**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to ensure that the resident and/or the resident's representative (RP) for two (Resident (R) 118, and R288) of 31 sampled residents were provided with a summary of the baseline care plan. The facility failed to provide written summaries of the baseline care plan that included, at a minimum, the initial goals of the resident; medications and dietary instructions; and services and treatments to be administered by the facility and personnel. Findings include: 1. Review of R118's undated face sheet located in the electronic medical record (EMR) under the demographic tab indicated the resident was admitted on [DATE] from the hospital. The resident's diagnoses included congestive heart failure, urinary tract infection, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, atrial fibrillation, anxiety disorder, hypokalemia, chronic pain, adult failure to thrive. Review of R118's Interdisciplinary Notes provided by the Social Service Director (SSD), dated 05/14/21, revealed Baseline care plan was reviewed with resident to include summary of resident's medications, initial goals, services, and treatment to be administered, primary diagnoses, and discharge plan. However, review of R118's EMR and hard chart revealed no evidence the facility had provided the resident and/or resident representative with a written summary of the baseline care plan. Review of R118's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/28/21, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13/15, indicating the resident was cognitively intact. During an interview conducted on 10/11/21 at 3:24 PM, R118 stated, I don't know what my care plan is. I don't remember anyone speaking to me and giving me any papers to keep related to my care plan needs. 2. Review of R288's undated Face Sheet located in the EMR under the demographic tab, indicated the resident was admitted to the facility on [DATE] from the hospital. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, hypertension, and cerebrospinal fluid drainage device. Review of R288's Interdisciplinary Notes provided by the SSD, dated 10/01/21, revealed Baseline care plan was reviewed with Resident/Family to include summary of resident's medications, initial goals, services, and treatments to be administered, primary diagnoses and discharge plan. However, review of R288's EMR and hard chart revealed no evidence the facility had provided the resident and/or resident representative with a written summary of the baseline care plan. Review of R288's admission MDS with an ARD of 10/05/21, revealed the resident had a BIMS score of 5/15, indicating severe cognitive impairment. As a result, an interview was conducted on 10/12/21 at 10:59 AM with R288's RP, who stated, I don't recall getting a written care plan, I would really like to be part of the care plan meeting. During an interview conducted on 10/13/21 at 12:39 PM, the SSD was asked to provide any documentation verifying the facility provided a written summary of the baseline care plan to these residents and/or their representative. The SSD stated, We [social services] document that we discuss the care plan, but we don't give them [resident/resident representatives] a copy. I wasn't aware that was a requirement. Review of the facility's policy titled Care Planning dated 01/21 revealed the baseline care plan is developed and implemented within the first 48 hours of admission .The interdisciplinary team will meet with the resident and/or representative to discuss the baseline care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to ensure the care plan for one (Resident (R) 103) of 31 sampled residents was revised as needed. R103's care plan was not reviewed and updated when the resident developed a facility-acquired Stage II pressure ulcer. Findings include: Review of a facility policy titled, 8.25 Care Planning, dated 01/21, revealed, An appropriate individualized plan is developed, reviewed, and modified throughout the resident's stay to ensure optimum levels of function .Policy: The facility will develop an Interdisciplinary Care Plan for each resident that includes measurable goals and objectives to meet the resident's medical, nursing .needs. The policy further indicated, In cases of significant changes, in the resident's condition, the Care Plan must be updated. During an observation and interview on 10/11/21 at 2:26 PM, R103 was observed to be in bed in his room. At this time R103 stated, I have a sore on my butt, but they are treating it. I didn't have it at the hospital. Review of R103's Face Sheet, located in the electronic medical record (EMR) under the Document Storage tab revealed R103 was admitted to the facility on [DATE]. Diagnoses included unspecified trochanteric fracture of the left femur, and encounter for other orthopedic aftercare. Review of an 09/17/21 Nursing admission Assessment, located in the EMR under the Clinical Documentation tab, revealed that upon admission, R103's skin was warm and dry, and the resident did not have a pressure ulcer. Review of an 09/17/21 Plan of Care, located in the EMR under the Plan of Care tab indicated, Pressure ulcer-at risk for altered skin integrity and pressure ulcers related to decreased mobility, decrease in Activities of Daily Living (ADL) abilities. The plan of care did not indicate that the resident had a pressure ulcer at that time. Review of an admission Minimum Data Set (MDS) assessment, located in R103's EMR under the Skilled tab, with an Assessment Reference Date (ARD) of 09/22/21, revealed R103 had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating no cognitive impairment. The MDS indicated R103 had impairment on both sides of the lower extremities. The MDS further indicated R103 was at risk of developing pressure ulcers/injures but did not have any pressure ulcers upon admission. Review of a 10/08/21 Interdisciplinary Note, located in the EMR under the Notes tab indicated, CNA [Certified Nursing Assistant] let this writer know of patient's buttocks breakdown. R [Right buttock] has open area of 0.5cm [centimeter] x 0.5cm. Triad cream applied and alleyvn. Charge nurse notified. Review of a 10/08/21 Admission/New Wound Assessment located in the EMR under the Clinical tab indicated, Wound Assessment- Present on Admission- No. Shape is irregular. Size is length: 0.5cm x Width: 0.5cm. Stage 2. Wound Intervention: Triad Cream, Dressing: Allevyn. Wound Plan of care: Daily dressing change. Risk Level for Skin Breakdown: Mild. Skin Breakdown Prevention Interventions in Place: Resident is able to turn and re-position self. Review of a body diagram on the Wound Assessment indicated 10/08/21- Site: Buttocks Pressure Injury. Acquired. Further review of R103's Plan of Care, revealed no evidence that, as of 10/13/21, the care plan had been revised to indicate that the resident had developed a facility-acquired pressure ulcer. The care plan failed to indicate the interventions what interventions were needed to assist in healing the pressure ulcer which developed in the facility. During an interview on 10/13/21 at 8:48 AM, Licensed Practical Nurse (LPN)7 stated, It was acquired on the right buttock on 10/08/21 and it was a Stage II at 0.5cm x 0.5cm. For treatment, we were doing triad cream daily and the treatment was changed yesterday when I saw him. Yesterday the measurements were 0.00 and it was fully closed. It was first identified on his bottom on 10/08, and it is healed now. During an interview on 10/13/21 at 10:05 AM, the MDS Coordinator stated, I was not aware he had a new pressure ulcer. This is the first time I'm hearing of it. The 8th was Friday. Normally, we have a clinical meeting in the morning Monday through Friday. Our clinical team meets after we have a stand-up meeting. We have not had a clinical meeting today. The MDS Coordinator continued, Normally, a new pressure ulcer is reported to us in clinical stand-up meetings, then I jot it down and report it to the other MDS Coordinators. At that time, the other MDS Coordinators would be updating the care plan. Whoever has that particular group, will update it at that time. Had we met in our clinical meetings, I would have reported it to our team, and we could have updated it right then, but you all have been here since Monday, and we haven't had our meeting. At this time, the MDS Coordinator verified the care plan for R103 was not updated to reflect the Stage II pressure ulcer that R103 acquired on 10/08/21. During an interview on 10/13/21 at 11:41 AM, the Director of Nursing (DON) confirmed the care plan for R103 was not updated to reflect the Stage II pressure ulcer when it was acquired on 10/08/21, stating, I do not see there has been anything added. The DON stated, Our process is usually there is a QVR (Incident Report) that is done. The Unit Manager gets it and receives it, and she comes to the morning meeting. We have a stand-up huddle and review the QVRs. Then the MDS person reports back to the team there is a pressure ulcer, so it can be added to the care plan. But this Monday, we had you all come in for survey. I don't see anything on the care plan that has been added at this time. At this time, while the DON was reviewing R103's care plan in the EMR, the DON then stated, I do now see that on 10/13/21 [today] there was something added. Prior to today, I don't see anything added. It was added by the MDS person as of today. During a second interview with the MDS Coordinator on 10/14/21 at 1:51 PM regarding R103s care plan, the MDS Coordinator stated, I corrected and updated the care plan yesterday. When we spoke, that was the first time I found out about the wound. I put in interventions yesterday. It was identified on 10/08. After I talked to you, I updated the care plan to reflect the pressure injury to the right buttock.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that one (Resident (R) 50) of 29 current sampled residents received activities in accordance with the resident's assessed preferences. The facility failed to assist R50 so the resident could attend a religious activity, per the resident's choice. Findings include: Review of the facility policy titled Therapeutic Recreation Department, dated 02/10/17, revealed the mission of the department was to plan and provide an ongoing, comprehensive program of recreation services which empowered the residents toward increased independence, personal choice, and expression, and to improve or maintain their level of physical and cognitive functioning. The policy stated that based on their interests and functioning level, a care plan was created. This would include bedside, 1:1 visits, small and/or large group activities. The policy related that a variety of activities would include religious, creative, physical, cognitive, and social-type activities. Per the policy, an activity calendar was to be produced monthly, and each resident would receive a large copy that was posted in their room. Review of R50's Face Sheet found in R50's Electronic Medical Record (EMR) under the Face Sheet tab revealed the resident had diagnoses of chronic respiratory failure and quadriplegia and was a long-term resident. Review of R50's Significant Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/29/21, found in R50's EMR under the MDS tab revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. The MDS also indicated that R50 stated it was very important to participate in religious services and practices. The MDS indicated R50 had limitations in range of motion (ROM) to the upper and lower extremities on both sides, and was totally dependent on staff for bed mobility, transfers, bathing, dressing and locomotion on and off the unit. Review of R50's comprehensive Care Plan, revised 08/17/21, found in R10's EMR under the Plan of Care tab indicated, Resident will engage in self-directed activities of interest (daily chronicle and bible) with assist from staff. The care plan also indicated Resident will attend worship or Bible Study two times a week when feasible to meet spiritual needs. Observation of R50's room revealed a recreation calendar dated 10/21 with Bible Study listed on 10/11/21 at 2:00 PM. Interview with R50 on 10/12/21 at 11:42 AM revealed that he wanted to go to the Bible Study activity on 10/11/21 at 2:00 PM. However, the nurse aide did not get him up to his chair. R50 stated the recreation assistant came by his room but he was not in his chair so she could not take him to the activity in the recreation room. R50 stated the nurse aide told him she had not put him in his chair because she was busy getting residents ready for their appointments and visits with family. Interview with Unit Manager (UM) 3 on 10/13/21 at 10:39 AM revealed she was not notified that the nurse aide did not get R50 up for his religious activity on 10/11/21. UM3 stated that it was a priority to get R50 up because Bible Study was one of his favorite activities. UM3 also stated she walked around the unit to ensure residents are ready for appointments and family visits. UM3 further stated she expected the nurse aides to ask for assistance with transfers from the bed to the chair from the nurse aide on their hall, team leader (nurse), or charge nurse on the unit. Interview with Certified Nursing Aide (CNA) 6 on 10/13/21 at 10:51 AM revealed that she was originally scheduled on the bath team on 10/11/21; however, another CNA called out that day, so she took their place. CNA6 stated R50 told her that he wanted to get up for Bible Study at 2:00 PM and she gave him a bed bath, but she did not get him up because she was still giving care to other residents. CNA6 stated she informed the oncoming CNA at 3:00 PM (after the activity occurred) but did not ask for assistance from other staff to get the resident up for the activity because they were also busy. Interview with the Director of Nursing (DON) on 10/15/21 at 12:04 PM revealed if a resident wants to go to something, then she expects staff to meet their needs to participate in that activity. The DON stated the Unit Managers were expected to manage their unit and prioritize the needs of the residents. The DON also stated she expected staff to complete their assignments, and work with the residents to meet their needs. Interview with Licensed Practical Nurse (LPN) 8 on 10/15/21 at 1:40 PM revealed she was the charge nurse on the unit on 10/11/21 and was responsible for ensuring that the nurse aides and nurses completed their assignments daily. LPN8 stated the nurse aide should have reported to the nurse or to her that she did not have time to get R50 up for the activity that day so she could have assured the resident received the needed assistance in attending his preferred activity Interview with LPN1 on 10/15/21 at 1:54 PM revealed she was assigned to R50 on 10/11/21. LPN 1 stated R50 mentioned he wanted to go to Bible Study at 2:00 PM but she did not have time to get back to him before the activity. LPN 1 confirmed that CNA6 failed to inform her that she needed assistance in transferring R50 to the chair so he could attend his activity that day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to ensure there was a sufficient supply of bath linens available on two of four units ([NAME] and Dogwood). This failure had the potential to affect 101 residents living on these two units, out of the total census of 145 residents. Findings include: 1. Interview on 10/11/15 at 11:11 AM with R84 revealed that the facility does not have enough washcloths and towels. R84 stated she likes to wash her face in the morning and most days when she asks for linens, none are available. The resident states that she does not get to wash her face before breakfast, and this is upsetting to her. 2. During a Resident Council Meeting held on 10/12/21 at 1:30 PM, seven of seven residents (Residents (R) 18, R35, R64, R75, R77, R131, and R134) who regularly attend resident council meetings expressed concerns about a shortage of washcloths/towels, specifically on the Camellia and Dogwood Long Term Care Units. During interview, R64 stated, There is a short supply of washcloths and towels every evening. There used to be a cart that was full of linen and now it's last minute. I doubt if there is anything in it today. R75 stated, Those that know your routine [staff], know how many washcloths you will need, but they are generally short. R134 (who resides on the Dogwood unit) stated, There is a closet in our hallway that stores everything and when I need something like an extra towel, I will open the door and help myself. There is not enough in there. The supply is generally low. R64 stated, The supply is generally low. All day it's low. I doubt there is [sic] any towels on the unit right now. About 3:30-4:00 PM, they will bring linens and lately, it is always short. During the Resident Council Meeting, R18, R35, R64, R75, R77, and R131, who all indicated they reside on the Camellia Unit agreed, There are not enough washcloths and towels. 