**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, and facility documentation, the facility staff failed to immediately inform the physician of the need to assess/evaluate, start, or alter treatment when there was a significant deterioration in the resident's condition for 1 of 59 residents (Resident #46) in the survey sample. The findings included: Resident #46 had four (4) falls between 04/24/23 - 05/22/23 and during that time she had behavioral and neurological changes. She was at risk for major injury related to being on an anticoagulation medication (blood thinner), independent with ambulation, and a diagnosis of dementia. The resident was not assessed after significant behavioral and neurological changes were identified. The resident was transferred to the local emergency room (ER), and diagnosed with subdural hematoma/hemorrhage. Resident #46 was transferred via 911 (emergent) to the local hospital on [DATE] due to acute left-sided weakness and altered mental status following a ground-level fall at the nursing facility. A computerized tomography (CT) scan was done to reveal a subdural hematoma/hemorrhage. On 05/23/23, Resident #46 underwent right [NAME] hole subdural hematoma evacuation with subdural drain placement. Resident #46 was originally admitted to the nursing facility on 05/14/21. Diagnosis for Resident #46 included but was not limited to acute subdural hemorrhage, dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, history of pulmonary embolism (a blood clot in the lungs), and cerebral infarction (stroke). The Minimum Data Set (MDS - an assessment protocol) an annual assessment with an Assessment Reference Date (ARD) of 04/28/23 coded Resident #46 with a 03 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The MDS coded Resident #46 total dependence on one with bathing, limited assistance of one with personal hygiene, supervised with limited assistance of one with dressing and toilet use, supervisor with one assistance with eating and transfer, and independent with bed mobility, locomotion on/off the unit, walking in room and corridor with a steady gait all the time. The most recent Minimum Data Set (MDS - an assessment protocol) a significant change assessment with an Assessment Reference Date (ARD) of 06/12/23 coded Resident #46 with a 03 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The MDS coded Resident #46 total dependence of one with bathing, extensive assistance of one with bed mobility, transfer, dressing, personal hygiene, and toilet use, and supervision with one assistance with eating for Activities of Daily Living (ADL) care. Under section G0300 (Balance during transitions and walking) was coded gait not steady, only able to stabilize with human assistance. Resident #46's person-centered care plan created on 05/24/21 and revised on 06/18/23 identified the resident at risk for falls related to psychotropic medication use. The goal set for the resident by the staff was that the resident will remain free from injury. Some of the interventions/approaches the staff would use to accomplish this goal are to assist with all transfers and mobility, obtain physical therapy (PT) consult as needed, resident is self-ambulatory and attempt to toilet resident every 2-3 hours and as needed. Resident #46's person-centered care plan created on 05/24/21 and revised on 06/18/23 identified the resident receiving anticoagulant therapy (blood thinner) due to a history of Pulmonary Embolism (PE). The goal set for the resident by the staff was that the resident will have no active bleeding. Some of the interventions/approaches the staff would use to accomplish this goal are to observe for signs of active bleeding (nosebleeds, bleeding gums, petechiae (tiny purple spots under the skin), purpura (rash of purple spots under the skin), ecchymosis (bruising) areas, hematoma, blood in urine, blood in stools, hemoptysis, elevated temp, pain in joints, abdominal pain, and epistaxis). A review of Resident #46's Medication Administration Record (MAR) for May 2023 revealed an order to administer Xarelto (blood thinner) 20 mg by mouth daily with dinner (for a history of pulmonary embolism). A nurse's note entered by License Practical Nurse (LPN) #2 on 04/24/23 at 10:47 a.m., documented Resident #46 with swelling and bruising to the left side of the face near the cheek bone. When asked what happened, Resident #46 said she almost fell getting the baby and pointed at the nightstand. The resident denied falling but has a diagnosis of dementia. The nightstand was re-arranged further away from the bed. The physician and Resident Representative (RR) were made aware of the above incident. According to the nurses' note dated 04/25/23 at 3:30 a.m., Resident #46 continued with swelling at the left upper cheek area and now to the outer corner of the left eye. On the same day at 2:49 p.m., Resident #46 was observed with a red spot on the sclera (the white outer layer of the eyeball), and swelling and bruising remained on the left side of the face. Further review of the note did not indicate the physician or Nurse Practitioner (NP) was informed related to the red spot observed on the sclera. On 04/28/23 at 8:22 a.m., a nurses' note entered by LPN #8 documented Resident #46 with increased pain in the left eye. The resident was medicated with Motrin (pain medication) with effective results. Further review of the note did not indicate the physician or NP was informed. A review of Resident #46's nurse's notes revealed on 05/10/23 at 1:45 p.m., the resident was observed with increased agitation. She refused her afternoon medications and vital signs. The note also indicated Resident #46's flooded the bathroom in (room #) with tissue paper and storage equipment. On 05/11/23, according to Resident #46's nurses' note, Resident #46 refused her afternoon medications and vital signs. On the same day, observed with increased agitation. The resident was seen by the Psych Nurse Practitioner (NP). The psych NP note documented resident was being seen today for a follow-up evaluation for a medication check. Resident #46 refusing medication, patient care and not eating. Resident #46 noted with increase paranoia which is something new. New orders were given for Urine Analysis (UA) with Culture and Sensitivity (C&S), Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) in the morning. The psych NP was interviewed on 07/21/23 at 2:51 p.m. He stated he was asked by nursing to see Resident #46 on 05/11/23 for increased agitation/behaviors. He stated he ordered labs on Resident #46 but it was the responsibility of the resident's primary physician to follow up with any necessary treatment. On 05/12/23, a change in condition form was completed on Resident #46. The form identified Resident #46 with increased confusion or disorientation and new or worsened delusions or hallucination. Resident #46 observed requiring more assistance with ADL's. The physician was informed of change in condition. Further review of the clinical record did not reveal a MD or NP visit related to change in condition with Resident #46. A nurses' note entered on 05/14/23 at 8:06 a.m., documented Resident #46 had a fall on the (11-7 shift). At this time, the resident was observed with a limp while dragging her left leg during ambulation. A message was left for the physician but did not indicate the physician returned the call. On 05/14/23 at 10:17 p.m., it was documented in the nurses' notes Resident #46 noted with increased agitation to noise, tremors, and unsteady gait and required two persons assist with care. Further review of the clinical record did not indicate the physician or NP was notified. A review of Resident #46's nurses' note dated 05/15/23 at 6:15 p.m., indicated the resident had been found on the floor in her bathroom without pain or discomfort. The note indicated neuro checks were within normal limits (WNL). A nurses' note dated 05/17/23 at 12:58 p.m., documented day three (3) after an unwitnessed fall indicated Resident #46 required max assist of two (2) person assistance with walking. The note documented the resident had been evaluated by therapy and Resident #46 was unaware of her left lower extremity when moving from sit/stand during therapy sessions. On 07/21/23 at 9:51 a.m., an interview was conducted with the Physical Therapist (PT). He stated Resident #46 was evaluated and picked up by therapy due to requent falls with poor safety awareness. He stated Resident #46 was dragging her left leg; unable to pick that leg up. He stated prior to her falls, Resident #46 was independent with ambulation and did not require an assistance device (walker or wheelchair). Resident #46 was evaluated by PT on 05/17/23. According to the evaluation, Resident #46 was seen for a significant decline in her functional mobility skills and what appears to be left lower extremity hemiplegia (weakness or partial paralysis on one side of the body.) It was documented the resident was unable to ambulate and required max assistance with transfers. It was also documented Resident #46 required the use of a wheelchair and Pommel seat cushion to reduce her risk of falls. On 07/21/23 at 4:14 p.m., an interview was conducted with the Director of Nursing (DON) with five (5) other surveyors present. She stated on 05/14/23, when Resident #46 exhibited increased sleeping, reaching for objects, and observed with tremors, the physician should have been notified. She stated the resident could be having neurological issues. She stated Resident #46 needed further evaluation and a clinical assessment by the physician or NP, but it didn't happen. The DON stated according to the nurses on 05/16/23, Resident #46 is leaning towards the left side and required assistance with ambulation which is abnormal for her. She stated when the NP was informed on 05/17/23 that Resident #46 noted with an increase in leaning to her left side with weakness, Resident #46 needed to be evaluated. The DON stated according to the resident's clinical record, the physician or NP did not assess Resident #46 from 05/12/23 when she first showed a change in condition to include frequent falls until she was discharged to the hospital on [DATE] with a subdural hemorrhage. The DON was asked if the physician or NP should have come to evaluate/assess Resident #46 she replied, Absolutely. She stated the facility/provider did not do further assessments to determine what the root cause of the change in condition was for Resident #46's. Resident #46 had an unwitnessed fall in the day room on 05/22/23. She was sent to the local emergency room (ER) via 911 emergence for further evaluation. On the same day at 9:50 p.m., the facility received a call from (name of hospital) informing them that Resident #46 was admitted to the Neuro Intensive Care Unit (ICU). A review of the hospital record revealed Resident #46 presented in the emergency room (ER) on 05/22/23 from (name of nursing facility) for further evaluation due to acute left-sided weakness and altered mental status following a ground-level fall at the nursing facility. The note indicated a subdural hemorrhage/hematoma may have been the result due to the ground-level fall. Over the past several days, Resident #46 had worsening gait instability and falls, and today observed with weakness in her left arm. The note indicated a computerized tomography (CT) scan was done to reveal a subdural hematoma/hemorrhage. On 05/23/23, Resident #46 underwent right [NAME] hole subdural hematoma evacuation with subdural drain placement. The resident remained in the Neuro Intensive Care Unit (ICU) for close monitoring and subdural drain until 05/25/23. A final meeting was held with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Clinical Operations on 07/21/23 at approximately 5:30 p.m. No further information was provided prior to exit. Definitions -Xarelto is used to treat deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in adults. Rivaroxaban is also used to prevent DVT and PE from happening again after initial treatment is completed in adults (https://medlineplus.gov/druginfo/meds). Subdural hemorrhage -A subdural hematoma is a type of bleed inside your head. It's a type of bleed that occurs within your skull but outside the actual brain tissue. Other names for subdural hematoma are subdural hemorrhage or intracranial hematoma. More broadly, it is also a type of traumatic brain injury (TBI). How do subdural hematomas happen? -Head injuries cause most subdural hematomas. If you fall and hit your head or take a blow to the head in a car or bike accident, a sporting activity or have another type of head trauma, you are at risk for developing a subdural hematoma. Are some people more likely to get a subdural hematoma? -People who take blood thinners: Blood thinners slow down the clotting process or prevent blood from clotting at all. If blood doesn't clot, bleeding can be severe and long-lasting, even after a relatively minor injury. Being careful when taking blood thinners: Even minor head injuries can cause a subdural hematoma in people who take blood thinners. What are the symptoms of subdural hematoma? -Because a subdural hematoma is a type of traumatic brain injury (TBI), they share many symptoms. Symptoms of a subdural hematoma may appear immediately following trauma to the head, or they may develop over time - even weeks to months. Signs and symptoms of a subdural hematoma include but are not limited to: -Confusion and drowsiness. -Slurred speech and changes in vision. -Dizziness, loss of balance, difficulty walking. -Weakness on one side of the body. -Memory loss, disorientation, and personality changes, especially in older adults with chronic subdural hematoma. Special note about head injury and symptoms in seniors: -Some of the symptoms of subdural hematoma in older people, like memory loss, confusion, and personality changes, could be mistaken for dementia. The older person may not remember hitting their head. Sometimes, people forget because they are disoriented. Other times, the injury was minor and may have occurred weeks before symptoms appeared. They should still see their healthcare provider for evaluation. What are the treatments for subdural hematoma? -Healthcare providers treat larger hematomas with decompression surgery. A surgeon drills one or more holes in the skull to drain the blood. Draining the blood relieves the pressure the blood buildup causes on the brain (https://my.clevelandclinic.org/health/diseases/21183-subdural-hematoma).

Based on observations, resident interviews and staff interview, the facility staff failed to ensure the sink in Resident #120's room drained after use for 1 of 59 residents (Resident #120), in the survey sample. The findings included: Resident #120 was originally admitted to the facility 3/8/23 after an acute care hospital stay. The resident had never been discharged from the facility. The current diagnoses included; high blood pressure, high cholesterol and hypothyroidism. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/13/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #120's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring physical help of one person with bathing, limited assistance of one person with dressing, supervision of one person with transfers, locomotion, toileting, and personal hygiene, independent after set-up with eating and walking, and independent with bed mobility. On 7/18/23 at approximately 4:35 p.m., during the initial tour the sink in Resident #120's bathroom was observed to be 1/3 full of standing water. An interview was conducted with Resident #120 on 7/18/23 at approximately 4:37 p.m. The resident stated there had been problems with the sink draining completely for many months. The resident also stated the toilet flushes but it is a matter of knowing the trick to hold the handled down until all of the waste is gone out of the commode. He further stated the roommate does not understand how to manage the toilet even though he had explained it to him multiple times. On 7/19/23 at approximately 1:40 p.m., another observation was made of Resident #120's bathroom sink. This time it was 2/3 full with soapy water. Resident #120 stated the roommate left the water running and when he went in, it was almost full. On 7/20/23 at approximately 11:45 p.m., the sink was again observed in Resident #120's room. It was still approximately 2/3 full with standing water, the pipes under the sink had been taken apart and a bucket had been placed beneath the sink to capture water. An interview was conducted with Resident #120 at approximately 11:46 p.m. The resident stated Maintenance was working on the sink but there was no improvement thus, he had given up on the sink getting repaired to drain completely. On 7/20/23 at approximately 4:00 p.m., an interview was conducted with the Maintenance Assistant. He stated they had did all they knew to do to get the sink in Resident #120's room to drain therefore, he felt it was time to bring in services from the outside. On 7/21/23 at approximately 4:30 p.m., a final interview was conducted with the Administrator, Director of Nursing and Corporate Consultant. They had no further comments and voiced no additional concerns about the non-draining sink in Resident #120's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a resident interview, staff interviews, and a clinical record review, the facility staff failed to assist and develop a discharge plan for a resident to make a successful discharge into the community after the initial option failed for 1 of 59 residents (Resident #114), in the survey sample. The findings included: Resident #114 was originally admitted to the facility 11/2/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included diabetes and bilateral above the knee amputations secondary to peripheral vascular disease. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/2/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #114's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of one person with personal hygiene, dressing and toileting, limited assistance of one person with bed mobility and transfers, independent with locomotion, and independent with eating after set-up. On 7/18/23 at approximately 4:40 p.m., an interview was conducted with Resident #114. The resident stated he desired to be discharged to an apartment in the community for which he had an application in his possession. The resident stated he would like assistance to complete the application and to help to determine if there are other resources in the community, he may be eligible to receive. A nurse's note dated 4/24/23 at 1:14 p.m., read the resident's daughter was looking to transition the resident back home with equipment and additional care as needed. The daughter also desired to discuss discharge plans further once rehabilitation services had dates in mind. Another nurse's note dated 5/4/23 at 10:26 a.m., read the resident's daughter stated she did not feel this would be the right time for the resident to return home because there was not a caregiver to be with him in the home during the day/night. The note also indicated the daughter stated that there were not reliable family members outside of herself and her husband to assist in providing his care. A review of the resident's care plan revealed a problem which read, return to Community Referral/Discharge. Resident expressed a desire to return to the community dated 5/01/23 and updated on 6/18/23. The goal read resident/resident representative will have access to necessary services to promote his adjustment to his new living environment post discharge from the skilled nursing facility by 9/15/23. The interventions included resident will discharge home with family/caregiver. Anticipated date of discharge is 5/9/23. There had been no modification of the original discharge plan after the daughter changed her mind. A further review of the resident's progress notes failed to reveal other options regarding the resident's discharge to the community therefore an interview was conducted with Social Worker (SW) #1 on 7/20/23 at approximately 10:23 a.m. SW #1 confirmed the resident could make a decision to return to the community and she would explore what planning was in place to assist with his preference. On 7/20/23 at approximately 11:50 a.m., another interview was conducted with SW #1. SW #1 stated she met with the resident, and he expressed his desire to transition back into the community to live independently in a handicapped accessible apartment in a desired location. SW #1 stated the resident came to her office with an application for the apartment complex he was desired, and they telephoned the complex. SW #1 stated they spoke with an apartment complex representative regarding income requirements and the waiting period for an apartment. SW #1 stated she assisted the resident to complete all sections of the application except the income section because the resident and/or the business office did not know or have access to his annual income information. SW #1 stated the Business Office Manager stated the resident's daughter managed his finances. SW #1 stated a message was left for the resident's daughter to verify his annual income and once the information was received the application would be submitted to the apartment complex. On 7/21/23 at approximately 4:30 p.m., a final interview was conducted with the Administrator, Director of Nursing and two Corporate Consultants. The Administrator stated they were awaiting a return call from the resident's daughter with the necessary information to proceed with submission of his application.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interviews, and a clinical record review, the facility staff failed to ensure a dependent resident's activities of daily living (ADL) were completed for 1 of 59 residents (Resident #1), in the survey sample. The findings included: Resident #1 was originally admitted to the facility 7/19/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; malnutrition, hyperparathyroidism, and chronic atrial fibrillation. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/7/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing and toileting, extensive assistance of one person with bed mobility, personal hygiene and dressing, and supervision after set-up with eating. The resident did not transfer or walk. On 7/18/23 at approximately 4:55 p.m., during the initial tour Resident #1 was observed in bed with large white flakes throughout her hair and with long yellow fingernails with some jagged edges. An interview was conducted with Resident #1 on 7/18/23 at approximately 4:58 p.m. The resident stated her fingernails were not cared for because she was required to get out of bed and go down stairs to activities in order to have them filed and painted. The resident also stated her teeth were not brushed and cleaned as often as she desired. Observation of her teeth reveal many broken and discolored teeth. An interview was conducted with the Activities Director on 7/19/23 at approximately 2:10 p.m. The Activities Director stated it is not necessary for a resident to come to an activity for nail care for if they are alerted they will come to the resident. On 7/20/23 at approximately 9:55 a.m., an interview was conducted with Certified Nursing Assistant (CNA) #8, CNA #8 stated it is the assigned CNA's responsibility to wash Resident #1's hair using a shower cap in bed and to provide oral care. CNA #8 also stated the resident does not have to go to activities for nail care for it is provided along with ADL care by the assigned CNA. On 7/21/23 at 9:48 a.m., another interview was conducted with Resident #1, she stated They came in last night filed and painted my fingernails, and washed my hair but the nurse had problems combing my hair out in the back because it was and remains matted. Resident #1 stated her teeth were also brushed before breakfast and her mouth was feeling fresh. On 7/21/23 at approximately 4:30 p.m., a final interview was conducted with the Administrator, Director of Nursing (DON) and Corporate Consultant. The DON stated the resident's hair had been shampooed and a medicated shampoo, had been ordered as well as a special mouthwash and her nails had been filed and painted, since the concerns had been brought to their attention.

