Based on observation, resident interview, facility staff interview, clinical record review, and facility documentation review, the facility staff failed to provide the necessary services to maintain personal hygiene for one resident (Residents # 43) in a survey sample of 28 residents. Findings included: 1. For Resident # 43, the facility staff failed to provide showers as scheduled and failed to document completion of bathing tasks every shift. Resident # 43 was admitted to the facility in June 2024 with diagnoses that included but were not limited to: Multiple Sclerosis, Pulmonary Embolism and Urinary Tract Infection. The most recent MDS (minimum data set) assessment was an admission assessment with an ARD (Assessment Review Date) of 06/6/2024. The MDS coded Resident #43 with a BIMS (Brief Interview for Mental Status) Score of 15/15 indicating no cognitive impairment. Resident # 43 required extensive assistance of staff persons with ADLs (activities of daily living.) Resident # 43 was coded as continent of bowel and bladder. Review of the clinical record was conducted 6/26/2024-6/28/2024. On 6/27/2024 at 10:30 a.m., an interview was conducted with Resident # 43 who stated no showers had been provided by the facility staff during the 3 week stay at the facility (at the time of the survey.) Resident # 43 stated only on one evening, a Certified Nursing Assistant asked her about getting a shower that evening. Resident # 43 stated she declined the shower that evening because she did not feel well. Resident # 43 stated that she was not offered a shower on the next shift, next day nor any time after that evening. Resident #43 stated she would like to receive showers at least twice a week as scheduled. On 6/27/2024 at 11:20 a.m., an interview was conducted with the Unit Manager who stated she was not aware that Resident # 43 did not receive showers as scheduled. The Unit Manager stated Resident # 43 was alert and oriented with no cognitive impairment. The Unit Manager stated she wanted to talk with Resident # 43. The Unit Manager and surveyor went to Resident # 43's room. The Unit Manager asked Resident # 43 if she had received any showers. Resident # 43 stated she had not received any showers since admission to the facility. Certified Nursing Assistants (CNAs) were interviewed on all three units during survey, and indicated they documented all care in the Point of Care computerized system for each of their residents at the end of every shift. Review of the records for June 2024 revealed there was no documentation of showers being provided twice a week. Review of Resident # 43's physician orders, Treatment administration records (TAR's), Care plan, and progress notes indicated that Resident # 43 needed assistance with Activities of Daily Living. The records indicated that Resident # 43 was dependent on staff for bathing and showering. Review of the ADLs Bathing task revealed there were 9 shifts with missing documentation of the task being provided or completed since admission. Review of the Progress Notes revealed no documentation of reasons for the missing documentation of bathing or showering. On 6/27/2024, the Director of Nursing (DON), and Administrator were interviewed and asked about their expectation for bathing and showering. They stated all residents should receive showers twice a week and bed baths on the other days, and that the provision of care must be documented afterwards. Staff stated that the facility's policy was for residents to receive showers twice a week and bed baths on they days they did not get a shower. On 6/28/2024 at 3:05 p.m., an interview was conducted with the Director of Nursing who stated the expectation was for all residents to receive a bed bath on the days they did not receive a shower. The Director of Nursing stated the staff should document all baths and showers in the clinical record. A review was conducted of the facility policy titled, Activities of Daily Living (ADLs). The policy read, .4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); i. Each resident shall receive tub or shower baths as often as needed, but not less than twice weekly or as required by state law . During the end of day debriefing on 6/28/2024, the facility's Administrator, Director of Nursing and two Corporate Nurse Consultants (Employee-J and Employee N) were informed of the findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure an area on the resident's groin was assessed and reported to the physician for 1 of 28 residents (Resident #74), in the survey sample. The findings included: Resident #74 was originally admitted to the facility 12/05/23 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Traumatic Brain Injury. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/07/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #74 cognitive abilities for daily decision making were intact. The Person-Centered Care Plan dated 12/13/23 read that resident has a potential for impairment to skin integrity related to muscle weakness and incontinence. The goal for the resident was to ensure skin remain intact. Interventions for the resident would be for staff to follow facility policies/protocol for routine skin monitoring and to report any changes and to administer medications, supplements and treatments as ordered. On 06/25/24 at approximately 2:01 PM., during the initial tour an interview was conducted with the resident and Responsible Party (RP). The RP said that Resident #74 has an Ingrown hair follicle to the left groin area for a week that causes irritation. Resident #74 says that the area only hurts when you press on it. The RP also said that she had informed Licensed Practical Nurse C saw the area a week ago. Certified Nursing Assistant (CNA) F entered the resident's room and assisted the RP to show resident's groin area. A visual observation was made of the resident's left groin area. A small brown bump with some redness was observed with no discharge noted. Shortly thereafter, Licensed Practical Nurse (LPN) D entered the room, assessed the area on the resident's left area saying that the Nurse Practitioner will be notified. On 6/26/24 at approximately 2:26 PM., NP, M entered the room, assessed the area on the resident's left groin, asked the resident how long has the area been on the groin. The RP stated that the area has been there for 1 week. The NP informed the resident that she will prescribe an antibiotic. On 06/28/24 at approximately 10:28 AM., an interview was conducted with LPN C. LPN C said that she was not assigned to the resident a week ago but stopped by to see how he was doing. LPN C also said she informed the resident and the resident's RP that the area on the left groin looked like a small hair bump. LPN C also said that she thought that the CNA assigned to the resident was going to inform the resident's nurse, but moving forward she should have informed the nurse as well. A progress note dated on 6/25/24 at approximately 3:14 PM., read: I was asked to exam bump to L groin. Wife reports she noticed it last week and does not think it has become larger in size. He reports mild tenderness to palpation. On exam folliculitis suspected to two (2) follicle areas to L groin merged into one larger nodule about 3/4 inch in length on exam with erythema, no current open pustule areas. Discussed antibiotic treatment with wife and patient and RN and watching catheter as tubing near area can be irritating as well. irritating as well. On 6/28/24 at approximately 3:20 p.m., the above findings were shared with the Administrator, Director of Nursing (DON) and Corporate Consultant. No further comments were made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to provide pain management for one of 28 residents (R #30) in the survey sample. The findings included; For Resident #30, the facility staff failed to provide Lidocaine pain patches as ordered by a physician to manage pain for a Resident with bilateral leg ulcers and leg pain. Resident #30 was admitted on [DATE], with diagnoses including; ESRD (end stage renal disease), dialysis, dysphagia, peripheral vascular disease (PVD) with vascular ulcers, heart failure, heart disease, and cardiac pacemaker. A review of the clinical record revealed that on admission, Resident #30 had no real cognitive impairment, and was able to make her needs known. A review of the clinical record revealed physician's orders given on 5-24-24 for the following; - Lidocaine external patch 4% apply 2 patches to skin topically two times per day for pain, to remove per schedule. The Lidocaine patches were intended for bilateral leg pain (one patch on each leg), and were only ever scheduled to be applied on the medication administration record (MAR) once per day at 9:00 AM, and scheduled to be removed at 9:00 PM. The patches were never scheduled to be applied twice per day as was ordered. On 6-25-24 at approximately 1:00 PM, the Resident was interviewed and stated my legs hurt all the time. The pain patches help but don't last long enough, I need them more often, and sometimes I don't get them at all and some of the girls say you were at dialysis and I can't get them. The MAR was reviewed and revealed that the patches were only scheduled to be given once per day at 9:00 AM, and they were not applied even once per day, and omitted entirely for both ordered doses on the following days; 6-3-24, 6-4-24, 6-5-24, 6-6-24, 6-7-24, 6-8-24, 6-11-24, 6-12-24, 6-18-24, 6-19-24, 6-24-24, and 6-27-24, omitting 12 of 27 daytime doses. All of the 27 evening doses that were ordered, were never scheduled for administration leaving the resident without the prescribed pain medication throughout the evening and night. The Resident only received the pain patches on 4 occasions on her dialysis days for the 27 day period. Those follow; 6-10-24, 6-14-24, 6-17-24, and 6-21-24. Resident #30 went to dialysis on Monday, Wednesday, and Friday, and was scheduled to leave for dialysis at 5:30 AM, (chair time 6:00 AM), and return to the facility at 9:30 AM. which would not have interfered with the 9:00 AM ordered administration time. An interview with LPNs on the afternoon of 6-25-24, revealed that if the medication was ordered to be given twice per day the person transcribing the order made a mistake. When asked to review the MAR, each stated yes, that's clear and it's a mistake. When asked if this meant the resident was without pain medication, the LPNs stated that Residents usually have an order for Tylenol that they can use. They were asked if they felt that Tylenol was adequate pain control for all types of pain, they stated that it was not. They also stated that Resident #30 often complained of leg pain, and back pain. On 6-26-24, during the end-of-day meeting, the Administrator and Director of Nursing (DON) were made aware of the findings, and they stated they had no further information to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #291, the facility staff failed to ensure her Over The Counter meds were available for administration for 9 days. Resident #291 was originally admitted to the facility 6/16/24 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; After Care Following Joint Replacement Surgery. The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/16/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #291 cognitive abilities for daily decision making were intact. The Medication Administration Record (MAR) read: Apple Cider Vinegar Oral Tablet (Apple Cider Vinegar) Give 2 tablet by mouth one time a day for Supplement Start date 6/17/24. Beet Root Oral Capsule (Misc Natural Products) Give 6 tablet by mouth one time a day for Supplement. Start Date 6/17/24. Biotin Oral Tablet 5000 MCG (Biotin) Start Date 6/17/24. Give 6 tablet by mouth one time a day for Supplement Start Date 06/17/2024. The above medications were missed for 9 consecutive days June 17th -June 25th, 2024. Coded as 9 meaning see progress notes. A review of progress notes revealed no reason for the missed doses of the above medications. On 06/27/24 at approximately 5:01 PM., an interview was conducted with Resident #291 concerning medications. Resident #291 said that she has not received her vitamins since her admission. On 06/28/24 at approximately 11:34 AM., an interview was conducted with Resident #291 concerning her missed vitamins. Resident #291 said that she was informed by the staff this morning that she needs to bring her vitamins from home because they don't have them available at the facility. On 06/28/24 at approximately 11:20 AM., an interview was conducted with Registered Nurse B concerning the above missed medications. RN B said that the Over the Counter (OTC) meds that she was taking at home should have been brought to the facility. RN B also mentioned that the DON does the ordering of OTC meds. On 6/28/24 an interview was conducted with Licensed Practical Nurse (LPN) B. LPN B said that the Director of Nursing (DON) usually orders OTC medications in house. On 6/28/24 at approximately 3:20 p.m., the above findings were shared with the Administrator, Director of Nursing (DON) and Corporate Consultant. The DON said that she was not aware that the resident wasn't getting her OTC medication nor was she aware that she would have to get the medications from CVS pharmacy. Based on observations, clinical record review, staff interview and facility document review, the facility staff failed to acquire medications for 2 of 28 residents (R#2 and R#291) in the survey sample. The findngs include: 1. For Resident # 2, the facility staff failed to ensure medications were available for administration as ordered by the physician. Resident # 2 was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Fracture of Left Fibula, Edema, Alzheimer's Disease, Gastroesophageal Reflux Disease, Anxiety and Hypertension. Resident #2's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 05/17/2024 was a quarterly assessment. The MDS coded Resident # 2 with a BIMS (Brief Interview for Mental Status) score of 2 out of 15, indicating severe cognitive impairment. The MDS coded Resident # 2 as requiring extensive to total staff assistance with Activities of Daily Living. Review of the clinical record was conducted on 6/26/2024 to 6/28/2024. Review of the Progress Notes revealed the following documentation regarding medications being unavailable: 6/25/2024-Protonix 40 milligrams one tablet by mouth on order. 6/15/2024-Boost supplement on order. 6/11/2024-Mucinex 400 milligrams three times per day x 3 days on order. Review of the Inventory of Medications on hand at the facility revealed Pantaprazole 40 milligrams was available as a bulk medication in the facility. Review of the June 2024 Medical Administration Record (MAR) revealed the medication, Protonix was documented as not available for administration on 6/25/2024. Review of Physicians Orders revealed valid orders for the medication not available for administration. On 6/27/2024 at 11:48 a.m., an interview was conducted with LPN (Licensed Practical Nurse) D who stated the staff should notify the Pharmacy when medications are not available for administration, check the Pixus STAT box, notify the MD (Medical Doctor) and make sure the Pharmacy sends the medication STAT. On 6/27/2024 at 12:10 p.m., an interview was conducted with the Unit Manager who stated if a medication was not available at the time of scheduled administration, the nurses should go to the Pixus (on-site Stat box) to see if the medication was available in that stock. On 6/27/2024 at 1:55 p.m., an interview was conducted with the Director of Nursing who stated the Pharmacy should have medications available for administration as per Physicians Orders. A copy of the Pixus Stat Box medications list to determine if the missing medications were available in that supply was requested and received. On 6/27/2024 at 3:05 p.m., an interview was conducted with the Director of Nursing who stated the Pharmacy was responsible for delivery of medications. The Director of Nursing stated the nurses had access to medications that were delivered to the facility, if a medication was not available at the time of scheduled administration, the nurses should go to the Pixus (on-site Stat box) to see if the medication was available in that stock. The Director of Nursing stated if the medication was not in the Pixus, the nurse was expected to inform the physician to see if there was another medication order or if the doctor would give the approval for the medication to be started later when available from the Pharmacy. The Director of Nursing stated the facility always had a supply of Boost supplement available for residents. She stated It should have administered as ordered by the physician. Review of the Pixus Medbank STAT box contents revealed Pantaprozole 40 milligrams was on hand and available as a bulk medication. During the end of day debriefing on 6/27/2024, the facility Administrator and Director of Nursing were informed of the findings. Review of Physicians Orders revealed valid orders for the medications not available for administration. Guidance from the National Institutes of Health in the article The nurses medication day stated that Nurses serve as a barrier, protecting residents from potential hazards. Calls were also common to request 'missing meds' followed by waits until they were delivered. Waiting reflected system failures ncbi.nlm.nih.gov accessed 6/28/2024. On 6/28/2024 at 9:15 a.m., the Director of Nursing was interviewed. The Director of Nursing stated she reviewed some of the documentation and noticed that several of the entries about medications being unavailable were written by one of the Agency nurses who worked in the facility as needed. The Director of Nursing stated some of those medications were available in the Pixus when the nurse documented they were not available. The Director of Nursing stated she and the Staff Development Coordinator would continue to conduct training with all of the nursing staff (including agency nurses) to make sure they understood the procedures regarding medications being unavailable. During the end of day debriefing on 6/28/2024, the Corporate Director of Clinical Services (Employee J), Director of Nursing and Administrator were informed of the findings. They stated medications should be available for administration. They also stated the facility's nursing staff and agency staff were being inserviced on the procedures to follow when medications were not available as ordered by the physician. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to follow physician orders for 3 of 28 residents (#293, #2 and #30) in the survey sample The findings included: 1. Resident #293, the facility staff failed to ensure that a dressing for a wound on the resident's right lower extremity was changed according to physician's order. Resident #293 was originally admitted to the facility 6/26/24 after an acute care hospital stay. The current diagnoses included; Cellulitis of Right Lower Limb. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/26/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #293 cognitive abilities for daily decision making were moderately impaired. The Care Plan dated 6/27/24 read that Resident #293 has potential for impairment to the skin integrity related to Cellulitis of right lower leg. The goal for Resident #293 was that skin will be intact, free of redness and discoloration. An Intervention was to administer medications, supplements and treatments as ordered. Monitor/document. The June 2023 Order Summary dated 6/27/24 read: Right foot wound care-Remove old packing and apply the Lidocaine for 5 minutes prior to wound care. Cleanse the wound by irrigating it with the Vashe solution (use a syringe) and then wipe the wound bed. Pack the wound with Vashe moistened packing strip and then cover with an Calcium Ag w/silver and bordered dressing. Reapply the sock after dating/timing the dressing. change daily and as needed as needed for wound care. The order details dated 6/27/24 at 8:48 AM., read the above order. The Medication Administration Record (MAR) read to change the above dressing daily and as needed with a start date of 6/27/24 at 9:00 AM., On 6/28/24 at approximately 11:25 AM., Resident #293's family member was observed approaching Registered Nurse (RN) B, Unit Manager. The family member was heard asking RN, B if they going to change the resident's dressing. RN, B informed the family member that the dressing should be changed today. An interview was conducted on 06/28/24 at approximately 11:25 AM., concerning Resident #293. RN, B said that the dressing should be changed today. A review of the Medical Records/MR showed that RN, B revised the wound care orders on 6/28/24 at 11:27 AM., after speaking to the resident's family member concerning wound care. On 6/28/24 at approximately 11:27 AM., Resident #293's dressing was observed on her right foot with a date of 6/26/24. According to the Physician's Order Summary (POS), the dressing on the resident's right foot should have been changed on 6/27/24 during the day shift. On 6/28/24 at approximately 3:20 p.m., the above findings were shared with the Administrator, Director of Nursing (DON) and Corporate Consultant. The DON said that the dressing should have been change according to the orders. 2. For Resident # 2, the facility staff failed to administer medications and treatments on several dates as ordered by the physician . Resident # 2 was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Fracture of Left Fibula, Edema, Alzheimer's Disease, Gastroesophageal Reflux Disease, Anxiety and Hypertension. Resident #2's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 05/17/2024 was a quarterly assessment. The MDS coded Resident # 6 with a BIMS (Brief Interview for Mental Status) score of 2 out of 15, indicating severe cognitive impairment. The MDS coded Resident # 2 as requiring extensive to total staff assistance with Activities of Daily Living. Review of the clinical record was conducted 6/26/2024-6/28/2024. The Medication and Treatment Administration Record (MAR/TAR) was reviewed for June 2024, and revealed medications were not administered as ordered by the physician. Those dates were as follows: There were valid Physician orders for the medications and treatments that were omitted. The nursing facility stated Mosby's as their nursing standard. Mosby's stated all medications must be administered by the physician's order. Guidance for nursing standards for the administration of medication provided by Fundamentals of Nursing, 7th Edition, Mosby's/ [NAME]-[NAME], p. 705 stated Professional standards, such as the American Nurses Association's Nursing Scope and Standards of Nursing Practice of (2004), apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation. Resident 2's care plan was reviewed and revealed a care plan that instructed to administer medications and treatments as ordered by the physician. On 6/27/2024 at 10:20 a.m., an interview was conducted with Licensed Practical Nurse D who stated the expectation was for nurses to administer medications and treatments as ordered by the physician. On 6/27/2024, during the end of day debriefing with all surveyors, the Administrator and Director of Nursing were made aware of the failure of staff to administer medications as ordered. The Director of Nursing stated the expectation was for the staff to administer medications and treatments as ordered by the physician. No further information was provided. 3. For Resident #30, the facility staff failed to provide Lidocaine pain patches as ordered by a physician for a Resident with bilateral leg ulcers and leg pain, to manage that pain. The findings included; Resident #30 was admitted on [DATE], with diagnoses including; ESRD (end stage renal disease), dialysis, dysphagia, peripheral vascular disease (PVD) with vascular ulcers, heart failure, heart disease, and cardiac pacemaker. A review of the clinical record revealed that on admission, Resident #30 had no real cognitive impairment, and was able to make her needs known. A review of the clinical record revealed physician's orders given on 5-24-24 for the following; - Lidocaine external patch 4% apply 2 patches to skin topically two times per day for pain, to remove per schedule. The Lidocaine patches were intended for bilateral leg pain (one patch on each leg), and were only ever scheduled to be applied on the medication administration record (MAR) once per day at 9:00 AM, and scheduled to be removed at 9:00 PM. The patches were never scheduled to be applied twice per day as was ordered. On 6-25-24 at approximately 1:00 PM, the Resident was interviewed and stated my legs hurt all the time. The pain patches help but don't last long enough, I need them more often, and sometimes I don't get them at all and some of the girls say you were at dialysis and I can't get them. The MAR was reviewed and revealed that the patches were only scheduled to be given once per day at 9:00 AM, and they were not applied even once per day, and omitted entirely for both ordered doses on the following days; 6-3-24, 6-4-24, 6-5-24, 6-6-24, 6-7-24, 6-8-24, 6-11-24, 6-12-24, 6-18-24, 6-19-24, 6-24-24, and 6-27-24, omitting 12 of 27 daytime doses. All of the 27 evening doses that were ordered, were never scheduled for administration leaving the resident without the prescribed pain medication throughout the evening and night. The Resident only received the pain patches on 4 occasions on her dialysis days for the 27 day period. Those follow; 6-10-24, 6-14-24, 6-17-24, and 6-21-24. Resident #30 went to dialysis on Monday, Wednesday, and Friday, and was scheduled to leave for dialysis at 5:30 AM, (chair time 6:00 AM), and return to the facility at 9:30 AM. which would not have interfered with the 9:00 AM ordered administration time. An interview with LPNs on the afternoon of 6-25-24, revealed that if the medication was ordered to be given twice per day the person transcribing the order made a mistake. When asked to review the MAR, each stated yes, that's clear and it's a mistake. When asked if this meant the resident was without pain medication, the LPNs stated that Residents usually have an order for Tylenol that they can use. They were asked if they felt that Tylenol was adequate pain control for all types of pain, they stated that it was not. They also stated that Resident #30 often complained of leg pain, and back pain. The nursing facility stated Mosby's and Lippincott as their nursing standard. Both followed the NIH guidelines, as below; Nurses follow health care providers' orders unless they believe the orders are in error or harm patients. Therefore you need to assess all orders; if you find one to be erroneous or harmful, further clarification from the health care provider is necessary. To prevent medication or treatment errors, follow the six rights of medication administration consistently every time you administer medications or treatments. Many errors can be linked, in some way, to an inconsistency in adhering to these rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation Resident #30's care plan was reviewed and revealed a care plan for medications to be administered per physician's orders. On 6-26-24, during the end-of-day meeting, the Administrator and Director of Nursing (DON) were made aware of the findings, and they stated they had no further information to provide.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards for one resident, Resident #1, in a survey sample of three (3) residents. The findings included: For Resident #1, facility staff failed to administer a nutritional supplement as ordered by the Nurse Practitioner on 02/22/2022. On 09/13/2023, Resident #1's clinical record was reviewed and revealed a prescribed order, Supplement: ProSource ZAC daily via PEG, Once a Day; 12:00 p.m., start date 02/22/2022. Resident #1 received the first dose on 02/23/2022. On 09/13/2023 at approximately 4:15 p.m., a group interview was conducted with the Director of Nursing (DON) and the ordering Nurse Practitioner (NP). The NP stated, During the IDT [Interdisciplinary Team] meeting on the morning of February 22nd, we discussed resuming [name redacted, Resident #1's] protein supplement following her readmission from the hospital the previous day [02/21/2022]. I gave the verbal order during the morning meeting to resume the ProSource as she had been getting it previously to help with wound healing, it was indeed my intent for her to start receiving it the same day [02/22/2022]. The DON stated, [Resident #1] should have been given the ProSource on the 22nd, it is readily available on the medication carts. According to Lippincott Manual of Nursing Practice, 11th edition, 2019, page 15, Standards of Practice-General Principles, item 1, read, The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable and Box 2-1, Common Legal Claims for Departure from the Standards of Care, item 8, read, Failure to implement a physician's, advanced practice nurse's, or physician assistant's order properly or in a timely fashion. On 09/13/2023 during the end of day conference, the DON was updated on the findings. No further information was provided.

Based on observation, resident interview, group interview and staff interview, the facility staff failed to act promptly to resolve grievances discussed in the group interviews. For 6 of 6 residents in the Resident Council group, the facility staff failed to resolve the issues/concerns discussed in Resident Council. The Findings included: Review of the Resident Council meeting minutes from March 2021 through July 2021, revealed documentation of the same concerns during several of the months. There was no documentation of the facility administration's response to the concerns expressed during the meetings. 4/28/2021 Meeting agenda- New Business included statement Nursing: DON (Director of Nursing) and Administrator will remind nursing to introduce them self (sic) at the beginning of each shift. 5/19/2021- Meeting Minutes-Old Business Aides still not introducing themselves when they come on shift (residents would like to know who their aides are for the morning and night. Under New Business, the statement was included When residents need something, they are having to go and find the staff. Staff are not checking on them as they feel they should. 6/14/2021- Meeting Agenda- Old Business included Aids-Let you know who they are. Under Discussion of New Business was written Aids-poor attitudes, make beds/open blinds, responding to call bells, check on residents. Not enough aids on every shift Under Action items -an X was written beside the space for issues to raise within facility (Such as with Administrator or Quality Assurance Committee). 7/17/2021- Meeting Agenda-Council Old Business- Aids-not making beds or wrong way/still not introducing themselves, not enough. Under Discussion of New Business was written Aids-trying to get more/addressing continuing issues from old business Under Action items -an X was written beside the space for issues to raise within facility (Such as with Administrator or Quality Assurance Committee). On 7/21/2021 at 2:30 PM, a Group interview was conducted with six residents (Residents # 13, # 19, # 34, # 64, # 67 and # 78) who attended the meeting. One resident (Resident # 13) first spoke up and stated she wished the nursing assistants would introduce themselves to the residents at the beginning of their shifts. Resident # 13 stated it would help to know which Certified nursing assistant was working with them so they would know who would give them care that day and provide showers. All of the other residents agreed that there was an issue with the CNAs not introducing themselves. Resident # 13 stated it was :a problem almost every day that she did not know who was working with her that day. Residents # 67, # 34 and # 19 stated they continued to experience this problem even though they had talked about it several times to the Administration staff. The other residents nodded in agreement. 5 Residents in the group stated they do not get feedback after the Resident Council meetings. They stated they express their concerns and wait to hear back but do not hear any results. One stated she did not feedback but did not know how to answer that question since she was still waiting to hear an answer. On 7/22/2021 at 2:35 PM, an interview was conducted with the Director of Nursing about the concerns expressed during the Group Interview on 7/21/2021. The Director of Nursing reviewed the minutes of the Resident Council from March - July 2021 with Surveyor. The Director of Nursing stated the nursing staff including Certified Nursing Assistants should introduce themselves to the residents with whom they are scheduled. The Director of Nursing stated the nursing staff should make rounds at the beginning of their shift on the residents with whom they were scheduled and should introduce themselves The Director of Nursing stated the facility administration should follow up with the residents about their concerns expressed during the council meetings. The Director of Nursing stated the expectation was that all staff would know they should make rounds and she stated that the issue would be added to the staff education meetings ,new employee orientation and during regular staff meetings. The Director of Nursing stated the facility often used agency staff but the expectation was the same that staff would introduce themselves at the beginning of their shifts. The Director of Nursing stated she would follow up with the residents to let them know their concerns have been heard and of any steps taken to resolve them. During the end of day debriefing, the Administrator and Director of Nursing were informed of the findings. No further information was provided.