3. Interview on 10/13/21 at 8:40 AM with Certified Nurse Aide (CNA) 25 revealed that she was having a hard time finding towels and washcloths for her morning rounds. CNA25 stated the linen closet had no towels and only a few washcloths. She added that the linen closet is not replenished until after 10:00 AM. Observation of the linen closet for Rooms 17-32 on the Dogwood Unit on 10/13/21 at 9:15 AM revealed there were no wash clothes and no towels in the closet. Interview with Linen Aide 2 on 10/13/21 at 9:28 AM revealed that he does not know how many towels and wash clothes should be available in each linen closet on each hallway, but he stocked the closet twice a day. Linen Aide 2 stated that there was a shortage of linens over the summer when they had more new admissions but was not aware of any recent issues. 4. Observation of the linen closet for Rooms 1-16 on the Dogwood Unit on 10/13/21 at 10:01 AM revealed there were 40 wash clothes and no towels available for use. Observation and interview on 10/13/21 at 10:20 AM with Linen Aide 1 revealed that he had just replenished the linen closet. Observation of the closet revealed there was a small stack of approximately 20 towels and approximately 40 washcloths. He stated that the laundry is outsourced and goes out daily and returns daily. He restocks what he has. Linen Aide 1 stated, Linen has been cut back and I have made numerous reports to the management that more linen is needed. 5. Interview with CNA4 on 10/13/21 at 10:23 AM revealed she was assigned to resident rooms 17-24 on the Dogwood unit and there were not enough wash clothes and towels to perform bed baths for the residents a couple of weeks ago. CNA4 stated she looked in the resident rooms and the closet on the other hallway for wash clothes, but none were found so CNA4 used a pillowcase to perform a bed bath for the resident. CNA4 stated that every resident was given at least a partial bed bath daily and she used a minimum of two wash clothes and one towel when performing the bed bath. Interview with Unit Manager (UM) 3 on 10/13/21 at 10:31 AM revealed there was one linen closet on each hallway on the Dogwood Unit and that the linen aides stock the closets at least twice daily. UM3 stated that she expected staff to check the other hallway closet for linens and then report to her if more were needed to perform their assignments. UM3 stated when the staff needed more linens, she would contact materials management and they would bring more linens to the unit. UM3 further stated she had only worked on the unit one week and was not aware of a time when no towels or wash clothes were available. Interview with CNA5 on 10/13/21 at 2:26 PM revealed she had worked at the facility six weeks and would use five wash clothes and three towels when performing a bed bath for a resident. CNA5 stated that there were not enough wash clothes and towels on the weekends and sometimes there were not enough during the week. CNA5 stated that when there were not any wash clothes and towels in the linen closet on her assigned hall, she would look in the other hall linen closet on the unit. Interview with the Director of Nursing (DON) on 10/14/21 at 3:40 PM revealed that it was important to have an adequate supply of linens available for staff use for resident care. The DON stated that linens were an ongoing issue because staff had been throwing them away and they were storing them in the resident's rooms. The DON also stated that all the staff had been trained on not throwing the linens away and storing them in the resident's rooms. Interview on 10/13/21 at 1:01 PM with the Director of Material Management revealed that linen is outsourced six days a week to an independent contractor who takes care of all linens for the facility. The Director of Material Management stated he would like to see more linen in the facility, adding they had an extra reserve this summer, but now it is low. The Director of Material Management noted that census increased, and the supply of linen went down. He stated, I am aware that the residents need linen, and we ensure that they have linen and provide what we can. He explained that if the linen supply gets low, the charge nurse will call down for linens and they pull from the next day's supply. Further interview revealed that that linen is listed by weight, and soiled linen weighs more than clean dry linen. Therefore, they never get back the same quantity of linen which they send out and there was no system in place to count or record the linen that goes out and the linen that is then returned. Record review of email documentation revealed 16 emails from 03/30/21 to 10/11/21 from the Director of Material Management to the linen company asking for various linen types because they were short.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to ensure the appropriate use of side rails for four cognitively impaired residents (Resident (R) 96, R125, R3, and R89) out of 31 sampled residents. The facility failed to ensure that prior to the installation of side rails (also known as bed rails), alternatives were attempted. The facility failed to assess each resident for the use of side rails, including a review of risks including entrapment; or obtained informed consent for the use of side rails from the resident and/or the resident representative. In addition, the facility failed to ensure that the bed was appropriate for the residents and that the side rails were routinely monitored for hazards and maintained in accordance with manufacturer specifications. Findings include: On 10/11/21 at 08:00 AM a recertification survey was initiated at Lake [NAME] Hospital. Observation revealed that the facility has four units and 145 residents. During the screening process conducted throughout the facility on 10/11/21, observation revealed that the facility currently uses three different types of beds. Although not in use for multiple residents, all beds had side rails attached. 1. Observation of R96 on 10/12/21 at 8:43 AM revealed the resident was in bed with three-quarter side rails up on both sides of the bed. The mattress failed to fit snuggly within the side rails and observation revealed a gap large enough for R96 to place her leg between the mattress and side rails. Review of R96's Face Sheet revealed diagnoses including anoxic brain damage, quadriplegia and seizures due to cardiac arrest, cerebral palsy, epilepsy and spastic movements. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/16/21 revealed the resident was moderately cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 8/15. Review of the both the electronic medical record (EMR) and hard-copy records provided by the facility chart revealed no evidence of any attempts to use other devices prior to side rails for R96's bed. There was no evidence in either record that the resident was assessed for the use of the side rails. There was no evidence that the facility considered the factors such resident's medical diagnoses, conditions, symptoms, and/or behavioral symptoms, size and weight, sleep habits, medication(s), acute medical or surgical interventions, underlying medical conditions, existence of delirium, cognition, communication, or mobility (in and out of bed) prior to the use of the side rails. There was no evidence that either R96 or their representative gave informed consent after being provided with the risks and the benefits of the side rail use. 2. Observation of R125 on 10/11/21 at 11:52 AM revealed she was laying in bed with three-quarter sized rails raised on both sides of the bed. Review of R125's Face Sheet found in R125's EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses including failure to thrive. Review of R125's Quarterly MDS, with an ARD of 09/30/21, found in R125's EMR under the MDS tab revealed the resident was severely cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 6/15. The MDS indicated R125 required extensive assistance of staff of one-person physical assistance for bed mobility, transfers, dressing, and personal hygiene. Review of R125's EMR revealed no evidence that other devices had been attempted prior to siderails, no evidence of an assessment for the use of the siderails, and no evidence that the facility had identified risks and benefits of the siderails. Further, there was no evidence that the facility informed the resident's Responsible Party (RP) or obtained informed consent for the use of the siderails. 3. Observation on 10/14/21 at 5:56 PM revealed R3 lying in bed with two half-side rails up. Review of R3's Face Sheet located in the EMR revealed that the resident was admitted to the facility in 2019 and had diagnoses including Alzheimer's disease unspecified and metabolic encephalopathy. A review of a quarterly MDS, with an ARD of 07/07/21, revealed that the resident was severely cognitively impaired, as evidenced by a BIMS score of 4/15. Per the MDS, R3 needed extensive assist for functional status. Further review of R3's EMR revealed no evidence of assessment for the use of the side rails or informed consent given after the risks and benefits of their use was explained to the resident and/or their representative. 4. Observation on 10/14/21 at 8:38 revealed R89 was in bed, with two half-side rails s up. During an interview on 10/13/21 1:12 PM, R89 stated that the side rails were on the bed when she came; the facility never asked if she needed them or wanted them, they were just there. Review of R89's face sheet in the EMR indicated that she was admitted on [DATE] with diagnoses including unspecified dementia without behaviors, COVID-19 and weakness. Review of an admission MDS, with an ARD of 08/03/21 revealed the resident was moderately cognitively impaired, as evidenced by a BIMS of 8/15. Further review of R3's EMR revealed no evidence of assessment for the use of the side rails or informed consent given after the risks and benefits of their use was explained to the resident and/or their representative. Interview on 10/14/21 at 10:33 AM with the Director of Plant Maintenance revealed that all beds have side rails, and they are attached when they assemble the bed. The Director of Plan Maintenance stated that every Wednesday, nursing, and maintenance make rounds of all rooms and check lights, beds, and anything that may need fixed. A list is made, and the work is completed. The Director of Plant Maintenance indicated that there was no system for routine checks of the mattress and its fit within the side rails to assure there were no entrapment hazards. When asked who assessed the use of side rails for each resident, he stated, Nursing does all of that. Interview on 10/14/21 at 01:40 PM, the Director of Nursing (DON) stated that side rails come with the beds and residents are not assessed. The DON stated that residents can choose whether they want the side rails up or not. The DON added that, since the side rails are attached to the bed, an informed consent is not completed, and the side rails are not care planned. The DON stated that the risks and benefits of the side rails are not discussed with the resident or the resident representative. The DON thought that maintenance logs were kept on bed installations. When asked if there were risks to a resident not being assessed for side rails, she stated, I cannot answer that. Review of the policy titled, Use of Restraint/Bed Rails/Safety Device, revised on 10/21, indicated .that restraints/safety devices shall only be used for the safety and well-being of the residents and will only be implemented after least restrictive alternatives have been unsuccessful. Further review of the policy revealed that it failed to address maintenance requirements for routine checks of issues such as loose side rails and monitoring for gaps sufficient in size to create a risk of entrapment.

Based on observation, interview, record review, and review of facility program documents, the facility failed to ensure that a paid feeding assistant provided dining assistance only for residents who had no complicated feeding problems. In addition, the facility failed to ensure appropriateness for the paid feeding assistance program was reflected in the care plan. The facility's failure affected one of four units, potentially affecting the 53 residents residing on the Dogwood Unit, out of a total of 145 residents. Findings include: Review of the paid feeding assistance program titled Feeding/Hydration Training Program, reviewed 12/17, revealed the purpose of the program was to provide adequate training for non-licensed assisting residents with feeding and drinking. Review of the seven sections of the program revealed an assessment to determine the residents eligible for the program was not identified. Review of R23's Face Sheet found in R23's electronic medical record (EMR) under the Face sheet tab revealed the resident was admitted to the facility in 1994 with diagnoses that included cerebral palsy and dysphagia. Review of R23's comprehensive Care Plan revised 10/30/20, found in R23's EMR under the Plan of Care tab indicated, [R23] receives diet of mechanically altered texture/thickened liquids with adaptive meal equipment and supplements as needed with the goal of not showing signs of aspiration. Review of R23's Care Plan revealed that it did not address the appropriateness of resident participation in a paid feeding program. Observation on 10/14/21 at 12:29 PM revealed Hospitality Aide 1 fed R23 pureed carrots with a small spoon. Review of the meal ticket dated 10/14/21 indicated R23 was on a pureed diet and had buildup utensils. The meal ticket did not address the appropriateness of R23 being fed be staff from the paid feeding program. Interview with Hospitality Aide 1 on 10/14/21 at 12:04 PM revealed she completed the paid feeding assistance training program last year and was assigned to the Dogwood Unit to assist in feeding residents. Hospitality Aide 1 stated she could feed any resident that needed assistance, including residents with swallowing issues on the unit. Review of the CMS 802 provided by the facility revealed that 53 residents resided on the Dogwood Unit. During this interview, Hospitality Aide 1 stated there was a list of residents that needed feeding at the nurse's station. Hospitality Aide 1 stated that she does not review the care plan to determine the resident's feeding assistance needs but reviewed the diet ticket which listed diet type and utensils needed to feed the resident. Interview with the Director of Quality Development on 10/14/21 at 12:32 PM revealed she oversaw the paid feeding assistance program since 2019 and verified that eligible residents were not identified for the program. The Director of Quality Development stated that any resident that needed feeding assistance could be fed by the hospitality aides, indicating the facility had no system in place to base resident selection on the interdisciplinary team's assessment and the resident's latest assessment and plan of care. Interview with Unit Manager (UM) 3 on 10/14/21 at 12:41 PM confirmed that although they could not perform care, hospitality aides could feed all residents. UM3 stated that the resident's dietary needs were listed on the meal ticket that came on the meal tray and that the hospitality aides were trained by the speech therapist on how to feed residents with swallowing difficulties. Interview with the Speech Therapist on 10/14/21 at 1:50 PM revealed that she trained the hospitality aides on basic feeding guidelines for the paid feeding assistance program. However, per the Speech Therapist, only licensed staff were allowed to feed residents with swallowing issues, not hospitality aides. The Speech Therapist stated that the unit managers were responsible for ensuring that the hospitality aides were feeding residents that were eligible for the program since they run their units. Interview with the MDS Coordinator on 10/15/21 at 7:35 PM revealed that the MDS Coordinators do not update the resident care plans to indicate that residents are appropriate to be fed by the hospitality aides or need dining assistance.

