Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for one of eight residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff failed to implement the comprehensive care plan to provide treatment to a pressure injury (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/28/24, the resident was assessed as having one unstageable deep tissue injury (2) that was not present on admission. The comprehensive care plan for R6 documented in part, Problem Start Date: 10/29/2024. I am at risk for pressure ulcers/impaired skin integrity due to: open lesion to the finger from ruptured gout nodule, incontinence, impaired mobility, skin tear to LLE (left lower extremity), edema, fragile skin due to fluid accumulation, right heel DTI (deep tissue injury). Edited: 10/31/2024. Under Approach it documented in part, .Treatment as ordered. Created: 10/29/2024 . The progress notes for R6 documented in part, - 10/28/2024 02:00 pm (Recorded as late entry on 11/01/2024 02:01 pm) DTI observed by therapy and was overheard speaking to son about floating resident's heal [sic] and possibly ordering bilateral heal [sic] protector boots. This writer was told and assessed the resident. It was noted that resident had DTI on right heal [sic] measuring 3.5x5.5cm (centimeter). Nurse made aware, and consult put in place for resident to be seen wound MD. Nursing care continues. - 10/29/2024 11:32 am Resident dx (diagnosed) with generalized weakness and declining last few weeks/months with AMS (altered mental status) possibly d/t (due to) UTI (urinary tract infection) on antibiotics .10/29 noted with right heel DTI . - 11/4/2024 12:54 am Resident continues skilled services r/t UTI, muscle weakness. Alert and oriented to self only, able to verbalize needs. No c/o (complaints of) pain or discomfort. Requires total assist x 1 w/ ADLs (activities of daily living). Air mattress in place and functioning. DTI to right heel remains, skin prep applied as ordered, heels floating . - 11/4/2024 2:07 pm .PA (physician's assistant) assessed resident at bedside, note new wound care orders to right heel & RUE (right upper extremity) . The wound physician evaluation dated 11/11/24 documented in part, .Unstageable DTI with intact skin .Wound size (LxWxD): 3.5x3.8xnot measurable cm) .Wound progress: Improved evidenced by decreased surface area . The physician order's for R6 documented in part, Skin prep to right heel. Every shift Days, Evenings, Nights. Start Date: 11/07/2024. Review of the eTAR (electronic treatment administration record) for R6 dated 10/1-10/31/24 documented the heels floated when in bed beginning on 10/28/24 however it failed to evidence any treatment to the right heel DTI that was first observed on 10/28/24. Review of the eTAR for R6 dated 11/1-11/30/24 documented the heels floated when in bed each shift. It further documented a treatment of Betadine to the right heel every shift beginning on 11/4/24 through 11/7/24. The eTAR further documented the skin prep treatment beginning every shift on 11/7/24. On 12/6/24 at 9:26 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the purpose of the care plan was to promote interventions for caring for the resident. She stated that the care plan should be implemented for safety reasons and to promote care of the resident to get them back to their baseline functioning. On 2/6/24 at 10:32 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that there was an order placed for skin prep for R6's right heel on 11/1/24 but the order did not show on the eTAR. She stated that the staff that entered the order placed it under the general flow sheet so it did not trigger to show on the eTAR and staff would not have known that the treatment needed to be completed. ASM #2 stated that when the DTI was first observed on 10/28/24 the nurse should have contacted the physician and entered the order for the treatment if not already entered. She stated that the purpose of the care plan was to plan the residents care and ensure that it was centered to the residents needs at the facility. She stated that the care plan should be implemented, because it was the way to know how to care for the resident based on their needs. The facility policy Comprehensive Person-Centered Care Planning revised May 7, 2024, documented in part, .The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychological needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process . On 12/6/24 at approximately 12:15 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the assistant administrator were made aware of the findings. No further information was provided prior to exit. Reference: (1) Pressure injury A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst.tage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm. (2) DTI- deep tissue injury Pressure sores that develop in the tissue deep below the skin. This is called a deep tissue injury. The area may be dark purple or maroon. There may be a blood-filled blister under the skin. This type of skin injury can quickly become a stage III or IV pressure sore. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide care and services to promote healing of a pressure injury for one of eight residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff failed to evidence a treatment for a facility acquired deep tissue injury (1) first observed on 10/28/24 until 11/4/24. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/28/24, the resident was assessed as having one unstageable deep tissue injury that was not present on admission. The progress notes for R6 documented in part, - 10/28/2024 02:00 pm (Recorded as late entry on 11/01/2024 02:01 pm) DTI observed by therapy and was overheard speaking to son about floating resident's heal [sic] and possibly ordering bilateral heal [sic] protector boots. This writer was told and assessed the resident. It was noted that resident had DTI on right heal [sic] measuring 3.5x5.5cm (centimeter). Nurse made aware, and consult put in place for resident to be seen wound MD. Nursing care continues. - 10/29/2024 11:32 am Resident dx (diagnosed) with generalized weakness and declining last few weeks/months with AMS (altered mental status) possibly d/t (due to) UTI (urinary tract infection) on antibiotics .10/29 noted with right heel DTI . - 11/4/2024 12:54 am Resident continues skilled services r/t UTI, muscle weakness. Alert and oriented to self only, able to verbalize needs. No c/o (complaints of) pain or discomfort. Requires total assist x 1 w/ ADLs (activities of daily living). Air mattress in place and functioning. DTI to right heel remains, skin prep applied as ordered, heels floating . - 11/4/2024 2:07 pm .PA (physician's assistant) assessed resident at bedside, note new wound care orders to right heel & RUE (right upper extremity) . The wound physician evaluation dated 11/11/24 documented in part, .Unstageable DTI with intact skin .Wound size (LxWxD): 3.5x3.8xnot measurable cm) .Wound progress: Improved evidenced by decreased surface area . The physician order's for R6 documented in part, Skin prep to right heel. Every shift Days, Evenings, Nights. Start Date: 11/07/2024. Review of the eTAR (electronic treatment administration record) for R6 dated 10/1-10/31/24 documented the heels floated when in bed beginning on 10/28/24 however it failed to evidence any treatment to the right heel DTI that was first observed on 10/28/24. Review of the eTAR for R6 dated 11/1-11/30/24 documented the heels floated when in bed each shift. It further documented a treatment of Betadine to the right heel every shift beginning on 11/4/24 through 11/7/24. The eTAR further documented the skin prep treatment beginning every shift on 11/7/24. The comprehensive care plan for R6 documented in part, Problem Start Date: 10/29/2024. I am at risk for pressure ulcers (2)/impaired skin integrity due to: open lesion to the finger from ruptured gout nodule, incontinence, impaired mobility, skin tear to LLE (left lower extremity), edema, fragile skin due to fluid accumulation, right heel DTI (deep tissue injury). Edited: 10/31/2024. On 12/6/24 at 9:26 a.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that skin assessments were completed weekly on each resident. She stated that if a new pressure injury was observed they were not allowed to stage the wound, so they called the RN (registered nurse) to come assess the wound and stage it. She stated that if there was no RN in the building, they wrote a detailed note regarding the wound and described it without staging it until the RN could assess it. She stated that no matter if it were an LPN or RN the nurse contacted the physician and obtained a treatment order and documented the wound. On 2/6/24 at 10:32 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that there was an order placed for skin prep for R6's right heel on 11/1/24 but the order did not show on the eTAR. She stated that the staff that entered the order placed it under the general flow sheet so it did not trigger to show on the eTAR, and staff would not have known that the treatment needed to be completed. ASM #2 stated that when the DTI was first observed on 10/28/24 the nurse should have contacted the physician and entered the order for the treatment if not already entered. The facility policy Pressure Ulcer and Skin Care revised 4/24/24 documented in part, .Intervention: i. Initiate and document nursing interventions (examples: pressure reduction mattress, supportive devices, turning schedule, catheter to prevent further breakdown, etc.) ii. Obtain a treatment order and/or other specific physician orders On 12/6/24 at approximately 12:15 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the assistant administrator were made aware of the findings. No further information was provided prior to exit. Reference: (1) DTI- deep tissue injury Pressure sores that develop in the tissue deep below the skin. This is called a deep tissue injury. The area may be dark purple or maroon. There may be a blood-filled blister under the skin. This type of skin injury can quickly become a stage III or IV pressure sore. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm (2) Pressure injury A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst.tage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to report and follow post fall procedures for one of eight residents in the survey sample, Resident #8. The findings include: For Resident #8 (R8), the facility staff failed to report a fall that occurred on evening shift 8/28/24. There was no documentation completed until 9/2/24 after the resident was discovered to have a fractured femur (1) and an investigation for the injury was started. R8 was admitted to the facility with diagnoses that included but were not limited to multiple fractures of pelvis, repeated falls, disorders of bone density and structure, and protein-calorie malnutrition (2). On the most recent MDS (minimum data set), a 5-day assessment with an ARD (assessment reference date) of 9/19/24, the resident was assessed as having one fall with fracture in the past month. The nursing progress notes documented in part, - 08/28/2024 08:23 pm (Recorded as Late Entry on 09/02/2024 08:33 pm). Resident was noted on the bathroom floor at the last round of the shift. Writer was noted called in by the aide and assessed and was noted with no visible injuries and no skin tears or bruises. Resident was placed in her w/c (wheelchair) and assisted back to bed. No pain on transfer to w/c or in bed. Fall event to follow. - 08/29/2024 07:22 am Resident continues skilled services r/t (related to) multiple left pelvic fractures, muscle weakness. Resident is alert and oriented to self only. Denies any pain or discomfort .No s/s (signs or symptoms) of distress . - 08/29/2024 03:22 pm .No s/s of discomfort/distress noted. Will continue to monitor. - 08/30/2024 03:55 am .Denies any pain or discomfort .Bed kept in lowest position for safety. Resting in bed @ this time. No s/s of distress . - 08/30/2024 03:56 pm .ambulates by wheelchair .resident is watching television in day room, no c/o (complaints of) pain/discomfort noted at this time, will continue to monitor per my shift. - 08/30/2024 08:26 pm N.O.S (new orders) received from MD for x-ray of pelvis r/t f/u (follow up) pelvis fx (fracture) and check urinalysis w/ reflex to cx (culture). RP (responsible party) [Name of RP] notified. - 08/31/2024 03:19 am Resident medicated @ the end of previous shift w/ prn (as needed) Oxycodone/acetaminophen r/t c/o (complaints of) back/pelvic pain, has been effective .No s/s of distress . - 08/31/2024 01:49 pm .No s/s of discomfort/distress noted. Will continue to monitor. N/O for pelvic x-ray submitted, but not completed, so far. - 09/01/2024 02:41 am (Recorded as late entry on 09/24/2024 11:42 am) .No s/s of discomfort/distress noted. Will continue to monitor. - 09/01/2024 11:26 am F/U with [Name of imaging] about x-ray and was informed that they're supposed to be here sometime today. - 09/02/2024 09:53 am Resident being sent to [Name of hospital], per MD, for a R femur fx, per x-ray. She will be picked up by non-emergency transportation about 11:30. RP aware, Resident was given a PRN Oxycodone/Acetaminophen for pain before being picked up. - 09/06/2024 04:00 pm Resident is a re-admit from [Name of hospital] via stretcher .admitted for skilled services r/t surgical aftercare for rt femur hemiarthroplasty, multiple pelvic fractures, muscle weakness . The physician progress note dated 8/30/24 documented in part, .A [Age and sex of R8] who was admitted to the hospital from 8/10 until 8/15 with multiple fractures .As per physical therapist she has been having increased weakness and has been complaining of more pain and not participating much with therapy. Not much meaningful history available form the patient at this time .Physical Exam: .Moving all 4 extremities . Assessment and Plan: Generalized weakness, multiple falls. Continue with PT/OT (physical and occupational therapy). Family is planning to put her and [sic] memory care here after her skilled stay. At this time, she has increased pain, weakness, planning on repeat x-rays and a UA. Multiple fractures of the pelvis, found to have acute left superior and inferior pubic rami and left sacral fractures with diffuse osteopenia (3). Non-operative management per orthopedics, weightbearing as tolerated. Continue on Percocet 5/325 Q4 (every four hours) for pain, Pain worse for the last couple of days, we will repeat x-ray of the pelvis. Altered mental status, now improved, likely delirium. Osteopenia, seen on CT scan. I suspect she has osteoporosis (4) since she has a fragility fracture. Now on calcium and Vitamin D, discussed about starting bisphosphonates with her daughter, and at this time we have decided against it . The physician progress note dated 9/2/2024 documented in part, .Assessment and Plans: Right femoral neck fracture, she was complaining of increased pain while being transferred. She was also had [sic] some altered mental status, we repeated the x-ray of her pelvis, and it showed a deformed right femoral fracture which was age indeterminate. Reviewing her hospital records her right femoral x-ray was normal in the hospital, so this is likely a new fracture. We will send her to the ER for further evaluation and an ortho consult for possible surgery . The radiology report for R8 with an exam date of 09/01/2024 documented an impression of 1. Prominently deformed subcapital fracture of undetermined age right femur. 2. Moderate osteopenia. 3. Otherwise, negative pelvis exam. The comprehensive care plan for R8 documented in part, Problem Start Date: 08/22/2024. Category: Falls. I am at risk for falls due to impaired mobility, weakness and unsteady gait, opioid med use. Edited: 09/12/2024. The fall risk assessment for R8 dated 8/16/24 documented the resident being at risk for falls. On 12/6/24 at approximately 9:55 a.m., ASM (administrative staff member) #1, the administrator stated that the nurse who documented the late entry for the fall on 8/28/24, the nurse who sent R8 out to the hospital on 9/2/24 and the physician who examined R8 on 8/30/24 and 9/2/24 no longer worked at the facility and could not be interviewed. On 12/5/24 at 10:45 a.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated that they were able to see in the computer when a resident was a high fall risk, and the nurse told them in report also. CNA #1 stated that if a resident fell, they called the nurse to come assess the resident for injuries before getting them up and back in the chair or bed. On 12/6/24 at 9:26 a.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that when a resident had a fall, they assessed the resident for injuries, sent them to the hospital if needed, notified the physician and responsible party and documented the fall in the computer. LPN #2 stated if the fall was unwitnessed that neurochecks should be done in case the resident hit their head to assess for change in condition. On 2/6/24 at 10:32 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that R8's fall was discovered during her investigation of the fracture. She stated that R8 was admitted to the facility with existing pelvic fractures and a history of falls and was a fall risk. She stated that when the x-ray came back showing the femur fracture, she started an investigation because it was a potential injury of unknown origin but when interviewing the nursing staff who worked with R8, one of the nurses told her that R8 had the fall in the bathroom. She stated that the CNA had confirmed the fall, and the nurse had entered the progress note as a late entry. She stated that they had not completed a fall investigation because they were not aware of the fall until R8 was sent to the ER. She stated that R8 had not complained of any pain until 8/30/24 when the physical therapist reported it, and she was seen by the physician who ordered the x-rays. She stated that R8 was unable to tell them what happened, and she had educated staff on notifying the physician if the x-ray was not done in a timely manner. She stated that the x-ray was not ordered stat and was done within 24 hours which was the expectation, but the staff should have called the physician to see if they wanted the resident sent out for the x-ray prior. She stated that she had suspended the nurse for not reporting the fall and they were terminated the next day. She stated that she had educated most of the nursing staff but not all of them and had not done a formal plan of correction. She stated that the process the nurse should have followed was to immediately check vital signs, neurological checks, check for any injuries, call 911 if needed, notify the physician and RP, document the event in the medical record and update the care plan. She stated that this was not done for R8 and if it had been done it would have triggered the post fall observations and other assessments. She stated that R8 was still getting out of bed and participating with physical therapy. She stated that R8's pain was assessed and addressed by the physician when they first complained of it. The facility policy, Post Fall Evaluation and Intervention revised 6/11/21 documented in part, The nursing staff will evaluate falls by assessing causation and potential contributing factors and implementing appropriate interventions to prevent reoccurrence as part of quality assurance of the facility . A post fall assessment in the electronic record is to be completed after each fall in its entirety . On 12/6/24 at approximately 12:18 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the assistant administrator were made aware of the above concern. No further information was provided prior to exit. Reference: (1) femur fracture You had a fracture (break) in the femur in your leg. It is also called the thigh bone. You may have needed surgery to repair the bone. You may have had surgery called an open reduction internal fixation. In this surgery, your surgeon will make a cut to open your fracture. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000166.htm. (2) malnutrition Food provides the energy and nutrients you need to be healthy. If you don't get enough nutrients -- including proteins, carbohydrates, fats, vitamins, and minerals - you may suffer from malnutrition. This information was obtained from the website: https://medlineplus.gov/malnutrition.html (3) osteopenia is a condition that begins as you lose bone mass and your bones get weaker. This happens when the inside of your bones become brittle from a loss of calcium. It ' s very common as you age. This information was obtained from the website: https://familydoctor.org/condition/osteopenia/?adfree=true (4) osteoporosis is a disease in which your bones become weak and are likely to fracture (break). The disease can develop when your bone mineral density and bone mass decrease. It can also happen if the structure and strength of your bones change. Osteoporosis is called a silent disease because it doesn't usually cause symptoms. You may not even know you have the disease until you break a bone. This could happen with any bone, but it's most common in the bones of your hip, vertebrae in the spine, and wrist. This information was obtained from the website: https://medlineplus.gov/osteoporosis.html

Based on staff interview, facility document review and clinical record review, it was determined that the facility failed to implement their abuse policy for investigating and reporting an allegation of abuse when reported to the facility staff for one of eight residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to implement their abuse policy to investigate and report an allegation of abuse that was reported to the executive director via email on 9/22/2023. The facility policy Right to Dignity Freedom from Abuse Neglect and Exploitation revised 2/13/2023 documented in part, . The Administrator or designee will immediately make an oral or written report of the allegation or of the first suspicion of abuse to the local social services department, to the adult protective services unit and to other agencies in accordance with established procedures. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident's property, are reported immediately, but not later than 2 hours after allegation is made if the events that cause the allegation involve abuse or results in serious bodily injury; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The Administrator will report the results of the investigation within five (5) working days of the first report of the incident . The Administrator or Assistant Administrator is responsible for the coordination of a timely and thorough internal investigation. The investigation will include, but is not limited to, a physical assessment of the resident; resident, staff and witness interviews, reportable incident form and chart reviews as necessary, and/or psychosocial assessment if warranted. Adult Protective Services, the local Ombudsman, and/or police department will be contacted to assist in the investigation as appropriate. The Administrator or designee will complete an investigative report summarizing the internal investigation. The investigative report will include the individuals involved; a description of the occurrence including date, location and description of the incident; injury to the resident, immediate corrective action taken, mechanisms in place to prevent recurrence and documentation of report to appropriate agencies. If needed, the Administrator or designee will submit this investigative report to the Office of License and Certification within 5 working days of the initial report . R1 no longer resided at the facility and could not be observed or interviewed during the survey dates. The record was reviewed as a closed record. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/25/2023, the resident scored 12 out of 15 on the BIMS (brief interview for mental status) assessment, which indicated the resident was moderately impaired for making daily decisions. Review of the facility synopsis of events from 4/1/2023 through the present failed to evidence any events for R1. Review of R1's clinical record failed to evidence documentation of allegations of abuse by R1 or R1's family. On 9/27/2023 at 11:40 a.m., an interview was conducted with ASM (administrative staff member) #1, the executive director. ASM #1 stated that they had several meetings with R1's son to discuss their care and concerns when they were at the facility. He stated that R1's son had discussed concerns regarding obtaining medical records, having to pay a fee for the records, call bell response, R1's medications, the resident's room not being clean, the attitudes of some of the CNA's (certified nursing assistants) and the end of skilled services at the facility. When asked if he received any email correspondence from R1's son regarding concerns, he stated that he had not received any directly from the son but had received an email from (Name of Senator's) office on 9/22/2023 which had concerns that R1 was being discharged for retaliation purposes. He stated that he did not go through the email completely because the parts that he saw were saying that they were deceptive and covering up the truth. When asked about the allegation of being shaken after pushing the call bell on 9/15/2023, ASM #1 stated that he was not aware of any allegations of R1 being shaken by anyone and he did not believe that it took place in any way, shape or form but he would have reported the allegation if it were brought to his attention. On 9/27/2023 at 12:45 p.m., ASM #1 provided a printed copy of the email addressed to them dated 9/22/2023 1:01 p.m. which documented in part, . Attached is correspondence from (Name of R1's son) regarding his mother, (Name of R1), who was a resident at (Name of facility). We are forwarding this correspondence as a courtesy to the family . The attached documented in part, Statement of Problem. Patient/Resident: (Name of R1). I am writing to once again formally communicate my horror and concerns of multiple incidents of elder abuse, flagrant violations of Resident's rights (per the Code of Federal Regulation), and medical malpractice that my helpless (age and name of R1), has experienced while in the care of you and your staff at (Name of facility) . b. When staff did respond to her (in the absence of advocates), they spoke to her in a threatening and aggressive manner saying disrespectful things to her like: What to you want now? or What is it now?. This was obviously done to intimidate her and make her feel scared to push the call button . e. My mom told me of one incident on 9/15/23 where she said: A lady grabbed me and shook me one evening after I pushed the call. That is clear criminal assault . 6. Physical assault from caregivers. She told me that a lady grabbed me and shook me after I pushed the call button for help. Unexplained cuts, bruises, and injuries . On 9/27/2023 at 1:20 p.m., ASM #1, the executive director was made aware of the findings. ASM #1 stated that they did not send a report because the resident was already discharged from the facility when they received the email and they did not read it completely. He stated that they had met with the son and the long term care ombudsman on the day of discharge and no one had reported any allegations of abuse to them at that time and they would have reported it if they had. No further information was provided prior to exit. As of 10/2/2023, the State Agency had not received notification from the facility staff of the allegation of abuse.