Based on observation, staff interview and group interview, the facility staff failed to ensure the results of the most recent surveys of the facility were readily accessible to residents and family representatives. For 6 of 6 attendees of the group interview, the facility staff failed to ensure the residents knew where to find the survey results form the previous surveys. The Findings included: The following written statement was submitted by Surveyor E regarding observations and an interview with the receptionist. On 7/21/21 at 10:40 AM, I (Surveyor E) went to the front lobby and reception area and didn ' t see any notice indicating where survey results were posted. I then went to the nursing station at unit 1 and looked around as well as looked on the bulletin board. I still didn ' t see any notice regarding the posting of survey results. I asked _____ (name redacted), the ADON (Assistant Director of Nursing) where they were kept and she said 'at the front desk.' I returned to the receptionist and behind her, against the wall on the counter was a sign that read last 3 years survey results and had an arrow pointing down to the drawer. I asked for the book and review of it did reveal 3 years of survey results contained within. On 7/21/21 at 10:46 AM, an interview was conducted with the receptionist. She indicated visitors don ' t come behind the desk that is considered her office area. She said people have to ask for the book of survey results and she will hand it to them. She also confirmed the receptionist area is staffed 24 hours a day. On 7/21/2021 at 2:30 PM, a Group interview was conducted with six residents (Residents # 13, # 19, # 34, # 64, # 67 and # 78) who attended the meeting. When the group was asked about the location of the previous survey results, all attendees stated they did not know exactly where to find the results. During the end of day debriefing on 7/22/2021. the administrator and Director of Nursing were informed of the findings. The Administrator stated the results were available in an area behind the receptionist. The Administrator stated the Receptionist's area was were the results were located inside a drawer under a sign pointing to the area. The Administrator was informed of the difficulty that the surveyor encountered in finding the results. The Administrator was informed of the fact that individuals who want to examine survey results have to ask to see them. The Administrator stated the receptionist would give the book with the results to anyone who requested to see them. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review and clinical record review, the facility staff failed to complete a SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice) for 1 Residents (Resident #66) in a survey sample of 33 Residents. For Resident #66, the facility staff failed to provide a SNF ABN notice prior to skilled care services, paid by Medicare, ended. Resident #66 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services, as known as a demand bill. The Findings included: Resident #66, was admitted to the facility on [DATE], with a readmission date of 3/5/21. Resident #66's diagnoses included but were not limited to: status post fall and hip fracture with repair. Resident #66's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 5/18/21 was coded as a quarterly assessment. Resident #66 was coded as cognitive skills for daily decision making being severely impaired. The resident was also coded as requiring extensive assistance of two staff members for activities of daily living (ADL's). Resident #66 was discharged from a Medicare covered Part A stay on 5/4/21, she remained in the facility. Facility record review of Medicare discharge notices on 7/21/21, revealed the facility issued a NOMNC (notice of Medicare non-coverage) and noted Resident #66's Responsible Representative was given the information via telephone on 4/30/21. When the staff provided a copy of the NOMNC for review, there had been a post-it note placed on the form which read, No ABN [Advance Beneficiary Notice] needed. Transitioned to MCD [Medicaid]. On 07/21/21 at 03:42 PM, an interview was conducted with Employee X, the Social Worker. Employee G confirmed that she is the person responsible for issuing NOMNC and ABN forms. Employee G stated that an ABN is the letter that explains once SNF [skilled nursing facility] services stop Medicare may not cover their stay here and why. It explains the costs for them to remain here if Medicare doesn't cover it. When asked who receives an ABN, Employee G stated, Anyone that is planning to remain in-house and they say whether they want to continue SNF services, or stay and pay privately. Employee G was asked if Resident #66 was issued an ABN and she said, No. She transitioned to where Medicaid was going to be covering and she didn't need any skilled services. The family wasn't responsible for the payment of anything and Medicaid was paying the room and board, so an ABN wasn't needed. Employee G was asked if Resident #66 had a patient liability [a financial obligation to pay towards her cost of care using her monthly income, then Medicaid pays the remainder of the costs]. Employee G stated, That I don't know. On 7/21/21 at approximately 4:00 PM, Surveyor E and Employee G went to the Administrator's office. The Administrator stated the purpose of ABN's and NOMNC's is to let the Resident know that their skilled stay is ending. The facility Administrator was unable to speak to when the 2 notices are provided and unable to speak to why Resident #66 was not issued an ABN. CMS identifies when the ABN is required to be issued in their document titled Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) read, Medicare requires SNFs to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: not medically reasonable and necessary; or Considered custodial. The SNFABN provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare Part A). SNFs will continue to use the ABN Form CMS-R-131 when applicable for Medicare Part B items and services. Accessed online at: https://www.cms.gov/search/cms?keys=ABN The Administrator was informed on 7/21/21 at approximately 4:10 PM, of the failure of facility staff to provide Resident #66 with a SNF ABN notice prior to skilled care services ending, which would have allowed Resident #66 or his representative, to make a decision about continuation of services and have Medicare make the coverage determination. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #2, the facility staff failed to prevent a Resident to Resident altercation and 2 recurrences with Resident #30 on 07/20/2021. Resident #2, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but were not limited to unspecified dementia with behavioral disturbance. Resident #2's most recent Minimum Data Set with an Assessment Reference Date of 03/08/2021 was coded as a quarterly assessment. Cognitive Skills for Daily Decision-Making were coded as severely impaired. Behavioral symptoms were coded as 0 meaning behaviors not exhibited during the 7-day lookback period. Resident #30, a 95- year old female, was admitted to the facility on [DATE]. Diagnoses included but were not limited to dementia and major depressive disorder. Resident #30's most recent Minimum Data Set with an Assessment Reference Date of 04/21/2021 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 9 out of possible 15 indicative of moderate cognitive impairment. Bed mobility and transfers were coded as requiring limited assistance from staff. Dressing was coded as requiring extensive assistance from staff. Mobility devices were coded as walker and wheelchair. Resident #17, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but were not limited to Alzheimer's disease and major depressive disorder. Resident #17's most recent Minimum Data Set with an Assessment Reference Date of 04/09/2021 was coded as a quarterly assessment. Cognitive Skills for Daily Decision-Making were coded as severely impaired. Functional status for bed mobility, transfers, and dressing were coded as requiring extensive assistance from staff. On 07/20/2021 at approximately 12:10 P.M., this surveyor entered Unit 4, the locked unit. At 12:13 P.M., this surveyor observed Certified Nursing Assistant A (CNA A) and another staff member attempt to redirect Resident #2 as she was yelling out to them. Resident #2 then hit CNA A on the left side of her head as she stood next to her. Resident #2 then sat down in a chair near the nurse's station. At approximately 12:15 P.M., this surveyor asked CNA A about the incident. CNA A stated that when [Resident #2] is [resistant], staff will redirect her and give her something to play with. CNA A also stated that [Resident #2] likes to clean so staff try to find things she can help us with. On 07/20/2021 at 12:20 P.M., Resident #2 was observed in Resident #17's room rummaging through the closet. Resident #17 was in her room seated in her wheelchair by her bed. Resident #2 then took a purple-colored top that was hanging on the door handle of Resident #17's room and proceeded to walk down the hall. Resident #2 then entered the room of Resident #30. Resident #30 was seated in her wheelchair and facing the hall just inside the threshold of her room entrance. Resident #2 walked past Resident #30, then turned and faced Resident #30 and shouted, Get out of here! Get out of here! Resident #30 stated, Why are you yelling at me? Licensed Practical Nurse A (LPN A) was there to redirect Resident #2 out of Resident #30's room. Resident #2 then walked back to Resident #17's room to the closet touching the clothes on hangers. A staff member stood in the doorway of Resident #17's room and tried to redirect Resident #2 to go to the dining room for lunch. Resident #2 stated, No! Get out of here! Resident #2 then took a floral sweater off of the hanger and walked back down the hall toward Resident #30's room with Resident #17's purple top and floral sweater. As Resident #2 entered Resident #30's room, LPN A and another staff member were heading toward Resident #30's room. Resident #2 started yelling unintelligibly. Resident #30 stated, I have no idea what she wants from me! Resident #2 then left Resident #30's room and stood outside her room door holding the purple top and floral sweater. LPN A positioned herself between Resident #2 and Resident #30 while trying to redirect Resident #2. Resident #2 then walked to the nurse's station area and sat in a chair nearby. On 07/20/2021 at 12:32 P.M., an interview with Registered Nurse A (RN A) was conducted. RN A was standing near the med card by the nurse's station. When asked about Resident #2's behaviors, RN A stated that Resident #2 had underlying mood behaviors. RN A also stated that [Resident #2] is usually easily redirected and we let her cool off. When asked if she has been involved in Resident-to-Resident Altercations, RN A stated, No. We don't see her yelling at other Residents. When asked about the process when a Resident-to-Resident Altercation occurs, RN A stated that they separate the Residents, try to figure out what happened, have activities come to offer snack, fluids, and games. RN A then stated they would document the altercation as well. On 07/20/2021 at 12:37 P.M., this surveyor noted Resident #2 was no longer sitting in the chair by the nurse's station. This surveyor went to Resident #30's room. The door was closed. This surveyor knocked on the door and heard Resident #30 state, Come in. From the hall, this surveyor observed Resident #30 in her wheelchair by a table just hanging up the phone and stated, I was just trying to call my son. Resident #30 then self-propelled her wheelchair near the entrance of her room. Her bathroom door was open slightly and situated to her left. When asked how she was feeling about what happened with [Resident #2], Resident #30 pointed to her bathroom and stated, She's washing something in my apartment! I don't know what the hell she wants! At that time, Resident #2 exited Resident #30's bathroom holding a roll of toilet paper and several paper towels in her left hand. Resident #2 spoke loudly in unintelligible speech. Resident #2 then grabbed Resident #30's right wheelchair handle and forcefully pushed Resident #30's wheelchair forward. The left side of Resident #30's wheelchair hit the door jamb of her room entrance. Resident #30 stated, Let go of my chair! Resident #2 then walked past Resident #30, exited her room, and walked down the hall with the roll of toilet paper and paper towels. When Resident #30 was asked if she was okay and how was she feeling about this, Resident #30 stated, I feel sorry for her. When asked if this happens frequently, Resident #30 stated, This has been happening a lot; especially today. There was no staff observed in the hall during this time. At 12:49 P.M., Resident #2 was observed seated by the nurse's station eating lunch. At 12:56 P.M., an interview with LPN A, the unit manager, was conducted. When asked about her perspective of the Resident-to-Resident altercation between [Resident #30 and Resident #2], LPN A stated that it sounded like [Resident #2] was telling [Resident #30] to get out of her own room. LPN A also stated that she was trying to redirect [Resident #2]. When asked if this occurs frequently, LPN A stated No. LPN A also stated that we try to redirect and normally that works. LPN A added that [Resident #2] was confused and upset about something. When asked about the process when a Resident-to-Resident Altercation occurs, LPN A stated that the staff is expected to make sure the one is safe and redirect the other. LPN A also stated that staff should reassure her [Resident #30] and make sure she [Resident #2] doesn't go back and do it again. LPN A also indicated the process included getting everyone to monitor her and keep an eye on her. LPN A was notified Resident #2 was observed by this surveyor in Resident #30's room for a third time and forcefully moving Resident #30's wheelchair into the door jamb. LPN A did not mention reporting Resident-to-Resident altercations to the administrator. At 1:36 P.M., the administrator was notified of the above observations of Resident to Resident altercations involving Resident #2, Resident #30, and Resident #17. The administrator stated he would send a Facility-Reported Incident (FRI) to the state agency and begin an investigation. On 07/20/2021 at 3:19 P.M., the facility staff provided a copy of the FRI that was submitted to the state agency related to the above observations. On 07/20/2021, Resident #2's clinical record was reviewed. A nurse's noted dated 07/20/2021 at 3:19 P.M. documented, Resident became agitated before lunch and went into another residents [sic] room then into her bathroom and washed her hands, came back out and resident in room [number] was sitting in her wheelchair and this resident shoved the wheelchair into the wall (resident in room [number] was unharmed) and left the room. A nurse's note dated 07/20/2021 at 3:19 P.M. documented, [Name] NP [nurse practitioner] notified and RP [responsible party] [name] via voicemail. Interventions to prevent recurrence were not addressed in the note. On 07/20/2021, Resident #30's most recent progress notes were reviewed. A nurse's note dated 07/20/2021 at 3:21 P.M., documented, Writer was notified that another resident entered this residents [sic] room and went into her bathroom and washed her hands then came out and told resident get out of the way and pushed resident's wheelchair into the wall with resident sitting in the chair - the chair hit the wall and the resident was unharmed. Writer went and spoke with resident about incident and she could not recall incident writer was describing. RP [responsible party] [name] notified - message left on voicemail. [name] NP [nurse practitioner] notified of above. At the end of day meeting on 07/20/2021 at 4:53 P.M., the administrator was asked about the process when a Resident-to-Resident altercation occurs, the administrator indicated that a FRI would be filled out; they would launch an investigation, obtain witness statements, compile all the information, have a plan, submit a 5-day follow-up [to the state agency] and re-evaluate the plan. On 07/20/2021, the facility staff provided a copy of their policy entitled, Abuse Prevention, Investigation and Reporting. An excerpt in Section IV (C) documented, Resident to Resident altercations are potentially situations of abuse.the facility will respond immediately to protect the safety of others, investigate the incident and respond with measure [sic] to prevent recurrence. On 07/21/2021 at 3:30 P.M., the administrator and Director of Nursing were notified of concerns with the repeated Resident-to-Resident altercations observed on 07/20/2021. By the end of survey on 07/22/2021, the administrator stated there was no further documentation or information to submit. Based on interview, clinical record review, and facility documentation review the facility staff failed to implement the abuse policy for 2 Residents (#71and #2) in a survey sample of 33 Residents. 1. For Resident #71 the facility staff failed to obtain prevent physical abuse of by a CNA contracted employee, and also failed to obtain the Virginia State Police criminal background check prior to allowing the staff to work with the Resident. Resident #71, a [AGE] year old woman admitted to the facility on [DATE] with diagnoses including diabetes type II, dementia with behavioral disturbance, chronic kidney disease, and pancreatitis. Resident #71's most recent MDS (Minimum Data Set) assessment coded Resident #71 as having a BIMS (Brief Interview of Mental Status) score of 4 indicating severe cognitive impairment. She was coded as requiring extensive assistance with all aspects of ADL (Activities of Daily Living) care. The Resident required the use of a sit to stand lift for transfers and a wheel chair for mobility. On 7/21/21 an interview was conducted at 9:36 AM with Resident #71's family member. During interview the family member stated that she comes to the facility every day. She showed folders where she takes notes on what is happening at the facility while she is present. She expressed concern that Resident #71 recently been hit by an agency staff member while she was being given a shower. She further stated the incident was witnessed by 2 other staff. The family member she got a call at 9:45 PM on 6/29/21 from the Administrator telling her of an incident involving her mother. She stated that he told her three CNA's were working in the memory care unit 2 were Agency and one was a staff CNA. One of the agency CNA's (CNA G) assigned to Resident #71 didn't want to give her shower. CNA G asked the other 2 CNA's for assistance with the shower as this Resident was confused and upset. While giving her a shower the Resident pushed CNA G's hand out of the way. CNA G then hit the Resident in the head with the hand held shower wand and sprayed her in the face with the water. [The facts of this story were corroborated by the FRI Investigation and Witness Statements sent in to the OLC.] An interview was conducted with the Business office Manager on 7/22/21 at approximately 2:00 PM. She stated that the facility did not have (Agency) CNA G's VA State Police Criminal background check at the facility. She stated that she made several attempts to obtain it from the agency, however they only received a criminal check from a private company not the Virginia State Police Background Check. The CNA's license was valid in VA, but they had no record of VA State Police Check to see if she had any barrier crimes prior to working in the facility. The criminal background check was performed by private company and the background check on file contained the following statement, criminal records obtained from a database search for employment screening purposes must be verified with a County Criminal Court Search to obtain current up to date case status. This report does not guarantee the accuracy or truthfulness of the information. A review of the facility Abuse and Neglect Policy read: Abuse Policy C. Criminal record checks are requested on all new employees prior to assuming resident related duties. If agency or contract staff is use the vendor providing the contracted service will be required to obtain a criminal record checks for all staff assigned to the home and make the criminal record checks information available to the facility in a timely manner upon request. On 7/22/21 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. For Resident #2, the facility staff failed to prevent a recurrence of Resident to Resident altercation with Resident #30 on 07/20/2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and facility documentation and in the course of an investigation the facility staff failed to develop and implement a baseline care plan for 1 Resident (#340) in a survey sample of 33 Residents. The findings included For Resident #340 the facility staff failed to develop and implement a baseline care plan that includes the instructions needed to provide person centered care to the Resident. Resident #340 was admitted to the facility on [DATE]. Diagnoses for Resident #340 included but were not limited to Rhabdomyolysis, acute respiratory failure, acute kidney failure, altered mental status, history of bladder cancer and BPH (Benign Prostatic Hypertrophy), history of UTI, and Atrial Fibrillation. Resident #340's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 1/26/21 coded Resident #340 with a BIMS (Brief Interview of Mental Status) score of 14 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #340 as requiring extensive assistance for Activities of Daily Living care with the exception of eating he was independent with meals. The resident required a mechanical lift for transfers and used a wheelchair for mobility as he was non-ambulatory. On 7/21/21 at approximately 2:00 PM an interview was conducted with Employee D who was asked if there were any more documents related to the care plan other than the 3 pages she had submitted during the complaint investigation. She stated she did not believe so, and when asked about a baseline care plan or admission care plan she replied We use the same form in the computer we just add to it, so it starts on admission and we just keep adding there is not a separate baseline and comprehensive. A review of the care plan submitted revealed that it was started on 1/20/21 and it read as follows; PROBLEM: Problem Start Date: 1/20/21 - CATEGORY - fall - Resident is at risk for falls due to weakness and history of falls GOAL: Short term target date 4/19/21 - Resident will be free of falls - APPROACH: Approach start date: 1/20/21 Implement exercise program that targets strength, gait and balance - Discipline - Nursing Approach Start date: 1/20/21 - Order comprehensive medication review by pharmacist, assess for polypharmacy and medication that will increase falls. - Discipline- Nursing PROBLEM: Problem Start Date: - 1/20/21 - CATEGORY - Nutritional Status - Resident is at nutrition risk d/t obesity atherosclerotic heart disease, HTN, GERD, Respiratory failure. GOAL: Short term target date 4/19/21 - Resident will remain at stable weight + / - 2# by next review APPROACH: Approach Start Date: 1/20/21 - Monitor and record intake at meals Discipline - Nursing Approach Start Date: 1/20/21 - Monitor weight monthly and weekly as needed - Discipline - Nurse Practitioner, Nursing, Physician, RD Approach Start Date: 1/20/21 - Offer h.s. snack compliant with current diet Discipline - Nursing, dietary Approach Start Date: 1/20/21 - provide diet as ordered Discipline - Nursing dietary PROBLEM Problem Start Date: 1/25/21 - CATEGORY - Activities GOAL: Short term target date 4/25/21 - Life Enrichment staff will visit resident 1:1 at least once a week for social and emotion [sic] well-being, Due to COVID 19 restrictions group activities are not allowed, therefore, life enrichment staff will provide resident with independent activities as well during his stay. APPROACH: Approach Start Date: 1/25/21 - Life Enrichment staff will make sure resident has updated TV guide to be able to watch his favorite shows. Discipline - Activities Approach Start Date: 1/25/21 - - Life Enrichment staff will make sure resident has books, magazines and newspapers to read to maintain cognition. Discipline - Activities Approach Start Date: 1/25/21 - - Life Enrichment staff will offer resident times to go outside when weather is nice to be able to get fresh air Discipline - Activities On 7/21/21 at approximately 11:00 AM an interview was conducted with LPN A, who was asked the purpose of a care plan. LPN A stated A care plan is to show the staff the needs of the Resident and how to meet the needs. It should tell you how they transfer and how they eat, if they wear briefs or are incontinent, even stuff like thickened liquids and behaviors. When asked who updates the care plans she stated that the nurses could all update it. When asked how often it should be updated she said any time there is a change in the Resident's status or condition. In summary during the time of this admission [DATE] through the discharge on [DATE] only 3 care areas were addressed, Activities, fall, and Nutrition. On 7/22/21 during the end of day conference the Administrator was made aware of the concerns and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to develop and implement the care plan for 2 residents (Resident #2 and Resident #71) in a sample size of 33 Residents. The Findings included: 1. For Resident #2, the facility staff failed to implement the care plan. Specifically, the facility staff failed to: a) Ensure adequate distance between resident and others to ensure safety of residents. This resulted in taking clothing from Resident #17 and 3 episodes of Resident-to-Resident altercations with Resident #30 on 07/20/2021. (b) Supervise wandering on units, resulting in Resident #2 walking with a fork, a stapler, and wandering into the unit manager's office on 07/21/2021. Resident #2, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but were not limited to unspecified dementia with behavioral disturbance. Resident #2's most recent Minimum Data Set with an Assessment Reference Date of 03/08/2021 was coded as a quarterly assessment. Cognitive Skills for Daily Decision-Making were coded as severely impaired. Behavioral symptoms were coded as 0 meaning behaviors not exhibited during the 7-day lookback period. Resident #30, a 95- year old female, was admitted to the facility on [DATE]. Diagnoses included but were not limited to dementia and major depressive disorder. Resident #30's most recent Minimum Data Set with an Assessment Reference Date of 04/21/2021 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 9 out of possible 15 indicative of moderate cognitive impairment. Bed mobility and transfers were coded as requiring limited assistance from staff. Dressing was coded as requiring extensive assistance from staff. Mobility devices were coded as walker and wheelchair. Resident #17, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but were not limited to Alzheimer's disease and major depressive disorder. Resident #17's most recent Minimum Data Set with an Assessment Reference Date of 04/09/2021 was coded as a quarterly assessment. Cognitive Skills for Daily Decision-Making were coded as severely impaired. Functional status for bed mobility, transfers, and dressing were coded as requiring extensive assistance from staff. On 07/20/2021 at approximately 12:10 P.M., this surveyor entered Unit 4, the locked unit. At 12:13 P.M., this surveyor observed Certified Nursing Assistant A (CNA A) and another staff member attempt to redirect Resident #2 as she was yelling out to them. Resident #2 then hit CNA A on the left side of her head as she stood next to her. Resident #2 then sat down in a chair near the nurse's station. At approximately 12:15 P.M., this surveyor asked CNA A about the incident. CNA A stated that when [Resident #2] is [resistant], staff will redirect her and give her something to play with. CNA A also stated that [Resident #2] likes to clean so staff try to find things she can help us with. On 07/20/2021 at 12:20 P.M., Resident #2 was observed in Resident #17's room rummaging through the closet. Resident #17 was in her room seated in her wheelchair by her bed. Resident #2 then took a purple-colored top that was hanging on the door handle of Resident #17's room and proceeded to walk down the hall. Resident #2 then entered the room of Resident #30. Resident #30 was seated in her wheelchair and facing the hall just inside the threshold of her room entrance. Resident #2 walked past Resident #30, then turned and faced Resident #30 and shouted, Get out of here! Get out of here! Resident #30 stated, Why are you yelling at me? Licensed Practical Nurse A (LPN A) was there to redirect Resident #2 out of Resident #30's room. Resident #2 then walked back to Resident #17's room to the closet touching the clothes on hangers. A staff member stood in the doorway of Resident #17's room and tried to redirect Resident #2 to go to the dining room for lunch. Resident #2 stated, No! Get out of here! Resident #2 then took a floral sweater off of the hanger and walked back down the hall toward Resident #30's room with Resident #17's purple top and floral sweater. As Resident #2 entered Resident #30's room, LPN A and another staff member were heading toward Resident #30's room. Resident #2 started yelling unintelligibly. Resident #30 stated, I have no idea what she wants from me! Resident #2 then left Resident #30's room and stood outside her room door holding the purple top and floral sweater. LPN A positioned herself between Resident #2 and Resident #30 while trying to redirect Resident #2. Resident #2 then walked to the nurse's station area and sat in a chair nearby. On 07/20/2021 at 12:32 P.M., an interview with Registered Nurse A (RN A) was conducted. RN A was standing near the med card by the nurse's station. When asked about Resident #2's behaviors, RN A stated that Resident #2 had underlying mood behaviors. RN A also stated that [Resident #2] is usually easily redirected and we let her cool off. When asked if she has been involved in Resident-to-Resident Altercations, RN A stated, No. We don't see her yelling at other Residents. When asked about the process when a Resident-to-Resident Altercation occurs, RN A stated that they separate the Residents, try to figure out what happened, have activities come to offer snack, fluids, and games. RN A then stated they would document the altercation as well. On 07/20/2021 at 12:37 P.M., this surveyor noted Resident #2 was no longer sitting in the chair by the nurse's station. This surveyor went to Resident #30's room. The door was closed. This surveyor knocked on the door and heard Resident #30 state, Come in. From the hall, this surveyor observed Resident #30 in her wheelchair by a table just hanging up the phone and stated, I was just trying to call my son. Resident #30 then self-propelled her wheelchair near the entrance of her room. Her bathroom door was open slightly and situated to her left. When asked how she was feeling about what happened with [Resident #2], Resident #30 pointed to her bathroom and stated, She's washing something in my apartment! I don't know what the hell she wants! At that time, Resident #2 exited Resident #30's bathroom holding a roll of toilet paper and several paper towels in her left hand. Resident #2 spoke loudly in unintelligible speech. Resident #2 then grabbed Resident #30's right wheelchair handle and forcefully pushed Resident #30's wheelchair forward. The left side of Resident #30's wheelchair hit the door jamb of her room entrance. Resident #30 stated, Let go of my chair! Resident #2 then walked past Resident #30, exited her room, and walked down the hall with the roll of toilet paper and paper towels. When Resident #30 was asked if she was okay and how was she feeling about this, Resident #30 stated, I feel sorry for her. When asked if this happens frequently, Resident #30 stated, This has been happening a lot; especially today. There was no staff observed in the hall during this time. At 12:49 P.M., Resident #2 was observed seated by the nurse's station eating lunch. At 12:56 P.M., an interview with LPN A, the unit manager, was conducted. When asked about her perspective of the Resident-to-Resident altercation between [Resident #30 and Resident #2], LPN A stated that it sounded like [Resident #2] was telling [Resident #30] to get out of her own room. LPN A also stated that she was trying to redirect [Resident #2]. When asked if this occurs frequently, LPN A stated No. LPN A also stated that we try to redirect and normally that works. LPN A added that [Resident #2] was confused and upset about something. When asked about the process when a Resident-to-Resident Altercation occurs, LPN A stated that the staff is expected to make sure the one is safe and redirect the other. LPN A also stated that staff should reassure her [Resident #30] and make sure she [Resident #2] doesn't go back and do it again. LPN A also indicated the process included getting everyone to monitor her and keep an eye on her. Resident #2's care plan was reviewed. A focus dated 08/20/2020 documented, [Resident #2] exhibits the following behaviors: she has poor safety awareness and she will bump into walls, objects etc. when walking at a fast pace. Observed to wipe down tables and desk areas. Wandering in and out of other resident rooms and turning lights on and off, pushing on exit doors. Combative with ADL care. Refusing skin care treatments. Verbally, and physically aggressive with staff. Behavior increases with staff attempts at redirection or when providing care. hx [history of] of Hit [sic] staff with her shoe, smack staff in the chest area, picking up objects in attempt to use as a weapon toward staff . Use of profanity toward staff: shove it up you ass, bitch, Nigger. Physically combative toward others, taking items of others, not belonging to her. Using others drinks to clean tables. Turning the lights on of others, removing the covers off of others, Not easily re-directed at times. Flailing her arms and yelling, cries. One intervention associated with this focus included but was not limited to the following: When resident becomes physically abusive, keep distance between resident and others to ensure safety of resident and others (e.g., staff, other residents, visitors). On 07/21/2021 at approximately 1:00 P.M., an interview with the Director of Nursing (DON) was conducted notified of finding and asked about the expectation of staff following a Resident-to-Resident altercation. The DON stated that staff should separate the Residents and redirect. The DON stated that staff should get her mind [Resident #2] on something else. The DON also stated the expectation is to call families and let them know and to document it. The DON also stated they could send an email to the pharmacist to have a look at her medications. On 07/21/2021 at 3:30 P.M., the administrator and DON were notified of concerns with the repeated Resident-to-Resident altercations observed on 07/20/2021. By the end of survey on 07/22/2021, the administrator stated there was no further documentation or information to submit. 