Based on observation and interview, the facility failed to ensure food, dishware, and cookware used for food preparation/service was stored in a sanitary manner. Food items were not labeled, dated when opened, and/or sealed closed. Dirty industrial fans were blowing on dishware which were clean and ready for use. Cookware was stacked wet. These failures had the potential to affect all 145 residents in the facility who were served food from the facility kitchen. Findings include: On 10/11/21 at 8:40 AM, the following observations were made with and verified by the Chef Manager: 1. The dry storage room contained one bag of egg noodles that was not sealed closed. There was one bag of spaghetti that was not labeled and dated after opening. The plastic flour bin was left open, with the lid sitting partially on the bin. 2. The walk-in refrigerator had a one container of chicken parmesan with no label or dating. A roll of ground beef in a plastic container with plastic wrap covering, had an expiration date of 10/09/21. The ground beef, which was not disposed of past its expiration date was a pale brown/gray color. There were four bags of raw chicken that were not sealed closed and had no labels or dates. 3. The walk-in freezer contained one bag of biscuits, and one bag of frozen pancakes that were not sealed closed. 4. The drying area contained one stack of loaf pans, baking sheets, and cake pans that were wet on the inside. 5. Two industrial fans that were visibly dirty with dust and black build-up, were blowing on clean dishes. An approximately three feet by three-foot area of the ceiling located directly above one of the two fans in the dish storage area was peeling. During an interview on 10/22/21 at 8:40 AM the Chef Manager stated, All opened bags of food should be sealed closed, labeled and dated . All opened bags of chicken in the refrigerator that had no labels and dates are going to be thrown out . and the fans are dirty and will be removed and cleaned. He also stated, The wet pans should not have been stacked until dried due to them harboring bacteria.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews the facility staff failed to complete a comprehensive resident assessment for 1 of 48 residents (Resident #119), in the survey sample. The facility's staff failed to complete Resident #119's admission Minimum Data Set (MDS) assessment within 14 calendar days after admission to the facility. The findings included: Resident #119 was originally admitted to the facility 9/25/18 and readmitted [DATE] after an acute hospital stay The current diagnoses included; diabetes and a right foot infection with an abscess as well as right third toe amputation. The uncompleted admission MDS assessment with an assessment reference date (ARD) of 10/16/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #119's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring supervision after set-up with eating, limited assistance of 1 person with bed mobility, transfers, walking in the corridor, locomotion, dressing, toileting, and personal hygiene and extensive assistance of 1 person with bathing. An MDS assessment dated [DATE] was observed in the facility's computer system for Resident #119. It was signed as completed 10/22/18. A copy was requested but the MDS Coordinator stated on 10/31/18 at 12:45 p.m., it was not completed and she was working on getting it completed. The MDS Coordinator further stated the staff responsible for completing the MDS had not informed her the assessment wasn't completed and it should have been completed by all disciplines on 10/22/18. The MDS Coordinator stated on 10/31/18 at approximately 12:45 p.m., they follow CMS requirements for completion of the MDS assessments. The CMS guidelines for Comprehensive Assessments are as follows: OBRA-required comprehensive assessments include the completion of both the MDS and the Care Area Assessments (CAA) process, as well as care planning. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred or a significant correction to a prior comprehensive assessment is required. They consist of: admission Assessment, Annual Assessment, Significant Change in Status Assessment, Significant Correction to Prior Comprehensive Assessment. The ARD (Item A2300) is the last day of the observation/look back period, and day 1 for purposes of counting back to determine the beginning of observation/look back periods. For example, if the ARD is set for day 14 of a resident's admission, then the beginning of the observation period for MDS items requiring a 7-day observation period would be day 8 of admission (ARD + 6 previous calendar days), while the beginning of the observation period for MDS items requiring a 14-day observation period would be day 1 of admission (ARD + 13 previous calendar days). (CMS's RAI Version 3.0 Manual, October 2018 Page 2-19). On 11/1/18, at approximately 6:05 p.m., the above findings were shared with the Administrator and Director of Nursing. The Director of Nursing stated she was aware the admission MDS for Resident #119 was not completed within the CMS specified timeline and it should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations during medication pour and pass, staff interviews, clinical record review, and review of the facility's policy the facility staff failed to ensure services met professional standards of quality for 2 of 48 residents (Resident #149 and #315 ), in the survey sample. 1. The facility's staff failed to assess and/or consult with the physician prior to holding Resident #149's blood pressure medication. 2. The facility staff failed to assess Resident #315 prior to offering and administering an opioid pain medication (Percocet) and failed to ensure Resident #315's Percocet order clearly defined when to administer one tablet and when to administer two tablets The findings included: 1. Resident #149 was originally admitted to the facility 8/29/18 and readmitted [DATE] after an acute hospital stay. The current diagnoses included; coronary artery disease, heart failure, and hypertension. The admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 9/15/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. That indicated Resident #149's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 1 person with bed mobility, transfers, locomotion, dressing, toileting, personal hygiene and bathing. The physician's order summary revealed an order dated 9/24/18 for Hydralazine Hcl (a blood pressure lowering medication) 100 milligrams; one tablet by mouth three times daily. On 10/31/18 at approximately 5:00 p.m., Resident #149 was scheduled to receive Hydralazine Hcl 100 milligrams; one tablet by mouth. Licensed Practical Nurse (LPN) #1 obtained the resident's blood pressure (BP) in the right arm. The BP reading was 127/49. LPN #1 stated the medication would be held and left the resident's room. LPN #1 was interviewed 10/31/18 at approximately 7:00 p.m., she stated she didn't return to Resident #149 to reassess his BP and she had not consulted the physician concerning the resident's BP. The facility's Medication Administration Policy with a revision date of 1/17 read at #13; If any deviation is made in administration of medicine, report the exact circumstances immediately to the Charge Nurse/Nurse Manager/Supervisor. Notify physician or provider for any medication not given. On 11/1/18, at approximately 6:05 p.m., the above findings were shared with the Administrator and Director of Nursing. The Director of Nursing stated LPN #1 should have reassessed the resident within two hours and consulted the Supervisor and physician/designee of the resident's condition for further orders. 2. Resident #315 was originally admitted to the facility 10/24/18 and had not been discharged from the since admission. The resident's current diagnoses included; end stage kidney disease with dialysis, diabetic pain of both feet, and surgical procedures of the left common femoral artery and left profunda endartectomy and external iliac artery. The admission Minimum Data Set (MDS) assessment had not been completed but the nursing admission assessment revealed Resident #315 was alert, and oriented to person, place, time and situation. The nursing admission assessment also revealed the resident's short and long term memory was intact. The physician's order summary revealed an order dated 10/29/18, for Percocet 5/325 (an opioid pain medication) milligrams 1-2 tablets by mouth every 4 hours as needed for pain. The care plan revealed problem which read; (name of resident) is at risk for altered comfort related due to surgical procedures of the left common femoral artery and left profunda endartectomy and external iliac artery. The goal read (name of resident) will verbalize or demonstrate an acceptable level of comfort and or be medicated with relief stated or observed daily through 1/30/19. The interventions include; Assess for pain and routinely document level of pain, location, what makes it worse or better. Assist with positioning for comfort. Medicate as ordered or requested. Follow up with resident after pain medication administration and assess effectiveness based on a 1-10 pain scale. Provide diversional activities such as TV, music, games, therapeutic recreations and socialization. On 10/31/18, at approximately 5:35 p.m., Resident #315 returned to the facility from an appointment in the community. She was explaining to the nurse the information the consulting physician gave her after assessing her feet and legs related to the pain she had been experiencing. The resident stated while removing the top from her dinner meal, I'm hungry and I need to get something to eat in my stomach. LPN #1 stated to the resident she didn't have medications scheduled to be administered at that time, but asked do you need pain medication. Resident #315 stated yes give me two tablets. LPN #1 was interviewed 10/31/18 at approximately 7:00 p.m., she stated she knew Resident #315 was going to request pain medication soon because she had been out all day and she usually requires pain medication in the evening. The facility's policy titled Pain Management - Acute SNF-NF, dated 3/2017 read under Procedure; Assess for the presence of pain, at regular intervals, with a minimum of four times a day (every 6 hours) and as needed. With each new report/rating of pain; before, during and after any known pain-producing event. Re-assess pain intensity after each pain management intervention (pharmacological and non-pharmacological) once a sufficient time has elapsed for the treatment to reach peak effect (within 2 hours of intervention general guidelines:. Assess resident's ability to use a pain rating scale and the resident's personal goal for pain relief. On 11/1/18, at approximately 6:05 p.m., the above findings were shared with the Administrator and Director of Nursing. The Director of Nursing stated LPN #1 should have reassessed the resident for pain and orders should contain parameters for administration for various doses of the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to ensure Resident #71 was provided ADL care to include removal of long discolored fingernails to both hands. Resident #71 was an [AGE] year old admitted to the facility on [DATE]. Diagnosis for Resident #71 included, but not limited to, Vascular Dementia with behavioral disturbances. Resident #71's Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 9/19/18 coded Resident #71 with a 6 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated severely impaired cognition. In addition, the MDS coded Resident #71 as requiring extensive assistance of one person physical assist for personal hygiene. Section E (Behavior) was not coded for rejection of care for ADL assistance. The comprehensive care plan dated 9/19/17 documented Resident #71 with decreased ability to independently complete Activities of Daily Living (ADL). The goal: the resident will have improved strength, range of motion (ROM), balance, increased activity tolerance to increase participation with functional daily activities and mobility. The intervention/approaches to manage goal included, set up resident ADL supplies and encourage or allow resident to complete care as able and then assist with completion and provide hands on assist of one staff member during ADLs. During the initial tour on 10/30/18 at approximately 12:15 p.m., Resident #71 was lying in bed in a supine position. Resident #71 was observed with long discolored fingernails to both hands measuring approximately 1 inch over resident fingertips. On 10/31/18 at approximately 11:15 am, while conducting a bedside observation, License Practical Nurse (LPN) #2 was also present at the bedside. Observation revealed the resident's fingernails remained unchanged. While observing the resident's hands the resident stated, They are long aren't they? LPN #2 then stated, Oh those nails are long . (Resident) could get stuff under them. On 11/1/18 at 1:00 p.m., Resident #71's fingernails were observed trimmed. An interview was conducted with LPN #2 who was asked what the expectations for completion of nail care are. LPN #2 stated, Residents get nails trimmed on shower days twice a week and as needed. LPN #2 was asked after seeing Resident #71 nails did it appear that nail care was provided appropriately and LPN #2 stated, No. A pre-exit interview was conducted with Director of Nursing (DON) and the facility's Administrator on 11/1/18 at approximately 5:45 p.m When asked what the expectations for completion of nail care are the DON stated, In facility ADL policy, residents get nails trimmed on shower days and as needed .nails should not have been that way for (resident). The facility did not have any further questions or present any further information about the findings. Based on observation, staff interviews and clinical record review the facility staff failed to ensure 2 of 48 residents (Resident #111 and 71) in the survey sample who were unable to carry out activities of daily living received the necessary services to maintain fingernail care. 1. The facility staff failed to provide fingernail care for Resident #111. 