Based on staff interview, facility document review and clinical record review, it was determined that the facility failed to report an allegation of abuse to the State Agency for one of eight residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to report an allegation of abuse to the State Agency that had been reported to the executive director via email on 9/22/2023. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/25/2023, the resident scored 12 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. R1 no longer resided at the facility and could not be observed during the survey dates. The record was reviewed as a closed record. Review of the facility synopsis of events from 4/1/2023 through the present failed to evidence any events for R1. Review of R1's clinical record failed to evidence documentation of allegations of abuse by R1 or R1's family. On 9/27/2023 at 11:40 a.m., an interview was conducted with ASM (administrative staff member) #1, the executive director. ASM #1 stated that they had several meetings with R1's son to discuss their care and concerns when they were at the facility. He stated that R1's son had discussed concerns regarding obtaining medical records, having to pay a fee for the records, call bell response, R1's medications, the resident's room not being clean, the attitudes of some of the CNA's (certified nursing assistants) and the end of skilled services at the facility. When asked if he received any email correspondence from R1's son regarding concerns, he stated that he had not received any directly from the son but had received an email from (Name of Senator's) office on 9/22/2023 which had concerns that R1 was being discharged for retaliation purposes. He stated that he did not go through the email completely because the parts that he saw were saying that they were deceptive and covering up the truth. When asked about the allegation of being shaken after pushing the call bell on 9/15/2023, ASM #1 stated that he was not aware of any allegations of R1 being shaken by anyone and he did not believe that it took place in any way, shape or form but he would have reported the allegation if it were brought to his attention. On 9/27/2023 at 12:45 p.m., ASM #1 provided a printed copy of the email sent to them dated 9/22/2023 1:01 p.m. which documented in part, . Attached is correspondence from (Name of R1's son) regarding his mother, (Name of R1), who was a resident at (Name of facility). We are forwarding this correspondence as a courtesy to the family . The attached documented in part, Statement of Problem. Patient/Resident: (Name of R1). I am writing to once again formally communicate my horror and concerns of multiple incidents of elder abuse, flagrant violations of Resident's rights (per the Code of Federal Regulation), and medical malpractice that my helpless (age and name of R1), has experienced while in the care of you and your staff at (Name of facility) . b. When staff did respond to her (in the absence of advocates), they spoke to her in a threatening and aggressive manner saying disrespectful things to her like: What to you want now? or What is it now?. This was obviously done to intimidate her and make her feel scared to push the call button . e. My mom told me of one incident on 9/15/23 where she said: A lady grabbed me and shook me one evening after I pushed the call. That is clear criminal assault . 6. Physical assault from caregivers. She told me that a lady grabbed me and shook me after I pushed the call button for help. Unexplained cuts, bruises, and injuries . The facility policy Right to Dignity Freedom from Abuse Neglect and Exploitation revised 2/13/2023 documented in part, . The Administrator or designee will immediately make an oral or written report of the allegation or of the first suspicion of abuse to the local social services department, to the adult protective services unit and to other agencies in accordance with established procedures. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident's property, are reported immediately, but not later than 2 hours after allegation is made if the events that cause the allegation involve abuse or results in serious bodily injury; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The Administrator will report the results of the investigation within five (5) working days of the first report of the incident . On 9/27/2023 at 1:20 p.m., ASM #1, the executive director was made aware of the findings. ASM #1 stated that they did not send a report because the resident was already discharged from the facility when they received the email and they did not read it completely. He stated that they had met with the son and the long term care ombudsman on the day of discharge and no one had reported any allegations of abuse to them at that time and they would have reported it if they had. No further information was provided prior to exit. As of 10/2/2023, the State Agency had not received notification from the facility staff of the allegation of abuse.

Based on clinical record review, staff interview and facility document review, it was determined the facility staff failed to review and revise the care plan for one of eight residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to review and revise the comprehensive care plan to evidence resident-centered preferences for care. On the most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 8/25/2023, the resident scored 12 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section G documented R1 requiring extensive assistance of one person for dressing, bathing and personal hygiene and extensive assistance of two persons for toileting. The comprehensive care plan for R1 documented in part, Problem Start Date: 08/28/2023. Category: ADLs (activities of daily living) Functional Status/Rehabilitation Potential. I have alteration in ADL function due to weakness associated with multiple compression fx's (fractures). Risk factors include: impaired mobility, anxiety. Created: 08/28/2023. The care plan failed to evidence resident-centered choices regarding preference for no male caregivers due to religious choices. The dietary communication orders documented, Muslim diet. 8/21/2023. and No Pork. 9/2/2023. The progress notes for R1 documented in part, 09/06/2023 01:17 pm Care plan meeting was held on Friday, September 1, 2023, with son, (Name of son), (Name of the executive director), (Name of the assistant director of nursing), (Name of occupational therapist), director of rehab services, and this writer [social worker]. Resident did not attend. Concerns and facility routines were discussed with son . Review of the clinical record failed to evidence documentation of the resident's preference for no male caregivers due to religious choices. Review of the as worked schedules for nursing dated 8/21/2023-9/20/2023 documented female CNA (certified nursing assistant) staff assigned to care for R1 each shift. On 9/26/2023 at 3:46 p.m., an interview was conducted with CNA (certified nursing assistant) #2, scheduling coordinator. CNA #2 stated that R1 and their son had requested that only women provide care for them due to their religion. She stated that they did not have many male CNA's and that they communicated the request to the nurses verbally so that none were assigned to care for them. On 9/26/2023 at 4:36 p.m., an interview was conducted with RN (registered nurse) #1, MDS coordinator. RN #1 stated that the purpose of the care plan was to identify the resident needs and used to provide individualized care to the residents. She stated that the comprehensive care plan was completed by MDS and included the care areas that were triggered by the MDS assessment and the interdisciplinary team updated the care plan as needed. She stated that she would expect that R1's preference to have female caregivers be addressed on the care plan and would expect the care plan to address cultural perspectives. On 9/27/2023 at 11:18 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that they worked with R1 often. LPN #3 stated that they did not have any male CNA's working their shift so R1 only had female CNA's taking care of them. She stated that there was one shift when R1 was assigned a male nurse and the nursing supervisor had handled the situation accordingly. On 9/27/2023 at 11:25 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that the care plan was developed by the MDS staff and nursing could add to it as needed. She stated that R1 and R1's son had requested to only have female caregivers and they had accommodated the request by assigning only females. She stated that they would expect to see the preference to have only female caregivers addressed on the care plan. The facility policy, Comprehensive Person-Centered Care Planning revised 11/15/2017 documented in part, .All reasonable efforts will be made to incorporate the resident's personal and cultural preferences in developing goals of care . On 9/27/2023 at 1:20 p.m., ASM #1, the executive director, was made aware of the findings. No further information was obtained prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, it was determined that the physician failed to write, sign and date a progress note during a visit for one of eight residents in the survey sample; Resident #2. The findings include: Resident #2 was most recently admitted on [DATE] and discharged to home on 8/3/23. The resident had diagnoses of, but not limited to, high blood pressure and atrial fibrillation (a-fib). The resident was coded on the most recent MDS (Minimum Data Set), an admission assessment dated [DATE] coded the resident as being cognitively intact in ability to make daily life decisions, scoring a 13 out of a possible 15 on the BIMS (Brief Interview for Mental Status). A review of the clinical record revealed the resident was admitted on [DATE]. The hospital discharge orders included Metoprolol Tartrate 100 mg (milligrams) twice daily (1). admission orders to the facility dated 6/30/23 included Metoprolol Tartrate 100 mg, twice daily. A review of the clinical record revealed blood pressure readings were obtained from admission on [DATE] through 7/14/23. The lowest reading was on 6/30/2023 at 02:58 PM and was documented as 97/52. The highest reading was on 7/03/2023 at 01:31 AM and was documented as 133/70. On 7/14/23 the dose was changed and an order was written for Metoprolol Tartrate 25 mg once daily. A review of the clinical record failed to reveal any documentation by the physician regarding her assessment and rationale for lowering the dose of this medication. On 9/26/23 at 1:50 PM, an interview was conducted with ASM #3 (Administrative Staff Member), the physician. She stated that she reviewed the blood pressures and noted that they were trending low, so she talked to the resident, who was awake, alert and oriented, regarding the blood pressure trending low, and wanted to reduced the dose of Metoprolol. She stated that the resident was in agreement. She stated that even after lowering the dose, the resident's blood pressure remained under control and was still low at times but she did not want to lower the dose any further because the resident needed the medication for a-fib. She stated that she probably should have wrote a note about her assessment of the resident's blood pressures and clinical decision to lower the dose. On 9/27/23 at 11:37 AM, ASM #1 the Administrator was made aware of the findings. He stated that there was not a policy regarding physician requirements for documentation. No further information was provided by the end of the survey. Reference: (1) Metoprolol is used to treat high blood pressure, angina, and heart failure.) Information obtained from https://medlineplus.gov/druginfo/meds/a682864.html

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to assess one of 28 residents in the survey sample for self-administration of medication, Resident #41. The findings include: For Resident #41 (R41), two bottles of diabetic Tussin (1) liquid medication and two bottles of Systane (2) lubricant eye drops were observed at the bedside in R41's room unsecured. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 4/14/2023, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. On 5/2/2023 at 10:14 a.m., an observation of R41's room was conducted. Two bottles of diabetic Tussin liquid medication were observed on a corner shelf storage rack, one four ounce bottle was observed to be unopened and one 8 ounce bottle was observed to be approximately three-quarters full. Two bottles of Systane lubricant eye drops were observed on the window sill to the right of R41's bed. Both bottles contained liquid inside. At that time, an interview was conducted with R41. When asked about the Tussin liquid medication, R41 stated that their daughter had brought the medication in and they had not taken any recently. When asked about the Systane lubricant eye drops, R41 stated that one bottle was given to them by the facility staff and they had purchased the other bottle. R41 stated that they put one drop in both eyes daily and it was effective. Additional observations of R41's room at 5/2/2023 at 2:00 p.m. revealed the two bottles of Tussin liquid medication on the corner shelf storage rack and two bottles of Systane lubricant eye drops on the window sill in the room. The physician orders for R41 failed to evidence an order for Systane lubricant eye drops or diabetic Tussin liquid medication or self-administration of medications. Review of R41's clinical record failed to evidence an assessment for self-administration of medications. On 5/2/2023 at approximately 2:00 p.m., a request was made to ASM (administrative staff member) #1, the executive director for evidence of a self-administration of medication assessment for R41 and the facility policy for self-administration of medications. On 5/2/2023 at 2:15 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that when a resident wanted to self-administer medications they notified the physician and completed an assessment to determine whether the resident was able to self-administer their medication. LPN #1 stated that they were required to observe the resident self-administering their medication to make sure they were able to perform the task and then they would put in an order for the medications that could be self-administered and left at the bedside. LPN #1 observed the two bottles of Tussin liquid medication and two bottles of Systane lubricant eye drops in R41's room and stated that they did not know if R41 was able to self-administer the medication or how it was to be stored in the room. LPN #1 stated that they typically do not lock medications up when residents self-administer medications and they thought that it would depend on the medication. LPN #1 stated that they would have to confirm with the director of nursing. On 5/2/2023 at approximately 4:00 p.m., ASM #2, the director of nursing stated that R41 did not have a medication self-administration assessment. ASM #2 stated that R41 should not have any medications in their room and they were not able to self-administer their medications. ASM #2 stated that they had residents who self-administered medications and some stored the medications in drawers and some kept them beside them. ASM #2 stated that the storage depended on the medication. On 5/2/2023 at approximately 4:03 p.m., ASM #1, the executive director stated that they did not have a policy regarding self-administration of medications. On 5/2/2023 at approximately 4:05 p.m., ASM #1, the executive director, ASM #2, the director of nursing and ASM #3, the assistant administrator were made aware of the concern. No further information was presented prior to exit. The facility policy, Medical Care Rights in Nursing Facility dated 12/31/2016 documented in part, .Each Resident has the right to self-administer medications. The interdisciplinary team will determined for each Resident that this practice is clinically appropriate. Such determinations will be documented in the Resident's plan of care . Reference: (1) Tussin Guaifenesin is used to relieve chest congestion. Guaifenesin may help control symptoms but does not treat the cause of symptoms or speed recovery. Guaifenesin is in a class of medications called expectorants. It works by thinning the mucus in the air passages to make it easier to cough up the mucus and clear the airways. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682494.html (2) Systane Systane is used in adults to relieve burning, irritation, and discomfort caused by dry eyes. This information was obtained from the webstie: https://www.drugs.com/mtm/systane.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, it was determined that the facility failed to promote and facilitate the resident's right to self-determination by promoting resident's choice in desired bedtime for one of 28 residents in the survey sample, Resident #23. The findings included: For Resident #23, the facility staff failed to promote the resident's desired bedtime. Resident #23 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: right lower leg fracture, DM (diabetes mellitus) and depression. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 3/20/23, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring limited assistance for bed mobility, transfer, walking, locomotion, dressing, eating, hygiene and bathing. A review of the comprehensive care plan dated 1/3/22, which revealed, PROBLEM: ADLs (activities of daily living) Functional Status/Rehabilitation Potential. Resident has alteration in ADL function due to weakness associated with right tibia/fibula fracture. Risk factors include impaired mobility, muscle weakness and NWB (non-weight bearing) status. APPROACH: Allow me choices regarding my preference with where I would like to eat, picking out clothing, taking baths/showers and how I would like to accept my medications. Assist with turning and repositioning on rounds and as needed. A review of the ADL form dated 4/30/23 at 7:00 PM, revealed, How did resident transfer? Activity did not occur. No other documentation on the ADL form for evening shift on 4/30/23. An interview was conducted with Resident #23 on 5/1/23 at 11:01 AM. Resident #23 stated, It took almost three hours for me to be able to get in bed on April 30th. I started calling every 15 minutes beginning at 9:00 PM till close to 12:00 AM when the night aide put me to bed. The evening aide would come into the room and shut off the light and tell me she would be back and never returned. Resident #23 was asked to push the call button which revealed it was functioning, and a nurse answered. When asked how the call system functioned, LPN (licensed practical nurse) #1 stated, the call bells go to the call bell phone that the CNAs (certified nursing assistant) carry. An interview was conducted on 5/1/23 at 2:45 PM with ASM (administrative staff member) #2, the director of nursing. When asked if she had been informed of the delay in getting Resident #23 into bed on evening shift 4/30/23, ASM #2 stated, yes, the executive director spoke with the daughter. This was an agency CNA and there will not be any agency CNAs assigned to Resident #23. An interview was conducted on 5/2/23 at 8:50 AM with Resident #23, when asked how their evening went, Resident #23 stated, It was great, they put me to bed when I wanted to go. On 5/2/23 at approximately 4:00 PM, ASM #1, the executive director, ASM #2, the director of nursing and ASM #3, the assistant administrator was made aware of the findings. On 5/3/23 at 9:15 AM, ASM #2, the director of nursing stated, in regard to the CNA with this resident, I have tried to contact her and she has not called me back, I called her agency and she still has not responded. Since she cannot be bothered to return my calls, she will not be back. According to the facility's policy Medical Care Rights in a Nursing Facility dated 12/2016, revealed, The Resident has the right to be fully informed in language that he or she can understand of his/her total health status, including but not limited to, his/her medical condition. The Resident has the right to refuse treatment and to refuse to participate in experimental research, and also the right to request treatment and/or discontinue treatment. Moreover, the Resident has the right to: Choose a personal attending physician; Be fully informed in advance about care and treatment, type of professional delivering care, risks and benefits of treatment and options, and of any changes in that care of treatment that may affect the Resident's well-being, and; insofar as possible, the Facility will assist Residents to use their preferred health care providers and to participate in planning their programs of care and services while in the Facility, and will respect each Resident's decision about accepting or refusing medical care. No further information was provided prior to exit.