1(b) On 07/202/2021, Resident #2's care plan was reviewed. A focus dated 01/24/2021 documented, [Resident #2] is at risk for: Skin Tears and Bruising related to: fragile skin and capillaries, hx [history] of multiple skin tears and bruises, reduced environmental safety awareness, wandering behaviors, hx of combative behaviors and during ADL [activities of daily living] care Dx [diagnosis]: Unspecified mood (affective) disorder, dementia with behavioral disturbance. One intervention associated with this focus included but was not limited to Supervise wandering on units. On 07/21/2021 at 8:10 A.M., Resident #2 was observed walking into the dining room on Unit 4 and standing next to a table situated by the glass wall on the right side of the room. Resident #2 was arranging silverware and napkins on the table. Resident #2 then picked up a fork, a spoon, and napkin and exited the dining room. Resident #2 was then observed entering the unit manager's office and closing the office door. Resident #2 was observed walking up to the desk, reaching out and touching the window beyond the desk, touching the desktop, then opening the office door, and exiting the office. Employee E was seated at the nurse's station which is just outside the unit manager's office. There were also 6 residents in chairs in close proximity to the nurse's station. Resident #2 walked to the desk behind Employee E. A staff member walked past the nurse's station toward the med cart beyond the unit manager's office. Neither staff member noticed Resident #2 had silverware in her hand. Resident #2 was observed cleaning the fork and spoon with the napkin while standing at the desk at the nurse's station behind Employee E. Employee E then left the area and walked down the hall. Resident #2 was observed with a stapler, opening and closing the anvil, and moving the spoon along the base of the stapler. At 8:14 A.M., Resident #2 was then observed picking up the stapler and the spoon (leaving the fork on the desk) and walking the length of the hallway and placed the stapler and the spoon on the windowsill at the end of the hall by room [ROOM NUMBER]. Resident #2 was observed opening and closing the stapler by that window at the end of the hall. Resident #2 left the stapler on the windowsill and sat down on a bench at the end of the hall. At 8:18 A.M., the Director of Nursing (DON) was on Unit 4 and this surveyor notified the DON of observations. The DON retrieved the fork from the desk and the stapler from the windowsill. On 07/21/2021 at approximately 1:00 P.M., the DON was interviewed. When asked about the expectation from staff concerning the observations of Resident #2 with a fork, the stapler, and entering the unit manager's office, the DON stated that the silverware should not have been set out on the tables in the dining room and the dining room doors should have been closed to keep [Resident #2 out of the dining room. The DON also stated that we can't let her walk around with a fork. The DON also stated that [Resident #2] likes to clean and that staff will let her clean the desk [at the nurse's station]. At approximately 1:10 P.M., this surveyor and the DON entered the unit manager's office. There was a corkboard with thumb tacks on the left wall. The desk on the right side of the room had three side drawers. The top drawer had a lock and the DON stated that the unit manager, [Licensed Practical Nurse A (LPN A)] usually locks these drawers. The DON then opened each of the drawers (they were unlocked). In the second drawer, the contents included but were not limited to 2 large pairs of scissors (one with orange handles and one with black handles). The DON removed them from the drawer and placed them on top of a cabinet in the office. At approximately 1:15 P.M., LPN A entered the office. When asked if the drawers were locked, she stated no and added that she didn't have a key to those drawers. On 07/21/2021 at approximately 3:30 P.M., the administrator and DON were notified of concerns. On 07/22/2021 at approximately 2:40 P.M., the DON was interviewed in the conference room with Surveyor A present. When asked about the intervention on the care plan Supervise wanderings on units, the DON stated it was not a good intervention because you can't watch her every second. On 07/22/2021, the facility staff provided a copy of their policy entitled, Comprehensive Care Planning. Under the header Procedure in Section 9 (e) and (h), it was documented, The comprehensive care plan will: (e) Reflect treatment goals, timetables, and objectives in measurable outcomes; (h) promote resident safety. By the end of survey on 07/22/2021, the administrator stated there was no further documentation or information to submit. 2. For Resident #71 the facility staff failed to develop and implement a care plan that was patient centered and included measurable objectives to meet the needs of the Resident. 2. For Resident #71 the facility staff failed to develop and implement a care plan that was patient centered and included measurable objectives to meet the needs of the Resident. Resident #71, a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to diabetes type II, dementia with behavioral disturbance, chronic kidney disease, and pancreatitis. Resident #71's most recent MDS (Minimum Data Set) assessment coded Resident #71 as having a BIMS (Brief Interview of Mental Status) score of 4 indicating severe cognitive impairment. She was coded as requiring extensive assistance with all aspects of ADL care. The Resident required the use of a sit to stand lift for transfers and a wheel chair for mobility. On 7/21/21 during the clinical record review it was noted that the Resident's care plan read: Care plan read as follows: PROBLEM: Problem Start Date - 6/5/2020 - Category: Falls [Resident name redacted] is at risk for falls r/t dementia with behavioral disturbance, metabolic encephalopathy, diminished safety awareness, impaired gait balance and mobility, use of assistive devices, side effects of cardiovascular and say psychotropic medication, history of falls sustaining fracture. Goal: long-term goal target 5/26/21 Resident will not experience a fall requiring hospital stay through the next review. Approach: Approach start date 6/5/20 - Assist resident as needed with toileting incontinent care on a regular basis. Discipline - Nursing Approach Start Date - 6/10/20 - Educate family and staff on needs for monitoring after window visits with family Discipline - nursing Approach Start Date: 8/30/20 OT Re-eval W/C positioning. Discipline: Nursing and OT Approach Start Date: 10/30/20 PT/OT referral -Discipline: Nursing Approach Start Date: 11/5/20 - transfers with sit to stand lift-Discipline: Nursing Approach Start Date: 4/20/21-Ensure completion of routine rounds every shift, every day, every evening, and every night. Discipline nursing Approach Start Date: 7/22/20 medication review completed to help patient sleep better at night. Discipline Nursing Approach Start Date: 7/22/20 safety checks as indicated -Discipline: Nursing. Approach Start Date: 2/17/21 psych consult as needed discipline nursing Approach Start Date: 2/17/21 PT to eval and treat as indicated discipline PT/OT Approach Start Date: 7/5/20 frequent observations for safety checks -Discipline: Nursing Approach Start Date: 7/22/20 bring resident to nurses station for closer monitoring.-Discipline: Nursing The following are excerpts from Resident #71's Care Plan for the Problem Category Behavioral Symptoms: PROBLEM: start date 6/8/20 CATEGORY: behavioral symptoms [Resident name redacted] has behavior hx of resist care, get agitated with requests and combative and verbally abusive at times and hx of plays with her stool. Verbally abusive to staff, cursing, yelling, attempting to hit staff, wandering, entering room of other, banging on closet door, disrobing self of clothes and incontinent briefs. [Resident name redacted] is usually not a morning person Her behaviors can place her at increased risk of abuse as she can be combative and physically aggressive towards staff. GOAL: Long term goal target date 5/26/21- Episodes of behaviors will decrease and resident's needs will be met thru next review. Approach Start Date: 6/8/20 Explain all procedures to resident before attempting. DO NO FORCE to participate in ADL's if behavior is escalating. Report to nurse and allow resident to calm down before re-attempting. PROBLEM: start date 6/30/21 CATEGORY: behavioral symptoms [Resident name redacted] is at risk for increased behaviors due to experiencing physical trauma. GOAL: long-term goal target gate 9/30/21 Resident will not experience increased behavior and all needs will be met through next review. APPROACH: Approach start date: 6/30/21 Assess for signs and symptoms of pain/discomfort and provide pain meds as ordered DISCIPLINE: nursing Approach start date 6/30/21 document residence behavior status on a regular basis. Discipline NURSING Approach start date 6/30/2021 explain all procedures to resident before attempting Discipline activities, nursing, OT/PT/RD and social services Approach start date: 6/30/21 offer support for family when needed and requested. DISCIPLINE administrator nurse practitioner nursing position and social services Approach start date: 6/30/21 provide support and encouragement when resident exhibits behaviors. DISCIPLINE activities, nursing, and social services Approach start date 6/30/21 psych consult as ordered Discipline NURSING Approach start date: 6/30/21 - Report increased behaviors or abnormalities to the MD discipline blank Approach start date 6/30/21 social service visits/consult as needed. The behavioral aspect of the care plan do not specify behaviors and or provide specific interventions to address each behavior that is targeted. This care plan Problem was only started after an incident of resident experiencing physical trauma, however the Resident's chart reflects behavior disturbances beginning on admission. On 7/21/21 at approximately 11:00 AM an interview was conducted with LPN A, who was asked the purpose of a care plan. LPN A stated A care plan is to show the staff the needs of the Resident and how to meet the needs. It should tell you how they transfer and how they eat, if they wear briefs or are incontinent, even stuff like thickened liquids and behaviors. When asked who updates the care plans she stated that the nurses could all update it. When asked how often it should be updated she said any time there is a change in the Resident's status or condition. On 7/22/21 at approximately 2:18 PM an interview was conducted with the DON who stated, that she was aware there were some issues with the care plans not being specific and resident centered with measurable objectives. She said We are trying to make it a team approach so that we can fine tune the care plans. On 7/22/21 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident interview, staff interview, facility documentation review and clinical record review, the facility failed to provide ADL assistance to maintain personal hygiene for 2 Residents (Resident #190, #71) in a survey sample of 33 Residents. For Resident #190, the facility staff failed to provide personal hygiene assistance for shaving; he was dependent on staff for assistance. The Findings included: Resident #190 was admitted to the facility on [DATE], following hospitalization for a surgical wound infection. Resident #190 came to the facility requiring skilled services for therapy and IV (intravenous) antibiotic therapy treatment. Resident #190's diagnosis included but were not limited to: MRSA( methicillin susceptible staphylococcus aureus) infection, cellulitis of left lower limb, difficulty walking, displaced intertrochanteric fracture of left femur, chronic atrial fibrillation, and hypertension. Resident #190 had not been in the facility long enough for an MDS (minimum data set) assessment to be completed. The clinical record revealed Resident #190 was alert, oriented and with some periods of confusion. He required assistance from facility staff with ADL's (activities of daily living). On 7/20/21 at 12:45 PM, observations were made of the Resident #190, he was observed with significant facial hair that was a full beard growth. On 7/20/21 at 3:10 PM, Resident #190 was interviewed and asked about the facial hair, when asked if he normally has a full beard, he said, No. I haven't been shaved since I've been here and I can't do it. On 7/21/21, Resident #190 was observed with the facial hair again. He had not been shaven. On 7/22/21 at approximately 2:00 PM, an interview was conducted with CNA I. CNA I confirmed she was assigned to care for Resident #190 on 7/22/21. CNA I said, I ask my male Residents in the morning if they want to be shaved. It took me 3 razors to get him shaved today. On 7/22/21 at approximately 2:30 PM, the Director of Nursing (DON) was asked about personal hygiene assistance for Resident #190. The DON stated, I know, I said something to them [the staff]. I told them to shave him. When asked when she made this request, she said, On Tuesday, I went and talked with him after you had talked to him, and he told me he wanted to be shaved and bathed. It should have been done days ago. Review of the clinical record revealed that Resident #190 required staff assistance with personal hygiene per the ADL records. There was no indication within the record that the Resident refused to be shaved or desired to have a full beard. Review of the facility policy titled, Resident Care and Services read, 3. Residents are assigned to caregivers on each shift, who will be responsible to provide the necessary assistance to the resident in accomplishing ADLs for that shift, including: * Showering or Bathing (twice per week or as needed) * Dressing * Toileting * Transferring * Incontinence management * Eating *Ambulation or Mobility *Personal hygiene (such as shaving, oral care, brushing hair) *Medication Administration. 4. The provision of ADL assistance is documented in the resident's record. On 7/22/21 at approximately 2:30 PM, the DON was informed that facility staff had not provided Resident #190 with personal hygiene assistance with shaving since his admission on [DATE], until 7/22/21. No further information was provided. 2. For Resident #71 during the one month period from 6/5/20 through 7/5/20 failed to provide adequate bathing and or showering. 2. For Resident #71, during the one month period from 6/5/20 through 7/5/20, the facility staff failed to provide adequate bathing and or showering. Resident #71, a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to diabetes type II, dementia with behavioral disturbance, chronic kidney disease, and pancreatitis. Resident #71's most recent MDS (Minimum Data Set) assessment coded Resident #71 as having a BIMS (Brief Interview of Mental Status) score of 4 indicating severe cognitive impairment. She was coded as requiring extensive assistance with all aspects of ADL care. The Resident required the use of a sit to stand lift for transfers and a wheel chair for mobility. On 7/22/20 after hearing concerns from Resident #71's family about ADL care provided and showers being given, as well as resident's laundry smelling of urine a review of the ADL records was conducted. It was noted that in POC (Point of Care), the CNA documentation area of the chart, that Resident # 71 was only given 1 shower between 6/5/20 and 7/5/20. She was given only one complete bed bath in that same time frame. The documentation coded the Resident as receiving Partial Bed Bath on 33 occasions in that same 1 month period. A review of the ADL policy revealed: From day of admission 6/5/20 through 7/5/20 Resident #71 was only given a shower on 1 occasion according to the POC (Point of Care) system where the CNA's document the care provided to the Residents. The Resident was also only given a Complete Bed Bath on one occasion during this same time period. On 7/21/21 at approximately 2:15 PM an interview with CNA B was conducted and she was asked how the CNA's documented care that was provided. CNA B stated that care was documented in POC. When asked how CNA's know the type of care to give and how much assistance is needed, she stated it's from the care plan. On 7/22/21 at approximately 2:10 PM an interview was conducted with the DON who stated that the CNA's use POC to document when they provide any ADL care. The DON was told of family concern regarding ADL care especially on weekends and she replied Weekend ADL's are tough due to staffing challenges. She was asked how often CNA's bathe or shower the Residents. She stated that each Resident was assigned 2 shower days a week. When asked if a Resident does not get a shower or refused a shower what should happen? She stated that the CNA should notify the Nurse and document the refusal, as well as, give a Complete Bed Bath instead. When asked if it was acceptable practice for a CNA to give only 1 Shower and 1Complete Bed Bath in a month, and give Partial Bed Baths 33 times in that same month, she stated that is was not acceptable. She stated the expectation is that the Resident should have 2 showers a week and be provided partial or complete bed bath between shower days. It was also noted in the POC documentation that some staff were documenting the resident was totally dependent, some wrote independent, and some wrote set up only. When asked how the CNA's knew what type of care and assistance was required she stated that it was addressed in the care plan. When asked do the CNA's have access to the care plan she stated that they did On 7/22/21 during the end of day conference the Administrator was made aware of the concerns with ADL care and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to supervise one Resident (Resident #2) in a sample size of 33 Residents. Specifically, Resident #2 was observed walking with a fork, a stapler, and entering into the unit manager's office with access to items including but not limited to thumb tacks and scissors resulting in a potential accident hazard. The Findings included: Resident #2, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but were not limited to unspecified dementia with behavioral disturbance. Resident #2's most recent Minimum Data Set with an Assessment Reference Date of 03/08/2021 was coded as a quarterly assessment. Cognitive Skills for Daily Decision-Making were coded as severely impaired. Behavioral symptoms were coded as 0 meaning behaviors not exhibited during the 7-day lookback period. On 07/21/2021 at 8:10 A.M., Resident #2 was observed walking into the dining room on Unit 4 and standing next to a table situated by the glass wall on the right side of the room. Resident #2 was arranging silverware and napkins on the table. Resident #2 then picked up a fork, a spoon, and napkin and exited the dining room. Resident #2 was then observed entering the unit manager's office and closing the office door. Resident #2 was observed walking up to the desk, reaching out and touching the window beyond the desk, touching the desktop, then opening the office door, and exiting the office. Employee E was seated at the nurse's station which is just outside the unit manager's office. There were also 6 residents in chairs in close proximity to the nurse's station. Resident #2 walked to the desk behind Employee E. A staff member walked past the nurse's station toward the med cart beyond the unit manager's office. Neither staff member noticed Resident #2 had silverware in her hand. Resident #2 was observed cleaning the fork and spoon with the napkin while standing at the desk at the nurse's station behind Employee E. Employee E then left the area and walked down the hall. Resident #2 was observed with a stapler, opening and closing the anvil, and moving the spoon along the base of the stapler. At 8:14 A.M., Resident #2 was then observed picking up the stapler and the spoon (leaving the fork on the desk) and walking the length of the hallway and placed the stapler and the spoon on the windowsill at the end of the hall by room [ROOM NUMBER]. Resident #2 was observed opening and closing the stapler by that window at the end of the hall. Resident #2 left the stapler on the windowsill and sat down on a bench at the end of the hall. At 8:18 A.M., the Director of Nursing (DON) was on Unit 4 and this surveyor notified the DON of observations. The DON retrieved the fork from the desk and the stapler from the windowsill. On 07/21/2021 at approximately 1:00 P.M., the DON was interviewed. When asked about the expectation from staff concerning the observations of Resident #2 with a fork, the stapler, and entering the unit manager's office, the DON stated that the silverware should not have been set out on the tables in the dining room and the dining room doors should have been closed to keep [Resident #2 out of the dining room. The DON also stated that we can't let her walk around with a fork. The DON also stated that [Resident #2] likes to clean and that staff will let her clean the desk [at the nurse's station]. At approximately 1:10 P.M., this surveyor and the DON entered the unit manager's office. There was a corkboard with thumb tacks on the left wall. The desk on the right side of the room had three side drawers. The top drawer had a lock and the DON stated that the unit manager, [Licensed Practical Nurse A (LPN A)] usually locks these drawers. The DON then opened each of the drawers (they were unlocked). In the second drawer, the contents included but were not limited to 2 large pairs of scissors (one with orange handles and one with black handles). The DON removed them from the drawer and placed them on top of a cabinet in the office. At approximately 1:15 P.M., LPN A entered the office. When asked if the drawers were locked, she stated no and added that she didn't have a key to those drawers. On 07/21/2021 at approximately 3:30 P.M., the administrator and DON were notified of concerns. By the end of survey on 07/22/2021, the administrator stated there was no further documentation or information to submit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and facility documentation, the facility staff failed to ensure residents are free from unnecessary psychotropic drugs for 1 Resident (#71) in a survey sample of 33 Residents. The Findings included: For Resident #71 the facility staff failed to attempt the required GDR's for the 3 psychotropic medications and failed to accurately document appropriate diagnoses for the medications. Resident #71, a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to diabetes type II, dementia with behavioral disturbance, chronic kidney disease, and Pancreatitis. Resident #71's most recent MDS (Minimum Data Set) assessment coded Resident #71 as having a BIMS (Brief Interview of Mental Status) score of 4 indicating severe cognitive impairment. She was coded as requiring extensive assistance with all aspects of ADL care. The Resident required the use of a sit to stand lift for transfers and a wheel chair for mobility. On 7/21/20 a review of the clinical record revealed that Resident #71 had orders for the following psychotropic medications: Sertraline [generic Zoloft-Anti-depressant] - 50 mg [DX. Other specified depressive episodes] Once a day at 9:00 AM (start 6/5/20 D/C -6/10/20) Sertraline [generic Zoloft-Anti-depressant] - 50 mg [DX. Other specified depressive episodes] Once a day at 9:00 PM (start 6/10/20 D/C 6/30/20) Mirtazapine [Generic Remeron -Anti-Depressant] 7.5 mg once a day at bedtime 9:00 PM [DX: Adverse effect of appetite depressants] (Start 6/11/20 DC 6/30/20) Mirtazapine [Generic Remeron -Anti-Depressant] 7.5 mg give once a day at bedtime 9:00 PM [DX: Anorexia] (Start 6/30/20 DC 8/07/20) Mirtazapine [Generic Remeron -Anti-Depressant] 7.5 mg give once a day at bedtime 9:00 PM [DX: Major depressive disorder, recurrent unspecified] (Start 8/7/20 DC 2/26/20) Mirtazapine [Generic Remeron -Anti-Depressant] 15 mg give once a day at bedtime 9:00 PM [DX: Major depressive disorder, recurrent unspecified] (Start 2/26/20 - open ended) Quetiapine [Generic Seroquel - Anti-psychotic] 25 mg Twice a day 9:00 AM, 5:00 PM [DX: unspecified mood disorder} (start date 6/30/20 DC 7/22/20) Seroquel [Generic- Quetiapine Anti-psychotic] Tablet 25 mg: amount 25 mg once a day at 6:00 AM [DX: unspecified mood disorder} (start date 7/22/20 DC 8/7/20) Seroquel [Generic- Quetiapine Anti-psychotic] Tablet 25 mg: amount 50 mg once a day at 5:00 PM [DX: unspecified mood disorder} (start date 7/22/20 DC 8/7/20) Seroquel [Generic- Quetiapine Anti-psychotic] Tablet 25 mg: amount 25 mg once a day at 6:00 AM [DX: unspecified mood disorder} (start date 8/7/20 - open ended) Seroquel [Generic- Quetiapine Anti-psychotic] Tablet 25 mg: amount 50 mg once a day at 5:00 PM [DX: unspecified mood disorder} (start date 7/22/20 - open ended) Lorazepam (ATIVAN - anti anxiety) 2 mg/ml (milligrams per milliliter) give 0.25 ml (0.5 mg) [Dx: anxiety disorder] every 12 hours PRN (start date 7/8/20 DC 7/22/20) Lorazepam (ATIVAN - anti anxiety) 0.5 mg Tablet; 0.25 mg amt.: [Dx: anxiety disorder] give twice a day 9:00 AM and 5:00 PM [start date 7/21/21 - DC 7/22/21) Lorazepam ((ATIVAN - anti anxiety)) 0.5 mg Tablet; 0.5 mg amt.: [Dx: anxiety disorder] give twice a day 9:00 AM and 9:00 PM [start date 7/21/20 - DC 7/22/20) Lorazepam ((ATIVAN - anti anxiety)) 0.5 mg Tablet; 0.5 mg amt: [Dx: anxiety disorder] give twice a day 9:00 AM and 9:00 PM [start date 8/7/20 - DC 9/22/20) Lorazepam ((ATIVAN - anti anxiety)) 0.5 mg Tablet; 0.5 mg [Dx: anxiety disorder] give twice a day 9:00 AM and 9:00 PM [start date 9/22/20- DC 10/30/20) Trazadone [Desyrel- Anti-Depressant] 50 mg at bedtime 9:00 PM [Dx; Primary Insomnia] (Start date 7/7/20 DC 8/7/20) Trazadone [Desyrel- Anti-Depressant] 50 mg at bedtime 9:00 PM [Dx; Primary Insomnia] (Start date 8/7/20 - open ended) On 7/22/21 a review of the pharmacy Gradual Dose Reduction Tracking Report for Resident #71 read as follows: Sertraline (Zoloft) Therapy start date 11/5/20 Last GDR Attempt [column left blank] -next GDR Eval. 5/5/21 Mirtazapine (Remeron) therapy start date 6/12/20 - Last GDR Attempt - [column left blank] - next GDR Eval. 12/31/21 Seroquel (Quetiapine) Therapy start date 6/30/20 - Last GDR Attempt [column left blank] Next GDR Eval 12/31/21 On 7/21/20 a review of the clinical record revealed that MDS diagnoses listed for Resident #71 included: MDS - admission 6/12/20 -Section I -Active Diagnosis - Psychiatric/ Mood disorder coded the Resident as having 15800 Depression other than bi-polar. Quarterly MDS -11/14/20 - Section I -Active Diagnosis - Psychiatric/ Mood disorder coded the Resident as having 15800 Depression other and anxiety disorder was also checked on this MDS. A review of the pharmacy recommendations revealed that on 7/2/20 the pharmacy report read: [Resident #71 name redacted] was admitted with an anti-psychotic, Seroquel, for an inappropriate indication: Dementia with behavioral disturbance Seroquel Labeled indications: Bipolar depression, Bipolar disorder, mania, schizophrenia. Recommendation: Please consider a GDR with the end goal of discontinuation while monitoring for re-emergence of target symptoms and or withdrawal. If this is not desired please update the medical record to include: 1. The specific diagnosis/indication requiring treatment that is used based upon an assessment of the resident's condition and therapeutic goals and 2. A list of the symptoms or target behaviors (e.g. hallucinations, scratching) including their impact on the resident (e.g. increases distress, presents a danger to the resident or others, interferes with his or her ability to eat) The physician checked the box that read: I accept the above with the following Mediation modifications: Indication- Mood Disorder. On 7/22/21 an interview was conducted with the DON who was asked about GDR for Psychotropic's and she stated that the physician signed for contraindication. When she examined the pharmacy consultation sheet she stated I see he checked the box but did not put in the rationale for not attempting GDR with this Resident . On 7/22/21 during the end of day meeting the Administrator was made aware of the concerns involving GDR and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility documentation review, the facility staff failed to label and store medication according to accepted professional principles for one Resident (Resident #10) out of a sample size of 33 Residents. The Findings included: For Resident #10, his multi-dose bottle of lorazepam suspension was opened and undated in the med room [ROOM NUMBER] fridge. Resident #10, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but were not limited to Parkinson's disease. On [DATE] at 10:55 A.M., this surveyor and Licensed Practical Nurse B (LPN B) entered the med room on Unit 2. When asked about the acceptable temperature range for the fridge, LPN B stated it should be between 40-45 degrees and added as long as it is not in the red zone. The temperature log for the small fridge could not be located. Upon opening the small med fridge, LPN B and this surveyor observed the temperature gauge inside the fridge to be 52 degrees Fahrenheit. LPN B stated that she would report it to maintenance and let the unit manager know. A sign on the wall next to the fridge documented the following: If the refrigerator temps are not between 36 and 46 degrees: Adjust the temperature so that it ends up in that temperature range. Recheck the temperature to make sure it adjusted; and record the corrected temp if in range. We are losing thousands of $$ in vaccines to out of range temps being recorded but not adjusted and re-recorded. 36 degrees to 46 degrees at all times. LPN B and this surveyor then observed the medications in the fridge. There was a locked, anchored box which contained an opened, undated bottle of lorazepam suspension labeled with Resident #10's name. When asked if the medication had been opened, LPN B stated, Yes. When asked how that was determined, LPN B stated that unopened bottles have a seal across the top but this bottle for Resident #10 did not have a seal. When asked when it was opened, stated the bottle was not dated. When asked about the importance of dating the bottle, LPN B stated so we'll know when it expires. When asked why that was important, LPN B stated that it's dangerous to give an expired medication to a Resident. At 11:08 A.M., this surveyor and LPN B saw LPN A, unit manager for Unit 4, outside the med room on Unit 2. LPN A was notified of observations in the med room. When asked about the expectation for dating medication, LPN A stated the bottle should be dated on the day it was opened. When asked about the fridge temperature log, LPN A went to the med room to look around. LPN A stated it is usually sitting on the top of the fridge and the 11-7 shift usually checks it. A copy of the manufacturer's information for Resident #10's lorazepam was requested as well as the narcotic sheet to determine when it was first opened. On [DATE] at approximately 1:20 P.M., LPN A offered an update. LPN A stated that Resident #10's lorazepam was first opened on [DATE] according to the narcotic sheet. LPN A also stated so it was disposed of. LPN A also stated that the small fridge temperature log was located in the protective sheet behind the other fridge's log. A copy of the temperature log was requested. On [DATE], the facility staff provided a copy of the small fridge temperature log, the manufacturer's information for Resident #10's lorazepam, and the narcotic sheet for Resident #10's lorazepam. The med room refrigerator temperature log document was entitled, 11-7 Shift Monthly Refrigerator/Freezer Checks. The sub-header was entitled, Unit: #2. Under the column labeled [DATE], there were 12 dates without temperatures recorded: [DATE] - [DATE]; [DATE]; [DATE]-[DATE]; and [DATE]-[DATE]. At the bottom of the page, it was documented, Note: the temperature of the Med Room refrigerator and freezer and the supplemental Refirgerator [sic] are to be read and recorded nightly by the 11-7 Nurse, for each unit. Please report all abnormal temperarures [sic] immediately to the Supervisor. On [DATE] the facility staff provided he manufacturer's information for Resident #10's lorazepam. Excerpts under the header, Lorazepam Oral Concentrate documented, Store at cold temperature. Refrigerate at 2 to 8 degrees [Centigrade] (36-46 degrees F [Fahrenheit]). Discard opened bottle after 90 days. On [DATE] at 3:30 P.M., the administrator and Director of Nursing were notified of findings. By the end of survey on [DATE], the administrator stated there was no further documentation or information to submit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident interview, staff interview, facility documentation review and clinical record review, the facility failed to provide beverages consistent with Resident needs and preferences for 1 Resident (Resident #190) in a survey sample of 33 Residents. For Resident #190, the facility staff failed to provide liquids/beverages in a consistency as ordered by the physician and requested by the Resident. The Findings included: Resident #190 was admitted to the facility on [DATE], following hospitalization for a surgical wound infection. Resident #190 came to the facility requiring skilled services for therapy and IV (intravenous) antibiotic therapy treatment. Resident #190's diagnosis included but were not limited to: MRSA( methicillin susceptible staphylococcus aureus) infection, cellulitis of left lower limb, difficulty walking, displaced intertrochanteric fracture of left femur, chronic atrial fibrillation, and hypertension. Resident #190 had not been in the facility long enough for an MDS (minimum data set) assessment to be completed. The clinical record revealed Resident #190 was alert, oriented and with some periods of confusion. He required assistance from facility staff with ADL's (activities of daily living). On 7/20/21 at 12:45 PM, observations were made of a cup of liquid on the bedside table that was congealed. Additionally, a packet of thickener was noted on the bedside table. On 7/20/21 at 12:45 PM, during an interview with Resident #190, he reported they keep giving me that stuff to drink and I would rather go home and die than drink that stuff! My son brought the papers over here showing them I'm not supposed to be on it, but they keep bringing it to me. I'm so thirsty. During this interview, staff brought in his meal tray which did have a cup of a thin consistency beverage. His meal tray ticket was observed and it read, Diet: Regular, Texture: Regular, Fluid: Thin. Review of the clinical record revealed that Resident #190 had an active physician order for liquids of a thin consistency that was effective 7/14/21. The care plan revealed a nutritional status care plan that read, Adjust diet, as needed, per SLP (Speech Language Pathologist). On 7/20/21 an interview was conducted with the Speech Therapist at the bedside of Resident #190. Resident #190 expressed his frustration to her over the facility staff continuing to provide thickened liquids. The speech therapist commented that I don't know why you are still getting it, I changed that a week ago. When asked about the cup of thickened liquid at the bedside, she said it appeared someone had thickened something that it had sat so long it started to congeal. She threw the cup away as well as the packet of thickener, stating it shouldn't be here. On 7/22/21, a request was made of the facility staff to provide their policy with regards to following physician orders and dietary preferences. The requested policies were not received prior to survey exit. On 7/22/21 at approximately 2:30 PM, the Director of Nursing (DON) was informed that facility staff continued to provide Resident #190 with thickened liquids which he did not have an order to receive and expressed dissatisfaction with. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to prevent abuse involving 4 Residents (Resident #30, #17, #2, #71) in a sample size of 33 Residents. The Findings included: 1. For Resident #30, the facility staff failed to protect her from 3 episodes of Resident-to-Resident altercations by another female Resident (Resident #2) on 07/20/2021. For Resident #17, the facility staff failed to prevent another female Resident (Resident #2) from rummaging through her closet and taking her purple top and floral sweater on 07/20/2021. Resident #30, a 95- year old female, was admitted to the facility on [DATE]. Diagnoses included but were not limited to dementia and major depressive disorder. Resident #30's most recent Minimum Data Set with an Assessment Reference Date of 04/21/2021 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 9 out of possible 15 indicative of moderate cognitive impairment. Bed mobility and transfers were coded as requiring limited assistance from staff. Dressing was coded as requiring extensive assistance from staff. Mobility devices were coded as walker and wheelchair. Resident #17, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but were not limited to Alzheimer's disease and major depressive disorder. Resident #17's most recent Minimum Data Set with an Assessment Reference Date of 04/09/2021 was coded as a quarterly assessment. Cognitive Skills for Daily Decision-Making were coded as severely impaired. Functional status for bed mobility, transfers, and dressing were coded as requiring extensive assistance from staff. Resident #2, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but were not limited to unspecified dementia with behavioral disturbance. Resident #2's most recent Minimum Data Set with an Assessment Reference Date of 03/08/2021 was coded as a quarterly assessment. Cognitive Skills for Daily Decision-Making were coded as severely impaired. Behavioral symptoms were coded as 0 meaning behaviors not exhibited during the 7-day lookback period. On 07/20/2021 at approximately 12:10 P.M., this surveyor entered Unit 4, the locked unit. At 12:13 P.M., this surveyor observed Certified Nursing Assistant A (CNA A) and another staff member attempt to redirect Resident #2 as she was yelling out to them. Resident #2 then hit CNA A on the left side of her head as she stood next to her. Resident #2 then sat down in a chair near the nurse's station. At approximately 12:15 P.M., this surveyor asked CNA A about the incident. CNA A stated that when [Resident #2] is [resistant], staff will redirect her and give her something to play with. CNA A also stated that [Resident #2] likes to clean so staff try to find things she can help us with. On 07/20/2021 at 12:20 P.M., Resident #2 was observed in Resident #17's room rummaging through the closet. Resident #17 was in her room seated in her wheelchair by her bed. Resident #2 then took a purple-colored top that was hanging on the door handle of Resident #17's room and proceeded to walk down the hall. Resident #2 then entered the room of Resident #30. Resident #30 was seated in her wheelchair and facing the hall just inside the threshold of her room entrance. Resident #2 walked past Resident #30, then turned and faced Resident #30 and shouted, Get out of here! Get out of here! Resident #30 stated, Why are you yelling at me? Licensed Practical Nurse A (LPN A) was there to redirect Resident #2 out of Resident #30's room. Resident #2 then walked back to Resident #17's room to the closet touching the clothes on hangers. A staff member stood in the doorway of Resident #17's room and tried to redirect Resident #2 to go to the dining room for lunch. Resident #2 stated, No! Get out of here! Resident #2 then took a floral sweater off of the hanger and walked back down the hall toward Resident #30's room with Resident #17's purple top and floral sweater. As Resident #2 entered Resident #30's room, LPN A and another staff member were heading toward Resident #30's room. Resident #2 started yelling unintelligibly. Resident #30 stated, I have no idea what she wants from me! Resident #2 then left Resident #30's room and stood outside her room door holding the purple top and floral sweater. LPN A positioned herself between Resident #2 and Resident #30 while trying to redirect Resident #2. Resident #2 then walked to the nurse's station area and sat in a chair nearby. On 07/20/2021 at 12:32 P.M., an interview with Registered Nurse A (RN A) was conducted. RN A was standing near the med card by the nurse's station. When asked about Resident #2's behaviors, RN A stated that Resident #2 had underlying mood behaviors. RN A also stated that [Resident #2] is usually easily redirected and we let her cool off. When asked if she has been involved in Resident-to-Resident Altercations, RN A stated, No. We don't see her yelling at other Residents. When asked about the process when a Resident-to-Resident Altercation occurs, RN A stated that they separate the Residents, try to figure out what happened, have activities come to offer snack, fluids, and games. RN A then stated they would document the altercation as well. On 07/20/2021 at 12:37 P.M., this surveyor noted Resident #2 was no longer sitting in the chair by the nurse's station. This surveyor went to Resident #30's room. The door was closed. This surveyor knocked on the door and heard Resident #30 state, Come in. From the hall, this surveyor observed Resident #30 in her wheelchair by a table just hanging up the phone and stated, I was just trying to call my son. Resident #30 then self-propelled her wheelchair near the entrance of her room. Her bathroom door was open slightly and situated to her left. When asked how she was feeling about what happened with [Resident #2], Resident #30 pointed to her bathroom and stated, She's washing something in my apartment! I don't know what the hell she wants! At that time, Resident #2 exited Resident #30's bathroom holding a roll of toilet paper and several paper towels in her left hand. Resident #2 spoke loudly in unintelligible speech. Resident #2 then grabbed Resident #30's right wheelchair handle and forcefully pushed Resident #30's wheelchair forward. The left side of Resident #30's wheelchair hit the door jamb of her room entrance. Resident #30 stated, Let go of my chair! Resident #2 then walked past Resident #30, exited her room, and walked down the hall with the roll of toilet paper and paper towels. When Resident #30 was asked if she was okay and how was she feeling about this, Resident #30 stated, I feel sorry for her. When asked if this happens frequently, Resident #30 stated, This has been happening a lot; especially today. There was no staff observed in the hall during this time. At 12:49 P.M., Resident #2 was observed seated by the nurse's station eating lunch. At 12:56 P.M., an interview with LPN A, the unit manager, was conducted. When asked about her perspective of the Resident-to-Resident altercation between [Resident #30 and Resident #2], LPN A stated that it sounded like [Resident #2] was telling [Resident #30] to get out of her own room. LPN A also stated that she was trying to redirect [Resident #2]. When asked if this occurs frequently, LPN A stated No. LPN A also stated that we try to redirect and normally that works. LPN A added that [Resident #2] was confused and upset about something. When asked about the process when a Resident-to-Resident Altercation occurs, LPN A stated that the staff is expected to make sure the one is safe and redirect the other. LPN A also stated that staff should reassure her [Resident #30] and make sure she [Resident #2] doesn't go back and do it again. LPN A also indicated the process included getting everyone to monitor her and keep an eye on her. LPN A was notified Resident #2 was observed by this surveyor in Resident #30's room for a third time and forcefully moving Resident #30's wheelchair into the door jamb. LPN A did not mention reporting Resident-to-Resident altercations to the administrator. At 1:36 P.M., this surveyor notified the administrator of the above observations of Resident to Resident altercations involving Resident #2, Resident #30, and Resident #17. The administrator stated he would send a Facility-Reported Incident (FRI) to the state agency and begin an investigation. On 07/20/2021 at 3:19 P.M., the facility staff provided a copy of the FRI that was submitted to the state agency related to the above observations. On 07/20/2021, Resident #2's clinical record was reviewed. A nurse's noted dated 07/20/2021 at 3:19 P.M. documented, Resident became agitated before lunch and went into another residents [sic] room then into her bathroom and washed her hands, came back out and resident in room [number] was sitting in her wheelchair and this resident shoved the wheelchair into the wall (resident in room [number] was unharmed) and left the room. A nurse's note dated 07/20/2021 at 3:19 P.M. documented, [Name] NP [nurse practitioner] notified and RP [responsible party] [name] via voicemail. Resident #2's care plan was reviewed. A focus dated 08/20/2020 documented, [Resident #2] exhibits the following behaviors: she has poor safety awareness and she will bump into walls, objects etc. when walking at a fast pace. Observed to wipe down tables and desk areas. Wandering in and out of other resident rooms and turning lights on and off, pushing on exit doors. Combative with ADL care. Refusing skin care treatments. Verbally, and physically aggressive with staff. Behavior increases with staff attempts at redirection or when providing care. hx [history of] of Hit [sic] staff with her shoe, smack staff in the chest area, picking up objects in attempt to use as a weapon toward staff . Use of profanity toward staff. Physically combative toward others, taking items of others, not belonging to her. Using others drinks to clean tables. Turning the lights on of others, removing the covers off of others, Not easily re-directed at times. Flailing her arms and yelling, cries. One intervention associated with this focus included but was not limited to the following: When resident becomes physically abusive, keep distance between resident and others to ensure safety of resident and others (e.g., staff, other residents, visitors). On 07/20/2021, Resident #30's most recent progress notes were reviewed. A nurse's note dated 07/20/2021 at 3:21 P.M., documented, Writer was notified that another resident entered this residents [sic] room and went into her bathroom and washed her hands then came out and told resident get out of the way and pushed resident's wheelchair into the wall with resident sitting in the chair - the chair hit the wall and the resident was unharmed. Writer went and spoke with resident about incident and she could not recall incident writer was describing. RP [responsible party] [name] notified - message left on voicemail. [name] NP [nurse practitioner] notified of above. At the end of day meeting on 07/20/2021 at 4:53 P.M., the administrator was asked about the process when a Resident-to-Resident altercation occurs, the administrator indicated that a FRI would be filled out; they would launch an investigation, obtain witness statements, compile all the information, have a plan, submit a 5-day follow-up [to the state agency] and re-evaluate the plan. On 07/20/2021, the facility staff provided a copy of their policy entitled, Abuse Prevention, Investigation and Reporting. An excerpt in Section IV (C) documented, Resident to Resident altercations are potentially situations of abuse.the facility will respond immediately to protect the safety of others, investigate the incident and respond with measure [sic] to prevent recurrence. On 07/21/2021 at 3:30 P.M., the administrator and Director of Nursing were notified of concerns with the repeated Resident-to-Resident altercations observed on 07/20/2021. By the end of survey on 07/22/2021, the administrator stated there was no further documentation or information to submit. 2. For Resident #71, the facility staff failed to ensure freedom from abuse by a contracted agency CNA. Resident #71, a [AGE] year old woman admitted to the facility on [DATE] with diagnoses that included diabetes type II, dementia with behavioral disturbance, chronic kidney disease, and pancreatitis. Resident #71's most recent MDS (Minimum Data Set) assessment coded Resident #71 as having a BIMS (Brief Interview of Mental Status) score of 4 indicating severe cognitive impairment. She was coded as requiring extensive assistance with all aspects of ADL (Activities of Daily Living). The Resident required the use of a sit to stand lift for transfers and a wheel chair for mobility. On 7/20/21 at approximately 12:30 PM during meal observations, Resident #71's family member requested to speak to surveyor A she stated she would like to come in the following day and bring her notes, a time was set for 7/21/21 at 9:30 AM. On 7/21/21 an interview was conducted at 9:36 AM with Resident #71's family member. During interview the family member stated that she comes to the facility every day. She showed folders where she takes notes on what is happening at the facility while she is present. She expressed concern that Resident #71 had recently been hit by an agency staff member while she was being given a shower. She further stated the incident was witnessed by 2 other staff. The family member got a call at 9:45 PM on 6/29/21 from the Administrator telling her of an incident involving her mother. She stated that he told her three CNA's were working in the memory care unit 2 were Agency and one was a staff CNA. One of the agency CNA's (CNA G) assigned to Resident #71 didn't want to give her shower. CNA G asked the other 2 CNA's for assistance with the shower as this Resident was confused and upset. While giving her a shower the Resident pushed CNA G's hand out of the way. CNA G then hit the Resident in the head with the hand held shower wand and sprayed her in the face with the water. [The facts of this story were corroborated by the FRI, Investigation and Witness Statements sent in to the OLC.] The family member stated I was upset because I was here at dinner time 5:30- ish and spoke to the 3 CNA's. They said they gave her a shower before dinner and everything was fine. Mom looked and smelled good. No one mentioned a word about the incident, and I didn't see any marks or bruises. So then at 9:45 PM [Administrator's name redacted] called and basically said it took the other 2 CNA's [that witnessed the incident] 3 hours to decide to report it She said The CNA that hit mom was a large intimidating woman the other two were younger they were intimidated by her. The facility told me they were firing the Agency CNA's and they asked me about the [NAME] employee, I told them I do want the [NAME] Sholom employee to work with mom because she knows her, yes she had a major lapse in judgement and should have reported it immediately, but in the end she did report it. A Review of the FRI submitted with the witness statements revealed that the supervisor sent the agency CNA's home that night, they did a head to toe assessment and no injuries were found at that time. 06/30/2021 12:26 AM - Writer assessed [Resident 71 name redacted] for injury and pain post reported incident, Resident denied pain and discomfort r/t incident and has no visible injurie's [sic] or skin impairments r/t incident. Will continue to monitor. On 7/21/20 at approximately 2:30 PM an interview was conducted with the DON who stated that she was made aware of the incident by [NAME]. She stated that it was her expectation that any time abuse is suspected the staff are to call her or the Administrator. She stated she came to the facility immediately after the phone call informing her of what happened. She stated that she suspended all three employees until the investigation was done. The agency CNA was terminated and banned from the building. They did a head to toe assessment to check for injuries and no bruises, red marks or open areas were found. Resident is unable to recall due to cognitive status. They submitted a FRI to the OLC on 6/29/21 at approximately 10:00 PM. The facility FRI was reviewed, and it included the initial FRI , the investigation witness statements and the subsequent statements that this employee was banned from working at the facility and the Ombudsman, APS, local police as well as the DPH were notified. All pieces of the FRI and Investigation were completed. The FRI investigation folder also contained in service education about timely reporting of abuse. During an interview with the Business office Manager on 7/22/21 at approximately 2:00 PM revealed the facility did not have the Agency Employee's VA State Police Criminal background check at the facility. They attempted to obtain it from the Agency however they only received a criminal check from a private company. She had a valid CNA license but they had no record of VA State Police Check to see if she had any barrier crimes prior to working in the facility. On 7/22/21 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and facility documentation the facility staff failed to ensure the Resident right to dignified existence for 1 Resident (#76) in a survey sample of 45 Residents. For Resident #76, the facility staff pulled the resident backwards down the hallway in his Broda Chair. The findings include: Resident # 76, a [AGE] year-old man admitted to the facility on [DATE] with diagnoses of but not limited to Unspecified Dementia with behavioral disturbances, Diabetes Type 2, Lewy Body Dementia and Insomnia. Resident #76 resides on the memory care unit of the facility due to his advanced Dementia. Resident #76's last (Minimum Data Set) MDS (screening tool) was an annual with an (Assessment Reference Date) of 1/11/19, which coded the Resident as having a (Brief Interview of Mental Status) BIMS score of 99 which indicates severe cognitive impairment / unable to complete assessment. He was also coded as being a two-person physical assist with bed mobility, incontinence care, transfers and he uses a Broda Chair for mobility. On 3/12/19, at 8:15 AM, during the initial tour of the facility it was observed that Resident # 76 was being pulled backwards down the hallway in his Broda Chair from his room to the dining room by CNA H. On 3/12/19 at 8:25 AM, CNA H was asked why she pulled Resident backward down the hall. The CNA stated: So he can't put his feet down and stop the chair. On 3/13/19 at 8:35 AM, an interview was conducted with LPN B. LPN B was asked about why the resident was pulled backward, in the Broda Chair. LPN B stated that normally it's not the way he is transported to breakfast. On 3/13/19 at 9:15 AM, an interview was conducted with the PT director (employee J). The PT director stated that although it's not ideal we have to pull him backward in his Broda Chair, he (the resident) will plant his feet so we cannot push him forward. When asked about the foot pedals that come with the Broda chair the PT director stated: If we put those on then he tries to stand up and it becomes a safety issue. When asked what the concern was associated with pulling a Resident backward in the hall the PT Director stated, Dignity. When asked what effect on a cognitively impaired Resident being pulled backward could have, the PT director stated, it could increase confusion or disorientation. On 3/13/19 at 10:45 AM, a clinical review of the care plan showed that there was no mention of pulling the chair backward down the hall. On 3/13/19 at approximately 3:00 PM, Unit Manager (LPN D) was asked to show where transporting in Broda Chair backward was addressed and she stated it was not in the care plan. On 3/13/19 at approximately 5:00 PM, the facility produced a new care plan which stated: Category: Falls [Resident name redacted] is at risk for falling R/T impaired cognition, Diabetes, Wandering, unsteady gait, medication side effects, and requiring staff assistance with transfers. He will get up unassisted at times despite redirection. He is up much during the night, related to past habits/history. Goal: [Resident name redacted] will remain free from injury thru next review. Approach: Approach Start Date: 3/13/19 [Resident name redacted] will plant feet or attempt to stand when being moved in Broda Chair, safest manner of mobility is to move backward. Inform [Resident name redacted] you will be moving him backward. At the end of day meeting on 3/13/19 and 3/14/19, the Administrator and DON were made aware but no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, family interviews, resident interviews and clinical record review, the facility staff failed to ensure reasonable accommodation of resident needs and preferences for one Resident (Resident # 36 and # 86) in a survey sample of 45 residents. 1. For Resident # 86, the facility staff failed to get the resident up early for breakfast as desired. Findings included: 1. For Resident # 86, the facility staff failed to get the resident up early for breakfast as desired. Resident # 86, a [AGE] year old female was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Chronic Obstructive Pulmonary Disease, Acute and chronic respiratory failure with hypercapnia, Heart Failure, Hypertension, anemia, Abdominal Aortic Aneurysm, and Osteoporosis. Resident # 86's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 2/22/2019. The MDS coded Resident # 86 with a BIMS (Brief Interview for Mental Status) score of 13 out of 15, indicating no cognitive impairment. Resident # 86 was coded as requiring extensive assistance of one staff person for Activities of Daily Living and occasionally incontinent of bowel and bladder. On 3/12/2019 at 9:40 AM, an interview was conducted with the daughter of Resident # 86 who stated there was a problem of the facility staff not getting her mother (Resident # 86) ready for breakfast early like she desired. Resident # 86's daughter stated that when her mother ate breakfast late, it meant she had decreased socialization with others. She stated there were times that breakfast was eaten so late that there were only a couple of hours between breakfast and lunch. She stated Resident # 86 did not want to eat lunch when breakfast was eaten so late. She also stated she was concerned because she did not want her mother to lose weight. She stated she had several discussions with the facility staff to express her desire to have her mother eat breakfast early in the dining room. Resident # 86's daughter stated changes were made to the care plan to help make sure her needs were met. Review of the clinical record was conducted on 3/12/2019. Review of care plan revealed: Page 1 of 35 Problem Start Date 3/4/2019 Resident is at risk for compromised quality of life secondary to cognitive deficits/memory loss Goal: Resident will receive assistance with daily routine with support and guidance from staff and need will be met thru [sic] next review Approach Start Date: 3/4/2019 Maintain consistency in daily routine as much as possible Page 19 of 35- Problem . requires multiple reminders of programs of interest. has some short term memory loss and poor vision. Requires 1:1 asst (assistance) during sight related programs to maximize participation Approaches included: Involve ____(Resident # 86) with those who have shared interests, seat next to during programs and encourage meals in the dining room. On page 22 of 35- Problem: .Is at nutritional risk due to decreased and variable P.O. (by mouth) intake, refusing nutritional supplements Approach Start Date: 03/04/2019-Encourage _____ (Resident # 86) to eat meals in the unit DR (Dining Room) On 3/13/2019 at 8:30 AM, Resident # 86 was observed lying in bed. Resident # 86 told the surveyor she was waiting to get up so she could go to breakfast. On 3/13/2019 at 9:30 AM, Resident # 86's daughter was observed walking in the hallway toward Resident # 86's room. Resident # 86's daughter asked Hi Mom, have you had breakfast yet? Let's get ready to go to the Dining Room Resident # 86's daughter helped Resident # 86 wash her face and hands, get dressed and wheeled her to the dining room. On 3/13/2019 at 9:40 AM, Resident # 86's daughter retrieved the breakfast tray from the ledge on the kitchen counter and at 9:42 AM, Resident # 86 began eating breakfast, her daughter was sitting beside her, talking to her. On 3/13/2019 at 9:55 AM, an interview was conducted with Resident # 86's daughter who stated now this means there would be less than 3 hours between breakfast and lunch! The daughter stated the other residents who sit at the table with her mother were finished eating. The daughter stated meal time is a time for socialization and not going to breakfast on time meant very little time for socialization. On 3/13/2019 at 12:07 PM, Resident # 86 was observed being wheeled by her daughter into the dining room for lunch. Resident # 86's daughter sat beside her. There were two other residents at the table eating lunch with Resident # 86. On 3/13/2019 at 2:10 PM, an interview was conducted with Registered Nurse (RN B) who stated the facility staff was working short and had not gotten Resident # 86 up for breakfast prior to when the daughter arrived. On 3/13/2019 during the end of day debriefing, the facility Administrator and Director of Nursing were informed of the findings. The Administrator stated the facility had ample staff of 3 to 4 Certified Nursing Assistants on each unit. The DON stated the facility staff were expected to get the residents ready for breakfast at the time they desired. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and facility documentation, the facility staff failed to ensure a resident's right to self-determination for 1 Resident (#75) in a survey sample of 45 Residents For Resident #75 the Physical Therapy staff faxed over a letter to his surgeon without first allowing the Resident to view it or have input in the content. The Resident is his own Responsible Party. The findings include: Resident # 75 a [AGE] year-old man admitted to the facility on [DATE] with diagnoses of but not limited to (Peripheral Vascular Disease) PVD, Orthopedic Surgical aftercare for (Below Knee Amputation) BKA of Left lower leg. Most recent (Minimum Data Set) MDS (an assessment tool) with an (Assessment Reference Date) ARD of 2/27/19 codes Resident as having a (Brief Interview of Mental Status) BIMS of 15 indicating No Cognitive Impairment. On 3/12/19, during an initial tour, Resident # 75 asked to have the door closed to discuss some issues he was not happy with. He stated that he felt there was incorrect information in his medical record and that the staff had sent erroneous information to his doctor by fax without first having let him have input into the document. He stated on 3/6/19 the Physical therapist had faxed a letter to his doctor without his knowledge. He stated that he usually brings the updates from the physical therapy dept to the doctor. He stated this time they faxed it without even letting me see it first. Resident # 75 stated that when he read the follow up to the doctor he objected to the terms Noncompliant with wearing [device] and CGA [Contact Guard Assist] due to decreased safety awareness. He stated that he felt this implied he was somehow cognitively deficient. He stated, I am not an Alzheimer's Patient, just because I am 70 doesn't mean I'm nuts . Resident #75 further went on to say that he did not want the doctor to get the wrong impression of his therapy sessions, he stated that he was progressing well in therapy. He went on to state that the [device] was cracked anyway and uncomfortable. (A crack was observed in the lower half of the device in question.) He stated they did not get him a new one when this one broke and that his doctor had told him that wearing the [device] was at his discretion. He stated he felt like they were telling on him behind his back to the doctor as if he were a child. On 3/13/19 at 4:45 an interview was conducted with Employee J the Director of Physical Therapy (PT) who submitted a written statement about the interactions with Resident# 75 as it relates to herself and another PT (Employee K) in her department. The statement dated 3/13/19 read: RE: Statement regarding therapy interaction with [Resident#75 name redacted] on 3/5/19. [PT name redacted -Employee K] prepared a letter to send with [Resident name redacted] to his MD [Medical Doctor] appointment with [Surgeon name redacted] regarding progress in therapy as well as current status. She discussed her concern with me regarding his [condition]. She prepared the letters as follows: Date: 3/5/19 Sub: Update of functional progress To: Respected Sir, [Resident name redacted] has been progressing well with therapy. He recently demonstrates [description of condition] which may lead to hindrance with future [device] management. Patient demonstrates non-compliance with respect to wearing the [device] which may contribute to [description of condition] Reports pain in L middle finger and L posterior deltoid about 10+ pain with weight bearing for transfer and gait. Reports 1-4/10 at rest for L posterior deltoid. Hence unable to perform ambulation today due to pain. Pt has contacted [name of clinic] regards new [device] as current [device] needs repair as lower portion dysfunctional. Informed them regards recent [description of condition]. He is mod 1 for rolling, supine, and sit to supine. Requires CGA [contact guard assist] for transfers due to impulsivity and decreased safety awareness. He was able to do hopping on RLE with front wheeled walker with contact guard assist for 120 feet last week with the wheelchair to follow closely. Thanks [PT name redacted] Employee J's written statement then goes on to read: She and I discussed delivery of information to [Surgeon's name redacted] and I suggested that given [Resident#75's name redacted] known history of non compliance that the letter should be faxed to his office and a phone call be made to insure [sic] delivery to [Surgeon's name redacted] in time for the afternoon appointment. This was done. The statement continues on to say that just prior to leaving for appointment Resident #75 was given a copy of the note and he became upset about the contents of the note at which point the Employee J offered to strike out the offending statements however the Resident stated It was too late by then it had already been faxed and I had to leave for my appointment. On 3/12/19, it appears that the facility staff faxed the Resident's Surgeon at the [redacted] Clinic to get clarification on when he should wear the [device] and they received a fax and showed it to the Resident. Once again the Resident had no knowledge of the contact between the two parties prior to the facility sending the document. The Resident stated that the nurse who wrote the clarification is not his doctor's nurse. The nurse wrote in her letter that the Resident is to wear the [device] and take it off three times per day for air. The clarification does not specify times or state if it must be worn a prescribed number of hours and it does not address the fact it is broken. Also the letter states that the resident is to Ambulate with walker Resident stated It's clear that nurse has never seen me I cannot ambulate with a walker I have [condition] and have not even been fitted [device] yet how can I ambulate? The resident produced a copy of the faxed letter from the nurse at the [redacted] Clinic. This sparked an argument between the Resident and the physical therapy assistant (Employee L) as Resident stated he felt as if the physical therapy staff were excluding him from treatment decisions. On 3/12/19 at the end of day conference the Administrator and the DON were made aware and no new information was submitted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure resident privacy and confidentiality of his or her personal medical records for one resident in a survey sample of 45 residents. For Resident #62, the facility staff failed to ensure the confidentiality of medical records by leaving resident information visible on the computer in the hallway while other residents, staff and visitors were in the hallway. The findings included: Resident #62, a [AGE] year old female, was admitted to the facility on [DATE]. Her diagnosis included but were not limited to: presence of right artificial hip joint, mood disorder, mild cognitive impairment, anxiety disorder, suicidal ideation's, primary insomnia, repeated falls, and overactive bladder. Resident #62's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of [DATE] was coded as a quarterly assessment. Resident #62 was coded as having a BIMS (Brief Interview for Memory Status) score of 13 indicating cognitively intact. She was also coded as requiring limited assistance with assistance of one staff member for walking in her room and corridor. She was coded as requiring extensive assistance of one staff member for bed mobility, dressing, toileting and personal hygiene. Requires supervision with setup help only for eating. She was coded as frequently incontinent of bowel and bladder. On [DATE] at 12:02pm, it was observed that the wall mounted computer beside the 200 hall clean utility room door, Resident #62's information to include MDS data, bowel incontinence, and code (CPR- Cardiopulmonary resuscitation) status. There was no staff member in sight but other residents and visitors were observed in the hallway and the information was visible to other residents and visitors who were present in the hallway. On [DATE] at 12:04pm, an interview with CNA D, whose name was listed as being logged onto the computer, stated she called me real quick referencing RN B. She acknowledged she had walked away leaving the resident medical record visible to persons walking by. The Administrator and DON were informed of the failure of the staff to ensure resident privacy and confidentiality of medical records on [DATE]. No further information was provided. COMPLAINT DEFICIENCY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #27, the facility failed to implement their abuse protocol policy for an injury of unknown origin. Resident #27, an [AGE] year old male, was admitted to the facility on [DATE]. His diagnosis included but were not limited to: aphasia, nontraumatic intracerebral hemorrhage, facial weakness, dysphagia, hypothyroidism, hyperlipidemia, compression of brain and hypertension . Resident #27's most recent MDS (Minimum Data Set) (an assessment tool) with an ARD (assessment reference date) of 1/3/19 was coded as a quarterly assessment. Resident #27 was coded as having a BIMS (Brief interview for mental status) score of 3, indicating severe cognitive impairment. He was also coded as requiring extensive assistance of one staff member for transfers, locomotion on and off unit, dressing, toileting and personal hygiene. He required supervision with setup assistance for eating. The MDS stated that he did not have any physical or verbal behavioral symptoms or any other behaviors directed toward others. During record review of nursing notes, Resident #27 was documented on 2/21/19 as having a 0.5 x 0.5 cm skin tear to the right wrist. The resident's record including nursing notes, physician notes and nursing assessments; make no indication of how the skin tear occurred. The DON was requested to provide any and all investigation on this particular injury of unknown source. The facility provided the survey team a two page document entitled Initial QA Report of Bruises, Skin Tears, Scratches or Other Skin Injuries. This document entailed a series of check boxes that were checked for the following three items; 1. observed thrashing limbs in bed or chair, 2. observed scratching or picking at skin, 3. demonstrate combative behavior with caregivers. It was also noted on the Initial QA Report of Bruises, Skin Tears, Scratches or Other Skin Injuries form that this information was described in the chart 2/21/19. However, there was no evidence in Resident #27's clinical chart, nursing notes, physician notes, careplan, nursing assessments or MDS, from 1/1/19-3/14/19 that the resident exhibited any of these behaviors. Accompanying this document, was an unsigned and undated statement allegedly from a CNA stating that Resident #27 was resisting getting up and yank his hand away from us a couple of times. [sic] The facility had no formal investigation of the injury of unknown source. The facility didn't have statements from all staff members involved in the care of the individual when the injury was identified. No report was made to the state agency regarding the injury of unknown source and no corrective action nor protection of the resident during an investigation was performed by the facility, which are the parts of the Abuse protocol mandated by Federal regulation. Review of the facility Policy and Procedure titled: Abuse Prevention, Investigation and Reporting states the facility is committed to maintaining a safe and abuse-free environment for all residents and committed to a comprehensive investigation of allegations of activities or situations that may constitute abuse. This policy further states that the procedure for Investigation includes: A. Designated staff will review and investigate all reports of incidents and occurrences that may represent abuse or neglect. C. Investigations may include, but are not limited to: a. assessment of the resident and nature of any injuries b. interviews of the resident, potential witnesses and staff c. assessment of the environment where the incident occurred and any physical factors d. evaluation by a physician or other licensed health professional where indicated e. utilizing available resources in the low enforcement community where applicable f. review of the medical record g. analysis of staffing reports and assignments. The facility failed to implement their abuse policy in regard to investigating and reporting allegations of alleged abuse. The facility Administrator, Director of Nursing and CEO were made aware of these findings on 3/13/19. No additional information was provided. 