019 11:30 a.m. The document failed to evidence written documentation that a bed hold notice was provided to the resident or representative for the facility initiated transfer on 10/11/19 for Resident #31. The document Nursing Home to Hospital Transfer Form dated 10/11/2019 12:03 PM also failed to evidence written documentation that the bed hold notice was provided to Resident #31or the resident or representative for the facility initiated transfer on 10/11/19. On 10/23/19 at 3:15 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 was asked to explain the facility process for transferring a resident to the hospital. RN #2 stated the nurses call the doctor, obtain an order to send the resident to the hospital and prepare the paperwork that is necessary to transfer a resident to the hospital. RN #2 was asked to describe the information that is provided to the hospital staff. RN #2 stated nurses are supposed to send an e-interact form, the care plan, and the bed hold policy. RN #2 stated nurses are supposed to write a note that documents all the information that is provided. On 10/24/19 at 8:35 a.m., an interview was conducted with OSM (Other Staff Member) #4, the front desk, staff member. When asked if written bed hold notice is provided to residents or resident representative, OSM #4 stated that it is but the new computer system started 7/1/19. OSM #4 stated, We mail a notification of discharge and the bed hold notice to the resident or represent, copy the envelope and keep it in a book. OSM #4 stated, Up until July it was all on paper so we kept it on paper. OSM #4 provided a binder containing the above referenced notices, copies of the discharge letters and copied envelopes for discharged residents. When asked for the evidence of written bed hold notice for the facility-initiated transfer of Resident #31 to the hospital on [DATE], OSM #4 stated that she did not have any evidence for that transfer. OSM #4 stated the only transfer information she had for Resident #31 was prior to July 2019. A review of the facility policy, Bedhold [Sic.]/Reservation of Room documented, The Bed-hold policy should be given upon admission, upon transfer of a resident to the hospital (if in an emergency within 24 hours), or the resident goes on therapeutic leave of absence. The facility will provide written information to the resident or resident representative the nursing facility policy on bed-hold periods and the residents return to the facility to ensure that residents are made aware of the facility's bed-hold and reserve bed payment policy before and upon transfer to a hospital . On 10/24/19 at approximately 12:15 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit. References: 1. Respiratory failure is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide. Sometimes you can have both problems. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=respiratory+failure&_ga=2.10765815.252353412.1572267082-1838772440.1562936034 2. Traumatic brain injury- Happens when a bump, blow, jolt, or other head injury causes damage to the brain. This information was obtained from the website: https://medlineplus.gov/traumaticbraininjury.html 3. Tracheostomy- A surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is most often placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube. This information was obtained from the website: https://medlineplus.gov/ency/article/002955.htm. 2. The facility staff failed to provide Resident #99 or the resident's representative written notification of the bed hold policy when the resident was discharged to the hospital on 8/7/19. Resident #99 was admitted to the facility on [DATE]. Resident #99's diagnoses included but were not limited to heart attack, high blood pressure and shortness of breath. Resident #99's most recent MDS (minimum data set), a five day Medicare assessment with an ARD (assessment reference date) of 8/5/19, coded the resident's cognition as moderately impaired. Review of Resident #99's clinical record revealed the resident was transferred to the hospital on 8/7/19 due to an episode of vomiting bright blood and pressure to the chest. Further review of Resident #99's clinical record failed to reveal documentation to evidence the facility, bed hold policy was provided to the resident and/or the representative for the facility initiated transfer to the hospital on 8/7/19. On 10/23/19 at 3:15 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 was asked to explain the facility process for transferring a resident to the hospital. RN #2 stated the nurses call the doctor, obtain an order to send the resident to the hospital and prepare the paperwork that is necessary to transfer a resident to the hospital. RN #2 confirmed a bed hold policy is supposed to be sent with residents when they are transferred to the hospital. RN #2 stated nurses are supposed to write a note that documents all the information that is provided. On 10/24/19 at 8:35 a.m., in an interview with OSM (Other Staff Member) #4, the front desk staff, she stated that the new system went into effect 7/1/19. OSM #4 stated, We send documentation to the family and the Ombudsman. We generate a letter and we mail that and copy the envelope, the notice of transfer and discharge, notice of non-coverage form. All of this is generated and copied and sent to the Ombudsman and the family and is kept all together. If they go to the hospital and come back, I send the letter and bed hold to the family. On 10/24/19 at 12:24 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop and implement the comprehensive plan of care for three of 47 residents in the survey sample, Residents #44, #20, and #50. The findings include: 1. The facility staff failed to implement Resident #44's comprehensive care plan to look at and loosen a physical restraint per physician orders every 30 minutes. Resident #44 was admitted to the facility on [DATE]. readmitted on [DATE] with diagnoses including, but not limited to history of a stroke, obstructive uropathy (1) and dementia with behaviors (2). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 9/3/19, Resident #44 was coded as being severely cognitively impaired for making daily decisions, having scored five out of 15 on the BIMS (brief interview for mental status). He was coded as having an indwelling catheter in his bladder, and as having a physical restraint on a daily basis. A review of Resident #44's comprehensive care plan dated 8/28/19 revealed, in part, the following: The resident uses abdominal binder for suprapubic cath (catheter). The resident will remain free of complications related to restraint use, including contractures, skin breakdown, altered mental status, isolation, or withdrawal through review date .Alternatives to abdominal binder was ABD (abdominal) pad and tape, but resident started pulling at suprapubic catheter; therefore abdominal binder was reinstated .RESTRAINT USE: Apply abdominal binder, check every 30 minutes and release every 2 hours. A review of Resident #44's clinical record revealed the following physician's order dated 8/21/19: Abdominal binder: Check abdominal binder every 30 minutes and release every 2 hours every shift for safety, to keep resident from pulling at suprapubic catheter (3). On 10/23/19 two surveyors continuously observed Resident #44, from 1:51 p.m. until 4:01 p.m. (135-minute period). During this time, Resident #44 was positioned in a reclining chair across from a nurses' station, just outside the main dining room. Resident #44's legs, torso, and arms were covered with a blanket. At no time during this observation did any staff member look underneath the blanket to verify the position of or to loosen Resident #44's abdominal binder, worn under his shirt. On 10/24/19 at 9:03 a.m., LPN (licensed practical nurse) #1 was interviewed. When asked if she had taken care of Resident #44 on 10/23/19, LPN #1 stated, Yes I did. When asked what restraint Resident #44 used, LPN #1 stated, He has an abdominal binder. He has a suprapubic catheter. Without the binder, he will rip [the catheter] out. He has pulled it out before and had to go back to have it replaced. That's why he has the binder. When asked why the abdominal binder is considered a restraint, LPN #1 stated, He can't take it off by himself, and he can't really access his abdominal area like normal because it is there. When asked what orders accompany the use of the abdominal binder, LPN #1 stated, We are supposed to check it every 30 minutes. When asked what checking the binder means, LPN #1 stated, We are supposed to actually look at it. That's all, I think. When asked if she was aware of anything that needed to be done every two hours, LPN #1 stated, No. I'm not familiar with anything else. LPN #1 was asked to check the physicians' orders for Resident #44. After reviewing the orders, LPN #1 stated, We are supposed to loosen it every two hours. When asked if she had looked at Resident #44's abdominal binder every thirty minutes on 10/23/19, LPN #1 stated, No, I didn't. When asked if she loosened the resident's abdominal binder every two hours on 10/23/19, LPN #1 stated, No, I didn't do that either. I'm sorry. When asked if looking at and loosening Resident #44's binder were a part of Resident #44's comprehensive care plan, LPN #1 stated, Yes, I'm sure it is. When asked the importance of a resident's care plan, LPN #1 stated, So we know what to do for them. When I first start working with a resident, I looked at the care plan often. I ask those questions in report. I want to know what I'm doing, but I've been taking care of [Resident #44] a long time. I haven't looked at the care plan very much lately, I'll admit. On 10/24/19 at 11:00 a.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Care Planning and Interventions, revealed, in part, the following: The interdisciplinary team meets on a scheduled basis and develops an individualized care plan. Interdisciplinary means that professional disciplines, as appropriate, work together to provide the greatest benefit to the resident .The Care Plan addresses, to the extent possible .Resident-specific interventions. No further information was provided prior to exit. (1) Obstructive uropathy is a condition in which the flow of urine is blocked. This causes the urine to back up and injure one or both kidneys. This information is taken from the website https://medlineplus.gov/ency/article/000507.htm. (2) Dementia is a gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information is taken from the website https://medlineplus.gov/ency/article/000746.htm. (3) A suprapubic catheter (tube) drains urine from your bladder. It is inserted into your bladder through a small hole in your belly. You may need a catheter because you have urinary incontinence (leakage), urinary retention (not being able to urinate), surgery that made a catheter necessary, or another health problem. This information is taken from the website https://medlineplus.gov/ency/patientinstructions/000145.htm. 2. The facility staff failed to implement Resident #20's comprehensive care plan to monitor the resident's fluid intake on multiple shifts during September 2019 and October 2019. Resident #20 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses including, but not limited to ESRD (end stage renal disease) (1) and COPD (chronic obstructive pulmonary disease) (2). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 7/26/19, Resident #20 was coded as being cognitively intact for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as having received dialysis during the look back period. A review of Resident #20's comprehensive care plan dated 9/16/19 revealed, in part, the following: Dialysis r/t related to) renal (kidney) failure .Fluid restriction as ordered. A review of Resident #20's clinical record revealed the following physician's order, dated 9/5/19: Fluid Restriction 1500 ml/day (milliliters per day). From Kitchen: Breakfast 720 ml, Lunch 240 ml, dinner 240 ml. From Nursing Days 150 ml, eves (evenings) 150 ml) nights 0 ml. Every shift document amount consumed. A review of Resident #20's September 2019 and October 2019 MARs (medication administration records revealed blanks on the following days in the space where the fluid restriction enforcement should have been documented: 9/7/19 day shift, 9/8/19 day shift, 9/9/19 day shift, 9/12/19 day and evening shifts, 9/19/19 evening shift, 9/21/19 day and evening shifts, 9/24/19 evening shift, 9/30/19 evening shift, 10/1/10 evening shift, 10/8/19 evening shift, 10/15/19 evening shift, and 10/18/19 day shift. On 10/24/19 at 9:01 a.m., LPN (licensed practical nurse) #1 was interviewed. LPN #1 stated she is not familiar with Resident #20's care. When shown the above-referenced MARs containing the blanks for the fluid restriction documentation, and when asked what these blanks mean, LPN #1 stated, I don't want to say what I think it means. Because I think, it's not good. I need to find out. On 10/24/19 at 10:07 a.m., LPN #5 was interviewed. LPN #5 stated she was very familiar with Resident #20's care. When asked why Resident #20 was on a fluid restriction, LPN #5 stated, He is a dialysis patient. Typically, they have some kind of fluid restriction. When asked what she knew about Resident #20's restrictions, LPN #5 stated, His fluid intake is monitored every shift. We keep track of what the resident takes in. Sometimes the aides record it sometimes I record it. But at the end of the shift, there is a box for me to add up all the totals and sign off on the total. When LPN #5 was shown the MARs referenced above for Resident #20, and when asked about blank spots, LPN #5 stated, If a box is not signed off and totaled, I can't tell how much he got. There is no way to tell. There is no way to know how much he would be allowed to have for the rest of the day. I can't see how anybody would miss that. When asked what the lack of documentation means, LPN #5 stated, Well, if it's not documented, I can only imagine it wasn't done. It doesn't look like anybody kept up with his fluid on those shifts. When asked the purpose of a resident's comprehensive care plan, LPN #5 stated, The care plan should always be followed. It is their plan of care. It is like a guideline to follow. On 10/24/19 at 11:00 a.