The facility staff failed to provide the necessary care and services to monitor, assess and treat one resident timely who presented with sign and symptoms and complications of a Urinary Tract Infection (UTI) for 1 out 59 residents (Resident #46) in the survey sample. The findings included: Resident #46 was originally admitted to the nursing facility on 05/14/21. Diagnosis for Resident #46 included but not limited to acute subdural hemorrhage, dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The most recent Minimum Data Set (MDS - an assessment protocol) a significant change assessment with an Assessment Reference Date (ARD) of 06/12/23 coded Resident #46 with a 03 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The MDS coded Resident #46 total dependence of one with bathing, extensive assistance of one with bed mobility, transfer, dressing, personal hygiene, and toilet use and supervision with one assist with eating for Activities of Daily Living (ADL) care. Resident #46's person-centered care plan created on 05/24/21 and revised on 06/18/23 identified the resident experiences bladder/bowel incontinence at times due to dementia. The goal set for the resident by the staff was that the resident will maintain current level of bladder/bowel incontinence and remain free from signs/symptoms (s/s) of Urinary Tract Infection (UTI). Some of the interventions/approaches the staff would use to accomplish this goal is to report any signs of UTI (acute confusion, urgency, frequently, bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low/back/flank pain, malaise, foul odor, concentrated urine and blood in urine), provide cueing/supervision assistance for toileting as needed and provide incontinence care after incontinent episodes as needed. On 05/11/23, Resident #46 complained of stomach pain and was administered Motrin (pain medication) 400 mg. On the same day, Resident #46 urinated on herself and on the bathroom floor. The urine noted to have a foul odor. Resident also observed with increased agitation. The resident was seen by the psych Nurse Practitioner (NP) on 05/11/23 with new orders to obtain Urine Analysis (UA) with Culture and Sensitivity (C&S), Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) in the morning. The psych NP was interviewed on 07/21/23 at 2:51 p.m. He stated he was asked by nursing to evaluated Resident #46 on 05/11/23 for increased agitation/behaviors. He stated he ordered labs for blood work and a UA/C&S to rule out an UTI. He stated he ordered labs on Resident #46 but it's the responsibility of the resident's primary physician to follow-up with treatment. On 05/12/23, a change in condition form was completed on Resident #46. The form identified Resident #46 with increased confusion or disorientation, new or worsened delusions or hallucination and blood-tinged urine. The physician was informed of change in condition. Further review of the clinical record did not reveal a MD or NP visit related to change in condition with Resident #46. A nurses' notes dated 05/13/23 at 2:05 p.m., revealed Resident #46 observed with intermittent confusion throughout the day. The note indicated lab results for C&S had not been received. The note indicated the physician was notified of Resident #46's intermittent confusion, but he wanted to wait for the final labs (C&S). During the review of Resident #46's nurses' note dated 05/14/23 at 8:23 a.m., indicated the resident was observed lying on the floor in the bathroom with several spots of urine on the floor. Resident #46 had a bowel movement in the commode with blood noted. The note stated hematuria but also document uncertain where the bleeding was coming from. At 12:30 p.m., Resident #46 was administered Motrin 400 mg for complaints of stomach pain. On the same day at 10:17 p.m., Resident observed to have increased agitation to noise, tremors noted, gait unsteady and required two (2) persons assist with care. Further review of the clinical record did not reveal a MD/NP visit or assessment. The nurses' note dated 05/17/23 at 12:58 p.m., indicated the facility was still waiting for the final urine report for the C&S. The note indicated Resident #46 noted to have hematuria with her bowel movement. NP #1 informed Resident #46 observed with increased behaviors, increased leaning to the left side with weakness and the facility was still waiting for the final urine report. On 05/19/23 at 7:22 a.m., the final urine sensitivity report showed the urine organism growing 50,000 (Escherichia coli). The physician was informed with a new order to start Resident #46 on Keflex (antibiotics) 500 mg every 12 hours x 7 days for UTI. On 05/20/23 at 6:47 p.m., Resident urinated on self while in the day room. Resident was assisted to the bathroom where she noted to have small amount of hematuria in the commode. The clinical note indicated on 05/21/23 at 12:07 a.m., Resident #46 had a bowel movement on the toilet with drips of blood noted. A phone interview was conducted with Resident #46's previous physician on 07/21/23 at 11:13 a.m. The nurses' notes and labs dated from 05/10/23 through 05/22/23 were reviewed with the physician. He was informed of the abnormal urine analysis with hematuria, increased confusion, tremors, and stomach pain. He stated the UA showed evidence of an UTI and should have been treated. He stated it's normal to treat prophylactic hoping the right medication was picked. He stated when the urine sensitivity report is obtained and if the wrong medication was prescribed, that medication will be discontinued and antibiotic that is sensitive to the organism growing will be prescribed. A review of Resident #46's clinical note dated 05/17/2023 at 2:35 p.m., revealed the NP #1 was informed Resident #46 continued with signs/symptoms of UTI, with no new orders. On 07/21/23 at 10:31 a.m., a phone interview was conducted with NP #1. She stated even though the C&S had not returned, the UA noted Resident #46 had a UTI. She stated it is normal to treat the older population if they are showing s/s of a UTI which she did. On 07/21/23 at 4:14 p.m., an interview was conducted with the Director of Nursing (DON) with five (5) other surveyors present who were informed regarding the above findings. She stated when Resident #46 was observed with increased sleeping, reach for objects, tremors, and hematuria, the physician or NP should have been notified. She stated the resident could have had neurological issues, internal bleeding, or possible UTI. She stated Resident #46 needed further evaluation and a clinical assessment by the physician or NP. She stated according to the clinical note written on 05/15/23, Resident #46 was observed with hematuria, the physician or NP should had been notified. She stated the physician or NP was never giving an opportunity to assess or treat Resident #46 for the change in condition. The DON was asked if Resident #46 was evaluated and assessed by physician or NP from 05/12/23 - 05/22/23, she replied, No. She was asked if Resident #46 should have been evaluated related to the continued change in condition, she replied, Absolutely. A final meeting was held with the Administrator, Director of Nursing, Assistant Director of Nursing and [NAME] President of Clinical Operations on 07/21/23 at approximately 5:30 p.m. No further information was provided prior to exit. McGreers definition of Urinary Tract Infection -Urinary tract infection includes only symptomatic urinary tract infections. Surveillance for asymptomatic bacteriuria (defined as the presence of a positive urine culture in the absence of new signs and symptoms or UTI) is not recommended, as this represents baseline status for many residents. Symptomatic urinary tract infection One of the following criteria must be met: The resident does not have an indwelling urinary catheter and has at least three of the following signs and symptoms: -Fever (>38ºC) or chills -New or increased burning pain on urination, frequency or urgency -May be new or increased incontinence -New flank or suprapubic pain or tenderness -Change in character of urine [may be clinical (e.g., bloody urine) or as reported by the laboratory (new pyuria or microscopic hematuria). For laboratory changes a previous urinalysis must have been negative. -Worsening of mental or functional status Definitions -Urinary Tract Infection (UTI) is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney. ttp://www.cdc.gov/HAI/ca_uti/uti.html). -Urine Analysis (UA) is a test to find germs (such as bacteria) in the urine that can cause an infection. Urine in the bladder. This means it does not contain any bacteria or other organisms (such as fungi) but bacteria can enter the urethra and cause a UTI. http://www.webmd.com/a-to-z-guides/urine-culture). -Culture and Sensitivity (C&S) is sample of urine is added to a substance that promotes the growth of germs. If no germs grow, the culture is negative. If germs grow, the culture is positive. The type of germ may be identified using a microscope or chemical tests. Sometimes other tests are done to find the right medicine for treating the infection. This is called sensitivity testing (http://www.webmd.com/a-to-z-guides/urine-culture).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat residents with respect and dignity by not ensuring the residents' rights to retain personal possessions for two of two sampled residents (Residents (R)52 and R82) reviewed for resident rights. This failure had the possibility to have a negative impact on numerous residents residing in the facility. Findings include: Review of R52's Face Sheet, located under the Profile tab of the electronic medical record (EMR) revealed R52 was admitted to the facility on [DATE] with diagnoses which included flaccid hemiplegia affecting the left non dominant side, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, heart failure, type II diabetes, major depressive disorder, major depressive disorder, bipolar disorder, aphasia, and anxiety disorder. Review of R52's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 05/31/23, located under the RAI tab indicated R52 was extensive assist of one staff member for toileting, supervision of one staff member for bed mobility, independent with transfers and wheelchair mobility, limited assist of one staff member for dressing. The MDS showed Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R52 was cognitively intact. Review of R82's Face Sheet, located under the Profile tab of the electronic medical record (EMR) revealed R82 was admitted to the facility on [DATE] with diagnoses which included sepsis, muscle weakness, diverticulitis of intestine, type II diabetes, Parkinson's disease, depression, unspecified dementia, and anxiety disorder. Review of R82's quarterly MDS with an ARD date of 05/30/23, located under the RAI tab indicated R82 was extensive assist of two staff members with transfers and bed mobility; total dependence of one staff member for toileting; extensive assistance of one staff member for dressing. The MDS showed Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R82 was cognitively intact. During a resident meeting held on 07/20/23 at 10:00 AM, several of the residents (R56, R2, R50, R61, R82, and R52) in attendance stated the facility laundry had not returned some of their clothing items. The residents said their clothing not being returned to them from the laundry had been an ongoing problem. R52 stated he was missing a hat, jacket, and a red, white, and blue blanket. Review of the Resident Council Meeting Minutes, dated for the past year July 2022 through July 2023 indicated there were 10 different residents with complaints of their clothing items not being returned to them from the laundry. R18 stated he did not send his clothes to laundry anymore because he did not get them back. R89 stated she was missing 21 items. R82 stated he was still missing clothes. R61 stated she was missing clothes. R52 stated he was missing jeans and pants and R50 stated was still missing pants. During an interview on 07/19/23 at 11:15 AM, with a laundry employee (LE), she stated finding a good way to mark a resident's clothing had always been an issue. LE said they now have a labeling machine which should fix the problem. LE was not sure what had been put in place to label all residents' clothing. During an interview on 07/19/23 at 1:25 PM, the Assistant Director of Nursing (ADON) stated the facility purchased a labeling machine and have piloted labeling resident's clothing on the third floor. The ADON said prior to the labeling machine they would encourage residents' family members to label a resident's clothing or would write the resident's name on the back of the clothing item with a permanent marker. The ADON stated the Activities Director (AD) has begun to hold a yard sale every Friday where she was using the labeling machine to label all the clothing items the residents obtain at the yard sale. During an interview on 07/20/23 at 3:50 PM, with the Activities Director to discuss plan for labeling Residents' clothing, the AD stated on Fridays after lunch they brought out clothes that have been donated or unclaimed and let residents look them over and choose clothes for themselves. The AD said she had the labeling machine there and labeled the clothes right at that time. The AD stated they have labeled some of the residents' clothes on the 3rd floor. During an interview on 07/21/23 at 10:30 AM, R52 stated that the facility losing some of his clothing was very frustrating for him especially when the items were a connection to his service in the military. During an interview on 07/21/23 at 11:00 AM, R82 stated when his clothing was not returned to him it was like a burden to me, because I need to get dressed every day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure residents received written discharge notices at the time of transfer to the hospital for four (Resident (R)119, R15, R64, and R70) of six residents reviewed for hospitalization. Findings include: Review of the facility's policy titled, Transfer/Discharge Notice dated 11/01/22 revealed for the Emergent Transfers to Acute Care section, the facility will send a written notice of discharge to the resident and/or resident representative when the resident was transferred/discharged to the hospital. 1. Review of Resident 119's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/16/23 revealed she had a Brief Interview for Mental Status score (BIMS) of 15 out of 15, indicating she was cognitively intact. On 07/18/23 at 1:48 PM, R119 was asked if she was sent to the hospital recently and she stated she had and that she did not get a written transfer. Review of the Census tab of Resident 119's electronic medical record (EMR) revealed the resident was discharged with return expected on 04/15/23 and was returned to the facility on [DATE]. Review of a progress note located in the Progress Note tab dated 04/15/23 at 11:00 AM revealed the resident had increased pain in his distended abdomen. The physician was called, and an order was given to send the resident to the emergency room. Review of progress note located under the Progress Note tab note dated 04/15/23 at 11:41 AM revealed the resident left the facility via stretcher. Review of progress note located under the Progress Note tab note dated 04/16/23 revealed the resident was admitted to the hospital and the admitting diagnosis was unknown. Review of R119's e EMR revealed no documentation that a written discharge notice was sent to the resident and resident representative. 2. Review of R15's quarterly MDS with an ARD of 05/08/23 revealed she had a BIMS score of 10 out of 15 indicating she was moderately cognitively impaired. Review of R15's MDS revealed she had a discharge return expected MDS completed on 02/18/23 and an entry MDS dated [DATE]. On 07/19/23 at 9:02 AM, R15 stated she had gone to the hospital and stayed overnight when she had a port put in her chest. She stated she could not remember if she received a written discharge notice. Review of R15's Census tab in the EMR revealed she was discharged return expected on 02/18/23 and returned to the facility on [DATE]. A nursing progress note under the Progress Note tab dated 02/18/23 at 10:40 PM revealed the resident was ordered to be transported to the hospital and a progress note dated 02/19/23 at 12:48 AM revealed the nurse contacted the emergency department and was told she was being admitted . 3. Review of R64's quarterly MDS with an ARD date of 06/30/23 revealed she had a BIMS score of 15 out of 15 indicating she was cognitively intact. Review of a progress note located under the Progress Note tab dated 06/18/23 at 11:38 AM revealed the resident was transported to the hospital due to having her head down with her chin over her open trach and refusing to allow staff to place the trach collar and refusing to allow staff to complete vital signs and care. The note revealed the physician and the resident's representative was called and she was transported to the hospital. A progress note located under the Progress Note tab dated 06/25/25 at 1:32 PM revealed the resident was readmitted to the facility. Review of R64's Progress Notes tab of the EMR revealed she had a nursing note dated 07/13/23 at 12:00 PM revealing she (R64) was observed on the floor. She stated she was attempting to bend over and pick something up off the floor .The resident communicated via communication board that she had pain in the right knee, and she wanted to go to the hospital. A progress note dated 07/13/23 at 1:00 PM revealed she left for the hospital. Review of R64's EMR revealed no documentation that a transfer/discharge notice was sent to the resident and/or resident representative. On 07/20/23 12:34 PM, the [NAME] President of Clinical Operations (VPO) verified that there was no documentation for the residents identified that the resident and their representative received a written transfer/discharge notice at the time of the transfers/discharge to the hospital. On 07/20/23 1:53 PM the VPO stated the facility did not give the resident or resident representative a written discharge/transfer notice. She stated the facility staff only informed the resident and resident representative verbally of the discharges. 4. Review of R70's Face Sheet located under the Profile tab of the EMR revealed R70 was admitted to the facility on [DATE]. Review of R70's quarterly MDS with an ARD date of 04/21/23 located under the RAI tab indicated R70 had a BIMS score of five out of 15 indicating R70 was severely cognitively impaired. Review of R70's EMR under the Progress Notes tab, dated 03/22/23 revealed, Resident noted exhibiting behaviors on this shift, resident noted vomiting x [times] 1, Loose watery stools x3, combative with staff and wandering in rooms .Resident was noted sweating profusely and breathing fast . writer called 911 due to resident becoming lethargic while pacing towards nurses station and having to be guided to floor to prevent injury .Resident complied with EMTs [Emergency Medical Technicians] .Resident's RP .has been made aware of resident's condition . Review of the facility's policy titled, Transfer/Discharge Notice reviewed 11/01/22 indicated, Policy Statement The appropriate notice will be provided to the resident and/or resident representative if it is necessary to transfer .a resident from a facility. Definitions .Emergent Transfer to Acute Care: Residents who are sent emergently to the hospital are considered facility-initiated transfers because the resident's return is generally expected .Facility-Initiated .Transfer: The facility may decide to .transfer a resident only for the reasons permitted under applicable federal and state law, which may include the following: Transferred .for the sake of the resident .2. In this event, the facility will notify the resident/resident representative in writing of: The reason the facility has initiated the involuntary transfer .to another legally responsible institution. The effective date of the transfer .The location to which the resident is transferred .

Based on family interview, staff interviews, clinical record review and facility documentation review the facility staff failed to invite 1 out of 50 resident (Resident #46) or their Responsible Representative (RR) to attend their person-centered care plan meeting. The findings included: Resident #46 was originally admitted to the nursing facility on 05/14/21. Diagnosis for Resident #46 included but not limited to acute subdural hemorrhage, dementia with behavioral disturbance and anxiety. The Minimum Data Set (MDS - an assessment protocol) an annual assessment with an Assessment Reference Date (ARD) of 04/28/23 coded Resident #46 with a 03 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. A phone interview was conducted with Resident #46's Responsible Representative (RR) on 07/19/23 at approximately 12:51 p.m. He stated he had never been invited to attend a care plan meeting for Resident #46. An interview was conducted with the Director of Social Services on 07/21/23 at 3:21 p.m. She stated she was not able to locate anywhere in Resident #46's clinical record that the Resident #46 or their RR were provided their care plan invitation invite/letter for the last 12 months or that care plan meetings were held. She stated care plan meetings should be held every quarter but was not sure why care plan meetings were not held for Resident #46. A final meeting was held with the Administrator, Director of Nursing, Assistant Director of Nursing and [NAME] President of Clinical Operations on 07/21/23 at approximately 5:30 p.m., who were informed of the above findings. No further information was provided prior to exit. The facility's policy titled Comprehensive Care Plan (Last Reviewed: 04/14/21). Guideline: The person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. 3. Each resident has the right to participate in choosing treatment options and will be given the opportunity to participate in the development, review, and revision of their care plan. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review and facility document review, the facility staff failed to ensure 1 of 59 residents (Resident #236) in the survey sample were free of significant medication errors. The findings included: The facility staff failed to ensure the significant medication Lopressor (used to treat high blood pressure) 25 mg was administered twice a day to Resident #326 from 11/14/20 through 11/20/20. Resident #236 was admitted to the facility on [DATE] and transferred to an acute care setting on 11/24/20. The resident did not return to the nursing facility. Diagnosis included but are not limited to Congestive Heart Failure (CHF) and Hypertension (high blood pressure). Resident #236's Minimum Data Set (MDS - an assessment protocol) an admission assessment with an Assessment Reference Date of 11/17/20 coded Resident #236's Brief Interview for Mental Status (BIMS) scored a 15 out of a possible score of 15 indicating no cognitive impairment. Resident #236's person-centered care plan created on 11/15/20 and revised on 11/20/20 identified the resident with health-related issues related to cardiovascular, respiratory and diabetes complications. The goal set for the resident by the staff was that the resident will not develop complications. Some of the interventions/approaches the staff would use to accomplish this goal is to start Lopressor 25 mg by mouth twice a day and to administer medication as ordered. A review of Resident #236's hospital Discharge summary dated [DATE] included an order to administer Metoprolol (Lopressor) 25 mg twice a day for high blood pressure. A review of Resident #236's clinical record to include the Physician Order Summary (POS) and Medication Administration Record (MAR) revealed the medication Lopressor was not started until 11/20/20. The clinical record indicated an Event Detail report dated 11/20/20 indicated a medication error related to Resident #236's high blood pressure medication (Lopressor) was not entered into the system on 11/13/20 indicating Resident #236 missed 13 does of her blood pressure medication. Further review of the Event Detail report documents the physician was made aware with a new order to start Lopressor 25 mg twice a day for high blood pressure. An interview was conducted with the Director of Nursing (DON) who was the MDS Coordinator when the medication error occurred on 11/13/20. She stated she was doing a chart audit review when she compared Resident #236's discharge order with the admission orders and discovered the resident's Lopressor 25 mg twice a day was omitted from the admission orders. She stated she immediately informed the physician on 11/20/20 with a new order to start Lopressor 25 mg twice a day. A final meeting was held with the Administrator, Director of Nursing, Assistant Director of Nursing, [NAME] President of Operations on 07/21/23 at 5:30 p.m. No further information was provided prior to exit. Definitions: -Congestive Heart Failure occurs when the heart muscle doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath. Certain heart conditions, such as narrowed arteries in the heart (coronary artery disease) or high blood pressure, gradually leave the heart too weak or stiff to fill and pump blood properly (https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms). -Hypertension is when your blood pressure, the force of your blood pushing against the walls of your blood vessels, is consistently too high (https://medlineplus.gov/ency/article/007365.htm).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interviews and facility documentation, the facility staff failed to ensure 1 of 63 residents (Resident #20) in the survey sample had a patient trust fund account. The findings included: The facility staff failed to ensure Resident #20 had a patient trust fund account. Resident #20 was originally admitted to the facility on [DATE]. Diagnosis for Resident #20 included but not limited to: Mild Intellectual disabilities. Resident #20's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/02/19 coded Resident #20's Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long term memory problems and with severe cognitive impairment - never/rarely made decisions. An interview was conducted with Resident #20 on 10/22/19 at approximately 11:53 p.m. She said the facility would not put money in her account until her niece got involved. She said her niece was putting money into her account every month. An interview was conducted with the Business Office Manager (BOM) on 10/23/19 at approximately 4:53 p.m. The BOM said she was not aware that Resident #20 did not have a patient fund account set-up until the resident's niece contacted her. She said the facility was not very good in requesting a Representative Payee so Resident #20 could receive her funds directly. The BOM said Resident #20 had a $0.00 liability or no income. The BOM said an application was submitted to Social Security Administration requesting a Representative Payee Application for Resident #20 on 10/04/18. She said Resident #20 did not starting receiving per personal funds until June 2019; which was $40 per month. A phone interview was conducted with the local Ombudsman on 10/24/19 at approximately 9:05 a.m., who stated, I was not aware that Resident #20 was not receiving her funds until I was contacted by Resident #20's niece a while ago (not sure of the date). He said he spoke with the current Business of Manager (BOM) who was not here when Resident #20 was originally admitted to the nursing facility. The Ombudsman stated, When Resident #20 was admitted to the facility, someone should have verified her payer source right away. He said the facility should have established where her money was going the minute Resident #20 was admitted to the nursing facility. The Administrator, Director of Nursing (DON) and Nurse Consultant was informed of the finding during a briefing on 10/24/19 at approximately 4:08 p.m. The staff were asked, When should the facility have started the process for setting up a Patient Fund Account for Resident #20? The Administrator replied, In January 2017, when she was admitted to the facility. Complaint deficiency