Based on staff interview and clinical record review, it was determined that the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 28 residents in the survey sample, Resident #29. The findings include: For Resident #29 (R29), the facility staff failed to code the quarterly MDS assessment with an ARD (assessment reference date) of 2/27/2023 for hospice services received during the assessment period. Review of the clinical record for R29 revealed the most recent MDS assessment to be a quarterly MDS with an ARD of 2/27/2023. Section O of the assessment failed to document R29 receiving hospice services during the assessment period. The physician orders for R29 documented in part, Admit to [Name of hospice] for Alzheimer's disease. Order Date: 11/24/2022. The comprehensive care plan for R29 failed to evidence a care plan related to hospice services. On 5/2/2023 at 1:45 p.m., an interview was conducted with RN (registered nurse) #2, MDS coordinator. RN #2 stated that they used the RAI (resident assessment instrument) manual when completing the MDS assessments. RN #2 reviewed R29's quarterly MDS assessment with the ARD of 2/27/2023 and stated that it looked like it was not coded for hospice services. RN #2 stated that R29 was receiving hospice services during the assessment period and that it should have been marked on the assessment. According to the RAI Manual, Version 1.16, dated October 2018, section O0100 documented in the steps for assessment, 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the last 14 days .O0100K, Hospice Care, Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider . On 5/2/2023 at 4:03 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the assistant administrator were made aware of the concern. No further information was provided prior to exit.

Based on staff interview and clinical record review, it was determined that the facility staff failed to develop the comprehensive care plan for one of 28 residents in the survey sample, Resident #29. The findings include: For Resident #29 (R29), the facility staff failed to develop the comprehensive care plan to include hospice services. Review of the clinical record for R29 revealed the most recent MDS assessment to be a quarterly MDS with an ARD of 2/27/2023. Section O of the assessment failed to document R29 receiving hospice services during the assessment period. The physician orders for R29 documented in part, Admit to [Name of hospice] for Alzheimer's disease. Order Date: 11/24/2022. Review of the comprehensive care plan for R29 failed to evidence a care plan related to hospice services. The progress notes for R29 documented in part, 2/13/2023 3:21 p.m. Resident currently on hospice, denies pain or discomfort at this time. Will continue to monitor and treat per provider orders. The progress notes further documented, 2/27/2023 10:45 a.m. MDS Quarterly - (Name of R29) is a LTC (long term care) resident receiving hospice care for Alzheimer's dementia . On 5/2/2023 at 1:45 p.m., an interview was conducted with RN (registered nurse) #2, MDS coordinator. RN #2 stated that they completed the comprehensive care plans for residents and updated them quarterly. RN #2 stated that the care plans were updated based on the MDS schedule based on the reviews and the areas that triggered from the assessment. RN #2 reviewed R29's comprehensive care plan and stated that they did not have a care plan for hospice and there should be one in place. On 5/2/2023 at 2:15 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the purpose of the care plan was to let the staff know what care the resident needed. LPN #1 stated that hospice services should be addressed on the residents care plan. On 5/2/2023 at 4:03 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the assistant administrator were made aware of the concern. No further information was provided prior to exit. The facility policy, Comprehensive Person-Centered Care Planning dated 11/15/2017 documented in part, .Each resident's comprehensive care plan will describe the following: Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychological well-being .

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to secure medications in resident rooms for two of 28 residents in the survey sample, Resident #41 and Resident #35. The findings include: 1. For Resident #41 (R41), the facility staff failed to secure two bottles of diabetic Tussin (1) liquid medication and two bottles of Systane (2) lubricant eye drops were observed at the bedside in R41's room unsecured. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 4/14/2023, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. On 5/2/2023 at 10:14 a.m., an observation of R41's room was conducted. Two bottles of diabetic Tussin liquid medication were observed on a corner shelf storage rack, one four ounce bottle was observed to be unopened and one 8 ounce bottle was observed to be approximately three-quarters full. Two bottles of Systane lubricant eye drops were observed on the window sill to the right of R41's bed. Both bottles contained liquid inside. At that time, an interview was conducted with R41. When asked about the Tussin liquid medication, R41 stated that their daughter had brought the medication in and they had not taken any recently. When asked about the Systane lubricant eye drops, R41 stated that one bottle was given to them by the facility staff and they had purchased the other bottle. R41 stated that they put one drop in both eyes daily they were effective. Additional observations of R41's room at 5/2/2023 at 2:00 p.m. revealed the two bottles of Tussin liquid medication on the corner shelf storage rack and two bottles of Systane lubricant eye drops on the window sill in the room. The physician orders for R41 failed to evidence an order for Systane lubricant eye drops or diabetic Tussin liquid medication or self-administration of medications. On 5/2/2023 at 2:15 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that they were required to observe the resident self-administering their medication to make sure they were able to perform the task and then they would put in an order for the medications that could be self-administered and left at the bedside. LPN #1 observed the two bottles of Tussin liquid medication and two bottles of Systane lubricant eye drops in R41's room and stated that they did not know if R41 was able to self-administer the medication or how it was to be stored in the room. LPN #1 stated that they typically do not lock medications up when residents self-administer medications and they thought that it would depend on the medication. LPN #1 stated that they would have to confirm with the director of nursing. On 5/2/2023 at approximately 4:00 p.m., ASM (administrative staff member) #2, the director of nursing stated that R41 did not have a medication self-administration assessment. ASM #2 stated that R41 should not have any medications in their room and they were not able to self-administer their medications. ASM #2 stated that they had residents who self-administered medications and some stored the medications in drawers and some kept them beside them. ASM #2 stated that the storage depended on the medication. On 5/2/2023 at approximately 4:05 p.m., ASM #1, the executive director, ASM #2, the director of nursing and ASM #3, the assistant administrator were made aware of the concern. No further information was presented prior to exit. The facility policy, Storage and Expiration of Medications, Biologicals, Syringes and Needles dated 12/01/07 documented in part, .13. Bedside Medication Storage: 13.1 Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration. 13.2 Facility should store bedside medications or biologicals in a locked compartment within the resident's room . Reference: (1) Tussin Guaifenesin is used to relieve chest congestion. Guaifenesin may help control symptoms but does not treat the cause of symptoms or speed recovery. Guaifenesin is in a class of medications called expectorants. It works by thinning the mucus in the air passages to make it easier to cough up the mucus and clear the airways. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682494.html (2) Systane Systane is used in adults to relieve burning, irritation, and discomfort caused by dry eyes. This information was obtained from the webstie: https://www.drugs.com/mtm/systane.html 2. For Resident #35 (R35), the facility staff failed to secure an Albuterol inhaler (1) that was observed at the bedside in R35's room. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/28/2023, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 5/1/2023 at 11:50 a.m., an observation of R35's room was conducted. An Albuterol inhaler was observed on R35's nightstand to the left of the bed, unsecured. A spacer (2) was observed to be attached to the inhaler. At that time, an interview was conducted with R35. When asked about the Albuterol inhaler, R35 stated that they kept the inhaler at their bedside to use when they had coughing spells and used it as needed. R35 stated that it had been a couple of days since they had used the inhaler. Additional observations of R35's room at 5/1/2023 at 2:10 p.m. and 5/2/2023 at 10:30 a.m., revealed the Albuterol inhaler on the nightstand to the left of the bed unsecured. The physician orders for R35 documented in part, albuterol sulfate HFA aerosol inhaler; 90 mcg (micrograms)/actuation; amt (amount): 2 puffs; inhalation; Every 6 Hours - PRN (as needed); dx: wheezing/sob (shortness of breath) *NEEDS HELP TO self administer and keep @ bedside*; Order Date: 03/23/2023 . The Self-Administration of Medication assessment for R35 dated 9/28/2022 documented in part, .List of medications resident would like to self-administer. Albuterol inhaler .Based on answers, is it appropriate for resident to self-administer any medications? Yes .Where will self-administered medications be stored? Resident Room . On 5/2/2023 at 2:15 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that R35 was able to self-administer the Albuterol inhaler and kept it at their bedside in the room. LPN #1 stated that they typically do not lock medications up when residents self-administer them and they thought that it would depend on the medication. LPN #1 stated that they would have to confirm with the director of nursing. On 5/2/2023 at approximately 4:00 p.m., ASM (administrative staff member) #2, the director of nursing stated that they had residents who self-administered medications and some stored the medications in drawers and some kept them beside them. ASM #2 stated that the storage depended on the medication. On 5/2/2023 at approximately 4:05 p.m., ASM #1, the executive director, ASM #2, the director of nursing and ASM #3, the assistant administrator were made aware of the concern. No further information was presented prior to exit. Reference: (1) Albuterol is used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases such as asthma and chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682145.html (2) If you use your inhaler the wrong way, less medicine gets to your lungs. A spacer device will help. The spacer connects to the mouthpiece. The inhaled medicine goes into the spacer tube first. Then you take two deep breaths to get the medicine into your lungs. Using a spacer wastes a lot less medicine than spraying the medicine into your mouth. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000042.htm

Based on observation, resident interview, clinical record review, facility document review and staff interview, it was determined facility staff failed to review the comprehensive care plan for one of 32 residents in the survey sample, Resident #28. On 11/14/21 Resident #28 sustained a fall. The residents comprehensive care plan was not reviewed or revised to address the residents 11/14/21 fall. The findings include: Resident #28 was admitted to the facility with diagnoses that included but were not limited to atrial fibrillation (1), pneumonia (2), and chronic respiratory failure with hypoxia (3). Resident #28's most recent MDS (minimum data set), a 5-day assessment with an ARD (assessment reference date) of 12/03/2021, coded Resident #28 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making daily decisions. Section J of the assessment documented Resident #28 having a fall in the month prior to entry and no falls since admission/entry or reentry. On 12/7/2021 at approximately 11:30 a.m., an observation was made of Resident #28 in their room. At that time an interview was conducted with Resident #28. Resident #28 stated that they had one recent fall but did not remember the exact date. Resident #28 stated that they were not injured and had not fallen since then. The progress notes for Resident #28 documented in part, - 11/14/2021 12:38 AM 3-11 (3:00 p.m.-11:00 p.m.) Resident skilled service for/t [sic] A-fib (atrial fibrillation) with RVR (rapid ventricular response), fall. Resident A & O x3 (alert and oriented to person, place and time) and able to make needs known. 1 (one) person assist with adl's (activities of daily living) and transfers. Continent of bowel and bladder. No c/o (complaints of) pain or s/s (signs or symptoms) of resp. (respiratory) distress. Resident in bed resting, call bell in reach. Will continue to monitor. The clinical record documented a fall assessment risk tool completed on 10/19/2021 and 11/29/2021 which assessed Resident #28 being a high fall risk. The comprehensive care plan for Resident #28 documented in part, Problem Start Date: 10/25/2021 Category: Falls I am at risk for falls due to recent syncope (4), muscle weakness, unsteady gait, hx (history) of falls, and use of cardiac and opiod medications. Under Goal it documented, .I will have no falls within this review period. Created 10/25/2021. The care plan failed to evidence documentation of a review completed after the fall documented on 11/14/2021. On 12/7/2021 at approximately 3:18 p.m., a request was made via written list to ASM (administrative staff member) #1, the executive director for the fall investigation for Resident #28 and the care plan addressing falls. The fall investigation for Resident #28 documented in part, Date: 11/14/2021; Time 06:40 PM; Shift 3-11 .Location Residents room; This resident lost her balance while transferring, wittnessed [sic] by staff member. Will continue to have her work with therapy for strenghtening [sic] and transfers; Event Type Fall; Actions Taken Fall Evaluation, if applicable (NF-96), Physician Notified, Responsible Party Notified, Vital signs taken and charted. The document failed to evidence a review of the comprehensive care plan for Resident #28. On 12/8/2021 at 1:55 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the MDS coordinator and the director of nursing reviewed and revised the care plans. LPN #1 stated that the purpose of the care plan was to guide them how to care for the resident. LPN #1 stated that a fall would warrant a review of the care plan to make sure they had all of the appropriate interventions in place to prevent another fall. On 12/8/2021 at 2:15 p.m., an interview was conducted with RN (registered nurse) #2, MDS coordinator. RN #2 stated that they completed the MDS assessment and revised the care plan in relation to items triggered on the assessment. RN #2 stated that the care plan should be updated after a fall and would have been updated by the nurse caring for the resident at the time. RN #2 stated that the purpose of the care plan was to direct patient centered care. RN #2 reviewed the fall care plan for Resident #28 provided by the facility and stated that there was no review after the fall on 11/14/2021. On 12/9/2021 at approximately 8:30 a.m., a request was made to ASM #1 for the facility policy regarding reviewing the care plan. The facility policy, Comprehensive Person-Centered Care Planning dated revised 11/15/2017 documented in part, .The Care Planning/Interdisciplinary Team are responsible for the review and updating of the care plans: When requested by the resident/resident representative; When there has been a significant change in the resident's condition; When the desired outcome is not met . On 12/8/2021 at approximately 4:15 p.m., ASM #1, the executive director was made aware of the findings. No further information was provided prior to exit. References: 1. Atrial fibrillation A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: <https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html>. 2. Pneumonia An infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia. You can also get pneumonia by inhaling a liquid or chemical. This information was obtained from the website: <https://medlineplus.gov/pneumonia.html> 3. Chronic respiratory failure When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. 4. Syncope Fainting. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/003092.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, clinical record review, facility document review and staff interview, it was determined facility staff failed to store respiratory equipment in a sanitary manner for two of 32 residents in the survey sample, Resident #28 and Resident #62. The facility staff failed to store nebulizer equipment in a sanitary manner for Resident #28 and failed to store an incentive spirometer in a sanitary manner for Resident #62. The findings include: 1. The facility staff failed to store nebulizer (1) equipment in a sanitary manner for Resident #28. Resident #28 was admitted to the facility with diagnoses that included but were not limited to congestive heart failure (2) and chronic respiratory failure with hypoxia (3). Resident #28's most recent MDS (minimum data set), a 5-day assessment with an ARD (assessment reference date) of 12/03/2021, coded Resident #28 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making daily decisions. On 12/7/2021 at approximately 11:30 a.m., an observation was made of Resident #28 in their room. A nebulizer machine was observed on the dresser in Resident #28's room, with a mask and medication delivery cup attached to tubing lying on the dresser surface draped across the nebulizer machine. At that time an interview was conducted with Resident #28. Resident #28 stated that the nurses administered medication in the nebulizer for breathing. Additional observations of Resident #28's room on 12/7/2021 at 1:32 p.m. and 12/7/2021 at 3:41 p.m. revealed the nebulizer mask and medication delivery cup attached to tubing lying on the dresser surface draped across the nebulizer machine. On 12/8/2021 at 8:45 a.m., observation revealed the nebulizer mask and medication delivery cup inside of a plastic bag on the dresser. The physician orders for Resident #28 documented, 12/06/2021 Albuterol Sulfate solution for nebulization 2.5 mg (milligram)/3 ml (milliliter) 0.083% every 4 (four) hours- prn (as needed) . The eMAR (electronic medication administration record) dated 12/1/2021-12/8/2021 documented Resident #28 received Albuterol Sulfate solution by nebulizer on 12/3/2021 at 5:00 p.m., 12/4/2021 and 12/5/2021 at 9:00 a.m. and 5:00 p.m., and 12/6/2021 at 9:00 a.m. The comprehensive care plan for Resident #28 documented in part, Problem: Risk for respiratory distress due to: anemia, CHF (congestive heart failure), HTN (hypertension), allergic rhinitis, refuses medications, Pneumonia. Start Date: 10/25/2021. Last Reviewed/Revised 11/30/2021 08:50 AM. On 12/8/2021 at 1:55 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that nebulizers were cleaned after use and stored in plastic bags with the residents name and the date on them. LPN #1 stated that they were stored this way to prevent dust from getting on them. LPN #1 stated that they checked them periodically to ensure they were stored properly and the bags were changed. When LPN #1 was made aware of the observations of Resident #28's nebulizer on 11/7/2021 at 11:30 a.m., 1:32 p.m. and 3:41 p.m., LPN #1stated that they were not sure when the bag was placed in the room but it [nebulizer mask and tubing] should have been stored in the bag when not in use. On 12/8/2021 at 9:40 a.m., ASM (administrative staff member) #1, the executive director provided a written document stating that the facility followed [NAME] as a standard of practice. On 12/9/2021 at approximately 8:30 a.m., a request was made to ASM #1 for the facility policy regarding reviewing storage of nebulizer equipment. On 12/9/2021 at 8:40 a.m., ASM #1 stated that they did not have a policy regarding storage of nebulizers or incentive spirometers. According to The Lippincott Manual of Nursing Practice 10th Edition, 2014, page 236, Procedure Guidelines 10-11 documented in part, Follow-up phase 1. Record medication used and description of secretions. 2. Disassemble and clean nebulizer after each use. Keep this equipment in the patient's room. The equipment is changed according to facility policy. Each patient has own breathing circuit (nebulizer, tubing and mouthpiece). Through proper cleaning, sterilization, and storage of equipment, organisms can be prevented from entering the lungs. On 12/8/2021 at approximately 4:15 p.m., ASM #1, the executive director was made aware of the findings. No further information was provided prior to exit. References: 1. Nebulizer - a device used to aerosolize medications for delivery to patients. Taken from Encyclopedia & Dictionary of Medicine, Nursing & Allied Health -Seventh Edition, [NAME]-[NAME], page 1182. 2. Congestive heart failure A condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. This information was obtained from the website: https://medlineplus.gov/heartfailure.html 3. Respiratory failure When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. 2. The facility staff failed to store an incentive spirometer (1) in a sanitary manner for Resident #62. Resident #62 was admitted to the facility with diagnoses that included but were not limited to diabetes (2) and hypertension. Resident #62's most recent MDS (minimum data set), a 5-day assessment with an ARD (assessment reference date) of 11/27/2021, coded Resident #62 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Section O coded Resident #62 as receiving respiratory therapy during the assessment period. On 12/7/2021 at approximately 12:25 p.m., an observation was made of Resident #62 in their room. An incentive spirometer was observed uncovered with the mouthpiece touching the surface of the dresser in the room. At that time an interview was conducted with Resident #62. Resident #62 stated that they used the spirometer when staff asked them to. Additional observations of Resident #62's room on 12/7/2021 at 3:43 p.m. revealed the incentive spirometer uncovered on top of the dresser with the mouthpiece touching the surface of the dresser in the room. On 12/8/2021 at 8:45 a.m., the incentive spirometer was observed on the nightstand beside Resident #62's bed uncovered. The physician orders for Resident #62 documented, 11/23/2021 Rehab [rehabilitation] Potential: PT/OT/RT/ST (physical therapy, occupational therapy, respiratory therapy, speech therapy) . The progress notes for Resident #62 documented in part the following: - 12/08/2021 01:52 PM. Met with resident for 30 minutes coaching IS (incentive spirometer). Provided a visual cue to remind her and to document. Spo2 (oxygen saturation) 94%, HR (heart rate) 63. - 12/07/2021 01:15 PM. Met with resident for 30 minutes coaching IS. Spo2 96% HR 67. - 12/06/2021 01:37 PM. Met with resident for 30 minutes coaching IS. Spo2 92% HR 68. - 11/30/2021 02:29 PM. Met with resident for 30 minutes coaching IS. Spo2 92% HR 60. - 11/29/2021 02:21 PM. Met with resident for 30 minutes coaching IS. Spo2 92% HR 60. - 11/26/2021 12:44 PM. Met with resident for 30 minutes coaching IS. Spo2 93% HR 56. - 11/24/2021 01:12 PM. Met with resident for 30 minutes assessing respiratory status and coaching IS. Spo2 96% HR 44. Informed PA (physician's assistant) of low heart rate. The comprehensive care plan for Resident #62 documented in part, Problem: Risk for respiratory distress due to: HTN (hypertension). Start Date: 11/29/2021. Last Reviewed/Revised 11/29/2021 12:11 p.m. On 12/8/2021 at 1:55 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that incentive spirometers were cleaned after use and stored in plastic bags with the residents name and the date on them. LPN #1 stated that they were stored this way to prevent dust from getting on them. LPN #1 stated that they checked them periodically to ensure they were stored properly and the bags were changed. LPN #1 observed the uncovered incentive spirometer on the nightstand beside Resident #62's bed and stated that it should be in a bag and they would let the nurse caring for the resident know to take care of it. On 12/8/2021 at 9:40 a.m., ASM (administrative staff member) #1, the executive director provided a written document stating that the facility followed [NAME] as a standard of practice. On 12/9/2021 at approximately 8:30 a.m., a request was made to ASM #1 for the facility policy regarding reviewing storage of incentive spirometers. On 12/9/2021 at 8:40 a.m., ASM #1 stated that they did not have a policy regarding storage of incentive spirometers. According to [NAME]'s Nursing Procedures (6th Edition) 2013. Wash the mouthpiece in warm water and dry it. Avoid immersing the spirometer itself in water because water enhances bacterial growth and impairs the internal filter's effectiveness in preventing inhalation of extraneous material. Place the mouthpiece in a plastic storage bag between exercises, and label it and the spirometer, if applicable, with the patient's name to avoid inadvertent use by another patient. Keep the incentive spirometer within the patient's reach. On 12/8/2021 at approximately 4:15 p.m., ASM #1, the executive director was made aware of the findings. No further information was provided prior to exit. References: 1. Incentive spirometer Your health care provider may recommend that you use an incentive spirometer after surgery or when you have a lung illness, such as pneumonia. The spirometer is a device used to help you keep your lungs healthy. Using the incentive spirometer teaches you how to take slow deep breaths. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm 2. Diabetes mellitus A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm.

Based on staff interview, facility document review, and employee record review, it was determined that the facility staff failed to ensure that training records reviewed included all the required annual training for one of 5 CNA [certified nursing assistant] records reviewed, CNA #1. The findings include: On 12/8/21 a review of 5 CNA (Certified Nursing Assistant) training / education records were reviewed. CNA #1 was hired on 5/16/11 and her most recent completed anniversary year for training and education was 5/16/20 to 5/16/21. A review of CNA #1's training records for 5/16/20 to 5/16/21 failed to evidence that any abuse training was provided. On 12/08/21 at 2:19 PM, an interview was conducted with ASM #1 (Administrative Staff Member) the Executive Director. He stated that he looked everywhere and contacted the former Administrator and searched for any ad hoc abuse training. He stated that none was found. He stated that the facility does not have a training/education coordinator due to the facility being only a 75 bed facility. He stated that (ASM #2, the Director of Nursing) manages most of the training. He stated there wasn't any evidence that abuse training was provided to this CNA during the anniversary year. A review of the facility policy, Employee Training and Orientation documented, .3. Training required for Direct Care Staff/C.N.A.s: a. The Director of Nursing Services or designee will be responsible for ensuring that each C.N.A. or Nurse attends twelve (12) hours of in-service education per year. Dementia education and resident abuse prevention training will be provided annually No further information was provided by the end of the survey.

Based on observations, staff interview and facility document review, it was determined the facility staff failed to store, food in accordance with professional standards for food service safety. The facility staff failed to dispose of expired food during the facility task- kitchen observation on 12/7/21 at 9:45 AM. The findings include: On 12/7/21 at 9:45 AM, an observation was conducted in the main kitchen dry storage room with OSM (other staff member) #3, the director of dining services. A 32-ounce bag of walnut halves and pieces was torn open and uncovered, with plastic wrap at the bottom of the bag. On the spice rack, there was a 20-ounce grape jelly jar, one third full, the jelly was at room temperature and the label on the bottle documented refrigerate after opening. An interview was conducted on 12/7/21 at 10:00 AM with OSM (other staff member) #3, the director of dining services. When asked if the walnuts should be opened, OSM #3 stated, No, they should be closed. It looks like someone was snacking. When asked about the grape jelly and the length of time out of the refrigerator, OSM #3 stated, I'm not sure. When shown the label on the one third full jar of grape jelly, which documented to refrigerate after opening, OSM #3 stated, That will be thrown away now. On 12/8/21 at 4:15 PM, ASM #1, the executive director was made aware of the above findings. The facility's Dining Services policy dated 11/11, documented in part, Any opened food item must be stored in clearly labeled containers with a clearly labeled lid. Food supplies should be stored in a manner to ensure 'first in, first out' usage. No further information was provided prior to exit.

Based on staff interview and facility document review, it was determined the facility staff failed to implement their abuse policy for three of twenty-five employee record reviews, (CNA (certified nursing assistant) #8, LPN (licensed practical nurse) #5 and LPN #7). The facility failed to perform a timely criminal background check for CNA #8 and failed to obtain references for LPN #5 and LPN #7. The findings include: A review of twenty-five employee records revealed the following: - Review of the employee file for CNA #8 revealed a hire date of 4/17/19. Further review of the employee file failed to evidence documentation of a criminal background check for CNA #8. - Review of the employee file for LPN #5, revealed a hire date of 4/17/19. Further review of the employee file failed to reveal any reference checks at or before the date of hire. - Review of the employee file for LPN #7, revealed a hire date of 5/22/19. Further review of the employee file failed to reveal any reference checks at or before the date of hire. An interview was conducted on 2/27/20 at 8:07 AM with OSM (other staff member) #1, the acting director of admissions, business office and human resources. When asked to provide a background check for CNA #8 (hire date 4/17/19), OSM #1 stated, I started in 10/19 in this office and immediately did audit due to concerns with the previous office manager's processes. I found that (CNA #8) did not have a criminal background check at all. I obtained a criminal background check which is dated 10/17/9. When asked to provide reference checks for LPN #5 (hire date 4/17/19) and LPN #7 (hire date 5/22/19), OSM #1 stated, When I started and performed the audit, I found no references for (LPN #5) and (LPN #7). On 2/27/20 at 12:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and RN (registered nurse) #1, the quality manager, were made aware of the above concerns. The facility policy, Abuse, Neglect, Exploitation & Misappropriation dated 11/28/16, documented in part, Patients of the Center have the legal right to be free from verbal, sexual, mental and physical abuse. Abuse includes sexual abuse (sexual harassment/inappropriate touching, sexual coercion, sexual assault or allowing a patient to be sexually assaulted by another). The facility's Right to Dignity, Freedom from Abuse, Neglect and Exploitation policy dated 1/8/18, documents in part, The administrator or department supervisors will use job descriptions, interviews, sworn disclosure statements, appropriate licensing board/agency registry check and reference checks to screen, select and employ only those staff considered able to perform their job duties in a considerate and respectful manner. All employees are hired pending a criminal background check by the State Police. A person cannot be employed in a position that involves direct contact with a resident unit results of a criminal history background check has been received. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence transfer discharge requirements to the hospital for one of thirty-eight residents, Resident #31, when the resident was transferred to the hospital on 2/8/20. The findings include: Resident #31 was admitted to the facility on [DATE]. Resident #31's diagnoses included but were not limited to: Alzheimer's disease (progressive loss of mental ability and function) (1), chronic kidney disease (decreased function of the kidneys) (2) and hydronephrosis (distension of the kidney, caused by accumulation of urine that cannot flow out due to an obstruction) (3). Resident #31's most recent MDS (minimum data set) assessment, a quarterly admission assessment, with an assessment reference date of 1/15/20, coded the resident as scoring 3 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. The resident was coded as requiring extensive assistance in bed mobility and dressing, total dependence for transfer, locomotion on unit, bathing, and toilet use; and supervision in eating. Review of Resident #31's clinical record revealed the resident was transferred to the hospital on 2/8/20 for lethargy, vomiting and positive urinary tract infection. A nurse's progress note dated 2/8/20 at 9:53 PM, documented Resident was sent to hospital for change of condition and lethargy. At the time of writing this report, the resident has been admitted for further monitoring and observation. No further information has been given. We shall continue to monitor her situation as communicated from the hospital. Unable to interview staff person as not in town. An interview was conducted on 2/26/20 at 10:36 AM with LPN (licensed practical nurse) #3. When asked what documentation is provided to the hospital, LPN #3 stated, We print the continuity of care document, face sheet, physician orders, and the comprehensive care plan including goals. When asked how it would be evidenced that documentation was provided, LPN #3 stated, I would chart that in a note. There is a transfer form of what is given. We would have that documentation. An interview was conducted on 2/26/20 at 1:49 PM with LPN #5. When asked what information was provided to the hospital when Resident #31 was transferred, LPN #5 stated, I would provide the physician orders, copy of DNR (do not resuscitate), bed hold policy, continuity of care document and the care plan goals. When asked if she could provide a copy of what was provided to the hospital, LPN #5 stated, No. When asked if there was a written progress note regarding the documentation sent with Resident #31, LPN #5 stated, No, there's no note that documents all that was sent. An interview was conducted on 2/27/20 at 9:17 AM with ASM (administrative staff member) #2, the director of nursing. When asked to provide a copy of the Transfer Form Nursing Facility to Emergency Department/Hospital for Resident #31, ASM #2 provided a blank form. When asked for documentation specific to Resident #31, ASM #2 stated, I do not have a copy of the documentation, (LPN #5) did not follow the checklist. When asked if there was a progress note that detailed the information sent to the hospital on 2/8/20, ASM #2, the director of nursing, stated, No, there was no progress note written either. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/20 at 5:40 PM. No further information was provided prior to exit. The facility's Transfers Discharges policy dated 1/3/19, documents in part, Prior to transfer or discharge of a resident, documentation will be made in the medical record that: the attending physician was notified, a family member who is the responsible party was notified and identified, the reason for the transfer or discharge and the specific resident needs that cannot be met at the facility. Information will be provided to the receiving provider to include a minimum of the following: contact information of the practitioner responsible for the care of the resident, responsible party contact information, advance directive information, all special instructions or precautions for ongoing care, comprehensive care plan goals and all other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 25. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 119. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 278.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide written notification upon transfer for one of thirty-eight residents in the survey sample, Resident #31. The facility staff failed to provide written notice of the reason for transfer to Resident #31 and or to the resident responsible party, when Resident #31 was transferred to the hospital on 2/8/2020. The findings include: Resident #31 was admitted to the facility on [DATE]. Resident #31's diagnoses included but were not limited to: Alzheimer's disease (progressive loss of mental ability and function) (1), chronic kidney disease (decreased function of the kidneys) (2) and hydronephrosis (distension of the kidney, caused by accumulation of urine that cannot flow out due to an obstruction) (3). Resident #31's most recent MDS (minimum data set) assessment, a quarterly admission assessment, with an assessment reference date of 1/15/2020, coded the resident as scoring 3 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. Review of Resident #31's clinical record revealed the resident was transferred to the hospital on 2/8/2020 for lethargy, vomiting and positive urinary tract infection. A nurse's progress note dated 2/8/2020 at 9:53 PM, documented Resident was sent to hospital for change of condition and lethargy. At the time of writing this report, the resident has been admitted for further monitoring and observation. No further information has been given. We shall continue to monitor her situation as communicated from the hospital. The staff that wrote this note was not available for interview at the time of the survey. An interview was conducted on 2/26/2020 at 10:36 AM with LPN (licensed practical nurse) #3. When asked if written notification of the reason for transfer to the hospital is provided to the responsible party, LPN #3 stated, We call the RP (responsible party), nothing is provided in writing. When asked how the RP notification would be evidenced, LPN #3 stated, I would chart that in a note. An interview was conducted on 2/26/20 at 1:49 PM with LPN #5. When asked what information was provided to Resident #31's RP in writing, LPN #5 stated, We call the RP. When asked if she could provide a copy of the written RP notification and progress note documenting the written RP notification of the reason for transfer to the hospital on 2/8/2020, LPN #5 stated, No. An interview was conducted on 2/27/2020 at 9:17 AM with ASM (administrative staff member) #2, the director of nursing. When asked to provide a copy of the RP written notification of the reason for Resident #31's transfer to the hospital on 2/8/2020, ASM #2 stated, I do not have a copy of the documentation; (LPN #5) did not follow the checklist. When asked if there was a progress note that detailed the RP notification on 2/8/2020, ASM #2, the director of nursing, stated, No, there was no progress note written either. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/2020 at 5:40 PM. The facility's Transfers Discharges policy dated 1/3/19, documented in part, In the event of an emergency discharge, the administrator or designee will provide written notification containing the reason for discharge in a manner and in the language understood by the Resident and/or legal representative as soon as practicable before the move. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 25. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 119. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 278.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #55 was admitted to the facility on [DATE]. Resident #55's diagnoses included but were not limited to: pneumonia (inflammation of the lungs usually caused by an infection) (1), bipolar disorder (mental disorder characterized by mania and depression) (2), schizophrenia (mental disorder characterized by gross distortions of reality, disturbances of thought, language and perception) (3). Resident #55's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/7/20, coded the resident as scoring 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. MDS Section I- Active Diagnosis: coded the resident with diagnosis of bipolar disorder and schizophrenia. A review of Resident #55's clinical record revealed the resident did not have a PASAAR (Pre-admission Screening and Resident Review) completed prior to and or upon admission on [DATE]. The PASARR for Resident #55 was completed by the OSM (other staff member) #4, the director of social services on 2/2/20 at 2:47 PM. The PASAAR Question #2 Does the individual have a current serious mental illness was incorrectly coded for Resident #55 as No. On 2/26/20 at 3:14 PM, an interview was conducted with OSM #4, the director of social services. When asked if she completed the PASAAR, OSM #4 stated, Yes, I've been checked off to complete the PASAAR form. When reviewing the PASAAR for Resident #55, OSM #4 stated, The mental illness is not (Resident #55's) primary diagnosis. In the hospital we did not consider mental illness unless it was primary diagnosis. When asked if a diagnosis of bipolar and schizophrenia are considered a serious mental illness, OSM #4 stated, Yes, I would consider those diagnosis as mental illness. When asked why the PASAAR for Resident #55 was completed on 2/26/20 instead of on admission 1/31/20, OSM #4 stated, I personally don't feel like we should have filled it out now. The PASAAR should have come from the hospital. When asked who is responsible to obtain the information from the hospital, OSM #4 stated, Admissions is responsible for obtaining forms prior to admission to the facility. An interview was conducted on 2/26/20 at 3:28 PM with OSM #5, the director of admissions. OSM #5 was asked if a resident should, they have a PASAAR when admitted . OSM #5 stated, Yes, that should come with their admission paperwork. When asked what should be done if the PASAAR is not present, OSM #5 stated, The social worker should complete one. OSM #5 was asked about the process staff follows for communicating that a PASAAR needs to be completed for a resident. OSM #5 stated, It would be discussed in the morning huddle. When asked if OSM #5 had communicated that Resident #55's PASAAR needed to be completed, OSM #5 stated, I really don't remember but I would assume I did. When asked if there was an admission checklist to ensure the PASAAR was completed, OSM #5 stated, Yes we have a checklist that we fill out. I will bring you a copy. The facility Nursing Center documentation and chart order form provided by OSM #5, the director of admissions, does not list the PASARR. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/20 at 5:40 PM. The facility's PASAAR for MIMR (mental illness mental retardation) documents in part, The facility will not admit any individual who has an indication of mental retardation (or a related condition) or mental illness unless it has been determined that he or she requires the level of services provided by a nursing facility and does not require active treatment in an ICF (intermediate care facilities). No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 461. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 71. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 518. Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure a PASAAR (Pre-admission Screening and Resident Review) was completed prior to admission for two of 38 residents in the survey sample, (Residents #34 and #55). The facility staff failed to ensure a level I PASARR was completed for Resident #34 and Resident #55, to ensure the residents were evaluated and receiving care and services in the most integrated setting appropriate for the residents' needs. The findings include: Resident #34 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: anxiety disorder, Bipolar disorder (a mental disorder characterized by episodes of mania and depression) (1), and major depressive disorder. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/21/2020 coded the resident as scoring a 1 on her BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions. In Section I - Active Diagnoses the resident was coded as having depression and Bipolar Disorder. Review of the clinical record failed to evidence documentation of a PASAAR completed prior to the resident's admission to the facility. On 2/26/2020 at 2:47 p.m. ASM (administrative staff member) #1, the administrator, stated they did not have a PASAAR for Resident #34. He stated the facility director of social services completed it today. The Screening for Mental Illness, Mental Retardation/Intellectual Disability, or Related Conditions for Resident #34 dated 2/26/2020, documented a circle around the word No when asked if the resident had a current serious mental illness. An interview was conducted with OSM (other staff member) #4, the director of social service, on 2/26/2020 at 3:16 p.m. The above form was reviewed with OSM #4. When asked who is responsible for completing the PASAAR forms, OSM #4 stated, the hospital. When asked who normally requests these forms, OSM #4 stated admissions but this resident came up from the assisted living here. OSM #4 stated, In the process I was to fill it out when she came up and I'm not sure that they would need to be completed prior to coming up (to the health care center). An interview was conducted with OSM #5, the director of admissions; on 2/26/2020 at 3:28 p.m., OSM #5 was asked if a resident should have a PASAAR upon admission to the facility. OSM #5 stated yes. OSM #5 was asked about the process staff follows for a resident who does not have a PASARR on admission. OSM #5 stated the social worker should be completing one. When asked how that is communicated to the social worker, OSM #5 stated in the morning meetings we communicate these types of things. When asked if she told someone that (Resident #34) needed a PASARR completed, OSM #5 stated she could not recall whom she told. When asked if there was, a process to ensure all of the admission paperwork is completed; OSM #5 stated there was a check off list. A copy of the check off list for Resident #34 was requested. Review of the check off list provided, revealed the check off list did not document the PASAAR as something to be completed as part of the admission process. The facility policy, PASAAR for MIMR (mental illness/mental retardation) documented in part, 1. All admissions to this facility must be screened for MI/MR before any consideration for admission is made.The Admissions Committee will review all admissions for conditions of MI and MR and to ensure that applicants meet the level of care criteria (Level I evaluation). Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing and RN (registered nurse) #1, the quality assurance nurse, were made aware of the above concern on 2/26/1010 at 5:45 p.m. No further information was obtained prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 72.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop a complete baseline care plan for one of 38 residents in the survey sample, Resident #162. The facility staff failed to develop a baseline care plan to address Resident #162's use of bed rails. The findings include: Resident #162 was admitted to the facility on [DATE]. Resident #162's diagnoses included but were not limited to diabetes, constipation and pulmonary fibrosis (a lung disease). Resident #162's admission MDS (minimum data set) assessment had not been completed yet at the time of the survey. An admission observation report dated 2/21/20 documented Resident #162 was alert and oriented to person, place, time and situation. Resident #162's baseline care plan with an admission date of 2/21/20 documented a section titled, Required Safety/Enablers measures. There was an option for side rails (bed rails); however, this option was not checked. On 2/25/20 at 3:57 p.m., Resident #162 was observed in bed with bilateral quarter bed rails up. On 2/26/20 at 10:36 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 confirmed residents' care plans should reflect the use of bed rails. On 2/26/20 at 2:35 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 was asked if residents' care plans should include the use of bed rails. RN #2 stated, Yes because it's a part of their plan of care for their care. On 2/26/20 at 5:56 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Comprehensive Person-Centered Care Planning documented, 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the resident's admission .The baseline care plan will include at a minimum: -The resident's initial goals for care; -The instructions needed to provide effective and person-centered care that meets professional standards of quality care; -The resident's immediate health and safety needs . No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, family interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the comprehensive care plan for two of 38 residents in the survey sample, ((Residents #163 and #14). The facility staff failed to implement Resident #163's oxygen care plan and failed to implement the Resident # 14's comprehensive care plan for side rail protectors. During separate observations, Resident #14 was observed lying in bed with bilateral side rails up. One side rail was covered, the other rail was uncovered and the black side rail covering was observed on the floor under the resident's bed. The findings include: 1. Resident #163 was admitted to the facility on [DATE]. Resident #163's diagnoses included but were not limited to respiratory failure, acute kidney failure and muscle weakness. Resident #163's quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/20/19, coded Resident #163's cognition as severely impaired. Section G coded the resident as requiring extensive assistance of one staff with bed mobility and personal hygiene. Section O coded Resident #163 as receiving oxygen therapy. Resident #163's comprehensive care plan dated 5/28/19 documented, Risk for respiratory distress due to: shortness of breath .Administer O2 (oxygen) as ordered . Review of Resident #163's clinical record revealed a physician's order dated 2/19/20 for oxygen at three liters per minute. On 2/25/20 at 12:05 p.m., Resident #163 was observed lying in bed receiving oxygen via a nasal cannula connected to an oxygen concentrator that was running. The oxygen concentrator was set at a rate between two and a half and three liters as evidenced by the ball in the concentrator flow meter positioned between the two and a half and three-liter lines. On 2/25/20 at 1:28 p.m., Resident #163 was observed lying in bed receiving oxygen via a nasal cannula connected to an oxygen concentrator that was running. The oxygen concentrator was set at a rate of two and a half liters as evidenced by the middle of the ball in the concentrator flow meter positioned on the two and a half liter line. On 2/25/20 at 4:01 p.m., Resident #163 was observed lying in bed receiving oxygen via a nasal cannula connected to an oxygen concentrator that was running. The oxygen concentrator was set at a rate between two and a half and three liters as evidenced by the ball in the concentrator flow meter positioned between the two and a half and three-liter lines. On 2/26/20 at 10:36 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 was asked to describe where the ball in an oxygen concentrator flow meter should be if a resident has a physician's order for three liters. LPN #3 stated the three-liter line should run through the middle of the ball at eye level. On 2/26/20 at 3:30 p.m., LPN #1 and LPN #2 (nurses caring for Resident #163) stated Resident #163 does not adjust the oxygen concentrator flow meter. On 2/26/20 at 5:56 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. On 2/27/20 at 8:05 a.m., ASM #2 and RN (registered nurse) #1 (the quality assurance nurse) requested a demonstration of this surveyor's observations of the rates Resident #163's oxygen concentrator was set on. A demonstration of an oxygen concentrator set at two and a half liters and set between two and a half liters and three liters was provided to ASM #2. The oxygen concentrator manufacturer's instructions documented, 5. Adjust the flow to the prescribed setting by turning the knob on the top of the flow meter until the ball is centered on the line marking the specific flow rate. The facility policy titled, Comprehensive Person-Centered Care Planning documented, 9. The resident will receive the services and/or items included in the plan of care. No further information was presented prior to exit. 2. Resident #14 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia, depression, stroke and high blood pressure. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/23/19, coded the resident as unable to complete the interview and coded the resident as having both short and long term memory difficulties and being severely impaired to make daily cognitive decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance of one staff member for moving in the bed. The comprehensive care plan dated 2/24/2020 documented in part, Problem: Resident with a hx (history) of pressure ulcers/impaired skin integrity due to: impaired mobility, incontinence, fragile skin, hx of skin tears. The Approach documented in part, Bilateral grab bars were zip tied to bed frame .Side rail protectors in place to prevent skin bruising and injuries. An interview was conducted with Resident #14's daughter on 2/25/2020 at 12:20 p.m. She stated that her mother had had a fall Saturday night into Sunday morning. They had contacted her around 5:30 a.m. She informed the surveyor that her mother was supposed to have padded rails on her bed but it was not on the bed. Resident #14 was observed in her bed on 2/26/2020 at 8:02 a.m. The resident's bed had both side rails up in the upright position. On the side next to the window, there was a black covering over the side rail. On the side closest to the door, there was a black covering observed lying under the bed, not on the side rail. On 2/26/2020 at 2:00 p.m., a second observation was made of Resident #14 in her bed with both side rails up; only the rail closest to the window had a cover over it. A third observation was made on 2/26/2020 at 5:18 p.m. of Resident #14's room with RN (registered nurse) # 4. When asked if the resident was supposed to have side rail covers, RN #4 stated she believed she was supposed to have them on. RN #4 observed the one black side rail, cover under the bed on the side closet to the door. The side by the window had the rail up and the black cover was on. On 227/2020 at 7:32 a.m., a copy of Resident #14's care plan was presented. The Approach: bilateral grab bars were zip tied to bed frame, was circled. A handwritten note documented, She does not utilize grab bars. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 2/27/2020 at 8:09 a.m. When asked what the documentation meant, ASM #2 stated her care plan says that her grab bars are zip tied to the bed frame. ASM #2 was informed of the observations above of Resident #14 in her bed with both rails up with only one protective covers on one side of the bed. ASM #2 stated they zip tied the grab bars so the resident would not get skin tears. With them zip tied, they still had a cover that is supposed to be on them even in the down position. ASM #2 was informed again of the observations of the resident in bed without bilateral protective covers in place and ASM #2 was informed the observations did not evidence the rails zip tied to the bed. ASM #1, the administrator, ASM #2, and RN #1, the quality assurance nurse, were made aware of the above concern on 2/27/2020 at 12:05 p.m. No further information was obtained prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide respiratory care and services for one of 38 residents in the survey sample, (Resident #163). The facility staff failed to administer oxygen to Resident #163 at the physician prescribed rate of three liters per minute. The findings include: Resident #163 was admitted to the facility on [DATE]. Resident #163's diagnoses included but were not limited to respiratory failure, acute kidney failure and muscle weakness. Resident #163's quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/20/19, coded Resident #163's cognition as severely impaired. Section G coded the resident as requiring extensive assistance of one staff with bed mobility and personal hygiene. Section O coded Resident #163 as receiving oxygen therapy. Review of Resident #163's clinical record revealed a physician's order dated 2/19/20 for oxygen at three liters per minute. Resident #163's comprehensive care plan dated 5/28/19 documented, Risk for respiratory distress due to: shortness of breath .Administer O2 (oxygen) as ordered . On 2/25/20 at 12:05 p.m., Resident #163 was observed lying in bed receiving oxygen via a nasal cannula connected to an oxygen concentrator that was running. The oxygen concentrator was set at a rate between two and a half and three liters as evidenced by the ball in the concentrator flow meter positioned between the two and a half and three liter lines. On 2/25/20 at 1:28 p.m., Resident #163 was observed lying in bed receiving oxygen via a nasal cannula connected to an oxygen concentrator that was running. The oxygen concentrator was set at a rate of two and a half liters as evidenced by the middle of the ball in the concentrator flow meter positioned on the two and a half liter line. On 2/25/20 at 4:01 p.m., Resident #163 was observed lying in bed receiving oxygen via a nasal cannula connected to an oxygen concentrator that was running. The oxygen concentrator was set at a rate between two and a half and three liters as evidenced by the ball in the concentrator flow meter positioned between the two and a half and three liter lines. On 2/26/20 at 10:36 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 was asked to describe where the ball in an oxygen concentrator flow meter should be if a resident has a physician's order for three liters. LPN #3 stated the three liter line should run through the middle of the ball at eye level. On 2/26/20 at 3:30 p.m., LPN #1 and LPN #2 (nurses caring for Resident #163) confirmed Resident #163 does not adjust the oxygen concentrator flow meter. On 2/26/20 at 5:56 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. On 2/27/20 at 8:05 a.m., ASM #2 and RN (registered nurse) #1 (the quality assurance nurse) requested a demonstration of this surveyor's observations of the rates Resident #163's oxygen concentrator was set on which was provided. The oxygen concentrator manufacturer's instructions documented, 5. Adjust the flow to the prescribed setting by turning the knob on the top of the flow meter until the ball is centered on the line marking the specific flow rate. The facility policy titled, Oxygen Therapy documented, The facility will ensure that safety precautions shall be met and maintained when oxygen therapy is provided. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure dialysis services, were provided consistent with professional standards of practice, and the comprehensive person-centered care plan, for one of 38 residents in the survey sample, Resident #55. The facility staff failed to evidence communication with the dialysis center and failed to have a contract with the dialysis center provider. The findings include: Resident #55 was admitted to the facility on [DATE]. Resident #55's diagnoses included but were not limited to: pneumonia [inflammation of the lungs usually caused by an infection.] (1), bipolar disorder [mental disorder characterized by mania and depression.] (2); schizophrenia [mental disorder characterized by gross distortions of reality, disturbances of thought, language and perception.] (3) Resident #55's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/7/20, coded the resident as scoring 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. MDS Section G- Functional Status: coded the resident as being totally dependent in bed mobility, dressing, toilet use, personal hygiene and bathing; requires supervision in eating. MDS Section O- Special Treatments and Procedures: coded the resident with receiving dialysis while a resident. A review of the physician's orders dated 1/31/20 documented in part, Hemodialysis on Tuesday, Thursday and Saturday at 5:00 AM. A review of Resident #55's comprehensive care plan dated 2/11/20 documented in part, Problem- I have ESRD (end stage renal disease) and receive dialysis on Tuesday, Thursday and Saturday. Approach-Dialysis three days a week. Check dialysis shunt for bruit and thrill. When asked to review the dialysis communication book for Resident #55, ASM (administrative staff member) #2, the director of nursing, provided the book on 2/25/20 at 4:40 PM. A review of the book, documented communication forms with the dialysis company on 2/3/20, 2/15/20, 2/20/20 and 2/22/20. Eleven dialysis treatments occurred from 2/3/20 through 2/25/20; seven communication forms were not evidenced in the book. An interview was conducted on 2/25/20 at 4:45 PM with LPN (licensed practical nurse) #3. When asked the purpose of the dialysis communication book, LPN #3 stated, It is to communicate the resident's vital signs and any resident issues with the dialysis facility. When asked if a form is completed for each dialysis trip, LPN #3 stated, Yes, we are to complete one form for each treatment. LPN #3 was shown Resident #55's dialysis communication book and forms for the dates of 2/3/20, 2/15/20, 2/20/20 and 2/22/20 and was asked what this meant. LPN #3 stated, It means that the forms were not completed on her other days of dialysis. LPN #3 was asked about which days of the week Resident #55 received dialysis. LPN #3 stated, She goes on Tuesday, Thursday and Saturday. An interview was conducted on 2/26/20 at 5:35 PM with ASM #2, the director of nursing. When asked about the dialysis communication book for Resident #55, ASM #2 stated, I talked with the night nurse (LPN #6). She evidently created a dialysis book of her own. She did not know that a dialysis book was already started. When asked if LPN #6 was working night shift 2/26/20, ASM #2 stated, Yes, you can talk with her in the morning. An interview was conducted on 2/27/20 at 7:35 AM with LPN #6, the night shift nurse. When asked to describe the second dialysis communication book for Resident #55, LPN #6 stated, (Resident #55) was admitted on [DATE]. The first day I was there when she went to dialysis was 2/4/20. I could not find a dialysis book for her, so I made one. Since I work nights and get her ready on most mornings, I put the book in the drawer at the nurse's station. When asked about the purpose of the book, LPN #6 stated, It is to provide communication between us and the dialysis center. Vital signs, any resident issues or concerns. The dialysis center sends us back any labs [laboratory tests] or new orders on the form. When asked how staff are made aware of new orders if there are two books, LPN #6 stated, I guess they would not know about new orders and I did not know there was another book, which is why I made a book for her. (ASM #2), the director of nursing, in-serviced us on 2/26/20 to make sure we kept the book at the nurses station. The second dialysis book was not available for review on 2/25 or 2/26. On 2/27/2020, the LPN #6 left without leaving 'second' dialysis's book for Resident #55's for review. An interview was conducted on 2/27/20 at 7:51 AM, with ASM #2, the director of nursing. When asked where the dialysis book should be kept, ASM #2 stated, It should be kept at the nurse's station. I in-serviced all the nurses about this yesterday morning, I told them there should be only one book, and that they need to merge the two books of (Resident #55). On 2/27/20 at 12:35 PM, when asked to provide the documented arrangement with the dialysis company for Resident #55, ASM #1, the administrator stated, We do not have a contract with that dialysis company. We have been trying to get one implemented. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/20 at 5:40 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 461. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 71. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 518.

Based on staff interview and facility document review, it was determined that the facility staff failed to ensure required annual in-service training's for CNAs (certified nursing aides) was completed for three of ten CNA records reviewed, (CNAs #3, #5 and #7). The facility staff failed to ensure CNAs #3, #5 and #7 completed the required annual 12 hours of training, including dementia management training and resident abuse prevention training. The findings include: Review of the employee records for ten CNAs revealed the following: CNA #3 was hired on 9/27/02. Review of CNA #3's employee record failed to reveal any completed trainings. CNA #5 was hired on 8/22/18. Review of CNA #5's employee record failed to reveal any completed trainings. CNA #7 was hired on 11/7/18. Review of CNA #7's employee record failed to reveal any completed trainings. On 2/26/20 at 5:55 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated the facility staff utilizes an online training company that determines the types of trainings that must be completed and these training's are based on state requirements. ASM #2 stated CNAs are responsible for completing the required trainings. ASM #2 stated CNAs do not receive a raise if they do not complete the required trainings. At this time, ASM #1 (the administrator) and ASM #2 were made aware of the above concern. The facility policy titled, Employee Assigned Educational Courses documented, All employees will remain up-to-date and current in required company education as assigned. Failure to complete assigned educational courses shall result in disciplinary and/or compensatory action. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, family interview, facility document review, and clinical record review, it was determined the facility staff failed to implement the facility policies to meet the requirements for advanced directives for four of thirty-eight residents, (Residents #31, Resident #33, Resident #14 and Resident #45). The facility staff failed to evidence documentation of an annual review of the advanced directives and wishes with Resident #31 and/or the resident's responsible party (RP), Resident #33 and/or the residents RP, Resident #14 and /or the residents RP, and Resident #45 and/or the resident's responsible party. The findings include: 1. Resident #31 was admitted to the facility on [DATE]. Resident #31's diagnoses included but were not limited to: Alzheimer's disease (progressive loss of mental ability and function) (1), chronic kidney disease (decreased function of the kidneys) (2) and hydronephrosis (distension of the kidney, caused by accumulation of urine that cannot flow out due to an obstruction) (3). Resident #31's most recent MDS (minimum data set) assessment, a quarterly admission assessment, with an assessment reference date of 1/15/20, coded the resident as scoring 3 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. Resident #31's care plan revised 2/24/20, documented Problem-Change in condition with sepsis and renal failure. Approach- No hospitalization, admit to hospice and coordinate care with hospice. Review of Resident #31's clinical record revealed the resident had an advanced directive in place with no evidence of the periodic annual review. The care plan conference summary dated 1/16/20 documented next to Advanced Directive/Code Status- DNR (do not resuscitate) with no further details. An interview was conducted on 2/26/20 at 9:32 AM with ASM (administrative staff member) #1, the administrator and OSM (other staff member) #5, the director of admissions. When asked about the process for obtaining advanced directive on admission, OSM #5, the director of admissions, stated, It is part of the admission packet with the disclosure agreement. We ask them to bring a copy of the advanced directive to us. When asked about periodic reviews of advanced directives, OSM #5, the director of admissions stated, During the care plan meetings, the staff verify code status and if there are any changes the advanced directive would be revised at that time. ASM #1, the administrator, stated, Social Services participate in the periodic care plan reviews. They capture the code status and change advanced directives at that time. An interview was conducted on 2/26/20 at 9:38 AM with OSM #4, the director of social services. When asked about her role with resident advanced directives, OSM #4 stated, We review if they have provided advanced directives and their code status. Care plan meetings are two weeks after admission and quarterly. Advanced directives are reviewed quarterly. When asked what information was reviewed, OSM #4 stated, We review the code status. I am not part of the nursing review portion where there is a review of specific information. The details are reviewed by nursing, such as feeding, hospitalizations and medications. Social services and the MDS coordinator make notes in the record. An interview was conducted on 2/26/20 at 10:07 AM with ASM #2, the director of nursing and RN #2, the MDS coordinator. When asked to define advanced directive, RN #2 states, The advanced directive is the documentation to direct medical care of the resident when they are in declining health are at the end stage of their life. When asked about the process staff follows for advance directive review during the care plan process, RN #2 stated, We discuss the advanced directive, but I don't specifically review it. We review the code status. The facility advanced directive policy A written notation indicating the type of advance directives will be reviewed annually by the interdisciplinary team was reviewed with ASM #2 and RN #2. When asked where documentation of the periodic annual review was located in the medical record, ASM #2 stated, So we need to have something written to document this, I did not know. We might have something that is written. RN #2 did not answer. The facility's Implementation of Advance Directives policy dated 3/5/19, documents The social worker or admissions counselor will interview the resident/legal representative at time of admission to determine if the resident has executed an Advanced Medical Directive or Durable Power of Attorney for Health Care. Copies of any directive or power of attorney will be placed in the resident's clinical file. A written notation indicating the type of advance directives will be reviewed annually by the interdisciplinary team. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/20 at 5:40 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 25. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 119. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 278. 2. Resident #33 was admitted to the facility on [DATE]. Resident #33's diagnoses included but were not limited to: Alzheimer's disease (progressive loss of mental ability and function) (1), dementia (progressive state of mental decline, memory function and judgement) (2) and bronchitis (inflammation of the bronchi often following an upper respiratory infection) (3). Resident #33's most recent MDS (minimum data set) assessment, a quarterly admission assessment, with an assessment reference date of 1/20/20, coded the resident as scoring 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. Review of Resident #33's clinical record revealed the resident had an advanced directive in place with no documented evidence of the periodic annual review. The care plan conference summary dated 10/31/19, documented next to Advanced Directive/Code Status- DNR (do not resuscitate) with no further details. An interview was conducted on 2/26/20 at 9:32 AM with ASM (administrative staff member) #1, the administrator and OSM (other staff member) #5, the director of admissions. When asked about the process for obtaining advanced directive on admission, OSM #5, the director of admissions, stated, It is part of the admission packet with the disclosure agreement. We ask them to bring a copy of the advanced directive to us. When asked about periodic reviews of advanced directives, OSM #5, the director of admissions stated, During the care plan meetings, the staff verify code status and if there are any changes the advanced directive would be revised at that time. ASM #1, the administrator, stated, Social Services participate in the periodic care plan reviews. They capture the code status and change advanced directives at that time. An interview was conducted on 2/26/20 at 9:38 AM with OSM #4, the director of social services. When asked about her role with resident advanced directives, OSM #4 stated, We review if they have provided advanced directives and their code status. Care plan meetings are two weeks after admission and quarterly. Advanced directives are reviewed quarterly. When asked what information was reviewed, OSM #4 stated, We review the code status. I am not part of the nursing review portion where there is a review of specific information. The details are reviewed by nursing, such as feeding, hospitalizations and medications. Social services and the MDS coordinator make notes in the record. An interview was conducted on 2/26/20 at 10:07 AM with ASM #2, the director of nursing and RN #2, the MDS coordinator. When asked to define advanced directive, RN #2 states, The advanced directive is the documentation to direct medical care of the resident when they are in declining health are at the end stage of their life. When asked about the process staff follows for advance directive review during the care plan process, RN #2 stated, We discuss the advanced directive, but I don't specifically review it. We review the code status. The facility advanced directive policy A written notation indicating the type of advance directives will be reviewed annually by the interdisciplinary team was reviewed with ASM #2 and RN #2. When asked where documentation of the periodic annual review was located in the medical record, ASM #2 stated, So we need to have something written to document this, I did not know. We might have something that is written. RN #2 did not answer. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/20 at 5:40 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 25. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 154. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 88. 3. Resident #14 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia, depression, stroke and high blood pressure. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/23/19, coded the resident as unable to complete the interview and coded the resident as having both short and long term memory difficulties and being severely impaired to make daily cognitive decisions. Review of the clinical record revealed an Acknowledgement of Receipt of Advance Directive Information form. This form was dated 10/14/10. There was an Advance Medical Directive for (Resident #14) in the clinical record. Further review of the clinical record failed to evidence documentation of an annual review of the advanced directive with Resident #14 and or the resident responsible party. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 2/26/2020 at 9:32 a.m. When asked if the advanced directive is reviewed periodically with the resident and/or resident representative, ASM #1 stated the staff during the care plan meetings, verify the code status and if there are any changes they would make to the advanced directive at that time. An interview was conducted with OSM (other staff member) #4, the director of social services, on 2/26/2020 at 9:39 a.m. When asked about the role she plays with the review of advanced directives, OSM #4 stated it's mostly through the care plan, especially the new admissions. We review if it (advanced directive) was provided during the admission process. When asked if the staff review the residents advanced directives during their care plan meeting, OSM #4 stated, I have not seen that in our process where the advanced directive has been reviewed, it's usually just the code status. An interview was conducted with RN (registered nurse) #2, the MDS nurse on 2/26/2020 at 10:07 a.m. When asked if she reviews the advanced directives of residents during the care plan process, RN #2 stated, I don't specifically review it. We discuss them. We go over the code status. When asked what an advanced directive is, RN #2 stated it's the documentation to direct medical care of a resident when they are declining or at the end stage of their life. The facility policy was reviewed with RN #2. RN #2 stated the facility reviews the advanced directive in the quality assurance program as to who has DNR (do not resuscitate). When asked about the location of the documentation of the individual resident review of the advanced directives, RN #2 did not answer. A Care Plan Conference Summary dated, 1/23/2020, documented in part, Discussed with RP/POA (responsible party/power of attorney) a check mark was documented next to Adv (advanced) directive/code status. Under the comments column it was documented, Reviewed DNR (do not resuscitate). Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing and RN (registered nurse) #1, the quality assurance nurse, were made aware of the above concern on 2/26/1010 at 5:45 p.m. No further information was obtained prior to exit. 4. Resident #45 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Alzheimer's disease (a progressive loss of mental ability and function, often accompanied by personality changes and emotional instability.) (1), abnormal posture, cough, and gastroesophageal reflux disease (backflow of the contents of the stomach into the esophagus, usually caused by malfunction of the sphincter muscle between the two organs; symptoms include burning pain in the esophagus, commonly known as heartburn) (2). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/31/2020, coded the resident as unable to understand other and unable to make herself understood. The resident was coded as being severely impaired to make daily cognitive decisions. Resident #45 was coded as being totally dependent of one or more staff members for all of her activities of daily living. Review of the clinical record revealed a documented Virginia Advance Medical Directive dated 6/24/2005. Further review of the medical record failed to evidence documentation that the advanced directive wishes were reviewed on an annual basis with Resident #45 or her responsible party. An interview was conducted with the resident's sitter on 2/27/2020 at 10:45 a.m. When asked if she attends the care plan meeting, the sitter stated she was here seven days a week for eight hours a day. She does attend care plan meetings and she does not recall them reviewing her (Resident #45's) advanced directive, just verifying her code status. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 2/26/2020 at 9:32 a.m. When asked if the advanced directive is reviewed periodically with the resident and/or resident representative, ASM #1 stated the staff during the care plan meetings, verify the code status and if there are any changes they would make to the advanced directive at that time. An interview was conducted with OSM (other staff member) #4, the director of social services, on 2/26/2020 at 9:39 a.m. When asked about the role she plays with the review of advanced directives, OSM #4 stated it's mostly through the care plan, especially the new admissions. We review if it (advanced directive) was provided during the admission process. When asked if the staff review the residents advanced directives during their care plan meeting, OSM #4 stated, I have not seen that in our process where the advanced directive has been reviewed, it's usually just the code status. An interview was conducted with RN (registered nurse) #2, the MDS nurse on 2/26/2020 at 10:07 a.m. When asked if she reviews the advanced directives of residents during the care plan process, RN #2 stated, I don't specifically review it. We discuss them. We go over the code status. When asked what an advanced directive is, RN #2 stated it's the documentation to direct medical care of a resident when they are declining or at the end stage of their life. The facility policy was reviewed with RN #2. RN #2 stated the facility reviews the advanced directive in the quality assurance program as to who has DNR (do not resuscitate). When asked about the location of the documentation of the individual resident review of the advanced directives, RN #2 did not answer. The Care Plan Conference Summary sheet dated 2/6/2020 documented in part, Discussed with RP/POA (responsible party/power of attorney) a check mark was documented next to Adv (advanced) directive/code status. Under the comments column it was documented, DNR (do not resuscitate). Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing and RN (registered nurse) #1, the quality assurance nurse, were made aware of the above concern on 2/26/1010 at 5:45 p.m. No further information was obtained prior to exit. References: (1) Barron's Dictionary of Medical Terms, 5th edition, Rothenberg and [NAME], page 26. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 243.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for five of thirty-eight residents in the survey sample, (Residents #17, #27, #55, #161, and #9). The facility staff failed to review and revise the comprehensive care plans for Resident #17, Resident # 27, Resident #55, Resident # 161 and Resident #9 to address and include the use of bed rails. The findings include: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: acute respiratory failure [inability of the heart and lungs to maintain an adequate level of gas exchange.] (1), atherosclerotic heart disease, [plaque consisting of cholesterol and lipids form on inner arterial walls of the heart.] (2); and pneumonia [inflammation of the lungs usually by bacterial infection.] (3). Resident #17's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 12/31/19, coded the resident as scoring 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status, coded the resident as requiring extensive assistance in bed mobility, transfers, dressing, bathing, toileting and personal hygiene; supervision in eating. Observation of Resident #17 on 2/26/20 at 7:30 AM, revealed the resident in bed with bilateral upper bed rails raised on the bed. A review of Resident #17's comprehensive care plan dated 1/2/20 failed to evidence documentation for the use of bed rails. An interview was conducted with Resident #17 on 2/26/20 at 7:30 AM. When asked if she used the bed rails, Resident #17 stated, Yes, I use them to help with getting in and out of bed. An interview was conducted on 2/26/20 at 10:36 AM with LPN (licensed practical nurse) #3. LPN #3 was asked about the assessment process staff follows for residents' use of bed rails. LPN #3 stated, When they are admitted we do an assessment to see if the rails are needed, if bed rail is there and it is used for positioning and mobility we leave it in place. We determine the need to leave it in place. When asked the purpose of the comprehensive care plan, LPN #3 stated, It is the individualized plan of care for the patient. When asked if bed rails should be included in the care plan, LPN #3 stated, Yes, the care plan should reflect the use of the bed rails. A review of Resident #17's bed rail with OSM (other staff member) #3, the director of maintenance, was conducted on 2/26/20 at 2:35 PM. When asked how he would identify the rails on Resident #17's bed, OSM #3 stated, I would call it a one half rail. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/20 at 5:40 PM. The facility's Comprehensive Person-Centered Care Planning policy dated 11/15/17, documents in part, A person-centered comprehensive care plan that includes measurable objectives and timetable to meet the resident's medical, nursing, mental and psychosocial needs shall be developed for each resident. The comprehensive care plan will aid in preventing or reducing declines in the resident's functional status and/or functional levels. The facility's Side Rail Assessment policy dated 11/21/17, documented in part, The reason for the side rails and their proper use will be integrated into the comprehensive care plan. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 502. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 52. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 461. 2. Resident #27 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: right knee replacement [replacement of the kneecap and joints, which connect the thighbone and lower leg bone.] (1), osteoarthritis of the knees bilaterally [common form of arthritis characterized by degenerative changes in the joints.] (2); and hypertension [high blood pressure.] (3) Resident #27's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/11/20, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status, coded the resident as requiring supervision in bed mobility, dressing, bathing and personal hygiene; limited assistance with transfers and toilet use and independent in eating. Observation of Resident #27 on 2/26/20 at 7:40 AM, revealed, the resident in bed, with the right upper bed rail raised on the bed, and the left upper bed rail lowered at mattress level. A review of Resident #27's comprehensive care plan dated 1/22/20 failed evidence the use of bed rails. An interview was conducted with Resident #27 on 2/26/20 at 7:40 AM. When asked if she used the bed rails, Resident #27 stated, Yes, I use them to help with turning. The one on my left side does not work correctly. It does not latch properly. It will be up and when you put pressure on it to get back in bed, then it falls down. It does not fall down all the way; it gets stuck at the mattress level. When asked if she had reported the bed rail concern to anyone, Resident #27 stated, Yes, I did last evening. I do not remember their name. The staff member that Resident #27 reported bed rail concern to could not be identified. An interview was conducted on 2/26/20 at 10:36 AM with LPN (licensed practical nurse) #3. LPN #3 was asked about the assessment process staff follows for residents' use of bed rails. LPN #3 stated, When they are admitted we do an assessment to see if the rails are needed, if bed rail is there and it is used for positioning and mobility we leave it in place. We determine the need to leave it in place. When asked the purpose of the comprehensive care plan, LPN #3 stated, It is the individualized plan of care for the patient. When asked if bed rails should be included in the care plan, LPN #3 stated, Yes, the care plan should reflect the use of the bed rails. A observation of Resident #27's bed rail with OSM (other staff member) #3, the director of maintenance, was conducted on 2/26/20 at 2:35 PM. OSM #3 was asked how he would identify the rails on Resident #27's bed. OSM #3 stated, I would call it a one half rail. When asked if he had received a work order or phone call regarding Resident #27's left bed rail, OSM #3 stated, No, we have not. It (left bed rail) does not retract all the way and I am having difficulty raising it. On 2/27/20 at 10:00 AM, OSM #3, the director of maintenance was asked if he had received an order for bed rail repair for Resident #27. OSM #3 stated, No, we did not. We immediately repaired the rail yesterday. There was a screw that had worked out. The facility's Comprehensive Person-Centered Care Planning policy dated 11/15/17, documents in part, A person-centered comprehensive care plan that includes measurable objectives and timetable to meet the resident's medical, nursing, mental and psychosocial needs shall be developed for each resident. The comprehensive care plan will aid in preventing or reducing declines in the resident's functional status and/or functional levels. The facility's Side Rail Assessment policy dated 11/21/17, documents in part, The reason for the side rails and their proper use will be integrated into the comprehensive care plan. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/20 at 5:40 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 319. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 420. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 282. 3. Resident #55 was admitted to the facility on [DATE]. Resident #55's diagnoses included but were not limited to: pneumonia (inflammation of the lungs usually caused by an infection) (1), bipolar disorder (mental disorder characterized by mania and depression) (2), schizophrenia (mental disorder characterized by gross distortions of reality, disturbances of thought, language and perception) (3). Resident #55's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/7/20, coded the resident as scoring 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. MDS Section G- Functional Status: coded the resident as being totally dependent in bed mobility, dressing, toilet use, personal hygiene and bathing; requires supervision in eating. Observation on 2/25/20 at 3:40 PM of Resident #55, revealed the resident in bed with bilateral upper bed rails raised on bed. A review of Resident #55's comprehensive care plan dated 2/11/20 fails to evidence documentation for the use of bed rails. An interview was conducted with Resident #55 on 2/26/20 at 9:40 AM. When asked if she used the bed rails, Resident #55 stated, Yes, I use them to help with turning in bed and getting in and out of bed. An interview was conducted on 2/26/20 at 10:36 AM with LPN (licensed practical nurse) #3. LPN #3 was asked about the assessment process staff follows for residents' use of bed rails. LPN #3 stated, When they are admitted we do an assessment to see if the rails are needed, if bed rail is there and it is used for positioning and mobility we leave it in place. We determine the need to leave it in place. When asked the purpose of the comprehensive care plan, LPN #3 stated, It is the individualized plan of care for the patient. When asked if bed rails should be included in the care plan, LPN #3 stated, Yes, the care plan should reflect the use of the bed rails. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/20 at 5:40 PM. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 461. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 71. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 518. 4. Resident #161 was admitted to the facility on [DATE]. Resident #161's diagnoses included but were not limited to high blood pressure, muscle weakness and osteoporosis. Resident #161's admission MDS (minimum data set) with an ARD (assessment reference date) of 2/7/20, coded the resident's cognition as moderately impaired. Section G coded Resident #161 as requiring extensive assistance of one staff with bed mobility. Resident #161's comprehensive care plan dated 2/10/20 failed to document information regarding the resident's use of bed rails. On 2/25/20 at 1:58 p.m., Resident #161 was observed in bed with bilateral quarter bed rails up. On 2/26/20 at 3:11 p.m., an interview was conducted with Resident #161. The resident stated she uses bed rails to turn in bed. On 2/26/20 at 10:36 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 confirmed residents' care plans should reflect the use of bed rails. On 2/26/20 at 2:35 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 was asked if residents' care plans should include the use of bed rails. RN #2 stated, Yes because it's a part of their plan of care for their care. On 2/26/20 at 5:56 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 5. Resident #9 was admitted to the facility on [DATE], with diagnoses that included but were not limited to: fracture of her femur, high blood pressure, abnormalities of gait and mobility, and diabetes. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/3/19, coded the resident as scoring a 12 on the BIMS (brief interview for mental status) score, indicating she was moderately impaired to make daily cognitive decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance of one staff member for moving in the bed. Resident #9 was observed and interviewed on 2/25/2020 at 1:48 p.m. The resident was in her bed with both bed rails up. The resident stated she used them to help position herself. Review of the comprehensive care plan dated, 12/6/19, failed to evidence documentation of the use of bed rails. Review of the physician's order failed to evidence documentation for an order for bed rails. On 2/26/20 at 10:36 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 confirmed residents' care plans should reflect the use of bed rails. When asked the purpose of the care plan LPN #3 stated it's the individualized care of the patient. On 2/26/20 at 2:35 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 was asked if residents' care plans should include the use of bed rails. RN #2 stated, Yes because it's a part of their plan of care for their care. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and RN #1, the quality assurance nurse, were made aware of the above findings on 2/27/2020 at 12:05 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident #17 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: acute respiratory failure [inability of the heart and lungs to maintain an adequate level of gas exchange.] (1), atherosclerotic heart disease [plaque consisting of cholesterol and lipids form on inner arterial walls of the heart.] (2); and pneumonia [inflammation of the lungs usually by bacterial infection.] (3) Resident #17's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 12/31/19, coded the resident as scoring 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status, coded the resident as requiring extensive assistance in bed mobility, transfers, dressing, bathing, toileting and personal hygiene; supervision in eating. Observation of Resident #17 on 2/26/20 at 7:30 AM, revealed the resident in bed with bilateral upper bed rails raised on the bed. A review of Resident #17's comprehensive care plan dated 1/2/20 failed to evidence documentation for the use of bed rails. An interview was conducted with Resident #17 on 2/26/20 at 7:30 AM. When asked if she used the bed rails, Resident #17 stated, Yes, I use them to help with getting in and out of bed. A list was provided to ASM (administrative staff member) #1, the administrator, on 2/25/20 at 5:00 PM. The list consisted of a request for documentation of the assessment for the use of bed rails, documentation of the risks of entrapment assessments and informed consent for the use of the bed rails for each resident listed. Resident #17 was included on this list. None of the requested information was provided for Resident #17. An interview was conducted on 2/26/2020 at 10:36 a.m. with LPN (licensed practical nurse) #3. When asked about the process staff follows for the use of bed rails including any assessments, LPN #3 stated, When they are admitted we do an assessment to see if the bed rail is needed. If the bed rail is there and it is used for positioning and mobility, we leave it in place. When asked if the risks/benefits or alternatives are reviewed, LPN #3 stated, No. When asked if informed consent was obtained and assessment for risk of entrapment was completed prior to the use of bed rails, LPN #3 stated, I will have to get back with you on that, but I don't believe so. An interview was conducted on 2/26/2020 at 2:04 p.m. with ASM (Administrative staff member) #1, the administrator. When asked for bed rail evaluations, ASM #1 stated, We have no side rail evaluations since 2018. When asked if there should be an assessment for the risk of entrapment, informed consent, explaining risks and benefits prior to the use of bed rails, ASM #1 stated, I don't have an answer for that. You cannot add bed rails with the new regulations. The bed rail evaluation is not consistently being done. If we take off the bed rails, we would be nullifying the bed warranty and modification of the bed may change bed integrity. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/20 at 5:40 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 502. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 52. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 461. 7. Resident #27 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: right knee replacement [replacement of the kneecap and joints, which connect the thighbone and lower leg bone.] (1), osteoarthritis of the knees bilaterally [common form of arthritis characterized by degenerative changes in the joints.] (2); and hypertension (high blood pressure) (3). Resident #27's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/11/20, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status coded the resident as requiring supervision in bed mobility, dressing, bathing and personal hygiene, limited assistance with transfers and toilet use and independent in eating. On 2/26/20 at 7:40 AM, Resident #27 was Observation resting in bed with right upper bed rail raised on the bed and the left upper bed rail lowered at mattress level. A list was provided to ASM (administrative staff member) #1, the administrator, on 2/25/20 at 5:00 PM. The list consisted of a request for documentation of the assessment for the use of bed rails, documentation of the risks of entrapment assessments and informed consent for the use of the bed rails for each resident listed. Resident #27 was included on this list. None of the requested information was provided for Resident #27. An interview was conducted on 2/26/2020 at 10:36 a.m. with LPN (licensed practical nurse) #3. When asked about the process staff follows for the use of bed rails including any assessments, LPN #3 stated, When they are admitted we do an assessment to see if the bed rail is needed. If the bed rail is there and it is used for positioning and mobility, we leave it in place. When asked if the risks/benefits or alternatives are reviewed, LPN #3 stated, No. When asked if informed consent was obtained and assessment for risk of entrapment was completed prior to the use of bed rails, LPN #3 stated, I will have to get back with you on that, but I don't believe so. An interview was conducted on 2/26/2020 at 2:04 p.m. with ASM (Administrative staff member) #1, the administrator. When asked for bed rail evaluations, ASM #1 stated, We have no side rail evaluations since 2018. When asked if there should be an assessment for the risk of entrapment, informed consent, explaining risks and benefits prior to the use of bed rails, ASM #1 stated, I don't have an answer for that. You cannot add bed rails with the new regulations. The bed rail evaluation is not consistently being done. If we take off the bed rails, we would be nullifying the bed warranty and modification of the bed may change bed integrity. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/20 at 5:40 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 319. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 420. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 282. (4) Medline Industries Inc., Owners & Maintenance Guide 2008, page 4 and 12. 8. Resident #55 was admitted to the facility on [DATE]. Resident #55's diagnoses included but were not limited to: pneumonia [inflammation of the lungs usually caused by an infection.] (1), bipolar disorder [mental disorder characterized by mania and depression] (2); schizophrenia [mental disorder characterized by gross distortions of reality, disturbances of thought, language and perception.] (3) Resident #55's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/7/20, coded the resident as scoring 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. MDS Section G- Functional Status: coded the resident as being totally dependent in bed mobility, dressing, toilet use, personal hygiene and bathing; requires supervision in eating. On 2/25/20 at 3:40 PM, Resident #55 was observed resting in bed with bilateral upper bed rails raised on bed. A list was provided to ASM (administrative staff member) #1, the administrator, on 2/25/20 at 5:00 PM. The list consisted of a request for documentation of the assessment for the use of bed rails, documentation of the risks of entrapment assessments and informed consent for the use of the bed rails for each resident listed. Resident #55 was included on this list. None of the requested information was provided for Resident #55. A list was provided to ASM (administrative staff member) #1, the administrator, on 2/25/20 at 5:00 PM. The list consisted of a request for documentation of the assessment for the use of bed rails, documentation of the risks of entrapment assessments and informed consent for the use of the bed rails for each resident listed. Resident #55 was included on this list. None of the requested information was provided for Resident #55. An interview was conducted on 2/26/2020 at 10:36 a.m. with LPN (licensed practical nurse) #3. When asked about the process staff follows for the use of bed rails including any assessments, LPN #3 stated, When they are admitted we do an assessment to see if the bed rail is needed. If the bed rail is there and it is used for positioning and mobility, we leave it in place. When asked if the risks/benefits or alternatives are reviewed, LPN #3 stated, No. When asked if informed consent was obtained and assessment for risk of entrapment was completed prior to the use of bed rails, LPN #3 stated, I will have to get back with you on that, but I don't believe so. An interview was conducted on 2/26/2020 at 2:04 p.m. with ASM (Administrative staff member) #1, the administrator. When asked for bed rail evaluations, ASM #1 stated, We have no side rail evaluations since 2018. When asked if there should be an assessment for the risk of entrapment, informed consent, explaining risks and benefits prior to the use of bed rails, ASM #1 stated, I don't have an answer for that. You cannot add bed rails with the new regulations. The bed rail evaluation is not consistently being done. If we take off the bed rails, we would be nullifying the bed warranty and modification of the bed may change bed integrity. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/20 at 5:40 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 461. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 71. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 518. (4) Joerns User-Service Manual, 2013 Joerns Healthcare, page 2. 4. Resident #161 was admitted to the facility on [DATE]. Resident #161's diagnoses included but were not limited to high blood pressure, muscle weakness and osteoporosis. Resident #161's admission MDS (minimum data set) with an ARD (assessment reference date) of 2/7/20, coded the resident's cognition as moderately impaired. Section G coded Resident #161 as requiring extensive assistance of one staff with bed mobility. Review of Resident #161's clinical record failed to reveal the facility attempted appropriate alternatives prior to the use of bed rails, failed to assess Resident #161 for the risk of entrapment, failed to review the risks and benefits with Resident #161 (or the resident's representative) and failed to reveal informed consent was obtained. Resident #161's comprehensive care plan dated 2/10/20 failed to document information regarding the resident's use of bed rails. On 2/25/20 at 1:58 p.m., Resident #161 was observed in bed with bilateral quarter bed rails up. An interview was conducted on 2/26/2020 at 10:36 a.m. with LPN (licensed practical nurse) #3. When asked about the process staff follows for the use of bed rails including any assessments, LPN #3 stated, When they are admitted we do an assessment to see if the bed rail is needed. If the bed rail is there and it is used for positioning and mobility, we leave it in place. When asked if the risks/benefits or alternatives are reviewed, LPN #3 stated, No. When asked if informed consent was obtained and assessment for risk of entrapment was completed prior to the use of bed rails, LPN #3 stated, I will have to get back with you on that, but I don't believe so. An interview was conducted on 2/26/2020 at 2:04 p.m. with ASM (Administrative staff member) #1, the administrator. When asked for bed rail evaluations, ASM #1 stated, We have no side rail evaluations since 2018. When asked if there should be an assessment for the risk of entrapment, informed consent, explaining risks and benefits prior to the use of bed rails, ASM #1 stated, I don't have an answer for that. You cannot add bed rails with the new regulations. The bed rail evaluation is not consistently being done. If we take off the bed rails, we would be nullifying the bed warranty and modification of the bed may change bed integrity. On 2/26/20 at 3:11 p.m., an interview was conducted with Resident #161. The resident stated she uses bed rails to turn in bed but staff has never explained risks and benefits or had a consent form signed. On 2/26/20 at 5:56 p.m., ASM #1 and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 5. Resident #162 was admitted to the facility on [DATE]. Resident #162's diagnoses included but were not limited to diabetes, constipation and pulmonary fibrosis (a lung disease). Resident #162's admission MDS (minimum data set) assessment was not completed. An admission observation report dated 2/21/20 documented Resident #162 was alert and oriented to person, place, time and situation. The report further documented Resident #162 transferred with two-person assistance. Review of Resident #162's clinical record failed to reveal the facility attempted appropriate alternatives prior to the use of bed rails, failed to assess Resident #162 for risk of entrapment, failed to review the risks and benefits with Resident #162 (or the resident's representative) and failed to reveal informed an consent was obtained prior to the use of bed rails. Resident #162's baseline care plan with an admission date of 2/21/20 failed to document the resident's use of bed rails. On 2/25/20 at 3:57 p.m., Resident #162 was observed in bed with bilateral quarter bed rails up. An interview was conducted on 2/26/2020 at 10:36 a.m. with LPN (licensed practical nurse) #3. When asked about the process staff follows for the use of bed rails including any assessments, LPN #3 stated, When they are admitted we do an assessment to see if the bed rail is needed. If the bed rail is there and it is used for positioning and mobility, we leave it in place. When asked if the risks/benefits or alternatives are reviewed, LPN #3 stated, No. When asked if informed consent was obtained and assessment for risk of entrapment was completed prior to the use of bed rails, LPN #3 stated, I will have to get back with you on that, but I don't believe so. An interview was conducted on 2/26/2020 at 2:04 p.m. with ASM (Administrative staff member) #1, the administrator. When asked for bed rail evaluations, ASM #1 stated, We have no side rail evaluations since 2018. When asked if there should be an assessment for the risk of entrapment, informed consent, explaining risks and benefits prior to the use of bed rails, ASM #1 stated, I don't have an answer for that. You cannot add bed rails with the new regulations. The bed rail evaluation is not consistently being done. If we take off the bed rails, we would be nullifying the bed warranty and modification of the bed may change bed integrity. On 2/26/20 at 5:56 p.m., ASM #1 and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. Based on observation, resident interview, staff interview, facility document review, it was determined that the facility staff failed to implement bed rails requirements for eight of 38 residents in the survey, Residents #9, #14, #45, #161, #162, #17, #27, and #55. The facility staff failed to attempt appropriate alternatives prior to use, failed to assess for the risk of entrapment, failed to review risks and benefits and failed to obtained informed consent prior to the use of bed rails for Residents ##9, #14, #45, #161, #162, #17, #27, and #55. The findings include: 1. Resident #9 was admitted to the facility on [DATE], with diagnoses that included but were not limited to: fracture of her femur, high blood pressure, abnormalities of gait and mobility, and diabetes. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/3/19, coded the resident as scoring a 12 on the BIMS (brief interview for mental status) score, indicating she was moderately impaired to make daily cognitive decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance of one staff member for moving in the bed. Review of the physician's order failed to evidence a documented order for bed rails. On 2/25/2020, at 1:48 p.m., an observation and interview was conducted with Resident #9. The resident was in her bed with both bed rails up. Resident #9 stated she used them (bed rails) to help position herself. Review of the clinical record failed to evidence documentation related to the assessment for the use of bed rails, a review/ assessment for the risk of entrapment, or an informed consent with the risks versus benefits prior to the use of bed rails. Review of Resident #9's comprehensive care plan failed to evidence documentation for the use of bed rails. A list was provided to ASM #1, the administrator, on 2/25/2020 at 5:00 p.m. The list consisted of a request for evidence of documentation of the assessment, for the use of bed rails, documentation of the assessments/evaluations for the risk of entrapment and informed consents with the risks versus benefits obtained prior to the use of bed rails for each resident listed. Resident #9 was documented on the list. An interview was conducted on 2/26/2020 at 10:36 a.m. with LPN (licensed practical nurse) #3. When asked about the process staff follows for the use of bed rails including any assessments, LPN #3 stated, When they are admitted we do an assessment to see if the bed rail is needed. If the bed rail is there and it is used for positioning and mobility, we leave it in place. When asked if the risks/benefits or alternatives are reviewed, LPN #3 stated, No. When asked if informed consent was obtained and assessment for risk of entrapment was completed prior to the use of bed rails, LPN #3 stated, I will have to get back with you on that, but I don't believe so. An interview was conducted on 2/26/2020 at 2:04 p.m. with ASM (Administrative staff member) #1, the administrator. When asked for bed rail evaluations, ASM #1 stated, We have no side rail evaluations since 2018. When asked if there should be an assessment for the risk of entrapment, informed consent, explaining risks and benefits prior to the use of bed rails, ASM #1 stated, I don't have an answer for that. You cannot add bed rails with the new regulations. The bed rail evaluation is not consistently being done. If we take off the bed rails, we would be nullifying the bed warranty and modification of the bed may change bed integrity. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/2020 at 5:40 p.m. The facility's policy Side Rail Assessment dated 11/21/17, documented in part, Any resident being considered for using a bed with side rails is assessed by the facility's interdisciplinary team to determine whether the resident's functional status and bed mobility is improved through the use of side rails, to identify individual characteristics that may increase the risk of entrapment by side rails or mattress. The side rail assessment is completed upon admission and at least annually. No further information was provided prior to exit. 2. Resident #14 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia, depression, stroke and high blood pressure. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/23/19, coded the resident as unable to complete the interview and coded the resident as having both short and long term memory difficulties and being severely impaired to make daily cognitive decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance of one staff member for moving in the bed. Review of the physician's order failed to evidence a documented order for the use of bed rails. On 2/26/2020 at 8:02 a.m., Resident #14 was observed in her bed with both bed rails up in the upright position. A second observation was made of Resident #14 in her bed with both side bed rails up on 2/26/2020 at 2:00 p.m. Review of the clinical record failed to evidence documentation related to the assessment for the use of bed rails, a review/ assessment for the risk of entrapment, or an informed consent with the risks versus benefits prior to the use of bed rails. The comprehensive care plan for Resident #14, dated 2/24/2020, documented in part, Problem: ADL (activities of daily living) Functional/Rehabilitation Potential. The Approach documented in part, Both grab bars in bed to assist with bed mobility due to generalized weakness. A list was provided to ASM #1, the administrator, on 2/25/2020 at 5:00 p.m. The list consisted of a request for evidence of documentation of the assessment, for the use of bed rails, documentation of the assessments/evaluations for the risk of entrapment and informed consents with the risks versus benefits obtained prior to the use of bed rails for each resident listed. Resident #9 was documented on the list. An interview was conducted on 2/26/2020 at 10:36 a.m. with LPN (licensed practical nurse) #3. When asked about the process staff follows for the use of bed rails including any assessments, LPN #3 stated, When they are admitted we do an assessment to see if the bed rail is needed. If the bed rail is there and it is used for positioning and mobility, we leave it in place. When asked if the risks/benefits or alternatives are reviewed, LPN #3 stated, No. When asked if informed consent was obtained and assessment for risk of entrapment was completed prior to the use of bed rails, LPN #3 stated, I will have to get back with you on that, but I don't believe so. An interview was conducted on 2/26/2020 at 2:04 p.m. with ASM (Administrative staff member) #1, the administrator. When asked for bed rail evaluations, ASM #1 stated, We have no side rail evaluations since 2018. When asked if there should be an assessment for the risk of entrapment, informed consent, explaining risks and benefits prior to the use of bed rails, ASM #1 stated, I don't have an answer for that. You cannot add bed rails with the new regulations. The bed rail evaluation is not consistently being done. If we take off the bed rails, we would be nullifying the bed warranty and modification of the bed may change bed integrity. RN (registered nurse) #1, the quality assurance nurse, presented a form titled, Side Rail Evaluation dated 7/27/18 with Resident #14's name documented on form and the resident's use of bilateral side rails. The Resident/Family section was blank and there was no signature of the responsible party on the reverse side where indicated. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/2020 at 5:40 p.m. No further information was provided prior to exit. 3. Resident #45 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Alzheimer's disease [a progressive loss of mental ability and function, often accompanied by personality changes and emotional instability.] (1), abnormal posture, cough, and gastroesophageal reflux disease [backflow of the contents of the stomach into the esophagus, usually caused by malfunction of the sphincter muscle between the two organs; symptoms include burning pain in the esophagus, commonly known as heartburn.] (2) The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/31/2020, coded the resident as unable to understand other and unable to make herself understood. The resident was coded as being severely impaired to make daily cognitive decisions. Resident #45 was coded as being totally dependent of one or more staff members for all of her activities of daily living. Review of the physician's order failed to evidence a documented order for bed rails. An interview was conducted with the resident's sitter on 2/27/2020 at 10:45 a.m. The resident was observed in bed with bilateral bed rails up at this time. When asked if the resident uses the bed rails, the sitter stated that she doesn't use them and they, the family, has put pillows on the inside of the rails so she doesn't hit her head on them. When asked if the staff ever explained the risk of entrapment or obtained a consent for the use of bed rails, Resident #45's sitter, stated they were there when she first came in and are still there. She stated she had been involved with her admission as the resident's husband was about to have surgery the next day so she would have recalled this. The comprehensive care plan for Resident #45 dated 2/7/2020, documented in part, Problem: ADL (activities of daily living) Functional/Rehabilitation Potential. The Approach documented in part, Both grab bars in bed to promote independence with bed mobility due to age related debility. A list was provided to ASM #1, the administrator, on 2/25/2020 at 5:00 p.m. The list consisted of a request for evidence of documentation of the assessment, for the use of bed rails, the documentation of the risk for entrapments and a consent for the use of the bed rails for each resident listed. Resident #14 was documented on the list. An interview was conducted on 2/26/2020 at 10:36 a.m. with LPN (licensed practical nurse) #3. When asked about the process staff follows for the use of bed rails including any assessments, LPN #3 stated, When they are admitted we do an assessment to see if the bed rail is needed. If the bed rail is there and it is used for positioning and mobility, we leave it in place. When asked if the risks/benefits or alternatives are reviewed, LPN #3 stated, No. When asked if informed consent was obtained and assessment for risk of entrapment was completed prior to the use of bed rails, LPN #3 stated, I will have to get back with you on that, but I don't believe so. An interview was conducted on 2/26/2020 at 2:04 p.m. with ASM (Administrative staff member) #1, the administrator. When asked for bed rail evaluations, ASM #1 stated, We have no side rail evaluations since 2018. When asked if there should be an assessment for the risk of entrapment, informed consent, explaining risks and benefits prior to the use of bed rails, ASM #1 stated, I don't have an answer for that. You cannot add bed rails with the new regulations. The bed rail evaluation is not consistently being done. If we take off the bed rails, we would be nullifying the bed warranty and modification of the bed may change bed integrity. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/2020 at 5:40 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms, 5th edition, Rothenberg and [NAME], page 26. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 243.