2. The facility staff failed to ensure Resident #71 was provided ADL care to include removal of long discolored fingernails to both hands. The findings included: 1. Resident #111 was admitted to the facility on [DATE]. Diagnosis for Resident #111 included, but not limited to, weakness. The most recent Minimum Data Set (MDS) was a 30-day Assessment Reference Date (ARD) of 09/26/18 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15, which indicated no cognitive impairment for daily decision-making. The resident was not coded for rejection of care to include Activities of Daily Living (ADL). Resident #111 was coded to require extensive assistance of one with bathing and limited assistance of one staff for personal hygiene. An interview was conducted with Resident #111 on 10/29/18 at approximately 2:30 p.m. Resident #111's fingernails were long and ragged with chipped fingernail polish. The resident stated, I would like to have my fingernail cut; they are too long but I guess they will get to it sooner or later. On 10/31/18 at approximately 9:57 a.m., and 3:28 p.m., Resident #111's fingernails remained unchanged. On the same day at 4:29 p.m., an interview was conducted with Registered Nurse (RN) #3 who stated, the nursing staff should be checking the resident's fingernails daily for cutting and trimming of nails. On 11/01/18 at approximately 8:10 a.m., Resident #111's fingernails were cut with no ragged edges. An interview was conducted with Director of Nursing (DON) on 11/01/18 at approximately 9:32 a.m., who stated, The CNA's (Certified Nursing Assistants) should be observing for nail care on a daily basis doing ADL care. The facility administration was informed of the finding during a briefing on 11/01/18 at approximately 5:45 p.m. The facility staff did not present any further information about the findings. The facility's policy titled Activities of Daily Living (ADL) Care-Hospital (Revision date: 3/17). -Purpose: To provide care for patients that give them a sense of comfort and well being. -Policy: Patients are provided assistance with all activities of daily living (ADL) by clinical staff as desired and based on the individual care needs. Procedure: ADL process will include, but not limited to: -Nail care is provided, if needed, during bath and prn.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #111 was admitted to the facility on [DATE]. Diagnosis for Resident #111 included but not limited to Weakness. The recent Minimum Data Set (MDS) was a 30-day Assessment Reference Date (ARD) of 09/26/18 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15, which indicated no cognitive impairment for daily decision-making. Resident #111 was coded to require extensive assistance of one transfers. In addition, the MDS was also coded for the assistance of one when moving from a seated to a standing position and having functional limitation in Range of Motion (ROM) for impairment on each side to upper and lower extremity. The care plan dated 10/17/18 identified Resident #111 care plan with the potential for safety hazard, injury related to smoking. The goal set for the resident by the staff was that the resident would not cause injury to self or others, or damage to property related to smoking. Some of the interventions/approaches the staff would use to accomplish this goal included to provide a copy of the facility smoking policy and instruct to smoke in designated smoking area and not inside the facility at any time. An interview was conducted with Resident #111 on 10/29/18 at approximately 2:30 p.m., who stated, I am a smoker. The surveyor asked, Is a staff member outside with you when you smoke she replied, No but sometimes I may see someone else out her smoking. The surveyor asked, Did the staff assess you for smoking she replied No. The resident stated, I smoke around 4-5 times a day. An interview was conducted with the Administrator and Director of Nursing (DON) on 11/01/18 at 9:25 a.m., who stated, We do not have an official smoking assessment form. An interview was conducted with RN #3 on 11/1/18 at approximately 2:44 p.m. The surveyor asked, Who decides if a resident can smoke independently she replied, That is a good question. The surveyor asked if Resident #111 had a smoking assessment completed before allowing her to go outside to smoke without staff supervision she said, No, Resident #111 was never assessed; there is no smoking assessment tool being used. The RN replied, That would be a great plan moving forward to have a smoking assessment completed on resident who smoke. The RN stated, Resident #111 smokes in the court yard. On the same day at 3:10 p.m., the surveyor assessed the ground where Resident #111 smokes. There was a smoking receptacle in the courtyard. The facility administration was informed of the finding during a briefing on 11/01/18 at approximately 5:45 p.m. The facility staff did not present any further information about the findings. The facility's policy titled Official Smoking Policy included but not limited to: -Residents may be allowed to utilize the outdoor designated smoking area. If a resident needs supervision in order to utilize the outdoor designated smoking area, employees shall be given the choice whether they wish to supervise a resident and thereby be exposed to secondhand smoke. Employees shall be given the right to refuse to accompany a resident to and in the outdoor designated smoking area. Based on observations, record review and staff interviews, the facility staff failed to have a smoking assessment for 2 residents (Resident #45 and Resident #111) in the survey sample of 45 residents. 1. The facility staff failed to assess Resident #45 for smoking. 2. The facility staff failed to assess Resident #111 for smoking. The findings included: 1. Resident #45 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis, vascular dementia with behavioral, contractures, hypertension, cerebral atherosclerosis anxiety, and chronic obstructive pulmonary disease. The facility staff failed to assess Resident #45 for smoking. Resident #45 was observed during all days of the survey smoking independently outside in front of the facility. During an interview on 10/31/18 at 11:05 a.m. with the resident, he was asked how often did he smoke? The resident responded when ever he wanted to smoke he would ask staff for a cigarette and come outside and smoke. This resident was observed smoking outside in front of the facility in the designated smoking area on 10/31/18 at 12:05 p.m., 10/31/18 at 2:30 p.m., 11/1/18 at 10:30 a.m. and 11/1/18 at 1:17 p.m. Observations made of Resident #45 did not indicate he was a danger to self or others. A Quarterly Minimum Data Set (MDS) dated [DATE] indicated: Resident #45 had no hearing, speech and vision difficulties. This resident was assessed as having a score of (11) in the area of Cognitive Patterns (Brief Interview for Mental Status) which indicated moderately impaired cognition. In the area of Functional Status this resident was assessed as requiring extensive assistance of one person in the area of bed mobility, transfers, dressing toilet use and personal hygiene. In the area of Functional Status this resident was assessed as using a wheelchair for mobility. A Care Plan dated 12/07/2016 Indicated: Problem: Potential for safety hazard, injury related to smoking. Goal- Resident will not cause injury to self or others or damage to property related to smoking. Target date-12/07/2018. Interventions- 1. Encourage to stop smoking and offer smoking-cessation assistance as desired. 2. Instruct to smoke in designated smoking area and not inside facility at any time. During an interview on 11/01/18 at 9:20 A.M. with the (Name of Unit) day Nurse Manager, she stated Resident #45 did not have a smoking assessment and the facility followed their Smoking Policy as a means of who could smoke. A review of the facilities Smoking Policy indicated: Regulation of Smoking: Residents may be allowed to utilize the outdoor designated smoking area. If a resident needs supervision (N.F.P.A. 101, Section 31-4.4) in order to utilize the outdoor designated smoking area, employees shall be given the choice whether they wish to supervise a resident and thereby be exposed to secondhand smoke. The facility failed to assess Resident #45 for smoking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility document review, the facility staff failed to notify the office of the State Long-Term Care Ombudsman in writing of applicable discharges for 4 of 48 residents (Residents #164, #163, #147 and #164 B) in the survey sample. 1. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #164's discharges to the hospital on 1/12/18 and 8/15/18. 2. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #163's discharge to the hospital on 4/18/18. 3. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #147's discharges to the hospital on 6/26/18 and 8/30/18. 4. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #164B's discharge to the hospital on [DATE]. The findings included: 1. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #164's discharge on [DATE]. Resident #164 was admitted to the nursing facility on 7/26/18 with diagnoses that included generalized weakness. The most recent Minimum Data Set (MDS) assessment was an admission dated 7/30/18 and coded the resident on the Brief Interview for Mental Status (BIMS) with a 15 out of a possible score of 15 which indicated the resident was cognitively intact with the necessary skills for daily decision making. During a discussion with the Administrator on 11/1/18 at 2:15 p.m., he stated they reported 30 day discharges to the Ombudsman, but no other discharges to include the emergency room, the local hospital or discharges to the community. There was no policy or procedures in place that detailed a process on reporting facility discharges to the Ombudsman. No further information was provided by the facility staff prior to survey exit on 11/1/18 at 7:30 p.m. 2. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #163's discharge on [DATE]. Resident #163 was admitted to the nursing facility on 8/30/18 with diagnoses that included high blood pressure. The most recent Minimum Data Set (MDS) assessment was an admission dated 9/6/18 and coded the resident on the Brief Interview for Mental Status (BIMS) with a 15 out of a possible score of 15 which indicated the resident was cognitively intact with the necessary skills for daily decision making. During a discussion with the Administrator on 11/1/18 at 2:15 p.m., he stated they reported 30 day discharges to the Ombudsman, but no other discharges to include the emergency room, the local hospital or discharges to the community. There was no policy or procedures in place that detailed a process on reporting facility discharges to the Ombudsman. No further information was provided by the facility staff prior to survey exit on 11/1/18 at 7:30 p.m. 3. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #147's discharge on [DATE]. Resident #147 was admitted to the nursing facility on 11/25/17 with diagnoses that included quadriplegia. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 6/28/18 and coded the resident on the Brief Interview for Mental Status (BIMS) with a 15 out of a possible score of 15 which indicated the resident was cognitively intact with the necessary skills for daily decision making. During a discussion with the Administrator on 11/1/18 at 2:15 p.m., he stated they reported 30 day discharges to the Ombudsman, but no other discharges to include the emergency room, the local hospital or discharges to the community. There was no policy or procedures in place that detailed a process on reporting facility discharges to the Ombudsman. No further information was provided by the facility staff prior to survey exit on 11/1/18 at 7:30 p.m. 4. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #164B's discharge on [DATE]. Resident #164B was admitted to the nursing facility on with diagnoses that included lumbar stenosis. The most recent Minimum Data Set (MDS) assessment dated [DATE] was a 5-day assessment and coded the resident on the Brief Interview for Mental Status (BIMS) with a 15 out of a possible score of 15 which indicated the resident was cognitively intact with the necessary skills for daily decision making. During a discussion with the Administrator on 11/1/18 at 2:15 p.m., he stated they reported 30 day discharges to the Ombudsman, but no other discharges to include the emergency room, the local hospital or discharges to the community. There was no policy or procedures in place that detailed a process on reporting facility discharges to the Ombudsman. No further information was provided by the facility staff prior to survey exit on 11/1/18 at 7:30 p.m.