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews the facility staff failed to ensure care equipment, a wheelchair and gel cushion, were maintained in a clean and sanitary condition, for 1 of 63 residents in the survey sample, Resident #51. The findings included: Resident #51 was admitted to the facility on [DATE] with a re-admit on 2/7/17 with diagnoses that included Parkinson's disease, major depression, and unspecified dementia without behavioral disturbances. The current MDS (Minimum Data Set) a quarterly with an assessment date of 8/16/19 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status, indicating the resident's cognition was intact. The resident was identified as utilizing a wheelchair for mobility and was always incontinent of bowel and bladder. On 10/22/19 at 12:03 p.m., Resident #51 was observed in bed. She stated she did not sleep well last night and was not going to get up today. A strong smell of urine was in the room. An inspection to identify the origin of the urine odor was found to be coming from the gel cushion on the resident's wheelchair. The gel cushion was observed to have approximately 50% of the top layered sheared off. This inspector with gloved hand pressed a paper towel down on the cushion and found that it was saturated with urine. The metal frame of the wheelchair had a large amount of debris that was built up. On 10/24/19 at 5:50 p.m., Resident #51 was in bed. The gel mattress was slightly damp, the urine odor remained and the debris on the metal frame remained the same. The unit manager was asked about the cleaning schedule of resident wheelchairs. She stated, We wipe them down when needed, I'm sure there is a schedule and then stated she would have to ask someone. The unit manager escorted this inspector to the resident's room to see the wheelchair and the gel cushion. The staff then immediately removed the gel cushion. A request for the wheelchair cleaning schedule was made at this time. On 10/24/19 the above findings was shared during the pre-exit meeting with the Administrator and the Director of Nursing. The Administrator provided a copy of the Wheelchair Cleaning Procedure. He stated this procedure was new and was initiated last week on 10/14/19. The procedure read, in part: 11-7 shift brings 4 chairs from each floor on Tuesdays and Thursdays down to Maintenance office by 05:00 for cleaning .this will average 24 chairs cleaned weekly .this will be a five or six week rotation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Facility Reported Incident, staff interview and the clinical record, facility staff failed to ensure that one of 63 residents was free from sexual abuse. The findings include: Resident # 90 was admitted to the facility on [DATE] with a readmission occurring on 11/15/2018 with the latest diagnosis including, but not limited to, spastic quadriplegic cerebral palsy, cervical spina bifida without hydrocephalus, unspecified convulsions conversion disorder with seizures or convulsions. Resident # 90's MDS (Minimum Data Set), Quarterly Review Assessment with an ARD (Assessment Review Date) of 9/18/2019 coded Resident #90 with a BIM (Brief Interview of Mental Status) as 14 out of a possible 15, cognitively intact with decisions of daily living. A review of Resident #90 Care Plan indicated limitations in ease of joining other residents in activities with a long term goal to express satisfaction with activity involvement; and, limited ability to maintain grooming/personal hygiene with a long term goal to be well groomed with staff assistance on a daily basis. Review of the FRI received on 8/8/2019 detailed a resident to resident incident where facility staff responded to repeated yelling by Resident #90 in the hallway. According to a written statement included in the facility investigation, CNA staff witnessed, rubbing his penis on the arm of Resident # 90. Details summarized within the FRI indicated a corrective action to move Resident #105 to another floor. Additionally, FRI documentation revealed that a skin assessment was conducted on Resident # 90, with a determination of no skin issues. A follow-up interview with Resident #90 on 10/23/2019 at approximately 9:30 a.m. regarding this incident stating, I was sitting in the hallway and Resident #105 walked up to me and rubbed his 'thing' on me. I started screaming for help and two CNA's moved him away from me. When asked if she saw him anymore that day, Resident #90 responded, No, they moved him to a room on the 4th floor. When asked if she was satisfied with the facility's resolution and response, she answered, yes, I am satisfied what they did. A review of Facility documentation verified that Resident #105 was moved to a room on the 4th floor on 8/8/2019. A review of the Facility Resident Handbook and admission Information found that the Residents have a right to be free from verbal, physical, or mental abuse, corporal punishment and involuntary seclusion. The facility Administrator was informed of the findings during a briefing on 10/24/2010 at approximately 7:30 p.m. The facility did not present any further information about the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and facility document review, the facility staff failed to ensure that a Baseline Care Plan was developed for 1 of 63 resident's in the survey sample, Resident #155. The findings included: Resident #155 was a [AGE] year old admitted to the facility on [DATE] for a respite stay with diagnoses to include but not limited to Dementia and Chronic Obstructive Pulmonary Disease. Resident #155's Facility Face Sheet was reviewed and documented in part, as follows: admit date : [DATE] discharged : 5/20/2019 Resident #155's Electronic Medical Record was reviewed for the Baseline Care Plan and was not identified. On 10/24/19 12:06 P.M., an interview was conducted with the Social Worker as to if a baseline care plan was completed. The Social Worker stated, No I cannot find a baseline care plan, the admitting nurse should have done it on admission. I guess it wasn't done because she was a respite resident we don't normally do them for respite stays. On 10/24/19 at approximately 2:10 P.M., an interview was conducted with the Director of Nursing regarding Resident #155 not having a BaseLine Care Plan. The Director of Nursing stated. She (Resident #155) should have had a baseline care plan complete just like all admissions do. Just because she was here for a respite stay was not a reason not to have completed it. The facility policy titled Baseline Care Plan Process last revised 7/19/18 was reviewed and is documented in part, as follows: Policy Statement: To ensure that care needs are met, utilizing a person centered focus, for newly admitted and/or re-admitted residents. Charge Nurse: 2. Begin initial care plan process as done in the past. This will be the start of the Baseline Care Plan. 3. Create Baseline Care Plan, High risk areas must be care planned within 24 hours. Utilize Baseline Care Plan form which incorporates the following: a. admission nursing evaluation/ancillary evaluations (triggered areas). b. Dietary orders. c. Goals for discharge. d. Goals based on admission orders. e. MD (Medical Doctor) orders. f. therapy. g. Social Services. h. Preadmission Screening and Resident Review (PASRR) recommendations. 4. Baseline Care Plan will be a working tool for the first 48 hours. 5. Baseline Care Plan is finalized during the first 48 hours after admit utilizing input from all disciplinary team members along with resident and/or resident's Power of Attorney/family. On 10/24/19 at 7:30 P.M. a pre-exit debriefing was held with the Administrator, Director of Nursing and the Regulatory Care Consultant where the above information was shared. Prior to exit no further information was shared.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, resident interview and clinical record review, the facility staff failed to address Activities of Daily Living (ADLs) in the comprehensive care plan for 1 of 63 resident's in the survey sample, Resident #403. The findings included: Resident #403 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Dementia and Cerebral Infarction. Resident #403's Minimum Data Set (MDS) with an Assessment Reference Date of 09/13/2019 coded Resident #403 with short term memory problems and long term memory problems and with severely impaired cognitive skills for daily decision making. In addition, the Minimum Data Set coded Resident #403 as requiring limited assistance of 1 with transfer, extensive assistance of 1 with bed mobility, dressing and personal hygiene, and total dependence of 1 for toilet use and bathing. On 10/24/2019 at 10:45 a.m., Resident #403's comprehensive care plan was reviewed and did not include information communicating the resident's needs with ADLs as identified in the comprehensive assessment. On 10/24/2019 at 11:10 a.m., an interview was conducted with Licensed Practical Nurse (LPN) #5 and she was asked, Does Resident #403 have a care plan addressing ADLs? LPN #5 stated, No she does not. ADL did not trigger, I did not put it in the care plan. MDS Coordinator was present and stated, The resident should have a ADL care plan. LPN #5 and the MDS Coordinator were asked, What is the purpose of the care plan? LPN #5 stated, It acknowledges the areas that the resident has problems with. MDS Coordinator stated, It drives the care for the resident. On 10/24/2019 at 11:45 a.m., the Director of Nursing was made aware that Resident #403's needs with ADLs was not addressed in her comprehensive care plan. The Director of Nursing stated, They are suppose to care plan everything. They should have care planned ADLs. The Administrator, Director of Nursing and Nurse Consultant was informed of the finding on 10/24/2019 at 7:30 p.m. at the pre-exit meeting. The facility staff did not present any further information about the finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, facility documentation review, and clinical record review, the facility staff failed to follow professional standards of nursing practices for 1 out of 63 residents (Resident #11) in the survey sample. The facility staff failed to obtain physician orders for a newly developed stage III sacral pressure ulcer for Resident #11. The findings included: Resident #11 was originally admitted to the facility on [DATE]. Diagnosis for Resident #11 included but not limited to *Pressure ulcer of other site, unspecified stage. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 07/22/19, coded the resident with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In addition, the MDS coded Resident #11 requiring total dependence of one with bathing, extensive assistance of one with bed mobility, transfer, dressing, toilet use and personal hygiene for Activities of Daily Living care. Resident #11 was coded always continent of bladder due to indwelling Foley catheter and frequently incontinent of bowel. Resident #11's person-centered comprehensive care plan last revised on 07/30/19 documented Resident #11 with multiple pressure ulcers. The goal: Resident's ulcer will heal without complications. Some of the intervention/approaches to manage goal included: to assess and record the condition of the skin surrounding the pressure ulcer, keep clean and dry as possible, provide incontinence care after each incontinent episode, treatment per physician order, use pressure reduction when resident is in the chair and bed, use moisture barrier product to perineal area, turn and reposition in bed and chair and conduct a systematic skin inspection weekly. Report any signs of further skin breakdown. The review of the wound information pressure ulcer form noted evidence of an entry dated 10/09/19 at 6:59 a.m., indicated the following: A new sacral pressure ulcer measured 6 cm (centimeters) x 4.3 cm with light seropurulent (yellow or tan, cloudy and thick exudate (drainage). The tissue type observed with slough, wound edges/margins well defined and pink/normal skin surrounding wound. The review of the Wound Information Pressure Ulcer form noted evidence of an entry dated on 10/16/19-sacrum pressure ulcer measuring 6 cm x 4 cm with 0.1 cm depth with moderate amount of serous (clear, amber, thin and watery) exudate. The tissue bed with slough, wound edges/margins well defined with pink/normal skin surround wound. Review of Resident #11's October 2019, Physician Order Sheet and Treatment Administration Record did not include a treatment for Resident #11's stage III sacral pressure ulcer first identified on 10/09/19. An interview was conducted with Unit Manager, Licensed Practical Nurse (LPN) #3 on 10/24/19 at approximately 11:23 a.m., who stated, I reviewed Resident #11's current Physician Order Sheet and Treatment Administration Record for October 2019 and was unable to locate a treatment for the sacral pressure ulcer identified on 10/09/19. On 10/24/19 at approximately 11:48 a.m., an interview was conducted with wound nurse (LPN #7) who identified the stage III sacral pressure ulcer on Resident #11. The LPN stated, I found the stage III pressure ulcer to Resident #11's sacrum on 10/09/19. She said I wrote an order for the sacral wound. The surveyor reviewed the October 2019's Physician Order Sheet and Treatment Administration Record with LPN #7. After she reviewed the Physician Order Sheet and Treatment Administration Record, she stated, I remember writing a treatment for the stage III sacral wound; it should be on the physician order sheet and treatment administration record for October 2019 but I do not see an order. An interview was conducted with LPN #3 on 10/24/19 at approximately 3:00 p.m. The LPN provided routine wound care on Resident #11 on 10/21/19. The LPN stated, I was not aware Resident #11 had a sacral wound pressure ulcer. The surveyor asked, Did Resident #11 have any other pressure ulcers she replied, Yes, but her wounds were on her feet, legs and hip/thigh area so I had no reason to look at her sacrum. The LPN stated, I did not do wound care to a sacral wound, I did not realize she had one. On 10/24/19 at approximately 3:05 p.m., an interview was conducted with LPN #4 who cared for Resident #11 on 10/20/19. The LPN said she was not aware Resident #11 had a sacral pressure ulcer. She stated, I went by the treatment administration record when providing wound care and since the sacral pressure ulcer was not on the treatment record, I did not do a wound treatment to the sacrum. A briefing was held with the Administrator, Director of Nursing and Cooperate Nurse on 10/24/19 at approximately 4:08 p.m. The facility did not present any further information about the findings. The facility's policy titled Pressure Ulcer Management Resources (Revised 07/24/19.) -Guideline steps to include but not limited to: -5. Inform the physician (and responsible party, as appropriate) of new pressure ulcer. Obtained and initiate treatment orders. Report the following to the physician to include but not limited to: -Current treatment and review of the past treatment, as appropriate. 6. Implement a preventative program to prevent additional new areas from developing. Ensure the preventative measures are listed on the care plan and flow sheets. 8. Initial ulcer care involves debridement, wound cleansing, dressing application, and possible adjunctive therapy. 11. Protect the wound with dressings. A dressing should protect the wound, be biocompatible and provide ideal hydration. The cardinal rule is to keep the ulcer tissue moist and the surrounding intact skin dry to prevent maceration. 13. All Stage 2, 3, and 4 ulcers are colonized with bacteria. Regular wound cleaning should prevent colonization from proceeding to infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews and facility document review, the facility staff failed to ensure that Discharge Planning was implemented for 1 of 63 resident's in the survey sample, Resident #155. The findings included: Resident #155 was a [AGE] year old admitted to the facility on [DATE] for a respite stay with diagnoses to include but not limited to, Dementia and Chronic Obstructive Pulmonary Disease. Resident #155's Facility Face Sheet was reviewed and is documented in part, as follows: admit date : [DATE] discharged : 5/20/2019 Resident #155's Electronic Medical Record was reviewed for Discharge Planning and there were none identified. On 10/24/19 at 12:06 P.M. an interview was conducted with the Social Worker regarding Resident #155's Discharge Planning. The Social Worker stated There was no discharge planning completed because she was respite and we knew she would be going back home and the PACE (Program of All-Inclusive Care for the Elderly) would be in place . On 10/24/19 at approximately 2:10 P.M. an interview was conducted with the Director of Nursing regarding Resident #155 not having any documented Discharge Planning. The Director of Nursing stated. Discharge Planning should have been started on admission with the baseline care plan. Just because she was here for a respite stay was not a reason not to have completed it. The facility policy titled Discharge Planning Process last revised 7/29/19 was reviewed and is documented in part, as follows: Policy Statement: The facility will ensure a discharge planning process is in place to address each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies, as appropriate, and involve the resident and if applicable, the resident representative, and the interdisciplinary team in developing the discharge plan. GUIDELINE: The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to a preventable readmissions. 1. Discharge planning begins upon admission and is based on the resident's assessment and goals for care, desire to be discharged , and the resident's capacity for discharge. On 10/24/19 at 7:30 P.M. a Pre-exit debriefing was held with the Administrator, Director of Nursing and the Regulatory Care Consultant where the above information was shared. Prior to exit no further information was shared.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews and facility document review the facility staff failed to ensure that a Discharge Summary was completed at discharge for 1 of 63 resident's in the survey sample, Resident #155. The findings included: Resident #155 was a [AGE] year old admitted to the facility on [DATE] for a respite stay with diagnoses to include but not limited to, Dementia and Chronic Obstructive Pulmonary Disease. Resident #155's Facility Face Sheet was reviewed and is documented in part, as follows: admit date : [DATE] discharged : 5/20/2019 Resident #155's Electronic Medical Record was reviewed for the Discharge Summary but one was not identified. On 10/24/19 12:06 P.M. an interview was conducted with the Social Worker regarding Resident #155's Discharge Summary. The Social Worker stated, There is no discharge summary, we didn't do one. I guess it wasn't done because she was a respite resident. On 10/24/19 at approximately 2:10 P.M. an interview was conducted with the Director of Nursing regarding Resident #155 not having a Discharge Summary. The Director of Nursing stated. She (Resident #155) should have had a Discharge Summary complete just like all discharges do. Just because she was here for a respite stay was not a reason not to have completed it. The facility policy titled Discharge or Transfer Summary last revised 6/28/18 was reviewed and is documented in part, as follows: Policy Statement: When a resident is discharged or transferred (voluntary or involuntary), a discharge summary and port-discharge plan will be developed. 3. A discharge summary will be prepared which will include, but is not limited to, the following: a. Summary of the resident's stay to include diagnoses, course of illness/treatment or therapy and pertinent lab, radiology and consultation results; b. A final summary of the resident's status; c. reconciliation of all pre-discharge medications with the resident's post-discharge medications. On 10/24/19 at 7:30 P.M. a Pre-exit debriefing was held with the Administrator, Director of Nursing and the Regulatory Care Consultant where the above information was shared. Prior to exit no further information was shared.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, family interview, clinical record review, facility document review and during the course of a complaint investigation the facility staff failed to ensure 1 of 16 residents in the survey sample was free from an avoidable fall from the bed during the provision of care, Resident #113. The findings included: Resident #113 was admitted to the facility on [DATE] with diagnoses to include stroke, contracture of left arm, and muscle weakness. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 9/10/19 coded the resident as scoring a 14 out of a possible 15 on the Brief Interview for Mental Status indicating the resident's cognition was intact. The resident required extensive assistance of 1 staff for bed mobility and personal hygiene and was totally dependent on two staff for transfers. The Comprehensive person centered plan of care identified the resident was a fall risk and had a history of a total of two falls in addition to the current fall on 11/20/19. The goal was that the resident would remain free of injury. The interventions were revised after the fall on 11/20/19 to include fall mats on both sides of the bed. Previous interventions included physical therapy evaluation, check posture while in the wheelchair, dycem to the wheelchair and observe frequently and place in supervised area when out of bed. A Facility Reported Incident was sent to the State Agency on 11/20/19 indicating the resident fell during the provision of ADL (activities of living) care. No injury was noted. An investigation was underway. Both Certified Nursing Assistants (CNA) involved with the fall were suspended. The facility final investigation summary indicated the fall was due to a combination of soap and water while bathing the resident and incorrect setting on the air loss mattress. Education was provided to one of the CNA's involved and the second CNA was terminated based on this action and another allegation involving a different resident. The summary indicated the resident had sustained two fractured ribs as a result of the fall per the X-rays obtained at the facility on 10/24/19. The mobile X-ray report dated 11/24/19 conclusion: Acute left 4th and 5th rib fractures, old healed right lateral rib fractures were noted. On 10/24/19 the resident was sent to the emergency room (ER) at a level 1 trauma center for evaluation of complaints of shortness of breath and pain to the left rib. While there the resident underwent multiple diagnostics to include; a chest X-ray and CT of the chest. Both the X-ray and CT came back negative for acute fracture of the left ribs. The resident was sent back to the facility the same day with new orders for left rib pain management with Ultracet 37.5-325 mg (milligram) one tablet every six hours as needed for pain. This medication was changed to Tramadol 50 mg one tablet every six hours as needed on 11/27/19 due to insurance issues. The Medication Administration Record's (MAR's) for November and December 2019 evidenced the resident was medicated once for left rib pain on 11/28/19, 11/29/19 and 12/10/19. On 12/10/19 at 11:25 a.m., the resident was observed asleep in bed on a low air loss mattress. The setting was on the appropriate therapy setting. The bed was in the low position and floor mats were observed on both sides of the bed. At 1:56 p.m., the resident was observed awake in bed, the low air loss mattress was set in the appropriate setting, the bed was in the lowest position and the floor mats were in use. The resident was interviewed and stated he did have a fall out of the bed, but could not recall the exact cause of the fall. The resident was asked if he was experiencing any pain and stated, Yes, he then pointed to the left side of his chest and rated the pain a 6-7 out of a possible 15. The nurse assigned to the resident was informed of the resident's complaint of pain and the resident was administered the 12/10/19 dose of Tramadol 50 mg. On 12/10/19 at 1:08 p.m., the Director of Nursing (DON) was interviewed. She was asked what was the root cause of Resident #113's fall on 11/20/19. She stated that from her investigation the staff failed to put the low air loss mattress setting to hard, and when the second CNA stepped away to discard the soiled bed linen the air in the mattress fluctuated and it pushed the resident off the bed. She further stated, When they go in to do care we tell them to put the bed on hard (autofirm) .this probably would not have happened if she (CNA) would have put it on hard because the resident is not able to roll himself. She stated as a result of the fall staff on that unit were educated by the unit manager and staff educator on how to take care of a resident on a low air low mattress. The DON stated that during orientation the staff are educated on how to take care of a resident on a low air low mattress. She also stated the daughter came in that same day and was upset and reported the fall to Adult Protective Services (APS). APS came to the building later that same day and recommended placement of the fall mats. The DON also stated a new fall intervention was to maintain the bed in the lowest position. A request to review evidence that staff are provided education during orientation on the use of the low air loss mattress while providing care. Prior to exit the DON stated education on the use of the low air low mattress was not included in orientation. On 12/10/19 at 1:49 p.m., the staff educator was interviewed. She stated when moving a resident in a low air loss mattress the setting should be placed on autofirm first, this allows for the bed to be a completely flat surface. If the mattress is not placed on autofirm different areas of the bed will inflate which could potentially make a resident roll out of the bed. On 12/11/19 at 9:45 a.m., CNA #1 was interviewed. She stated that while she was washing the resident's back the other CNA walked towards the door to put soiled linen into the barrel located outside the door. She stated that the resident was on his right side near the edge of the bed the bed inflated on one side .he fell off the bed .it happened so quickly .I always need someone to help turn him. When asked if she had ever had any education on turning a low air mattress setting to autofirm while providing care she stated she had not prior to this incident. On 12/11/19 at 11:06 a.m., the resident was observed asleep in bed, the low air loss mattress was set in the appropriate setting, the bed was in the lowest position and the floor mats were in use. On 12/11/19 at 12:50 p.m., the Nurse Practitioner was interviewed. She stated she examined the resident on 12/3/19 and did not find any evidence of bruising to the residents left chest area. When asked about the chest X-ray taking at the facility with findings of acute fractures to the left ribs in comparison to the ER findings, she stated, It is not common, but I have seen it with mobile X-rays .we sent him out to be evaluated .there was no documentation from the ER of a lung contusion, it would show up on the CT scan .the CT is more definitive and was negative for acute fractures. The low air loss mattress instructions provided by the facility read, in part: Autofirm mode provides maximum air inflation designed to assist both residents and caregivers during resident transfer and treatment .When using the mattress system, always ensure that the resident is positioned properly within the confines of the bed .it may be helpful to activate the Autofirm mode to achieve a firm surface for repositioning purposes. The above finding was shared with the Administrator, the DON and the Nurse Consultant during the pre-exit meeting on 12/12/19 at 12:45 p.m. The facility was given ample time to provide additional information prior to exit. No additional information was provided to the survey team for this deficiency. Complaint deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to follow the physician orders to obtain weekly weights for 1 of 63 residents in the survey sample, Resident #94. The findings included: Resident #94 was originally admitted to the facility on [DATE] with a re-admission date of 9/3/19 with diagnoses to include chronic obstructive pulmonary disease, type II diabetes, and schizophrenia. The current Minimum Data Set an annual with an assessment reference date of 9/17/19 coded the resident as scoring a 9 out of a possible 15 on the Brief Interview for Mental Status, indicating the resident's cognition was moderately impaired. The resident's weight was 109 pounds. The physician orders dated 9/3/19 directed the staff to obtain the resident's weight on admission and then weekly for four weeks following a hospitalization. The clinical record evidenced the resident's weight was obtained on 9/4/19 