Based on staff interview and facility document review, it was determined that the facility staff failed to complete annual CNA (certified nursing aide) performance reviews for seven of ten CNA employee records reviewed. The facility staff failed to complete annual performance reviews for CNA #1, CNA #2, CNA #3, CNA#4, CNA #5, CNA #6 and CNA #7. The findings include: The employee files of ten CNAs was completed and revealed the following: CNA #1 was hired on 10/11/05. Review of CNA #1's employee record revealed the last performance review was completed on 3/2/17. CNA #2 was hired on 6/13/17. Review of CNA #2's employee record revealed no performance review. CNA #3 was hired on 9/27/02. Review of CNA #3's employee record revealed no performance review. CNA #4 was hired on 5/16/11. Review of CNA #4's employee record revealed the last performance review was completed on 1/27/17. CNA #5 was hired on 8/22/18. Review of CNA #5's employee record revealed no performance review. CNA #6 was hired on 7/7/08. Review of CNA #6's employee record revealed the last performance review was completed on 2/22/18. CNA #7 was hired on 11/7/18. Review of CNA #7's employee record revealed no performance review. On 2/26/20 at 5:55 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated CNA performance reviews should be completed six months after an employee is hired then annually. ASM #2 stated she was initially completing performance reviews based on employee's anniversary date but now the acting business office manager sends her emails to remind her of performance reviews that are due. At this time, ASM #1 (the administrator) and ASM #2 were made aware of the above concern. The facility policy titled, Performance/Review/Employee Evaluation documented, It is the supervisor's responsibility to conduct a written evaluation of each staff member directly reporting to him/her at a minimum of the following periods: -Completion of six months of employment. -Annually on the anniversary date (one year from the date the staff member is removed from the initial period of employment). No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident #17 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: acute respiratory failure [inability of the heart and lungs to maintain an adequate level of gas exchange.] (1), atherosclerotic heart disease [plaque consisting of cholesterol and lipids form on inner arterial walls of the heart.] (2); and pneumonia [inflammation of the lungs usually by bacterial infection.] (3) Resident #17's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 12/31/19, coded the resident as scoring 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status, coded the resident as requiring extensive assistance in bed mobility, transfers, dressing, bathing, toileting and personal hygiene; supervision in eating. Observation of Resident #17 on 2/26/20 at 7:30 AM, revealed the resident in bed with bilateral upper bed rails raised on the bed. A list was provided to ASM (administrative staff member) #1, the administrator, on 2/25/20 at 5:00 PM. The list consisted of a request for documented evidence of the annual bed safety inspection. Resident #17 was included on this list. None of the requested information for Resident #17 was provided. An interview was conducted on 2/26/20 at 10:57 AM with OSM (other staff member) #3, the director of maintenance. When asked what checks are done for safety inspections of beds and bed rails, OSM #3 stated, We perform a monthly room check that is random. We check that the bed and rails are functioning properly. We do not check every room monthly. Housekeeping informs maintenance if there is an issue. We do not have anything to do with checking for risk of entrapment. An interview was conducted on 2/26/2020 at 2:04 p.m. with ASM (administrative staff member) #1, the administrator. When asked for bed rail evaluations, ASM #1 stated, We have no side rail evaluations since 2018. When asked if there should be an assessment for risk of entrapment completed regularly, ASM #1 stated, I don't have an answer for that. You cannot add bed rails with the new regulations. The bed rail evaluation is not consistently being done. If we take off the bed rails, we would be nullifying the bed warranty and modification of the bed may change bed integrity. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/20 at 5:40 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 502. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 52. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 461. 7. Resident #27 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: right knee replacement [replacement of the kneecap and joints, which connect the thighbone and lower leg bone.] (1), osteoarthritis of the knees bilaterally [common form of arthritis characterized by degenerative changes in the joints.] (2); and hypertension (high blood pressure) (3). Resident #27's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/11/20, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status coded the resident as requiring supervision in bed mobility, dressing, bathing and personal hygiene, limited assistance with transfers and toilet use and independent in eating. On 2/26/20 at 7:40 AM, Resident #27 was Observation resting in bed with right upper bed rail raised on the bed and the left upper bed rail lowered at mattress level. A list was provided to ASM (administrative staff member) #1, the administrator, on 2/25/20 at 5:00 PM. The list consisted of a request for documented evidence of the annual bed safety inspection. Resident #27 was included on this list. None of the requested information for Resident #27 was provided. An interview was conducted on 2/26/20 at 10:57 AM with OSM (other staff member) #3, the director of maintenance. When asked what checks are done for safety inspections of beds and rails, OSM #3 stated, We perform a monthly room check that is random. We check that the bed and rails are functioning properly. We do not check every room monthly. Housekeeping informs maintenance if there is an issue. We do not have anything to do with checking for risk of entrapment. When the manufacturer's recommendations for Resident #27's bed were requested, OSM #3 stated, we do not have the manufacturer's guidelines for that bed, but I can get it. An interview was conducted on 2/26/2020 at 2:04 p.m. with ASM (administrative staff member) #1, the administrator. When asked for bed rail evaluations, ASM #1 stated, We have no side rail evaluations since 2018. When asked if there should be an assessment for risk of entrapment completed regularly, ASM #1 stated, I don't have an answer for that. You cannot add bed rails with the new regulations. The bed rail evaluation is not consistently being done. If we take off the bed rails, we would be nullifying the bed warranty and modification of the bed may change bed integrity. A review of Resident #27's bed rail with OSM (other staff member) #3, the director of maintenance, was conducted on 2/26/20 at 2:35 PM. When asked how he would identify the rails on Resident #27's bed, OSM #3 stated, I would call it a one half rail. When asked if he had received a work order or phone call regarding Resident #27's bed rail, OSM #3 stated, No, we have not. It does not retract all the way and I am having difficulty raising it. 2/26/20 at approximately 2:38 PM, the manufacturer's guidelines for Resident #27's bed, were provided, and reviewed with OSM (other staff member) #3, the director of maintenance. The guidelines documented in part the Safety Summary- Variations in side rail design and thickness, size or density of the mattress could cause entrapment. Maintenance and Cleaning- Maintenance and cleaning procedures should be performed at least once every three months. (4) ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/20 at 5:40 PM. On 2/27/20 at 10:00 AM, OSM #3, the director of maintenance was asked if he had received an order for bed rail repair for Resident #27. OSM #3 stated, No, we did not. We immediately repaired the rail yesterday. There was a screw that had worked out. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 319. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 420. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 282. (4) Medline Industries Inc., Owners & Maintenance Guide 2008, page 4 and 12. 8. Resident #55 was admitted to the facility on [DATE]. Resident #55's diagnoses included but were not limited to: pneumonia [inflammation of the lungs usually caused by an infection.] (1), bipolar disorder [mental disorder characterized by mania and depression] (2); schizophrenia [mental disorder characterized by gross distortions of reality, disturbances of thought, language and perception.] (3) Resident #55's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/7/20, coded the resident as scoring 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. MDS Section G- Functional Status: coded the resident as being totally dependent in bed mobility, dressing, toilet use, personal hygiene and bathing; requires supervision in eating. On 2/25/20 at 3:40 PM, Resident #55 was observed resting in bed with bilateral upper bed rails raised on bed. A list was provided to ASM (administrative staff member) #1, the administrator, on 2/25/20 at 5:00 PM. The list consisted of a request for documented evidence of the annual bed safety inspection. Resident #55 was included on this list. None of the requested information for Resident #55 was provided. An interview was conducted on 2/26/20 at 10:57 AM with OSM (other staff member) #3, the director of maintenance. When asked what checks are done for safety inspections of beds and rails, OSM #3 stated, We perform a monthly room check that is random. We check that the bed and rails are functioning properly. We do not check every room monthly. Housekeeping informs maintenance if there is an issue. We do not have anything to do with checking for risk of entrapment. When asked to be provided with the manufacturers recommendations for Resident #55's bed, OSM #3 stated, we do not have the manufacturer's guidelines for that bed, but I can get it. An interview was conducted on 2/26/2020 at 2:04 p.m. with ASM (administrative staff member) #1, the administrator. When asked for bed rail evaluations, ASM #1 stated, We have no side rail evaluations since 2018. When asked if there should be an assessment for risk of entrapment completed regularly, ASM #1 stated, I don't have an answer for that. You cannot add bed rails with the new regulations. The bed rail evaluation is not consistently being done. If we take off the bed rails, we would be nullifying the bed warranty and modification of the bed may change bed integrity. On 2/26/20 at approximately 2:010 PM, the manufacturer's guidelines for Resident #55's bed, were provided and reviewed with OSM (other staff member) #3, the director of maintenance. The guidelines documented in part the Important Precaution: An optimal bed system assessment should be conducted on each resident by a qualified clinician to ensure maximum safety of the resident. The assessment should be conducted within the context of, and in compliance with, the state and federal guidelines related to the use of restraints and bed system entrapment guidance, including the Clinical Guidance for the Assessment and Implementation of Side Rails published by the Hospital Bed Safety Workgroup of the U.S. Food and Drug Administration. (4) ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/20 at 5:40 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 461. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 71. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 518. (4) Joerns User-Service Manual, 2013 Joerns Healthcare, page 2. 4. Resident #161 was admitted to the facility on [DATE]. Resident #161's diagnoses included but were not limited to high blood pressure, muscle weakness and osteoporosis. Resident #161's admission MDS (minimum data set) with an ARD (assessment reference date) of 2/7/20, coded the resident's cognition as moderately impaired. Section G coded Resident #161 as requiring extensive assistance of one staff with bed mobility. On 2/25/20 at 1:58 p.m., Resident #161 was observed in bed with bilateral quarter bed rails up. Review of Resident #161's clinical record failed to reveal the facility staff assessed the resident's bed for areas of possible entrapment. On 2/26/20 at 4:14 p.m., an interview was conducted with OSM (other staff member) #3 (the maintenance director). OSM #3 stated the maintenance staff does conduct periodic random inspections of beds but does not assess beds for areas of possible entrapment. On 2/26/20 at 5:56 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 5. Resident #162 was admitted to the facility on [DATE]. Resident #162's diagnoses included but were not limited to diabetes, constipation and pulmonary fibrosis (a lung disease). Resident #162's admission MDS (minimum data set) assessment was not completed. An admission observation report dated 2/21/20 documented Resident #162 was alert and oriented to person, place, time and situation. The report further documented Resident #162 transferred with two person assistance. On 2/25/20 at 3:57 p.m., Resident #162 was observed in bed with bilateral quarter bed rails up. Review of Resident #162's clinical record failed to reveal the facility staff assessed the resident's bed for areas of possible entrapment. On 2/26/20 at 4:14 p.m., an interview was conducted with OSM (other staff member) #3 (the maintenance director). OSM #3 stated the maintenance staff does conduct periodic random inspections of beds but does not assess beds for areas of possible entrapment. On 2/26/20 at 5:56 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to inspect beds to identify areas of possible entrapment for eight of 38 residents, Residents #9, #14, #45, #161, #162, #17, #27, and #55. The findings include: 1. Resident #9 was admitted to the facility on [DATE], with diagnoses that included but were not limited to: fracture of her femur, high blood pressure, abnormalities of gait and mobility, and diabetes. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/3/19, coded the resident as scoring a 12 on the BIMS (brief interview for mental status) score, indicating she was moderately impaired to make daily cognitive decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance of one staff member for moving in the bed. On 2/25/2020, at 1:48 p.m., an observation and interview was conducted with Resident #9. The resident was in her bed with both bed rails up. Resident #9 stated she used them (bed rails) to help position herself. A list was provided to ASM (administrative staff member) #1, the administrator, on 2/25/20 at 5:00 PM. The list consisted of a request for documented evidence of the annual bed safety inspection. Resident #9 was included on this list. None of the requested information for Resident #9 was provided. An interview was conducted on 2/26/2020 at 10:57 a.m. with OSM (other staff member) #3, the director of maintenance, regarding the maintenance program for inspecting of all bed frames, mattresses, and bed rails, to identify areas of possible entrapment. OSM #3 stated, We perform a monthly room check that is random. We check that the bed and rails are functioning properly. We do not check every room monthly. Housekeeping informs maintenance if there is an issue. We do not have anything to do with checking for risk of entrapment. An interview was conducted on 2/26/2020 at 2:04 p.m. with ASM (administrative staff member) #1, the administrator. When asked for bed rail evaluations, ASM #1 stated, We have no side rail evaluations since 2018. When asked if there should be an assessment for risk of entrapment completed regularly, ASM #1 stated, I don't have an answer for that. You cannot add bed rails with the new regulations. The bed rail evaluation is not consistently being done. If we take off the bed rails, we would be nullifying the bed warranty and modification of the bed may change bed integrity. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/2020 at 5:40 p.m. The facility's policy Bed Safety Inspection dated 11/22/17, documented in part, Resident beds will be inspected at least annually for safe operation, risk of entrapment, resident comfort and potential for other adverse events. The community will establish a mechanism for completing the bed inspections at least annually or when a concern is identified. No further information was provided prior to exit. 2. Resident #14 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia, depression, stroke and high blood pressure. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/23/19, coded the resident as unable to complete the interview and coded the resident as having both short and long term memory difficulties and being severely impaired to make daily cognitive decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance of one staff member for moving in the bed. On 2/26/2020 at 8:02 a.m., Resident #14 was observed in her bed with both bed rails up in the upright position. A second observation was made of Resident #14 in her bed with both side bed rails up on 2/26/2020 at 2:00 p.m. A list was provided to ASM (administrative staff member) #1, the administrator, on 2/25/20 at 5:00 PM. The list consisted of a request for documented evidence of the annual bed safety inspection. Resident #14 was included on this list. None of the requested information for Resident #14 was provided. An interview was conducted on 2/26/2020 at 10:57 a.m. with OSM (other staff member) #3, the director of maintenance, regarding the maintenance program for inspecting of all bed frames, mattresses, and bed rails, to identify areas of possible entrapment. OSM #3 stated, We perform a monthly room check that is random. We check that the bed and rails are functioning properly. We do not check every room monthly. Housekeeping informs maintenance if there is an issue. We do not have anything to do with checking for risk of entrapment. An interview was conducted on 2/26/2020 at 2:04 p.m. with ASM (administrative staff member) #1, the administrator. When asked for bed rail evaluations, ASM #1 stated, We have no side rail evaluations since 2018. When asked if there should be an assessment for risk of entrapment completed regularly, ASM #1 stated, I don't have an answer for that. You cannot add bed rails with the new regulations. The bed rail evaluation is not consistently being done. If we take off the bed rails, we would be nullifying the bed warranty and modification of the bed may change bed integrity. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/2020 at 5:40 p.m. No further information was provided prior to exit. 3. Resident #45 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Alzheimer's disease [a progressive loss of mental ability and function, often accompanied by personality changes and emotional instability.] (1), abnormal posture, cough, and gastroesophageal reflux disease [backflow of the contents of the stomach into the esophagus, usually caused by malfunction of the sphincter muscle between the two organs; symptoms include burning pain in the esophagus, commonly known as heartburn.] (2) The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/31/2020, coded the resident as unable to understand other and unable to make herself understood. The resident was coded as being severely impaired to make daily cognitive decisions. Resident #45 was coded as totally dependent of one or more staff members for all of her activities of daily living. An observation was conducted on 2/27/2020 at 10:45 a.m., and revealed Resident #45 in bed with bilateral bed rails up at this time. A list was provided to ASM (administrative staff member) #1, the administrator, on 2/25/20 at 5:00 PM. The list consisted of a request for documented evidence of the annual bed safety inspection. Resident #45 was included on this list. None of the requested information for Resident #45 was provided. An interview was conducted on 2/26/2020 at 10:57 a.m. with OSM (other staff member) #3, the director of maintenance, regarding the maintenance program for inspecting of all bed frames, mattresses, and bed rails, to identify areas of possible entrapment. OSM #3 stated, We perform a monthly room check that is random. We check that the bed and rails are functioning properly. We do not check every room monthly. Housekeeping informs maintenance if there is an issue. We do not have anything to do with checking for risk of entrapment. An interview was conducted on 2/26/2020 at 2:04 p.m. with ASM (administrative staff member) #1, the administrator. When asked for bed rail evaluations, ASM #1 stated, We have no side rail evaluations since 2018. When asked if there should be an assessment for risk of entrapment completed regularly, ASM #1 stated, I don't have an answer for that. You cannot add bed rails with the new regulations. The bed rail evaluation is not consistently being done. If we take off the bed rails, we would be nullifying the bed warranty and modification of the bed may change bed integrity. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concerns on 2/26/2020 at 5:40 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms, 5th edition, Rothenberg and [NAME], page 26. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 243.

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to maintain the dumpster area in a clean and sanitary manner to prevent pests. Behind the three facility dumpsters, Styrofoam cups, three used gloves, one green and two blue were observed on the ground. Bits of trash were observed behind all three dumpsters The findings include: Observation was made of the three facility dumpsters was conducted on 2/27/2020 at 9:17 a.m., with OSM (other staff member) #3, the director of maintenance. Between two dumpsters, a puddle of spilled milk was observed on the ground. Behind the dumpsters, Styrofoam cups, three used gloves, one green and two blue were observed on the ground. There were bits of trash behind all three dumpsters. There were leaves and pine needles in the debris behind the dumpsters. When asked who is responsible for maintaining the area, OSM #3 stated ultimately, the grounds department. A copy of the policy for maintaining the dumpsters and dumpster area was requested. The facility policy titled, Dumpster Cleaning and Inspection documented in part, Policy: each community dumpster is to be kept free of litter, cleaned and disinfected according to the following procedure. The dumpster lid is to be kept closed. The Maintenance Director is responsible for maintaining the dumpster according to this policy .1. All staff members who discard trash/debris into the dumpster area will police the area to pick up any loose litter or debris. The staff person will close the dumpster lid prior to leaving the dumpster area. 2. The dumpster area will be swept daily. 3. The dumpster area will be cleaned as detailed in the procedure outline below at least monthly .5. The Maintenance Director, Administrator or designee, will inspect the dumpster area daily and document the inspection on the Dumpster Inspection Log. Any items needing attention will be corrected. 6. The Administrator will inspect the log and dumpster area at least monthly. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing and RN (registered nurse) #1, the quality assurance nurse, were made aware of the above concern on 2/27/1010 at 12:05 p.m. No further information was provided prior to exit.