Based on observations during medication pour and pass, resident statement, staff interviews, clinical record review, and review of the facility's policy, the facility staff failed to ensure the medication error rates was not 5 percent or greater for 3 of 48 residents (Resident #152, #314 and #27), in the survey sample. During the medication pour and pass observation conducted with several staff over different shifts. Twenty-six (26) medication opportunities were observed; five (5) medication errors occurred resulting in a 19.23% medication error rate. 1. The facility staff crushed Resident #152's Alfuzosin Hydrochloric (a medication to decrease urinary retention) (Hcl) Extended Release (ER) 24 hours, which is a do not crush medication. 2. The facility staff crushed Resident #314's Potassium Chloride Extended Release (ER), which is a do not crush medication. 3. On 10/31/18 at 10:00 a.m., during the morning medication pass, two medications were omitted (Colace 100 milligrams and Atrovent nasal spray) and a third medication was administered in the wrong route (Artificial tears drops instead of artificial tears ointment) for Resident #27. The findings included: 1. Resident #152 was originally admitted to the facility 8/1/18 and has not been discharged from the facility. The current diagnoses included; stroke with swallowing problems requiring use of a jejunostomy (J-tube) and gastrostomy (G-tube) tube and use of an indwelling catheter for urinary retention related to benign prostatic hyperplasia (BPH). The admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/8/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. That indicated Resident #152's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 2 people with bed mobility and transfers, extensive assistance of 1 person with off unit locomotion, dressing, toileting, personal hygiene and bathing and total care with eating. In Section H0100A, the resident was coded as requiring use of an indwelling urinary catheter. The physician's order summary revealed an order dated 8/6/18, for Alfuzosin Hcl ER 10 milligrams tablet via G-tube every day after the same meal. The care plan revealed a problem dated 8/2/18 which read; (name of resident) receives 100% of nutritional needs via J/G-tube; tube feedings and medications. The goal read; (name of resident) will tolerate tube feedings without residuals or signs of nausea, vomiting, diarrhea through 11/20/18. (name of resident) will show no signs of aspiration through 11/20/18. The interventions included; Monitor intake, weights, labs, medications for changes and adjust medical nutrition therapy as needed to meet nutrition needs. On 10/31/18, at approximately 4:00 p.m., Licensed Practical Nurse (LPN) #1 crushed the Alfuzosin Hcl ER 10 milligrams and mixed it with water to administer via Resident #152's G- tube. For 26 minutes LPN #1 mixed the crushed tablet in water but it congealed into a clump of white which couldn't pass from the syringe into the G-tube. LPN #1 then discarded the white clump into the trash. An interview was conducted with Licensed Practical Nurse (LPN) #1, on 10/31/18 at approximately 7:00 p.m., LPN #1 stated she didn't understand why the medication clumped and wasn't capable of passing from the syringe in to the G- tube. LPN #1 further stated she wasn't aware the medication was a do not crush medication. An interview was conducted with on 11/1/18, at approximately 6:20 p.m., with the consulting Pharmacist. The Pharmacist stated she reviewed Resident #152's medications approximately 8/2/18 and the resident wasn't receiving the medication at that time and she missed crushing the medication during the 9/2018 and 10/2018 reviews. On 11/1/18; at approximately 6:20 p.m.,the facility staff presented a new order dated 11/1/18 at 10:10 a.m., to discontinue the Alfuzosin Hcl ER 10 milligrams and start Oxybutinin ER liquid via G-tube, everyday. The facility's Medication Administration Policy with a revision date of 1/17 read at #6; Drugs must be administered correctly as ordered and according to specific instructions. On 11/1/18, the above findings were shared with the Administrator and Director of Nursing. The Director of Nursing stated no extended release medications should be crushed. DEFINITIONS A jejunostomy tube is a tube inserted through the abdomen that delivers nutrition directly into the small intestine A gastrostomy tube is a tube inserted through the abdomen that delivers nutrition directly to the stomach. Benign prostatic hyperplasia (BPH) is an enlargement prostate gland. 2. Resident #314 was originally admitted to the facility 10/22/18 and had not been discharged from the facility. The The current diagnoses included; high blood pressure and localized edema. The admission Minimum Data Set (MDS) assessment had not been completed but the nursing admission assessment revealed Resident #314 was alert, and oriented to person, place, time and situation. The nursing admission assessment also revealed the resident short and long term memory was intact and she was capable of understanding what was said to her and making her needs known. The physician's order summary revealed an order dated 10/22/18, for Potassium Chloride Extended Release (ER) 20 milli-equivalent 1 by mouth two times each day for low potassium. The care plan revealed a problem which read; Potential for complications related to hypertension. The goal read; (name of resident) will be/remain free of signs and symptoms or complications related to hypertension through 1/24/19. The interventions included; Obtain and monitor labs/diagnostic work as ordered. Report results to physician and follow-up as indicated. Provide medications as ordered and monitor for side effects/effectiveness. On 10/31/18, at approximately 5:58 p.m., Licensed Practical Nurse (LPN) #1 crushed Resident #314's Potassium Chl ER and mixed it in applesauce. She stated that was how the resident liked to take it. Upon entering Resident #314's room the resident asked when I go home can I go back taking my small potassium pill? I don't like that big pill. LPN #1 handed the resident the cup and she accepted the crushed medicine as well as two other medication capsules in another cup. An interview was conducted with Licensed Practical Nurse (LPN) #1, on 10/31/18 at approximately 7:00 p.m., LPN #1 stated she didn't realize the potassium was an extended release medication, she just knew the resident didn't like the big pill and crushing it solved her concern. On 11/1/18 at approximately 6:20 p.m.,the facility staff presented a new order dated 11/1/18 at 10:10 a.m., to change the Potassium Chl ER tablet to a liquid form two times per day and to offer yogurt along with the liquid potassium. The facility's Medication Administration Policy with a revision date of 1/17 read at #6; Drugs must be administered correctly as ordered and according to specific instructions. On 11/1/18, the above findings were shared with the Administrator and Director of Nursing. The Director of Nursing stated no extended release medications should be crushed. 3. On 10/31/18 at 10:00 a.m., during the morning medication pass, two medications were omitted (Colace 100 milligrams and Atrovent nasal spray) and a third medication was administered in the wrong route (Artificial tears drops instead of artificial tears ointment). Resident #27 was admitted to the nursing facility on 2/12/14 with diagnoses that included *osteoarthritis and *Alzheimer's disease. *Osteoarthritis is a chronic arthropathy characterized by disruption and potential loss of joint cartilage along with other joint changes (https://www.merckmanuals.com/professional/musculoskeletal-and-connective-tissue-disorders/joint-disorders). *Alzheimer's disease, also referred to simply as a chronic neurodegenerative brain disease that usually starts slowly and worsens over time (https://www.nia.nih.gov/health). The most recent Minimum Data Set (MDS) was a quarterly dated 8/9/18 and coded the resident on Brief Interview for Mental Status (BIMS) with a score of 13 out of a possible score of 15 which indicated she was intact in the skills needed for daily decision making. The resident was coded to have constipation, dry eye syndrome of unspecific lacrimal gland, as well as allergic rhinitis and congestive heart failure. The care plan dated as revised on 8/22/18 indicated the resident had altered discomfort related to eye irritation and the goal set for the resident by the staff was that she would not have any complication related to prescribed medication. One of the approaches the staff would take to accomplish this goal included administered eye medication as ordered by the physician. The care plan identified the resident was at risk for constipation as a result of side effects from medication. The goal the staff set for the resident was that she would have regular bowel movements 2-3 days per week. One of the approaches the staff would implement to accomplish this goal included to administer bowel protocol that included administering the bowel medications as ordered by the physician. The care plan identified episodes of dyspnea and upper respiratory allergic symptoms. The goal set for the resident by the staff indicated the resident would be free of any upper respiratory allergic symptoms. The approaches the staff would take to accomplish this goal included administer medication as ordered by the physician. Resident #27 had physician orders dated 10/30/18 for artificial tears ointment to apply in both eyes three times a day for dry eyes and was transcribed as the same on the Medication Administration Record (MAR). The resident also had physician orders dated 1/25/17 for Colace (stool softener) twice a day, and Atrovent nasal spray for allergic rhinitis, 2 sprays into each nostril BID (twice a day) ordered 2/8/16. On 10/31/18 at 10:00 a.m., during the morning medication pass, Licensed Practical Nurse (LPN) #4 omitted Colace 100 milligrams and Atrovent nasal spray and a third medication was administered in the wrong form: Artificial tears drops instead of artificial tears ointment. Review of the Medication Administration Record was conducted on 10/31/18 at 2:30 p.m. On 11/1/18 at 1:50 p.m., the aforementioned medication errors were reviewed with Unit Manager Registered Nurse #6. She stated LPN #4 was an agency nurse, floated all over the facility and was scheduled to work another unit for 11/1/18, thus she was not able to review the errors with her. On 11/1/18 at 6:15 p.m., a pre-exit meeting was conducted with the Administrator and Director of Nursing (DON). The medication errors were brought to their attention. No further information was provided prior to survey exit on 11/1/18 at 7:30 p.m. The facility's policy and procedures titled Medication Administration revised 1/17 included: the licensed nurse will observe the five rights of administration when passing medications: Right patient, right drug, right dose, right time and right route.

Based on observation, staff interviews and facility document review the facility staff failed to store food in accordance with professional standards for food service safety. The food service staff failed to ensure foods stored in the freezer and dry storage were sealed, labeled and dated when opened. The findings included: On 10/30/18 at 11:00 a.m., during the initial inspection of the kitchen with the Director of Food Services, the following were observed: 1. Inside the walk in freezer was 1 bag of corn on the cob, 1 bag of tilapia, 1 bag of baby shrimp, 1 bag of green beans, 1 bag of zucchini, 1 bag of meatballs, 1 bag of bagels and 1 bag of omelets; which were not sealed closed, labeled or dated. 2. Inside the dry storage was an opened bag of granola; not sealed closed, labeled or dated. On 10/30/18 at approximately 11:14 a.m., the surveyor asked the Director of Food Services, Should the open bag of corn on the cob, tilapia, baby shrimp, green beans, zucchini, meatballs, bagels and omelets and granola be labeled and dated once opened he replied, All food items should be dated after they are open. The Director of Food Services removed all frozen food from the freezer and the bag from dry storage that were open and not dated. The facility administration was informed of the finding during a briefing on 11/01/18 at approximately 5:45 p.m. The facility staff did not present any further information about the findings. The facility's policy titled Food Handling (Revision 09/27/17). -8.1.1. Labeling tools, uses, and required information -Refrigerated/Frozen food label - use for: -All refrigerated foods after opening, preparing, cooking, and cooling -Put this information on the label include but not limited to: -Product name -Open/Production/Freeze date -Initials of Associate

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on on observations and staff interviews the facility staff failed to provide a safe functional sanitary and comfortable environment for residents, staff and the public. The findings included: During an Environmental Tour on 11/01/18 at 2:42 PM, trash and debris were observed outside of the building by the Dogwood Unit near room [ROOM NUMBER], on the North End of the facility. Several PVC pipes, rotten wood, approximately 20 window screens, wooden benches, standing water in drainage area, cigarette butts, beach chairs, cones for hazardous areas, no parking signs, approximately 20 wooden pallets, and discarded fence were observed in this area. A review of the Pest Control Log dated 09/24/18 indicated a black and white snake was found in room [ROOM NUMBER] on the Dogwood Unit. During an interview on 11/01/18 at 3:05 with the Housekeeping Director she stated, maintenance staff were responsible for ensuring the area was clean and maintained. An Exterior Maintenance Policy indicated: Check ground area daily: (Maintenance every other week, House Keeping (payday week) every other week). The ground is clean and containers are securely fastened with lids. Dumpster's and garbage areas are washed/scrubbed weekly with hot water and de-[NAME] detergent. During an interview with the Administrator on 11/1/18, he was asked for a policy and stated the facility did not have a safe, sanitary, comfortable environmental policy. The Administrator stated, the area should not have the trash and debris piled up outside the building.