at 108.6 pounds, and 9/11/19 at 108.8 pounds, there were no other weekly weights obtained. The physician orders dated 9/29/19 directed the staff to obtain the resident's weight weekly every Tuesday for abnormal weight loss. On 10/3/19 the Registered Dietitian (RD) conducted a review of the resident due to a three week 14.7% weight loss. On 10/2/19 the resident weighed 92.8 pounds. The RD documented, in part: Resident appears to have had weight fluctuations. Weights 7/1, 9/4 and 9/11 higher than usual weight range of 91-98.8# x 180 days. The RD recommended weekly weights and to continue to monitor nutrition parameters. On 10/23/19 the clinical record evidenced a weight was obtained on 10/7/19 at 97.4 pounds. There were no other weekly weights documented in the clinical record after that date. On 10/24/19 the above findings was shared with the Administrator and the Director of Nursing during the pre-exit meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to follow the physician order for the oxygen flow rate for 1 of 63 residents in the survey sample, Resident #94. The findings included: Resident #94 was originally admitted to the facility on [DATE] with a re-admission date of 9/3/19 with diagnoses to include chronic obstructive pulmonary disease (COPD). The current Minimum Data Set an annual with an assessment reference date of 9/17/19 coded the resident as scoring a 9 out of a possible 15 on the Brief Interview for Mental Status, indicating the resident's cognition was moderately impaired. The resident was coded as receiving oxygen therapy. The comprehensive person-centered plan of care dated 9/25/19 identified as a problem, that the resident requires oxygen therapy related to COPD. The goal was that the resident will not exhibit signs of hypoxia (low levels of oxygen). One of the approaches was to administer oxygen at 2 Liters (per minute-rate) via a nasal cannula. The clinical record evidenced a physician order dated 9/25/19 that directed the staff to administer oxygen at 2 liters per minute via nasal cannula. On 10/22/19 during the initial tour of the facility, the resident was observed in bed with a nasal cannula on and oxygen infusing at 3 liters per the oxygen concentrator. On 10/23/19 and 10/24/19 when the resident was in bed, the oxygen was observed infusing at 3 liters. On 10/24/19 at 9:59 a.m., the resident's nurse (Licensed Practical Nurse-LPN #9) was asked what the liter flow was supposed to be on. LPN #9 stated, Three liters, I'm usually on the other side. The nurse reviewed the order and noted it was for 2 liters. She was asked to check the flow rate. After noting that it was set at 3 liters, she lowered the flow rate to 2 liters. The above findings was shared with the Administrator and the Director of Nursing during the pre-exit meeting. No further information was provided. Complaint deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility documentation review the facility's staff failed to ensure the medication Procrit (a red blood cell producing drug) was available to be administered as ordered to 1 of 63 residents (Resident #88) in the survey sample. The findings included: Resident #88 was originally admitted to the facility on [DATE] and with a readmission date of 8/1/19. Resident #88's diagnoses included anemia, paraplegia, multiple sclerosis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/16/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision making were intact. Review of the current physician order summary revealed Resident #88 had an order dated 9/20/19 for Procrit 10,000 units/milliliter injection once per week on Mondays between 7:15 a.m., and 11:00 a.m., for anemia. PROCRIT is indicated for the treatment of anemia due to chronic kidney disease including patients on dialysis and not on dialysis to decrease the need for red blood cell transfusion. (https://www.procrit.com/professionals/chronic_kidney.html). Review of the physician's progress note dated 10/1/19, revealed on 9/23/19 Resident #88's hemoglobin was 6.9 (low) and white blood count was 10.8, therefore the resident received one unit of packed red blood cells and tolerated it. The 10/11/19, physician's progress note stated between 7/20/19 and 8/1/19 the resident was transfused five units of blood. Resident was started on Procrit weekly. Review of the Medication manifest revealed the facility's staff received Procrit 20,000 units/milliliter in the facility for Resident #88, 9/24/19 and 10/23/19. A dose was scheduled to be administered for Monday 9/23/19 but the medication wasn't delivered until 9/24/19. The Medication Administration Record revealed the resident received a 10,000 unit/milliliter dose 9/30/19. Procrit wasn't administered 10/7/19, due to a condition. Procrit was administered late 15:07 (3:07 PM), on 10/14/19. Procrit wasn't administered 10/21/19, because it wasn't available. An interview was conducted with the Licensed Practical Nurse (LPN) #1 on 10/23/19 at approximately 12:30 p.m., regarding the Procrit for Resident #88. LPN #1 stated the staff should order the Procrit the day the last dose is used to ensure it is available for the next dose but it wasn't happening. She further stated because the dose wasn't available 10/21/19 to be administered the Nurse Practitioner changed administration to Wednesdays. LPN #1 was unable to state how the change in day of the week would ensure the medication was ordered and available for administration. On 10/24/19 at approximately 6:00 p.m., the above findings were shared with the Administrator, Director of Nursing, and Corporate Consultant. The Director of Nursing stated they had identified a problem with delivery and administration of Resident #88's Procrit but they hadn't instituted a plan to correct the concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility documentation review the facility's staff failed to ensure 1 of 63 residents (Resident #88) in the survey sample was free from significant medication error. The findings included: Resident #88 was originally admitted on [DATE] with a readmission date of 8/1/19. Resident #88's diagnoses included anemia, paraplegia, multiple sclerosis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/16/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision making were intact. Review of the current physician order summary revealed Resident #88 had an order dated 9/20/19 for Procrit (a red blood cell producing drug) 10,000 units/milliliter injection once per week on Mondays between 7:15 a.m., and 11:00 a.m., for anemia. PROCRIT is indicated for the treatment of anemia due to chronic kidney disease including patients on dialysis and not on dialysis to decrease the need for red blood cell transfusion. (https://www.procrit.com/professionals/chronic_kidney.html). Review of the physician's progress note dated 10/1/19, revealed on 9/23/19 Resident #88's hemoglobin was 6.9 (low) and white blood count was 10.8, therefore the resident received one unit of packed red blood cells and tolerated it. The 10/11/19, physician's progress not stated between 7/20/19 and 8/1/19 the resident was transfused five units of blood. Resident was started on Procrit weekly. Review of the Medication manifest revealed the facility's staff received Procrit 20,000 units/milliliter in the facility for Resident #88 on 9/24/19 and 10/23/19. A dose was due to be administered on Monday 9/23/19 but the medication wasn't delivered until 9/24/19. The Medication Administration record revealed the resident received a 10,000 unit/milliliter dose on 9/30/19. The Procrit wasn't administered 10/7/19, due to condition. Procrit was administered late at 15:07 (3:07 PM)) on 10/14/19. Procrit wasn't administered 10/21/19, because it wasn't available. An interview was conducted with the Licensed Practical Nurse (LPN) #1 on 10/23/19 at approximately 12:30 p.m., regarding the Procrit for Resident #88. LPN #1 stated the staff should order the Procrit the day the last dose is used to ensure it is available for the next dose but it wasn't happening. She further stated because the dose wasn't available 10/21/19 to be administered the Nurse Practitioner changed administration to Wednesdays. LPN #1 was unable to state how the change in day of the week would ensure the medication was ordered and available for administration. On 10/24/19 at approximately 6:00 p.m., the above findings were shared with the Administrator, Director of Nursing, and Corporate Consultant. The Director of Nursing stated they had identified a problem with delivery and administration of Resident #88's Procrit but they hadn't instituted a plan to correct the concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and facility documentation review, the facility staff failed to ensure an accurate medical record for 1 of 63 residents (Resident #304) in the survey sample. The findings include: Resident #304 was a [AGE] year old admitted to the facility on [DATE] with diagnoses to include but not limited to Adrenomyeloneurpathy, Major Depressive Disorder and Anxiety Disorder. Jewish Family Services was Resident #304's court appointed Legal Guardian. Resident #304 expired in the facility on [DATE]. The most recent Minimum Data Set (MDS) was a Quarterly with an Assessment Reference Date (ARD) of [DATE]. Resident #18's Brief Interview for Mental Status (BIMS) was a 15 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making. Resident #304's Progress Notes were reviewed and are documented in part, as follows: [DATE] 9:30 A.M.: Resident LOA (leave of absence) to urology appointment via stretcher. NAD (no apparent distress) noted. On [DATE] at approximately 4:30 P.M. the Director of Nursing was asked if there was any further documentation she could provide regarding Resident #304's urology appointment on [DATE]. On [DATE] at approximately 3:00 P.M. the Director Of Nursing provided a faxed copy dated [DATE] of Resident #304's urology appointment encounter dated [DATE] which was reviewed and documented in part, as follows: Progress Note: Please inform pt (patient) that urine culture was positive. Please send in Macrobid 100 mg (milligrams) bid (twice a day) for 7 days and will need a repeat urine culture 1 week prior to UDS (Urodynamic Study). On [DATE] at 3:05 P.M. the Director of Nursing was asked if the urology encounter information for Resident #304 was previously available in the resident's medical record. The Director of Nursing stated, I was not able to locate it, so I had them fax it over to us. The Director of Nursing was also asked what was the procedure when a resident goes to an appointment to ensure if there are any new orders that the facility is aware of them. The Director of Nursing stated, We send paperwork with them for the office to fill out with any new orders and they send it back to us. If the papers do not come back I expect for the nurses to call and ask for the documentation to be sent over. On [DATE] at 7:30 P.M. a Pre-exit debriefing was held with the Administrator, Director of Nursing and the Regulatory Care Consultant where the above information was shared. Prior to exit no further information was shared. Complaint Deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and clinical record review, the facility staff failed to follow infection control practices during wound care for 1 of 63 residents, Resident #32. The Findings included: Resident #32 was originally admitted to the facility on [DATE]. Diagnoses for Resident #32 included but not limited to Pressure Ulcer of unspecified buttock stage 2 and Pressure Ulcer of Sacral Region. The current Minimum Data Set (MDS), an annual assessment with an Assessment Reference Date (ARD) of 08/02/19 coded the resident with a staff assessment for mental status because resident was unable to complete the interview. Staff assessment for mental status coded the resident as having short-term and long-term memory problems. On 10/23/19 at approximately 10:46 AM wound care observation was conducted. The wound care nurse Licensed Practical Nurse (LPN) #7 sanitized the resident's bedside table, allowed it to dry, placed a drape on the table, and added wound care items. After the completion of wound care and disposal of wound care items, LPN #7 rolled the bedside table within reach of the resident and placed his personal items on the table. Once stepping outside of Resident #32's room LPN #7 was asked if she was done with her wound care procedure. She stated, Yes. She was asked if she would normally sanitize the bedside table when wound care was completed. She stated, Oh I forgot. She was then asked why is it important to disinfect/sanitize the Resident's bedside table? LPN #7 stated, Infection control reasons. A Pre-exit interview was conducted on 10/24/19 at approximately, 5:30 PM. The Administrator, the Director of Nursing (DON) and the Corporate Nurse Consultant were informed of the findings. The DON stated, We're suppose to sanitize the table, they eat their meals from the table. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. The Facility failed to extend the right to formulate an Advanced Directive. Resident # 90 was admitted to the facility on [DATE] with a readmission occurring on [DATE] with the latest diagnosis including, but not limited to, spastic quadriplegic cerebral palsy, cervical spina bifida without hydrocephalus, unspecified convulsions conversion disorder with seizures or convulsions. Resident # 90's MDS (Minimum Data Set), Quarterly Review assessment dated [DATE] coded Resident #90 with a BIM (brief interview of mental status) as 14 out of a possible 15, moderately cognitively impaired with decisions of daily living. On [DATE] at approximately 4:30 p.m., a request for any documentation regarding an Advanced Directive was given to Other Administrative Staff (OS) #6. OS #6 stated We don't have one for him. The facility Administrator was informed of the findings during a briefing on [DATE] at approximately 7:30 p.m. The facility did not present any further information about the findings. 10. The facility failed to extend the right to formulate an Advanced Directive to Resident #42. Resident #42 was admitted to the facility on [DATE] with diagnoses including flaccid hemiplegia affecting left nondominant side, muscle weakness, cerebral infarction due to unspecified cerebral artery, difficulty walking, heart failure, and, aphasia and type 2 diabetes. Resident # 42's MDS (Minimum Data Set), Quarterly Review Assessment with an ARD (Assessment Review Date) of [DATE], indicated a BIMS (Brief Interview of Mental Status) score of 12 out of a possible 15, moderately cognitively impaired. On [DATE] at approximately 4:30 p.m., a request for any documentation regarding an Advanced Directive was given to Other Administrative Staff (OS) #6. OS #6 stated We don't have one for him. The facility Administrator was informed of the findings during a briefing on [DATE] at approximately 7:30 p.m. The facility did not present any further information about the findings. 15. For Resident #139, the facility staff failed to ensure Advance Directives / Informed Consent was reviewed with the resident or resident's responsible party. Resident #139 was admitted to the facility on [DATE]. Diagnosis for Resident #139 included but were not limited to, Arthritis and Hip Fracture. Resident #139's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of [DATE] was coded with a BIMS (Brief Interview for Mental Status) score of 14, indicating no cognitive impairment. On [DATE] at approximately 5:30 p.m., an interview was conducted with the Marketing Director in Admissions. A copy of Resident #139's Advanced Directive was requested from the Marketing Director and she stated, The Advanced Directive has not been signed by the resident as of present. The Marketing Director stated, The resident is a new admit and every time I have went to review it with her she has been asleep. The resident's mother is her responsible party and she has not been in to review the form with me. On [DATE] at approximately 4:00 p.m., an interview was conducted with the Social Worker and she stated, I spoke with (Resident Name) and she stated that she wanted to be a Full Code. The Social Worker provided a copy of her conversation in a progress note dated [DATE]. The Administrator, Director of Nursing and Nurse Consultant was informed of the finding on [DATE] at 7:30 p.m. at the pre-exit meeting. The Director of Nursing was asked, What are your expectations regarding Advance Directives? The Director of Nursing stated, I expect the Admissions Department to review the Advance Directive Informed Consent with the resident or resident responsible party upon admission and the nurses to follow up as needed. The Director of Nursing also stated, I expect changes to be made as needed. The facility staff did not present any further information about the finding. 16. For Resident #124, the facility staff failed to ensure that the Advance Directives / Informed Consent reflected the resident's DNR (Do Not Resuscitate) code status. Resident #124 was initially admitted to the facility on [DATE]. Resident #124 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnosis for Resident #124 included but are not limited to, Cerebral Infarction, Dementia and Chronic Obstructive Pulmonary Disease. Resident #124's Quarterly Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of [DATE] was coded with a BIMS (Brief Interview for Mental Status) score of 13 indicating no cognitive impairment. On [DATE] a copy of Resident 124's Advance Directives and a copy of the Physician Order Summary were requested. On [DATE] at approximately 5:30 p.m., the facility provided a copy of a Durable Do Not Resuscitate Order for Resident #124 dated [DATE] and a copy of the Physician Order Report. Review of the Physician Order Report revealed Resident #124's Code Status as DNR (Do Not Resuscitate), start date [DATE]. On [DATE] at approximately 6:25 p.m., Resident #124's clinical record was reviewed and revealed that there was an Advance Directives / Informed Consent on the chart dated [DATE] with the following elected statement which reads as follows: I do not choose to formulate or issue any Advanced Directives at this time. I want efforts made to prolong my life and warrant life-sustaining treatment to be provided. The Administrator, Director of Nursing and Nurse Consultant were informed of the finding on [DATE] at 7:30 p.m. at the pre-exit meeting. The Director of Nursing was asked, What are the expectations regarding Advance Directives? The Director of Nursing stated, I expect the Admissions Department to review the Advance Directive Informed Consent with the resident or resident responsible party upon admission and the nurses to follow up as needed. The Director of Nursing also stated, I expect changes to be made as needed. The facility staff did not present any further information about the finding. 8. The facility staff failed to have an advance directive accessible in Resident #15's clinical record. Resident #15 was originally admitted to the facility on [DATE]. Diagnosis for Resident #15 included but not limited to Type 2 diabetes Mellitus without complications and Chronic Kidney Disease. The current Minimum Data Set (MDS), an annual assessment with an Assessment Reference Date (ARD) of [DATE] coded the resident with a BIMS summary score of 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. A review of the clinical record on [DATE] at approximately, 11:21 AM revealed there was no advanced directive in the clinical record. On [DATE] at approximately 5:06 PM, an interview was conducted with the Marketing Liasion. A copy of Resident #15's advance directive was received. She stated that the advance directive was located in file cabinet in the business office. She was asked how would the staff access the advance directive. She stated, I don't know. On [DATE] at approximately, 4:17 PM, an interview was conducted with the social services worker (Other Staff #14) concerning the location of the advance directive. She stated, It's usually in front of the chart .Physician Order Summary will state if Resident is full code or DNR. On [DATE] at approximately, 5:28 PM the pre-exit interview was conducted. Present were the Administrator, the DON (Director of Nursing) and the Corporate Nurse Consultant. The DON stated that the Advance Directive can be found in the patient's chart under the advance directive tab The original should be in the chart. 5. The facility staff failed to ensure that Resident #11's Advanced Directive was sent upon transfer/discharge to the hospital on [DATE]. Resident #11 was originally admitted to the facility on [DATE]. Diagnosis for Resident #11 included but not limited to Thromobocytopenia. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of [DATE] coded the resident with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. On [DATE], according to the facility's documentation, Resident #11, left the facility via ambulance service for a direct admit to the hospital, pending a surgical procedure. The clinical record did not show evidence that Resident #11's Advanced Directive was sent with her when discharged to the hospital. Review of Resident #11's clinical record indicated that there was an Advanced Directive on the chart; however, there was no documentation the form was sent upon residents discharge to the local hospital on [DATE]. The Health Care Instructions document included the following information: I specifically do not wish to receive the following treatments: Cardiopulmonary Resuscitation (CPR), Ventilator or Dialysis. The document was witnessed, signed and dated on [DATE]. An interview was conducted with the Unit Manger on who stated, Resident #11's Advanced Directive should have been sent with her when discharged to the hospital on [DATE] and documented in the resident's nurses notes. The surveyor asked, How would the hospital know Resident #11's wishes not to receive the following: CPR, Ventilator or Dialysis if her Advanced Director was not sent with her when discharged to the hospital, she replied, They don't. The Administrator, Director of Nursing (DON) and Nurse Consultant was informed of the finding during a briefing on [DATE] at approximately 4:08 p.m. The DON stated, A copy of the resident's Advanced Directive should go with them to the hospital and should be documented in their clinical record. The facility's policy titled Discharge or Transfer Summary (Last Revision date: [DATE]). Guidelines include but not limited to: -1. G: For the residents transferred to another provider the following will be documented and communicated to the receiver provider: Advanced Directive Information. 4. Resident #78 was originally admitted to the facility on [DATE] with diagnoses to include but not limited to Diabetes Mellitus and Urine Retention. The most recent Minimum Data Set (MDS) was a Annual with an Assessment Reference Date (ARD) of [DATE]. Resident #78's Brief Interview for Mental Status (BIMS) was a 13 out of a possible 15 which indicated the resident was cognitively intact and capable of daily decision making. On [DATE] at 10:36 AM, Resident #78's electronic and paper medical record was reviewed for the Advance Directives. Resident #78's Advance Directives were not found in the medical record. On [DATE] a copy of Resident #78's Advance Directives were provided from the Admissions Coordinator who stated, There were in a file in the business office. On [DATE] at approximately 11:30 A.M. an interview was conducted with the Admissions Coordinator regarding the location of the Advance Directives after being obtained from the resident or family. The Admissions Coordinator stated, They have been being kept in the business office in their files, but the new admissions and able to sign electronically and they are being put into the EMR (Electronic Medical Record) so there are accessible to all staff. We are going to do an audit of all the charts. On [DATE] at 7:30 P.M., a pre-exit debriefing was held with the Administrator, Director of Nursing and the Regulatory Care Consultant where the above information was shared. The Administrator stated, Admissions has completed an audit last night for the Advance Directives. Prior to exit no further information was shared. 11. Resident #88 was originally admitted on [DATE] with a readmission date of [DATE]. Resident #88's diagnoses included paraplegia, multiple sclerosis and anemia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision making were intact. Review of the clinical record didn't reveal written Advanced Directive, but the physician's order summary stated the resident was a full code. Review of the person-centered care plan revealed a care plan dated [DATE] and edited [DATE] with a problem documenting: Advanced Directives, resident desires to be a full code. The goal read: Resident wishes to be a full code which will be followed in the event his heart has stopped through [DATE]. The approaches included: 911 will be called for transfers to the hospital, CPR will be conducted in accordance to the resident's wishes, discuss code status during full life conference quarterly during care plan. No information was included in the medical record concerning what to do if the resident becomes incapacitated, a designated health care surrogate, medical/surgical treatments, feeding restrictions, organ donation, autopsy request or other. On [DATE] at approximately 10:45 a.m., the Social services Director stated the Advanced Directives are managed by the Admission/Marketing staff and if the Advanced Directive is not on the resident's chart it is in a file in the Admission's office. An interview was conducted with the Marketing Director on [DATE] at approximately 1:45 p.m. The Marketing Director stated it was true if the form wasn't on the record it was likely in the Admission's Office but, currently she was conducting a 100% audit and if there wasn't a form in either place they were completing one today. The Admission's Director stated Resident #88 had no Advanced Directive form completed but it was completed today. On [DATE] at approximately 6:00 p.m., the above findings were shared with the Administrator Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but nothing was provided. 12. Resident #61 was originally admitted on [DATE] with a readmission date of [DATE] after an acute hospital stay. Resident #61's diagnoses included stroke and asthma. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision were severely impaired. Review of the clinical record didn't reveal written Advanced Directives but the physician's order summary stated the resident was a full code. Review of the person-centered care plan revealed a care plan dated [DATE] and edited [DATE] with a problem documenting: Advanced Directives, resident desires to be a full code. The goal read: Resident wishes to be a full code which will be followed in the event his heart has stopped through [DATE]. The approaches included: 911 will be called for transfers to the hospital, CPR will be conducted in accordance to the resident's wishes, discuss code status during full life conference quarterly during care plan. No information was included in the medical record concerning what to do if the resident becomes incapacitated, a designated health care surrogate, medical/surgical treatments, feeding restrictions, organ donation, autopsy request or other. On [DATE] at approximately 10:45 a.m., the Social services Director stated the Advanced Directives are managed by the Admission/Marketing staff and if the Advanced Directive is not on the resident's chart it is in a file in the Admission's office. An interview was conducted with the Marketing Director on [DATE] at approximately 1:45 p.m. The Marketing Director stated it was true if the form wasn't on the record it was likely in the Admission's Office but; currently she was conducting a 100% audit and if there wasn't a form in either place they were completing one today. The Admission's Director stated Resident #88 had no Advanced Directive form completed but it was completed today. On [DATE] at approximately 6:00 p.m., the above findings were shared with the Administrator Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but nothing was provided. 13. Resident #72 was originally admitted on [DATE] and had not been discharged since admitted . Resident #72's diagnoses included stroke, hemiparesis and diabetes. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #72's cognitive abilities for daily decision making were intact. Review of the clinical record did reveal written Advanced Directives dated [DATE]. It stated I do not choose to formulate or issue Advanced Directives at this time. I want efforts made to prolong my life and warrant life-sustaining treatment to be provided. The current physician's order summary dated [DATE], stated the resident's code status was Do Not Resuscitate. Further review of the record reveal a Do Not Resuscitate form dated [DATE], signed by the resident and the physician. Review of the person-centered care plan dated [DATE] and edited [DATE], revealed no Advanced Directive care plan. On [DATE] at approximately 10:45 a.m., the Social services Director stated the Advanced Directives are managed by the Admission/Marketing staff and if the Advanced Directive is not on the resident's chart it is in a file in the Admission's office. An interview was conducted with the Marketing Director on [DATE] at approximately 1:45 p.m. The Marketing Director stated it was true if the form wasn't on the record it was likely in the Admission's Office but, currently she was conducting a 100% audit and if there wasn't a form in either place they were completing one today. The Admission's Director stated Resident #88 had no Advanced Directive form completed but it was completed today. On [DATE] at approximately 6:00 p.m., the above findings were shared with the Administrator Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but nothing was provided. 14. Resident #61 was originally admitted on [DATE] with a readmission date of [DATE] after an acute care hospital stay. Resident #61's diagnoses included stroke and asthma. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for short term memory problems as well as modified independence for decision making in new situations. Review of the clinical record didn't reveal written Advanced Directives but the Marketing Director was able to locate it in the Admission's office. The Advanced Directives form was signed but not dated and read as follows: I do not choose to formulate or issue Advanced Directives at this time. I want efforts made to prolong my life and warrant life-sustaining treatment to be provided. Review of the person-centered care plan revealed a care plan dated [DATE] and edited [DATE] with a problem documenting: Resident has the following Advanced Directives on record, Full code. The goal read: Resident Advanced Directives are in effect, and their wishes and directions will be carried out in accordance with their advanced directives on an ongoing basis through the next review date [DATE]. The approaches included: Discuss Advanced Directives with the resident and/or appointed health care representative, An Advanced Directive can be revoked or changed if the resident and/or appointed health care representative changes their mind about the medical care they want delivered, Advise resident and/or appointed health care representative to provide copies to the facility of any updated Advanced Directives. No information was included in the medical record concerning what to do if the resident becomes incapacitated, a designated health care surrogate, medical/surgical treatments, feeding restrictions, organ donation, autopsy request or other. On [DATE] at approximately 10:45 a.m., the Social services Director stated the Advanced Directives are managed by the Admission/Marketing staff and if the Advanced Directive is not on the resident's chart it is in a file in the Admission's office. An interview was conducted with the Marketing Director on [DATE] at approximately 1:45 p.m. The Marketing Director stated it was true if the form wasn't on the record it was likely in the Admission's Office but, currently she was conducting a 100% audit and if there wasn't a form in either place they were completing one today. The Admission's Director stated Resident #88 had no Advanced Directive form completed but it was completed today. On [DATE] at approximately 6:00 p.m., the above findings were shared with the Administrator Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but nothing was provided. 6. The facility staff failed to ensure that Resident #51's advance directive was on the clinical record and valid to include a date and witness signatures. Review of Resident #51's clinical record indicated the resident was admitted to the facility on [DATE] with a re-admit on [DATE] with diagnoses that included Parkinson's disease, major depression, and unspecified dementia without behavioral disturbances. Review of the clinical record revealed that there were no advance directive on the chart. On [DATE] 12:33 p.m., an interview with the Director of Social Services was conducted. She was asked where the Advance Directives could be found. She stated they are kept in the Business Office. A request was made to the Business Office Manager to provide the Advance Directive for Resident #51. During the survey the Admission's Coordinator was able to provide a copy of the advance directive that was filed with the resident's admission paperwork information. This copy was not valid and it was not signed, dated and did not have two witness signatures. 7. The facility staff failed to ensure that Resident #50's advance directive was on the clinical record and valid to include two witness signatures. Review of Resident #50's clinical record indicated the resident was admitted to the facility on [DATE] with diagnoses that included high blood pressure, diabetes, and vascular dementia without behavioral disturbances. Review of the clinical record revealed that there were not an advance directive on the chart. On [DATE] 12:33 p.m., an interview with the Director of Social Services was conducted. She was asked where the Advance Directives could be found. She stated they are kept in the Business Office. A request was made to the Business Office Manager to provide the Advance Directive for Resident #50. The Businees Office Manager was able to provide a copy of the advance directive that was filed with the resident's admission paperwork information. This copy was not valid as it did not have two witness signatures. Based on clinical record reviews, staff interviews and facility documentation review, the facility staff failed to ensure residents were able to formulate advance directives, obtain advance directives, and/or send them upon transfer to hospital; and have these documents maintained in the clinical record, readily accessible to the direct care staff for 16 of 63 residents in the survey sample (#64, #95, #128, 78, #11, #51, #50, #15, #90, #42, #88, #61, #72, #61, #139 and #124). The findings include: 1. Resident #64 did not have an advance directive readily available for direct care staff. Upon inquiry, an advance directive was located in a file drawer in the business office, not in the clinical record. Additionally, there was no evidence the resident's advance directive was sent with her when the resident was transferred to the local hospital on [DATE] or [DATE]. Resident #64 was admitted to the nursing facility on [DATE] with diagnoses that included generalized muscle weakness, bipolar disease and schizophrenia. Resident #64's most recent Minimum Data Set (MDS) was a significant change in status assessment. The resident scored a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated she was fully intact with the skills for daily decision making. On [DATE] at 1:48 p.m., the Unit II Nurse Manager stated, I am not sure if (Resident #64's name) has an advance directive. I have never seen one and don't know where I would find one if she indeed had one. I do know she is a full code. There is no paperwork that we know of that says she wanted one or not. On [DATE] at 2:30 p.m., Resident #64 stated that she had an advance directive about some of her medical care decisions along with being a full code and hoped the facility did not lose her important paperwork. On [DATE] at 10:30 a.m., the Unit II Nurse Manager, Licensed Practical Nurse (LPN) #18 and the Director of Nursing (DON) stated the document related to whether or not a resident wanted an advance directive and that it had been reviewed, should be accessible to the nurses and kept in the clinical record, as well as the advanced directive. On [DATE] at 1:02 p.m., upon inquiry, the Business Office Manager (BOM) stated she searched for an advance directive and found a document titled Advance Directives/Informed Consent form dated [DATE] that indicated the resident did not want to formulate an advance directive. She stated the document was located in the file drawer in the business office. The BOM said the document should be kept on the unit where the resident resided and a copy in the business office. On [DATE] at 3:30 p.m., the BOM returned to present an advance directives form for Resident #64. The BOM stated, I dug to find this resident actually did have an advance directive dated [DATE] that was also in a file drawer in the business office. This should have been on the resident's chart and a copy left in the admissions or business office, as well. We will be fixing this immediately with some education because we don't want any mix-ups. On [DATE] at 4:08 p.m., during the debriefing with the Administrator and DON, the aforementioned issue was readdressed. They stated the facility's policy was not followed that indicated all information about informing the resident of their rights and all rules and regulations regarding decisions concerning medical care, and if they had an advance directives be available and kept in the resident's medical record. The DON stated, A copy of the resident's Advanced Directive should go with them to the hospital and should be documented in their clinical record. The Administrator and the DON stated they would be putting together a training plan for the staff. 2. Resident #95 did not have an advance directive readily available for direct care staff. Upon inquiry, an advance directive was located in a file drawer in the business office, not in the clinical record. The Business Office Manager (BOM) located a document titled Advance Directives/Informed Consent dated [DATE] that was found in a file drawer in the business office that indicated the resident had an advance directive. This advance directive was not found prior to survey exit. The facility could not provide evidence that Resident #95's advance directives were sent with her upon transfer to the local hospital on [DATE] or [DATE]. Resident #95 was admitted to the nursing facility on [DATE] with diagnoses that included stroke, diabetes and heart failure. Resident #95's most recent Minimum Data Set (MDS) assessment was a significant change in status assessment dated [DATE] and coded the resident on the Breif Summary for Mental Status (BIMS) with a score of 3 out of a possible score of 15 which indicated the resident was severely impaired in the skills needed for daily decision making. On [DATE] at 1:48 p.m., the Unit II Nurse Manager stated she was not sure if Resident #95 had an advance directive. The Unit II Manager stated, I have never seen one and don't know where I would find one if she indeed had one. I do know she is a DNR (do not resusitate). There is no paperwork that we know of that says she wanted one or not. On [DATE] at 10:30 a.m., the Unit II Nurse Manager, Licensed Practical Nurse (LPN) #18 and the Director of Nursing (DON) stated the document related to whether or not a resident wanted an advance directive and that it had been reviewed, should be accessible to the nurses and kept in the clinical record, as well as the advanced directives. On [DATE] at 1:02 p.m., the Business Office Manager (BOM) stated she searched for an advance directive and found a document titled Advance Directives/Informed Consent form dated [DATE] that indicated the resident formulated an advance directive dated 7/2007. She stated the Advance Directives/Informed Consent document was located in the file drawer in the business office, but she could not find the advanced directive. The BOM said the documents should be kept on the unit where the resident resided and a copy in the business office. On [DATE] at 3:30 p.m., the BOM stated the facility needed to do some training immediately because she did not want any mix-ups. On [DATE] at 4:08 p.m., during the debriefing with the Administrator and DON, the aforementioned issue was readdressed. They stated the facility's policy was not followed that indicated all information about informing the resident of their rights and all rules and regulations regarding decisions concerning medical care, and if they had an advance directives be available and kept in the resident's medical record. The DON stated, A copy of the resident's Advanced Directive should go with them to the hospital and should be documented in their clinical record. The Administrator and the DON stated they would be putting together a training plan for the staff. 3. Resident #128 did not have evidence readily accessible that the facility had offered the resident an opportunity to formulate an advance directive. Additionally, according to the current physician orders for [DATE] the resident was a DNR (do not resusitate), but no DNR form was located in the clinical record. Resident #128 was admitted to the nursing facility on [DATE] with diagnoses that included diabetes mellitus, enlarged heart. Resident #128's most recent Minimum Data Set (MDS) assessment was a quarterly dated [DATE] and coded the resident on the Breif Summary for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident was intact in the skills needed for daily decision making. On [DATE] at 9:20 a.m., Licensed Practical Nurse (LPN) #19 on Unit III stated she was not sure if Resident #128 had an advance directive, but she knew she was a DNR. LPN #19 stated, I do not know where the DNR form is. It should be located in the front of the resident's chart on the unit. She could not determine if there was paperwork that addressed the resident's right to formulate or refuse advance directives. On [DATE] at 10:30 a.m., the Director of Nursing (DON) stated the document related to whether or not a resident wanted an advance directive and that it had been reviewed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Resident #32 was originally admitted to the facility on [DATE]. Diagnosis for Resident #32 included but not limited to Anemia and Altered Mental Status. The current Minimum Data Set (MDS), an annual assessment with an Assessment Reference Date (ARD) of 08/02/19. Staff assessment for mental status was conducted because resident was unable to complete the interview. Staff assessment for mental status coded the resident as having short-term and long-term memory problems. The Discharge MDS assessments was dated for 04/13/19 - discharged with return anticipated. On 04/13/19, according to the facility's documentation, Resident departed facility with local transport to the local hospital. On 10/24/19 at approximately, 3:21 PM an interview was conducted with LPN #1, Unit Manager. She stated, No care plan summary was sent. A briefing was held with the Director of Nursing (DON), Administrator and with the Corporate Nurse Consultant on 10/24/19 at approximately 5:25 P.M. No further comments were made. 8. The facility staff failed to ensure that Resident #11's Plan of Care Summary to include her care plan goals was sent upon transfer/discharge to the hospital on [DATE]. Resident #11 was originally admitted to the facility on [DATE]. Diagnosis for Resident #11 included but not limited to Thromobocytopenia. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 07/22/19 coded the resident with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. On 09/16/19, according to the facility's documentation, Resident #11, left the facility via ambulance service as a direct admit to the hospital, pending a surgical procedure. The clinical record did not show evidence that Resident #11's care plan summary to include her goals were sent upon discharge to the hospital or shortly after. An interview was conducted with License Practical Nurse (LPN) #3 on 10/22/19 at approximately 4:10 p.m. The LPN stated, I have never sent the resident's care plan summary when sending them out to the hospital, I was not aware we were suppose to. A briefing was held with the Administrator, Director of Nursing and Cooperate Nurse on 10/24/19 at approximately 4:08 p.m. The facility did not present any further information about the findings. 3. Resident #78 was originally admitted to the facility on [DATE] with diagnoses to include but not limited to, Diabetes Mellitus and Urine Retention. The most recent Minimum Data Set (MDS) was a Annual with an Assessment Reference Date (ARD) of 9/6/19. Resident #78's Brief Interview for Mental Status (BIMS) was a 13 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making. On 10/22/19 at 11:02 A.M. Resident #78 was asked if he had been to the hospital recently. Resident #78 stated, I went a few months ago the staff were unable to wake me up. Resident #78's Facility Census History was reviewed and is documented in part, as follows: 03/23/2019 Discharge-Return Expected 03/27/2019 Return 05/16/2019 Discharge-Return Expected. 05/21/2019 Return. 08/06/2019 Discharge-Return Expected 08/07/2019 Return On 10/23/19 at 1:45 P.M. the Director of Nursing was asked for documentation to show that the care plan goals were sent with Resident #78 to the hospital for the 3 discharges this year. Resident #78's care plan was reviewed and is documented in part, as follows: Problems: Infection Control, Restorative Nursing, Diabetes, Psychotropic Drug Use, Falls, Skin Integrity, Elimination, Visual Function, Tremors, Depression, Resists Care, Nutritional Status and Advance Directives. On 10/23/19 at approximately 4:00 P.M. the Director of Nursing stated I don't have any documentation to support that the care plan goals were sent with (Name-Resident #78) for the 3 discharges this year. On 10/24/19 at 7:30 P.M. a Pre-exit debriefing was held with the Administrator, Director of Nursing and the Regulatory Care Consultant where the above information was shared. Prior to exit no further information was shared Based on clinical record reviews, staff interviews, clinical record review, facility documentation review and the facility's policy; the facility's staff failed to covey a copy of the resident's comprehensive care plan goals to the transferring facility for 10 of 63 residents (Resident #88, #112, #78, #64, #95, #128, #32, #11, #94, and #605) in the survey sample. The findings included: The facility's policy titled Discharge or Transfer Summary (Last Revision date: 06/28/19). Guidelines include but not limited to: -1. G: For the residents transferred to another provider the following will be documented and communicated to the receiver provider: Comprehensive Care Plan goals. 1. Resident #88 was originally admitted on [DATE] with a readmission date of 8/1/19. Resident #88's diagnoses included paraplegia, multiple sclerosis and anemia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/16/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision making are intact. Review of the clinical record reveal Resident #88 was discharged from the facility return anticipated to an acute care hospital 7/20/19 for a critical hemoglobin and hematocrit. On 10/23/19 at approximately 1:30 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 stated there was no documentation available stating the resident's comprehensive care plan goals were sent with the resident to the hospital at the time of his 7/20/19 discharge. On 10/24/19 at approximately 6:00 p.m., the above findings were shared with the Administrator and Director of Nursing. An opportunity was offered to the facility's staff to present additional information but they did not. 2. Resident #112 was originally admitted on [DATE] with a readmission date of 7/25/19. Resident #112's diagnoses included dementia, Parkinson's disease and schizophrenia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/20/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision were severely impaired. Review of the clinical record reveal Resident #112 was discharged from the facility return anticipated to an acute care hospital 7/22/19 after a fall. On 10/23/19 at approximately 2:45 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #2. LPN #2 stated there was no documentation available stating the resident's comprehensive care plan goals were sent with the resident to the hospital at the time of his 7/22/19 discharge. On 10/24/19 at approximately 6:00 p.m., the above findings were shared with the Administrator Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but they did not. 9. Resident #94 was originally admitted to the facility on [DATE] with a re-admission date of 9/3/19 with diagnoses to include chronic obstructive pulmonary disease, type II diabetes, and schizophrenia. The current Minimum Data Set an annual with an assessment reference date of 9/17/19 coded the resident as scoring a 9 out of a possible 15 on the Brief Interview for Mental Status, indicating the resident's cognition was moderately impaired. The clinical record failed to evidence documentation that upon transfer to the hospital on 8/28/19 a copy of Resident #94's care plan was sent along with other required documents. 10/23/19 11:24 a.m., the unit manager was asked to locate documentation of the facility sending the care plan. The unit manager stated, I can not locate any documentation of bed hold or care plan sent with the resident for the last transfer to the hospital. On 10/24/19 the above findings was shared with the Administrator and the Director of Nursing during the pre-exit meeting. 4. Resident #64 was admitted to the nursing facility on 7/29/16 with diagnoses that included generalized muscle weakness, bipolar disease and schizophrenia. Resident #64's most recent Minimum Data Set (MDS) was a significant change in status assessment. The resident scored a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated she was fully intact with the skills for daily decision making. There was no evidence provided that the facility staff conveyed the summary and goals of the comprehensive plan of care upon transfer/discharge to the local hospital on [DATE] and 7/7/19 for Resident #64. No documentation was included in the transfer summary that indicated the facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge or as soon as possible to the actual time of transfer. On 10/24/19 at 10:30 a.m., the Unit II Nurse Manager stated she was not aware of the process to send a care plan summary and goals when a resident is transferred to the Emergency Department (ED) or hospital. On 10/24/19 at 11:00 a.m., the Director of Nursing (DON) stated, We are not going far enough in the interact form or the discharge summary form that will actually generate the care plan summary goals. You might as well stop searching, we are not sending this document and education will have to take place, as well as draft a facility policy and procedure. On 10/24/19 at 4:08 p.m., during the debriefing with the Administrator and DON, the aforementioned issue was readdressed and no further information was provided prior to survey exit. 5. Resident #95 was admitted to the nursing facility on 1/6/18 with diagnoses that included stroke, diabetes and heart failure. Resident #95's most recent Minimum Data Set (MDS) assessment was a significant change in status assessment dated [DATE] and coded the resident on the Brief Summary for Mental Status (BIMS) with a score of 3 out of a possible score of 15 which indicated the resident was severely impaired in the skills needed for daily decision making. There was no evidence provided that the facility staff conveyed the summary and goals of the comprehensive plan of care upon transfer/discharge to the local hospital on 5/11/19 and 9/3/19 for Resident #95. No documentation was included in the transfer summary that indicated the facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge or as soon as possible to the actual time of transfer. On 10/24/19 at 10:30 a.m., the Unit II Nurse Manager stated she was not aware of the process to send a care plan summary and goals when a resident is transferred to the Emergency Department (ED) or hospital. On 10/24/19 at 11:00 a.m., the Director of Nursing (DON) stated, We are not going far enough in the interact form or the discharge summary form that will actually generate the care plan summary goals. You might as well stop searching, we are not sending this document and education will have to take place, as well as draft a facility policy and procedure. On 10/24/19 at 4:08 p.m., during the debriefing with the Administrator and DON, the aforementioned issue was readdressed and no further information was provided prior to survey exit. 6. Resident #128 was admitted to the nursing facility on 5/6/09 with diagnoses that included diabetes mellitus, enlarged heart. Resident #128's most recent Minimum Data Set (MDS) assessment was a quarterly dated 9/23/19 and coded the resident on the Brief Summary for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident was intact in the skills needed for daily decision making. There was no evidence provided that the facility staff conveyed the summary and goals of the comprehensive plan of care upon transfer/discharge to the local hospital on 9/11/19 for Resident #128. No documentation was included in the transfer summary that indicated the facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge or as soon as possible to the actual time of transfer. On 10/24/19 at 9:20 a.m., Licensed Practical Nurse (LPN) #19 on Unit III stated she did not know about sending a summary of the resident's care plan goals when the residents are sent to the Emergency Department (ED) or hospital. On 10/24/19 at 11:00 a.m., the Director of Nursing (DON) stated, We are not going far enough in the interact form or the discharge summary form that will actually generate the care plan summary goals. You might as well stop searching, we are not sending this document and education will have to take place, as well as draft a facility policy and procedure. On 10/24/19 at 4:08 p.m., during the debriefing with the Administrator and DON, the aforementioned issue was readdressed and no further information was provided prior to survey exit 10. Resident #605 was admitted to the facility on [DATE] with diagnosis of Bipolar disorder, muscle weakness, dysphasia, abnormalities of gait and mobility, hypertension, schizophrenia, acute respiratory failure with hypoxia, reflux disease, insomnia, major depression and anemia. An admission Minimum Data Set, dated [DATE] assessed the resident in the area of Cognitive Patterns as having a Brief Interview for Mental Status (BIMS) score of (13) indicating intact cognition. In the area of Activities of Daily Living (ADL'S) this resident was assessed as requiring total care in the areas of dressing, eating, personal hygiene and toileting. Resident #605 was transferred to the hospital from the facility on 09/22/19. There was no evidence that the facility provided a care plan regarding ongoing care needs to the receiving hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Resident #11 was originally admitted to the facility on [DATE]. Diagnosis for Resident #11 included but not limited to Thromobocytopenia The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 07/22/19 coded the resident with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. On 09/16/19, according to the facility's documentation, Resident #11, left the facility via ambulance service as a direct admit to the hospital, pending a surgical procedure. The clinical record did not show evidence that Resident #11's care plan summary to include her goals were sent upon discharge to the hospital or shortly after. An interview was conducted with License Practical Nurse (LPN) #3 on 10/22/19 at approximately 4:10 p.m. The LPN reviewed Resident #11's clinical record then stated, I am unable to provide evidence that Resident #11 was given the bed hold policy when transferred and admitted to the hospital on [DATE]. A briefing was held with the Administrator, Director of Nursing and Cooperate Nurse on 10/24/19 at approximately 4:08 p.m. The facility did not present any further information about the findings. 3. Resident #78 was originally admitted to the facility on [DATE] with diagnoses to include but not limited to Diabetes Mellitus and Urine Retention. The most recent Minimum Data Set (MDS) was a Annual with an Assessment Reference Date (ARD) of 9/6/19. Resident #78's Brief Interview for Mental Status (BIMS) was a 13 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making. On 10/22/19 at 11:02 A.M. Resident #78 was asked if he had been to the hospital recently. Resident #78 stated, I went a few months ago the staff were unable to wake me up. Resident #78's Facility Census History was reviewed and is documented in part, as follows: 03/23/2019 Discharge-Return Expected 03/27/2019 Return 05/16/2019 Discharge-Return Expected. 