4. For Resident #85, the facility failed to implement their abuse protocol policy for an injury of unknown origin. Resident #85, a [AGE] year old female, was admitted to the facility on [DATE]. Her diagnosis included but were not limited to: Alzheimer's disease, dementia, Hypertension, unspecified diastolic heart failure, hypothyroidism, generalized anxiety, and type 2 diabetes. Resident #85's most recent MDS (minimum data set) (an assessment) with an ARD (assessment reference date) of 2/22/19 was coded as an annual assessment. Resident #85 was coded as having a BIMS (Brief Interview for Mental Status) score of 5, indicating severe cognitive impairment. She was also coded as requiring extensive assistance with two staff members for her activities of daily living to include transfers and bed mobility. She required extensive assistance with one staff member for locomotion on unit and dressing. Was totally dependent with assistance of one staff member for eating, toileting, personal hygiene and bathing. Further, her MDS is coded as her not having any behavioral symptoms. During record review the nursing notes revealed Resident #85 had a irregularly shaped 6 x 6 cm bruise to the back of her left hand. The color is noted to be purplish-black and reddish black. Aide made writer aware that resident had two combative episodes one on 12/31/18 where the resident struck out at the aides with both hands and feet. One earlier on 7-3. There was no further documentation recorded in the resident's record of her being combative during care. Resident #85 careplan doesn't indicate she is resistive to or combative during care that would indicate this is routine behavior for this resident. The facility provided the survey team with a document titled Initial QA Report of Bruises, Skin Tears, Scratches or other skin injuries which states the bruise was noted when CNA was ready to do pm care. The facility concludes: writer notes that resident had x 2 combative episodes and noted to thrash in bed. Resident is also on ASA (aspirin). Writers think resident received bruise during combative episode. There is no evidence in the clinical chart other than the note the day the bruise was noted for combativeness. There are no witness statements obtained to identify if the bruise had been present previously. Review of the facility Policy and Procedure titled: Abuse Prevention, Investigation and Reporting states the facility is committed to maintaining a safe and abuse-free environment for all residents and committed to a comprehensive investigation of allegations of activities or situations that may constitute abuse. This policy further states that the procedure for Investigation includes: A. Designated staff will review and investigate all reports of incidents and occurrences that may represent abuse or neglect. C. Investigations may include, but are not limited to: a. assessment of the resident and nature of any injuries b. interviews of the resident, potential witnesses and staff c. assessment of the environment where the incident occurred and any physical factors d. evaluation by a physician or other licensed health professional where indicated e. utilizing available resources in the low enforcement community where applicable f. review of the medical record g. analysis of staffing reports and assignments. The facility failed to implement their abuse policy in regard to investigating and reporting allegations of alleged abuse. The resident's incident/injury was not reported to the State Survey Agency nor the results of the investigation of this injury of unknown origin. The facility Administrator, Director of Nursing and CEO were made aware of these findings on 3/13/19. No additional information was provided. Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to implement the abuse policy for 3 resident (Resident #3, # 27, and # 85) of 45 residents in the survey sample and they failed to ensure the abuse policy was accurate. 1. For Resident #3, the facility did not implement the abuse policy after discovery of an injury of unknown origin described as an unwitnessed fall with injury. 2. The abuse policy did not clearly state that injuries of unknown origin will be reported to the State Agency and thoroughly investigated. The policy did not state the final report of the investigation would be provided to the State Agency within 5 business days. 3. For Resident #27, the facility failed to implement their abuse protocol policy for an injury of unknown origin. 4. For Resident #85, the facility failed to implement their abuse protocol policy for an injury of unknown origin. The findings included: 1. For Resident #3, the facility did not implement the abuse policy after discovery of an injury of unknown origin described as an unwitnessed fall with injury. Resident #3, an [AGE] year old female, was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: Vascular Dementia, Hypokalemia, Osteoarthritis, Anorexia, Repeated falls, Hypertension, and Anxiety. The most recent Minimum Data Set assessment was an admission assessment with an assessment reference date (ARD) of 11/12/18. Resident # 3 was coded with a Brief Interview of Mental Status (BIMS) score of 5 indicating severe cognitive impairment. Resident # 3 was coded as requiring limited to extensive assistance of one staff person for Activities of Daily Living except she required total assistance of one staff person for bathing. Resident # 3 was coded to need extensive assistance of one staff person for ambulation. During the initial tour of the facility on 3/12/2019 at 10:45 AM, Resident # 3 was observed sitting in a wheelchair at the nurses station. There was a bruise over her left eye and steri strips covering a wound. On 3/12/19 at 2 PM, an interview was conducted with LPN (Licensed Practical Nurse) E who stated Resident # 3 fell and sustained the injury the night before on 3/11/2019 on the 3-11 shift. LPN E stated the CNA found the resident on the floor according to the report. Review of the progress notes revealed no documentation of the unwitnessed fall on 3/11/2019. On 3/12/19 at 4:30 PM, an interview was conducted with the Director of Nursing (DON) who stated she was informed that Resident # 3 fell on the 3-11 shift on 3/11/2019. The DON stated the injury over Resident # 3's eye was the result of the fall. When asked to see a copy of the investigation, the DON stated no investigation was done because the nurse determined the resident had fallen. The DON stated the nurse filled out a fall investigation form but no further investigation was conducted. The DON was asked to submit a copy of the fall investigation. Review of the Fall investigation Report dated 3/11/19 at 8:40 PM Under Initial Investigation: Documented the fall occurred in the resident's room. List all witnesses to the fall (staff, residents, visitors) None. What was the resident observed doing immediately before the fall? in bed asleep What does the resident say they were doing before the fall no explanation Is there any reason to believe that another person was involved in the fall? If , so why and who[sic]: No Review of the Fall Investigation Report dated 3/11/2019 revealed no documentation of any injuries. There was no mention of the bruise or injury above the left eye. On 3/14/2019 at 10:36 a.m., an interview was conducted with the Administrator and Director of Nursing regarding the process regarding any Unwitnessed falls and injuries of unknown origin. The Director of Nurses stated the expectation is: the nurse would assess the resident for injuries, if they look like they are not seriously injured, move them, start neuro (neurological) checks, notify the md (medical doctor), and rp (responsible party), apply first aid if necessary, nurse on unit is responsible for starting the fall investigation including interviewing resident if possible, interviewing staff, inspect to make sure the equipment is operating properly, bed brakes, alarm, putting appropriate interventions in place, example, use non skid socks, if incontinent, look at toileting patterns, care plan updates. The fall investigation form is reviewed by the unit manager who makes sure it is completed accurately or if it needs any more information. It was reviewed with the DON and Administrator that an allegation should be reported before it is investigated. The Administrator and DON stated the facility would not report an unwitnessed fall with injury to the State Agency. When asked to describe the process for a resident who had an unwitnessed fall with an injury in the cognitively impaired resident, the DON stated we do not report unwitnessed falls to the state. The Administrator stated we ask the resident what happened. The surveyor asked how the facility would determine what happened if the resident had cognitive impairment. The Administrator and DON stated the nurses were able to determine if there was a need for an investigation based on the assessment of the situation. Both stated that the facility did not need to report the unwitnessed fall with injury as an injury of unknown origin because the nurse would be able to look at the situation and determine if it looked like the injury was the result of a fall. The DON was interviewed regarding abuse. She was the Abuse Coordinator at the facility. The DON was asked to explain her process. She stated that once an allegation was made, she would investigate. If the allegation was an issue, then she would report. The Administrator, Director of Nursing and Chief Executive Officer were asked to come to the conference room to discuss the abuse policies with the entire survey team. On 3/14/2019 at 10:50 a.m., the administrator, DON and CEO came to the conference room to continue the conversation regarding the definition of an injury of unknown origin, the need to report injuries of unknown origin, unwitnessed falls with injury in the cognitively impaired and implementation of the abuse policies. The DON stated we would immediately report any suspected abuse if we thought that was a problem. The DON stated the facility was aware of the 24 hour and two hour reporting requirement for suspected abuse but the injury for Resident # 3 was not considered possible abuse. The DON stated the CNA (Certified Nursing Assistant) reported she found the resident had fallen on the floor and the nurse determined the injury was the result of the fall. After a lengthy discussion, the Administrator stated he understood the definition of and the need to report injuries of unknown origin to the State Agency prior to investigating. The DON stated the facility would be submitting lots of FRIs (Facility Reported Incidents) as a result of this interpretation. The DON also stated she was going to have to figure out how to educate the nursing staff on reporting injuries of unknown origin. The DON stated she thought the nurses would have a hard time understanding because they know the residents and would be able to figure out how the injuries happened. When asked again about abuse allegations, the DON stated that she would report to the state agency with in 24 hours. The DON was asked if she was aware of the new two hour rule. This rule required allegations of abuse to be reported immediately but not later that two hours after the allegation is made. She stated that she had read about it in the new regulation and would read the regulation again. It was reviewed with the DON that the facility abuse policy did not reflect the new reporting time frame required for the final report within 5 days. The CEO (Chief Executive Officer) stated the current facility policy stated the final report would be provided to the agencies with the timeframes required by regulations. The CEO was informed that the policy needed to be specific to state the final report would be submitted with 5 working days. The facility abuse policy Abuse: Prevention, Investigation and Reporting, Revision date 2/13/18 was reviewed. Policy Section VII (7) Reporting and follow up Response B. The Administrator (or designee) will report all alleged violations to the state survey agency and to all other required agencies: Adult Protective Services, the Ombudsman (DARS) and where applicable, the Board of Nursing and law enforcement. The initial report is made as soon as possible: a. Allegations involving abuse, neglect, or exploitation of a resident must be reported within two hours (first report), in the event that there has been serious bodily injury to a resident. b. Allegations that have resulted in no serious harm to the resident are reported as soon as is possible, and within 24 hours. C. If the allegation will require additional time for thorough investigation, the initial report will indicate this and the final report (a summary of the conclusion) will be provided to the same agencies within the timeframes required by regulations. On 3/14/19 at 5:00 p.m., the Administrator and DON were asked to submit any information they would like to have reviewed regarding the issue. The DON stated the facility did not submit a report to the State Agency for Resident # 3. No further information was provided. 2. The abuse policy did not clearly state that injuries of unknown origin will be reported to the State Agency and thoroughly investigated. The policy did not state the final report of the investigation would be provided to the State Agency within 5 business days. On 3/14/19 at 10:36 AM., The DON was interviewed regarding abuse. She was the Abuse Coordinator at the facility. The DON was asked to explain her process. She stated that once an allegation was made, she would investigate. If the allegation was an issue, then she would report. It was reviewed with the DON that an allegation should be reported before it is investigated. The DON and Administrator stated an unwitnessed fall with injury in a resident with cognitive impairment did not indicate an injury of unknown origin because they would ask the resident what happened. Both stated the facility staff would do the investigation and then report if there was abuse. The Administrator and Director of Nursing again stated the facility would investigate the unwitnessed fall with injury and report to the State Agency if it was determined there was abuse. It was reviewed with the Administrator and DON that the injury should be reported to the State Agency and then thoroughly investigated. When asked again about abuse allegations, the DON stated that she would report to the state agency with in 24 hours. The DON was asked if she was aware of the new two hour rule. This rule required allegations of abuse to be reported immediately but not later that two hours after the allegation is made. She stated that she had read about it in the new regulation and would read the regulation again. It was reviewed with the DON that the facility abuse policy did not reflect the new reporting time frame required for the final report within 5 days. The CEO (Chief Executive Officer) stated the current facility policy stated the final report would be provided to the agencies with the timeframes required by regulations. The CEO was informed that the policy needed to be specific to state the final report would be submitted with 5 working days. The facility abuse policy Abuse: Prevention, Investigation and Reporting, Revision date 2/13/18 was reviewed. Policy Section VII (7) Reporting and follow up Response B. The Administrator (or designee) will report all alleged violations to the state survey agency and to all other required agencies: Adult Protective Services, the Ombudsman (DARS) and where applicable, the Board of Nursing and law enforcement. The initial report is made as soon as possible: a. Allegations involving abuse, neglect, or exploitation of a resident must be reported within two hours (first report), in the event that there has been serious bodily injury to a resident. b. Allegations that have resulted in no serious harm to the resident are reported as soon as is possible, and within 24 hours. C. If the allegation will require additional time for thorough investigation, the initial report will indicate this and the final report (a summary of the conclusion) will be provided to the same agencies within the timeframes required by regulations. On 3/14/19 at 5:00 PM., the findings were reviewed with the Administrator, DON and Chief Executive Officer. They were asked to submit any information they would like to have reviewed regarding the issue. The Administrator stated the facility policy would be updated to include reporting injuries of unknown origin and requirements of investigation reporting times. The DON stated injuries of unknown origin would be reported to the State Agency as required. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #27, the facility failed to report an injury of unknown origin and failed to report investigation results. Resident #27, an [AGE] year old male, was admitted to the facility on [DATE]. His diagnosis included but were not limited to: aphasia, nontraumatic intracerebral hemorrhage, facial weakness, dysphagia, hypothyroidism, hyperlipidemia, compression of brain and hypertension . Resident #27's most recent MDS (Minimum Data Set) (an assessment tool) with an ARD (assessment reference date) of 1/3/19 was coded as a quarterly assessment. Resident #27 was coded as having a BIMS (Brief interview for mental status) score of 3, indicating severe cognitive impairment. He was also coded as requiring extensive assistance of one staff member for transfers, locomotion on and off unit, dressing, toileting and personal hygiene. He requires supervision with setup assistance for eating. It states that he doesn't have any physical or verbal behavioral symptoms or any other behaviors directed toward others. During record review of nursing notes, Resident #27 was documented on 2/21/19 as having a 0.5 x 0.5 cm skin tear to the right wrist. The resident's record including nursing notes, physician notes and nursing assessments; make any indication of how the skin tear occurred. The DON was requested to provide any and all investigation on this particular injury of unknown source. The facility provided the survey team a two page document entitled Initial QA Report of Bruises, Skin Tears, Scratches or Other Skin Injuries. This document entailed a series of check boxes that were checked for the following three items; 1. observed thrashing limbs in bed or chair, 2. observed scratching or picking at skin, 3. demonstrate combative behavior with caregivers. It was also noted on the Initial QA Report of Bruises, Skin Tears, Scratches or Other Skin Injuries form that this information was described in the chart 2/21/19. There was no evidence in Resident #27's clinical chart, nursing notes, physician notes, careplan, nursing assessments or MDS, from 1/1/19-3/14/19 that the resident exhibited any of these behaviors. Accompanying this document, was an unsigned and undated statement allegedly from a CNA stating that Resident #27 was resisting getting up and yank his hand away from us a couple of times. [sic] The facility had no formal investigation of the injury of unknown source. The facility didn't have statements from all staff members involved in the care of the individual when the injury was identified. No report was made to the state agency regarding the injury of unknown source and no corrective action nor protection of the resident during an investigation was performed by the facility, which are the parts of the Abuse protocol mandated by Federal regulation. Review of the facility Policy and Procedure titled: Abuse Prevention, Investigation and Reporting states outside entities, including regulatory agencies, ombudsmen, protective services, and legal investigators will be notified and involved as appropriate to the situation. It further states the facility will investigate and report all observations, allegation, incidents or occurrences that may indicate abuse or neglect to the state survey and other interested agencies in accordance with federal and state regulations. The facility Administrator, Director of Nursing and CEO were made aware of these findings on 3/13/19. No additional information was provided. 3. For Resident #85, the facility failed to report an injury of unknown origin and failed to report investigation results. Resident #85, an [AGE] year old female, was admitted to the facility on [DATE]. Her diagnosis included but were not limited to: Alzheimer's disease, dementia, Hypertension, unspecified diastolic heart failure, hypothyroidism, generalized anxiety, and type 2 diabetes. Resident #85's most recent MDS (minimum data set) (an assessment) with an ARD (assessment reference date) of 2/22/19 was coded as an annual assessment. Resident #85 was coded as having a BIMS (Brief Interview for Mental Status) score of 5, indicating severe cognitive impairment. She was also coded as requiring extensive assistance with two staff members for her activities of daily living to include transfers and bed mobility. She requires extensive assistance with one staff member for locomotion on unit and dressing. Is totally dependent with assistance of one staff member for eating, toileting, personal hygiene and bathing. Further, her MDS is coded as her not having any behavioral symptoms. During record review the nursing notes revealed Resident #85 had a irregularly shaped 6 x 6 cm bruise to the back of her left hand. The color is noted to be purplish-black and reddish black. Aide made writer aware that resident had two combative episodes one on 12/31/18 where the resident struck out at the aides with both hands and feet. One earlier on 7-3. There was no further documentation recorded in the resident's record of her being combative during care. Resident #85 careplan did not indicate that she is resistive to or combative during care. The DON was requested to provide any and all investigation on this particular injury of unknown source. The facility provided the survey team an Initial QA Report of Bruises, Skin Tears, Scratches or Other Skin Injuries which indicates that resident might have [NAME] hand causing a skin tear. [sic] The facility had no formal investigation of the injury of unknown source. The facility didn't have statements from staff members involved in the care of the individual when the injury was identified. No report was made to the state agency regarding the injury of unknown source and no corrective action nor protection during an investigation was performed by the facility, which are the parts of the Abuse protocol mandated by Federal regulation. Review of the facility Policy and Procedure titled: Abuse Prevention, Investigation and Reporting states outside entities, including regulatory agencies, ombudsmen, protective services, and legal investigators will be notified and involved as appropriate to the situation. It further states the facility will investigate and report all observations, allegation, incidents or occurrences that may indicate abuse or neglect to the state survey and other interested agencies in accordance with federal and state regulations. The facility Administrator, Director of Nursing and CEO were made aware of these findings on 3/13/19. No additional information was provided. Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to report an injury of unknown origin for 3 residents (Resident # 3, # 27, and # 85) of 45 residents in the survey sample. 1. For Resident #3, the facility did not report to the State Agency the discovery of an injury of unknown origin from 3/11/2019 at 8:40 PM which was described as an unwitnessed fall with injury. 2. For Resident #27, the facility failed to report an injury of unknown origin and failed to report investigation results. 3. For Resident #85, the facility failed to report an injury of unknown origin and failed to report investigation results. The findings included: 1. For Resident #3, the facility did not report to the State Agency the discovery of an injury of unknown origin from 3/11/2019 at 8:40 PM described as an unwitnessed fall with injury. Resident #3, an [AGE] year old female, was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: Vascular Dementia, Hypokalemia, Osteoarthritis, Anorexia, Repeated falls, Hypertension, and Anxiety. The most recent Minimum Data Set assessment was an admission assessment with an assessment reference date (ARD) of 11/12/18. Resident # 3 was coded with a Brief Interview of Mental Status (BIMS) score of 5 indicating severe cognitive impairment. Resident # 3 was coded as requiring limited to extensive assistance of one staff person for Activities of Daily Living except she required total assistance of one staff person for bathing. Resident # 3 was coded to need extensive assistance of one staff person for ambulation. Review of the clinical record revealed no documentation of an injury of unknown origin being reported to the State Agency. On 3/14/2019 at 10:36 a.m., an interview was conducted with the Administrator and Director of Nursing regarding the process regarding any Unwitnessed falls. The Director of Nurses stated the expectation is: the nurse would assess the resident for injuries, if they look like they are not seriously injured, move them, start neuro (neurological) checks, notify the md (medical doctor), and rp (responsible party), apply first aid if necessary, nurse on unit is responsible for starting the fall investigation including interviewing resident if possible, interviewing staff, inspect to make sure the equipment is operating properly, bed brakes, alarm, putting appropriate interventions in place, example, use non skid socks, if incontinent, look at toileting patterns, care plan updates. The fall investigation form is reviewed by the unit manager who makes sure it is completed accurately or if it needs any more information. It was reviewed with the DON and Administrator that an allegation should be reported before it is investigated. The Administrator and DON stated the facility would not report an unwitnessed fall with injury to the State Agency. When asked to describe the process for a resident who had an unwitnessed fall with an injury in the cognitively impaired resident, the DON stated we do not report unwitnessed falls to the state. The Administrator and DON stated the nurses were able to determine if there was a need for an investigation based on the assessment of the situation. Both stated that the facility did not need to report the unwitnessed fall with injury as an injury of unknown origin because the nurse would be able to look at the situation and determine if it looked like the injury was the result of a fall. The DON was interviewed regarding abuse. She stated that once an allegation was made, she would investigate. If the allegation was an issue, then she would report it to the State Agency. It was reviewed with the DON that an allegation should be reported before it is investigated. The Administrator, Director of Nursing and Chief Executive Officer were asked to come to the conference room to discuss the abuse policies with the entire survey team. On 3/14/2019 at 10:50 a.m., the administrator, DON and CEO came to the conference room to continue the conversation regarding the definition of an injury of unknown origin, the need to report injuries of unknown origin, unwitnessed falls with injury in the cognitively impaired and implementation of the abuse policies. The DON stated we would immediately report any suspected abuse if we thought that was a problem. The DON stated the facility was aware of the two hour and 24 hour reporting requirement for suspected abuse but the injury for Resident # 3 was not considered possible abuse. The DON stated the CNA (Certified Nursing Assistant) reported she found the resident had fallen on the floor and the nurse determined the injury was the result of the fall. On 3/14/2019 at 3:15 PM, the DON presented another copy of the Abuse Policy which included 7 pages. The DON stated the previous copy she presented was missing two pages since both sides of each page had not been copied. Review of the facility abuse policy Abuse: Prevention, Investigation and Reporting, Revision date 2/13/18 was reviewed. Policy Section VII (7) Reporting and follow up Response B. The Administrator (or designee) will report all alleged violations to the state survey agency and to all other required agencies: Adult Protective Services, the Ombudsman (DARS) and where applicable, the Board of Nursing and law enforcement. The initial report is made as soon as possible: a. Allegations involving abuse, neglect, or exploitation of a resident must be reported within two hours (first report), in the event that there has been serious bodily injury to a resident. b. Allegations that have resulted in no serious harm to the resident are reported as soon as is possible, and within 24 hours. C. If the allegation will require additional time for thorough investigation, the initial report will indicate this and the final report (a summary of the conclusion) will be provided to the same agencies within the timeframes required by regulations. On 3/14/19 at 5:00 p.m., the Administrator and DON were asked to submit any information they would like to have reviewed regarding the issue. The DON stated the facility did not submit a report to the State Agency for the injury of unknown origin over the left eye of Resident # 3 on 3/11/2019. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #27, the facility failed to protect the resident, conduct an investigation of an injury of unknown origin and did not provide corrective action for an injury of unknown origin. Resident #27, an [AGE] year old male, was admitted to the facility on [DATE]. His diagnosis included but were not limited to: aphasia, nontraumatic intracerebral hemorrhage, facial weakness, dysphagia, hypothyroidism, hyperlipidemia, compression of brain and hypertension . Resident #27's most recent MDS (Minimum Data Set) (an assessment tool) with an ARD (assessment reference date) of 1/3/19 was coded as a quarterly assessment. Resident #27 was coded as having a BIMS (Brief interview for mental status) score of 3, indicating severe cognitive impairment. He was also coded as requiring extensive assistance of one staff member for transfers, locomotion on and off unit, dressing, toileting and personal hygiene. He requires supervision with setup assistance for eating. The MDS stated that he did not have any physical or verbal behavioral symptoms or any other behaviors directed toward others. During a record review of nursing notes, Resident #27 was documented on 2/21/19 as having a 0.5 x 0.5 cm skin tear to the right wrist. The resident's record including nursing notes, physician notes and nursing assessments did not make any indication of how the skin tear occurred. The DON was requested to provide any and all investigation on this particular injury of unknown source. The facility provided the survey team a two page document entitled Initial QA Report of Bruises, Skin Tears, Scratches or Other Skin Injuries. This document entailed a series of check boxes that were checked for the following three items; 1. observed thrashing limbs in bed or chair, 2. observed scratching or picking at skin, 3. demonstrate combative behavior with caregivers. It was also noted on the Initial QA Report of Bruises, Skin Tears, Scratches or Other Skin Injuries form that this information was described in the chart 2/21/19. However, there is no evidence in Resident #27's clinical chart, nursing notes, physician notes, careplan, nursing assessments or MDS, from 1/1/19-3/14/19 that the resident exhibited any of these behaviors. Accompanying this document, was an unsigned and undated statement allegedly from a CNA stating that Resident #27 was resisting getting up and yank his hand away from us a couple of times. [sic] The facility had no formal investigation of the injury of unknown source. The facility didn't have statements from all staff members involved in the care of the individual when the injury was identified nor protection of the resident during an investigation was performed by the facility. Review of the facility Policy and Procedure titled: Abuse Prevention, Investigation and Reporting states outside entities, including regulatory agencies, ombudsmen, protective services, and legal investigators will be notified and involved as appropriate to the situation. It further states the facility will investigate and report all observations, allegation, incidents or occurrences that may indicate abuse or neglect to the state survey and other interested agencies in accordance with federal and state regulations. The facility Administrator, Director of Nursing and CEO were made aware of these findings on 3/13/19. No additional information was provided. 3. For Resident #85, the facility failed to protect the resident, conduct an investigation of an injury of unknown origin and did not provide corrective action for an injury of unknown origin. Resident #85, an [AGE] year old female, was admitted to the facility on [DATE]. Her diagnosis included but were not limited to: Alzheimer's disease, dementia, Hypertension, unspecified diastolic heart failure, hypothyroidism, generalized anxiety, and type 2 diabetes. Resident #85's most recent MDS (minimum data set) (an assessment) with an ARD (assessment reference date) of 2/22/19 was coded as an annual assessment. Resident #85 was coded as having a BIMS (Brief Interview for Mental Status) score of 5, indicating severe cognitive impairment. She was also coded as requiring extensive assistance with two staff members for her activities of daily living to include transfers and bed mobility. She required extensive assistance with one staff member for locomotion on unit and dressing. Was totally dependent with assistance of one staff member for eating, toileting, personal hygiene and bathing. Further, her MDS is coded as her not having any behavioral symptoms. During record review the nursing notes revealed Resident #85 had a irregularly shaped 6 x 6 cm bruise to the back of her left hand. The color is noted to be purplish-black and reddish black. Aide made writer aware that resident had two combative episodes one on 12/31/18 where the resident struck out at the aides with both hands and feet. One earlier on 7-3 (shift). There was no further documentation recorded in the resident's record of her being combative during care. Resident #85 careplan did not indicate she is resistive to or combative during care or that it was routine behavior for this resident. The DON was requested to provide any and all investigation on this particular injury of unknown source. The facility provided the survey team an Initial QA Report of Bruises, Skin Tears, Scratches or Other Skin Injuries which indicates that resident might have [NAME] hand causing a skin tear. [sic] The facility had no formal investigation of the injury of unknown source. The facility didn't have statements from staff members involved in the care of the individual when the injury was identified. Review of the facility Policy and Procedure titled: Abuse Prevention, Investigation and Reporting states outside entities, including regulatory agencies, ombudsmen, protective services, and legal investigators will be notified and involved as appropriate to the situation. It further states the facility will investigate and report all observations, allegation, incidents or occurrences that may indicate abuse or neglect to the state survey and other interested agencies in accordance with federal and state regulations. The facility Administrator, Director of Nursing and CEO were made aware of these findings on 3/13/19. No additional information was provided. Based on staff interview, clinical record review and facility documentation review, the facility staff failed for 3 residents (Resident #3, # 27 and # 85) of 45 residents in the survey sample to investigate an injury of unknown origin. 1. For Resident #3, the facility staff failed to investigate an incident of the resident being found on the floor with an injury of her left eye as an injury of unknown origin. The incident was documented as an unwitnessed fall. 2. For Resident #27, the facility failed to protect the resident, conduct an investigation of an injury of unknown origin and did not provide corrective action for an injury of unknown origin. 3. For Resident #85, the facility failed to protect the resident, conduct an investigation of an injury of unknown origin and did not provide corrective action for an injury of unknown origin. The findings included: 1. For Resident #3, the facility staff failed to investigate an incident of the resident being found on the floor with an injury of her left eye as an injury of unknown origin. The incident was documented as an unwitnessed fall. Resident #3, an [AGE] year old female, was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: Vascular Dementia, Hypokalemia, Osteoarthritis, Anorexia, Repeated falls, Hypertension, and Anxiety. The most recent Minimum Data Set assessment was an admission assessment with an assessment reference date (ARD) of 11/12/18. Resident # 3 was coded with a Brief Interview of Mental Status (BIMS) score of 5 indicating severe cognitive impairment. Resident # 3 was coded as requiring limited to extensive assistance of one staff person for Activities of Daily Living except she required total assistance of one staff person for bathing. Resident # 3 was coded to need extensive assistance of one staff person for ambulation. During the initial tour of the facility on 3/12/2019 at 10:45 AM, Resident # 3 was observed sitting in a wheelchair at the nurses station. There was a bruise over her left eye and steri strips covering a wound. Review of the clinical record was conducted on 3/12/2019. On 3/12/19 at 2 PM, an interview was conducted with LPN (Licensed Practical Nurse) E who stated Resident # 3 fell and sustained the injury the night before on 3/11//2019 on the 3-11 shift. LPN E stated the CNA found the resident on the floor according to the report. On 3/12/19 at 4:30 PM, an interview was conducted with the Director of Nursing (DON) who stated she was informed that Resident # 3 fell on the 3-11 shift on 3/11/2019. The DON stated the injury over Resident # 3's eye was the result of the fall. When asked to see a copy of the investigation, the DON stated no investigation was done because the nurse determined the resident had fallen. The DON stated the nurse filled out a fall investigation form but no further investigation was conducted. The DON was asked to submit a copy of the fall investigation form. Review of the Fall investigation Report dated 3/11/19 at 8:40 PM documented the fall occurred in the resident's room. The form read: List all witnesses to the fall (staff, residents, visitors) None. What was the resident observed doing immediately before the fall? in bed asleep What does the resident say they were doing before the fall no explanation Is there any reason to believe that another person was involved in the fall? If, so why and who[sic]: No Review of the Fall Investigation Report dated 3/1/2019 revealed no documentation of any injuries. There was no mention of the bruise or injury above the left eye. On 3/14/19 at 5:00 p.m., the Administrator and DON were asked to submit any information they would like to have reviewed regarding failure to thoroughly investigate the injury of unknown origin to the State Agency. The DON stated injuries of unknown origin would be reported to the State Agency prior to investigating and a final report would be submitted within 5 days as required in the future. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, the facility staff failed for 1 residents (Resident #33) of 45 sampled residents to ensure that necessary discharge documentation was completed and sent to the receiving facility. The facility staff failed to ensure that physician documentation, care plan goals, etc. were completed and sent to the receiving facility. The Findings included: Resident # 145 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #145's diagnoses included Heart Failure, Hypertension, Diabetes Mellitus, Dementia, and Depression. The Minimum Data Set, which was an admission Assessment, with an Assessment Reference Date of 10/26/18 was reviewed. Resident #145 was coded as having a Brief Interview of Mental Status score of 8, indication severe cognitive impairment. On 3/14/19, a review was conducted of Resident #145's clinical record, revealing the following nurse's note: 11/13/18. Skilled rehab for weakness. Alert and oriented x 2, confused. Vitals wni (within normal limits). Patient anxious and upset this shift due to being discharged today and time. Lungs clear, no sob (shortness of breath) noted. No pain. No bowel movement (BM) x 3 days. Patient refused Sorbitol-no BM this shift. Patient is discharging to (Nursing Facility) and was evaluated today by hospice nurse. Patient to be transported via ambulance at 5 PM. No additional concerns. The clinical record did not contain documentation that the following written documentation was sent to the receiving facility: Discharge Summary, Comprehensive Care plan goals, Advance Directives, Physician documentation of the basis for the transfer, list of medications, and contact information of the practitioner responsible for the care of the resident. On 3/14/19 at 2:45 P.M., an interview was conducted with the Discharge Licensed Practical Nurse (LPN B), who was asked for copies of the above-mentioned documents, and proof that the documents had been sent to the receiving facility. LPN B stated, We don't have a copy of the paperwork, we sent it off. On 3/14/19 at 4:00 P.M. the Administrator was notified of the findings. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure a Quarterly Minimum Data Set was completed at least every 92 days for two residents (Resident # # 2 and # 3) in a survey sample of 45 residents. 1. For Resident #2, the facility staff failed to complete a (Minimum Data Set) MDS since the Significant Change MDS with and (Assessment Reference Date) ARD of 11/6/18. There are 128 days between 11/6/18 and 3/14/18 (the end of survey). 2. For Resident #3, the facility staff failed to complete a Minimum Data Set (MDS) since the admission MDS with an Assessment Reference Date (ARD) of 11/12/2018. There are 122 days between 11/12/2018 and 03/14/2019 (the end of survey). The findings include: 1. For Resident #2, the facility staff failed to complete a (Minimum Data Set) MDS since the Significant Change MDS with and (Assessment Reference Date) ARD of 11/6/18. There are 128 days between 11/6/18 and 3/14/18 (the end of survey). Resident #2 an [AGE] year-old female was admitted to the facility on [DATE] with diagnoses of but not limited to (Coronary Artery Disease) CAD, Hypertension, Dementia, Arthritis, Anxiety, and Depression. On 3/14/19 at 6:45 PM, the ASPEN system identified Resident #2 as not having a Quarterly Assessment as required. On 3/14/19 at 6:50 PM, an interview was conducted with the DON who stated that Resident #2 must have had a Quarterly MDS assessment. She looked in her computer and found that the Resident had the following listed: 09/24/18 - Entry Tracking 10/4/18- OBRA Assessment 11/6/18 - OBRA Significant Change It had been 128 days since the last MDS assessment. The DON then stated, I don't know how it got missed. On 3/14/19 at 7: 45 PM during the end of day meeting the Administrator and the DON were made aware of the issue with the MDS and no further information was provided. 2. For Resident #3, the facility staff failed to complete a Minimum Data Set (MDS) since the admission MDS with an Assessment Reference Date (ARD) of 11/12/2018. There are 122 days between 11/12/2018 and 03/14/2019 (the end of survey). Resident #3, a [AGE] year old female, was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: Vascular Dementia, Hypokalemia, Osteoarthritis, Anorexia, Repeated falls, Hypertension, and Anxiety. The most recent Minimum Data Set assessment was an admission assessment with an assessment reference date (ARD) of 11/12/18. Resident # 3 was coded with a Brief Interview of Mental Status (BIMS) score of 5 indicating severe cognitive impairment. Resident # 3 was coded as requiring limited to extensive assistance of one staff person for Activities of Daily Living except she required total assistance of one staff person for bathing. Resident # 3 was coded to need extensive assistance of one staff person for ambulation. Review of the clinical record was conducted on 3/12/19 and 3/13/19. Review of the MDS assessments revealed the only assessment was done on 11/12/2018. A Quarterly Assessment was due by 2/12/19. The facility staff did not complete a quarterly assessment since the admission Assessment on 11/12/2019. On 3/14/2019 at 6:50 PM, an interview was conducted with the Director of Nursing who stated she did not know why the MDS was not done. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident # 76 the facility failed to address transporting the resident in Broda Resident # 76, a [AGE] year-old man admitted to the facility on [DATE] with diagnoses of but not limited to Unspecified Dementia with behavioral disturbances, Diabetes Type 2, Lewy Body Dementia and Insomnia. Resident #76's last (Minimum Data Set) MDS (screening tool) was an annual with an (Assessment Reference Date) of 1/11/19, which coded the Resident as having a (Brief Interview of Mental Status) BIMS score of 99 which indicates severe cognitive impairment / unable to complete assessment. He was also coded as being a two-person physical assist with bed mobility, incontinence care, transfers and he uses a Broda Chair for mobility. On 3/12/19, at 8:15 AM, during the initial tour of the facility Resident # 76 was observed being pulled backward down the hallway in his Broda Chair from his room to the dining room by CNA H. On 3/12/19 at 8:25 AM, CNA H was asked why she pulled Resident backward down the hall. CNA H stated: So he can't put his feet down and stop the chair. On 3/13/19 at 8:35 AM, LPN B was asked about why the resident was pulled backward in the Broda Chair the day before. LPN B stated that normally it's not the way he is transported to breakfast. On 3/13/19 at 9:15 AM, the PT director (employee J) stated that although it's not ideal, we have to pull him backward in his Broda Chair because he will plant his feet so we cannot push him forward. When asked about the foot pedals that come with the Broda chair she stated: If we put those on then he tries to stand up and it becomes a safety issue. On 3/13/19 at 10:45 AM, Upon clinical review of the care plan it was noted that there is no mention of pulling the chair backward down the hall. On 3/13/19 at approximately 3:00 PM, Unit Manager (LPN D) was asked to show where transporting in Broda Chair backward was addressed in the care plan. LPN D stated it was not in the care plan. On 3/13/19 at approximately 5:00 PM, the facility produced a new care plan which stated: Category: Falls [Resident name redacted] is at risk for falling R/T impaired cognition, Diabetes, Wandering, unsteady gait, medication side effects, and requiring staff assistance with transfers. He will get up unassisted at times despite redirection. He is up much during the night, related to past habits/history. Goal: [Resident name redacted] will remain free from injury thru next review. Approach: Approach Start Date: 3/13/19 [Resident name redacted] will plant feet or attempt to stand when being moved in Broda Chair, safest manner of mobility is to move backward. Inform [Resident name redacted] you will be moving him backward. At the end of day meeting on 3/13/19 the DON was and 3/14/19 the Administrator and DON were made aware but no further information was provided. Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed for 2 residents (Resident #29 and #76) of 45 sampled residents to develop and implement a comprehensive care plan. 1. For Resident #29, the facility staff failed to develop and implement a comprehensive care plan to include a specialized High-Back Reclining wheelchair for fall prevention. 2. For Resident # 76 the facility failed to address transporting Resident in Broda Chair. The Findings included: 1. Resident #29 was a [AGE] year old who had been admitted to the facility on [DATE]. Resident #29's diagnoses included Dementia, Parkinson's Disease, Urinary Tract Infection, Hypertension and Neurogenic Bladder. The Minimum Data Set, which was a Significant Change Assessment with an Assessment Reference Date of 1/7/19 was reviewed. It coded Resident #29 as having a Brief Interview of Mental Status score of 5, indicating severe cognitive impairment. In addition, Resident #29 was coded as having Inattention and Disorganized thinking. On 3/13/19 at approximately 11:15 A.M., an observation was conducted of Resident #29 sitting upright in his wheelchair at the nurse's station. He was observed bending forward a few times and touching his shoes. Nursing staff were observed to walk past the nurse's station, and occasionally sit at the nursing station. On 3/13/19 at 11:31 A.M., an interview was conducted with the Certified Nursing Assistant (CNA A) who was assigned to work with Resident #29. She stated that she had worked with Resident #29 for approximately 8 months. When asked why Resident #29 had not been put in a reclining position prior to his fall, CNA A stated, He's supposed to be in that broda chair because he leans and has a bruise on his lower back from leaning. If he's leaning a lot, we put him in a broda chair. There is a broda chair on Unit 1. No one else is using it. That's the only broda chair. This morning I kept hearing the nurse saying to him sit back and keep on your shoes. She stated that facility staff were aware that Resident #29 had been leaning forward to try to take off his shoes several times. When asked if she had received any training on when, how, and to what degree to recline Resident #29's wheelchair, CNA A stated No. I just use common sense. On 3/13/19 a review was conducted of Resident #29's clinical record, revealing his care plan. The care plan did not address the use of his specialized wheelchair for fall prevention or other use. On 3/13/19 at 2:41 P.M., an interview was conducted with the Director of Rehabilitation (Employee J). When asked if the facility had provided staff training on the use of Resident #29's High Back Reclining Wheelchair, The Director of Rehabilitation stated, We didn't provide a training on the use of the reclining chair. When asked about the degree of decline that should be used, she stated, The degree of decline varies according to how he's feeling. She acknowledged that Resident #20's wheelchair had not been reclined on 3/12/19 and 3/13/19. When asked about the purpose of Resident #29 having a reclining wheelchair, the Director of Rehabilitation stated, If the chair is reclined it helps with facilitating rest. If he's leaning forward it's reclined for safety and redirection. On 3/14/19 at 3:41 P.M., the facility Administrator (Employee B, and Director of Nursing (Employee C) were notified of the findings. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and resident record review the facility failed to review and revise the careplan for one resident in a sample of 45 residents. 1. For Resident #62, the facility staff failed to review and update the careplan to remove the 15 minute checks/observations after being cleared by psychiatric services to no longer be suicidal. The Findings include: Resident #62, a [AGE] year old female, was admitted to the facility on [DATE]. Her diagnosis included but were not limited to: presence of right artificial hip joint, mood disorder, mild cognitive impairment, anxiety disorder, suicidal ideation, primary insomnia, repeated falls, and overactive bladder. Resident #62's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/13/19 was coded as a quarterly assessment. Resident #62 was coded as having a BIMS (Brief Interview for Memory Status) score of 13, indicating cognitively intact. She was also coded as requiring limited assistance with assistance of one staff member for walking in her room and corridor. She is coded as requiring extensive assistance of one staff member for bed mobility, dressing, toileting and personal hygiene. Requires supervision with setup help only for eating. She is frequently incontinent of bowel and bladder. During clinical record review of nursing notes, physician progress notes and careplan, on 3/13/19 it was noted in the nursing notes that Resident #62 verbalized thoughts of suicide on 2/11/19 and again on 2/15/19. The facility implemented 15 minute checks on the resident on each occasion and ordered psychiatric consult. She was seen by psychiatric services on 2/12/19 and they indicated no need for suicide precautions to continue. Resident #62 again on 2/15/19 verbalized suicidal thoughts and the facility again placed her on 15 minute checks. Resident #62's careplan still has listed that she is on 15 minute checks as of record review on 3/13/19 and 15 minute checks were not being done at the present time. The careplan had not been reviewed/updated to reflect the discontinuance of the 15 minute safety checks. The Administrator and Director of Nursing were made aware of these findings on 3/13/19. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, Resident interview, facility documentation review, and clinical record review, the facility staff failed to follow professional standards of practice for medication and treatment administration for 1 Resident (Residents #75) in a survey sample of 45 Residents. For Resident #75 facility staff failed to administer medications and change dressing to the Left Stump as ordered by the physician. The findings include: Resident # 75, a [AGE] year-old man admitted to the facility on [DATE] with diagnoses of but not limited to (Peripheral Vascular Disease) PVD, Orthopedic Surgical aftercare for (Below Knee Amputation) BKA of Left lower leg. Most recent (Minimum Data Set) MDS (an assessment tool) with an (Assessment Reference Date) ARD of 2/27/19 codes Resident as having a (Brief Interview of Mental Status) BIMS of 15 indicating No Cognitive Impairment. On 3/12/19 at 10:00 AM, during an initial tour the Resident removed his sock covering his stump to the left leg and a dressing was observed to be dated 3/10/19. During this same interaction, Resident #75 provided a copy of the follow-up report from the Surgeon dated 3/6/19 with orders for dressing changes that read: Result Type: Orthopedic Surgery OP Established Visit Date: March 5, 2019 16:23 [4:23 PM] Author: [Surgeon Name Redacted] F/u Left BKA [follow up Left below Knee Amputation] Patient [Resident #75 name and medical record information redacted] Chief Complaint: Follow- up Left BKA History of Present Illness [AGE] year old male status post left below knee amputation. Date of surgery was January 16, 2018. Comes in today for follow up visit. Denies fevers chills chest pain shortness of breath. However, he does have some erythema [redness] and drainage from the medial aspect of the incision. He states that it started a couple of weeks ago. He was seen last week and started on Keflex. He feels like it is better. Plan: We will add Doxycycline to the antibiotic regimen because of him being in a facility and cover MRSA. We will do Keflex and Doxycycline. We will have him do DAILY Mepilex AG dressing changes to leg. Once it heals up we will give him a prescription for a temporary prosthesis. We will see the stump shape is an issue. If it is we may have to consider revision surgery to reshape it. In terms of wound care change the Mepilex AG dressing one a day. Just cover the medial aspect of the incision where it is draining. Continue with the antibiotics follow up in 2 weeks. On follow up we will get x-rays of the left tibia stump. According to the facility (Treatment Administration Record), the new treatment with Mepilex was not initiated until 3/9/19. During interview with the Resident on 3/12/19 the Resident stated that he had been given the Mepilex by the staff at the hospital on his follow up on 3/5/19 and told Mepilex is very expensive this box costs about $600.00 keep it in your room and cut off a piece every day to give to the treatment nurse to do your dressing changes. The facility may use it for someone else if you give it to them to hold. When asked when he gave the information about the new orders to the facility staff he stated when he got back from the doctor he made copies and gave to the nursing staff. He did not recall which nurse was working at the time. He stated that the nurse told him she couldn't start the new antibiotic until the facility doctor sees the new orders. The Resident admits to being upset by this but states that the new Antibiotic was started the next evening. According to the (Medication Administration Report) MAR, the antibiotic ordered by the Surgeon on 3/5/19 was initiated on 3/6/19 at 5:00 PM. Guidance for nursing standards for the administration of medication is provided by Fundamentals of Nursing, 7th Edition, Mosby's/ [NAME]-[NAME], p. 705: Professional standards, such as the American Nurses Association's Nursing Scope and Standards of Nursing Practice of (2004), apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation Administrator and DON were made aware during the end of day meeting on 3/13/19 at 6:00 PM no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation the facility staff failed to provide appropriate treatment to prevent urinary tract infection for 1 Resident in a survey sample of 45 Residents. For Resident #48 the facility staff failed to ensure proper catheter care by allowing the catheter tubing to drag on the floor while transporting Resident in a wheelchair and while sitting in the hall. The findings include: Resident # 48, a [AGE] year-old woman was admitted to the facility on [DATE] with diagnoses of but not limited to Dementia, abnormal weight loss, history of stroke, history of pneumonia, anxiety disorder, and urinary retention related to Neurogenic Bladder. Most recent (Minimum Data Set) MDS (an assessment tool) was an annual with an (Assessment Reference Date) ARD of 1/16/19 codes Resident as being unable to assess using the (Brief Interview of Mental Status) BIMS tool. The Resident is coded as not being understood and unable to screen indicating severe cognitive impairment. On 3/13/19 at 10:30 AM Resident #48 was observed being propelled in the wheelchair to the nurse's station. The catheter bag was placed in a dignity bag however the tubing was dragging on the floor under the wheelchair. The resident was observed sitting in her wheelchair at the nurse's station for over an hour. On 3/14/19 at 11:50, an interview was conducted with LPN C. LPN C was asked if she saw a problem with the way Resident #48 was dozing in her wheelchair at the nurses' station. LPN C stated, oh she needs to be repositioned. She then realized the Resident's glasses were on the floor and knelt down to pick them up. LPN C was then asked what about her catheter? Is it supposed to be dragging on the ground under her chair? LPN C stated, no I will take her to fix it and proceeded to wheel Resident down the hall. When asked what would be the potential problem with the catheter dragging the floor, LPN C stated contamination with germs and it could get caught on something. On 3/14/19 at 1:00 PM, an interview was conducted with the DON about catheter care. She stated that the catheter should be in a drainage bag and neither should be touching the floor. On 3/14/19 the facility's catheter care policy/procedure was reviewed but it did not address the tubing being kept off of the floor. On 3/14/19 during the end of day meeting, the DON and Administrator were made aware and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, family interview, clinical record review and facility documentation review, the facility staff failed to administer oxygen in a manner to prevent the spread of infection for two Residents (Residents #70 and # 86) in a survey sample of 45 Residents. 1. For Resident #70, the nebulizer tubing was not dated. 2. For Resident # 86, there were two different dates on the oxygen humidifier bottle. The finding include: 1. For Resident #70, the nebulizer tubing was not dated. Resident #70, a [AGE] year old woman who was admitted to the facility on [DATE] with diagnoses of but not limited to Hemiparesis following stroke affecting right (dominant) side, anemia, history of heart attack, long term use of inhaled steroids, osteo arthritis and dementia without behavioral disturbance. On 3/12/19, upon initial tour, it was observed that Resident #70 had a nebulizer in her room with tubing that was not dated. On 3/12/19 at 11:50 AM, an interview with the DON was conducted and she was asked about the policy for oxygen and Nebulizer tubing. The DON stated It is changed and dated weekly on Wednesday night shift. The facility Oxygen and Respiratory care policy (provided by the DON) reads: Related Supplies and Storage 5. Oxygen tubing, nebulizers, masks and humidifier bottles will be dated when changed. Changing of the oxygen tubing and related supplies will be done weekly by night shift. On 3/13/19 the Administrator and the DON were made aware during the end of day meeting and no additional information was provided. 2. For Resident # 86, there were two different dates on the oxygen humidifier bottle. Resident # 86, a [AGE] year old female was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Chronic Obstructive Pulmonary Disease, Acute and chronic respiratory failure with hypercapnia, Heart Failure, Hypertension, anemia, Abdominal Aortic Aneurysm, and Osteoporosis. Resident # 86's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 2/22/2019. The MDS coded Resident # 86 with a BIMS (Brief Interview for Mental Status) score of 13 out of 15, indicating no cognitive impairment. Resident # 86 was coded as requiring extensive assistance of one staff person for Activities of Daily Living and occasionally incontinent of bowel and bladder. On 3/12/19 at 9:40 AM during the initial tour of the facility, Resident # 86 was observed sitting in a chair in her room with oxygen via nasal cannula at 2 liters per minute. The oxygen humidifier bottle had a date of 3/5/2019 written in fine point black ink and the top of the bottle had the date 3/9/19. The 9 was visibly written on top of another date that was illegible. There was a red Oxygen in Use sign on the door frame. On 3/12/2019 at 9:45 AM , an observation of a visitor enter Resident # 86's room. The visitor identified herself as Resident # 86's daughter. On 3/12/2019 at 9:50 AM, an interview was conducted with the daughter of Resident # 86 who stated the oxygen is an issue She stated the facility staff often put the nasal cannula upside down in the resident's nose. The daughter stated the oxygen tubing and humidifiers were not changed weekly as they were supposed to be changed. Daughter stated she saw there was no date on the oxygen humidifier, so on 3/5/2019, she put the date 3/5/2019 on the label on the front of the humidifier bottle in pen to see if it was going to be changed., Daughter stated she noticed that someone wrote a different date written on top of the bottle in magic marker and that it was in conflict with when the bottle was put in her mother's room. Review of the Care Plan on Page 8 of 35 revealed problem: start date 3/4/2019, Category: Respiratory ____(Resident # 86 ) has a diagnosis of exacerbation of COPD and chronic respiratory failure. Approach: Start date: 3/4/2019 Oxygen as ordered: use concentrator when resident is seated or in bed in room,, oxygen tanks to chair when mobile and in activity and dining areas. Resident is to take concentrator out of room to dinning [sic] room for meals per RP (Responsible Party) request. On Page 31 of 35 Problem start date 3/4/2019 ____(Resident # 86) is on oxygen therapy as ordered for SOB (Shortness of Breath): Approaches included: Oxygen administered as ordered During the end of day debriefing on 3/1/19 at approximately 5:00 PM, the Administrator and Director of Nursing were informed of the different dates on the humidifier bottle. The Director of Nursing stated the oxygen tubing and supplies were expected to be changed weekly on night shift every Wednesday night. On 3/13/2019 at 6:15 PM, the Director of Nursing and surveyor went to Resident 86's room to inspect the oxygen equipment. The Director of Nursing inspected the oxygen equipment and stated she could not explain the different dates on the humidifier bottle. Review of the Facility Policy on Oxygen administration storage and maintenance, Date 9/1/2015 revealed: Related supplies and storage 5. Oxygen tubing, nebulizers, masks and humidifier bottles will be dated when changed. Changing of oxygen tubing an related supplies is done weekly by night shift. No further information was provided.

Based on facility documentation review and staff interview the facility failed to provide regular in-service education based on the outcome of performance reviews at least every 12 months for one employee in a survey sample of 6 employees. The facility failed to ensure CNA F was provided a minimum of 12 hours of in-service training annually. The findings include: Employee records were reviewed with the HR Director on 3/14/19 at 2:19pm. Those records indicated that CNA F, with a hire date of 8/17/11, had attended several training's in December 2018. She stated they usually last 15-20 minutes each. A total of 1.25 hours of inservice hours were recorded for CNA F for 2018. There was no evidence of receiving the required 12 hours of in-service training, based on performance reviews for 2017 or 2018. Interview with Employee K, HR Generalist on 3/14/19 at approximately 2:50pm indicated she had no further information she could afford to the survey team. The Administrator was made aware of the findings during the end of day meeting on 3/14/19. No additional information was provided.