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, he facility staff failed to maintain an effective pest control program. The findings included: During the environmental tour on 11/1/2018 at 2:15 P.M. ants were observed on the Dogwood Unit. During a review of the Pest Control Log on 11/01/18 at 2: 33 P.M. noted: ants were sited (sic) in room [ROOM NUMBER] on the Camellia Unit on 10/29/18. On 10/22/18 Roaches were sited (sic) in the laundry room. On 10/8/18 Roaches were sited (sic) on the [NAME] Unit. On 10/01/18 ants were sited (sic) in room [ROOM NUMBER] of the [NAME] Unit. Roaches and Water bugs were sited in the Admissions office. Ants were sited (sic) in the Quality Assurance office. Roaches were sited (sic) in the laundry room. On 09/24/18 water bugs were sited (sic) in room [ROOM NUMBER] on the Camellia Unit. On 09/21/18 a snake was sited (sic) and killed in room [ROOM NUMBER] on the Dogwood Unit. On 09/17/18 roaches were sited (sic) in room [ROOM NUMBER] on the Dogwood Unit. Ants were sited (sic) in room [ROOM NUMBER] on the Dogwood Unit. In the Maintenance Room Birchwood bugs were sited (sic). In the [NAME] (sic) Room water bugs were sited (sic). On 09/10/18 bugs were sited (sic) in the Nursing Administration Office. Ants were sited (sic) on the Camellia Unit- in rooms #1, #4 and #5. On 09/03/18 roaches were sited (sic) on the Camellia Unit in room [ROOM NUMBER], #3 and #19-B. Roaches were sited (sic) in the camellia storage room. Ants were sited (sic) in the Camellia Unit day Room. During an interview on 11/01/18 at 2:45 P.M. with the Housekeeping Director she stated, the pest control vendor came out weekly to spray. During an interview on 11/1/18 at 7:00 P.M. with the Administrator he stated, the facility sprays weekly. A Pest Control policy was requested and the Administrator stated the facility did not have one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interviews, clinical record review and facility document review the facility staff failed to ensure 1 of 24 residents in the survey sample (Resident #16) was free from abuse-misappropriation of resident property. During the survey Resident #16 informed this inspector that three Amazon Voice Activated Firesticks purchased on line and stored in his room inside a leather brief case had been stolen. The facility staff was made aware of this allegation. According to the resident there was no follow up or resolution of the missing items. The Amazon Fire TV Stick connects to your TV's HDMI port. It's an easy way to enjoy over 4,000 channels, apps, and games including access to over 250,000 TV episodes and movies on Netflix, Amazon Video, HBO NOW, Hulu, and more. www.Amazon.com The findings included: Resident #16 was admitted to the facility on [DATE] with a diagnosis of quadraplegia (paralysis of all four extremities). The current MDS (Minimum Data Set) an annual with an assessment reference date of 12/29/16 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status, indicating the residents cognition was intact. The resident was completely dependent on staff for all activities of daily living, such as repositioning, transfers, dressing, eating, bathing and personal hygiene. On 4/4/16 at 3:00 pm, this inspector was walking by the resident's room. He promptly stated, Hey, come here. This inspector went inside the resident's room. The resident was in bed. There were numerous electronic devices observed such as a lap top, a printer, and a flat screen TV. There was a small filing cabinet with two locks and a zippered black leather case with a small lock that was not secured. The resident stated that one night he observed a night shift CNA return my leather case, he stated when she noticed he was awake, She fled out of my room. The next day, he asked a staff member to assist him with unlocking the case, the staff told him the lock was not locked. The resident keeps the keys on his wrist. When the case was opened the three Amazon Fire Sticks were missing. The resident stated the Social Worker (SW) was made aware. The SW spoke with him and he was asked to produce a bill of receipt for these items. He stated a bill of receipt was provided and given to the SW. No further action was taken. The clinical record progress notes dated 11/4/16 authored by the Social Worker read, in part: SW (Social Work) Director and DON (Director of Nursing) met w/ (with) Resident @ (at) bedside @ residents request to discuss missing items: 3 Firesticks. Resident was encouraged to report missing items immediately so situation can be addressed in a timely manner. Resident was encouraged to produce delivery/purchase receipt. SW will follow up w/resident for requested information. Resident agreed to provide receipt once obtained. The clinical record did not evidence any further follow up for the allegation of these missing items. The [NAME] President of Patient Services acting as the interim Director of Nursing (DON), who is also the Facility's Grievance Officer was interviewed on 4/5/17 at 10:10 am. She was asked about the alleged misappropriation of property for Resident #16. She stated, He claimed he had Amazon Fire Sticks that were stolen out of his room. I spoke with him and told him we can't be responsible for everything. She stated the resident was asked to provide receipts and stated she did not think he had provided any. She further stated the Administrator, the prior DON and the Social Worker were also aware of this allegation. When asked if misappropriation of property is abuse, she stated, Yes, and stated, In our mind we resolved it. The previous DON and the Social Worker were no longer employed at the facility. On 4/5/17 at 10:30 am, the Administrator stopped this inspector in the hallway outside of Resident #16's room. He stated the resident runs an E-commerce business from his room and they were not able to keep track of all items the resident receives. He also stated the facility provides a space for the resident to keep items with locks. The Administrator stated he was not aware of the allegation of the missing Firesticks. On 4/5/17 at 10:35 am, a Hospitality Aide was interviewed. She stated the resident did inform her that a CNA had took some Firesticks from his room. She stated she did not report this to anyone as she figured he had already reported it. On 4/5/17 at approximately 2:00 pm, the resident produced and provided to this inspector a bill of receipt for the purchase of the 3 Amazon Voice Activated Firesticks dated 7/25/16 and 8/15/16. The facility was not able to produce any evidence of an investigation for this allegation of misappropriation of property for Resident #16. The facility did not report this allegation to the State Survey Agency. The facility's policy subject: Prevention of Resident/Patient Abuse, Neglect or Mistreatment revised 11/15/16 Policy #4-22: Patient/Resident Abuse read, in part: General Policy Statement- Residents at Lake [NAME] Transitional Care Hospital will be free from verbal, sexual, physical, and mental abuse. Accountability: Incidents involving allegations of mistreatment, neglect, abuse, or injuries of an unknown source will be immediately reported to the Administrator of the facility. The Director of Nursing and/ or the Director of Social Services will conduct an immediate investigation to confirm or deny allegations covered by this policy. Policy: 5. Misappropriation of a Patient/Resident's Property a. Theft, or attempted theft of a patient/resident's money or personal property. 4. Local and state agencies will be notified for reporting and/ or assistance as needed. On 4/6/17 at 4:43 pm, a pre-exit meeting was conducted with the Administrator and the [NAME] President of Patient Services acting as the interim Director of Nursing. The above findings was shared.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews and facility documentation, the facility staff failed to ensure procedures were followed regarding allegations of misappropriation of property for 1 of 24 residents in the survey sample, Resident #16. The facility staff failed to investigate and report to the State Survey Agency an allegation of abuse-Misappropriation of personal property, for Resident #16. The findings include: During the survey Resident #16 informed this inspector that three *Amazon Voice Activated Firesticks purchased on line and stored in his room inside a leather brief case had been stolen. The facility staff was made aware of this allegation. The facility did not investigate this allegation or report this to the State Survey Agency. *The Amazon Fire TV Stick connects to your TV's HDMI port. It's an easy way to enjoy over 4,000 channels, apps, and games including access to over 250,000 TV episodes and movies on Netflix, Amazon Video, HBO NOW, Hulu, and more. www.Amazon.com Resident #16 was admitted to the facility on [DATE] with a diagnosis of quadraplegia (paralysis of all four extremities). The current MDS (Minimum Data Set), an annual with an assessment reference date of 12/29/16, coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status, indicating the residents cognition was intact. The resident was completely dependent on staff for all activities of daily living, such as repositioning, transfers, dressing, eating, bathing and personal hygiene. On 4/4/16 at 3:00 pm, this inspector was walking by the resident's room. He promptly stated, Hey, come here. This inspector went inside the resident's room. The resident was in bed. There were numerous electronic devices observed such as a lap top, a printer, and a flat screen TV. There was a small filing cabinet with two locks and a zippered black leather case with a small lock that was not secured. The resident stated that one night he observed a night shift CNA return my leather case, he stated when she noticed he was awake, She fled out of my room. The next day, he asked a staff member to assist him with unlocking the case, the staff told him the lock was not locked. The resident keeps the keys on his wrist. When the case was opened the three Amazon Fire Sticks were missing. The resident stated the Social Worker (SW) was made aware. The SW spoke with him and he was asked to produce a bill of receipt for these items. He stated a bill of receipt was provided and given to the SW. No further action was taken. The clinical record progress notes dated 11/4/16 authored by the Social Worker read, in part: SW (Social Work) Director and DON (Director of Nursing) met w/ (with) Resident @ (at) bedside @ residents request to discuss missing items: 3 Firesticks. Resident was encouraged to report missing items immediately so situation can be addressed in a timely manner. Resident was encouraged to produce delivery/purchase receipt. SW will follow up w/ resident for requested information. Resident agreed to provide receipt once obtained. The clinical record did not evidence any further follow up for the allegation of these missing items. The [NAME] President of Patient Services acting as the interim Director of Nursing (DON), who is also the Facility's Grievance Officer was interviewed on 4/5/17 at 10:10 am. She was asked about the alleged misappropriation of property for Resident #16. She stated, He claimed he had Amazon Fire Sticks that were stolen out of his room. I spoke with him and told him we can't be responsible for everything. She stated the resident was asked to provide receipts and stated she did not think he had provided any. She further stated the Administrator, the prior DON and the Social Worker were also aware of this allegation. When asked if misappropriation of property is abuse, she stated, Yes, and stated, In our mind we resolved it. The previous DON and the Social Worker were no longer employed at the facility. On 4/5/17 at 10:30 am, the Administrator stopped this inspector in the hallway outside of Resident #16's room. He stated the resident runs an E-commerce business from his room and they were not able to keep track of all items the resident receives. He also stated the facility provides a space for the resident to keep items with locks. The Administrator stated he was not aware of the allegation of the missing Firesticks. On 4/5/17 at 10:35 am, a Hospitality Aide was interviewed. She stated the resident did inform her that a CNA had took some Firesticks from his room. She stated she did not report this to anyone as she figured he had already reported it. On 4/5/17 at approximately 2:00 pm, the resident produced and provided to this inspector a bill of receipt for the purchase of the 3 Amazon Voice Activated Firesticks dated 7/25/16 and 8/15/16. The facility was not able to produce any evidence of an investigation for this allegation of misappropriation of property for Resident #16. The facility did not report this allegation to the State Survey Agency. The facility's policy subject: Prevention of Resident/Patient Abuse, Neglect or Mistreatment revised 11/15/16 Policy #4-22: Patient/Resident Abuse read, in part: General Policy Statement- Residents at Lake [NAME] Transitional Care Hospital will be free from verbal, sexual, physical, and mental abuse. Accountability: Incidents involving allegations of mistreatment, neglect, abuse, or injuries of an unknown source will be immediately reported to the Administrator of the facility. The Director of Nursing and/ or the Director of Social Services will conduct an immediate investigation to confirm or deny allegations covered by this policy. Policy: 5. Misappropriation of a Patient/Resident's Property a. Theft, or attempted theft of a patient/resident's money or personal property. 4. Local and state agencies will be notified for reporting and/ or assistance as needed. On 4/6/17 at 4:43 pm, a pre-exit meeting was conducted with the Administrator and the [NAME] President of Patient Services acting as the interim Director of Nursing. The above findings was shared.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a Medication Administration Observation, staff interviews, clinical record review and facility document review the facility staff failed to ensure their Medication Error rate did not exceed 5 percent or greater involving 3 of 24 residents in the survey sample, Resident #18, Resident #19 and Resident #20. The Medication Administration Observation allowed for 33 opportunities and 3 medication errors, resulting in a 9.09% facility Medication Administration Error Rate. The facility staff failed to correctly administer Resident #18's Gaviscon (1), Resident #19's Xarelto (2), and Resident #20's Tamsulosin Hydrochloride (3) as ordered by the Physician during a Medication Administration Observation on 4/4/17. The findings included: On 4/4/17 at 4:30 p.m. a Medication Administration Observation was conducted with LPN (Licensed Practical Nurse) #2. On 4/4/17 at 4:30 p.m. LPN #2 prepared and administered the medication Gaviscon 30 ml (milliliters) by mouth to Resident #18. The medication order on the Medication Administration Record and the Medication Blister Pack read as follows: Gaviscon 30 ml 1 hour after meals and hs (bedtime). Resident #18's dinner tray arrived at 4:55 p.m. On 4/4/17 at 4:35 p.m. LPN #2 prepared and administered the medication Xarelto 20 mg (milligrams) 1 by mouth to Resident #19. The medication order on the Medication Administration Record and the Medication Blister Pack read as follows: Xarelto 20 mg 1 by mouth at 1800 (6:00 p.m.) for DVT (Deep Vein Thrombosis) prevention. On 4/4/17 at 4:40 p.m. LPN #2 prepared and administered the medication Tamsulosin Hydrochloride 0.4 mg 1 capsule extended release by mouth to Resident #20. The medication order on the Medication Administration Record and the Medication Blister Pack read as follows: Tamsulosin Hydrochloride 0.4 mg 1 by mouth after dinner. Resident #20's wife was taking him to the facility dining room for dinner after the medication was administered. The Medication Administration Observation was stopped at this point and LPN #2 was asked by the surveyor to review the Medication Administration Records and the Medication Blister Packs for Resident #18's Gaviscon, Resident #19's Xarelto, and Resident #20's Tamsulosin Hydrochloride. After reviewing the Medication Administration Records and the Medication Blister Packs for the above residents LPN #2 stated, I should have waited until after they had their meals for (Name of Resident #18) and (Name of Resident #20). I should have waited until 1800 (6:00 p.m.) to give (Name of Resident #19) her Xarelto. Most places give that at 6:00 a.m. I have only been here since November. The Surveyor asked LPN #2 what she should have done before administering the medications to the residents, LPN #2 stated, I need to read more carefully and follow the doctors orders. Resident #18 was a [AGE] year old admitted to the facility on [DATE] with diagnosis to include Gastro-Esophageal Reflux Disease (GERD) (4). The most recent comprehensive MDS assessment was a Significant Change with an Assessment Reference Date (ARD) of 4/18/16. On the Brief Interview for Mental Status (BIMS) the resident scored a 15 out of a possible 15 which indicated Resident #18 was cognitively intact and capable of daily decision making. Resident #18's Comprehensive Plan of Care last reviewed 1/24/17 is documented in part, as follows: Date: 1/24/17 Problem: Potential for complications of discomfort, related to dx (diagnosis) of GERD. Interventions: Administer medications and/or treatments as ordered and monitor for side effects, effectiveness Resident #18's Physician Order Sheet for April 2017 signed by the Attending Physician on 4/3/17 is documented in part, as follows: GAVISCON 30 ML BY MOUTH 1 HOUR AFTER MEALS AND AT BEDTIME-GI (Gastro-intestional) DISTRESS Resident #18's Medication Administration Record for April 2017 is documented in part, as follows: GAVISCON 30 ML BY MOUTH 1 HOUR AFTER MEALS AND AT BEDTIME-GI(Gastro-intestional) DISTRESS Medication Administration Times: 0900 (9:00 a.m.), 1300 (1:00 p.m.), 1700 (5:00 p.m.), 2100 (9:00 p.m.). Resident #19 was a [AGE] year old admitted to the facility on [DATE] with diagnosis to include Deep Vein Thrombosis (DVT) (5). The most recent comprehensive MDS assessment was an admission 5 Day with an Assessment Reference Date (ARD) of 2/28/17. On the Brief Interview for Mental Status (BIMS) the resident scored a 14 out of a possible 15 which indicated Resident #19 was cognitively intact and capable of daily decision making. Resident #19's Comprehensive Plan of Care last reviewed 2/22/17 is documented in part, as follows: Date: 2/22/17 Problem: Potential for bleeding, bruising and skin tear due to anticoagulant therapy. At risk for Deep Vein Thrombosis. Interventions: Administer medications as ordered. Resident #19's Physician Order Sheet for April 2017 signed by the Attending Physician on 4/4/17 is documented in part, as follows: XARELTO 20 MG TABLET 1 TABLET BY MOUTH EVERY DAY AT 1800 (6:00 p.m.) FOR DVT PREVENTION. Resident #19's Medication Administration Record for April 2017 is documented in part, as follows: XARELTO 20 MG TABLET 1 TABLET BY MOUTH EVERY DAY AT 1800 (6:00 p.m.) FOR DVT PREVENTION. Medication Administration Time: 1800 (6:00 p.m.). Resident #20 was a [AGE] year old admitted to the facility on [DATE] with diagnoses to include Urinary Retention (6) and Benign Prostatic Hypertrophy (7). The most recent comprehensive MDS assessment was an admission 5 Day with an Assessment Reference Date (ARD) of 3/04/17. On the Brief Interview for Mental Status (BIMS) the resident scored a 13 out of a possible 15 which indicated Resident #20 was cognitively intact and capable of daily decision making. Resident #20's Comprehensive Plan of Care last reviewed 3/20/17 is documented in part, as follows: Date: 3/20/17 Problem: Potential for discomfort, complications related to dx of Benign Prostatic Hypertrophy. Interventions: Administer medications and/or treatments as ordered and monitor for side effects, effectiveness. Resident #20's Physician Order Sheet for April 2017 signed by the Attending Physician on 4/3/17 is documented in part, as follows: TAMSULOSIN HCL (Hydrochloride) 0.4 MG CAP (Capsule) ER (Extended-Release) 1 CAP BY MOUTH AFTER DINNER-URINARY RETENTION. Resident #20's Medication Administration Record for April 2017 is documented in part, as follows: TAMSULOSIN HCL (Hydrochloride) 0.4 MG CAP (Capsule) ER (Extended-Release) 1 CAP BY MOUTH AFTER DINNER-URINARY RETENTION. Medication Administration Time: 1800 (6:00 p.m.). A Medication Pass Observation for LPN #2 was reviewed. The Medication Pass Observation for LPN #2 was completed in the facility on 12/5/16 with 1 resident, 5 opportunities, and 0 errors noted. The facility policy titled Medication Administration Policy last reviewed 5/16 is documented in part, as follows: Purpose: A) To administer medications safely, accurately, and in a timely manner. B) To comply with regulatory standards. Policy: A) Licensed nurses will observe the five rights of administration when passing medications. Procedure: B) Medication Pass 6. Drugs must be administered correctly as ordered and according to specific instructions. 8. Read medication label or single dose pack carefully comparing with the MAR. (Medication Administration Record) 9. Check MAR and pour medication to be given. C) Medication Pass Specifies 1. Medications may be administered within 60 minutes prior to and no later than 60 minutes after scheduled time. On 4/6/17 at 2:20 p.m. an interview was conducted with the [NAME] President of Patient Services and the above information was shared. The [NAME] President of Patient Services was asked by the surveyor what she would have expected from LPN #2 during the Medication Administration Observation. The [NAME] President of Patient Services stated, I would have expected her to have read the MAR and followed the Physician's Orders. On 4/6/17 at 4:45 p.m. during a pre-exit debriefing with the Administrator and the [NAME] President of Patient Services the above information was shared. Prior to exit no further information was provided to the surveyor. (1) Gaviscon: an antacid, an acid reflux and heartburn medication (2) Xarelto: a blood thinner to prevent blood clots and used to treat deep vein thrombosis. (3) Tamsulosin Hydrochloride: Anti-adrenergic, decreases smooth muscle contractions of the prostate. This action increases urine flow and reduces symptoms of benign prostatic hypertrophy. The above definitions are derived from [NAME]-Hill Nurse's Drug handbook 7th Edition. (4) Gastro-Esophageal Reflux Disease (GERD): a backflow of contents of the stomach into the esophagus that is often the result of incompetence of the lower esophageal sphincter. Gastric juices are acidic and therefore produce burning pain in the esophagus. (5) Deep Vein Thrombosis (DVT): a disorder involving a thrombus in one of the deep veins of the body, most commonly the iliac or femoral vein. (6) Urinary Retention: the condition is described as the state in which an individual experiences incomplete emptying of the bladder. (7) Benign Prostatic Hypertrophy: noninflammatory enlargement of the prostate. The above definitions are derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interview and facility documentation, the facility staff failed to ensure restraints were not imposed for the purposes of staff convenience for 2 out of 24 residents (Resident #13 and #10). 1. Resident #13, assessed at high risk for falls and with a history of falls, was observed reclined in a Geriatric Lounger pushed up against and under the dining room table, on the Dogwood Unit. 2. Resident #10, assessed at high risk for falls and with a history of falls, was observed in bed with bilateral half bed rails and bilateral wedges, under the fitted sheet that extended from the end of the bed rails to approximately mid-calf region. The staff stated the wedges along with the side rails kept the resident from trying to out of bed. The findings include: 1. Resident #13 was admitted to the nursing facility on 7/1/16 with diagnoses that included stroke, arthritis, seizure disorder, dementia and altered mental status. The Significant change Minimal Data Set (MDS) assessment dated [DATE] coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 6 out of a possible score of 15 which indicated the resident was severely impaired in the skills needed for daily decision making. Resident #13 required extensive assistance of 2 staff for bed mobility, transfers and toilet use. The resident did not have any limitations in range of motion. A wheelchair was coded for the mobility device normally used. She was assessed frequently incontinent of bowel and bladder. The resident was coded to have fallen prior to admission and to have fallen in the last 2-6 months. Resident #13 was not coded for restraints to include chair that prevents rising or other restraint type when out of bed. The MDS dated [DATE] assessed the resident with falls since prior assessment; two or more without injury. The care plan dated 1/10/17 identified Resident #13 was at risk for falls an injury related to history of frequent falls, weakness or deconditioning, impaired balance, requiring assistance with transfers, ambulation and locomotion, history of falls (last 30 days), seizure disorder, impaired cognition/orientation, poor safety awareness and impulsive. The goal the staff set for the resident was that the resident would be provided a safe environment and appropriate staff assistance and appropriate staff assistance in order to minimize the risk for injury and falls daily. Some of the approaches the staff would implement to accomplish this goal included when she was out of bed in recliner, assist to remain at nurses station for closer nursing supervision. Place her next to charge nurse when nurse is at desk, other staff if charge nurse not at desk. The resident was not care planned for a chair that prevents rising or other restraint type when out of bed to include usage of a table to stop the resident from standing with attempts to walk. There were no restraint assessments in the resident's clinical record, nor evidence that other alternatives were tried prior to use of a chair and other device (table) that prevented the resident from rising. There were no physician orders for restraints to include a Geri-lounger maintained in a reclined position pushed up and under a table. Resident #13's fall history was reviewed from November 2016 to current which indicated she had fallen 16 times. There was no documentation as to when the table was added to the Geri-lounger to block the resident in to prevent her from rising. The following observations were made of Resident #13 out of bed: 4/4/17 at 3:45 p.m., Resident #13 was in the day room on the Dogwood Unit, positioned in a Geri-lounger, reclined and pushed up against a 6 foot table with other residents. She was pleasant and responded appropriately to simple questions. 4/4/17 at 5:00 p.m., the resident was in the same position. Licensed Practical Nurse (LPN) #8 stated the resident stayed in the recliner when out of bed and for most of the day. The LPN stated the resident would tell them when she had to go to the bathroom. She said the staff keep her in the dayroom so they could see her, but could move around and do what they needed to do because she was in the recliner pushed up to the table. The LPN stated, If we did not position her that way in the recliner up to the table, she would try to get up and walk. She has fallen in the past so this chair and table stops her from trying to get up. On 4/4/17 at 5:15 p.m., the resident was at the table eating her evening meal in the day room in the Geri-lounger. On 4/5/17 at 10:00 a.m. and 12:00 p.m. Resident #13 was in the day room, positioned in the Geri-lounger, reclined and pushed up against the table along with other residents. She was not involved in any type of activity. On 4/5/17 at 12:50 p.m., the resident was in the same position eating her lunch meal at the table. LPN #9 stated, (Resident #13's name) has to be in this chair like this up to the table all the time because she will try to get up. We put a pillow behind her back to rest her back. You see she will still try to lean forward. The table stops her from trying to rise up and walk. On 4/5/17 at 1:30 p.m., Resident #13 asked to go to the bathroom, at which time she was transferred to her room and taken to the bathroom. With instructions from Certified Nursing Assistant (CNA) #8, the resident stood, held on to the railings along side the commode, stood and pivoted and sat on the commode. After the resident was transferred back to the Geri-lounger, she was reclined and pushed back up to the table in the dayroom. CNA #8 stated, We must keep the resident in the Geri-lounger up to the table so she would not try and stand to walk. As you can see she can walk some, but she will fall as she has done in the past. On 4/5/17 from 4:00 p.m. to 5:30 p.m., the resident was in the same position in the dayroom. On 4/6/17 at 11:00 a.m. and 2:00 p.m. Resident #13 remained in the same position as previously observed. On 4/6/17 at 2:45 p.m., the Dogwood Unit Manager said she had no residents on her unit that were assessed to require restraints and that the facility was a restraint free facility. On 4/5/17 at 2:00 p.m., the Director of Nursing stated the facility was restraint free and there were no residents in the building using restraints. On 4/5/17 at 2:15 p.m., the Minimum Data Set (MDS) coordinator stated she was sure there were no residents in the building with restraint usage, but if restraints were used she followed the Resident Assessment Instrument (RAI) 3.0 guidelines. She stated she was sure she had not assessed Resident #13 for the use of a physical restraint. On 4/6/17 at 4:45 p.m., an interview was conducted with the Administrator and the Director of Nursing (DON). When explained to the DON how Resident #13 was positioned in the Geri-lounger up against the table in the day room, the DON stated That is a restraint. We have not assessed her to have a restraint. The facility's policy and procedure titled Use of Restraint/Safety Device revised 8/2015 indicated the following: Purpose-To ensure all resident's individual needs are taken into consideration and are only utilized when a resident has demonstrated a threat to himself and alternatives have been unsuccessful. Policy-Safety devices will only be implemented after all alternatives have been unsuccessful. Procedure-A) Report any and all potential need for restrictive devices to the Nurse Manager, House supervisor (if after normal business hours) and the DON immediately for a comprehensive review and subsequent decision. B) Under no circumstances may a MD (Medical Director) order be requested or a device be initiated without the above notification being made. The RAI Manual 3.0 indicated the steps for assessment of a physical restraint included: 1. Review the resident's medical record (e.g., physician orders, nurse's notes, nursing assistant documentation) to determine if physical restraints were used during the 7-day look-back period. 2. Consult the nursing staff to determine the resident's cognitive and physical status/limitations. 3. Considering the physical restraint definition as well as the clarifications listed below, observe the resident to determine the effect the restraint has on the resident's normal function. Do not focus on the type, intent, or reason behind its use. 4. Evaluate whether the resident can easily and voluntarily remove any manual method or physical or mechanical device, material, or equipment attached or adjacent to his or her body. If the resident cannot easily and voluntarily do this, continue with the assessment to determine whether or not the manual method or physical or mechanical device, material or equipment restrict freedom of movement or restrict the resident's access to his or her own body. 5. Any manual method or physical or mechanical device, material or equipment should be classified as a restraint only when it meets the criteria of the physical restraint definition. This can only be determined on a case-by-case basis by individually assessing each and every manual method or physical or mechanical device, material or equipment (whether or not it is listed specifically on the MDS) attached or adjacent to the resident's body, and the effect it has on the resident. 6. Determine if the manual method or physical or mechanical device, material, or equipment meets the definition of a physical restraint as clarified below. Remember, the decision about coding any manual method or physical or mechanical device, material, equipment as a restraint depends on the effect it has on the resident. 7. Any manual method or physical or mechanical device, material, or equipment that meets the definition of a physical restraint must have: -physician documentation of a medical symptom that supports the use of the restraint, -a physician's order for the type of restraint and parameters of use, and -a care plan and a process in place for systematic and gradual restraint reduction (and/or elimination, if possible), as appropriate. Clarifications: -Remove easily means that the manual method or physical or mechanical device, material, or equipment can be removed intentionally by the resident in the same manner as it was applied by the staff (e.g., side rails are put down or not climbed over, buckles are intentionally unbuckled, ties or knots are intentionally untied), considering the resident's physical condition and ability to accomplish his or her objective (e.g., transfer to a chair, get to the bathroom in time). -Freedom of movement means any change in place or position for the body or any part of the body that the person is physically able to control or access. ENABLER vs. PHYSICAL RESTRAINT In classifying any manual method or physical or mechanical device, material or equipment as a physical restraint, the assessor must consider the effect it has on the resident, not the purpose or intent of its use. It is possible that a manual method or physical or mechanical device, material or equipment may improve a resident's mobility but also have the effect of physically restraining him or her. For residents who have the ability to transfer from other chairs, but cannot transfer from a geriatric chair, the geriatric chair would be considered a restraint to that individual, and should be coded as P0100G-Chair Prevents Rising. Geriatric chairs used for residents who are immobile. For residents who have no voluntary or involuntary movement, the geriatric chair does not meet the definition of a restraint. 2. Resident #10 was admitted to the nursing facility on 12/1/16 with diagnoses that included history of falling at home with his resident representative. Diagnoses included a brain lesion and brain abscess, unsteady gait, macular degeneration (1), nocturia (2), hard of hearing and dementia. The resident fell on [DATE] and sustained orbital fracture and was transferred to the hospital and re-admitted to the nursing facility on 12/8/16. Other major injuries from falls were on 1/15/17 with facial fractures and on 2/26/17 with TMJ (Temporomandibular joint) fracture (3). The Minimum Data Set (MDS) assessment dated [DATE] coded Resident #10 on the Brief Interview for Mental Status (BIMS) with a score of 12 out of a possible score of 15 which indicated the resident was moderately impaired in the skills needed for daily decision making. The resident was coded to require extensive assistance from one staff for bed mobility, transfers walking in room, eating, toilet use, bathing and personal hygiene. He was assessed totally dependent on one staff for locomotion off the unit. The resident had no impairment in range of motion. The MDS coded that the resident believed he was was capable of increased independence in at least some Activities of Daily Living (ADL). It was coded that the direct care staff believed the resident was capable of increased independence in at least some ADLs. The wheelchair was the resident's primary mobility device. Resident #10 was assessed occasionally incontinent of urine and frequently incontinent of bowel. The resident was assessed to have fallen prior to admission and within 2-6 months with no injury and falls with minor and major injury. The resident was not assessed to use physical restraints in or out of bed. The MDS dated [DATE] assessed the resident with falls since prior assessment; two or more falls without injury, 2 or more with injury and 2 or more with major injury. The care plan 12/28/16 identified the resident was at risk for falls and required assistance with transfers, ambulation and locomotion related to weakness/deconditioning, impaired balance and history of falls. The goal the staff set for the resident was that he would have no injury from falls. A listing of all the resident's falls included 11 falls (8 from fall out of bed) since his admission to the nursing facility, three with major injury: 12/7/16 fall out of bed with orbital fracture, 1/15/17 fall from wheelchair with facial fracture and on 2/26/17 fall out of bed with TMJ fracture. The resident had a low bed with bilateral half bed rails from admission. There were no other devices care planned for the resident while he was in bed to include bilateral wedges under the fitted sheet extended beyond the half side rails. The following observations were made of Resident #10 in bed: On 4/4/17 at 2:30 p.m., 3:30 p.m. and at 5:30 p.m., Resident #10 was observed in bed with both half side rails up and bilateral large foam wedges that extended from the end of the half side rails to mid calf region. The foam wedges were tucked on each side of the bed under the fitted sheets. On 4/4/17 at 5:30 p.m. two Certified Nursing Assistants (CNA), #6 and #7 came to place the resident in the wheelchair and take him to the dayroom for the dinner meal. CNA #6 removed the wedges and exited the resident from the left side of the bed. She stated the wedges were placed under the fitted sheet to block the resident from coming out of bed from either side. CNA #6 and #7 stated the resident was a frequent faller and would try to get out of bed, stand and walk. The CNAs indicated it was the Cans practice to place the wedges on each side of the bed to block him from trying to get out of bed. On 4/5/17 at 12:00 p.m., the Unit Manager was asked about the aforementioned use of the wedges and responded that the resident only had one wedge that was to be used to position the resident on his side. This surveyor and the Unit Manager went to the resident's room and observed there were two wedges. The Unit Manager stated, They can't use the wedges that way, it is considered a restraint. I did not know the wedges were used in that way. On 4/6/17 at 10:45 p.m., the Dogwood Unit Manager stated she called CNA #6 at which time she told by her that the CNAs used the wedges as mentioned above to block the resident from getting out of bed and falling. The Unit Manager stated she called CNA #6 on the telephone to educated her that that the use of the two wedges on each side extending from the ends of the side rails blocking the resident from exiting the bed was considered a restraint. She stated she would continue educating the other CNAs. On 4/6/17 at approximately 3:00 p.m., an interview was conducted with the Physician's Assistant (PA). He was asked about a progress note he wrote on 1/29/17 that indicated the following: .Status post fall with traumatic head injury. The patient is currently on a low bed. Mats have been removed due to the patient's ability to ambulate and potentially creating a fall due to mat placement. He does have wedges on his bed at this time to prevent any rolling out of bed inadvertently . The PA stated he had been seeing the wedges positioned lower midway the bed on each side and was only documenting what he observed and did not order wedges to be used in that manner. The PA offered no explanation when asked if the resident had the ability to independently get out of bed and wedges were used to stop that action would the wedges be considered restraints. Based on the date of this PA progress note and the observations 4/4/17, this practice had been in place at least 2 months. The Dogwood Unit Manager was shown the PA's progress note that indicated at the nursing staff were in the practice of using the wedges as restraints for at least 2 months. On 4/6/17 at 4:45 p.m., the aforementioned observations of Resident #10 in bed with the bilateral wedges, as well as the interview with the PA, his progress note and the interview with the Dogwood Unit Manager was shared with the Administrator and the DON. The DON stated she thought one wedge was used for side lying positioning at the resident's back. (1) Macular degeneration - MD is a common eye condition and a leading cause of vision loss among people age [AGE] and older. It causes damage to the macula, a small spot near the center of the retina and the part of the eye needed for sharp, central vision, which lets us see objects that are straight ahead (https://[NAME].nih.gov/health/maculardegen/armd_facts). (2) Nocturia-Some people wake up from sleep more often to urinate during the night. This can disrupt sleep cycles (https://medlineplus.gov/ency/article/003141.htm). (3) The TMJ connects the lower jaw (mandible) to the skull (temporal bone) in front of the ear. Certain facial muscles that control chewing are also attached to the lower jaw (http://www.emedicinehealth.com/temporomandibular_joint_tmj_syndrome/article_em.htm).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interview and facility documentation, the facility staff failed to ensure residents were able to maintain or improve their current level of functioning of Activities of Daily Living (ADL) for 1 of 24 residents (Resident #10) in the survey sample. Resident #10 was assessed with the ability to feed himself, but staff did not allow him this opportunity, but instead totally hand fed him all his meals. The findings included: Resident #10 was admitted to the nursing facility on 12/1/16 with diagnoses that included history of falling at home where he resided with his resident representative. Diagnoses included a brain lesion and brain abscess, unsteady gait, macular degeneration (1), nocturia (2), hard of hearing and dementia. The resident fell on [DATE] and sustained orbital fracture and was transferred to the hospital and re-admitted to the nursing facility on 12/8/16. Other major injuries from falls were on 1/15/17 with facial fractures and on 2/26/17 with TMJ (Temporomandibular joint) fracture (3). The Minimum Data Set (MDS) assessment dated [DATE] coded Resident #10 on the Brief Interview for Mental Status (BIMS) with a score of 12 out of a possible score of 15 which indicated the resident was moderately impaired in the skills needed for daily decision making. The resident was coded to require extensive assistance from one staff for eating. The resident had no impairment in range of motion. The MDS coded that the resident believed he was capable of increased independence in at least some Activities of Daily Living (ADL). It was coded that the direct care staff believed the resident was capable of increased independence in at least some ADLs. The care plan dated 1/6/17 and 3/29/17 identified Resident #10 on nectar thickened liquids and pureed diet to require assistance with intake as needed. On 4/5/17 at 2:00 p.m., the MDS Coordinator stated she and the other MDS staff obtained information to determine how a resident eats from observations, interviews with CNAs and licensed nurses, as well as ADL logs. The following observations were made of Resident #10 during meals: On 4/4/17 at 12:30 p.m., a Certified Nursing Assistant (CNA) was observed totally feeding the resident his lunch meal. On 4/4/17 at 5:45 p.m., Licensed Practical Nurse (LPN) #10 was observed totally feeding the resident his dinner meal. All along the LPN stated, He is trying to feed himself, grabbing at the spoon and the tray. She turned the tray away from him, not allowing him to use the utensils to attempt to feed himself and proceeded to totally feed the resident 100% of the meal. On 4/5/17 at 12:15 p.m., a different CNA (#5) from the previous day, was also observed totally feeding the resident his lunch meal. She had the lunch tray turned toward he on the table and not toward the resident as she was feeding him each spoonful. The resident was observed reaching for his tray and trying to take the spoon, at which time the CNA would say, That's okay, I got it (Resident #10's name). The LPN #7 charge nurse stated that the resident was totally fed by staff and was always fed by staff. On 4/5/17 at 12:30 p.m., this surveyor asked CNA #5 why she did not allow the resident to try and feed himself; she stated, He can't do it, we have always fed him. He likes to reach out for the spoon. The Unit Manager verified that the resident was fed by the staff, but stated she would have the Occupational Therapist come to evaluate the resident for possible self feeding. On 4/5/17 at 2:20 p.m., the Occupational Therapist (OT) #1 gave the resident a cup of applesauce and a placed a plastic spoon in his hand. The resident fed himself at a normal pace, did not overfill the spoon and consumed 100% of the applesauce. The OT stated she would say he was able to totally feed himself with set up and supervision by the staff and placing the utensil in his hands. She stated she would probably check the resident out for lunch on 4/6/17 with a plate of food before she completed her evaluation. The Unit Manager was present during the aforementioned observation and stated she did not know he could feed himself and was happy to see how independent and relaxed the resident was while feeding himself. On 4/6/17 at 1:55 p.m., OT #2 stated Resident #10 had already been evaluated 1/10/17 to feed himself with minimal assistance, place utensils in hands and encourage him to take smaller bites and slow down his pace. OT #1 was also present during this interview and stated she concluded the same in her evaluation after the plated lunch meal on 4/6/17. OT #1 stated, He did really well and just needs oversight and cueing during eating. On 4/6/17 at 4:45 p.m., the above observations of the resident during meal times and OT evaluations were shared with the Administrator and the Director of Nursing (DON). The DON was not aware of the resident's abilities to feed himself and depended on the staff to know how all residents ate to maintain their current status. The DON stated they had no policies that addressed resident ADL needs to include eating. (1) Macular degeneration MD is a common eye condition and a leading cause of vision loss among people age [AGE] and older. It causes damage to the macula, a small spot near the center of the retina and the part of the eye needed for sharp, central vision, which lets us see objects that are straight ahead (https://[NAME].nih.gov/health/maculardegen/armd_facts). (2) Nocturia-Some people wake up from sleep more often to urinate during the night. This can disrupt sleep cycles (https://medlineplus.gov/ency/article/003141.htm). (3) The TMJ connects the lower jaw (mandible) to the skull (temporal bone) in front of the ear. Certain facial muscles that control chewing are also attached to the lower jaw (http://www.emedicinehealth.com/temporomandibular_joint_tmj_syndrome/article_em.htm).