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing, were informed of these concerns. No further information was provided prior to exit. (1) End-stage kidney disease (ESKD) is the last stage of long-term (chronic) kidney disease. This is when your kidneys can no longer support your body's needs. End-stage kidney disease is also called end-stage renal disease (ESRD). This information is taken from the website https://medlineplus.gov/ency/article/000500.htm. (2) COPD is a general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. 3. The facility staff failed to implement Resident # 50 comprehensive care plan to maintain Resident # 50's heels elevated when in bed. Resident # 50 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included but were not limited to: pain, hemiplegia [1] and aphasia [2]. Resident # 50's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/26/19, coded Resident # 50 as scoring a five on the brief interview for mental status (BIMS) of a score of 0 - 15, five - being severely impaired of cognition for making daily decisions. Section M Skin Conditions coded Resident # 50 as being at risk for developing pressure ulcers. The comprehensive care plan for Resident # 50's skin integrity dated 06/24/2019 documented, The resident has potential for impaired skin integrity r/t [related to] fragile skin. Revision Date: 10/23/2019. Under Interventions it documented, Encourage heels while up in bed. Date Initiated: 06/24/2019. On 10/22/19 at 12:25 p.m. an observation of Resident # 50 was conducted with CNA [certified nursing assistant] # 3. Resident # 50 was observed lying in bed with his legs covered by a blanket. Resident #50 was asked if this surveyor could look at his feet with the assistance of CNA # 3. Resident # 50 stated, Yes. CNA # 3 removed the blanket exposing Resident # 50's feet and lower legs [below the knees]. Observation of Resident # 50's lower legs revealed a cushion and pillow under both calves. Observation of Resident # 50 right and left heels revealed they were resting directly on the bed. When asked to describe the position of Resident # 50's heels, CNA # 3 stated, They are on the bed. When asked what position the heels should be in, CNA # 3 stated, Off the bed and immediately repositioned Resident # 50's feet and legs so the heels were elevated. On 10/23/19 08:28 a,m. an observation of Resident # 50 was conducted with CNA # 1. Resident # 50 was observed lying in bed with his legs covered by a blanket. Resident #50 was asked if this surveyor could look at his feet with the assistance of CNA # 1. Resident # 50 stated, Yes. CNA # 1 removed the blanket exposing Resident # 50's feet and lower legs [below the knees]. Observation of Resident # 50's lower legs revealed a cushion and pillow under both calves. Observation of Resident # 50 right and left heels revealed they were resting directly on the bed. When asked to describe the position of Resident # 50's heels, CNA # 1 stated, They are on the bed. When asked what position the heels should be in, CNA # 1 stated, Off the bed and immediately repositioned Resident # 50's feet and legs so the heels were elevated. When asked to describe the procedure for positioning a resident CNA 1 stated, They should be repositioned every 2 hours and as needed. On 10/23/19 at 2:50 p.m. an interview was conducted with the ADON (assistand Director of nursing), RN(registered nurse) #3, regarding the above observations and Resident # 50's care plan. RN # 3 was asked if the care plan was being implemented. RN # 3 stated, No. On 10/24/19 at 12:10 p.m., ASM [administrative staff member] # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] Also called: Hemiplegia, Palsy, Paraplegia, Quadriplegia. Paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread This information was obtained from the website: https://medlineplus.gov/paralysis.html. [2] A disorder caused by damage to the parts of the brain that control language. It can make it hard for you to read, write, and say what you mean to say) This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/aphasia.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and facility document review it was determined facility staff failed to accurately revise the care plan for two of 47 residents in the survey sample, Resident #31. The facility staff failed to review and revise the comprehensive care plan upon readmission to the facility for Resident #31 to address the discontinuation of oxygen and for #23 to address the use of a spirometer. The findings include: 1. The facility staff failed to revise the comprehensive care plan for Resident #31 after a readmission on [DATE] to address the discontinuation of oxygen. Resident #31was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included but were not limited to chronic respiratory failure (1) and traumatic brain injury (2). Resident #31's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 08/09/19, coded Resident #31 in a persistent vegetative state/no discernible consciousness. The comprehensive care plan The resident at risk for altered respiratory status/difficulty breathing r/t (related to) Chronic raspatory [sic] Failure, Hx (history) of Bronchitis (3), Date Initiated: 10/16/2019; Revision on: 10/16/2019. Under Interventions/Tasks it documented, Oxygen Settings: 2 (two) liters with humidification via trach (tracheostomy) (4) collar (mask). Date Initiated: 10/16/2019; Revision on 10/16/2019. On 10/22/19 at approximately 1:45 p.m., an observation was conducted of Resident #31 in her room. Resident #31 was lying in bed on her left side facing the window with her eyes closed. The head of the bed was observed to be elevated at a 45 degree angle. Resident #31 was not observed wearing any oxygen. Observation of Resident #31's room failed to evidence any oxygen equipment. Additional observations on 10/23/19 at approximately 9:00 a.m. and 10/24/19 at approximately 8:45 a.m. revealed Resident #31 not wearing any oxygen and failed to evidence any oxygen equipment in the room. Review of Resident #31's clinical record failed to evidence documentation of Resident #31 receiving oxygen since readmission to the facility on [DATE] after a facility initiated transfer on 10/11/19. On 10/24/19 at 9:10 a.m., an interview was conducted with RN (registered nurse) #3, the assistant director of nursing. When asked how often the care plan is reviewed and updated, RN #3 stated that it is updated with any changes, quarterly, annually and with new orders. When asked if a readmission warrants a care plan update, RN #3 stated, Yes. When asked about the readmission on [DATE] for Resident #31, RN #3 stated that the care plan should be updated with the date of her readmission. When asked if Resident #31 is currently using oxygen, RN #3 stated that she is not. RN #3 stated that the tracheostomy was removed when Resident #31 was sent to the hospital and that the stoma (surgical opening) has closed. When asked if Resident #31 has used oxygen at since being readmitted to the facility, RN #3 stated No. After reviewing the care plan The resident at risk for altered respiratory status/difficulty breathing .Date Initiated: 10/16/2019; Revision on: 10/16/2019 with the documented intervention for Oxygen Settings: 2 (two) liters with humidification via trach (tracheostomy) (4) collar (mask). Date Initiated: 10/16/2019; Revision on 10/16/2019, RN #3 stated that the oxygen should not be there. RN #3 stated that the care plan had been updated on readmission but the oxygen had not been taken off. RN #3 stated that Resident #31 no longer uses oxygen and no longer has the tracheostomy and that the care plan had been updated this morning to reflect this. On 10/24/19 at 9:30 a.m., an interview was conducted with LPN (licensed practical nurse) #4, the MDS (minimum data set) coordinator. When asked how often care plans are updated LPN #4 stated that they are updated quarterly and when a significant change occurs. When asked if a readmission is a significant change LPN #4 stated Yes. When asked about the care plan for Resident #31 LPN #4 stated that the oxygen at 2 liters via trach collar should have come off of the care plan when Resident #31 was readmitted . LPN #4 stated that the resident came back to the facility without the tracheostomy and the oxygen. A review of the facility policy, Care Planning and Intervention documented, The care plan is updated as needed, but no less than quarterly as: conditions change. Goals are met. Interventions are determined to be ineffective or need to be revised. On 10/24/19 at approximately 12:15 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit. References: 1. Respiratory failure Respiratory failure is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide. Sometimes you can have both problems. When you breathe, your lungs take in oxygen. The oxygen passes into your blood, which carries it to your organs. Your organs, such as your heart and brain, need this oxygen-rich blood to work well. Another part of breathing is removing the carbon dioxide from the blood and breathing it out. Having too much carbon dioxide in your blood can harm your organs. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=respiratory+failure&_ga=2.10765815.252353412.1572267082-1838772440.1562936034 2. Traumatic brain injury- Happens when a bump, blow, jolt, or other head injury causes damage to the brain. Symptoms of a TBI may not appear until days or weeks following the injury. This information was obtained from the website: https://medlineplus.gov/traumaticbraininjury.html 3. Chronic bronchitis- An inflammation of the bronchial tubes, the airways that carry air to your lungs. It causes a cough that often brings up mucus. This information was obtained from the website: https://medlineplus.gov/chronicbronchitis.html 4. Tracheostomy - A surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is most often placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube. This information was obtained from the website: https://medlineplus.gov/ency/article/002955.htm. 2. The facility staff failed to review and revise the comprehensive care plan to included the use of the incentive spirometer (1) for Resident #23 as documented on the discharge After Visit Summary from [Name of Hospital] on readmission. Resident #23 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to sepsis (2), and orthopedic (3) aftercare. Resident #23's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/03/19, coded Resident #23 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making daily decisions. On 10/22/19 at approximately 2:30 p.m., an interview was conducted with Resident #23. Resident #23 was observed sitting in the wheelchair beside the bed wearing an oxygen cannula. An incentive spirometer was observed on the bedside table in front of Resident #23. When asked about the incentive spirometer on the table, Resident #23 stated that it was given to her when she was at the hospital the prior week for hip surgery. When asked if the staff assist her with using it, Resident #23 stated that she does it herself most of the time five or six times a day. When asked if the staff know that she is using the incentive spirometer, Resident #23 stated, Yes, some of them help me. The comprehensive care plan for Resident #23 dated 10/23/2019 failed to evidence documentation for use of the incentive spirometer. The document Discharge Summary; After Visit Summary provided by the discharging provider on 10/18/2019 documented the following for Resident #23. - This after visit summary contains important discharge instructions related to your care after discharge from the hospital. - Additional instructions as follows: Use Incentive Spirometer every hour while awake. On 10/23/19 at 4:35 p.m., an interview was conducted with RN (registered nurse) #5. When asked about the incentive spirometer for Resident #23, RN #5 stated that it was brought back from the hospital last Tuesday when the resident had a surgery performed. When asked if Resident #23 uses the incentive spirometer, RN #5 stated, Yes, she does. When asked if it is documented how often, the resident uses the incentive spirometer, RN #5 stated that there was no official order and they do not document when she uses it. When asked how the staff knows when and if the resident is using the incentive spirometer as instructed, RN #5 stated that the resident is alert and oriented and she does the incentive spirometer herself. When asked if the practice is to have an order and care plan in place for an incentive spirometer, RN #5 stated that they have never had orders for them before or put them on care plans in the past that she is aware of. On 10/24/19 at 11:20 a.m., an interview was conducted with RN (registered nurse) #3. When asked the process for transcribing orders from the hospital, RN #3 stated that the discharge summary is utilized. RN #3 stated that the physician or nurse practitioner is called and the discharge summary is reviewed with them, the orders are received, reviewed and then transcribed into the computer where a physician order summary is printed off. The nurse checks the orders again for accuracy. When asked if the nurse uses the after visit summary as part of the discharge orders, RN #3 stated, Yes, the nurse looks at it for follow up appointment information. After reviewing the after visit summary for Resident #23 dated 10/18/19, RN #3 stated that the incentive spirometry was not transcribed to the physician order summary although the other orders including the TED hose and the dressing change instructions were. RN #3 stated that they have never put orders in for incentive spirometers in the past and that