Based on observation, staff interview and facility documentation review the facility staff failed to store and serve food in accordance with professional standards for food service safety. 1. Facility staff failed to ensure an air gap was in place between the ice machine drainage pipe and floor drain for the ice machine in the main kitchen. 2. Nursing staff CNA (Certified Nursing Assistant) D was observed entering the kitchen without a hair net on Unit 2. The findings included: 1. Facility staff failed to ensure an air gap was in place between the ice machine drainage pipe and floor drain for the ice machine in the main kitchen. A tour of the main kitchen took place on 3/12/19 at 8:10 a.m. with the Dietary Manager. Upon inspection of the ice machine, it was observed that one of the two drainage pipes from the ice machine was flush against the floor drain cover plate. There was no air gap in place to allow for back flow from the drain. After looking at the drainage pipe, the Dietary Manager stated that both pipes should be elevated off the drain. She stated that it looked like the weight of one pipe was pressing against the other and caused one pipe to hang too low. The Dietary Manager stated the Maintenance Director would be notified immediately of the problem. On 3/12/2019 at 1:10 PM, during another inspection of the kitchen, it was observed that both pipes were elevated off the drain cover plate. On 3/12/2019 at 3:05 PM, the administrator was informed of no air gap on the ice machine in the main kitchen. The administrator stated he would make sure the problem was corrected. During the end of day debriefing on 3/13/2019, the facility administrator and Director of Nursing were informed of the findings of the drainage pipe from the ice machine in the main kitchen was flush against the floor drain. There was no air gap in place. The Administrator stated the problem had been corrected immediately by Maintenance. No further information was provided. 2. Nursing staff, CNA (Certified Nursing Assistant) D, was observed entering the kitchen without a hair net on Unit 2. On 3/14/2019 at 9:30 AM, CNA (Certified Nursing Assistant) D, was observed entering the kitchen without a hairnet on. Employee G turned around to see who entered the kitchen. CNA D was going to the ice machine with a large plastic drinking cup in her hand. CNA D was interviewed immediately. CNA D stated she was sorry and stated she thought the dining services were finished. CNA D stated she should have had a hairnet on before entering the kitchen. Employee G stated all staff should have on hairnets before entering the kitchen. Employee G showed the surveyor that hairnets were available in the kitchen. On 3/14/2019 during the end of day debriefing, the Administrator and Director of Nursing (DON) were informed that facility nursing staff did not wear a hairnet when she entered the kitchen. The DON stated all staff should wear hairnets in the kitchen. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to assess and determine that residents are safe and appropriate to self administer medications for 4 residents (Resident #87, 21, 11, and 26) in a survey sample of 45 residents. 1. For Resident #87, the facility failed to assess that the resident was safe to self administer medications that she had access to her room. 2. For Resident #21 the facility failed to assess that the resident was safe to self administer medications that he had immediate access to. 3. For Resident #11 the facility failed to assess that she was safe to self administer medications that she had immediate access to. 4. For Resident #26 the facility failed to assess that he was safe to self administer medications that he had immediate access to. The findings included: 1. For Resident #87, the facility failed to assess that the resident was safe to self administer medications that she had access to her room. Resident #87, an [AGE] year old female, was admitted to the facility on [DATE], with her most recent readmission being on 12/7/18. Her diagnosis included but were not limited to: unspecified dementia with behavioral disturbance, urinary tract infection, nausea with vomiting, cellulitis, pain in right wrist, osteoarthritis of left knee and failure to thrive. Resident #87's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/25/19 was coded as a quarterly assessment. Resident #87 was coded as having a BIMS (Brief interview for mental status) score of 3 indicating severe cognitive impairment. She was also coded as requiring supervision of one staff member for her activities of daily living to include, bed mobility, walking in and out of room, locomotion on and off unit and eating. She was coded as requiring extensive assistance of one staff member for dressing, toilet use and personal hygiene. During initial observation and facility tour of the locked dementia unit, on 3/12/19 at approximately 8:30am in the bathroom of Resident #87 there was 3 containers of Greer's [NAME] (a barrier cream consisting of a mixture containing nystatin powder, hydrocortisone powder and zinc oxide paste) accessible to the resident in the bathroom cabinet. Review of Resident #87's nursing notes, careplan, physician orders, nursing assessments and MDS revealed that no type of assessment had been conducted to determine if she was safe to self administer this medication. An interview with LPN D was conducted on 3/14/19 at approximately 3:20pm. LPN D stated that Resident #87 is ambulatory and therefore would have access to items within her room, bathroom and on the unit. Review of the facility policy and procedure titled Self-Administration of Medications reads, If a resident requests to self-administer medication medications, it is the responsibility of the interdisciplinary team to determine that it is clinically appropriate for the resident to self-administer the medications, before the resident may exercise that right. The interdisciplinary team must also determine who will be responsible [the resident or nursing staff] for storage and documentation of the administration of the medication, as well as the location of the medication administration. Appropriate notation of these determinations will be maintained in the resident's clinical record. The decision that it is clinically appropriate for a resident to self-administer medication is subject to periodic re-evaluation based on change in the resident's condition or a change in the medications. The attending physician must approve a recommendation from the interdisciplinary team prior to being permitted to self-administer medications. [sic] The Administrator and Interim Director of Nursing were made aware of the lack of assessment to self administer medications on 3/13/19. No further information was provided. 2. For Resident #21 the facility failed to assess that the resident was safe to self administer medications that he had immediate access to. Resident #21, an [AGE] year old male, was admitted to the facility on [DATE]. His diagnosis included but were not limited to: Dementia, anemia, anxiety, hypertension and benign prostatic hyperplasia. Resident #21's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/27/19 was coded as a quarterly assessment. Resident #21 was coded as having a BIMS (Brief interview for mental status) score of 3 indicating severe cognitive impairment. He was also coded as requiring supervision of one staff member for eating. Other activities of daily living to include, walking in his room, locomotion on and off unit, dressing, personal hygiene he requires extensive assistance of one staff member. During initial observation and facility tour of the locked dementia unit, on 3/12/19 at approximately 8:30am in the bathroom of Resident #21 there was a container of [NAME] Tears eye drops accessible to the resident in the bathroom cabinet. The bottles read, if swallowed get medical help or contact poison control right away. During an observation on 3/14/19 at approximately 1:58pm the [NAME] Tears were still present in the bathroom cabinet. Review of Resident #21's nursing notes, careplan, physician orders, nursing assessments and MDS revealed that no assessment had been conducted to determine if he was safe to self administer this medication. An interview with LPN D was conducted on 3/14/19 at approximately 3:20pm. LPN D stated that Resident #21 is ambulatory at times and self propels his wheelchair at other times and therefore would have access to items within his room, bathroom and on the unit. Review of the facility policy and procedure titled Self-Administration of Medications read, If a resident requests to self-administer medication medications, it is the responsibility of the interdisciplinary team to determine that it is clinically appropriate for the resident to self-administer the medications, before the resident may exercise that right. The interdisciplinary team must also determine who will be responsible [the resident or nursing staff] for storage and documentation of the administration of the medication, as well as the location of the medication administration. Appropriate notation of these determinations will be maintained in the resident's clinical record. The decision that it is clinically appropriate for a resident to self-administer medication is subject to periodic re-evaluation based on change in the resident's condition or a change in the medications. The attending physician must approve a recommendation from the interdisciplinary team prior to being permitted to self-administer medications. [sic] The Administrator and Interim Director of Nursing were made aware of the lack of assessment to self administer medications on 3/13/19. No further information was provided. 3. For Resident #11 the facility failed to assess that she was safe to self administer medications that she had immediate access to. Resident #11, an [AGE] year old female, was admitted to the facility on [DATE], with her most recent readmission being on 5/8/18. Her diagnosis included but were not limited to: unspecified dementia with behavioral disturbance, hyperlipidemia, anxiety disorder, schizophrenia, hypothyroidism and paranoid schizophrenia. Resident #11's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 12/13/18 was coded as a quarterly assessment. Resident #11 was coded as having a BIMS (Brief interview for mental status) score of 7 indicating severe cognitive impairment. She was also coded as requiring supervision of one staff member for her activities of daily living to include eating. Other activities of daily living, such as bed mobility, transfers, ambulation in and out of her room and locomotion on and off of the unit required limited assistance of one staff member. She was coded as requiring extensive assistance of one staff member for dressing, personal hygiene and bathing. During an initial observation and facility tour of the locked dementia unit, on 3/12/19 at approximately 8:30am, in the bathroom of Resident #11, there was a container of Gold Bond Medicated Powder accessible to the resident in the bathroom cabinet. Review of Resident #11's nursing notes, careplan, physician orders, nursing assessments and MDS revealed that no assessment had been conducted to determine if she was safe to self administer this medication. An interview with LPN D was conducted on 3/14/19 at approximately 3:20pm. LPN D stated that Resident #11 is able to self propel her wheelchair and therefore would have access to items within her room, bathroom and on the unit. Review of the facility policy and procedure titled Self-Administration of Medications reads, If a resident requests to self-administer medication medications, it is the responsibility of the interdisciplinary team to determine that it is clinically appropriate for the resident to self-administer the medications, before the resident may exercise that right. The interdisciplinary team must also determine who will be responsible [the resident or nursing staff] for storage and documentation of the administration of the medication, as well as the location of the medication administration. Appropriate notation of these determinations will be maintained in the resident's clinical record. The decision that it is clinically appropriate for a resident to self-administer medication is subject to periodic re-evaluation based on change in the resident's condition or a change in the medications. The attending physician must approve a recommendation from the interdisciplinary team prior to being permitted to self-administer medications. [sic] The Administrator and Interim Director of Nursing were made aware of the lack of assessment to self administer medications on 3/13/19. No further information was provided. 4. For Resident #26 the facility failed to assess that he was safe to self administer medications that he had immediate access to. Resident #26, an [AGE] year old male, was admitted to the facility on [DATE]. His diagnosis included but were not limited to: unspecified dementia with behavioral disturbance, metabolic encephalopathy, vomiting, dry eye syndrome, urinary tract infection, frequency of micturition, unspecified mood disorder, insomnia and overactive bladder. Resident #26's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 12/28/18 was coded as an admission assessment. Resident #26 was coded as having a BIMS (Brief interview for mental status) score of 5 indicating severe cognitive impairment. He was also coded as being independent with set up assistance only for eating. Other activities of daily living to include, bed mobility, transfers, dressing, toilet use and personal hygiene he requires extensive assistance of one staff member. He is coded as needing only limited assistance of one staff member for walking in corridor. During an initial observation and facility tour of the locked dementia unit, on 3/12/19 at approximately 8:30am in the bathroom of Resident #26 there was a container of [NAME] Tears eye drops accessible to the resident in the bathroom cabinet. The bottles read, if swallowed get medical help or contact poison control right away. During an observation on 3/14/19 at approximately 1:58pm the [NAME] Tears were still present in the bathroom cabinet. Review of Resident #26's nursing notes, careplan, physician orders, nursing assessments and MDS revealed that no assessment had been conducted to determine if he was safe to self administer this medication. An interview with LPN D was conducted on 3/14/19 at approximately 3:20pm. LPN D stated that Resident #26 is ambulatory and therefore would have access to items within his room, bathroom and on the unit. Review of the facility policy and procedure titled Self-Administration of Medications read, If a resident requests to self-administer medication medications, it is the responsibility of the interdisciplinary team to determine that it is clinically appropriate for the resident to self-administer the medications, before the resident may exercise that right. The interdisciplinary team must also determine who will be responsible [the resident or nursing staff] for storage and documentation of the administration of the medication, as well as the location of the medication administration. Appropriate notation of these determinations will be maintained in the resident's clinical record. The decision that it is clinically appropriate for a resident to self-administer medication is subject to periodic re-evaluation based on change in the resident's condition or a change in the medications. The attending physician must approve a recommendation from the interdisciplinary team prior to being permitted to self-administer medications. [sic] The Administrator and Interim Director of Nursing were made aware of the lack of assessment to self administer medications on 3/13/19. No further information was provided.

Based on observation, Resident interview, and staff interview, the facility staff did not allow a private Resident council meeting with state agency surveyors for 7 Resident attendees. Staff entered the Private group council meeting, while in progress, to interrupt the proceedings on 4 occasions during the hour long meeting. This staff intrusion in a confidential meeting, made Residents feel uncomfortable, and fearful of retaliation, should they share complaints with surveyors. The findings included; A Resident council private session with state agency surveyors commenced on 3-13-19 at 11:00 a.m. In attendance were 7 members of the resident population. The Resident council President was not in attendance, however, was interviewed prior to the meeting, and previous minutes from meetings were reviewed. Approximately 20 minutes into the session, and during Resident disclosure of grievances, a private duty sitter for a Resident entered the room, and was told this was a private meeting and please to place signs on the door to restrict access to all staff while the private meeting was being held, and to let the unit manager know of this. She stated she would do so, and proceeded out of another door after greeting several Residents. The meeting continued, and in approximately 10 minutes more, A laundry staff member entered the room with a laundry cart full of clean linen. The Laundry staff member was told a meeting was being held, and the same instructions were given to her as she exited the room. In 10 to 15 minutes more 2 staff CNA's (certified nursing assistants) entered the room to obtain a weight scale, and were told the same information, with the addition of asking for the unit managing nurse to come to the room to make sure staff entry was restricted. In approximately 10 minutes more another CNA entered the room, and simply walked through without speaking to anyone. At this point the Residents refused to speak further as they divulged they were afraid if they shared any negative information they would be retaliated against, and stated that they were being watched. At this time the meeting was adjourned, as the Residents were not being afforded their right to a private meeting with surveyors. The unit manager nurse never responded to the request of her presence at the meeting. The Administrator and Director of Nursing were made aware of the incident at the end of day meeting on 3-13-19. No further information was supplied by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #87, the facility failed to ensure the environment is free of accident hazards by allowing resident access to medications, sharps and trip hazards. Resident #87, an [AGE] year old female, who resides in a secure memory care unit, was admitted to the facility on [DATE], with her most recent readmission being on 12/7/18. Her diagnosis included but were not limited to: unspecified dementia with behavioral disturbance, urinary tract infection, nausea with vomiting, cellulitis, pain in right wrist, osteoarthritis of left knee and failure to thrive. Resident #87's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/25/19 was coded as a quarterly assessment. Resident #87 was coded as having a BIMS (Brief interview for mental status) score of 3 indicating severe cognitive impairment. She was also coded as requiring supervision of one staff member for her activities of daily living to include, bed mobility, walking in and out of room, locomotion on and off unit and eating. She was coded as requiring extensive assistance of one staff member for dressing, toilet use and personal hygiene. During initial observation and facility tour of the locked dementia unit, on 3/12/19 at approximately 8:30am in the bathroom of Resident #87 there was 3 containers of Greer's [NAME] (a barrier cream consisting of a mixture containing nystatin powder, hydrocortisone powder and zinc oxide paste) accessible to the resident in the bathroom cabinet. Also in the bathroom cabinet was a disposable razor without a cover/safety cap. During observation on 3/13/19 at 9:32am the razor and Greer's [NAME] was still present. During facility tour and observation of the locked dementia unit, on 3/12/19 at 8:30am, other medications to include Gold Bond Medicated powder with the label reading for external use only. In case of accidental ingestion get medical help or contact a poison control center right away [NAME] Tears with a label reading if swallowed get medical help or contact poison control right away was noted on the unit and accessible to residents during observation on 3/12/19, 3/13/19 and again on 3/14/19. On 3/12/19 during observation in room [ROOM NUMBER] there was a water barrier strip at the base of the shower unsecured, which created a trip hazard. During observation on 3/14/19 Resident #87 was observed to be independently walking on the unit. An interview with LPN D was conducted on 3/14/19 at approximately 3:20pm. LPN D stated that Resident #87 is ambulatory and therefore would have access to items within her room, bathroom and on the unit. The Administrator and Interim Director of Nursing were made aware of the safety hazards on 3/13/19. No further information was provided. 3. For Resident #21 the facility failed to provide a safe environment by allowing resident access to medications, sharps and trip hazards. Resident #21, an [AGE] year old male, who resides in a secure memory care unit, was admitted to the facility on [DATE]. His diagnosis included but were not limited to: Dementia, anemia, anxiety, hypertension and benign prostatic hyperplasia. Resident #21's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/27/19 was coded as a quarterly assessment. Resident #21 was coded as having a BIMS (Brief interview for mental status) score of 3 indicating severe cognitive impairment. He was also coded as requiring supervision of one staff member for eating. Other activities of daily living to include, walking in his room, locomotion on and off unit, dressing, personal hygiene he requires extensive assistance of one staff member. During initial observation and facility tour of the locked dementia unit, on 3/12/19 at approximately 8:30am in the bathroom of Resident #21 there was a container of [NAME] Tears eye drops accessible to the resident in the bathroom cabinet. The bottles reads if swallowed get medical help or contact poison control right away. Also during observation on 3/12/19 at approximately 8:30am multiple items were noted throughout the unit that Resident #21 would have access to which included, a disposable razor without a cover, Gold Bond Medicated Powder, Greer's [NAME] (a barrier cream consisting of a mixture containing nystatin powder, hydrocortisone powder and zinc oxide paste). On 3/12/19 during observation in room [ROOM NUMBER] there was a water barrier strip at the base of the shower, unsecured which created a trip hazard. Observation of the locked dementia unit, on 3/13/10 at 9:32am revealed the razor, Greer's Goo, [NAME] Tears and Gold Bond Medicated Powder still present and accessible. During observation of the locked dementia unit, on 3/14/19 at approximately 1:58pm the [NAME] Tears were still present in the bathroom cabinet and Gold Bond Medicated Powder was present in another room. Resident #21 was propelling himself without any assistance down the hallway to his room. An interview with LPN D was conducted on 3/14/19 at approximately 3:20pm. LPN D stated that Resident #21 is ambulatory at times and self propels his wheelchair at other times and therefore would have access to items within his room, bathroom and on the unit. The Administrator and Interim Director of Nursing were made aware of the accident hazards on the unit on 3/13/19. No further information was provided. 4. For Resident #345 the facility failed to provide a safe environment by allowing resident access to medications, a disposable razor, and trip hazards. Resident #345, an [AGE] year old female, resides in the secure memory care unit, was admitted to the facility on [DATE]. Her diagnosis included but are not limited to: vitamin deficiency, hyperlipidemia, hypokalemia, unspecified dementia without behavioral disturbance, anxiety disorder, confusional arousals, and other specified rheumatic heart disease. Resident #345 doesn't have a MDS (minimum data set) (an assessment tool) due to being a new admission to the facility. Facility records to include Physician Visit- admission dated 3/11/19 indicates Resident #345 has significantly impaired cognitive impairment and is ambulatory. During initial observation and facility tour of the locked dementia unit, on 3/12/19 at approximately 8:30am on the memory care unit Resident #345 had access to multiple hazardous items. Observation noted a container of Gold Bond Medicated Powder in a bathroom cabinet; label read for external use only. In case of accidental ingestion get medical help or contact a poison control center right away. [NAME] Tears eye drops were also noted on the unit, accessible to the resident. The bottles reads if swallowed get medical help or contact poison control right away. Also during observation of the locked dementia unit, on 3/12/19 at approximately 8:30am a disposable razor without a cover, Greer's [NAME] (a barrier cream consisting of a mixture containing nystatin powder, hydrocortisone powder and zinc oxide paste) was observed and in room [ROOM NUMBER] there was a water barrier strip at the base of the shower, unsecured and created a trip hazard. During observation of the locked dementia unit, on 3/13/19 at 9:29am Resident #345 was observed walking in the hallway of rooms 409-421 without any staff assistance. Observations on 3/13/19 at 9:32am revealed the Gold Bond Medicated Powder, [NAME] Tears, razor and Greer's [NAME] were still present and accessible. Observation on 3/14/19 at approximately 1:58pm the Gold Bond Medicated power and [NAME] Tears were still on the unit and accessible to Resident #345. An interview with LPN D was conducted on 3/14/19 at approximately 3:20pm. LPN D stated that Resident #345 is able to ambulate and therefore would have access to items within her room, bathroom and on the unit. The Administrator and Interim Director of Nursing were made aware of the safety hazards on 3/13/19. No further information was provided. 5. For Resident #11 the facility failed to provide a safe and accident free environment by allowing resident access to medications, sharps and trip hazards. Resident #11, an [AGE] year old female, resides in the secure memory care unit, was admitted to the facility on [DATE], with her most recent readmission being on 5/8/18. Her diagnosis included but were not limited to: unspecified dementia with behavioral disturbance, hyperlipidemia, anxiety disorder, schizophrenia, hypothyroidism and paranoid schizophrenia. Resident #11's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 12/13/18 was coded as a quarterly assessment. Resident #11 was coded as having a BIMS (Brief interview for mental status) score of 7 indicating severe cognitive impairment. She was also coded as requiring supervision of one staff member for her activities of daily living to include eating. Other activities of daily living, such as bed mobility ,transfers, ambulation in and out of her room and locomotion on and off of the unit required limited assistance of one staff member. She was coded as requiring extensive assistance of one staff member for dressing, personal hygiene and bathing. During initial observation of the locked dementia unit, and facility tour on 3/12/19 at approximately 8:30am in the bathroom of Resident #11 there was a container of Gold Bond Medicated Powder in the cabinet; label read for external use only. In case of accidental ingestion get medical help or contact a poison control center right away. [NAME] Tears eye drops were also noted on the unit, accessible to the resident. The bottles reads if swallowed get medical help or contact poison control right away. Also during observation of the locked dementia unit, on 3/12/19 at approximately 8:30am multiple items were noted throughout the unit that Resident #11 would have access to which included, a disposable razor without a cover, Greer's [NAME] (a barrier cream consisting of a mixture containing nystatin powder, hydrocortisone powder and zinc oxide paste). On 3/12/19 during observation in room [ROOM NUMBER] there was a water barrier strip at the base of the shower unsecured and creating a trip hazard. During observation of the locked dementia unit, on 3/13/19 at 9:32am the Gold Bond Medicated Powder, [NAME] Tears, razor and Greer's [NAME] were still present and accessible. Observation on 3/14/19 at approximately 1:58pm the Gold Bond Medicated power was still present in the bathroom cabinet and [NAME] Tears was present in another room. An interview with LPN D was conducted on 3/14/19 at approximately 3:20pm. LPN D stated that Resident #11 is able to self propel her wheelchair and therefore would have access to items within her room, bathroom and on the unit. The Administrator and Interim Director of Nursing were made aware of the safety hazards on 3/13/19. No further information was provided. 6. For Resident #26 the facility failed to provide a safe environment by allowing the resident access to medications, sharps and trip hazards. Resident #26, an [AGE] year old male, who resides in a secure memory care unit, was admitted to the facility on [DATE]. His diagnosis included but were not limited to: unspecified dementia with behavioral disturbance, metabolic encephalopathy, vomiting, dry eye syndrome, urinary tract infection, frequency of micturition, unspecified mood disorder, insomnia and overactive bladder. Resident #26's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 12/28/18 was coded as an admission assessment. Resident #26 was coded as having a BIMS (Brief interview for mental status) score of 5 indicating severe cognitive impairment. He was also coded as being independent with set up assistance only for eating. Other activities of daily living to include, bed mobility, transfers, dressing, toilet use and personal hygiene he requires extensive assistance of one staff member. He is coded as needing only limited assistance of one staff member for walking in corridor. During initial observation and facility tour of the locked dementia unit, on 3/12/19 at approximately 8:30am in the bathroom of Resident #26 there was a container of [NAME] Tears eye drops accessible to the resident in the bathroom cabinet. The bottles reads if swallowed get medical help or contact poison control right away. On 3/14/19 at approximately 1:58pm observations of the locked dementia unit, noted the [NAME] Tears were still present in the bathroom cabinet. During observation of the locked dementia unit, on 3/12/19 at approximately 8:30am Gold Bond Medicated Powder, label reading for external use only. In case of accidental ingestion get medical help or contact a poison control center right away; was accessible to the resident in another room's bathroom cabinet. Also during observation on 3/12/19 at approximately 8:30am multiple items were noted throughout the unit that Resident #26 would have access to which included, a disposable razor without a cover, Greer's [NAME] (a barrier cream consisting of a mixture containing nystatin powder, hydrocortisone powder and zinc oxide paste). On 3/12/19 during observation in room [ROOM NUMBER] there was a water barrier strip at the base of the shower unsecured, which created a trip hazard. During observation of the locked dementia unit, on 3/13/19 at 9:32am the [NAME] Tears, Gold Bond Medicated Powder, Greer's [NAME] and razor were still present and accessible. During observation of the locked dementia unit, again on 3/14/19 at approximately 1:58pm the [NAME] Tears were still present in the bathroom cabinet and the Gold Bond Medicated Powder was present in another room. An interview with LPN D was conducted on 3/14/19 at approximately 3:20pm. LPN D stated that Resident #26 is ambulatory and therefore would have access to items within his room, bathroom and on the unit. The Administrator and Interim Director of Nursing were made aware of the lack of assessment to self administer medications on 3/13/19. No further information was provided. 7. For Resident #62 the facility failed to provide a safe environment by failing to provide 15 minute checks for safety after she verbalized suicidal thoughts. Resident #62, a [AGE] year old female, was admitted to the facility on [DATE]. Her diagnosis included but were not limited to: presence of right artificial hip joint, mood disorder, mild cognitive impairment, anxiety disorder, suicidal ideation's, primary insomnia, repeated falls, and overactive bladder. Resident #62's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/13/19 was coded as a quarterly assessment. Resident #62 was coded as having a BIMS (Brief Interview for Memory Status) score of 13 indicating cognitively intact. She was also coded as requiring limited assistance with assistance of one staff member for walking in her room and corridor. She is coded as requiring extensive assistance of one staff member for bed mobility, dressing, toileting and personal hygiene. Requires supervision with setup help only for eating. She is frequently incontinent of bowel and bladder. Review of Resident #62's nurses notes from 1/30/19-2/27/19 indicate that on 2/15/19 at 11:33am Resident #62 stated that she had thoughts of suicide but with no plan. Patient stated she wanted to end it all. Writer offered encouragement and support. Resident was assisted with hygiene and is sitting near nursing station Patient is also on 15 minute checks. Facility Administration provided survey team with Safety Rounds for Resident #62 dated 2/16/19 which covered from 12 midnight until 7:30pm. An additional sheet was attached that is unlabeled, listing times from 7:45pm-10:45pm stating calm EB[sic]. There is no resident name or date on the paper provided. Nursing notes continue to state resident is on 15 minute checks through 2/19/19, no evidence of the 15 minute checks was provided beyond 2/16/19. Survey team asked Director of Nursing if they had any additional safety checks for Resident #62 on 3/14/19 and no additional information was provided. The facility failed to provide a safe environment and/or monitoring for Resident #62 who was verbalizing feelings of suicide. Facility Administrator and Director of Nursing were notified of safety concerns for Resident #62 on 3/14/19. No further information was provided. 8. For resident #27 the facility failed to provide an environment free of accident hazards due to the water barrier strip at the base of the shower being unsecured and creating a trip hazard and access to medications. Resident #27, an [AGE] year old male, was admitted to the facility on [DATE]. His diagnosis included but were not limited to: aphasia, nontraumatic intracerebral hemorrhage, facial weakness, dysphagia, hypothyroidism, hyperlipidemia, compression of brain and hypertension . Resident #27's most recent MDS (Minimum Data Set) (an assessment tool) with an ARD (assessment reference date) of 1/3/19 was coded as a quarterly assessment. Resident #27 was coded as having a BIMS (Brief interview for mental status) score of 3, indicating severe cognitive impairment. He was also coded as requiring extensive assistance of one staff member for transfers, locomotion on and off unit, dressing, toileting and personal hygiene. He requires supervision with setup assistance for eating. On 3/12/19 during observation of the locked dementia unit, in Resident #27's room there was a water barrier strip at the base of the shower unsecured and creating a trip hazard. An interview with LPN D was conducted on 3/14/19 at approximately 3:20pm. LPN D stated that Resident #27 self propels and therefore would have access to items within his room, bathroom and on the unit. The Administrator and Interim Director of Nursing were made aware of the safety concerns on 3/13/19. No further information was provided. Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed for 8 residents (Resident #29, #87, #21, #345, #11, #26, #62, #27) in a sample of 45 residents to prevent accident hazards. 1. For Resident #29, the facility staff failed to recline a specialized High-Back Reclining wheelchair for fall prevention. 2. For Resident #87, the facility failed to ensure the environment is free of accident hazards by allowing resident access to medications, sharps and trip hazards. 3. For Resident #21 the facility failed to provide a safe environment by allowing resident access to medications, sharps and trip hazards. 4. For Resident #345 the facility failed to provide a safe environment by allowing resident access to medications, a disposable razor, and trip hazards. 5. For Resident #11 the facility failed to provide a safe and accident free environment by allowing resident access to medications, sharps and trip hazards. 6. For Resident #26 the facility failed to provide a safe environment by allowing the resident access to medications, sharps and trip hazards. 7. For Resident #62 the facility failed to provide a safe environment by failing to provide 15 minute checks for safety after she verbalized suicidal thoughts. 8. For resident #27 the facility failed to provide an environment free of accident hazards due to the water barrier strip at the base of the shower being unsecured and creating a trip hazard and access to medications. The Findings included: 1. For Resident #29, the facility staff failed to recline a specialized High-Back Reclining wheelchair for fall prevention. Resident #29 was a [AGE] year old who had been admitted to the facility on [DATE]. Resident #29's diagnoses included Dementia, Parkinson's Disease, Urinary Tract Infection, Hypertension and Neurogenic Bladder. The Minimum Data Set, which was a Significant Change Assessment with an Assessment Reference Date of 1/7/19 was reviewed. It coded Resident #29 as having a Brief Interview of Mental Status score of 5, indicating severe cognitive impairment. In addition, Resident #29 was coded as having Inattention and Disorganized thinking. On 3/13/19 at approximately 11:15 A.M., an observation was conducted of Resident #29 sitting upright in his wheelchair at the nurse's station. He was observed bending forward a few times and touching his shoes. Nursing staff were observed to walk past the nurse's station, and occasionally sit at the nursing station. On 3/13/19 at 11:31 A.M., an interview was conducted with the Certified Nursing Assistant (CNA A) who was assigned to work with Resident #29. She stated that she had worked with Resident #29 for approximately 8 months. When asked why Resident #29 had not been put in a reclining position prior to his fall, CNA A stated, He's supposed to be in that broda chair because he leans and has a bruise on his lower back from leaning. If he's leaning a lot, we put him in a broda chair. There is a broda chair on Unit 1. No one else is using it. That's the only broda chair. This morning I kept hearing the nurse saying to him sit back and keep on your shoes. CNA A stated that facility staff were aware that Resident #29 had been leaning forward to try to take off his shoes several times. When asked if she had received any training on when, how, and to what degree to recline Resident #29's wheelchair, CNA A stated No. I just use common sense. On 3/13/19 a review was conducted of Resident #29's clinical record, revealing his care plan. The care plan did not address the use of his specialized wheelchair for fall prevention or other use. On 3/13/19 at 2:41 P.M., an interview was conducted with the Director of Rehabilitation (Employee J). When asked if the facility had provided staff training on the use of Resident #29's High Back Reclining Wheelchair, The Director of Rehabilitation stated, We didn't provide a training on the use of the reclining chair. When asked about the degree of recline that should be used, she stated, The degree of recline varies according to how he's feeling. She acknowledged that Resident #20's wheelchair had not been reclined on 3/12/19 and 3/13/19. When asked about the purpose of Resident #29 having a reclining wheelchair, the Director of Rehabilitation stated, If the chair is reclined it helps with facilitating rest. If he's leaning forward it's reclined for safety and redirection. On 3/14/19 at 3:41 P.M., the facility Administrator (Employee B, and Director of Nursing (Employee C) were notified of the findings. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, family interview, staff interviews and facility documentation review, the facility staff failed to provide meals at regular times for five residents (Residents # 46, # 62, # 40, # 48, # 34 and # 86) in the survey sample of 45 residents. 1. For Resident # 46, breakfast was not served until 10:05 AM on 3/12/2019. 2. For Resident # 62, breakfast was not served until 9:46 AM on 3/13/19 3. For Resident # 40, breakfast was not served until 9:48 AM on 3/13/19. 4. For Resident # 48, breakfast was not served until 9:58 AM on 3/13/19. 5. For Resident # 34, breakfast was not served until 10:08 AM on 3/13/19. 6. For Resident # 86, breakfast was not served until 9:42 AM on 3/13/2019. Findings included: On 3/12/2019, the following observations were made concerning breakfast being served in the Second Floor Dining Room Unit 2. 3/12/2019 at 10:00 AM, Observed CNA J sitting at table with two residents helping them finish the last of their meal. 3/12/2019 at 10:05 AM, observed CNA (Certified Nursing Assistant) D go to the counter for a tray and gave to Resident # 46. 3/12/2019 at 10:10 AM, observed Resident # 46 being fed by CNA (Certified Nursing Assistant) D. On 3/13/2019 at 9:42 AM an interview was conducted with dining staff (Employee G) who showed the meal cards still on the counter waiting for breakfast to be prepared. There were cards still waiting for four residents. (Residents # 40, # 62, # 34, and # 48). Employee G explained the process for dining services in the dining rooms on each unit. Employee G stated the Dietary Staff serve a hot meal from the steam tables on each unit. The meal tray tickets are placed on the counter. The nursing staff pick up the meal tray ticket and give to the Dietary Staff when the resident is ready to be served the meal. Breakfast is from 8:00 am -9:30 am each day. Lunch is 12:00 pm -1:30 pm Dinner is 5:45 pm - 7:15 pm On 3/13/2019, the following observations were made concerning breakfast being served in the Second Floor Dining Room Unit 2. 9:44 AM: CNA G went to the pantry window, requested the breakfast for Resident # 40. Dietary staff prepared tray, pureed diet-eggs, pancakes with syrup, cream of wheat, and placed on counter 9:46 AM: RN (Registered Nurse) B, unit manager, wheeled Resident # 62 in Dining Room, sat her at a table with two residents who were already finishing their meals. RN B retrieved the breakfast tray for Resident # 62 from the dining counter. 9:48 AM: CNA G retrieved Resident # 40's tray from counter and took to Resident # 40's room. 9:50 AM: two tickets were still on counter- One for Resident # 34 and one for Resident # 48. RN B stated the staff was getting Resident # 48 up now and Resident # 34 went somewhere this morning. 9:58 AM: Resident # 48 was wheeled into the dining room, sat at table by herself, nurse put on apron, retrieved her tray from the ledge and sat down to feed her. 10:06 AM: CNA D wheeled Resident # 34, into dining room and told dining staff to prepare her breakfast tray. 10:07 AM: CNA D poured orange juice into a glass and gave it to Resident # 34. 10:08 AM: CNA D retrieved the breakfast tray from the ledge and placed it in front of the Resident # 34. 10:24 AM: Resident # 34 still eating breakfast, feeding self with cueing from CNA D 10:30 AM: Resident # 34 finished eating breakfast, CNA D wheeled Resident # 34 out of the dining room. 10:35 AM: Dining room staff finished cleaning the dining area and took food cart to kitchen along with another staff person. 12:07 PM: staff wheeling residents into the dining room for lunch. On 3/14/2019 at 9:00 AM, An interview with Employee G from Dietary was conducted. Employee G stated if the nursing staff has not brought the residents to the dining room by the time she leaves, she wraps the plate in plastic, puts it in the refrigerator and the nursing staff will use the microwave to heat it. Employee G stated there are alcohol wipes and a thermometer left on the counter for the staff to make sure the food is at the right temperature. Employee G stated she waits as long as she cans before leaving the dining room to go back to the kitchen. Employee G stated she has to wash dishes to prepare for the next meal after leaving the dining room. Employee G stated the dining room could not be cleaned until the residents finished eating. On 3/14/2019 at 12:05 PM, an interview with the Dietary Manager was conducted. The Dietary Manager state that the dining services are delivered on time and they are dependent on nursing staff to get the food to resident. The Dietary Manager stated she was concerned about the quality of the food after 2 hours. Dietary Manager stated the facility administrative staff have a stand up meeting every morning where they discuss issues with the managers of each department. The Dietary Manager stated they discuss ways to problem solve any issues presented. The Dietary Manager stated when the nursing staff worked short of staff, it affected the times the meals were finished on each unit. The Dietary Manager stated snacks were available on each unit and the nursing staff had access to the pantry. On 3/14/2019 at 5:10 PM, an interview was conducted with LPN (Licensed Practical Nurse) C who stated the nursing staff was responsible for getting residents to the dining room to eat meals. LPN C stated Resident # 34 typically ate her meals in the dining room. LPN C stated on the 3-11 shift, all of the residents usually have been served their meals and the kitchen area is cleaned. Review of the Healthcare Center Meal Delivery Log for March 2019 revealed documentation of breakfast times for the last resident served varied from 8:45 AM to 10:00 AM. The times the server and hot box left the pantry varied from 9:15-10:15 and the times the pantry and dining room were cleaned varied from 10:15-11:30. Residents in the survey sample who were observed to receive breakfast late listed below: 1. For Resident # 46, breakfast was not served until 10:05 AM on 3/12/2019. Resident # 46, a [AGE] year old male, was admitted to the facility on [DATE]. His diagnosis included but were not limited to: Hypertension, Diabetes, Dementia, and Depression Resident # 46's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 1/31/19 was coded as a quarterly assessment. Resident #46 was coded as having a BIMS (Brief Interview for Memory Status) score of 10 indicating moderate cognitive impairment. He was also coded as requiring extensive assistance with assistance of one to two staff members for bed mobility, dressing, toileting and personal hygiene. Resident # 46 required supervision with setup help only for eating. He was always incontinent of bowel and bladder. On 3/12/2019 at 10:00 AM, Resident # 46 was observed sitting in a wheelchair at a table with two other residents. The other residents were finishing their breakfast. 3/12/2019 at 10:05 AM, observed CNA (Certified Nursing Assistant) D go to the counter for a tray and gave to Resident # 46. 3/12/2019 at 10:10 AM, observed Resident # 46 being fed by CNA (Certified Nursing Assistant) D. During the end of day debriefing on 3/13/2019, the Administrator and Director of Nursing were informed of the findings. No further information was provided. 2. For Resident # 62, breakfast was not served until 9:46 AM on 3/13/19. Resident #62, a [AGE] year old female, was admitted to the facility on [DATE]. Her diagnosis included but were not limited to: presence of right artificial hip joint, mood disorder, mild cognitive impairment, anxiety disorder, suicidal ideation's, primary insomnia, repeated falls, and overactive bladder. Resident #62's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/13/19 was coded as a quarterly assessment. Resident #62 was coded as having a BIMS (Brief Interview for Memory Status) score of 13 indicating cognitively intact. She was also coded as requiring limited assistance with assistance of one staff member for walking in her room and corridor. She is coded as requiring extensive assistance of one staff member for bed mobility, dressing, toileting and personal hygiene. Requires supervision with setup help only for eating. She is frequently incontinent of bowel and bladder. On 3/13/19 at 9:46 AM, RN (Registered Nurse) B, unit manager, wheeled Resident # 62 in Dining Room, sat her at a table with two residents who were already finishing their meals. RN B retrieved the breakfast tray for Resident # 62 from the dining counter. 3. For Resident # 40, breakfast was not served until 9:48 AM on 3/13/19. Resident # 40, a [AGE] year old female, was admitted to the facility on [DATE]. Her diagnosis included but were not limited to: presence of right artificial hip joint, mood disorder, mild cognitive impairment, anxiety disorder, suicidal ideation's, primary insomnia, repeated falls, and overactive bladder. Resident # 40's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/13/19 was coded as a quarterly assessment. Resident # 40 was coded as having a BIMS (Brief Interview for Memory Status) score of 13 indicating cognitively intact. She was also coded as requiring limited assistance with assistance of one staff member for walking in her room and corridor. She is coded as requiring extensive assistance of one staff member for bed mobility, dressing, toileting and personal hygiene. Requires supervision with setup help only for eating. She is frequently incontinent of bowel and bladder. On 3/13/19 at 9:44 AM, CNA G went to the pantry window, requested the breakfast for Resident # 40. Dietary staff prepared tray, pureed diet-eggs, pancakes with syrup, cream of wheat, and placed the tray on the counter 9:48 AM: CNA G retrieved Resident # 40's tray from counter and took it to Resident # 40's room. 10:20 AM: Observed CNA G bringing the tray out of Resident # 40's room. During the end of day debriefing on 3/13/2019, the Administrator and Director of Nursing were informed of the findings. No further information was provided. 4. For Resident # 48, breakfast was not served until 9:58 AM on 3/13/19. Resident # 48, a [AGE] year old woman was admitted to the facility on [DATE] with diagnoses of but not limited to Dementia, abnormal weight loss, history of stroke, history of pneumonia, anxiety disorder, and urinary retention related to Neurogenic Bladder. The most recent (Minimum Data Set) MDS (an assessment tool) was an annual assessment with an (Assessment Reference Date) ARD of 1/16/19 coded Resident# 48 as being unable to assess using the (Brief Interview of Mental Status) BIMS tool. The Resident was coded as not being understood and unable to screen indicating severe cognitive impairment. On 3/13/2019, breakfast meal was observed in the dining room on Unit 2. 9:50 AM: two tickets were observed still on counter and one was for Resident # 48. RN B stated the staff was getting Resident # 48 up now. 9:58 AM: Resident # 48 was wheeled into the dining room, sat at table by herself. Licensed Practical Nurse, LPN K, put on apron, retrieved her tray from the ledge and sat down to feed her. On 3/13/19 at 10:26 AM, Resident # 48 was finished with the meal. LPN (Licensed Practical Nurse) C wheeled Resident # 48 out of the dining room. During the end of day debriefing on 3/13/2019, the Administrator and Director of Nursing were informed of the findings. No further information was provided. 5. For Resident # 34, breakfast was not served until 10:08 AM on 3/13/19. Resident # 34, a [AGE] year old female was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Diabetes, Hypertension, Parkinson's Dementia and Depression . Resident # 34's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 2/22/2019. The MDS coded Resident # 34 as having severe cognitive impairment. Resident # 34 was coded as requiring extensive assistance of one staff person. for Activities of Daily Living and always incontinent of bowel and bladder. On 3/13/2019 at 10:06 AM, staff member, CNA (Certified Nursing Assistant) D, wheeled Resident # 34, into dining room. CNA D told the dining staff to prepare breakfast tray for Resident # 34. On 3/13/2019 at 10:07 AM, CNA D poured orange juice into a glass and gave it to Resident # 34. On 3/13/2019 at 10:08 AM, CNA D retrieved the breakfast tray from the ledge and placed it in front of the resident. On 3/13/2019 at 10:24 AM, Resident # 34 still eating breakfast, feeding self with cueing from CNA D. On 3/13/2019 at 10:30 AM, Resident # 34 finished eating breakfast. CNA D wheeled Resident # 34 out of the dining room. On 3/13/2019 at 10:35 AM, Dining room staff finished cleaning the dining area and took food cart to kitchen along with another staff person. On 3/13/2019 at 12:07 PM, staff wheeling residents into the dining room for lunch. During the end of day debriefing on 3/13/2019, the Administrator and Director of Nursing were informed of the findings. No further information was provided. 6. For Resident # 86, breakfast was not served until 9:40 AM on 3/13/2019. Resident # 86, a [AGE] year old female was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Chronic Obstructive Pulmonary Disease, Acute and chronic respiratory failure with hypercapnia, Heart Failure, Hypertension, anemia, Abdominal Aortic Aneurysm, and Osteoporosis. Resident # 86's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 2/22/2019. The MDS coded Resident # 86 with a BIMS (Brief Interview for Mental Status) score of 13 out of 15, indicating no cognitive impairment. Resident # 86 was coded as requiring extensive assistance of one staff person. for Activities of Daily Living and occasionally incontinent of bowel and bladder. On 3/12/2019 at 9:40 AM, an interview was conducted with the daughter of Resident # 86 who stated there was a problem of the facility staff not getting her mother (Resident # 86) ready for breakfast early like she desired. Resident # 86's daughter stated that when her mother ate breakfast late, it meant she had decreased socialization with others. She stated there were times that breakfast was eaten so late that there were only a couple of hours between breakfast and lunch. She stated Resident # 86 did not want to eat lunch when breakfast was eaten so late. She also stated she was concerned because she did not want her mother to lose weight. She stated she had several discussions with the facility staff to express her desire to have her mother eat breakfast early in the dining room. Resident # 86's daughter stated changes were made to the care plan to help make sure her needs were met. On 3/13/2019 at 8:30 AM, Resident # 86 was observed lying in bed. Resident # 86 told the surveyor she was waiting to get up so she could go to breakfast. On 3/13/2019 at 9:30 AM, Resident # 86's daughter was observed walking in the hallway toward Resident # 86's room. Resident # 86's daughter asked Hi Mom, have you had breakfast yet? Let's get ready to go to the Dining Room Resident # 86's daughter helped Resident # 86 wash her face and hands, get dressed and wheeled her to the dining room. On 3/13/2019 at 9:40 AM, Resident # 86's daughter retrieved the breakfast tray from the ledge on the kitchen counter and at 9:42 AM, Resident # 86 began eating breakfast, her daughter was sitting beside her, talking to her. On 3/13/2019 at 9:55 AM, an interview was conducted with Resident # 86's daughter who stated now this means there would be less than 3 hours between breakfast and lunch! The daughter stated the other residents who sit at the table with her mother were finished eating. The daughter stated meal time is a time for socialization and not going to breakfast on time meant very little time for socialization. On 3/13/2019 at 12:07 PM, Resident # 86 was observed being wheeled by her daughter into the dining room for lunch. Resident # 86's daughter sat beside her. There were two other residents at the table eating lunch with Resident # 86. On 3/13/2019 at 2:10 PM, an interview was conducted with Registered Nurse (RN B) who stated the facility staff was working short and had not gotten Resident # 86 up for breakfast prior to when the daughter arrived. On 3/13/2019 during the end of day debriefing, the facility Administrator and Director of Nursing were informed of the findings. The Administrator stated the facility had ample staff of 3 to four Certified Nursing Assistants on each unit. The DON stated the facility staff were expected to get the residents ready for breakfast at the time they desired. No further information was provided.

Based on facility records and staff interview the facility failed to ensure the minimum staff were part of the facility quality assessment and assurance committee. The facility failed to ensure the director of nursing services and medical director attended the quality assurance meetings. The findings included: Review of the facility quality assurance meeting held on 1/16/19 sign in sheet, showed that the Director of Nursing failed to attend the meeting. During interview with interim Director of Nursing on 3/14/19 at approximately 3:40pm regarding the absence of the director of nursing, the interim Director of Nursing (DON) acknowledged the DON had not been present for at least 50% of the meeting. She stated, She must have forgot to sign in, I know she was there because we were half way through the meeting when she came in. Quality Assurance meeting held 9/25/18 sign in sheet showed that the Medical Director did not attend the meeting. The facility Administrator was made aware of the findings on 3/14/19 at approximately 3:45pm. No further documents were provided.

9. The facility failed to develop and implement a water management plan for Legionella. During review of the facility water management program the facility had blank forms for the facility risk assessment, used to identify where Legionella and other waterborne bacteria could grow and spread in the facility water system. Review of the facility policy, Water Management Program the purpose of the policy and procedure reads, The purpose of this policy is to provide a method to identify areas in the water system where Legionella bacteria can grow and spread, to monitor these areas and to reduce the risk of Legionnaire's disease. Procedures include but are not limited to: 1. The facility's water management program includes a description of the water system in the facility, and methods to monitor temperature and bacterial risk. 2. A risk management assessment is done annually and at any time there is a disturbance or change in the facility's water supply. 3. In addition to the annual assessment will be done annually, a risk assessment will be done any time there has been: a. A change in the pipework or system b. A change in the use of the system c. Any time there is reason to suspect contamination of the system. [sic] Interview with the facility maintenance director on 3/14/19 was conducted. When asked about the description of the water system in the facility he stated, I don't have that. When asked about the facility risk assessment to identify where Legionella and other waterborne bacteria could grow, employee D responded, It should be in this book. When asked if it could be anywhere else he said no. The facility reported to the State Agency on 2/8/18 that they were undergoing a major plumbing repair in the main kitchen, which will put the kitchen out of service for the next 24 to 48 hours. The facility again communicated on 2/9/18 to let the office know of the completion of the kitchen plumbing repair. When employee D was asked about water testing after this incident he indicated it had not prompted any additional water testing. The facility Legionella policy was reviewed and revealed that any time there is a disturbance or change in the facility's water supply a risk management assessment is completed. The Maintenance Director, Employee D stated the assessment was not reviewed or updated after the repairs were made, as per their policy. Administrator was made aware of the lack of a water management program on 3/14/19. No further information was provided. Based on observation, staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide Linens, Oxygen, and Activities of Daily Living (ADL) care supplies in a manner to prevent the spread of infection, in the general environment, laundry, in the unit 2 clean utility room, on medication carts in unit 1, and in the shower room of unit 2. In addition, the facility failed to develop and implement a water management plan for Legionella. Dust and mildew were on ventilation areas. Clean Linens were left uncovered, and handled improperly. Used and dirty oxygen tanks were commingled with clean unused oxygen tanks. Dirty ADL carts were brought into the clean utility room from the shower room, containing used and dirty resident care items. Medication carts were unsanitary, and dirty. Clean items were stored together in the room, with dirty items, and commingled. Staff did not practice accepted infection control standards. The findings included: The observations of 3-12-19 through 3-14-19 included the following (8) areas: 1. During initial tour of the facility, in the units 1, and 2 hallways, the ceiling vents were thickly coated in a spotty black substance which appeared like mildew, and covered in dust. Mattresses were found propped against the walls in numerous rooms, and found to have holes, and rips (appeared shredded) in various areas of the plastic/nylon fabric coverings, revealing the sponge like foam core which could not be disinfected. Staff stated these were used for fall mats, after they could no longer be used on beds because of the torn up covers. 2. During observations of unit 3, laundry staff on unit 3 at 10:58 a.m., were pushing dirty laundry through the unit in an uncovered cart. 3. In a unit 2 shower stall which was dirty, a black spotted substance which appeared to be mildew was circumferentially around the base of the shower. There was a soap residue clumped and white on the shower floor, a staff member (CNA D) was seen from the hallway exiting the shower room with a large 2 shelf cart, and pushed the cart into the clean utility room. 4. In the dirty utility room the cabinet under the sink had a broken door which had fallen with one corner touching on the floor. 5. The unit 2 clean utility room observation was conducted with the unit 2 nurse manager. No Isolation supplies (gowns, and masks) were in the clean utility room, and were not readily available to staff. The unit 2 clean utility room contained 2 oxygen racks side by side as if they were connected, with 9 slots each, for oxygen tanks. In the first rack there were 6 oxygen tanks, 3 of the tanks were open, and 3 were closed. In the second rack there were 6 closed tanks. There was one more tank sitting in a rolling cart, with a regulator attached to it, that administers the oxygen for use. The oxygen had been recently used, as the oxygen regulator had been tapped into the tank, and the Christmas tree green oxygen tubing connector was still attached to the tank which allows tubing to be immediately connected. The tank was half full. The key to tap and access the oxygen, was laying on the floor connected to the rack by a lanyard. The Registered Nurse unit manager (RN B) was asked why clean and dirty oxygen was stored together in the clean utility room, when the clean and dirty utility rooms were directly beside one another. She responded I would consider these open, and used, and I see what you are saying, it is questionable, I absolutely get it. She stated they had an oxygen delivery gentleman that brings the oxygen in and takes away the empty bottles, and that is where he put them. Oxygen policies were requested and supplied. The facility policy on oxygen storage stated under item #7, Full and empty cylinders are segregated (separated) in facility storage. If a cylinder is partially full, it is stored with the empty cylinders or stored completely separately from full and empty cylinders. 6. The unit 2 clean utility room also contained 2 soiled PVC plastic rolling carts. The carts were approximately 3 feet tall by 2 feet wide by 4 feet long with an upper and lower shelf. The carts were heavily soiled on both shelves. The shelves were covered in a red speckled greasy substance, tan crusty crumbs which looked like cracker crumbs, human hair, a brown caked substance, and the wheels were wet with hair wrapped in them. On one cart was a clear bag open and the contents spilling onto the cart. The bag held clean, and dirty gloves and an open tube of lotion with a black banded watch wrapped around the lotion. The unit 2 nurse manager stated she believed the watch belonged to a male resident, and would find out. The carts also contained clean linens (towels and wash cloths) commingled with soiled gloves, soiled soap, soiled lotion, 2 used small rat tail combs, for hair, heavily soiled with grease, dandruff, and hair, a used drinking cup with a lid had fallen onto the floor. Another bag open and spilling onto the second cart contained open butt paste incontinence barrier cream, drinking cups open and spilling uncovered onto the dirty cart. This room contained the uncovered clean linen on shelves for the residents on the unit, nutritional supplements such as ensure and glucerna and lab supplies for drawing blood, and nebulizer and suction machines. A third cart was in the room, and the unit manager stated it was a treatment cart. The trash can on the treatment cart had used gloves and bandages in the open trash can on the cart. Interview with CNA D immediately after the observation (certified nursing assistant) revealed After we use a linen cart, we are to remove the items on it, and return the cart to the clean utility room. CNA D was asked if the 2 carts in the clean utility room were clean linen carts used to deliver linen to Resident rooms, and she stated yes, everybody uses them. RN B was asked if this was acceptable in the clean utility room to commingle obviously soiled items with clean items that would be distributed to residents all over the unit. RN B stated no, these carts look well used, and this one, it's filthy dirty. 7. On 3-14-19 during medication pour and pass observations, and medication storage observations, the medication carts on units 1 and 2 were examined. The carts were found to have cracker crumbs, red sticky liquid, hair, what appeared to be insect wings, all inside the medication drawers where the bulk dose and unit dose medications were stored and administered from. A red, white, and brown commingled bumpy substance stuck to the outside of the medication cart above the trash can. The accumulated different substances had been adhered to the cart for long enough for each layer to dry hard, and could not be removed by a gloved hand wiping it briskly. 8. On 3-14-19 during environmental rounds observations, the laundry was observed at 2:30 p.m. The dining services director opened the laundry and went in with surveyors. The room was found to have dirty linen carts immediately in the first door, and the carts were covered. Mattresses were found propped against the wall, and found to have holes, and rips (appeared shredded) in various areas of the plastic/nylon fabric coverings, revealing the sponge like foam core, and could not be disinfected. The clean laundry was around a corner by the dryers, folded and uncovered under a vent which was covered in dust. In the clean laundry area, the 3 dryers were full of damp clothes, and condensation from moisture was visible on the clear glass dryer doors. The laundry was still wet, and would remain that way until the following day. The Dining services director stated the laundry staff had gone home for the day, as they only worked until 2:30 p.m. As the area was being examined a nursing staff member entered with what she described as Dirty laundry, in a thin large clear plastic bag. She carried the bag with both arms next to her uniform, while wearing gloves through the facility, without it being in a covered cart. She was asked if anything in the bag posed an infection control hazard. She stated I don't know. She was asked what she would do if the bag broke in a hallway while she carried it, and she stated I don't know. She removed her gloves grabbed an uncovered full clean linen cart and exited to carry the cart to the unit. No handwashing was performed. The facility infection control linen transport operational policy stated Separate carts must be used for transporting clean and soiled linens. The interim Director of Nursing (DON), was interviewed on 3-14-19 at 3:00 p.m. in regard to the facility infection control program. The DON was asked what the facility infection control policy reference was, and she stated We use med pass policies and procedures. She was asked if any other sources were used, and she stated No., She was asked if any governmental reference was used or researched, and she stated No. She was then asked directly if the CDC (Centers for Disease Control) was referenced at any time. She stated We use CDC for handwashing times, and TB (tuberculosis) screening. I believe the medical director uses CDC guidelines. A copy of the facility infection control policies was requested, and supplied. The facility infection control policy manual which was devised in 2001, and purchased from Med Pass, Inc. was not facility specific, nor devised by the facility. The document was reviewed. The facility Administrator and DON were notified on 3-13-19, and 3-14-19, at the end of day debriefs, of the failure of staff to adequately implement an infection control program, and to practice accepted infection control standards. No further information was presented by the facility. Complaint deficiency.