05/21/2019 Return. 08/06/2019 Discharge-Return Expected 08/07/2019 Return On 10/23/19 at 1:45 P.M. the Director of Nursing was asked for documentation that bedhold information was sent with Resident #78 to the hospital for the 3 discharges this year. On 10/23/19 at approximately 4:00 P.M. the Director of Nursing stated I don't have any documentation to support that the bedholds were sent with (Name-Resident #78) for the 3 discharges this year. On 10/24/19 at 7:30 P.M. a Pre-exit debriefing was held with the Administrator, Director of Nursing and the Regulatory Care Consultant where the above information was shared. Prior to exit no further information was shared. Based on clinical record review, staff interviews, facility documentation review and the facility's policy; the facility's staff failed to provide written information to the resident and/or resident representative explaining how a resident's bed is held while the resident is absent from the facility due to hospitalization for 9 of 63 residents (Resident #88, #112, #78, #64, #95, #128, #11, #94 and #605) in the survey sample. The findings included: 1. Resident #88 was originally admitted on [DATE] with a readmission date of 8/1/19. Resident #88's diagnoses included paraplegia, multiple sclerosis and anemia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/16/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision making are intact. Review of the clinical record reveal Resident #88 was discharged from the facility return anticipated to an acute care hospital 7/20/19 for a critical hemoglobin and hematocrit. On 10/23/19 at approximately 1:30 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 stated there was no documentation available stating the resident was given information of the bed-hold policy at the time of his 7/20/19 discharge. On 10/24/19 at approximately 6:00 p.m., the above findings were shared with the Administrator and Director of Nursing. An opportunity was offered to the facility's staff to present additional information but they did not. 2. Resident #112 was originally admitted on [DATE] with a readmission date of 7/25/19. Resident #112's diagnoses included dementia, Parkinson's disease and schizophrenia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/20/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision were severely impaired. Review of the clinical record revealed Resident #112 was discharged from the facility return anticipated to an acute care hospital 7/22/19 after a fall. On 10/23/19 at approximately 2:45 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #2. LPN #2 stated there was no documentation available stating the resident was given information of the bed-hold policy at the time of his 7/22/19 discharge On 10/24/19 at approximately 6:00 p.m., the above findings were shared with the Administrator Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but they did not. 8. Resident #94 was originally admitted to the facility on [DATE] with a re-admission date of 9/3/19 with diagnoses to include chronic obstructive pulmonary disease, type II diabetes, and schizophrenia. The current Minimum Data Set an annual with an assessment reference date of 9/17/19 coded the resident as scoring a 9 out of a possible 15 on the Brief Interview for Mental Status, indicating the resident's cognition was moderately impaired. Review of the clinical record nursing progress notes indicated Resident #94 was transferred to the emergency room on 8/28/19 for evaluation of a change in condition and admitted to the hospital. The resident was re-admitted back to the facility on 9/3/19. The clinical record failed to evidence documentation that upon transfer or after transfer and admission to the hospital that a copy of the bed hold policy was sent/ information provided to the resident /Responsible Party. On 10/23/19 at 11:24 AM and interview was conducted with the Unit Manager who stated I can not locate any documentation of bed hold or care plan sent with the resident for the last transfer to the hospital. On 10/24/19 the above findings was shared with the Administrator and the Director of Nursing during the pre-exit meeting. 4. Resident #64 was admitted to the nursing facility on 7/29/16 with diagnoses that included generalized muscle weakness, bipolar disease and schizophrenia. Resident #64's most recent Minimum Data Set (MDS) was a significant change in status assessment. The resident scored a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated she was fully intact with the skills for daily decision making. Upon review of Resident #64's clinical record, no documentation was located that supported the resident or representative was issued a bed hold notice at the time of transfer to the local hospital on [DATE] and 7/7/19. On 10/24/19 at 10:30 a.m., the Unit II Nurse Manager stated she was not aware of the process to issue a bed hold notice to either the resident of Resident Representative upon transfer to the Emergency Department (ED) or hospital. On 10/24/19 at 11:00 a.m., the Director of Nursing (DON) stated the nursing staff was not issuing a bed hold notice to residents when they are transferred to the ED or hospital and that procedure and policy changes need to take place along with education to the nursing staff. On 10/24/19 at 4:08 p.m., during the debriefing with the Administrator and DON, the aforementioned issue was readdressed and no further information was provided prior to survey exit. 5. Resident #95 was admitted to the nursing facility on 1/6/18 with diagnoses that included stroke, diabetes and heart failure. Resident #95's most recent Minimum Data Set (MDS) assessment was a significant change in status assessment dated [DATE] and coded the resident on the Brief Summary for Mental Status (BIMS) with a score of 3 out of a possible score of 15 which indicated the resident was severely impaired in the skills needed for daily decision making. Upon review of Resident #95's clinical record, no documentation was located that supported the resident or representative were issued a bed hold notice at the time of transfer to the local hospital on 5/11/19 and 9/3/19. On 10/24/19 at 10:30 a.m., the Unit II Nurse Manager stated she was not aware of the process to issue a bed hold notice to either the resident of Resident Representative upon transfer to the Emergency Department (ED) or hospital. On 10/24/19 at 11:00 a.m., the Director of Nursing (DON) stated the nursing staff was not issuing a bed hold notice to residents when they are transferred to the ED or hospital and that procedure and policy changes need to take place along with education to the nursing staff. On 10/24/19 at 4:08 p.m., during the debriefing with the Administrator and DON, the aforementioned issue was readdressed and no further information was provided prior to survey exit. 6. Resident #128 was admitted to the nursing facility on 5/6/09 with diagnoses that included diabetes mellitus, enlarged heart. Resident #128's most recent Minimum Data Set (MDS) assessment was a quarterly dated 9/23/19 and coded the resident on the Brief Summary for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident was intact in the skills needed for daily decision making. Upon review of Resident #95's clinical record, no documentation was located that supported the resident or representative were issued a bed hold notice at the time of transfer to the local hospital on 5/11/19 and 9/3/19. On 10/24/19 at 9:20 a.m., Licensed Practical Nurse (LPN) #19 on Unit III stated she did not know about issuing a bed hold notice with the resident or representative upon transfer to ED or hospital. On 10/24/19 at 11:00 a.m., the Director of Nursing (DON) stated the nursing staff was not issuing a bed hold notice to residents when they are transferred to the ED or hospital and that procedure and policy changes need to take place along with education to the nursing staff. On 10/24/19 at 4:08 p.m., during the debriefing with the Administrator and DON, the aforementioned issue was readdressed and no further information was provided prior to survey exit. 9. Resident #605 was admitted to the facility on [DATE] with diagnosis of Bipolar disorder, muscle weakness, dysphasia, abnormalities of gait and mobility, hypertension, schizophrenia, acute respiratory failure with hypoxia, reflux disease, insomnia, major depression and anemia. Resident #605 was discharged from the facility on 9/22/19. An admission Minimum Data Set, dated [DATE] assessed this resident in the area of Cognitive Patterns as having a Brief Interview for Mental Status (BIMS) score of (13) indicating intact cognition. Resident #605 was transferred to the hospital from the facility on 09/22/19. There was no evidence in the clinical record that the facility provided a Notice of Bed Hold Policy at the time of transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident # 105 was admitted to the facility on [DATE] with a readmission occurring on 12/07/2018 with the latest diagnosis including, but not limited to, Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus, encephalopathy. Unspecified, contracture, right hand, muscle weakness (generalized, type 2 diabetes mellitus, unspecified convulsions. Resident # 105's MDS (Minimum Data Set), Quarterly Review assessment dated [DATE] coded Resident #105 with a BIMS (brief interview of mental status) as 2 out of a possible 15, indicating severe cognitive impairment. Review of a Facility Reported Incident (FRI) received at the Office of Licensure and Certification on 8/8/2019 detailed a resident to resident incident where facility staff responded to repeated yelling of a resident (Resident #90) in the hallway. According to a written statement, Certified Nursing Assistant (CNA) staff witnessed, Resident #105 rubbing his penis on the arm of Resident #90. A review of Resident #105's Behavior Management Care Plan dated 5/10/2019 included addressing wandering behavior with a goal to have fewer episodes of wandering, evidenced by behaviors occurring less than weekly. An additional Behavior Care Plan was initiated on 10/28/2015 with updates through 11/15/2018 and a final target date of 5/19/2019 identifying socially inappropriate behavior, walking around in the nude, and approaching visitors while undressed. The goal was to not harm himself or others and a target to a reduction in occurrences of behavior to less than 3 times per week. Identified approaches include, report to physician changes in behavioral status, reinforce positive behavior, educate the resident/responsible party on the causal factors of the behavior, address wandering behavior by walking with resident, investigate monitor need for psychological/psychiatric support, intervene as needed to protect the rights & safety of others, and, monitor resident closely for whereabouts. There were no revisions to the Care Plan as a response to the aforementioned incident. At 10/23/19 at approximately 1:45 PM a phone interview was conducted with Resident #105's authorized representative, regarding the aforementioned incident, stating, Yes, there was an incident back in August. This was very unusual. Usually staff will give him privacy so he can take care of his nature. We talked about this in care planning. On 10/24/2019, follow-up activities to the FRI submitted on 8/8/2019, included an interview with the Director of Nursing (DON) who was asked if Resident #105 has a history of sexually inappropriate behaviors, she answered, Yes he does, about every 2 months. The DON was subsequently asked about the facility management of identified behaviors, the DON answered, We monitor him. The Facility Administrator was informed of the findings during a briefing on 10/24/2019 at approximately 7:30 p.m. The Facility did not present any further information about the findings. 3. Resident #11 was originally admitted to the facility on [DATE]. Diagnosis for Resident #11 included but not limited to *Pressure ulcer of other site, unspecified stage. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 07/22/19 coded the resident with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In addition, the MDS coded Resident #11 requiring total dependence of one with hygiene, extensive assistance of one with transfer, dressing, personal hygiene, bed mobility and toilet use. The review of Resident #11's comprehensive person care plan with a revision date of 07/30/19 did not include the stage III sacral pressure ulcer identified on 10/09/19. The review of the wound information pressure ulcer form noted evidence of an entry dated 10/09/19 at 6:59 a.m., indicated the following: A new sacral pressure ulcer measured 6 cm x 4.3 cm with light seropurulent (yellow or tan, cloudy and thick exudate (drainage). The tissue type observed with slough, wound edges/margins well defined and pink/normal skin surrounding wound. The review of the Wound Information Pressure Ulcer form noted evidence of an entry dated on 10/16/19 - sacrum pressure ulcer measuring 6 cm x 4 cm with 0.1 cm depth with moderate amount of serous (clear, amber, thin and watery) exudate. The tissue bed with slough, wound edges/margins well defined with pink/normal skin surround wound. An interview was conducted with the MDS Coordinator on 10/24/19 at approximately 9:00 a.m., who stated, I was unable to locate a revised skin integrity care plan to include the stage III sacral wound identified on 10/09/19. She said the nurses as well as MDS are responsible for updating/revising care plans. The MDS Coordinator said the nurse who found the wound should have revised the care plan with a new intervention, but it was not done. On 10/24/19 at approximately 11:48 a.m., an interview was conducted with the wound nurse (Licensed Practical Nurse-LPN #7), who stated, I found the stage III pressure ulcer to Resident #11's sacrum on 10/09/19. The surveyor asked, Should Resident #11's care plan be revised to include the newly identified stage III sacral pressure ulcer. The LPN replied, Absolutely, I should have made an adjustment to Resident #11's care plan to include the stage III sacral pressure ulcer. A briefing was held with the Administrator, Director of Nursing and Cooperate Nurse on 10/24/19 at approximately 4:08 p.m. The facility did not present any further information about the findings. The facility's policy title Pressure Ulcer Management Resources (Revised 07/24/18.) Guideline Steps include but not limited to: -Revise the care plan to reflect the change in condition. Develop an effective plan of are consistent with resident goals and wishes. Update the care plan to reflect new treatment goals and approaches. Definitions: *Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). *Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). Based on clinical record review, staff interview, family interview, facility documentation review and in the course of a complaint investigation, the facility staff failed to review and revise the person-centered care plan as their condition changed for 5 of 63 residents (Resident #88, #112, #11, #94 and #105) in the survey sample. The findings included: 1. Resident #88 was originally admitted on [DATE] with a readmission date of 8/1/19. Resident #88's diagnoses included paraplegia, multiple sclerosis and anemia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/16/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded as requiring total care with eating, personal hygiene and bathing, extensive assistance of two with bed mobility, extensive assistance of one with person with toileting and dressing. Review of a nursing progress note dated 8/2/19, at 3:25 p.m., revealed Resident #88 was readmitted to the facility 8/1/19, with a new stage 3 pressure ulcer to the left ischium and currently wound care continued to the area. Review of the physician's order summary revealed an order dated 10/17/19 which read: clean left ischium wound with Dakins 1/4 strength solution, apply a nickel layer of Santyl, apply Dakins gauze and cover with a border gauze daily and as needed. Review of the active care plan dated 5/24/19 and edited 9/24/19 revealed the following problem: Resident has a pressure ulcer stage 4 of the right ischium. The goal read: Resident will not develop additional pressure ulcers through 12/23/19. Some of the approaches included Apply dressings per physician order. Conduct a systematic skin inspection weekly. Report any signs of any further skin breakdown (sore, tender, red or broken areas). A complete review of the entire care plan didn't reveal a care plan for the pressure ulcer to the left ischium therefore, an interview was conducted with the wound care nurse on 10/23/19 at approximately 2:00 p.m. The wound care nurse provided a pressure ulcer report dated 10/22/19, revealing the left ischium was currently a stage 4 pressure ulcer measuring 4.0 x 4.0 x 1.5 centimeters and presenting with 75% granulation tissue and 25% necrotic tissue. The wound care nurse also stated the resident was non-compliant with turning and positioning to relieve pressure as necessary. On 10/24/19 at approximately 1:30 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #5. LPN #5 stated the care plan we were reviewing was the resident's current and active care plan but it didn't include a care plan for Resident #88's left ischial pressure ulcer but there should have been a care plan for the site. LPN #5 stated the left ischial pressure ulcer would be added to the current person-centered plan of care. On 10/24/19 at approximately 6:00 p.m., the above findings were shared with the Administrator and Director of Nursing. An opportunity was offered to the facility's staff to present additional information; no further information was presented. 2. Resident #112 was originally admitted on [DATE] with a readmission date of 7/25/19. Resident #112's diagnoses included dementia, Parkinson's disease and schizophrenia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/20/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care with bathing, extensive assistance of one person with dressing, toileting, and personal hygiene, supervision of one person with bed mobility and transfers, and supervision after set-up with eating. Review of the clinical record revealed Resident #112 had a modified barium swallow completed 9/4/19, which revealed the resident was a high risk for aspiration. Nothing by mouth was recommended with an alternate means of nutrition. A physician's progress note dated 10/10/19, stated the power of attorney (POA) was notified approximately one week ago of the modified barium swallow results and of the recommendations for nothing by mouth. The physician's progress further stated the POA decided against a peg tube and to continue with the current diet, knowing the risk of aspiration pneumonia. An interview was conducted with the Nurse Practitioner on 10/23/19 at approximately 11:00 a.m., she stated she is monitoring the resident's potential for aspiration by performing routine chest x-rays for changes in the lungs indicating an acute problem. Review of Resident #112's care plan revealed a nutritional care plan dated 5/27/19 and edited 8/15/19. The problem read: at nutritional risk related to dementia. At risk for weight fluctuations related to congestive heart failure, slight weight loss exhibited. The goal read: no significant weight changes through next review and 75% intake of diet through next review 11/24/19. Some of the interventions included: diet as ordered, medication as ordered, review labs as available and weights per protocol. On 10/23/19 at approximately 3:15 p.m., an interview was conducted with Registered Nurse MDS Coordinator, she stated the care plan we were reviewing was the resident current active care plan and it didn't address the resident's aspiration risk but the care plan would be updated to include the risk. On 10/24/19 at approximately 6:00 p.m., the above findings were shared with the Administrator Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility staff to present additional information; no further information was provided. 4. Resident #94 was originally admitted to the facility on [DATE] with a re-admission date of 9/3/19, with diagnoses to include neuralgia (severe pain occurring along the course of a nerve), neuritis ( inflammation of a nerve) and right shoulder pain. The current Minimum Data Set an annual with an assessment reference date of 9/17/19 coded the resident as scoring a 9 out of a possible 15 on the Brief Interview for Mental Status, indicating the resident's cognition was moderately impaired. The resident was coded as being on a scheduled pain medication regimen. 10/22/19 at 4:39 p.m., the resident was in bed and complained of back pain, the resident could not give a pain level number. The nurse who was outside in the hallway was informed of the resident's pain. The physician orders dated 9/3/19 were to administer Neurontin 300 milligrams by mouth twice daily for neuralgia and neuritis and Tylenol 650 milligrams every six hours as needed for right shoulder pain. The Comprehensive Person-Centered Plan of Care for Resident #94 was not revised to include a pain management plan of care. The above findings was shared during the pre-exit meeting conducted on 10/24/19 with the Administrator and the Director of Nursing. No further information was provided by facility staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident record review, staff interviews and facility document review the facility staff failed to ensure dialysis services to include ongoing communication with the dialysis center was in place for 1 of 63 residents in the survey sample, Resident #18. The findings included: Resident #18 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, End Stage Renal Disease and Schizoaffective Disorder Resident #18 attended dialysis on Tuesday, Thursday and Saturdays. The most recent Minimum Data Set (MDS) was a Quarterly with an Assessment Reference Date (ARD) of 8/1/19. Resident #18's Brief Interview for Mental Status (BIMS) was a 15 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making. Under Section O Special Treatments, Procedures, and Programs Resident #18 was coded for Dialysis while a resident. On 10/22/19 at approximately 1:00 P.M. the resident was not observed in the facility and the staff stated she was at dialysis. On 10/23/19 at 10:20 A.M. Resident #18's Dialysis Communication Book was reviewed. The last Post Dialysis Treatment documentation from the Dialysis Center was July 25, 2019. Licensed Practical Nurse (LPN) #10 was asked where the rest of Resident #18's Post Dialysis Treatment documentation sheets were. LPN #10 stated Name (Resident #18) usually carries the book herself and sometimes she doesn't bring it back. She stated, The ones in the book are all we have. I can call dialysis to see if they have them. On 10/23/19 at approximately 4:30 PM the surveyor was provided a stack of Resident #18's Post Dialysis Treatment sheets from 7/25/19 to present. All presented dialysis post treatments were faxed over from the dialysis center to the facility on [DATE] at 13:59 and ending at 14:22 P.M. On 10/23/19 AT 5:00 P.M. an interview was conducted with the Director of Nursing and she was asked what were her expectations for communication with the dialysis center in regards to the facility residents. The Director of Nursing stated Sometimes Name (Resident #18) does not bring her book back and if that is the case I would expect for the nurses to call over to the dialysis center and have the communication sheet sent over that day. The facility policy titled Care of End Stage Renal Disease Resident last revised 8/7/19 was reviewed and is documented in part, as follows: Guideline: 6. Collaborate with the Dialysis Team if you have any concerns about complications post treatment. The Dialysis Team will provide handoff communication post treatment. On 10/24/19 at 7:30 P.M. a Pre-exit debriefing was held with the Administrator, Director of Nursing and the Regulatory Care Consultant where the above information was shared. Prior to exit no further information was shared.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, resident interview and facility document review, the facility staff failed to ensure that the physician was notified of a positive urine culture in a timely manner for 1 of 63 residents in the survey sample, Resident #78. The findings included: Resident #78 was a [AGE] year old originally admitted to the facility on [DATE] with diagnoses to include but not limited to Urine Retention and Diabetes Mellitus. The most recent Minimum Data Set (MDS) was a Annual with an Assessment Reference Date (ARD) of 9/6/19. Resident #78's Brief Interview for Mental Status (BIMS) was a 13 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making. Resident #78's Progress Notes were reviewed and are documented in part, as follows: 10/15/2019 15:46 (3:46 P.M.): urinalysis results received and placed in md (medical doctor) folder, greater than 100,000 gram negative rods, resident positive for uti (urinary tract infection), urine culture pending, np (nurse practitioner) notified, will continue to monitor. Resident #78's Electronic Medical Record was reviewed for the urine culture results and were not found. On 10/22/19 at approximately 12:30 P.M. Unit Manager LPN (Licensed Practical Nurse) #4 was asked if she could find Resident #78 urine culture results. Unit Manager LPN (Licensed Practical Nurse) #4 stated, I have been on vacation for the past week and am just coming back I will have to go look for them. At approximately 2:00 P.M. Unit Manager LPN #4 returned to the conference room and stated, I had to pull them off the computer today, while I was off no one pulled them. I have notified the Nurse Practitioner with the results and I am waiting for her to call back with orders. Unit Manager LPN #4 was then asked when were the urine culture results available and when should they have been reported the physician. Unit Manager LPN #4 stated, On the 16th and we alert the physician as soon as we obtain the results Resident #78's Progress Notes were reviewed and are documented in part, as follows: 10/22/19 15:40 (3:40 P.M.): final us (urinalysis), c&s (culture and sensitivity) results from 10/6 received. Name (NP) notified and said she will call back with orders. 3-11 nurse notified and will follow-up. 10/22/2019 18:16 (6:16 P.M.): Name (NP), in to view C&S results; >100,000 Pseudomonas Aeruginosa-new order received to change foley catheter tonight, and start Cipro 500mg every 12 hours for 10 days-orders noted-care plan updated-patient is own RP (responsible party), aware. Resident #78's Urinalysis Culture and Sensitivity Laboratory Report was reviewed and is documented in part, as follows: Collection Date/Time: 10/13/19 Received: 10/15/19 Reported: 10/16/19 Organism 1: Urine >100,000 Pseudomonas Aeruginosa Resident #78's current Comprehensive Care Plan was reviewed and is documented in part, as follows: The facility's policy titled Laboratory Diagnostic Testing/Reporting last revised 7/10/18 was reviewed and is documented in part, as follows: Purpose: Diagnostic tests and clinical labs will be obtained based on physician/NP orders and the results reported to the physician/NP timely. Guideline Steps: 3. Each facility will maintain a lab/diagnostic log to identify lab/diagnostic studies and validate receipt of results and MD notification. c. DON (Director of Nursing)/designee will monitor all orders for lab/diagnostics to ensure all entries, requisitions are entered and follow-up has occurred per log. The log book will be reviewed for completion each day during clinical meeting. 4.f. Abnormal labs will be called to the MD for follow-up at the time of receipt with information noted on the lab to include date, time, initials and orders. On 10/24/19 at 7:30 P.M. a Pre-exit debriefing was held with the Administrator, Director of Nursing and the Regulatory Care Consultant where the above information was shared. The Director of Nursing was asked what would have been the expectation for reporting abnormal lab values to the physician. The Director of Nursing stated, We should make the physician aware of the results as soon as they are available. Prior to exit no further information was shared.