most residents do not have them. When asked if the incentive spirometer should have been on the physician order summary, RN #3 stated that she was not sure, it has never been their practice. When asked what the purpose of an incentive spirometer is, RN #3 stated that it is a piece of equipment used after surgery to expand the lungs and prevent atelectasis (lung collapse). When asked how often the care plan is updated RN #3 stated that it is updated with any changes, quarterly, annually and with new orders. When asked if other respiratory treatments are included on the care plan, RN #3 stated, Yes. When asked what standard of practice is used at the facility, RN #3 stated the facility policies and [NAME]. The facility's policy Care Planning and Interventions documented in part, The Care Plan addresses, to the extent possible: Interventions for preventing avoidable declines in functioning or functional levels; Treatment objectives with measurable outcomes; Parameters for monitoring; According to Fundamentals of Nursing [NAME] and [NAME] 2007 pages 65-77 documented, A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care .expect to review, revise and update the care plan regularly, when there are changes in condition, treatments, and with new orders . On 10/24/19 at approximately 12:15 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: 1. Incentive spirometer is a device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm 2. Sepsis is an illness in which the body has a severe, inflammatory response to bacteria or other germs. This information was obtained from the website: https://medlineplus.gov/ency/article/000666.htm. 3. Orthopedic or orthopedic services, aim at the treatment of the musculoskeletal system. This includes your bones, joints, ligaments, tendons, and muscles. This information was obtained from the website: https://medlineplus.gov/ency/article/007455.htm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview and facility document review it was determined facility staff failed to follow professional standards of care for transcribing orders from the discharge after visit instructions received from the hospital for one of 47 residents in the survey sample, Resident #23. The facility staff failed to transcribe the order for hourly incentive spirometer use while awake for Resident #23 as documented on the After Visit Summary received from [Name of Hospital]. The findings include: Resident #23 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to sepsis (1), and orthopedic (2) aftercare. Resident #23's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/03/19, coded Resident #23 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making daily decisions. On 10/22/19 at approximately 2:30 p.m., an interview was conducted with Resident #23. Resident #23 was observed to be sitting in the wheelchair beside the bed wearing an oxygen cannula. An incentive spirometer (3) was observed on the bedside table in front of Resident #23. When asked about the incentive spirometer on the table Resident #23 stated that it was given to her when she was at the hospital the prior week following hip surgery. When asked if the staff assist her with using it Resident #23 stated that she does it herself five or six times a day. When asked if the staff know that she is using the incentive spirometer Resident #23 stated, Yes. When asked if the staff assist her to use it Resident #23 stated, Sometimes they do. The physicians Order Summary Report dated Oct (October) 21, 2019 and [DATE] for Resident #23 failed to evidence documentation of an active order for the incentive spirometer use. The document After Visit Summary from [Name of Hospital] provided by the discharging provider on 10/18/2019 documented the following in part for Resident #23. - Discharge instructions, This after visit summary contains important discharge instructions related to your care after discharge from the hospital. - Additional instructions as follows: Use Incentive Spirometer every hour while awake. Wear your TED (thrombo-embolic-deterrent) hose (worn to prevent blood clots) during the day, off at night. Leave Aquacel (sterile medicated wound dressing) dressing in place for 7 (seven) days . The eTAR (electronic treatment administration record) dated 10/1/2019-10/31/2019 documented, Left hip aquacel: Leave in place for 7 (seven) days .Order Date 10/18/2019; TED hose on every AM (morning) and off every PM (evening) Order Date 10/18/2019. Further review of the eTAR failed to evidence documentation of the incentive spirometer. The comprehensive care plan for Resident #23 dated 10/23/2019 failed to evidence documentation of the use of an incentive spirometer. On 10/23/19 at 4:35 p.m., an interview was conducted with RN (registered nurse) #5. When asked about the incentive spirometer for Resident #23 RN #5 stated that it was brought back from the hospital last Tuesday when the resident had a surgery performed. When asked if Resident #23 uses the incentive spirometry RN #5 stated, Yes, she does. When asked if it is documented how often the resident uses the incentive spirometer RN #5 stated that there was no official order and they do not document when she uses it. RN #5 was asked how staff would know how often and if the resident is to use the incentive, spirometer as instructed. RN #5 stated that the resident is alert and oriented and she does the incentive spirometer herself. When asked if the practice is to have an order in place for an incentive spirometer RN #5 stated that she was not aware of orders for them before in the past. On 10/24/19 at 11:20 a.m., an interview was conducted with RN (registered nurse) #3, the assistant director of nursing. When asked the process for transcribing orders from the hospital RN #3 stated that the discharge summary is utilized. RN #3 stated that the physician or nurse practitioner is called and the discharge summary is reviewed with them, the orders are received, reviewed and then transcribed into the computer where a physician order summary is printed off. The nurse checks the orders again for accuracy. When asked if the nurse uses the after visit summary as part of the discharge orders RN #3 stated, Yes, the nurse looks at it for follow up appointment information. After reviewing the after visit summary for Resident #23 dated 10/18/19 RN #3 stated that the incentive spirometry was not transcribed to the physician order summary although the other orders including the TED hose and the dressing change instructions were. RN #3 stated that they have never put orders in for incentive spirometers in the past. When asked if the incentive spirometry should be on the physician order summary, RN #3 stated that she was not sure, it has never been their practice. When asked what the purpose of an incentive spirometer, RN #3 stated that it is a piece of equipment used after surgery to expand the lungs and prevent atelectasis (lung collapse). When asked if other respiratory treatments have orders placed for them RN #3 stated, Yes. When asked what standard of practice is used at the facility RN #3 stated the facility policies and [NAME]. The facility's policy Physician Order Processing Procedure- Electronic Process, Effective Date: 4/10/19 documented in part, admission orders are received prior to or upon each admission or readmission. Orders may be written by the physician, nurse practitioner or physician's assistant; obtained via (by way of) telephone by the nursing staff from the physician, or transcribed from the transfer orders. The facility's policy Physician Orders, Last Revised: 1/2018 documented in part, Physician orders include the following. Medications and Treatments .Special medical procedures required for the safety and well-being of the resident. The policy further documented, Note: Medications, diets, therapy, and any treatment may not be administered to the resident without a written order form the attending physician. According to Fundamentals of Nursing- [NAME], [NAME] and [NAME] 2007 page 169, After you receive a written medication order, transcribe it onto a working document approved by your health care facility .read the order carefully, concentrate on copying it correctly, check it when you're finished. Be sure to look for order duplications that could cause your patient to receive a medication in error On 10/24/19 at approximately 12:15 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: 1. Sepsis is an illness in which the body has a severe, inflammatory response to bacteria or other germs. This information was obtained from the website: https://medlineplus.gov/ency/article/000666.htm. 2. Orthopedics or orthopedic services, aim at the treatment of the musculoskeletal system. This information was obtained from the website: https://medlineplus.gov/ency/article/007455.htm 3. Incentive spirometer- An incentive spirometer is a device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review and facility document review, it was determined that facility staff failed to provide care and services for an indwelling catheter to prevent urinary tract infections for one of 40 residents in the survey sample, Residents # 49. The facility staff failed to maintain Resident # 49 catheter tubing off the floor while he was sitting in his wheelchair. The findings include: Resident # 49 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Parkinson's disease [1], obstructive and reflux uropathy [2] and anxiety [3]. Resident # 49's most recent MDS (minimum data set), an quarterly assessment with an ARD (assessment reference date) of 09/06/19, coded Resident # 49 as scoring a four on the brief interview for mental status (BIMS) of a score of 0 - 15, four - being severely impaired of cognition for making daily decisions. Resident # 49 was coded as requiring extensive assistance of one staff member for all activities of daily living. Section H Bladder and Bowel coded Resident # 50 as having an indwelling catheter [2]. The POS [physician's order sheet] for Resident # 39 dated) CT [October] 2019 documented, Catheter Care every shift and p.m. every shift for PREVENTION. Date Ordered: 06/19/2019. The comprehensive care plan for Resident # 49 dated 06/08/2019 documented, Focus. Resident has an indwelling catheter: Urinary retention r/t [related to] obstructive uropathy. Date Initiated: 06/08/2019. On 10/22/19 at 1:57 p.m., Resident # 49 was observed in his wheelchair engaged in an Ice Cream Social in the facility's activity room. Observation of Resident # 49's catheter collection bag revealed it was hanging under the wheelchair in a privacy bag. Observation of the catheter tubing revealed it was resting directly on the floor under the wheelchair. Further observation revealed Resident # 49's right foot resting on the tubing, putting the tubing between the bottom of his foot and the floor. On 10/22/19 at 2:25 p.m., Resident # 49 was observed being pushed down the hallway in his wheelchair. Observation of the wheelchair revealed the catheter collection bag was hanging under the wheelchair in a privacy bag. Observation of the catheter tubing revealed it was rubbing on the floor under the wheelchair as Resident # 49 was being pushed down the hall. On 10/23/19 at 4:10 p.m., Resident # 49 was observed sitting in his wheelchair in the hallway in front of the nurse's station. Observation of Resident # 49's catheter collection bag revealed it was hanging under the wheelchair in a privacy bag. Observation of the catheter tubing reveal it was resting directly on the floor under the wheelchair. Further observation revealed Resident # 49's right foot resting on the tubing, putting the tubing between the bottom of his foot and the floor. On 10/24/19 at 8:40 a.m., an interview was conducted with CNA [certified nursing assistant] # 1. When asked to describe how a resident's catheter collection bag and catheter tubing should be positioned when a resident is in a wheelchair, CNA # 1 stated, The bag should be in a privacy bag and the tubing and the bag should not be touching the floor. When asked why the bag and tubing should not be touching the floor, CNA # 1 stated, To prevent infection. When asked who was responsible for ensuring the catheter bag and tubing are not in contact with the floor, CNA # 1 stated, Any nursing staff. When asked how often staff check the position of the catheter bag and tubing, CNA # 1 stated, Every two hours and as needed. On 10/24/19 at 8:45 a.m., an interview was conducted with CNA # 2. When asked to describe how a resident's catheter collection bag and catheter tubing should be positioned when a resident is in a wheelchair CNA # 2 stated, The bag should be in a privacy bag and the tubing and the bag should not be touching the floor. When asked why it should not be touching the floor CNA # 2 stated, To prevent infection. On 10/24/19 at 8:50 a.m., an interview was conducted with LPN [licensed practical nurse # 1, regarding how a resident's catheter collection bag and catheter tubing should be positioned when a resident is in a wheelchair. LPN # 1 stated, The bag should be in a privacy bag and the tubing and the bag should not be touching the floor. When asked why the Foley catheter bag and tubing should not be touching the floor, LPN # 1 stated, To prevent it from leaking, or tearing and for infection. When asked who was responsible for ensuring the catheter bag and tubing are not in contact with the floor, LPN # 1 stated, Any nursing staff. When asked how often the position of the catheter bag and tubing are checked, LPN # 1 stated, Every two hours and as needed. According to Lippincott Manual of Nursing Practice, Eighth Edition 2006, chapter 21, Renal and Urinary Disorders, page 757, Maintaining a Closed Urinary Drainage System: Many UTI's (urinary tract infections) are due to extrinsically acquired organisms transmitted by cross-contamination. 2. c. Keep the drainage bag off the floor to prevent bacterial contamination. On 10/24/19 at 12:10 p.m. ASM [administrative staff member] # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] A type of movement disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/parkinsonsdisease.html. [2] A condition in which the flow of urine is blocked. This causes the urine to back up and injure one or both kidneys. This information was obtained from the website: https://medlineplus.gov/ency/article/000507.htm. [3] Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview and facility document review it was determined facility staff failed to provide respiratory services consistent with professional standards of practice, the comprehensive person-centered plan for one of 47 residents in the survey sample, Resident #23. The facility staff failed to provide the incentive spirometer (1) treatments every hour while awake as ordered on the After Visit Summary from the hospital upon readmission to the facility for Resident #23. The finding include: Resident #23 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to sepsis (2), and orthopedic (3) aftercare. Resident #23's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/03/19, coded Resident #23 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making daily decisions. The document Discharge Summary; After Visit Summary provided by the discharging provider on 10/18/2019 documented the following for Resident #23. - This after visit summary contains important discharge instructions related to your care after discharge from the hospital. - Additional instructions as follows: Use Incentive Spirometer every hour while awake . The eTAR (electronic treatment administration record) dated 10/1/2019-10/31/2019 for Resident #23 failed to evidence documentation of the incentive spirometer every hour while awake. On 10/22/19 at approximately 2:30 p.m., an interview was conducted with Resident #23. Resident #23 was observed to be sitting in the wheelchair beside the bed wearing an oxygen cannula. An incentive spirometer was observed on the bedside table in front of Resident #23. When asked about the incentive spirometer on the table, Resident #23 stated that it was given to her when she was at the hospital the prior week following hip surgery. When asked if the staff assist her with using it, Resident #23 stated that she does it herself five or six times a day. When asked if the staff know that she is using the incentive spirometer, Resident #23 stated, Yes. When asked if the staff assist her to use it Resident #23 stated, Sometimes they do. The physicians Order Summary Report dated Oct (October) 21, 2019 and [DATE] for Resident #23 failed to evidence documentation of an active order for the incentive spirometer use. The comprehensive care plan for Resident #23 dated 10/23/2019 failed to evidence documentation of a comprehensive care plan for use of the incentive spirometer. On 10/23/19 at 4:35 p.m., an interview was conducted with RN (registered nurse) #5. When asked about the incentive spirometer for Resident #23, RN #5 stated that it was brought back from the hospital last Tuesday when the resident had a surgery performed. When asked if Resident #23 uses the incentive spirometry RN #5 stated, Yes, she does. When asked if it is documented how often the resident uses the incentive spirometer RN #5 stated that there was no official order and they do not document when she uses it. When asked how staff know when and if the resident is using the incentive spirometer as instructed RN #5 stated that the resident is alert and oriented and she does the incentive spirometer herself. On 10/24/19 at 11:20 a.m., an interview was conducted with RN (registered nurse) #3, the assistant director of nursing. When asked about the incentive spirometer for Resident #23 RN #3 stated that she was not aware the resident had one or was using it until today but other staff were aware. When asked if a resident has an incentive spirometer and uses it if it is documented RN #3 stated that she did not think so. RN #3 stated that they have never put orders in for incentive spirometers in the past and that most residents do not have them. When asked how staff know when the resident is using the incentive spirometer if it is not documented RN#3 stated that the situation has never come up before that she knows of. When asked what standard of practice is used at the facility RN #3 stated that they use their policies and [NAME]. On 10/24/19 at approximately 8:30 a.m., a request was made to ASM (administrative staff member) #2, the director of nursing for the facility policy on incentive spirometry use and storage. On 10/24/19 at approximately 12:00 p.m., the facility's policy Oxygen Therapy- Mask & Nasal Cannula was provided. The policy failed to evidence guidance on incentive spirometers. According to Lippincott Nursing Procedures, Seventh edition, page 384 documented in part Documentation .Document the flow or volume levels, date and time of the procedure, type of spirometer, and number of breaths taken. Also record the patient's condition before and after the procedure, tolerance for the procedure, and the results of the preprocedure and postprocedure auscultation. On 10/24/19 at approximately 12:15 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: 1. Incentive spirometer- An incentive spirometer is a device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm 2. Sepsis- An illness in which the body has a severe, inflammatory response to bacteria or other germs. The symptoms of sepsis are not caused by the germs themselves. This information was obtained from the website: https://medlineplus.gov/ency/article/000666.htm. 3. Orthopedic or orthopedic services, aim at the treatment of the musculoskeletal system. This information was obtained from the website: https://medlineplus.gov/ency/article/007455.htm

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store controlled substances per regulations in one of two observed medication storage rooms, the willow medication storage room. The facility staff failed to store controlled substances in a separately locked, permanently affixed compartment. The findings include: On 10/23/19 at 10:45 a.m., observation of a medication refrigerator in the willow unit medication storage room was conducted, accompanied by LPN (licensed practical nurse) #2. LPN #2 unlocked the medication refrigerator. The following was observed inside the medication refrigerator: - Two bottles of lorazepam intensol (1) solution inside of a separately locked compartment that was unlocked. - Three bottles of lorazepam intelsol solution on a shelf on top of the separately locked compartment. - The separately locked compartment was attached/under the refrigerator shelf that could be completely removed from the refrigerator. Other medications such as insulin were also stored in the refrigerator. On 10/23/19 at 11:03 a.m., an interview was conducted with LPN #2. LPN #2 was asked how lorazepam intensol should be stored. LPN #2 stated, In a locked box in a locked refrigerator. When asked if someone should be able to remove the locked box from the refrigerator, LPN #2 stated, No. LPN #2 confirmed all of the above observations. The facility/pharmacy policy titled, 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles documented, 12.2 After receiving controlled substances and adding to inventory, Facility should ensure that Schedule II-V controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable Law). On 10/23/19 at 4:25 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was provided prior to exit. (1) Lorazepam is a prescription medicine used: To treat anxiety disorders. Lorazepam is a federal controlled substance (C-IV) because it can be abused or lead to dependence. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=5ff82103-cc57-4af9-9362-82a7c686271d

Based on observation, staff interview, and facility document review it was determined facility staff failed to serve and store food in a sanitary manner. The facility staff failed to document an opened date on dry goods in the kitchen and discard thickened tea past its use by date in the stand-up refrigerator. The findings include: On 10/22/19 at approximately 12:30 p.m., an observation of the facility's kitchen was conducted with OSM (other staff member) #7, the dietary manager. Observation of the dry food storage area revealed an opened 16-ounce bag of miniature marshmallows approximately one-half full. Observation of the bag failed to evidence an opened or use by date. OSM #7 stated that the bag should have been dated when opened. OSM #7 removed the bag from the dry storage area. Further observation of the kitchen area revealed a double door stand up refrigerator, which contained a 46-ounce carton, labeled honey like consistency thickened sweetened tea. Further observation of the carton revealed a date of 7/3/19 written in black marker and a yellow stick-on note attached to the carton with UB [use by] 10-3-19. When asked what the dates meant, OSM #7 stated that 7/3/19 was the date the carton was received at the facility and that 10-3-19 was the date that the carton should be used by. When asked if the carton should be in the stand-up refrigerator, OSM #7 stated, No. When asked if it was available for use, OSM #7 stated, Yes, but she did not think that there were any residents who drink that anymore. OSM #7 stated that is should have been removed from the refrigerator on 10-3-19. On 10/22/19 at 1:00 p.m., an interview was conducted with OSM #7. When asked about the process for opened dry goods, OSM #7 stated that items are dated when opened. When asked about the one-half full, 16-ounce bag of mini marshmallows observed in the kitchen dry storage area, OSM #7 stated, They should have had a date. When asked the process staff follows for opened refrigerated items, OSM #7 stated that they are dated when opened and discarded when they reach the use by date. OSM #7 stated that the thickened sweetened tea found in the stand-up refrigerator had not been used because there were not any residents that drink it at the facility currently. The facility policy Food in Storage Areas documented in part, Dry storage; Be sure to label and date the container. Folding the top down, taping, or wrapping the item in plastic wrap is not sufficient. The policy failed to document guidance on discarding refrigerated items past their use by date. According to ServSafe Manager, 7th edition, 2017, page 5.16 documented If you find expired, damaged, spoiled, or incorrectly stored food that has become unsafe, you should discard it. This includes food that is missing a date mark, ready-to-eat TCS (time/temperature control for safety) food that has exceeded its date mark, and food that has exceeded time/temperature requirements. On 10/24/19 at approximately 12:15 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to maintain an accurate clinical record for two of 47 residents in the survey sample, Residents #67 and #12. Resident #67's Level 1 (initial) PASRR (Preadmission Screening and Resident Review) screening was coded incorrectly at the time of Resident #67's admission on [DATE]. The facility staff failed to ensure that Resident #12's clinical record did not contain documents that belonged to another resident. The findings include: 1. Resident #67 was admitted to the facility on [DATE]; diagnoses include, but are not limited to, Parkinson's disease (1) and schizophrenia (2). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 9/20/19, Resident #67 was coded as being mildly cognitively impaired for making daily decisions, having scored 13 out of 15 on the BIMS (brief interview for mental status). On the admission MDS, with an assessment reference date of 6/20/19, in Section A1500, Resident #20 was coded as not having been evaluated by a Level 2 PASRR (Preadmission Screening and Resident Review), and determined to have a serious mental illness and/or mental retardation or a related condition. A review of Resident #20's clinical record revealed a document, Screening for Mental Illness, Mental Retardation/Intellectual Disability, or Related Conditions. A review of this document revealed, in part, the following: 5. RECOMMENDATION: a. Refer for secondary assessment .MI (mental illness). The a. was circled. Further review of the clinical record revealed no evidence of a secondary assessment for Resident #20. On 10/23/19 at 11:11 a.m., OSM (other staff member) # 3, the social services director, was interviewed. When asked why the secondary mental health assessment had not been done for Resident #20, OSM #3 stated, Sometimes it can take a few months to get them done. When asked the purpose of a secondary/level 2 assessment for a resident, OSM #3 stated, I am really new to this job. I've only been here a few months. I'm not really sure, to tell you the truth. Let me get back to you and let you know. On 10/23/19 at 3:30 p.m., OSM #3 returned and stated, I have done some checking. The Level 1 (initial) screening was coded incorrectly. This resident should never have been marked as needing any follow-up. She doesn't need screening for additional services. She does not qualify. It is a mistake in the document. On 10/24/19 at 11:00 a.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Pre-admission Screening, revealed, in part, the following: Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. No further information was provided prior to exit. (1) Parkinson's disease (PD) is a type of movement disorder. It happens when nerve cells in the brain don't produce enough of a brain chemical called dopamine. Sometimes it is genetic, but most cases do not seem to run in families. This information is taken from the website https://medlineplus.gov/parkinsonsdisease.html. (2) Schizophrenia is a serious brain illness. People who have it may hear voices that aren't there. They may think other people are trying to hurt them. Sometimes they don't make sense when they talk. The disorder makes it hard for them to keep a job or take care of themselves. This information is taken from the website https://medlineplus.gov/schizophrenia.html 2. The facility staff failed to ensure that Resident #12's clinical record did not contain documents that belonged to another resident. Resident #12 was admitted on [DATE], diagnoses include but are not limited to, high blood pressure, heart disease, edema, atrial fibrillation, congestive heart failure, and diabetes. The annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/11/19 coded the resident as being severely impaired in ability to make daily life decisions, scoring a 3 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. A review of the clinical record revealed a physician's progress note that belonged to another resident. On 10/24/19 at 9:22 AM, an interview was conducted with OSM (other staff member) #5, Medical Records. When asked about the process for filing in the charts, OSM #5 stated, We go through them, file and remove items to be thinned out. OSM #5 stated, We have folders for each unit with room numbers, we file the paperwork in there and then file them in the charts. Whenever we go to thin the records we try to check to see if stuff is misplaced or the wrong stuff is in there. When asked how frequently this process is completed, OSM #5 stated, For new admission people we check in 72 hours and in 15 days. For long-term care people we just do it whenever we think it needs to be thinned. There is no time schedule on it. When asked if another resident's paperwork should be on Resident #12's chart, OSM #5 stated, No. Because it wasn't for that resident. When asked if there was any potential outcome for having another resident's paperwork on the wrong chart, OSM #5 stated, It could be if that person went out and it got sent to an appointment or hospital and someone else could have got that information. On 10/24/19 at 12:16 AM, ASM #1 (Administrative Staff Member) the Executive Director, and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to implement infection control practices for storage of the incentive spirometer (1) Resident #23. Resident #23 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to sepsis (2), and orthopedic (3) aftercare. Resident #23's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/03/19, coded Resident #23 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making daily decisions. On 10/22/19 at approximately 2:30 p.m., an observation was made of Resident #23's room. Resident #23 was observed to be sitting beside the bed in a wheelchair, with the bedside table in front of her. An uncovered incentive spirometer was observed on the bedside table in front of Resident #23. The incentive spirometer was located between a foam cup with a lid and straw and a box of tissues. At this time, an interview was conducted with Resident #23. When asked about the incentive spirometer on the table Resident #23 stated that it was given to her when she was at the hospital the prior week following hip surgery. When asked if had used it recently Resident #23 stated she had used it this morning and she tries to do it five or six times a day. When asked if the staff know that she is using the incentive spirometer Resident #23 stated, Yes. When asked how the incentive spirometer is stored Resident #23 stated that it stays on the bedside table. When asked if it is ever covered Resident #23 stated, No. Additional observations on 10/22/19 at 4:15 p.m., 10/23/19 at 9:00 a.m., and 10/24/19 at 9:15 a.m. revealed the incentive spirometer uncovered on the bedside table in Resident #23's room. The document Discharge Summary; After Visit Summary dated 10/18/2019 for Resident #23 documented Additional instructions as follows: Use Incentive Spirometer every hour while awake . On 10/23/19 at 4:25 p.m., an interview was conducted with LPN (licensed practical nurse) #3. When asked how incentive spirometers are stored LPN #3 stated that she was not sure. When asked if an incentive spirometer should be covered, LPN #3 stated that they have never been covered in the years that she has worked at the facility. LPN #3 stated that CPAP (continuous positive airway pressure) masks and nebulizer (handheld mouthpiece for medication delivery) are stored covered. LPN #3 stated that incentive spirometers could possibly be stored like these items as well. When asked why the CPAP masks and nebulizers are covered LPN #3 stated for infection control purposes. On 10/23/19 at 4:35 p.m., an interview was conducted with RN (registered nurse) #5. When asked the process for storage of incentive spirometers RN #5 stated that they are uncovered and have never covered them in the past. RN #5 stated that staff have never been told that they should but she would consider it if it was something that needed to be done. When asked the process for storage of other respiratory items that reach the residents mouth RN #5 stated that they are stored covered. When asked why RN #5 stated to keep them clean. When asked about the incentive spirometer for Resident #23, RN #5 stated that it was brought back from the hospital last Tuesday when the resident had a surgery performed. When asked if Resident #23 uses the incentive spirometry RN #5 stated, Yes, she does. On 10/24/19 at 11:20 a.m., an interview was conducted with RN (registered nurse) #3, the assistant director of nursing. When asked what the purpose of an incentive spirometer, RN #3 stated that it is a piece of equipment used after surgery to expand the lungs and prevent atelectasis (lung collapse). When asked how it should be stored, RN #3 stated that she was not sure. When asked if an incentive spirometer reaches the resident's mouth, RN #3 stated, Yes. When asked if respiratory equipment that reaches a resident's mouth should be kept clean, RN #3 stated yes and that infection control measures should be in place to keep it clean and it should be kept covered. When asked about the incentive spirometer for Resident #23, RN #3 stated that she was not aware the resident had one or was using it until today but other staff were aware. When asked what standard of practice is used at the facility RN #3 stated that they use their policies and [NAME]. On 10/24/19 at approximately 8:30 a.m., a request was made to ASM (administrative staff member) #2, the director of nursing for the facility policy on incentive spirometry use and storage. On 10/24/19 at approximately 12:00 p.m., the facility's policy Oxygen Therapy- Mask & Nasal Cannula was provided. The policy failed to evidence guidance on the storage of incentive spirometers. According to [NAME]'s Nursing Procedures seventh edition, page 384 documented, Wash the mouthpiece in warm water and dry it. Avoid immersing the spirometer itself in water because water enhances bacterial growth and impairs the internal filter's effectiveness in preventing inhalation of extraneous material. Place the mouthpiece in a plastic storage bag between exercises, and label it and the spirometer, if applicable, with the patient's name to avoid inadvertent use by another patient. Keep the incentive spirometer within the patient's reach. On 10/24/19 at approximately 12:15 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: 1. Incentive spirometer An incentive spirometer is a device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. Using the incentive spirometer teaches you how to take slow deep breaths. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm 2. Sepsis An illness in which the body has a severe, inflammatory response to bacteria or other germs. The symptoms of sepsis are not caused by the germs themselves. Instead, chemicals the body releases cause the response. This information was obtained from the website: https://medlineplus.gov/ency/article/000666.htm. 3. Orthopedic Orthopedics, or orthopedic services, aim at the treatment of the musculoskeletal system. This includes your bones, joints, ligaments, tendons, and muscles. This information was obtained from the website: https://medlineplus.gov/ency/article/007455.htm Based on resident interview, staff interview, clinical record review and facility document review, it was determined that facility staff failed to implement infection control practices for the care of an indwelling catheter for two of 47 residents in the survey sample, Residents # 49 and # 23. The facility staff failed to maintain Resident # 49 catheter tubing off the floor to prevent possible infection while he was sitting in his wheelchair. The findings include: 1. Resident # 49 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Parkinson's disease [1], obstructive and reflux uropathy [2] and anxiety [3]. Resident # 49's most recent MDS (minimum data set), an quarterly assessment with an ARD (assessment reference date) of 09/06/19, coded Resident # 49 as scoring a four on the brief interview for mental status (BIMS) of a score of 0 - 15, four - being severely impaired of cognition for making daily decisions. Resident # 49 was coded as requiring extensive assistance of one staff member for all activities of daily living. Section H Bladder and Bowel coded Resident # 50 as having an indwelling catheter [2]. On 10/22/19 at 1:57 p.m., Resident # 49 was observed in his wheelchair engaged in an Ice Cream Social in the facility's activity room. Observation of Resident # 49's catheter collection bag revealed it was hanging under the wheelchair in a privacy bag. Observation of the catheter tubing reveal it was resting directly on the floor under the wheelchair. Further observation revealed Resident # 49's right foot resting on the tubing, putting the tubing between the bottom of his foot and the floor. On 10/22/19 at 2:25 p.m., Resident # 49 observed being pushed down the hallway in his wheelchair. Observation of the wheelchair revealed the catheter collection bag was hanging under the wheelchair in a privacy bag. Observation of the catheter tubing reveal it was rubbing on the floor under the wheelchair as Resident # 49 was being pushed down the hall in his wheelchair. On 10/23/19 at 4:10 p.m., Resident # 49 was observed sitting in his wheelchair in the hallway in front of the nurse's station. Observation of Resident # 49's catheter collection bag revealed it was hanging under the wheelchair in a privacy bag. Observation of the catheter tubing reveal it was resting on the floor under the wheelchair. Further observation revealed Resident # 49's right foot resting on the tubing, putting the tubing between the bottom of his foot and the floor. The POS [physician's order sheet] for Resident # 39 dated OCT [October] 2019 documented, Catheter Care every shift and p.m. every shift for PREVENTION. Date Ordered: 06/19/2019. The comprehensive care plan for Resident # 49 dated 06/08/2019 documented, Focus. Resident has an indwelling catheter: Urinary retention r/t [related to] obstructive uropathy. Date Initiated: 06/08/2019. On 10/24/19 at 8:40 a.m., an interview was conducted with CNA [certified nursing assistant] # 1. When asked to describe how a resident's catheter collection bag and catheter tubing should be positioned when a resident is in a wheelchair CNA # 1 stated, The bag should be in a privacy bag and the tubing and the bag should not be touching the floor. When asked why it should not be touching the floor CNA # 1 stated, To prevent infection. When asked who was responsible for ensuring the catheter bag and tubing are not in contact with the floor CNA # 1 stated, Any nursing staff. When asked how often the position of the catheter bag and tubing are checked, CNA # 1 stated, Every two hours and as needed. On 10/24/19 at 8:45 a.m., an interview was conducted with CNA # 2. When asked to describe how a resident's catheter collection bag and catheter tubing should be positioned when a resident is in a wheelchair, CNA # 2 stated, The bag should be in a privacy bag and the tubing and the bag should not be touching the floor. When asked why it should not be touching the floor, CNA # 2 stated, To prevent infection. On 10/24/19 at 8:50 a.m., an interview was conducted with LPN [licensed practical nurse # 1. When asked to describe how a resident's catheter collection bag and catheter tubing should be positioned when a resident is in a wheelchair, LPN # 1 stated, The bag should be in a privacy bag and the tubing and the bag should not be touching the floor. When asked why it should not be touching the floor, LPN # 1 stated, To prevent it from leaking, or tearing and for infection. When asked who was responsible for ensuring the catheter bag and tubing are not in contact with the floor, LPN # 1 stated, Any nursing staff. When asked how often the position of the catheter bag and tubing are checked, LPN # 1 stated, Every two hours and as needed. On 10/24/19 at 12:10 p.m. ASM [administrative staff member] # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] A type of movement disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/parkinsonsdisease.html. [2] A condition in which the flow of urine is blocked. This causes the urine to back up and injure one or both kidneys. This information was obtained from the website: https://medlineplus.gov/ency/article/000507.htm. [3] Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility staff failed to periodically review Resident #27's (or the resident's representative) decisions regarding advance directives. Resident #27 was admitted to the facility on [DATE] with a readmission on [DATE]. Resident #27's diagnoses included but were not limited to atrial fibrillation (1) and diabetes (2). Resident #27's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of [DATE], coded Resident #27 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Review of Resident #27's clinical record revealed a document Advance Directives/Medical Treatment Decisions Acknowledgement of Receipt dated [DATE] but failed to evidence documentation of periodic review after [DATE]. Further review of the clinical record revealed a document Consent for Treatment dated [DATE], which documented the resident and/or resident's representative receiving information regarding advanced directives on readmission to the facility but failed to evidence documentation of periodic review after [DATE]. The comprehensive care plan for Resident #27 dated [DATE] documented Resident has Advance Directives DNR-Do Not Resuscitate; Date initiated: [DATE]; Revision on [DATE]. Under Goal it documented, Resident's Advance Directives will be honored. Date initiated: [DATE]. Under Interventions/Tasks it documented, Code status will be reviewed on a quarterly basis and PRN (as needed); Date initiated: [DATE]. On [DATE] at approximately 3:30 p.m., an interview was conducted with Resident #27. When asked if staff periodically review advance directives, Resident #27 stated, I don't think so. On [DATE] at 12:30 p.m., an interview was conducted with OSM (other staff member) #3, social services director. When asked if periodic reviews of Advance Directives are conducted with the residents and/or the resident's representative, OSM #3 stated, I don't do that. I don't know if anyone does. We review the code status but I don't know about Advance Directives. On [DATE] at approximately 1:00 p.m., a request was made in writing to ASM (administrative staff member) #2, the director of nursing, for additional information on any evidence of periodic advance directive review for Resident #27. On [DATE] at approximately 5:30 p.m., a progress note was received from ASM #2 for Resident #27. The note documented, Note Text: Significant Change of Condition: Resident was alert and oriented today. BIM (Brief Interview for Mental Status) score was 15/15. MOOD (depression rating scale) score was 03 indicated minimal depression .Current code status is DNR (do not resuscitate). SS (social services) will continue to monitor for cognitive loss. The progress note failed to evidence documentation of periodic review of advance directives. On [DATE] at approximately 8:00 a.m., an interview was conducted with OSM (other staff member) #3, the director of social services. When asked what is discussed during care plan meetings, OSM #3 stated that currently only code status is being reviewed in care plan meetings. OSM #3 stated that periodic review or offering to establish an advance directive is not being done at the quarterly care plan meetings or periodically at the facility. The facility policy, Advance Directives documented, 7. Each time the resident is admitted to the facility, quarterly, after a significant change, and as needed, Social Services should review the advance directive information for accuracy with the resident or legal representative and document the findings in the progress notes. On [DATE] at approximately 12:15 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. References: 1. Atrial fibrillation- A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html 2. Diabetes- A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm. 5. The facility staff failed to periodically review Resident #82's (or the resident's representative) decisions regarding advance directives. Resident #82 was admitted to the facility on [DATE] with a readmission on [DATE]. Resident #82's diagnoses included but were not limited to major depressive disorder (1) and diabetes (2). Resident #82's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident #82 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Review of Resident #82's clinical record revealed a document Consent for Treatment dated [DATE], which documented the resident and/or resident's representative receiving information regarding advanced directives on admission to the facility but failed to evidence documentation of periodic review after [DATE]. The comprehensive care plan for Resident #82 dated [DATE] documented Resident has Advance Directives DNR-Do Not Resuscitate; Date initiated: [DATE]; Revision on [DATE]. Under Goal it documented, Resident's Advance Directives will be honored. Date initiated: [DATE]. Under Interventions/Tasks it documented, Code status will be reviewed on a quarterly basis and PRN (as needed); Date initiated: [DATE]. On [DATE] at approximately 9:15 p.m., an interview was conducted with Resident #82. When asked if staff periodically review advance directives, Resident #82 stated that he did not know what that was. On [DATE] at 12:30 p.m., an interview was conducted with OSM (other staff member) #3, social services director. When asked if periodic reviews of Advance Directives are conducted with the residents and/or the resident's representative, OSM #3 stated, I don't do that. I don't know if anyone does. We review the code status but I don't know about Advance Directives. On [DATE] at approximately 1:00 p.m., a request was made in writing to ASM (administrative staff member) #2, the director of nursing, for additional information on any evidence of periodic advance directive review for Resident #82. On [DATE] at approximately 5:30 p.m., ASM #2 provided a packet of documents for Resident #82. The Care Plan Conference Record dated [DATE] documented Advance Directive: POST (Virginia Physician Orders for Scope of Treatment) Form. Review of the referenced document POST form for Resident #82 revealed a status of DNR (do not resuscitate)/No CPR (cardiopulmonary resuscitation), Comfort Measures, No feeding tube dated [DATE]. Additional documents provided by the facility revealed a progress note for Resident #82. The note documented, Note Text: Quarterly Note: BIM/PHQ9 (brief interview for mental status/patient health questionnaire) interview conducted with resident in the midafternoon in his room with minimal distractions. BIM score was 15 with no indication of cognitive loss .Resident current code status is DNR (do not resuscitate) .SS (social services will continue to monitor. On [DATE] at approximately 8:00 a.m., an interview was conducted with OSM (other staff member) #3, the director of social services. When asked what is discussed during care plan meetings, OSM #3 stated that currently only code status is being reviewed in care plan meetings. OSM #3 stated that periodic review or offering to establish an advance directive is not being done at the quarterly care plan meetings or periodically at the facility. On [DATE] at approximately 12:15 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. References: 1. Major depressive disorder is a mood disorder. This information was obtained from the website: https://medlineplus.gov/ency/article/000945.htm. 2. Diabetes is a chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm 6. The facility staff failed to evidence periodic reviews were conducted to provide Resident # 88 and/or Resident # 88's representative, with the opportunity to develop an advance directive. Resident # 88 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Parkinson's disease [1], osteoporosis [2] and anxiety [3]. Resident # 88's most recent MDS (minimum data set), an quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident # 88 as scoring a 12 on the brief interview for mental status (BIMS) of a score of 0 - 15, 12 - being moderately impaired of cognition for making daily decisions. The clinical record and the EHR (electronic health record) for Resident # 88 failed to evidence an advance directive. On [DATE] at 12:30 PM in an interview was conducted with OSM [other staff member] # 3, Social Worker. When asked if the facility does periodic reviews of advance directives or to develop an advance directive with the residents and/or responsible party, OSM #3 stated, I don't do periodic reviews. We review the code status. On [DATE] at 7:57 AM, during a follow up interview with OSM #3; she provided notes where Resident #89's code status was reviewed but not advance directives. When asked if a periodic review or opportunity to establish advance directives, at a later- time other than at admission, was completed, OSM #3 stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. On [DATE] at 12:10 p.m. ASM [administrative staff member] # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] A type of movement disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/parkinsonsdisease.html. [2] Makes your bones weak and more likely to break. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/osteoporosis.html. [3] Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary. 7. The facility staff failed to evidence periodic reviews were conducted to provide Resident # 85 and/or Resident # 85's representative with the opportunity to develop an advance directive. Resident # 85 was admitted to the facility on [DATE] and a readmission of [DATE] with diagnoses that included but were not limited to chronic obstructive pulmonary disease [1], chronic kidney disease [2] and anxiety [3]. Resident # 85's most recent MDS (minimum data set), an quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident # 85 as scoring a nine on the brief interview for mental status (BIMS) of a score of 0 - 15, nine - being moderately impaired of cognition for making daily decisions. The clinical record and the EHR (electronic health record) for Resident # 88 failed to evidence an advance directive. On [DATE] at 12:30 PM in an interview was conducted with OSM [other staff member] # 3, Social Worker. When asked if the facility does periodic reviews of advance directives, or to provide information and develop an advance directive with the residents and/or responsible party, OSM #3 stated, I don't do periodic reviews. We review the code status. On [DATE] at 7:57 AM, in a follow up interview with OSM #3, she provided notes where Resident #85's code status was reviewed but no information for review of the residents advance directives. When asked if a periodic review or opportunity for the resident's right to establish advance directives, at a later- time other than at admission, was done, OSM #3 stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. On [DATE] at 12:10 p.m. ASM [administrative staff member] # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. [2] Kidneys are damaged and can't filter blood as they should. This information was obtained from the website: https://medlineplus.gov/chronickidneydisease.html. [3] Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary. 8. The facility staff failed to evidence periodic reviews were conducted to provide Resident # 49 and/or Resident # 49's representative with the opportunity to develop an advance directive. Resident # 49 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Parkinson's disease [1], high blood pressure and anxiety [2]. Resident # 49's most recent MDS (minimum data set), an quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident # 49 as scoring a four on the brief interview for mental status (BIMS) of a score of 0 - 15, four - being severely impaired of cognition for making daily decisions. The clinical record and the EHR (electronic health record) for Resident # 49 failed to evidence an advance directive. On [DATE] at 12:30 PM in an interview was conducted with OSM [other staff member] # 3, Social Worker. When asked if the facility does periodic reviews of advance directives or provides information to develop an advance directive with the residents and/or responsible party, OSM #3 stated, I don't do periodic reviews. We review the code status. On [DATE] at 7:57 AM, a follow up interview was conducted with OSM #3. She provided notes where code status was reviewed for Resident #49 but not advance directives. When asked if a periodic review or opportunity to establish advance directives at a later -time other than at admission was completed, OSM #3 stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. On [DATE] at 12:10 p.m. ASM [administrative staff member] # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] [A type of movement disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/parkinsonsdisease.html. [2] Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary. 9. The facility staff failed to evidence periodic reviews were conducted to provide Resident # 15 and/or Resident # 15's representative with the opportunity to develop an advance directive. Resident # 15 was admitted to the facility on [DATE] and a readmission of [DATE] with diagnoses that included but were not limited to hemiplegia [1], heart disease [2] and atrial fibrillation [3]. Resident # 15's most recent MDS (minimum data set), an significant change assessment with an ARD (assessment reference date) of [DATE], coded Resident # 15 as scoring a seven on the brief interview for mental status (BIMS) of a score of 0 - 15, seven - being severely impaired of cognition for making daily decisions. The clinical record and the EHR (electronic health record) for Resident # 15 failed to evidence an advance directive. On [DATE] at 12:30 PM in an interview was conducted with OSM [other staff member] # 3, Social Worker. When asked if the facility does periodic reviews of advance directives or provides information to develop an advance directive with the residents and/or responsible party, OSM #3 stated, I don't do periodic reviews. We review the code status. On [DATE] at 7:57 AM, a follow up interview was conducted with OSM #3. She provided notes documenting the code status for Resident #15was reviewed, but no documentation evidencing advance directives were reviewed. When asked if a periodic review or opportunity to establish advance directives at a later -time other than at admission was completed, OSM #3 stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. On [DATE] at 12:10 p.m. ASM [administrative staff member] # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] Also called: Hemiplegia, Palsy, Paraplegia, Quadriplegia. Paralysis is the loss of muscle function in part of your body. This information was obtained from the website: https://medlineplus.gov/paralysis.html. [2] There are many different forms of heart disease. The most common cause of heart disease is narrowing or blockage of the coronary arteries, the blood vessels that supply blood to the heart itself. This is called coronary artery disease and happens slowly over time. This information was obtained from the website: https://medlineplus.gov/heartdiseases.html. [3] A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html. 10. The facility staff failed to evidence periodic reviews were conducted to provide Resident # 8 and/or Resident # 8's representative with the opportunity to develop an advance directive. Resident # 8 was admitted to the facility on [DATE] and a readmission of [DATE] with diagnoses that included but were not limited to hemiplegia [1], heart disease [2] and atrial fibrillation [3]. Resident # 8's most recent MDS (minimum data set), an significant change assessment with an ARD (assessment reference date) of [DATE], coded Resident # 8 as scoring a 13 on the brief interview for mental status (BIMS) of a score of 0 - 15, 13 - being cognitively intact for making daily decisions. The clinical record and the EHR (electronic health record) for Resident # 8 failed to evidence an advance directive. On [DATE] at 12:30 PM in an interview was conducted with OSM [other staff member] # 3, Social Worker. When asked if the facility does periodic reviews of advance directives or to develop an advance directive with the residents and/or responsible party, she stated, I don't do periodic reviews. We review the code status. On [DATE] at 7:57 AM, a follow up interview was conducted with OSM #3. She provided notes where code status for Resident #8 was reviewed but no documentation evidencing advance directives were reviewed. When asked if a periodic review or opportunity to establish advance directives at a later -time other than at admission was completed, OSM #3 stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. On [DATE] at 12:10 p.m. ASM [administrative staff member] # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] Also called: Hemiplegia, Palsy, Paraplegia, Quadriplegia. Paralysis is the loss of muscle function in part of your body. It can also occur in just one area, or it can be widespread This information was obtained from the website: https://medlineplus.gov/paralysis.html. [2] There are many different forms of heart disease. The most common cause of heart disease is narrowing or blockage of the coronary arteries, the blood vessels that supply blood to the heart itself. This is called coronary artery disease and happens slowly over time. This information was obtained from the website: https://medlineplus.gov/heartdiseases.html. [3] A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html. 11. The facility staff failed to evidence periodic reviews were conducted to provide Resident # 21 and/or Resident # 21's representative with the opportunity to develop an advance directive. Resident # 21 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia [1], high blood pressure and osteoarthritis [2]. Resident # 21's most recent MDS (minimum data set), an quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident # 21 as scoring a five on the brief interview for mental status (BIMS) of a score of 0 - 15, five - being severely impaired of cognition for making daily decisions. The clinical record and the EHR (electronic health record) for Resident # 21 failed to evidence an advance directive. On [DATE] at 12:30 PM in an interview was conducted with OSM [other staff member] # 3, Social Worker. When asked if the facility does periodic reviews of advance directives or to develop an advance directive with the residents and/or responsible party, she stated, I don't do periodic reviews. We review the code status. On [DATE] at 7:57 AM, during a follow up interview with OSM #3, she provided notes where Resident #21's code status was reviewed but not the residents advance directives. When asked if a periodic review or opportunity to establish advance directives at a later -time, other than at admission, was done, OSM #3 stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. On [DATE] at 12:10 p.m. ASM [administrative staff member] # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. [2] The most common form of arthritis. It causes pain, swelling, and reduced motion in your joints. It can occur in any joint, but usually it affects your hands, knees, hips or spine. This information was obtained from the website: https://medlineplus.gov/osteoarthritis.html. 12 The facility staff failed to evidence periodic reviews were conducted to provide Resident # 50 and/or Resident # 50's representative with the opportunity to develop an advance directive. Resident # 50 was admitted to the facility on [DATE] and a readmission of [DATE] with diagnoses that included but were not limited to dysphagia [1], high blood pressure [2] and atrial fibrillation [3]. Resident # 50's most recent MDS (minimum data set), an quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident # 50 as scoring a five on the brief interview for mental status (BIMS) of a score of 0 - 15, five - being severely impaired of cognition intact for making daily decisions. The clinical record and the EHR (electronic health record) for Resident # 50 failed to evidence an advance directive. On [DATE] at 12:30 PM in an interview was conducted with OSM [other staff member] # 3, Social Worker. When asked if the facility does periodic reviews of advance directives or to develop an advance directive with the residents and/or responsible party, OSM #3 stated, I don't do periodic reviews. We review the code status. On [DATE] at 7:57 AM, during a follow up interview with OSM #3, she provided notes where Resident #50's code status was reviewed but not the residents advance directives. When asked if a periodic review or opportunity to establish advance directives at a later -time, other than at admission, was done, OSM #3 stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. On [DATE] at 12:10 p.m. ASM [administrative staff member] # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. [2] A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html. 13. The facility staff failed to evidence periodic reviews were conducted regarding Resident # 43's advance directive. Resident # 43 was admitted to the facility on [DATE] and a readmission of [DATE] with diagnoses that included but were not limited to dysphagia [1], high blood pressure [2] and atrial fibrillation [3]. Resident # 43's most recent MDS (minimum data set), an quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident # 43 as scoring a ten on the brief interview for mental status (BIMS) of a score of 0 - 15, five - being severely impaired of cognition intact for making daily decisions. The clinical record and the EHR (electronic health record) for Resident # 50 evidenced an Advance Medical Directive dated 21st [DATE]. Further review failed to evidence periodic reviews of the advance directive. On [DATE] at 12:30 PM in an interview was conducted with OSM [other staff member] # 3, Social Worker. When asked if the facility does periodic reviews of advance directives, OSM #3 stated, I don't do periodic reviews. We review the code status. On [DATE] at 7:57 AM, during a follow up interview with OSM #3, she provided notes where Resident #43's code status was reviewed but not the residents advance directives. When asked if a periodic review or opportunity to establish advance directives at a later -time, other than at admission, was done, OSM #3 stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. On [DATE] at 12:10 p.m. ASM [administrative staff member] # 1, executive director and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. [2] A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html. Based on staff interview, resident interview, facility document review and clinical record review, it was determined that the facility staff failed to meet Advance Directive requirements for Thirteen of 47 residents in the survey sample, Residents #71, #52, #64, #27, #82, #88, #85, #49, #15, #8, #21, #50, #43. The facility staff failed to evidence resident advance directives or information for developing an advanced directive was periodically reviewed with the resident and/or Resident Representative (RR) to residents wished change anything or maintain the advanced directive as written and or formulate an advanced directive for Residents #71, #52, #64, #27, #82, #88, #85, #49, #15, #8, #21, #50, #43. The findings include: 1. The facility staff failed to evidence Resident #71's advance directives dated [DATE], was periodically reviewed with the resident and/or Resident Representative (RR) to determine if she wanted to change anything or maintain the advanced directive as written. Resident #71 was admitted to the facility on [DATE]; diagnoses included but are not limited to, dementia, chronic obstructive pulmonary disease, high blood pressure, hypothyroidism, depression, bipolar disorder, and osteoarthritis. The annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of [DATE] coded the resident as moderately significantly impaired in ability to make daily life decisions. A review of the clinical record revealed an advance directive dated [DATE]. Further review failed to reveal any evidence of periodic review with Resident #71 to determine if she wanted to change anything or maintain the advanced directive as written. On [DATE] at 12:30 PM in an interview with [NAME] #3 (Other Staff Member), Director of Social Services, when asked if the facility does periodic reviews of advance directives with the residents and/or RP, [NAME] #3 stated, I don't do that. I do not know if anyone does. We review the code status but I don't know about Advance Directives. On [DATE] at 7:57 AM, a follow up interview was conducted with [NAME] #3. She provided notes where code status was reviewed with Resident #71, but nothing evidencing advance directives had been reviewed. When asked if a periodic review or opportunity to establish advance directives later other than at admission was done, OSM #3 stated, It is not being done. She stated that the only thing reviewed in care plan meetings is the code status. The comprehensive care plan dated [DATE], documented, Resident has Advance Directive DNR - Do Not Resuscitate. This care plan included the interventions, Code status will be reviewed on a quarterly basis and PRN (as needed), and Resident has signed Do Not Resuscitate (DNR). The care plan did not include anything about the Advance Directives. A review of the facility policy, Advance Directives documented, An Advance Directive is a written document prepared by the resident as to how he/she wants medical decisions to be made should he or she lose the ability to make decisions for him or herself. The two most commonly prepared advance directives are a living will and durable power of attorney for health care. However, (facility) also recognizes the following medical orders for advance directives: Do Not Resuscitate (DNR) order Feeding Restrictions and Hydration Measures Medication Restrictions Do Not Hospitalize Organ Donation Autopsy Request Other Treatment Restrictions 7. Each time the resident is admitted to the facility, quarterly, after a significant change, and as needed, Social Services should review the advance directive information for accuracy with the resident or legal representative and document the findings in the progress notes. On [DATE] at 12:16 AM, ASM #1 (Administrative Staff Member) the Executive Director, and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. 2. The facility staff failed to evidence that a periodic review was conducted with Resident #52 and/or Resident Representative (RR) who did not have any Advance Directive, to determine if she wanted to develop an advanced directive at any time after the initial review and offer at the time of admission. Resident #52 was admitted to the facility on [DATE] with the diagnoses of but not limited to dementia, bipolar disorder, depression, insomnia, and osteoarthritis. The quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of [DATE], coded the resident as being cognitively intact in ability to make daily life decisions. A review of the clinical record

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for three of 47 residents in the survey sample, Resident #20, Resident #44 and Resident. On 10/11/19, a wound care specialist treated Resident #20. The facility did not act on the specialist's recommendations until 10/14/19, even though a facility staff member was in possession of the wound specialist's report/recommendation on the afternoon of 10/11/19. Staff also failed to monitor Resident #20's fluid intake as ordered by the physician on multiple shifts during September 2019 and October 2019 and the staff failed to look at Resident #44's abdominal binder every 30 minutes and failed to loosen the abdominal binder every two hours per physician orders. The findings include: 1. a. Resident #20 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses including, but not limited to ESRD (end stage renal disease) (1) and COPD (chronic obstructive pulmonary disease) (2). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 7/26/19, Resident #20 was coded as being cognitively intact for making daily decisions, have scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as having a wound that was not a pressure ucler, and as having received dialysis during the look back period. A review of Resident #20's clinical record revealed a physician's order dated 9/6/19, that was discontinued on 10/14/19: Cleanse left heel with NS (normal saline), pat dry, and apply wet-to dry dressing. Cover with dry gauze, wrap with kerlix (gauze wrap) and ace wrap twice daily. Further review of the record revealed the following order dated 10/14/19: Clean left heel with normal saline, pat dry and apply hydrofera blue transfer foam kling and tape three times a week, every day shift every Monday, Wednesday, and Friday. A review of Resident #20's progress notes revealed the following nurse's note written 10/12/19 at 9:17 a.m.: Orders - Administration Note: Cleanse left heel with NS, pat dry, and apply wet-to-dry dressing, cover with dry gauze, wrap with kerlix, and ace wrap twice daily .Resident states that wound center told him dressing is to be changed 3X/week (three times a week) and that they would fax orders to facility. No new orders received resident declined dressing change. A review of Resident #20's progress notes revealed the following nurse's note dated 10/12/19 at 10:01 p.m.: Orders - Administration Note: Cleanse left heel with NS, pat dry, and apply wet-to-dry dressing, cover with dry gauze, wrap with kerlix, and ace wrap twice daily. /refused drsg (dressing) change. Stated it was not due today. A review of Resident #20's progress notes revealed the following nurse's note dated 10/13/19 at 9:32 p.m.: Orders - Administration Note: Cleanse left heel with NS, pat dry, and apply wet-to-dry dressing, cover with dry gauze, wrap with kerlix, and ace wrap twice daily. States dressing is not to be chaned (sic) yet. A review of Resident #20's progress notes revealed the following nurse's note dated 10/14/19 at 12:46 p.m.: Wound center returned call back with clarification with dressing changes. Should be cleaned with normal saline then apply hydrofera blue transfer foam kling and tape. Change three times a week. A review of Resident #20's comprehensive care plan dated 9/16/19 revealed, in part, the following: At risk for break in skin integrity; Resident has left heel wound .Treatment as ordered. On 10/24/19 at l0:10 a.m., LPN (licensed practical nurse) #5 was interviewed. When asked about the above-referenced orders and communication from the wound care center, physician for Resident #20, LPN #5 stated, Usually they come back from the wound center with a consult sheet. The sheet contains any new orders and we take the orders from the consult sheet and call the attending physician. Once they are approved, we start the treatment. When asked if a resident should wait three days before new wound care orders are implemented, LPN #5 stated, No. It should happen pretty much right away. On 10/24/19 at 10:45 a.m., OSM (other staff member) #10, the transportation coordinator, provided the surveyor with a copy of the wound care consultation, report for Resident #20 from 10/11/19. The fax date stamp at the top of the page was 10/11/19 at 2:33 p.m. Under the Recommendations section, the report documented: Cleanse left heel wound with normal saline then apply hydrofera blue transfer foam, kling wrap, and tape. Change three times a week. When asked where she got this report, OSM #10 stated, It was downstairs in my office. They always fax me so I know when to set up the transportation for the next appointment. When asked if she ever shares the faxes with the nursing staff, OSM #10 stated, No, because they get their own. On 10/24/19 at 11:13 a.m., RN (registered nurse) #3, the ADON (assistant director of nursing) was interviewed. She stated the process is for residents to return from outside appointments with a consult report with them. She stated the nurse is responsible for taking care of any new orders. She further stated that on 10/11/19, Resident #20 had gone straight from the wound care physician to dialysis, and that Resident #20 had returned late in the day back to the facility. RN #3 stated that there was no wound care consult, report anywhere in the record for 10/11/19, and that Resident #20 must have returned from dialysis without the wound care consult, report. RN #3 stated that it was so late in the day (a Friday evening) that the wound care center would have been closed, and that no information would have been available about Resident #20's appointment until Monday morning, 10/14/19. At this time, RN #3 was informed about OSM #10 having the faxed wound care report. On 10/24/19 at 11:27 a.m., RN #3, returned and stated, I have been looking into this. I just now found out that the wound center also faxes the transport driver with the consultation reports. I didn't know that. I don't know how we are supposed to know that there is another fax. I don't know how the nurses are supposed to know that there is another fax somewhere in the building. Our hands were tied when the resident returned to the building too late for us to call the wound center. When asked if she could foresee a concern related to this lack of communication if a resident was not cognitively intact and could not speak up to tell the facility staff that there should be new orders, RN #3 stated, Yes. On 10/24/19 at 11:00 a.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing, were informed of these concerns. A facility policy regarding outside consultation communication/coordination was requested. On 10/24/19 at 1:23 p.m., ASM #2 stated the facility did not have a policy on outside consultation communication/coordination. References: (1) End-stage kidney disease (ESKD) is the last stage of long-term (chronic) kidney disease. This is when your kidneys can no longer support your body's needs. End-stage kidney disease is also called end-stage renal disease (ESRD). This information is taken from the website https://medlineplus.gov/ency/article/000500.htm. (2) COPD is a general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. (3) Absorptive dressing combines two organic pigments (methylene blue and gentian violet) to create a wound environment that is prime for healing; suitable for use on partial and full thickness wounds. This information is taken from the website https://www.medline.com/product/Hydrofera-Blue-Ready-Transfer-Foam-Dressings-by-Hydrofera/Z05-PF184203. 1. b. The facility staff failed to monitor Resident #20's fluid intake as ordered by the physician on multiple shifts during September 2019 and October 2019. A review of Resident #20's clinical record revealed the following physician's order, dated 9/5/19: Fluid Restriction 1500 ml/day (milliliters per day). From Kitchen: Breakfast 720 ml, Lunch 240 ml, dinner 240 ml. From Nursing Days 150 ml, eves (evenings) 150 ml) nights 0 ml. Every shift document amount consumed. A review of Resident #20's September 2019 and October 2019 MARs (medication administration records revealed blanks on the following days in the space where the fluid restriction enforcement should have been documented: 9/7/19 day shift, 9/8/19 day shift, 9/9/19 day shift, 9/12/19 day and evening shifts, 9/19/19 evening shift, 9/21/19 day and evening shifts, 9/24/19 evening shift, 9/30/19 evening shift, 10/1/10 evening shift, 10/8/19 evening shift, 10/15/19 evening shift, and 10/18/19 day shift. A review of Resident #20's comprehensive care plan dated 9/16/19 revealed, in part, the following: Dialysis r/t related to) renal (kidney) failure .Fluid restriction as ordered. On 10/24/19 at 9:01 a.m., LPN (licensed practical nurse) #1 was interviewed. She stated she is not familiar with Resident #20's care. When shown the above-referenced MARs containing the blanks for the fluid restriction documentation, and when asked what these blanks mean, LPN #1 stated, I don't want to say what I think it means. Because I think, it's not good. I need to find out. On 10/24/19 at 10:07 a.m., LPN #5 was interviewed. She stated she was very familiar with Resident #20's care. When asked why Resident #20 was on a fluid restriction, LPN #5 stated, He is a dialysis patient. Typically, they have some kind of fluid restriction. When asked what she knew about Resident #20's restrictions, LPN #5 stated, His fluid intake is monitored every shift. We keep track of what the resident takes in. Sometimes the aides record it and sometimes I record it. But at the end of the shift, there is a box for me to add up all the totals and sign off on the total. When shown the MARs referenced above for Resident #20, and when directed to the blank spots, LPN #5 was asked what the blank spots mean. LPN #5 stated, If a box is not signed off and totaled, I can't tell how much he got. There is no way to tell. There is no way to know how much he would be allowed to have for the rest of the day. I can't see how anybody would miss that. When asked what the lack of documentation meant, LPN #5 stated, Well, if it's not documented, I can only imagine it wasn't done. It doesn't look like anybody kept up with his fluid on those shifts. On 10/24/19 at 11:00 a.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Fluid Restrictions, revealed, in part, the following: Fluid restrictions are coordinated between Nursing Services and Food and Nutrition Services .The fluid restriction is noted on the tray card and clearly identifies the type and amount of fluids to be served. No further information was provided prior to exit. 2. The faciity staff failed to look at Resident #44's abdominal binder every 30 minutes and failed loosen the abdominal binder every two hours per physician orders. Resident #44 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses that include, but are not limited to, history of a stroke, obstructive uropathy (1) and dementia with behaviors (2). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 9/3/19, Resident #44 was coded as being severely cognitively impaired for making daily decisions, having scored five out of 15 on the BIMS (brief interview for mental status). He was coded as having an indwelling catheter in his bladder, and as having a physical restraint on a daily basis. On 10/23/19 from 1:51 p.m. until 4:01 p.m., (135-minute period), two surveyors continuously observed Resident #44. During this time, Resident #44 was positioned in a reclining chair across from a nurses' station, just outside the main dining room. Resident #44's legs, torso, and arms were covered with a blanket. At no time during this observation did any staff member look underneath the blanket to verify the position of or to loosen Resident #44's abdominal binder, worn under his shirt. A review of Resident #44's clinical record revealed the following physician's order dated 8/21/19: Abdominal binder: Check abdominal binder every 30 minutes and release every 2 hours every shift for safety, to keep resident from pulling at suprapubic catheter (3). A review of Resident #44's comprehensive care plan dated 8/28/19 revealed, in part, the following: The resident uses abdominal binder for suprapubic cath (catheter). The resident will remain free of complications related to restraint use, including contractures, skin breakdown, altered mental status, isolation, or withdrawal through review date .Alternatives to abdominal binder was ABD (abdominal) pad and tape, but resident started pulling at suprapubic catheter; therefore abdominal binder was reinstated .RESTRAINT USE: Apply abdominal binder, check every 30 minutes and release every 2 hours. On 10/24/19 at 9:03 a.m., LPN (licensed practical nurse) #1 was interviewed. When asked if she had taken care of Resident #44 on 10/23/19, LPN #1 stated, Yes I did. When asked what restraint Resident #44 used, LPN #1 stated, He has an abdominal binder. He has a suprapubic catheter. Without the binder, he will rip [the catheter] out. He has pulled it out before and had to go back to have it replaced. That's why he has the binder. When asked what orders accompany the use of the abdominal binder, LPN #1 stated, We are supposed to check it every 30 minutes. When asked what checking the binder means, LPN #1 stated, We are supposed to actually look at it. That's all, I think. When asked if she was aware of anything that needed to be done every two hours, LPN #1 stated, No. I'm not familiar with anything else. LPN #1 was asked to review the physicians' orders for Resident #44. After reviewing the physician's orders, LPN #1 stated, We are supposed to loosen it every two hours. When asked if she had looked at Resident #44's abdominal binder every 30 minutes on 10/23/19, LPN #1 stated, No, I didn't. When asked if she loosened the resident's abdominal binder every two hours on 10/23/19, LPN #1 stated, No, I didn't do that either. I'm sorry. When asked why looking at the binder every 30 minutes and loosening the binder every two hours are important actions to take, LPN #1 stated, We need to make sure it is in the right place. There was a time when one of the binders we had was digging into him. This would let us see underneath it every now and then. On 10/24/19 at 11:00 a.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Restraint and Position Change Alarm Use, revealed, in part, the following: A physician's order is required for the use of the specific type of restraint. The order should include the specific type of restraint, the condition and/or medical symptom that warrants restraint use, where and how the restraint is to be applied and used, and the time and frequency the restraint should be released .The use of the restraint must be individualized and must be based upon the resident's condition and medical symptoms that must be treated. The care plan is revised as needed and must include .The time and frequency the restraint should be released; the type of specific direct monitoring and supervision provided during the use of the restraint. No further information was provided prior to exit. (1) Obstructive uropathy is a condition in which the flow of urine is blocked. This causes the urine to back up and injure one or both kidneys. This information is taken from the website https://medlineplus.gov/ency/article/000507.htm. (2) Dementia is a gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information is taken from the website https://medlineplus.gov/ency/article/000746.htm. (3) A suprapubic catheter (tube) drains urine from your bladder. It is inserted into your bladder through a small hole in your belly. You may need a catheter because you have urinary incontinence (leakage), urinary retention (not being able to urinate), surgery that made a catheter necessary, or another health problem. This information is taken from the website https://medlineplus.gov/ency/patientinstructions/000145.htm.