Based on identified quality deficiencies determined during this survey the QAA (Quality Assessment and Assurance) committee failed to develop and implement an appropriate plan of action to correct repeat harm deficiencies in the area of Quality of Care-Pressure Injuries affecting 1 of 63 residents and potentially affecting all residents. The findings included: The facility was cited with harm in the area of Quality of Care for Pressure Injuries during the last survey ending 7/13/18. During the current survey, the facility was cited with a level 3 isolated (G) harm deficiency in the same area. The plan of correction for the last survey did not correct the deficient practice.

Based on staff interview the facility failed to ensure quarterly QAA (Quality Assessment and Assurance) meetings were conducted as required and required members were in attendance. The findings included: During the QAPI (Quality Assurance and Performance Improvement) review conducted on 10/24/19 at approximately 6:30 p.m., the Administrator was asked to provide evidence of quarterly QAA meetings to include the sign in sheets. The Administrator stated that he had identified that the facility QAA committee was lacking in participation from all department heads. He stated they have QAPI every month and revamped the QAPI process. The Administrator stated he did not have all the sign in sheets to show evidence of quarterly QAA committee attendance. The third quarter July 2019 QAPI meeting signature sheet did not have the Medical Director or his/her designee in attendance. No other information was provided to the survey team about the facility's QAPI quarterly meetings prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews the facility staff failed to ensure privacy curtains were maintained in a sanitary condition in three resident rooms which included 6 of 169 beds. The findings included: On 10/22/19, 10/23/19 and 10/24/19 the privacy curtains in rooms 205, 206 and 208 were observed with visible stains; and food debris was noted on the curtains in room [ROOM NUMBER]. On 10/24/19 at approximately 10:00 a.m., an Environmental Services Staff (other staff #12) was asked how often are privacy curtains cleaned. He stated whenever the housekeeping staff let him know. He was asked to check the three rooms with the dirty curtains, he stated they need to be changed out. The Housekeeping Staff (other staff #11) who was responsible for cleaning the rooms on that hallway was interviewed. She was asked the process on how dirty privacy curtains get changed. She stated that if she finds any privacy curtains that need to be cleaned she writes them down and forwards the information. She was asked about the dirty curtains in rooms 205, 206 and 208. She stated her boss had told her a couple of days ago that the curtains needed to be taken down and cleaned, she stated, It slipped my mind. The above findings were shared with the Administrator and Director of Nursing during the pre-exit meeting on 10/24/19.

Based on observations and staff interviews, the facility staff failed to handle, prepare and store food in a manner to prevent foodborne illness potentially affecting all residents. The findings included: During the Initial Kitchen Inspection at 10:31 A.M. on 10/22/19 a side salad with a use by date of 10/14/19 was observed in the two door glass refrigerator. Shredded cheese with a use by date of 10/09/19 was observed in the two door glass refrigerator. A French Silk Pie with a use by date of 10/09/19 was observed in the two door glass refrigerator. A container of Tuna with a use by date of 10/10/19 was observed in the two door glass refrigerator. A bag of cooked link sausage with a use by date of 10/19/19 was observed in the two glass refrigerator. A plastic scoop was observed in a 50 pound bag of sugar with the scoop was touching the sugar. The bag was not sealed nor in a container. Boxes of food items were stored on the floor of the dry storage room. The floor was noted to have dirt, debris, spilled food crumbs and paper. Two male staff members were observed in the kitchen handling various food items without beard guards. A Food Service Policy regarding storage, preparation and handling was requested during the survey. No Policy was provided.

Based on observations and staff interview, the facility staff failed to maintain an effective pest control system/program potentially affecting all residents. The findings included: During the kitchen inspection on 10/22/19 at 10:31 A.M. house flies were observed in the kitchen area. Drain flies were observed in the mop room and dishwasher room. Fruit flies and house flies were observed in the conference room. House flies were observed in the dining room area. Flies were observed on all units. During an interview on 10/23/19 at 3:50 P.M. with the Maintenance Director he stated, the drain flies, fruit flies and house flies have been a concern and there is a need for pest control. The Maintenance Director stated The Pest Control company comes out to service the facility. The Maintenance Director stated the flies will be in the building like this until it turns cold out side. A review of the Pest Management policy indicated: Mission-We shall first seek to understand the unique needs of each customer, formulate effective solutions, and implement the actions in a timely professional manner. No further information was provided by facility staff.

Based on clinical record review, staff interviews and facility documentation review, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 38 residents (Resident #101 and 126) in the survey sample. 1. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #101 who was discharged from skilled services with Medicare days remaining. 2. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #126 who was discharged from skilled services with Medicare days remaining. The findings included: 1. Resident #101 was readmitted to the nursing facility on 02/13/18. Diagnosis for Resident #101 included but not limited to Chronic Kidney Disease - stage IV (kidney failure). Resident #101's Minimum Data Set (MDS) quarterly assessment with an Assessment Reference Date (ARD) date of 5/23/18 coded Resident #101 a 3 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident with severe cognitive impairment. On review of the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review provided by the facility to surveyors it was noted that Resident #101 was not issued the SNF ABN (Skilled Nursing Facility-Advanced Beneficiary Notice, form CMS-10055). The resident had received a NOMNC (Notice of Medicare Provider Non-Coverage- form CMS-10123), but the SNF ABN (CMS-10055) was never provided. Resident #101 started a Medicare Part A stay on 02/13/18 and the last covered day of this stay was 03/20/18. Resident #101 was discharged from Medicare Part A services when benefit days were not exhausted and should have been issued a SNF ABN (CMS-10055) and an NOMNC (CMS-10123). Resident #101 had only used 36 days of her Medicare Part A services. The resident's representative was informed verbally of the NOMNC on 3/18/18. An interview was conducted with Assistant Business of Manager (ABOM) on 7/11/18 at approximately 4:00 p.m., stated, I misunderstood what was to be delivered to the resident upon discharge from skilled services; I thought it was only the one notice (NOMNC) but an ABN letter was never given to the resident or their representative. The Administrator was informed of the finding on 7/11/18 at approximately 4:10 p.m. The facility did not present any further information about the findings. 2. Resident #126 was admitted to the nursing facility on 1/16/18. Diagnosis for Resident #126 included but not limited to Hypertension (high blood pressure). Resident #126 Minimum Data Set (MDS) quarterly assessment with an Assessment Reference Date (ARD) date of 4/25/18 coded Resident #126 an 11 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident with moderate cognitive impairment. On review of the SNF Beneficiary Protection Notification Review provided by the facility to surveyors it was noted that Resident #126 was not issued the SNF ABN (Skilled Nursing Facility-Advanced Beneficiary Notice, form CMS-10055). The resident had received a NOMNC (Notice of Medicare Provider Non-Coverage- form CMS-10123), but the SNF ABN (CMS-10055) was never provided. Resident #126 started a Medicare Part A stay on 1/16/18, and the last covered day of this stay was 3/2/18. Resident #126 was discharged from Medicare Part A services when benefit days were not exhausted and should have been issued a SNF ABN (CMS-10055) and an NOMNC (CMS-10123). Resident #126 only used 44 days of her Medicare Part A services. The resident's representative was informed verbally of the NOMNC on 2/28/18. An interview was conducted with Assistant Business of Manager (ABOM) on 7/11/18 at approximately 4:00 p.m., stated, I misunderstood what was to be delivered to the resident upon discharge from skilled services; I thought it was only the one notice (NOMNC) but an ABN letter was never given to the resident or their representative. The Administrator was informed of the finding on 7/11/18 at approximately 4:10 p.m. The facility did not present any further information about the findings. The facility's policy and procedures titled Notice of Medicare Non-Coverage (NOMNC) effective: 3/1/2015. Purpose: NOMNC will be delivered to a resident in accordance with the Medicare and Managed care guidelines as outlined in this policy. Skilled Nursing Facilities (SNF's) NOMNCs are presented to resident beneficiaries for purpose of alerting them that Medicare covered item(s) and /or services(s) are ending and for providing beneficiaries the opportunity to request an expedited determination form Quality Improvement Organization (QIO). A Detailed Explanation of Non-Coverage (DENC) is given when the QIO review is requested in order to provide the beneficiary with a more detailed explanation on why coverage is ending. Procedure: -Copies of the completed NOMNC are: a. Given to the resident or the authorized representative who signed the NOMNC. b. Signed original is paced in the resident's medical record at the SNF. c. Placed in the ABN/NOMNC binder in the business office.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, facility documentation review and clinical record review the facility staff failed to accurately complete each required section of the MDS (Minimum Data Set) assessment for 2 out of 38 residents (Resident #126 & #135) in the survey sample. 1. The facility staff failed to complete the required section of Resident #126 quarterly MDS: section C-Brief Interview for Mental Status. 2. The facility staff failed to code Resident #135 for hospice care. The findings included: Resident #126 was admitted to the facility on [DATE]. Diagnoses for Resident #126 included but are not limited to Hypertension (high blood pressure). Resident #126 MDS with an Assessment Reference Date (ARD) of 4/25/18 coded the resident's Brief Interview for Mental Status (BIMS) score 11 of a possible 15 with moderate cognitive impairment. Review of the quarterly MDS with ARD of 06/13/18 noted it was marked with dashes under section C-Brief Interview for Mental Status. On 07/12/18 at 8:10 a.m., an interview was conducted with MDS Coordinator #2 regarding the dashes on Resident #126 quarterly MDS with ARD date 06/13/18. The surveyor asked the MDS coordinator what the dashes mean on the MDS, she replied, That section was not assessed or no information was provided. The surveyor asked if section C on the 6/13/18 MDS should have been completed she replied, Yes. The review of section Z on the 6/13/18 quarterly MDS was reviewed with the following information: the Social Worker (SW) had signed off on 6/14/18 that section C was completed. The following sections of the MDS were marked with dashes: Under Section C - C0100 - Brief Interview for Mental Status, section C0200, C0300 -Temporal Orientation (section A, B, C), section C0400, C0500, C0600, C0700, C0800, C1000, C1300, C1600 all coded with dashes. An interview was conducted with MDS Coordinator #1 on 8:25 a.m. The surveyor asked, Do you check to make sure MDS sections are completed, she replied, Yes. The surveyor informed the MDS #2 that section C on MDS with ARD date of 6/13/18 under section C was not completed, she then replied, I check section Z to make sure they have signed off for being completed. An interview was conducted with SW on 7/12/18 at approximately 8:30 a.m., who stated, I do not know what happen but section C should have been completed. The facility Administrator was informed of the findings during a briefing on 7/12/18 at approximately 2:40 p.m. The facility did not present any further information about the findings. Facility policy titled Resident Assessment (Revised June 2017). -Guideline: The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. The assessment coordinator will be responsible for assigning sections of the MDS to be completed by the interdisciplinary team. Sections can be assigned and reassigned as appropriate and determined by the MDSC. a. MDS sections can and will have multiple disciplines assigned. b. General assign sections by discipline read in part: Social Service - C,D,E,Q -Individuals who complete a portion of the assessment must sign and certify the accuracy of the area/item of the assessment per the RAI Manual 3.0. Signatures must in include their title, area/item completed and date they completed that area/item of the assessment. -A Registered nurse will sign and certify that the assessment is completed per the RAI Manual. 2. Resident #135 was originally admitted to the facility 7/24/13 and has never been discharged from the facility. The current diagnoses included; anemia, diabetes, and dementia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/16/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of 15. This indicated the resident was with moderately impaired daily decision making abilities. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 1 person with bed mobility, total care of 1 person with personal hygiene, bathing and dressing. In section O0100K2of the 3/16/18 MDS assessment; the resident was not coded for hospice care while a resident. A physician order dated 12/12/17 revealed an order for evaluation and treatment for hospice services. On 7/12/18 at approximately 4:30 p.m., the MDS Coordinator stated the 3/16/18, MDS assessment was not coded for hospice care but the 6/15/18, MDS assessment was coded for hospice care. The MDS Coordinator stated a modification was made to the 3/16/18 MDS assessment and presented a copy of the modified assessment. The active care plan dated 6/21/18 had a problem reading the resident elected hospice care. The facility's guideline titled; Resident Assessment with a revision date of June 2017 read; the facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. At #4 the guideline read; the assessment process includes direct observation and communication with the resident, resident's family or legal guardian, as well as communication with licensed and non-licensed direct care staff members. On 7/12/18, at approximately 2:30 p.m.,the above findings were shared with the Administrator and Director of Nursing. An opportunity to present additional information was offered but none was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, facility document review and staff interviews the facility failed to revise the Person Centered Care Plan's for 2 of 38 Resident's in the Survey Sample, Resident #34 and Resident #108. 1. The facility staff failed to revise Resident #34's Person Centered Care Plan in the area of Activities to include the resident's assessed activities of preference. 2. The facility staff failed to review effectiveness of interventions and review/revise Resident #108's person centered care plan after a fall resulting in a left hip fracture. The Findings Included: 1. Resident #34 is a [AGE] year old admitted to the facility 4/26/16 with diagnoses to include Depression and Dementia. The most recent Comprehensive Minimum Data Set (MDS) assessment was an Annual with an Assessment Reference Date (ARD) of 5/3/18. The Brief Interview for Mental Status (BIMS) for Resident #34 was attempted but unable to be completed by the Resident. Under Section C Cognitive Patterns Resident #34 was coded to have long and short term memory problems. Resident #34 was also coded to be severely impaired in cognitive skills for daily decision making. Under Section F Preferences for Customary Routines and Activities the following activities were coded as Very Important for Resident #34: having books, newspapers, and magazines to read, listen to music you like, keep up with the news, and participate in religious services and practices. Under Section F Preferences for Customary Routines and Activities the following activities were coded as Somewhat Important for Resident #34: be around animals such as pets, do things with groups of people, do your favorite activities, and go outside to get fresh air when the weather is good. Resident #34's Comprehensive Care Plan last revised 5/8/18 was reviewed and is documented in part, as follows: Problem: Name (Resident #34) needs 1:1 (one to one) attention for activity stimulation; Spends most of the time in bed watching tv (television), listens to music, enjoys playing games on tablet, and daily visits from mother. Approach: 1. Provide leisure supplies to self direct pursuits. 2. Obtain prior level of activity involvement and interests by talking with resident,staff, family. 3. Consider impact of medical problems on activity level. Resident #34's One to One Participation Log for July 2018 was reviewed and is documented in part, as follows: Resident #34 was coded as A (Active Participation) for the following activities: Art/Crafts- 7/2/18 Beauty/Grooming- 7/2/18, 7/6/18, 7/7/18, 7/9/18, and 7/11/18. Visual Stimulation- 7/2/18, 7/6/18, 7/7/18, 7/9/18, and 7/11/18. Lotion/Aromatherapy- 7/7/18 and 7/9/18. Music Tapes-no entries. Spiritual/Prayer/Chaplain Visit- no entries. On 7/12/18 at 10:00 AM an interview was conducted with the Activities Director. The Activities Director was asked who was responsible for updating/revising the Resident's Person Centered Care Plans for Activities. The Activity Director stated, The Activities Director is responsible for updating the activities care plan either during or after the care plan meeting. I have only just taken over as the Activities Director a few days ago I was the Admissions Director and I'm still training the new Admissions Director. I haven't updated any care plans yet. My activity assistant can probably tell you more. On 7/12/18 at 10:30 AM an interview was conducted with the Activities Assistant. The Activities Assistant was asked if she updated Resident #34's Person Centered Care Plans for Activities or if she looks at the care plan to see the resident's activity preferences prior to carrying out activities with the resident. The Activities Assistant stated, No I don't know anything about Name (Resident #34's) care plan, and no absolutely not I just go by what's on the activity log sheet for the resident. We have had over 5 different Activity Director's in the last year. On 7/12/18 at 11:45 the Activities Director provided the surveyor with a revised Person Centered Care Plans for Activities for Resident #34 which was reviewed and documented in part, as follows: Problem: Resident exhibits strong reluctance to be out of room for group activities as evidenced by outburst, stammering and agitation within group settings. Approach: 1. Use soft touch and gentle massages for at least 2 minutes during 1:1 visits. 2. Introduce yourself to resident and use calm slow approach. 3. During visits, offer snack, open blinds, raise head of bed up and engage resident in reality orientation. 4. At least one visit per week read daily bread to the resident and gain recognition with responses. 5. Offer out-of-room, one-on-one quite activities such as sitting on the patio when up in chair. 6. Observe resident for signs of escalating tension, anxiety and overstimulation. 7. Resident enjoys watching tv throughout the day. Ensure that the tv is within comfortable viewing before exiting the room. The facility policy titled Care Plans-Comprehensive effective date 10/31/17 was reviewed and is documented in part, as follows: POLICY STATEMENT A person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, goals and preferences. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the Resident Assessment Instrument. 4. Each resident's comprehensive care plan is designed to: d. Reflect the resident's expressed wishes regarding care and treatment goals. 13. Care plans are ongoing and revised as information about the resident and the resident's condition change. The facility policy titled Activity Care Plans effective date 7/25/17 was reviewed and is documented in part, as follows: POLICY STATEMENT An individual comprehensive and person-centered care plan including measurable objectives and timetables is developed for each resident based on the comprehensive assessment and the preferences of the resident to enhance his/her sense of well-being. GUIDELINE: 2. The Quality of Life Director/designee will coordinate development of the activity care plan to support each resident's choice of activities including group, individual, and independent activities designed to meet the interests of the resident. 4. The resident's interests, hobbies, and cultural preferences will be incorporated in the development of the care plan. 5. The Quality of Life Director/designee will review the care plan at least quarterly; and as appropriate, revise the resident's care plan as indicated. On 7/13/18 at 11:15 AM a pre-exit conference was conducted with the Administrator and the Director of Nursing where the above information was shared. The Director of Nursing was asked what she would have expected for Resident #34's Person Centered Care Plan. The Director of Nursing stated, They should be updated to reflect the resident in realtime, what is going on today. Prior to exit no further information was shared. 2. Resident #108 was originally admitted to the facility 4/23/18 and readmitted [DATE] from a local acute care hospital, after repair of a left hip fracture. The current diagnoses included; a left hip fracture, advanced dementia and an anxiety disorder. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/31/18 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making. In section D (Mood) the resident is coded for a poor appetite. In section E (Behavior), Resident #108 is coded for verbal aggression which significantly interferes care, activities and socialization as well as rejection of care 1-3 days each week. In section G (Physical functioning) the resident was coded as requiring total care of 1 with off unit locomotion, personal hygiene and bathing, extensive assistance of 2 people with bed mobility, transfers, dressing, and toileting. She requires extensive assistance of 1 person with on unit locomotion, and supervision after set-up with eating. The clinical record and the fall report revealed on 5/21/18, staff heard a loud noise and found Resident #108 on the floor in her room complaining of left hip pain. The resident was diagnosed with a left hip fracture at the local hospital. The Fall Risk Evaluation, dated 5/24/18 scored Resident #108 at 22 (the evaluation stated a score of 10 or higher is at risk for falls). Review of the undated active care plan revealed the facility staff failed to review the previous fall which resulted in the hip fracture to ensure interventions were in place to prevent further fall related injuries for Resident #108, who was identified upon readmission as having a high risk for more falls. The care plan problem read; at risk for fall related injury as evidenced by a previous fall, Alzheimer's Dementia fractured right hip, a normal progression of disease process with unavoidable and/or predictable decline. Use of a rolling walker and non-compliance with requesting assistance with transfers. The goal read; the resident will not sustain a fall related injury by utilizing fall precautions through the next review date. The interventions were; use fall risk screen to identify risk factors on admission and quarterly. Report falls to physician and responsible party. Observe for side effects of any drug that can cause gait disturbances, orthostatic hypotension, weakness, sedation, lightheadedness, dizziness and change in mental status. Report to the physician any side effects associated with the resident's medication use. Provide environmental adaptations; low platform bed, call light within reach, adequate glare free lighting, and keep area free of clutter. Observe use of walker/cane. Lock brakes on bed, chair, etc. before transferring. When arising sit on the side of the bed before transferring/standing. Educate/remind resident to request assistance prior to ambulation. Appropriate footwear. Weight bearing as tolerated to right hip/leg. Invite, encourage, remind, escort to activity programs consistent with resident's interests to enhance physical strengthening needs. Referral for screen physical therapy, mental health, and treatment as needed. Provide resident/family teaching to include safety measures to reduce fall risk. 1/4 side rails as an enabler. Frequent rounds. An interview was conducted with Licensed Practical Nurse (LPN) #3 on 7/12/18, at approximately 12:10 p.m. LPN #3 stated Resident #108 was very confused and combative, paced to the door and back most of the day, repeatedly stated she wanted to leave the facility, and she often spoke in Spanish but understood English. LPN #3 also stated the resident walked with assistance of a walker because of balance problems. Also during the interview with LPN #3 she stated the investigation of the fall didn't reveal the last time the resident was observed prior to the fall, what the resident was doing prior to the fall, if the resident was in a low bed, were fall mats in use or if non-skid socks were in use, or if the resident had eliminated in an inappropriate place resulting in a slip/fall. She was certain no alarms were in use because they are not used by the facility. The incident report, neither the fall investigation report stated the resident was wearing or had remove the non-skid sock or if the bed was in its lowest position at the time of the fall. The care plan indicated Resident #108 was capable of making good decision when she wasn't due to her long and short term memory problems as well as severely impaired daily decision making . Most of the above interventions are standard interventions for all residents not interventions specific to Resident #108. LPN #3 stated the resident didn't have the cognitive ability to institute the above interventions and the questions asked during the fall investigation were not used to develop new care plan interventions. On 7/12/18, at approximately 2:30 p.m., the above findings were shared with the Administrator and Director of Nursing. An opportunity to present additional information was offered but none was provided. The Director of Nursing stated; the Unit Manager follows up on falls and they discuss all falls in the morning meeting, determine a root cause of the fall, develop interventions and update the person-centered care plan based on the information reviewed. The Director of Nursing further stated, it doesn't look like we reviewed the fall and updated the care plan thoroughly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #1 is a [AGE] year old that was admitted to the facility originally on 3/1/17 and re-admitted on [DATE] and again on 6/14/18. Resident #1's diagnoses included Chronic Kidney Disease and Diabetes Mellitus. The most recent Minimum Data Set (MDS) assessment was a Quarterly with an Assessment Reference Date (ARD) of 6/22/18. The Brief Interview for Mental Status (BIMS) for Resident #1 was a 4 out of a possible 15 which indicated the resident was severely cognitively impaired. Resident #1's Progress notes for 1/23/18 and 6/12/18 were reviewed and are documented in part, as follows: Date: January 23, 2018 Resident loa (leave of absence) via medical transport on stretcher, call received from dialysis that resident was being transported to ER (Emergency Room) for eval (evaluation) and treatment RP (responsible party) notified. Date: June 12, 2018 Received report from (name) at (Dialysis Center Name) via phone that resident completed 20 minutes of treatment when Resident's B/P (blood pressure) dropped to 87/50, resident was unresponsive and vigorous sternum rub was not effective, Resident was sent to (Hospital Name) via 911 when EMT's (emergency medical team) arrived resident was reported back at baseline, awake with a B/P of 194/80 resident c/o (complained of) headache and slurred speech noted by (Dialysis Center Name) staff. On 7/12/18 at 11:00 AM an interview was conducted with the Director of Nursing and she was asked if Resident #1's Responsible Party was notified of the facility's bed-hold and reserve bed payment policy upon transfer/discharge to the hospital on 1/23/18 and 6/12/18. The Director of Nursing stated, I don't see anywhere in the nurse's notes that the family was made aware of the bed hold at discharge. The Surveyor asked the Director of Nursing who was responsible for notifying the resident/responsible party of the bed hold at discharge. The Director of Nursing stated, The nurses' on the floor are responsible for notifying the family's of bed holds. On 7/12/18 at 11:30 AM the Director of Nursing came to surveyor and stated, I spoke with the nurse and bed holds were not discussed with the family when the resident was discharged . On 7/12/18 at 12:15 PM an interview was conducted with Licensed Practical Nurse (LPN) #7 who was a floor nurse on Resident #1's unit. LPN #7 was asked if she notify's the resident/responsible party of the bed hold policy and reserve bed payment policy upon transfer/discharge to the hospital. LPN #7 stated, No the nurse's don't do that, that is done through the business office. The facility policy titled Facility Bedhold was reviewed and is documented in part, as follows: POLICY STATEMENT The facility will notify the resident/responsible party of the facility's bed hold and re-admission policies at admission and anytime a resident is transferred to the hospital or goes out on a therapeutic leave. Bed Hold: 1. The facility's bed hold and re-admission policies will be discussed with the resident/responsible party and the facility will provide written notice of the bed hold and re-admission policies: *Before a resident's transfer to the hospital or for overnight therapeutic leave and included in the resident's transfer packet. The facility's clinical team will facilitate the resident's transfer packet. The facility's business office team or designee will document verbal and written notification in the medical record. On 7/13/18 at 11:15 AM a pre-exit conference was conducted with the Administrator and the Director of Nursing where the above information was shared. The Administrator stated, Yes, this is a system wide failure. Prior to exit no further information was shared. 5. Resident #108 was originally admitted to the facility 4/23/18 and readmitted [DATE] from a local acute care hospital, after repair of a hip fracture. The current diagnoses included; a left hip fracture, advanced dementia and an anxiety disorder. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/31/18 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making. A clinical note dated 5/21/18, at 5:41 a.m., revealed a Certified Nursing Assistant (CNA) found Resident #108 lying on the floor, on her back. The note also stated the resident was assessed to be alert yet confused, the left leg appeared externally rotated and the resident was crying out in severe pain. Another note dated 5/21/18 at 6:47 a.m., read; the nursing supervisor was made aware of the resident's transfer to a local hospital's emergency room and the supervisor notified the Director of Nursing. A note dated 5//21/18 at 3:03 p.m., stated the physician was notified the resident had been admitted to the local hospital with a diagnosis of a left hip fracture. On 7/12/18 at approximately 12:15 p.m., an interview was conducted with the Social Worker. The Social Worker stated she notifies the Ombudsman of discharges but she does not manage notifications of the bed hold policy because the facility staff decided discharges could be at any hour of the day therefore; the bed hold notification would become a nursing staff responsibility since they would be speaking with Resident Representatives and/or Resident at the time of a discharge. There was no documentation stating the facility staff notified Resident #108 and/or the Resident Representative of the bed hold policy when she was admitted to the hospital, 5/21/18. On 7/12/18, at approximately 2:30 p.m., the above information was shared with the Administrator and Director of Nursing. The Administrator stated the bed hold notification procedure had resulted in a system failure and they would develop a more effective plan. Based on record review and staff interview, the facility staff failed to provide notice of Bed Hold and Reserve Bed Payment Policy for five Residents (Resident #6, #82, #89, #1, #108 ) in the survey sample. 1. The facility staff failed to provide notice of Bed Hold and Reserve Bed Payment Policy to Resident #6 upon discharge to the hospital. 2. The facility staff failed to provide notice of Bed Hold and Reserve Bed Payment Policy to Resident #82 upon discharge to the hospital. 3. The facility staff failed to provide notice of Bed Hold and Reserve bed Payment Policy to Resident #89 upon discharge to the hospital. 4. The facility staff failed to ensure that Resident #1 was made aware of the facility's bed-hold and reserve bed payment policy upon transfer/discharge to the hospital on 1/23/18 and 6/12/18. 5. The facility staff failed to provide notice of Bed Hold and Reserve Bed Payment Policy to Resident #108 upon discharge to the hospital. The findings included: 1. Resident #6 was readmitted to the facility on [DATE] with diagnoses of muscle weakness, dysphagia, hypertension, diabetes, seizures, GERD, dementia, anxiety and depression. A Quarterly Minimum Data Set (MDS) assessed this resident as having a Brief Interview for Mental Status (BIMS) score of 15 in the area of Cognitive Patterns (no cognitive impairment). In the area of Activities of Daily Living (ADL) this resident was assessed as requiring Supervision with Setup help in the areas of mobility, transfer, dressing, eating, and personal hygiene. A Care Plan dated 7/5/18 indicated: Resident Hoards items, she refuses to send items home and continue to have things brought in. Resident has pulmonary condition and has potential for difficulty breathing (shortness of breath). A review of the clinical records indicated Resident #6 requested to go to the ER. Resident stated that she has been having sob (shortness of breath) for a few days. Resident #6 was discharged to the hospital on 3/15/18. During an interview on 7/11/18 at 10:30 A.M. with the Third Floor Unit Manager, she stated, Resident #6 was not provided with a Bed Hold Notice or a Reserve Bed Payment Policy. 2. Resident #82 was readmitted to the facility on [DATE] with diagnoses of cardiomyopthy, hypertension, dysphagia, B Cell Lymphoma, Bipolar Disorder and depression. A re-admission Minimum Data Set, dated [DATE] assessed this resident as having hearing difficulty. In the area of Cognitive Patterns this resident was assessed as having a Brief Interview for Mental Status (BIMS) score of 10. In the area of Activities of Daily Living (ADL) this resident was assessed as requiring Total Dependence in the areas of Transfer, Dressing, and personal Hygiene. A Care Plan dated 5/31/18 indicated: Resident at risk for falls. Resident needs/requires assist in Transfer, bathing, dressing and incontinence care. A review of the clinical records indicated on 4/6/18, Resident #82's son wanted resident to be sent to ER, requesting resident to be admitted to psych floor. Physician gave order to send resident to ER. During an interview on 7/11/18 at 10:30 A.M. with the Third Floor Unit Manager, she stated, Resident #82 was not provided with a Bed Hold Notice or a Reserve Bed Payment Policy. 3. Resident #89 was readmitted to the facility on [DATE] with diagnoses of coronary heart disease, anemia, diabetes, depression, hypertension, CVA, and GERD. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident as having short term memory loss. In the area of Cognitive Skills for daily Decision Making this resident was assessed as having moderately impaired decision making regarding tasks of daily life. In the area of Activities of Daily Living (ADL) this resident was assess as requiring total dependence in the areas of transfer, mobility, dressing and personal hygiene. A Care Plan dated 5/18/18 indicated: Resident at risk for aspiration as resident has a Peg Tube. A review of the clinical records indicated on 5/8/18 resident's grand daughter notified nurse of patient shaking and having a substance coming from patients mouth noted what looked like feeding tube residual coming from patients mouth or possible vomiting. Physician notified and agreed to send patient to hospital for further examination in respect to family wishes. During an interview on 7/11/18 at 11:30 A.M. with the Second Floor Unit Manager, she stated, Resident #89 was not provided with a Bed Hold Notice or a Reserve Bed Payment Policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility staff failed to assure medications were secure and inaccessible to one Resident (#139) who ingested anti-fungal ointment. Resident #139 was admitted to the facility on [DATE] with diagnoses that include but are not limited to altered mental status unspecified, fungal infection on the buttocks, muscle weakness, and spinal stenosis (narrowing on the spinal canal). Resident #139 was discharged into the community on [DATE]. The facility staff failed to assure medications were secure and inaccessible to Resident #139 who ingested anti-fungal ointment left on her over bed table. An admission MDS 3.0 (Minimum Data Set) was completed for Resident #139 on the ARD (Assessment Reference Date) of [DATE], which included a BIMS (Brief Interview for Mental Status) score of 6 indicating severely impaired cognition. Resident #139's ADL (Activities of Daily Living) status was listed as totally dependent for self-performance in the areas transfers, dressing, and toilet use, needing extensive assistance of bed mobility, eating, and hygiene. She needed the assistance of 2 facility staff member for bed mobility, transfers, and toileting, and assistance of 1 staff member for dressing, eating, and hygiene. Resident #139 did not walk. A care plan was developed and revised for Resident #139 on [DATE] which included Problem, Resident has ADL (activities of daily living) self-care deficit, and is at risk for complications, resident needs assist with transfers, toileting, grooming, locomotion, and dressing, Goal: Resident will be clean groomed, and dressed by staff daily throughout the next review. Approach: Refer to therapy as needed, Staff to assist with ADL's, Resident educated on tasting things left on bedside table and asked to call nurse if anything in med cups left in reach. Resident states she understood and would not have normally done that. Review of facility documentation dated [DATE] noted Resident #139 stated she ingested some ointment that was in a med cup on her over bed table less than 10ml [milliliters]. Called pharmacy and poison control / nontoxic. Resident [#139] sent to the ER as a precaution. She was sent back with no adverse effects to resident. Action plan developed/implemented. All rooms checked for medications/hazardous material and no issues identified. Staff to be in re-educated on storage of medications and hazardous material. A review of the emergency room report dated [DATE] noted Today nurse report that she [Resident #139] accidentally ate barrier cream (bamex/nystatin). Upon assessment, she denies any issues. Pharmacy was called and report there shouldn't be any harm to patient. Discussed with unit manager, her [Resident #139] son is adamant that patient goes out 911 to ER for eval [evaluation]. Resident #139 stated I thought it was cream cheese. Resident was returned to the facility. A review of Resident # 139's medication orders included Nystatin Triamcinolone cream (anti-fungal)-apply to peri area (genital area) and buttocks after each incontinent episode. On [DATE] at 10:00 AM an interview with the Administrator was conducted and the incident was reviewed. He stated the medication was non-toxic and Resident #139 had applied it to her lips, but should not have been left at the resident's bedside. He stated further that staff has been in serviced on medication storage. Facility policy titled 4.1 Storage of Medication issued 11/17 stated in part: Medications and biologicals are stored properly. Medication supply shall be accessible only to licensed nursing personnel, or staff members authorized to administer medications. A review of the facility policy for Medication Administration Section 7.1 and dated 05/16 in part stated: Medication Administration: 4. Medications are to be administered at the time they are prepared. 15. Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care centers Interdisciplinary Team (IDT) and in accordance with procedures for self-administration of medications and state regulations. The facility staff failed to assure medications were secure and inaccessible to Resident #139 who ingested anti-fungal ointment left on her over bed table. Based on observation, staff interviews and facility documentation review the facility staff failed to ensure drugs and biological were secured and stored and discarded per professional guidelines. 1. The facility staff failed to discard 3 expired Culture Swab Collection and Transport System tubes that were located in the medication room on Unit 2. 2. The facility staff failed to discard an expired Lantus insulin located in the medication cart on Unit 2 (Long hall medication cart). 3. The facility staff failed to ensure a medication cart was locked when not in direct site of the nurse for 1 of 3 units (Unit 3). 4. The facility staff failed to assure medications were secure and inaccessible to Resident #139 who ingested anti-fungal ointment. 5. The facility staff failed to ensure that 3 medications supplied by the Resident #13's family were stored appropriately and not left at the resident's bedside. The findings include: 1. On [DATE] at approximately 8:15 a.m., the Medication Storage Room on Unit 3 was inspected with Unit Manager - License Practical Nurse (LPN) #2. Inside the medication room were three (3) Culture Swab Collection and transport system tubes with an expiration date of [DATE]. The surveyor handed the culture swab tubes Unit Manager who stated, They expired in [DATE]. The surveyor asked, Should the culture swab tubes be in your medication storage room, she replied, No ma'am - I'm moving it right now. The surveyor asked, Who is responsible to ensure expired biological are removed from the med storage room she replied, All nurses are responsible actually. An interview was conducted with Director of Nursing (DON) on at [DATE] at approximately 12:20 p.m., who stated, The Unit Manager is to inspect the medication room for expired biologicals. 2. On [DATE] at approximately 2:30 p.m., the medication cart on Unit 2 was inspected with License Practical Nurse (LPN) #1. Inside the medication cart was a multi dose vial of Lantus Insulin with an open date of [DATE]. The surveyor asked, Has the Lantus stored on the medication cart with an open date of [DATE] expired and she replied Yes. The surveyor asked LPN #1 how long is Lantus good for once open, she replied 30 days. LPN stated, The Lantus insulin should have been taken off the cart, I will remove now. The LPN removed the open vial of Lantus with an open date of [DATE] off the medication cart. The surveyor asked, Who is responsible for making sure expired insulin's are removed from the medication cart, she replied, Who ever gives the medication. An interview was conducted with Director of Nursing (DON) on at [DATE] at approximately 12:20 p.m., who stated, The insulin should not have been there. The DON then said the nurses should check the medications before med pass for expiration dates on each shift. *Lantus is used to treat type 1 diabetes (condition in which the body does not produce insulin and therefore cannot control the amount of sugar in the blood). It is also used to treat people with type 2 diabetes (condition in which the body does not use insulin normally and, therefore, cannot control the amount of sugar in the blood) who need insulin to control their diabetes) (https://medlineplus.gov/ency/article/007365.htm). The manufactures recommendation on how to store Lantus: -The Lantus vials you are using should be thrown away after 28 days, even if it still has insulin left in it. 3. On [DATE] at approximately 9:42 a.m., the medication cart on unit 3 was unlocked and left unattended when not in direct site of the nurse. Three staff members walked past the medication cart while unlocked and unsupervised. LPN #2 came out of a resident room saying, I forgot to lock my medication cart, I can't believe I did that. The surveyor asked, How did you know your cart was unlocked, she replied, Someone came in and told me. While this surveyor was standing at the medication unlocked; there were 2 staff members who walked past the medication cart while unlock and unsupervised by the nurse. An interview was conducted with Social Worker (SW) on [DATE] at approximately 9:50 a.m. The SW said she was in the hallway and noticed that LPN #1 had left her medication cart unlocked so I went and told her. An interview was conducted with Director of Nursing (DON) on at [DATE] at approximately 12:20 p.m., who stated, The medication cart should be locked when in not in the nurses view. The facility Administrator was informed of the findings during a briefing on [DATE] at approximately 2:40 p.m. The facility did not present any further information about the findings. The facility policy titled Storage of Medication - Section 4.1 (Revision 2007). Policy: Medications and biologicals are stored properly, following manufacture's or provide pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures to read in part: -In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not is use or attended by personals with authorized access. 5. The facility staff failed to ensure that 3 medications supplied by the Resident #13's family were stored appropriately and not left at the resident's bedside. Resident #13 was a [AGE] year old admitted to the facility on [DATE] with diagnoses to include (1.) End Stage Renal Disease and Depression. The most recent Minimum Data Set (MDS) assessment was a Quarterly with an Assessment Reference Date (ARD) of [DATE]. Under Section C, Cognitive Patterns Resident #13 was coded to be modified independent in cognitive skills for daily decision making. Resident #13's Comprehensive Care Plan last revised [DATE] was reviewed and is documented in part, as follows: Problem: Potential for complications related to hemodialysis, ERSD (end stage renal disease) dialysis Tuesday-Thursday-Saturday. Approach: Nursing to apply Lidocaine gel to extremity, dialysis access 30 minutes prior to dialysis. On [DATE] 8:38 PM surveyor entered resident's room for initial greeting. Resident #13 was observed sitting up on side of bed watching television. He was alert and oriented, told surveyor about his parents and that he goes to dialysis. Noted a yellowish box on the resident's bedside table with a tube of Lidocaine 5% Anorectal Cream from Pharmacy (Name) dated [DATE], a spray can of Pain Ease Medium Strength Aerosol from Pharmacy (Name) dated [DATE], and one tube of Triple Antibiotic Ointment 1 ounce. Resident was asked about the 3 medications at his bedside and he stated, Yes they are mine and I use then 30 minutes before dialysis on my arm. My mom got it for me. The surveyor asked if the nurses' apply the medications or if he does and if they are always at his bedside. The Resident stated, They do it at dialysis and its always with me, I keep it. On [DATE] 11:30 AM a box with a tube of Lidocaine 5% Anorectal Cream from the Pharmacy dated [DATE] and a spray can of Pain Ease Medium Strength Aerosol 3.5 fluid ounces from the Pharmacy dated [DATE], and one tube of Triple Antibiotic Ointment 1 ounce remains at the resident's bedside. On [DATE] 02:12 PM a box with a tube of Lidocaine 5% Anorectal Cream from the Pharmacy dated [DATE] and a spray can of Pain Ease Medium Strength Aerosol 3.5 fluid ounces from the Pharmacy dated [DATE], and one tube of Triple Antibiotic Ointment 1 ounce remains at the resident's bedside. On [DATE] 02:12 PM a box with tube of Lidocaine 5% Anorectal Cream from the Pharmacy dated [DATE] and a spray can of Pain Ease Medium Strength Aerosol 3.5 fluid ounces from the Pharmacy dated [DATE], and one tube of Triple Antibiotic Ointment 1 ounce remains at the resident's bedside. On [DATE] 2:36 PM An interview was conducted with the Unit Manager Registered Nurse (RN) #2. RN #2 was taken to the resident's room and shown the 3 medications on the resident's bedside table. RN # 2 stated, He applies those to his arm before he leaves for dialysis. Floor nurse Licensed Practical Nurse (LPN) #8 entered the room who is the regular nurse for the resident. LPN #8 was asked if the 3 medications on the resident's bedside should been there and if the resident had been assessed to self administer his own medications. LPN #8 stated, No the medications should not be at his bedside and no he has not been assessed to self administer. These medications are not even from our pharmacy they are from (Name) Pharmacy and this isn't even his doctor in here. I will call his doctor and get it taken care of. RN #2 and LPN #8 were asked why the medications should not be at the bedside. LPN #8 stated, Because it's a safety reason for the resident and all the other resident's. On [DATE] 2:40 PM The above information was shared with the Director of Nursing and she was asked what she would have expected regarding the medications at Resident #13's bedside. The DON stated, Medications should only be at the bedside with a physician order, the resident should have had a medication self-administration assessment completed, and the care plan should have been updated for the medications at the bedside and self administration if appropriate for that resident. Resident #13's Progress Noted dated [DATE] at 3:35 PM by LPN #8 was reviewed and is documented in part, as follows: Spoke with Dialysis, Lidocaine spray order given by Doctor Name on [DATE] at Dialysis, order was picked up by mother and given to resident. Lidocaine spray D/C (discontinued) at this time per MD (medical doctor) order. Resident to continue current lidocaine ointment per order. Spoke with Resident's mother via phone and educated that resident may not self administer medications and not to bring in medications for resident without nurse's notification. Resident's mother made aware she is to pick up lidocaine spray and triple antibiotic. Resident's mother states that she does not remember why the triple antibiotic was given to resident. MD made aware. The facility policy titled Bedside Medication Storage dated 11/17 was reviewed and is documented in part, as follows: POLICY: Bedside medication storage is permitted for resident's who are able to self-administer medications, upon written order of the prescriber and when it is deemed appropriate in the judgement of the nursing care center's interdisciplinary resident assessment team. 5. All nurses and nursing aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary. On 7/ 13/18 at 11:15 AM a pre-exit conference was conducted with the Administrator and the Director of Nursing where the above information was shared. Prior to exit no further information was shared. (1). End Stage Renal Disease: a disease condition that is essentially terminal because of irreversible damage to vital tissue or organs. Kidney or renal end stage disease is defined as a point at which the kidney is so badly damaged or scarred that dialysis or transplantation is required for patient survival. The above definitions were derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition.