Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure the privacy of resident information on one of six medication carts. The findings include: An observation was made on 4/22/2024 at 11:32 a.m. of RN (registered nurse) #1 administering medications on the 200 hallway. RN #1 entered a resident room, while leaving her report sheet on top of the cart. The report sheet contained resident's room numbers, names, vital signs, and notes regarding the residents. This information was left where residents or family members could see. While RN #1 was in a room, five residents went past her medication cart and one family member walked by. An interview was conducted with RN #1 on 4/22/2024 at 11:50 p.m. When asked why the document was on the cart, with resident information visible, RN #1 stated she should have turned it over. When asked why, RN #1 stated because of resident privacy. The facility policy, Guest/Resident Rights documented in part, The staff will safeguard the privacy of guests/residents protected health information from improper use and disclosure and will inform the guest/resident both orally and in writing of his or her rights as a resident, as well as the rules and regulations governing the guests/ residents conduct and responsibilities during his or her stay at the facility. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional clinical coordinator, were made aware of the above concern on 4/23/2024 at 4:50 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence the required documents were sent to the hospital upon transfer for two of 39 residents in the survey sample, Resident #2 and Resident #137. The findings include: 1. For Resident #2, the facility staff failed to evidence the required documents were sent to the hospital with the resident on 1/7/2024. The nurse's note dated, 1/7/2024 at 1:09 a.m. documented, Guest called 911 requesting transport. States to paramedics c/o (complaint of) chest pain. Guest did not notify staff at any point of chest discomfort or SOB (shortness of breath). Guest medicated due to c/o coughing episode only. Guest currently being transported to (Name of hospital). Further review of the clinical record failed to evidence what documents were sent with the resident to the hospital. An interview was conducted with LPN (licensed practical nurse) #7 on 4/24/2024 at 10:35 a.m. When asked what documents are sent with the resident if they are transferred to the hospital, LPN #7 stated she sends the face sheet, medication list, diagnoses list, bed hold policy and the care plan. When asked if the resident calls 911 do you still send the paperwork, LPN #7 stated yes. LPN #7 was asked where you document the paperwork that is sent to the hospital, LPN #7 stated it should be documented in a nurse's note. On 04/24/2024 at 12:37 p.m., ASM (administrative staff member) #3, the regional clinical coordinator, stated she had no documentation of what papers went to the hospital. She stated it was a resident-initiated transfer, the resident called 911. When asked if the papers sent should still be sent and documented, ASM #3 stated, yes. The facility policy, Transfer and Discharge documented in part, A transfer form is completed, a list of medications and a copy of the care plan goals is sent to the receiving hospital. Nursing documents the transfer in the medical record. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, were made aware of the above concern on 4/24/2024 at 2:03 p.m. No further information was obtained prior to exit. 2. For Resident #137, the facility staff failed to evidence the required documents were sent to the hospital with the resident on 2/4/2024. The nurse's note dated 2/4/2024 at 6:52 p.m. documented in part, At 10:15 a.m. Resident was brought by her physical therapist this morning concerning her rapid breathing. Physical therapist has stated her respirations was 40. Nurse practitioner has assessed resident signs and her symptoms . Resident is not verbally responding to the nurse. Resident was only just looked at the nurse .Nurse Practitioner has stated to send resident out to the ER (emergency room) to be evaluated. Writer (nurse) has called 911 and emergency response team has arrived and sent the resident to (name of hospital) at 10:30 A.M. Called RP (responsible party) left voicemail to give the facility a return call. Further review of the clinical record failed to evidence what documents were sent with the resident to the hospital. On 4/24/2024 at 1:19 p.m., ASM #3 presented a copy of the SNF/NF Transfer to hospital form. When asked if it documents the paperwork that was sent with th resident, ASM #3 stated, no. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, were made aware of the above concern on 4/24/2024 at 2:03 p.m. No further information was obtained prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide a bed hold notice upon transfer for two of 39 residents in the survey sample, Resident #2 and Resident #137. The findings include: 1. For Resident #2, the facility staff failed to provide a bed hold notice upon transfer to the hospital on 1/7/2024. The nurse's note dated, 1/7/2024 at 1:09 a.m. documented, Guest called 911 requesting transport. States to paramedics c/o (complaint of) chest pain. Guest did not notify staff at any point of chest discomfort pr SOB (shortness of breath). Guest medicated due to c/o coughing episode only. Guest currently being transported to (Name of hospital). Further review of the clinical record failed to evidence what documents were sent with the resident to the hospital. An interview was conducted with LPN (licensed practical nurse) #7 on 4/24/2024 at 10:35 a.m. When asked what documents are sent with the resident if they are transferred to the hospital, LPN #7 stated she sends the face sheet, medication list, diagnoses list, bed hold policy and the care plan. When asked if the resident calls 911 do you still send the paperwork, LPN #7 stated yet. LPN #7 was asked where you document the paperwork that is sent to the hospital, LPN #7 stated it should be documented in a nurse's note. On 4/24/2024 at 12:37 p.m., ASM (administrative staff member) #3, the regional clinical coordinator, she stated she had no documentation of what papers went to the hospital or evidence of the bed hold. She stated it was a resident-initiated transfer, the resident called 911. When asked if the required papers should still be sent and documented, yes. Should the bed hold be sent also, ASM #3 stated, yes and documented in the clinical record. The facility policy, Bed Hold, documented in part, 2. Within 24 hours of a hospital transfer the admission Director or designee will contact the Resident and/or Responsible Party regarding the possible length of transfer and offer a bed hold. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, were made aware of the above concern on 4/24/2024 at 2:03 p.m. No further information was obtained prior to exit. 2. For Resident #137, the facility staff failed to provide a bed hold notice upon transfer to the hospital on 2/4/2024. The nurse's note dated 2/4/2024 at 6:52 p.m. documented in part, At 10:15 a.m. Resident was brought by her physical therapist this morning concerning her rapid breathing. Physical therapist has stated her respirations was 40. Nurse practitioner has assessed resident signs and her symptoms . Resident is not verbally responding to the nurse. Resident was only just looked at the nurse .Nurse Practitioner has stated to send resident out to the ER (emergency room) to be evaluated. Writer (nurse) has called 911 and emergency response team has arrived and sent the resident to (name of hospital) at 10:30 A.M. Called RP (responsible party) left voicemail to give the facility a return call. Further review of the clinical record failed to evidence what documents were sent with the resident to the hospital. On 4/24/2024 at 1:19 p.m., ASM #3 presented a copy of the SNF/NF Transfer to hospital form. When asked if it documents the paperwork that was sent with the resident, ASM #3 stated, no. ASM #3 stated, there is no evidence of a bed hold either. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, were made aware of the above concern on 4/24/2024 at 2:03 p.m. No further information was obtained prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure accurate MDS assessments for one of 39 residents in the survey sample; Resident #63. The findings include: For Resident #63, the facility staff failed to accurately code the MDS (Minimum Data Set) assessments regarding the administration of insulin. The 3/20/24 quarterly, 9/28/23 quarterly, and 6/28/23 annual MDS assessments were coded as the resident being on insulin, having received one insulin injection during the seven day look back period. The resident was on Trulicity (1), which was not an insulin. The resident was not on any prescribed insulin. A review of the above MDS assessments revealed the following: In Section N - Medications, was documented, Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days. In the box was typed 1 for one day. The next part, Insulin documented, Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days. In the box was typed 1 for one injection of insulin. A review of the clinical record revealed an order dated 11/8/22 for Trulicity, 0.75 mg (milligrams) / 0.5 ml (milliliters) injection every Tuesday. Further review of the clinical record revealed there were no active insulin orders at the time of any of the above MDS assessments. On 4/24/24 at 10:50 AM, an interview was conducted with RN #2 (Registered Nurse) the MDS nurse. She stated that there were new MDS staff who misunderstood about coding insulin injections. She stated that it was coded incorrectly, and that they probably confused it with insulin because it is an injection used for diabetes. The facility policy, Accuracy of MDS was reviewed. This policy documented, Purpose: The Accuracy of the MDS must be verified to ensure that the residents strengths, weaknesses, status and areas of actual decline or risk of decline are addressed to provide quality care and to develop and individualized plan of care for the resident. Accuracy is also necessary as the MDS is directly responsible and linked to the Medicare Prospective Payment System, state Medicaid reimbursement programs, Quality Indicator Reports, Public Reporting, Research and development of Policies. Procedure: 1. Each individual that completes a section of the MDS must verify accuracy of the MDS as specified by the MDS 3.0 User's manual by: Review of the resident's record, Observation of the resident, Communication with the resident, direct care staff, physician, family and licensed professionals, Any other route by which information needs to be obtained On 4/24/24 at 2:15 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing and ASM #3 the Regional Clinical Coordinator were made aware of the findings. No further information was provided by the end of the survey. References: (1) Trulicity - Dulaglutide injection is in a class of medications called incretin mimetics. It works by helping the pancreas to release the right amount of insulin when blood sugar levels are high. Information obtained from https://medlineplus.gov/druginfo/meds/a614047.html

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a PASARR was completed accurately for one of 39 residents in the survey sample; Resident #20. The findings include: For Resident #20, the facility staff failed to ensure the PASARR (Pre admission Screening and Resident Review) was completed accurately to determine if the resident did or did not have a mental condition requiring additional services. A review of the clinical record for Resident #20 revealed a PASARR form, dated 7/20/22. This form documented the following: 2. DOES THE INDIVIDUAL HAVE A CURRENT SERIOUS MENTAL ILLNESS (MI)? Yes No (Check Yes only if each item below are all Yes. If No, do not refer for evaluation of active treatment needs for MI (mental illness) Diagnosis.) a. Is this major mental disorder diagnosable under DSM (Diagnostic and Statistical Manual of Mental Disorders) (e.g., schizophrenia, mood, paranoid, panic, or other serious anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or other mental disorder that may lead to a chronic disability)? Yes No b. Has the disorder resulted in functional limitations in major life activities within the past 3-6 months, particularly with regard to interpersonal functioning; concentration, persistence, or pace; and adaptation to change? Yes No c. Does the treatment history indicate that the individual has experienced psychiatric treatment more intensive than outpatient care more than once in the past 2 years or the individual has experienced within the last 2 years an episode of significant disruption to the normal living situation due to the mental disorder? Yes No In the above form, for Question #2, does the individual have a current serious mental illness, was marked Yes. However, each of the following three questions, Items a, b, and c, were all marked No. This was not in accordance with the instructions documented above to Check Yes (for Question #2) only if each item below (a, b, and c) are all Yes. On 4/24/24 at 8:52 AM, an interview was conducted with OSM #1 (Other Staff Member) the Director of Social Services. She stated the PASARR was not completed correctly. She stated that the facility would not know if the resident needed any kind of additional services, based on the way it was completed. She stated that is she saw one come in like that, the facility would have to make an adjustment and do another one because that one was not correct. She stated that the resident either she has a mental illness or she doesn't and the way the PASARR was completed did not reflect which status was accurate for the resident. The facility policy, Pre-admission Screening and Guest/Resident Review - PASARR Virginia was reviewed. This policy documented, screen all individuals admitted for nursing care to ensure that needs are met to assist the individual in reaching their highest potential. All persons seeking admission to a nursing facility, who are seriously mentally ill and/or have an intellectual/developmental disability, are required to be evaluated to determine if a nursing facility is the appropriate place to receive services Complete: a new Level 1/DMAS 95 (PASARR screening) for the following changes in condition: 1. An incorrect Level 1/DMAS 95 received upon admission . On 4/24/24 at 2:15 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing and ASM #3 the Regional Clinical Coordinator were made aware of the findings. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide ADL care of a dependent resident to one of 39 residents in the survey sample; Resident #136. The findings include: For Resident #136, the facility staff failed to evidence that ADL care was provided. Resident #136 was admitted to the facility on [DATE] and discharged on 1/25/24. A review of the ADL (Activities of Daily Living) record for December 2023 and January 2024 revealed that the resident was to have showers on Mondays and Thursdays. In December 2023 there were seven opportunities for a shower. There were four showers documented. One occasion contained documentation that the resident was unavailable. On two occasions, no shower was documented. In January 2024 there were seven opportunities for a shower. There were four showers documented. On three occasions, no shower was documented. The facility's ADL logs did not include a line item for documenting any bathing outside of shower days. Therefore it could not be determined how much bathing, if any, the resident received outside of showers. On 4/24/24 at 11:43 AM, an interview was conducted with CNA #2 (Certified Nursing Assistant). She stated that regarding showers, it should be documented on the ADL log. She stated that if it was not documented, then she would assume the resident didn't get the shower and the nurse should be notified of it. A policy regarding ADL care - showers/bathing was requested. None was provided. On 4/24/24 at 2:15 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing and ASM #3 the Regional Clinical Coordinator were made aware of the findings. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide care and services for the treatment of pressure injuries for one of 39 residents in the survey sample, Resident #189. The findings include: For Resident #189, the facility staff failed to evidence, the treatments for pressure injuries (1), were completed per the physician orders. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/4/2022, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section M - Skin Conditions, the resident was coded as having two stage three pressure injuries (2). Sacral Wound The physician order dated, 10/15/2022, documented, Cleanse sacral wound with ns (normal saline) and apply hydrofera blue (3) and secure with island border dsg (dressing) QD (every day; every evening for wound care. The November 2022 TAR (treatment administration record) documented the above order. On 11/12/2022, there was a blank where the treatment was to be documented as completed. The physician order dated 1/8/2023 documented, Cleanse sacral wound with Dakin's solution (4), apply hydrofera blue and secure with island border dsg QD every evening shift for wound care. The January2023 TAR documented the above order. On 1/22/2023 and 1/24/2023, there was a blank where the treatment was to be documented as completed. Review of the nurse's notes failed to evidence documentation as to why the dressings were not completed. Left Heel The physician order dated 10/15/2022, documented, Cleanse wound left heel with NS, apply medihoney (5) with calcium alginate (6) and secure island border dsg every evening shift for wound care. The November 2023, TAR documented the above order. On 11/12/2023, there was a blank where the treatment was to be documented as completed. The December 2023 TAR documented the above order. On 12/8/2023 and 12/19/2023, there was a blank where the treatment was to be documented as completed. The January 2023 TAR documented the above order. On 1/4/2023 and 1/5/2023, there was a blank where the treatment was to be documented as completed. The physician order dated 1/7/2023, documented, Cleanse wound left heel with Dakin's, apply Dakin's moistened gauze with gentamicin ointment (antibiotic), wrap with kerlix and secure with retention tape, every evening shift for wound care. The January 2023 TAR documented the above order. On 1/22/2023 and 1252023, there was a blank where the treatment was to be documented as completed. Review of the nurse's notes failed to evidence documentation as to why the dressings were not completed. Right heel The physician order dated, 1/12/2023, documented, Iodine to right heel QD preventative every evening shift. The January 2023 TAR documented the above order. On 1/22/2023 and 1/24/2023, there was a blank where the treatment was to be documented as completed. Review of the nurse's notes failed to evidence documentation as to why the dressings were not completed. The comprehensive care plan dated, 2/2/2022, documented in part, Focus: (Resident #189) is at risk for impaired skin integrity/pressure injury and currently has PU (pressure ulcer - injury) on admission. The Interventions documented in part, Tx (treatment) as ordered. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 4/23/2024 at 5:01 p.m. When asked what blanks on the TAR indicated, ASM #2 stated, In general, it would indicate the employee did not document the medication or treatment. ASM #2 was asked how you can tell if the nurse did the treatment, ASM #2 stated, It does not disclose if it was done or not. An interview was conducted with LPN (licensed practical nurse) #1 on 4242024 at 10:17 a.m. When asked what a blank on the TAR indicated, LPN #1 stated, if it's not documented it wasn't done. The facility policy, Skin Management documented in part, Guest/residents with wounds and/or pressure injuries and those at risk for skin compromise, are identified, evaluated and provided appropriate treatment to promote prevention and healing. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, were made aware of the above concern on 4/24/2024 at 2:03 p.m. No further information was obtained prior to exit. References: (1) Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. This information was obtained from the following website: https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf (2) Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. This information was obtained from the following website: https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf (3) Hydrofera Blue -- A foam dressing bound with gentian violet and methylene blue (GV/MB) antibacterial agents (Hydrofera Blue; [NAME] Wound Care, Libertyville, IL) has been shown to be effective against a wide spectrum of microorganisms found in wounds, including methicillin-resistant staphylococcus aureus (MRSA), vancomycin-resistant enterococcus VRE and Candida. This information was obtained from the following website: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4717508/ (4) Dakin's solution: Dilute Dakin solution (0.05% to 0.025%) can be used to irrigate, cleanse, or as a component in wet-to-dry dressings to treat or prevent skin and soft tissue infections.[5] This information was obtained from the following website: https://www.ncbi.nlm.nih.gov/books/NBK507916/ (5) Medi - honey (medical honey) Applying honey preparations directly to wounds or using dressings containing honey seems to improve healing. Honey seems to reduce odors and pus, help clean the wound, reduce infection, reduce pain, and decrease time to healing. This information was obtained from the following website: https://medlineplus.gov/druginfo/natural/738.html. (6) Calcium alginate is a highly absorbent, biodegradable alginate dressing derived from seaweed. Alginate dressings maintain a physiologically moist microenvironment that promotes healing and the formation of granulation tissue cover with dry dressing. This information was obtained from the following website: https://www.o-wm.com/content/wonder-calcium-alginate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide monitoring for fluid restriction and intake for three of 39 residents, Resident #17, Resident #18 and Resident #35. The findings include: 1.The facility failed to provide monitoring for fluid restriction and intake for Resident #17. Resident #17 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure) and DM (diabetes mellitus). A review of the comprehensive care plan dated 4/18/24, which revealed, FOCUS: Resident is at nutritional and/or dehydration risk related to: edema, CHF and DM. Requires therapeutic diet and mechanically altered diet with fluid restriction. INTERVENTIONS: Provide diet as ordered. Fluid Restriction: 1800cc. A review of the physician's orders dated 3/28/24, revealed, Fluid Restriction diet Chopped Meat texture, Regular consistency, 1800ml per day 720 ml nursing/ 1080 ml kitchen for CHF. A review of the March 2024 MAR (Medication Administration Record) did not evidence any fluid restriction. A review of the April 2024 MAR revealed that day shift was allocated 300 ml, evening 300 ml and night shift 120 ml. On 4/13/24 and 4/14/24 day shift documented 330 ml; and on evening shifts 4/6/24, 4/7/24, 4/9/24, 4/11/24, 4/12/24 and 4/13/24 documented 330 ml exceeding the fluid restriction amount. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked how fluid restrictions are determined, LPN #3 stated, the physician writes the order then dietary and nursing divide the amount. When asked where evidence of fluid restriction is documented, LPN #3 stated, it would be on the MAR (Medication Administration Record). On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. A review of the facility's Fluid Restriction policy revealed, Upon notification of a fluid restriction via physician order, the Dietary Manager meets with the Charge Nurse to determine the amount of total fluid that will be provided by each department. The Dietary Manager visits with the guest/resident and adjusts their beverage preferences to adhere to the fluid restriction. The guest/resident and family are educated on the fluid restriction and documented in the medical record. No further information was provided prior to exit. 2.The facility failed to provide monitoring for fluid restriction and intake for Resident #18. Resident #18 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure), acute respiratory failure and chronic kidney disease stage III. A review of the comprehensive care plan dated 3/6/24, which revealed, FOCUS: Resident is at nutritional and/or dehydration risk related to: CHF and respiratory failure. Requires therapeutic diet with fluid restriction. INTERVENTIONS: Encourage to follow fluid restriction order: 2000cc. A review of the physician's orders dated 2/29/24, revealed, No Added Salt diet Regular texture, Thin consistency, small portions per guest request-2000CC FR (fluid restriction). A review of the March and April 2024 MAR revealed missing documentation on following shifts and dates: day shift: 3/24/24, 4/5/24; evening shift: 3/22/24, 3/23/24, 3/25/24, 4/1/24 and night shift: 3/21/24, 3/23/24 and 4/5/24. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked how fluid restrictions are determined, LPN #3 stated, the physician writes the order then dietary and nursing divide the amount. When asked where evidence of fluid restriction is documented, LPN #3 stated, it would be on the MAR (Medication Administration Record). On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. A review of the facility's Fluid Restriction policy revealed, Upon notification of a fluid restriction via physician order, the Dietary Manager meets with the Charge Nurse to determine the amount of total fluid that will be provided by each department. The Dietary Manager visits with the guest/resident and adjusts their beverage preferences to adhere to the fluid restriction. The guest/resident and family are educated on the fluid restriction and documented in the medical record. No further information was provided prior to exit. 3.The facility failed to provide monitoring for fluid restriction and intake for Resident #35. Resident #35 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), COPD (chronic obstructive pulmonary disease), CHF (congestive heart failure) and DM (diabetes mellitus). A review of the comprehensive care plan dated 4/18/24, which revealed, FOCUS: Resident is at nutritional and/or dehydration risk related to: CHF, ESRD, COPD and DM. Requires therapeutic diet with fluid restriction. INTERVENTIONS: Provide diet as ordered. Fluid Restriction: 1500cc. A review of the physician's orders dated 4/16/24, revealed, No Added Salt diet Regular texture, Regular consistency, 1500cc Fluid restriction: 800cc dietary/700cc nursing. A review of the April 2024 MAR did not evidence any fluid restriction. An interview was conducted on 4/24/24 at 9:40 AM with Resident #35. When asked if they knew their fluid restriction Resident #35 stated, no, I do not. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked how fluid restrictions are determined, LPN #3 stated, the physician writes the order then dietary and nursing divide the amount. When asked where evidence of fluid restriction is documented, LPN #3 stated, it would be on the MAR (Medication Administration Record). On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. A review of the facility's Fluid Restriction policy revealed, Upon notification of a fluid restriction via physician order, the Dietary Manager meets with the Charge Nurse to determine the amount of total fluid that will be provided by each department. The Dietary Manager visits with the guest/resident and adjusts their beverage preferences to adhere to the fluid restriction. The guest/resident and family are educated on the fluid restriction and documented in the medical record. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 39 residents in the survey sample, Resident #35. The findings include: The facility failed to provide evidence of monitoring for bruit and thrill for Resident #35. Resident #35 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease) and diabetes. A review of the comprehensive care plan dated 3/20/24, which revealed, FOCUS: Resident is at risk for complications related to dialysis due to: End Stage Renal Disease. INTERVENTIONS: Observe signs/symptoms of the following: Bleeding, Bruising, Hemorrhage, presence of aneurysm, Bacteremia & septic shock. Document and report abnormal findings to the physician. A review of the physician's orders dated 4/23/24, revealed, Hemodialysis Tuesday, Thursday, Saturday. Observe dialysis catheter for bleeding, infection, and catheter caps intact. every shift. Observe dialysis site for thrombosis, bleeding, stenosis, infection, Steal Syndrome, and aneurysm every shift for HD (hemodialysis). A review of Resident #35's medical record evidenced that she went to dialysis on 3/21, 3/23, 3/26, 3/28, hospitalized 3/28-4/11, 4/16, 4/18, 4/20 and 4/23/24. A review of Resident #35's March and April 2024 MAR (medication administration record) and TAR (treatment administration record) revealed no evidence of assessment of bruit and thrill of left arm fistula. An interview was conducted on 4/22/24 at 12:45 PM with Resident #35. When asked if they monitor the bruit and thrill of her fistula, Resident #35 stated, no, I do not believe so. On 4/23/24 at 1:00 PM, ASM (administrative staff member) #2, the director of nursing, stated, we do not have the bruit and thrill evidence for this resident. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked where the bruit and thrill are documented, LPN #3 stated, it would be documented on the TAR. Asked if the documentation was missing what that indicated, LPN #3 stated, it means that it was not done. On 4/23/24 at 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse were made aware of the findings. A review of the facility's Hemodialysis policy revealed, Evaluate the resident daily for dialysis access site and possible complications, including, but not limited to: a. Evaluation of the access site for: i. Thrombosis or bleeding, ii. Stenosis - small blue/purple veins. Constriction or narrowing within an orifice, iii. Infection - redness, drainage, abscess, warmth of the extremity. b. Thrill- palpation of the fistula site, it can be described as a purring vibration. c. Bruit- a continuous, machine-like sound that can be heard during auscultation with a stethoscope. It can also be described as a whooshing or a high pitched whistling. d. If the resident has a catheter for hemodialysis access, evaluate the catheter and site for: i. Bleeding, ii. Signs of infection, iii. To ensure that the catheter caps are intact. e. Notify physician of absence of bruit or thrill, signs of infection or other irregularity. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to maintain infection control practices during the medication administration observation for one of three nurses observed. The findings include: Observation was made on 4/22/2024 at 11:32 a.m. of RN (registered nurse) #1 administering medications on the 200 hallway. RN #1 was observed popping two medications out of the medication bubble pack and dropping the pills into her hand. She then put the pills into the medication cup and administered the medications to the resident. An interview was conducted with RN #1 on 4/22/2024 at 11:55 a.m. The above observation was shared with RN #1. She stated she guessed she had done that. When asked should the nurse touch a resident's medications with her hands, RN #1 stated, no. When asked why, RN #1 stated because of sanitary reasons, germs. The facility policy, Medication administration, documented in part, 1 . If medications come into contact with the bare hands of the nurse/med(medication) tech (technician), or with the med cart, the medication should be disposed of per policy and new medications obtained. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional clinical coordinator, were made aware of the above concern on 4/23/2024 at 4:50 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete immunization program for one of five residents reviewed for immunizations, Resident #5. The findings include: For Resident #5 (R5) the facility staff failed to provide education for and offer the most recent influenza vaccination. R5 was admitted to the facility on [DATE]. A review of R5's clinical record revealed no evidence that she was educated about or offered the most recent influenza vaccine. On 4/24/24 at 12:34 p.m., ASM (administrative staff member) #2, the director of nursing was interviewed. She stated the assistant director of nursing, who no longer works at the facility, was responsible for making sure all residents were offered the influenza vaccine when it became available in the fall of 2023. She stated residents should have been given a form with the risks and benefits of receiving the vaccine, and provided an opportunity to accept or decline its administration. She stated she could not explain why the staff member responsible for the vaccinations did not follow through with their responsibilities. On 4/24/24 at 2:30 p.m., ASM #1, the administrator, ASM #2, and ASM #3, the regional clinical director, were informed of these concerns. A review of the facility policy, Immunizations: Influenza Vaccination of Guest/Residents, revealed, in part: Beginning in October .Follow standing protocol to administer vaccine. If guest/resident is eligible, obtain an order for the vaccine and provide education. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete immunization program for one of five residents reviewed for immunizations, Resident #5. The findings include: For Resident #5 (R5) the facility staff failed to provide education for and offer the most recent COVID vaccination. R5 was admitted to the facility on [DATE]. A review of R5's clinical record revealed no evidence that she was educated about or offered the most recent COVID vaccine. On 4/24/24 at 12:34 p.m., ASM (administrative staff member) #2, the director of nursing was interviewed. She stated the assistant director of nursing, who no longer works at the facility, was responsible for making sure all residents were offered the most recent COVID vaccine when it became available. She stated residents should have been given a form with the risks and benefits of receiving the vaccine, and provided an opportunity to accept or decline its administration. She stated she could not explain why the staff member responsible for the vaccinations did not follow through with their responsibilities. On 4/24/24 at 2:30 p.m., ASM #1, the administrator, ASM #2, and ASM #3, the regional clinical director, were informed of these concerns. A review of the facility policy, COVID-19 Vaccination, revealed, in part: The vaccine administrator will identify residents that would qualify to receive the additional dose of booster dose of COVID-19 vaccine based on CDC (Centers for Disease Control) recommendations .Educate resident or responsible party on additional dose of COVID-19 vaccine. The facility will obtain a signed consent form for the administration of the additional dose of COVID-19 vaccine from the resident .A declination will be signed if consent is not given. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident/staff interviews, facility document review and clinical record review, it was determined the facility staff failed to develop/implement the care plan for five of 39 residents in the survey sample, Residents #17, #18, #35, #135 and #189. The findings include: 1.The facility staff failed to develop the comprehensive care plan for anticoagulation therapy for Resident #17. Resident #17 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure) and DM (diabetes mellitus). A review of the comprehensive care plan dated 4/18/24, which revealed, FOCUS: Resident is at nutritional and/or dehydration risk related to: edema, CHF and DM. Requires therapeutic diet and mechanically altered diet with fluid restriction. INTERVENTIONS: Provide diet as ordered. Fluid Restriction: 1800cc. There is no evidence of anticoagulation therapy on the care plan. A review of the physician's order dated 3/28/24 revealed, Eliquis Oral Tablet 5 MG (milligram) Give 5 mg by mouth every 12 hours. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the purpose of the care plan, LPN #3 stated, it is to develop the plans for the resident to receive care. When asked if anticoagulation therapy should be on the care plan, LPN #3 stated, yes, it should. When asked what should be included, LPN #3 stated, monitoring for bruising/bleeding and notifying the physician if this occurs. On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. A review of the facility's Care Planning policy revealed, In addition to care plans based on admission orders, goals for admission and desired outcomes, IDT (interdisciplinary team) assessments, physician orders, dietary needs, therapy services, social services, PASSAR (preadmission screening and resident review) recommendations, and discharge plans the baseline care plans are triggered in PCC (point click care) from the Nursing Comprehensive assessment. No further information was provided prior to exit. 2.The facility staff failed to develop the comprehensive care plan for anticoagulation therapy for Resident #18. Resident #18 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure), acute respiratory failure and chronic kidney disease stage III. A review of the comprehensive care plan dated 3/6/24, which revealed, FOCUS: Resident is at nutritional and/or dehydration risk related to: CHF and respiratory failure. Requires therapeutic diet with fluid restriction. INTERVENTIONS: Encourage to follow fluid restriction order: 2000cc. There is no evidence of anticoagulation therapy on the care plan. A review of the physician's order dated 2/29/24 revealed, Apixaban Oral Tablet 2.5 MG (milligram) Give 2.5 mg by mouth two times a day. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the purpose of the care plan, LPN #3 stated, it is to develop the plans for the resident to receive care. When asked if anticoagulation therapy should be on the care plan, LPN #3 stated, yes, it should. When asked what should be included, LPN #3 stated, monitoring for bruising/bleeding and notifying the physician if this occurs. On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. No further information was provided prior to exit. 3. The facility failed to develop the comprehensive care plan for dialysis care and to implement the care plan for oxygen therapy for Resident #35. Resident #35 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), COPD (chronic obstructive pulmonary disease) and diabetes. A review of the comprehensive care plan dated 3/20/24 and revised 4/22/24, which revealed, FOCUS: Resident is at risk for complications related to dialysis due to: End Stage Renal Disease. Resident has a potential for difficulty breathing and risk for respiratory complications related to: Asthma, COPD, SOB (shortness of breath) with exertion and when lying flat. INTERVENTIONS: Observe signs/symptoms of the following: Bleeding, Bruising, Hemorrhage, presence of aneurysm, Bacteremia & septic shock. Document and report abnormal findings to the physician. Oxygen 2LPM continuously. Administer medication & treatments per physician orders. Monitor for ineffectiveness, side effects and adverse reactions, report abnormal findings to the physician. There is no evidence of monitoring for bruit/thrill of fistula. A review of the physician's orders dated 4/11/24, revealed, Oxygen continuous @ 2Liters nasal cannula (lnc). A review of the physician's orders dated 4/23/24, revealed, Hemodialysis Tuesday, Thursday, Saturday. Observe dialysis catheter for bleeding, infection, and catheter caps intact. every shift. Observe dialysis site for thrombosis, bleeding, stenosis, infection, Steal Syndrome, and aneurysm every shift for HD (hemodialysis). An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the purpose of the care plan, LPN #3 stated, it is to develop the plans for the resident to receive care. When asked if dialysis care should be on the care plan, LPN #3 stated, yes, it should. When asked what should be included, LPN #3 stated, monitoring the bruit/thrill and for bleeding and notifying the physician if this occurs. When asked if oxygen is set at a rate different from what is in physician orders and on the care plan, has the care plan been implemented, LPN #3 stated, no, it was not implemented. On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. No further information was provided prior to exit. 4. The facility staff failed to develop the comprehensive care plan for anticoagulation therapy for Resident #35. Resident #135 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: breast cancer with metastasis to the bone and DM (diabetes mellitus). A review of the comprehensive care plan dated 3/8/24, which revealed, FOCUS: Resident is at risk for is at risk for pain and has acute/chronic pain related to low back pain. INTERVENTIONS: Offer Non-Pharmacological Interventions: 1) Massage, 2) Meditation/Relaxation, 3) Positioning, 4) Ice/cold pack, 5) Diversional Activity, 6) Guided Imagery, 7) Rest, 8) Social Interaction. Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal finding to the physician. There is no evidence of anticoagulation therapy on the care plan. A review of the physician orders dated 3/8/24 revealed, Apixaban Oral Tablet 5 MG (milligram) Give 1 tablet by mouth two times a day for anticoagulant. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the purpose of the care plan, LPN #3 stated, it is to develop the plans for the resident to receive care. When asked if anticoagulation therapy should be on the care plan, LPN #3 stated, yes, it should. When asked what should be included, LPN #3 stated, monitoring for bruising/bleeding and notifying the physician if this occurs. On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. No further information was provided prior to exit. 5. For Resident #189, the facility staff failed to implement the comprehensive care plan to administer treatments for pressure injuries (1). The comprehensive care plan dated, 2/2/2022, documented in part, Focus: (Resident #189) is at risk for impaired skin integrity/pressure injury and currently has PU (pressure ulcer - injury) on admission. The Interventions documented in part, Tx (treatment) as ordered. Sacral Wound The physician order dated, 10/15/2022, documented, Cleanse sacral wound with ns (normal saline) and apply hydrofera blue (3) and secure with island border dsg (dressing) QD (every day; every evening for wound care. The November 2022 TAR (treatment administration record) documented the above order. On 11/12/2022, there was a blank where the treatment was to be documented as completed. The physician order dated 1/8/2023 documented, Cleanse sacral wound with Dakin's solution (4), apply hydrofera blue and secure with island border dsg QD every evening shift for wound care. The January2023 TAR documented the above order. On 1/22/2023 and 1/24/2023, there was a blank where the treatment was to be documented as completed. Review of the nurse's notes failed to evidence documentation as to why the dressings were not completed. Left Heel The physician order dated 10/15/2022, documented, Cleanse wound left heel with NS, apply medihoney (5) with calcium alginate (6) and secure island border dsg every evening shift for wound care. The November 2023, TAR documented the above order. On 11/12/2023, there was a blank where the treatment was to be documented as completed. The December 2023 TAR documented the above order. On 12/8/2023 and 12/19/2023, there was a blank where the treatment was to be documented as completed. The January 2023 TAR documented the above order. On 1/4/2023 and 1/5/2023, there was a blank where the treatment was to be documented as completed. The physician order dated 1/7/2023, documented, Cleanse wound left heel with Dakin's, apply Dakin's moistened gauze with gentamicin ointment (antibiotic), wrap with kerlix and secure with retention tape, every evening shift for wound care. The January 2023 TAR documented the above order. On 1/22/2023 and 1252023, there was a blank where the treatment was to be documented as completed. Review of the nurse's notes failed to evidence documentation as to why the dressings were not completed. Right heel The physician order dated, 1/12/2023, documented, Iodine to right heel QD preventative every evening shift. The January 2023 TAR documented the above order. On 1/22/2023 and 1/24/2023, there was a blank where the treatment was to be documented as completed. Review of the nurse's notes failed to evidence documentation as to why the dressings were not completed. An interview was conducted with LPN (licensed practical nurse) #1 on 4/24/2024 at 10:17 a.m. When asked the purpose of the care plan LPN #1 stated it's to assist the resident in their needs. LPN #1 was asked if the care plan should be followed, LPN #1 stated, yes. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional clinical coordinator, were made aware of the above concern on 4/24/2024 at 2:03 p.m. No further information was obtained prior to exit. References: (1) Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. This information was obtained from the following website: https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf (2) Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. This information was obtained from the following website: https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf (3) Hydrofera Blue -- A foam dressing bound with gentian violet and methylene blue (GV/MB) antibacterial agents (Hydrofera Blue; [NAME] Wound Care, Libertyville, IL) has been shown to be effective against a wide spectrum of microorganisms found in wounds, including methicillin-resistant staphylococcus aureus (MRSA), vancomycin-resistant enterococcus VRE and Candida. This information was obtained from the following website: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4717508/ (4) Dakin's solution: Dilute Dakin solution (0.05% to 0.025%) can be used to irrigate, cleanse, or as a component in wet-to-dry dressings to treat or prevent skin and soft tissue infections.[5] This information was obtained from the following website: https://www.ncbi.nlm.nih.gov/books/NBK507916/ (5) Medi - honey (medical honey) Applying honey preparations directly to wounds or using dressings containing honey seems to improve healing. Honey seems to reduce odors and pus, help clean the wound, reduce infection, reduce pain, and decrease time to healing. This information was obtained from the following website: https://medlineplus.gov/druginfo/natural/738.html. (6) Calcium alginate is a highly absorbent, biodegradable alginate dressing derived from seaweed. Alginate dressings maintain a physiologically moist microenvironment that promotes healing and the formation of granulation tissue cover with dry dressing. This information was obtained from the following website: https://www.o-wm.com/content/wonder-calcium-alginate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility failed to evidence monitoring of anticoagulation side effects for Resident #17. Resident #17 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure) and DM (diabetes mellitus). A review of the comprehensive care plan dated 4/18/24, which revealed, FOCUS: Resident is at nutritional and/or dehydration risk related to: edema, CHF and DM. Requires therapeutic diet and mechanically altered diet with fluid restriction. INTERVENTIONS: Provide diet as ordered. Fluid Restriction: 1800cc. A review of the physician's order dated 3/28/24 revealed, Eliquis Oral Tablet 5 MG (milligram) Give 5 mg by mouth every 12 hours. A review of the March and April MAR/TAR (medication administration record/treatment administration record) revealed no evidence of anticoagulation monitoring. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the process for monitoring anticoagulants, LPN #3 stated, we would assess the resident for signs of bruising and bleeding. When asked where the anticoagulation monitoring would be documented, LPN #3 stated, it would be documented on the MAR/TAR. Asked if the documentation was missing what that indicated, LPN #3 stated, it means that it was not done. On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. A review of the facility's Anticoagulation Therapy policy revealed, Throughout anticoagulant therapy monitor the resident for signs and symptoms of bleeding. If signs and symptoms of bleeding are noted, hold anticoagulant medication and notify physician immediately. No further information was provided prior to exit. 3. The facility failed to evidence monitoring of anticoagulation side effects for Resident #18. Resident #18 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure), acute respiratory failure and chronic kidney disease stage III. A review of the comprehensive care plan dated 3/6/24, which revealed, FOCUS: Resident is at nutritional and/or dehydration risk related to: CHF and respiratory failure. Requires therapeutic diet with fluid restriction. INTERVENTIONS: Encourage to follow fluid restriction order: 2000cc. A review of the physician's order dated 2/29/24 revealed, Apixaban Oral Tablet 2.5 MG (milligram) Give 2.5 mg by mouth two times a day. A review of the March and April MAR/TAR (medication administration record/treatment administration record) revealed no evidence of anticoagulation monitoring. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the process for monitoring anticoagulants, LPN #3 stated, we would assess the resident for signs of bruising and bleeding. When asked where the anticoagulation monitoring would be documented, LPN #3 stated, it would be documented on the MAR/TAR. Asked if the documentation was missing what that indicated, LPN #3 stated, it means that it was not done. On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. No further information was provided prior to exit. 4. The facility failed to evidence monitoring of anticoagulation side effects for Resident #135. Resident #135 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: breast cancer with metastasis to the bone and DM (diabetes mellitus). A review of the comprehensive care plan dated 3/8/24, which revealed, FOCUS: Resident is at risk for is at risk for pain and has acute/chronic pain related to low back pain. INTERVENTIONS: Offer Non-Pharmacological Interventions: 1) Massage, 2) Meditation/Relaxation, 3) Positioning, 4) Ice/cold pack, 5) Diversional Activity, 6) Guided Imagery, 7) Rest, 8) Social Interaction. Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal finding to the physician. A review of the physician orders dated 3/8/24 revealed, Apixaban Oral Tablet 5 MG (milligram) Give 1 tablet by mouth two times a day for anticoagulant. A review of the March and April MAR/TAR (medication administration record/treatment administration record) revealed no evidence of anticoagulation monitoring. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the process for monitoring anticoagulants, LPN #3 stated, we would assess the resident for signs of bruising and bleeding. When asked where the anticoagulation monitoring would be documented, LPN #3 stated, it would be documented on the MAR/TAR. Asked if the documentation was missing what that indicated, LPN #3 stated, it means that it was not done. On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. No further information was provided prior to exit. Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure four of 39 residents in the survey sample, received care and services in accordance with professional standards of practice and the comprehensive care plan, Residents #2, #17, #18, and #135. The findings include: 1. For Resident #2, the facility staff failed to follow physician orders for obtaining weights and notifying the provider of a change in weight. The physician order dated, 3/31/2024, documented, Weights in the morning every Mon, Wed, Fri for HF (heart failure). NOTIFY PROVIDED IF WEIGHT GAIN OF 3 LBS (POUNDS) IN 24 HOURS OR 5 LBS IN A WEEK. The MAR (medication administration record) for April 2024, documented the above order. There were no weights documented on 4/5/2024 and 4/12/2024. Further review of the Weight tab in the medical, record failed to evidence weights for those two days. The MAR documented the following weights: 4/15/2024 - 238.2 4/22/2024 - 244.2 An increase of 6.2 pounds in a week. Review of the nurse's notes failed to evidence documentation of notification to the nurse practitioner or physician of the gain of over five pounds in one week. An interview was conducted with LPN (licensed practical nurse) #7 on 4/24/2024 at 10:35 a.m. The above order was reviewed with LPN #7. When asked what the nurse should do with this order, LPN #7 stated they should carry it through. LPN #7 was asked where to document the notification of the physician or nurse practitioner, LPN #7 stated they document it in the communication book and in the nurse's notes. When asked what the blanks on the MAR where there were not any weights documented, LPN #7 stated, It's the golden rule, if not documented not done. The facility policy, Physician Orders, documented in part, Treatment rendered to a resident must be in accordance with the specific standing, written, verbal, or telephone order of a physician or other licensed health professional ordering within their scope of practice and clinical privileges. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional clinical coordinator, were made aware of the above concern on 4/24/2024 at 2:03 p.m. No further information was obtained prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to provide respiratory therapy per physician orders for Resident #35. Observations of Resident #35's oxygen setting on 4/22/24 at 12:45 PM and 4/24/24 at 9:30 AM revealed the oxygen setting was at 3 lnc (liters nasal cannula). Resident #35 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), COPD (chronic obstructive pulmonary disease) and diabetes. A review of the comprehensive care plan dated 4/22/24, which revealed, FOCUS: Resident has a potential for difficulty breathing and risk for respiratory complications related to: Asthma, COPD, SOB (shortness of breath) with exertion and when lying flat. INTERVENTIONS: Oxygen 2LPM continuously. Administer medication & treatments per physician orders. Monitor for ineffectiveness, side effects and adverse reactions, report abnormal findings to the physician. A review of the physician's orders dated 4/11/24, revealed, Oxygen continuous @ 2Liters nasal cannula (lnc). An interview was conducted on 4/22/24 at 12:45 PM with Resident #35. When asked if they knew what their oxygen setting was, Resident #35 stated, it is on 2 liters. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the oxygen setting, LPN #3 stated, it is on 3 lnc, it should be on 2 lnc. When asked where she read the oxygen level, LPN #3 stated, the line should be in the middle of the ball. On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. A review of the facility's Use of Oxygen policy revealed, To promote guest/resident safety in administering oxygen. No further information was provided prior to exit. Based on observation, resident interview, staff interview, and clinical record review, it was determined that facility staff failed to provide respiratory care and services for four of 39 residents in the survey sample, Resident #s (R) R32, R38, R 35 and R2. The findings include: 1a. For R32, the facility staff failed to store a Bi-PAP mask (1) in a sanitary manner. R32 was admitted to the facility with diagnoses that included but were not limited to obstructive sleep apnea (2) and COPD (chronic obstructive pulmonary disease) (3). On the most recent comprehensive MDS (minimum data set), a 5-Day admission assessment with an ARD (assessment reference date) of 01/04/2024, R32 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R32 was cognitively intact for making daily decisions. On 04/22/2024 at approximately 1:00 p.m., an observation of R32's Bi-PAP mask revealed it was laying on top of the bed side table uncovered. On 04/22/2024 at approximately 2:05 p.m., an observation of R32's Bi-PAP mask revealed it was laying on top of the bed side table uncovered. On 04/23/2024 at approximately 8:20 a.m., an observation of R32's Bi-PAP mask revealed it was laying on top of the bed side table uncovered. The physician's order for R32 dated 04/16/2024 documented in part, Check BI-PAP placement and function on night shift, every night shift for sleep apnea. Order Date: 4/16/2024. On 04/22/2024 at approximately 2:15 p.m., an interview was conducted with R32. When asked about the Bi-PAP mask R32 stated she uses the Bi-PAP at night for sleep apnea. She further stated that the nurse takes it off her in the morning and puts it on her at night. On 04/24/2024 at approximately 10:22 a.m., an interview was conducted with LPN #1 regarding R32's Bi-PAP mask. When informed of the observations of R32's Bi-PAP mask being uncovered LPN #1 stated that it should be placed in a plastic bag when it is not being used. On 04/23/2024 at approximately 4:45 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings. No further information was provided prior to exit. References: (1) Stands for Bi-level Positive Airway Pressure. A BiPAP machine is a non-invasive form of therapy for patients suffering from sleep apnea. It deliver pressurized air through a mask to the patient's airways. The air pressure keeps the throat muscles from collapsing and reducing obstructions by acting as a splint. A BiPAP machines allow patients to breathe easily and regularly throughout the night. This information was obtained from the website: https://www.alaskasleep.com/blog/what-is-bipap-therapy-machine-bilevel-positive-airway-pressure. (2) Sleep apnea is a common disorder that causes your breathing to stop or get very shallow. Breathing pauses can last from a few seconds to minutes. They may occur 30 times or more an hour. This information was obtained from the website: https://medlineplus.gov/sleepapnea.html. (3) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 1b. For R32, facility staff failed to administer oxygen according to the physician's orders. The physician's order for R32 dated 04/16/2024 documented in part, O2 (oxygen) at 6 LPM (liters per minute) via (by) NC (nasal cannula) when on portable tank, as needed for COPD. Order Date: 04/24/2024. 8:47 a.m. On 04/24/2024 at 10:25 a.m., an observation of R32's oxygen flow meter on portable oxygen cylinder position of the back of R32's wheelchair revealed she was receiving oxygen at four liter per minute. On 04/24/2024 at approximately 10:22 a.m., an interview was conducted with LPN #1 ([NAME]) regarding R32's oxygen flow rate on the portable oxygen cylinder. At 10:25 a.m., an observation conducted with LPN #1 of R32 revealed she was sitting in her wheelchair receiving oxygen by nasal cannula. Further observation with LPN #1 of the portable oxygen cylinder positioned on the back of R32's wheelchair revealed an oxygen flow rate of four liters per minute. After a review of R32's physician's orders for oxygen as stated above LPN #1 stated the flow rate should have been at six liters per minute. The facility's policy Physician's Orders documented in part, Treatment rendered to a resident must be in accordance with the specific standing, written, verbal, or telephone order of a physician or other licensed health professional ordering within their scope of practice and clinical privileges. On 04/23/2024 at approximately 4:45 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings. No further information was provided prior to exit. 2. For R38, facility staff failed to administer Oxygen according to the physician's order. R38 was admitted to the facility with diagnoses that included but were not limited to COPD (chronic obstructive pulmonary disease) (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/06/2024, R38 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R38 was cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded R38 as receiving oxygen. On 04/23/2024 at 9:47 a.m., an observation of R38 revealed he was laying in bed. Further observation revealed an oxygen concentrator next to his bed running and the oxygen tubing and nasal cannula laying on the floor in front of the oxygen concentrator and R38 not receiving oxygen. At 10:11 a.m., an observation revealed R38 laying in bed and LPN (licensed practical nurse) #1 enter R38's room and spoke with him then left the room. Further observation revealed the oxygen concentrator next to his bed running and the oxygen tubing and nasal cannula laying on the floor in front of the oxygen concentrator and R38 was not receiving oxygen. At 10:14 a.m., LPN #1 re-entered R38's room and provided him a beverage and left the room. Further observation revealed the oxygen tubing and nasal cannula in the same position as stated above and R38 was not receiving oxygen. At 10:28 a.m., an observation revealed LPN #1 entered R38's room, administered his medications then left the room. Further observation revealed R38 was not receiving oxygen. On 04/23/2024 at approximately 10:45 a.m., an interview was conducted with LPN #1. After reviewing the physician's order for R38's oxygen she was asked to explain what was indicated by Oxygen continuous. LPN #1 stated R38 was to receive oxygen all, the time. When informed of the observation stated above LPN #1 stated that R38 refused the oxygen. When asked at what point in time did R38 refuse the oxygen she stated that she asked R38 when she administered his medication. When asked if R38 received his oxygen from 9:47 a.m. to 10:28 a.m., approximately 41 minutes, LPN #1 stated no. When asked if R38 should have been offered his oxygen earlier LPN #1 stated yes. The physician's order for R38 dated 02/06/2024 documented in part, Oxygen Continuous at 2L (two liters) via (by) NC (nasal cannula) while in bed every shift for COPD. Order Date: 2/06/2024. On 04/23/2024 at approximately 4:45 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings. No further information was provided prior to exit. References: (1) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html.4. For Resident #2, the facility staff failed to store a BiPap (1) mask in a sanitary manner. On the most recent MDS (Minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/12/2024, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section O - Special Treatments, Procedures and Programs, the resident was coded as using a Non-invasive Mechanical Ventilator. Observation was made of Resident #2's BiPap machine 4/23/2024 at 10:46 a.m. The BiPap mask was hanging over the BiPap machine, not contained or covered. An interview was conducted with Resident #2, she stated the staff hand her, her mask and she puts it on and off but they put it on the machine. Resident #2 further stated she believed the mask should be stored in a bag during the day when it's not in use to keep it clean. The physician order dated, 2/15/2024 documented, BiPap on q(every) hs (hours of sleep) a set by pulmonologist with 3 liters of oxygen. Dx (Diagnosis): Sleep apnea every day and evening shift for sleep apnea. An interview was conducted with LPN (licensed practical nurse) #7 on 4/24/24 at 10:35 a.m. When asked how a BiPap mask is to be stored when not in use, LPN #7 stated the mask is usually put in a zip lock baggies to store them in. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the above concern on 4/24/2024 at 2:03 p.m. No further information was obtained prior to exit. (1) Positive airway pressure (PAP) treatment uses a machine to pump air under pressure into the airway of the lungs. This helps keep the windpipe open during sleep. Bilevel positive airway pressure (BiPAP or BIPAP) has a higher pressure when you breathe in and lower pressure when you breathe out. This information was obtained from the following website: https://medlineplus.gov/ency/article/001916.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.The facility failed to provide a complete pain management program for Resident #135. Resident #135 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: breast cancer with metastasis to the bone and DM (diabetes mellitus). A review of the comprehensive care plan dated 3/8/24, which revealed, FOCUS: Resident is at risk for is at risk for pain and has acute/chronic pain related to low back pain. INTERVENTIONS: Offer Non-Pharmacological Interventions: 1) Massage, 2) Meditation/Relaxation, 3) Positioning, 4) Ice/cold pack, 5) Diversional Activity, 6) Guided Imagery, 7) Rest, 8) Social Interaction. Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal finding to the physician. A review of the physician orders dated 3/8/24 revealed, Pain-Non-Pharmacological Interventions: Document Non-Pharmacological interventions used: 1) Massage. 2) Meditation/Relaxation. 3) Positioning. 4)Ice/cold pack. 5) Diversional Activity. 6) Guided Imagery. 7) Rest. 8) Social Interaction. as needed Document Non-Pharmacological interventions using the corresponding number. A review of the March and April MAR (medication administration record) revealed the section to document Pain-Non-Pharmacological Interventions: Document Non-Pharmacological interventions used: 1) Massage. 2) Meditation/Relaxation. 3) Positioning. 4)Ice/cold pack. 5) Diversional Activity. 6) Guided Imagery. 7) Rest. 8) Social Interaction. as needed Document Non-Pharmacological interventions using the corresponding number was blank for both months. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the process to pain management, LPN #3 stated, we would assess the resident's pain level and implement non-pharmacological pain interventions. If they did not work, we would administer the pain medication ordered. When asked where the non-pharmacological pain interventions would be documented, LPN #3 stated, it would be documented on the MAR. Asked if the documentation was missing what that indicated, LPN #3 stated, it means that it was not done. On 4/23/24 at 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. A review of the facility's Pain Management policy revealed, Each resident identified with pain will have a Pain Management Care Plan. The care plan will have: a consistent pain scale to measure the pain and frequency of re-evaluation, a desired level of pain reduction or acceptable level of pain, resident centered functional outcomes, pain monitoring and who will monitor for pain, nursing comfort measures to alleviate pain, potential adverse effects of treatment and individualized interventions related to that resident's individual control of pain management should include both pharmacological, non-pharmacological and include Complementary and Alternative Medicine (CAM) pain management interventions. No further information was provided prior to exit. Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for three of 39 residents in the survey sample, Resident #s R97, R38 and R135. The findings include: 1. For R97, the facility staff failed to attempt non-pharmacological interventions prior to the administration of a prn (as needed) pain medications of Oxycodone (1) 5mg (five milligrams). On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 04/04/2024, R97 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R97 was cognitively intact for making daily decisions. Section J Pain Management coded R97 as having occasional pain at a pain level of five out of ten, with ten being the worse pain. The physician order for R97 documented in part, Oxycodone Tablet 5MG. Give 1 (one) tablet by mouth every 8 (eight) hours as needed for pain. Order Date: 11/29/2023. The eMAR (electronic medication administration record) for R97 dated April 2024 documented the physician's orders as stated above. The eMAR revealed that R97 received Oxycodone 5mg on 04/02/2024 at 5:26 a.m. with a pain level of four, 04/07/2024 at 5:00 a.m. with pain level of five, on 04/14/2024 at 8:17 a.m. with a pain level of three, 04/15/2024 at 6:16 a.m. with a pain level of seven, 04/20/2024 at 1:06 a.m. with a pain level of five, 04/21/2024 at 6:44 a.m. with a pain level of four, and on 04/22/2024 at 1:18 a.m. with a pain level of four and at 10:15 p.m. with a pain level of eight. Further review of the April 2024 eMAR failed to document evidence of non-pharmacological interventions for the dates and times listed above. The facility's progress notes for R97 for the dates and times listed above on the eMARs dated 04/01/2024 through 04/23/2024 failed to evidence documentation of non-pharmacological interventions. On 04/23/24 at approximately 10:58 a.m., an interview was conducted with R97 regarding the prn pain medication. When asked if the nursing staff attempt non-pharmacological interventions before administering his prn pain medication R97 stated the nurses try most of the time. On 04/23/2024 at approximately 2:30 p.m., an interview was conducted with LPN (licensed practical nurse) #1. When to describe the procedure for administering prn pain medications LPN #1 stated she would assess the resident, ask the where the location of the resident's pain is, try non-pharmacological interventions, and if the interventions were not effective, administer the medication that was prescribed. LPN #1 further stated that non-pharmacological interventions should always be attempted before administering the prn pain medication. When asked where it would be documented that the non-pharmacological interventions were attempted, she stated in the nursing notes or on the eMAR. LPN #1 was asked to review the eMAR and progress notes for R97 for documented evidence of non-pharmacological interventions being attempted on the above dates. On 04/24/2024 at approximately 10:10 a.m., an interview was conducted with LPN #1 regarding the documentation of non-pharmacological interventions for R97. After reviewing the nursing progress notes and the April 2024 eMAR for the dates and times listed above, LPN #1 stated that it appeared that the interventions were not attempted. The facility's policy Pain Management documented in part, Individualized interventions related to that resident's individual control of pain management should include both pharmacological, non-pharmacological and include Complementary and Alternative Medicine (CAM) pain management interventions. On 04/23/2024 at approximately 4:45 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings. No further information was provided prior to exit. References: (1) Oxycodone is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html. 2. For R38, the facility staff failed to attempt non-pharmacological interventions prior to the administration of a prn (as needed) pain medications of Oxycodone (1) 5mg (milligrams) and Acetaminophen (2) 650mg. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/06/2024, R38 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R38 was cognitively intact for making daily decisions. Section J Pain Management coded R97 as having occasional pain at a pain level of four out of ten, with ten being the worse pain. The physician order for R38 documented in part, Oxycodone Tablet 5MG. Give 1 (one) tablet by mouth every 8 (eight) hours as needed for pain. Order Date: 2/06/2024 and Acetaminophen Tablet 650MG. Give 2 (two) tablet by mouth every 4 (four) hours as needed for General Discomfort/Pain. Order Date: 2/06/2024. The eMAR (electronic medication administration record) for R38 dated April 2024 documented the physician's orders as stated above. The eMAR revealed that R38 received Oxycodone 5mg Oxycodone on 04/07/2024 at 10:36 a.m. with a pain level of seven, on 04/09/2024 at 11:00 a.m. with a pain level of three, on 04/10/2024 at 10:22 a.m. with a pain level of two, on 04/14/2024 at 9:05 p.m. with a pain level of three, on 04/20/2024 at 1:03 p.m. with a pain level of five and at 11:15 a.m. with a pain level of eight, on 04/21/2024 at 12:22 p.m. with a pain level of five, on 04/23/2024 at 10:24 a.m. with a pain level of three and on 04/24/2024 at 3:15 a.m. with a pain level of seven. The April eMAR further documented R38 received Acetaminophen on 04/04/2024 at 5:52 p.m. with a pain level of two, on 04/05/2024 at 7:06 p.m. with a pain level of three, on 04/09/2024 at 6:30 p.m. with a pain level of four, on 04/12/2024 at 4:20 p.m. with a pain level of five, on 04/19/2024 at 4:43 a.m. with a pain level of four, and on 04/20/2024 at 3:41 p.m. with a pain level of five. Further review of the April 2024 eMAR failed to document evidence of non-pharmacological interventions for the dates and times listed above. The facility's progress notes for R38 for the dates and times listed above on the eMARs dated 04/01/2024 through 04/23/2024 failed to evidence documentation of non-pharmacological interventions. On 04/23/2024 at approximately 2:30 p.m., an interview was conducted with LPN (licensed practical nurse) #1. When asked to describe how they determine which prn (as needed) pain medication to administer a when the physician has ordered two pain medications, LPN #1 stated go by the pain level on the physician's order and use the residents pain level. When asked to describe the procedure she would follow if the physician's orders do not specify the pain level for each prn pain medication LPN #1 stated she would use her nursing judgement. When asked to describe the procedure for administering prn pain medications LPN #1 stated she would assess the resident, ask the where the location of the resident's pain is, try non-pharmacological interventions, and if the interventions were not effective, administer the medication that was prescribed. LPN #1 further stated that non-pharmacological interventions should always be attempted before administering the prn pain medication. When asked where it would be documented that the non-pharmacological interventions were attempted, she stated in the nursing notes or on the eMAR. LPN #1 was asked to review the eMAR and progress notes for R38 for documented evidence of non-pharmacological interventions being attempted on the above dates. On 04/24/2024 at approximately 10:10 a.m., an interview was conducted with LPN #1 regarding the documentation of non-pharmacological interventions for R38. After reviewing the nursing progress notes and the April 2024 eMAR for the dates and times listed above, LPN #1 stated there was no documentation of non-pharmacological interventions being implemented and the order for the prn pain medications should have been clarified with a pain scale. LPN #1 further stated If the non-pharmacological interventions are not documented then they were not done. On 04/23/2024 at approximately 4:45 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings. No further information was provided prior to exit. References: (1) Oxycodone is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html. (2) Used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. This information was obtained from the website: https: https://medlineplus.gov/druginfo/meds/a681004.html.

Based on observation, staff interview, and facility document review it was determined facility staff failed to store, prepare, and serve food in a sanitary manner in one of one facility kitchens. The findings include: On 04/22/2024 at approximately 11:25 a.m., an inspection of the facility's kitchen was conducted with OSM (other staff member) #4, dietary manager. 1. On 04/22/2024 at approximately 11:35 a.m., an observation of the top shelf inside the walk-in refrigerator revealed five bags of chopped cabbage available for use. Further observation revealed each of the one-gallon zip-loc storage bags had a use-by-date of 04/19/2024. OSM #4 immediately removed the bags of cabbage from the refrigerator. 2. On 04/22/2024 at approximately 11:38 a.m., an observation of the three-compartment sink in the facility's kitchen revealed two cooking pots, a whisk, a ladle, pair of tongs and a large colander, submerged in the sink compartment labeled Sanitize. OSM #4 was asked to test the level of sanitizer. She removed a test strip from its container, placed it in the sanitized solution and compared the results with the sanitizer color scale. When asked what the sanitizer level was, OSM #4 stated it was 50ppm (parts per million). When asked if that was the correct level of sanitizer for the item soaking in the sink OSM #4 stated no and that it should have been 200ppm. 3. On 04/22/2024 at approximately 11:45 a.m., an observation of the tray line inside the facility's kitchen releveled OSM #5, dietary aide, standing, wearing a beard uncovered at the tray line. Further observation revealed OSM #5 moving resident's trays that were plated with food and beverages, down the tray line to another dietary aide who placed the tray on the food carts. 4. On 04/22/2024 at approximately 1:40 p.m., an observation of the facility's three nourishment rooms was conducted with OSM #4. Observation of the inside of the freezer in the nourishment located on the 200-hallway revealed a box containing a one serving frozen dinner. Observation of the box failed to evidence a resident's name and/or a room number; Observation of the inside of the refrigerator in the nourishment located on the 500-hallway revealed two 16-ounce bottles of soda approximately half full and a 12-ounce bottle of a tropical drink approximately three-quarters full. Observation of the inside of the freezer revealed a box containing a one serving frozen breakfast sausage bowl. Further observation of the above food items failed to evidence a resident's name and/or a room number; Observation of the inside of the refrigerator in the nourishment located on the 300-hallway revealed a one-pound package of lunch meat, 5-ounce container of yogurt, and a package of five strips of uncooked bacon. Observation of the inside of the freezer revealed a five-ounce bowl of ice cream, three slices of lunch meat in a zip-loc bag, a pint size zip-loc bag containing half-a-dozen shrimp, frozen burrito, eight-ounce package of chocolate truffles, a zip-loc bag containing a Salsbury steak, and a one serving frozen dinner. Further observation of the above food items failed to evidence a resident's name and/or a room number. On 04/22/2024 at approximately 1:55 p.m., an interview was conducted with OSM #4. When asked to describe the procedure for food brought in from outside of the facility OSM #4 stated that nursing should label the food item with the resident's name and room number. When asked who was responsible for checking the refrigerators and freezers in the nourishment rooms OSM #4 stated that the dietary aides should be checking the food when they stock the refrigerators with snacks and supplements for the residents. When asked how often the staff stock the refrigerators and freezers, she stated that it is done two times a day and the refrigerators and freezers should be checked each time. On 04/22/2024 at approximately 2:00 p.m., an interview was conducted with OSM #5. When asked to describe the task he was performing at the tray line earlier that day OSM #5 stated he was checking the food on the resident's trays with the resident's meal ticket to make sure the resident was receiving the correct food. When informed of the above observation OSM #5 stated he should have had his beard covered but did not know where the beard guards were kept. When asked if found out where they were kept, he stated and showed the surveyor the beard guards were on top of the hair nets next to the kitchen door. When asked why it was important to have a beard covered, he stated to prevent hair from falling into the food. On 04/23/2024 an interview was conducted with OSM #4. When asked to describe the procedure for keeping expired food items from being available for use she stated the cooks should be checking the items in the walk-in refrigerator daily. When asked to describe the procedure for the ensuring the correct amount of sanitizer is put in the sink OSM #4 stated the sanitizer level should be checked before placing items in the sanitizer. The facility's policy Three Compartment Sink documented in part, 5. Monitor and record sanitizing solution concentration with appropriate test strip: QAC (Quaternary Ammonium Compound) 150-400 ppm concentration, 60 second contact time (per Manufacturer's Instructions). The facility's policy Dress Code documented in part, 7. Culinary staff must wear hair restraints(e.g.) hair net, hat, and beard restraint) to prevent their hair from contacting exposed food . The facility's policy Food from Outside Sources documented in part, 5. All food brought in is to be checked by the Nurse, Dietary Manager, or Dietician. It must be placed in a sealed container and labeled for the content, the guest's/resident's name, and date the food was received, and an expiration date of 3 (three) days after the food was brought in . On 04/23/2024 at approximately 4:45 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for one of eight residents in the survey sample, Resident #1. The findings include: The facility staff failed to develop a comprehensive care plan for the care of the Resident #1's fingernail avulsion (1) per physician orders; and failed to implement the comprehensive care plan for having the overhead light on during care for Resident #1. Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: quadriplegia, chronic pain, and generalized anxiety disorder. The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 12/19/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being totally dependent for bed mobility, bathing, transfers, dressing and hygiene; extensive assistance for eating. A review of the physician orders dated 3/15/23, revealed, Wound care to Right 4th digit, nail avulsion. Cleanse nailbed with wound cleanser or normal saline, pat dry. Apply small amount of Bacitracin; cover with nonadherent dressing. Change daily or as needed with soilage or drainage present. A review of the comprehensive care plan dated 3/5/19, revealed, FOCUS: Resident has an actual behavior problem, related to personal choice. Diagnosis of Quadriplegia. Frequently expresses concerns regarding staff performance and delivery of care. INTERVENTIONS: Guest prefers overhead light on prior to care daily. Anticipate and meet resident's needs. Approach in a calm manner. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. A review of the nursing progress note dated 3/14/23 at 1:36 AM, revealed, The resident had an issue with movement of the table and the positioning of the table near the chest. Also, at this time the resident refused to be turned and repositioned. When asked about said issue the resident stated, I am calling the police because I do not like people messing with my table and lights! The nurse (writer) then asks if I can place call light next to him to call for help and then we can evaluate as staff before calling emergency services. Resident refused and stated he does not want call light next to him and wanted writer out. After what assistance the writer (nurse) could give I left the call light clipped next to him and lights on and the table where it was not on his chest, will continue to monitor for aggressive behaviors. A review of the nursing note dated 3/14/23 at 4:52 PM, revealed, Wound care completed to the 4th right digit/nail avulsion, with no issues. Will continue plan of care and update as needed. A review of the nursing progress note dated 3/15/23 at 3:53 PM, revealed, Wound care completed to right 4th digit. Finger cleansed, pat dried, ointment and bandage applied. Guest tolerated well and has no complaints or issues. Will continue plan of care and update as needed. An interview was conducted on 3/20/23 at 12:00 PM with Resident #1. When asked to describe the events on 3/14/23, Resident #1 stated, the aide did not listen to me. I asked her to turn on the light so she could see. She said she could see just fine. She came in to empty my urine bag. I have a condom catheter. She emptied the bag and then to lower my head to reposition me, she moved the overbed table closer to me. She was going to leave me with my head lowered and I must have my head raised so I can use the eraser to type on my laptop as I am a quadriplegic. I asked her to raise my head. She raised the head but did not push the table back and my hand got caught on the overbed table with the laptop. I did not feel anything. In the morning, when they were bringing in breakfast, the nurse asked what had happened as I had a little blood on my towel. She looked and my nail was off. They got orders for care and then put a dressing on it. Resident #1 stated if she would have turned on the light, she could have seen what she was doing. I do not know that she did was purposeful, except that she moved the tray table too close so that when my head was raised, my hand hit the table. An interview was conducted on 3/20/23 at 12:30 PM, with RN (registered nurse) #2. When asked if she could provide any details about Resident #1's missing fingernail, RN #2 stated, Once we knew the nail was missing, we obtained orders for treatment and I provided the treatment. I do the treatment every day that I am here. An interview was conducted on 3/21/23 at 1:00 PM, with LPN #2. When asked if the care plan was being followed based on Resident #1's light not turned-on during care on 3/14/23 at approximately 1:30 AM, LPN #2 stated, no, the care plan was not followed. When asked if wound care to the missing nail bed should have been included on the care plan, LPN #2 stated, yes, it should be on there. On 3/21/23 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the senior clinical transition specialist was made aware of the findings. According to the facility's Care Planning policy, dated 6/24/21, revealed, The care plan must be specific, resident centered, individualized and unique to each resident and may include: it should be oriented toward preventing avoidable declines, how to manage risk factors, address/include resident strengths, utilize current standards of practice, treatment objectives should have measurable outcomes, respect the resident's right to refuse treatment, utilize an interdisciplinary approach to include certified nurse aide, involve and communicate the needs of the resident with the direct care staff (1.e. CNA [NAME]). No further information was provided prior to exit. Reference: (1) Losing a toenail or fingernail because of an injury is called avulsion. The nail may be completely or partially torn off after a trauma to the area. https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.toenail-or-fingernail-avulsion-care-instructions.zp4213

Based on resident interview, staff interview and clinical record review it was determined that the facility staff failed to maintain a completed and accurate clinical record for one of eight residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff failed to document the dressing changes for a surgical wound. R5 was admitted to the facility with diagnoses that included but were not limited to cutaneous abscess (1) of buttocks. On the most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 12/21/2022, R5 scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. The physician's orders for R5 dated 03/17/2023 documented, If wound vac (2) is off or not functioning properly, cleanse right buttock wound with dakins (3), apply dakins moistened gauze and secure with dry dsg (dressing). Every 24 hours as needed for wound care. Review of R5 comprehensive care plan with a revision date of 12/19/2022 documented in part, (R5) is at risk for further impaired skin integrity/pressure injury R/T (related to): decreased mobility and endurance cutaneous abscess of buttocks .Date Initiated: 12/19/2022. The eTAR (electronic treatment administration record) for R5 dated March 2023 documented the physician's order as stated above. Further review of the eTAR revealed blank spaces, where staff document treatment was done, under the dates 03/18/2023 and 03/19/2023. The facility's nursing progress notes dated 03/18/2023 through 03/19/2023 failed to evidence if wound care was provided to R5 or refused. On 03/20/2023 at approximately 11:50 a.m., an interview was conducted with R5 regarding their wound care on 03/18/2023 and 03/19/2023. R5 stated that they did receive wound care on 03/18/2023 and 03/19/2023. On 03/21/2023 at approximately 12:43 p.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. When asked about the blanks on the eTAR dated 03/18/2023 and 03/19/2023 for R5's wound care, ASM #2 stated they would investigate it. At 1:07 p.m., ASM #2 stated that they contacted the nurse who worked on 03/18/2023 by telephone. ASM #2 stated that the nurse informed them that the wound care was administered but they failed to document that it was done. ASM #2 further stated the physician order for the dressing change was as needed and that R5's dressing may not have needed to be changed on 03/19/2023. The facility's policy Electronic Medical Records documented in part, Policy: Electronic records are an acceptable format for medical record management. The facility will comply with laws and regulations (federal and state-specific) for the management of computerized medical records. On 03/21/2023 at approximately 2:10 p.m., ASM #1, administrator, ASM #2, director of nursing and ASM # were made aware of the above findings. No further information was provided prior to exit. References: (1) A localized collection of pus in the skin and may occur on any skin surface. Symptoms and signs are pain and a tender and firm or fluctuant swelling. Diagnosis is usually obvious by examination. Treatment is incision and drainage. This information was obtained from the website: Cutaneous Abscess - Dermatologic Disorders - Merck Manuals Professional Edition (2) Vacuum-assisted closure of a wound is a type of therapy to help wounds heal. It's also known as wound VAC. During the treatment, a device decreases air pressure on the wound. This can help the wound heal more quickly. The gases in the air around us put pressure on the surface of our bodies. This information was obtained from the website: https://www.hopkinsmedicine.org/health/treatment-tests-and therapies/vacuumassisted-closure-of-a-wound. (3) A broad-spectrum antimicrobial cleanser that is gentle to the skin. Effective against MRSA, VRE, other bacteria, viruses, molds, fungi, and yeast. Also used for odor control. This information was obtained from the website: Dakin's Solution Quarter Strength | Wound Care Debridement (woundsource.com)

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to honor a resident and/or a resident family's choices for one of 59 residents in the survey sample, Resident #103 (R103). The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 05/13/2022, the resident scored 3 out of 15 on the BIMS (brief interview for mental status) assessment, which indicated the resident was severely impaired for making daily decisions. Section G documented R103 being totally dependent on two or more staff members for transfers and totally dependent of one person for dressing. On 6/13/2022 at approximately 12:15 p.m., an observation was made of R103 in their room. R103 was observed in bed wearing a hospital gown. R103 was observed to have their eyes open and respond by nodding yes or no to questions. R103 did not respond verbally. A handwritten note was observed to be written in a black marker on the bulletin board beside R103's bed on the right side and also on the bulletin board beside the doorway to the room. The note stated, Please dress [R103] daily (needs total help) Please get [R103] out of the bed so she can participate in daily activities (needs total help). Please check [R103] for wetness as she will not just tell you. All of [R103] items are in her cabinets. Please leave TV on at night. Thank you, [R103] family. She can speak & understands what you are saying. When asked if they had been dressed or out of bed on 6/13/2022, R103 nodded No. When asked if they had been bathed, R103 nodded Yes. Additional observations on 6/13/2022 at 2:12 p.m. and 4:25 p.m. revealed the findings as described above. On 6/14/2022 at 8:33 a.m., R103 was observed in a hospital gown in bed. On 6/14/2022 at 10:31 a.m., R103 was observed in bed in a hospital gown, when asked if they had a bath R103 nodded Yes, when asked if they wanted to get dressed and out of bed today R103 nodded Yes. On 6/14/2022 at 12:30 p.m. and 2:45 p.m., R103 was observed in bed in a hospital gown. The handwritten signs were observed to remain in place on R103's bulletin boards in the room. On 6/15/2022 at 9:15 a.m. and 10:30 a.m., R103 was observed in bed with a hospital gown on. The comprehensive care plan dated 4/5/2022 documented in part, [R103] has an ADL (activities of daily living) self care performance deficit and requires assistance with ADL's and mobility r/t (related to): H/O (history of) CVA (cardiovascular accident) and decreased ability to do ADL's. Date Initiated: 04/05/2022. Revision on: 04/06/2022 . The Documentation Survey Report (a report of CNA documentation for the month) for R103 dated 6/1/2022-6/30/2022 for Transferring for 6/13/2022 was observed to be blank for day and night shift and a NA was observed to be documented in the evening shift area. On 6/14/2022, the day and evening shift areas were observed to be blank and the night shift was observed to contain a NA. On 6/14/2022 at 2:48 p.m., an interview was conducted with CNA (certified nursing assistant) #5. CNA #5 stated that R103 required a hoyer lift to get out of bed and required 2 staff members to get out of bed. CNA #5 stated that when they worked with R103 they asked them what they wanted and had them dressed and out of bed each day. CNA #5 stated that all residents should be dressed every day and that the CNA assigned should wash them up and put clothes on them. CNA #5 stated that residents wear hospital gowns when they don't have anything else and their personal clothes make them feel more presentable. CNA #5 stated that they try their best to honor any family preferences for getting residents out of bed and their choices. CNA #5 stated that R103 was non-verbal but could communicate with their eyes and nodding. CNA #5 stated that they had not been assigned R103 on 6/14/2022 but had told the other CNA to get them up earlier that day but they had not done it. CNA #5 stated that the day shift CNA had already left for the day. On 6/14/2022 at 3:08 p.m., an interview was conducted with LPN (licensed practical nurse) #9. LPN #9 stated that residents should be dressed and offered to get out of bed daily. LPN #9 stated that each resident had the right to be dressed in their own clothes and to get out of bed each day if they wanted to. LPN #9 reviewed the notes in R103's room written by R103's family and stated that they had asked the CNA that morning to get them out of bed for therapy to work with them but they had not done this. LPN #9 stated that they normally get R103 up and dressed by 10:00 a.m. On 6/15/2022 at 10:54 a.m., an interview was conducted with LPN #3, unit manager. LPN #3 stated that they had been at the facility for one week and were still learning the residents. LPN #3 stated that all residents had the right to get out of bed each day and should be dressed each day. LPN #3 stated that each resident should be given the choice to get out of bed or stay in bed. LPN #3 observed R103 in their room who was observed to be in bed with a hospital gown on. LPN #3 stated that they were unaware of the handwritten notes from R103's family and it was observed the notes from R103's family had been taken down. The facility policy Guest/Resident Rights dated 9/1/2013 documented in part, .Guests/residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations affecting guest/resident conduct and those regulations governing protection of guest/resident health and safety .A facility must promote the exercise of rights for each guest/resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A guest/resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability . The facility policy Routine Guest/Resident Care dated 3/1/2013 documented in part, .Guests/residents are encouraged or assisted to dress in appropriate clothing and footwear daily (appropriate to season and weather, clean and in good repair) . On 6/15/2022 at approximately 4:05 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the southside regional clinical coordinator and ASM #4, the regional director of operations were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to maintain the call bell in a position accessible to the resident for one of 59 residents in the survey sample, Resident #114 (R114). The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/23/2022, the resident scored 3 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is severely impaired for making daily decisions. Section G documented R114 having functional limitations in range of motion to both upper and lower extremities. The comprehensive care plan for R114 dated 2/25/2022 documented in part, [R114] is at risk for fall related injury and falls R/T (related to): new admit, confusion, psychoactive medication. Date Initiated: 02/25/2022. Revision on: 02/26/2022. Under Interventions it documented in part, .Put the resident's call light within reach and encourage him to use it for assistance as needed. Date Initiated: 02/26/2022 . On 6/13/2022 at 1:59 p.m., an observation was made of R114 in their room. R114 was observed lying in bed with a t-shirt on and asleep. R114's call light cord with push button was observed to be clipped onto the call light cord plugged into the wall at the center of the room. The call light was not in reach of R114 in the bed. Additional observations of R114 in their bed in the room on 6/13/2022 at 3:41 p.m. and 4:24 p.m. revealed the call light in the same position as described above. On 6/14/2022 at 8:45 a.m. and 1:45 p.m. the call light was observed in the same position as described above with R114 in the bed. On 6/14/2022 at 2:48 p.m., an interview was conducted with CNA (certified nursing assistant) #5. CNA #5 stated that the call bell should be clipped to the sheet or something in reach of the resident. CNA #5 stated that the purpose of this was to be within reach for them to call when they needed something. CNA #5 stated that R114 was able to use their call bell and the phone. CNA #5 observed R114 in the bed with the call bell clipped to the cord plugged into the wall at the center of the room at the patient station and stated that it was not in their reach and should not have been there because they could not reach it to call if needed. On 6/14/2022 at 3:08 p.m., an interview was conducted with LPN (licensed practical nurse) #9. LPN #9 stated that the call bell should be placed within reach of the resident at all times for them to be able to call. LPN #9 stated that staff should check the call bell placement during rounding every time they enter the room. The facility policy, Routine Guest/Resident Care dated 3/1/2013 documented in part, .The call light should be easily accessible to the guests/residents at all times . On 6/14/2022 at 4:15 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the southside regional clinical coordinator and ASM #4, the regional director of operations were made aware of the findings. No further information was presented prior to exit.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to maintain a clean, comfortable, homelike environment for one of 59 residents in the survey sample, Resident #134. The facility staff failed to maintain Resident #134's (R134) bathroom in a clean and homelike manner. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/27/22, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. On 6/13/22 at 12:51 p.m., R134 was observed lying in bed. During an interview with R134, the resident stated the bathroom was dirty and the facility staff do not clean the floor in the bathroom. At that time, an observation of R134's bathroom was conducted. Small brown particles were observed on the floor in the right corner behind the toilet and in the corners under the sink; hair was observed around the trash can. On 6/14/22 at 3:05 p.m., another observation of R134's bathroom was conducted. The brown particles and hair remained on the floor. On 6/14/22 at 3:49 p.m., an interview was conducted with OSM (other staff member) #6 (a housekeeper). OSM #6 stated bathroom floors should be swept and mopped once every day and more than once if needed. OSM #6 stated the housekeeper responsible for cleaning R134's bathroom had left for the day. At that time, R134's bathroom was observed with OSM #6. OSM #6 stated the bathroom should have been cleaned and was not clean or homelike. On 6/15/22 at 11:35 a.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing), ASM #3 (the regional clinical coordinator) and ASM #4 (the regional director of operations) were made aware of the above concern. The facility policy titled, Federal & State - Guest/Resident Rights & Facility Responsibilities documented, It is the facility's policy to abide by all guest/resident rights .i. Safe environment. The guest/resident has a right to a safe, clean, comfortable and homelike environment . No further information was presented prior to exit.

Based on staff interview, facility document review and in the course of a complaint investigation, the facility staff failed to implement the facility abuse policy for 4 of 11 employee record reviews. The facility staff failed to conduct certification and nursing license verifications upon hire for two CNAs)certified nursing assistant) #3 and #4, and two LPNs (licensed practical nurse) #10 and #11. The findings include: The facility abuse prohibition policy was reviewed and documented, A. Screening Employees and Guests/Residents: 1. The facility will screen potential new employees for a history of abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law .2. Without exception, all potential licensed and certified candidates must have their status confirmed with the appropriate boards to verify license/certification and to determine if any action has been taken against the license or certification. CNA #3 was hired on 8/25/21. CNA #4 was hired on 8/4/21. LPN #10 was hired on 8/18/21. LPN #11 was hired on 8/18/21. On 6/15/22 at 11:04 a.m., a review of certification and license verifications was conducted with OSM (other staff member) #9 (the accounts payable payroll coordinator). OSM #9 could not provide evidence that a license verification was conducted upon hire for CNA #3, CNA #4, LPN #10 or LPN #11. OSM #9 stated the nursing department was responsible for conducting license verifications when those employees were hired. OSM #9 stated she is now responsible for conducting license verifications. OSM #9 stated she conducts license verifications through the Virginia board of nursing website as soon as she receives potential employees' applications. On 6/15/22 at 11:35 a.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing), ASM #3 (the regional clinical coordinator) and ASM #4 (the regional director of operations) were made aware of the above concern. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review it was determined that the facility staff failed to evidence that all required documentation was provided to the receiving facility for a hospital transfer for 1 of 59 residents in the survey sample; Resident #128. The findings include: Resident #128 was transferred to the hospital on 5/17/22. There was no evidence that the comprehensive care plan goals, medication list, relevant progress notes or labs were provided to the hospital. Resident #128 was admitted to the facility on [DATE]. On the most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 5/30/22, the resident scored an 11 out of a possible 15 on the BIMS (Brief Interview for Mental Status) indicating the resident was moderately impaired cognitively in ability to make daily life decisions. The resident was coded as requiring extensive assistance for eating and total care for all other areas of activities of daily living. A review of the clinical record revealed a nurse's note dated 5/17/22 that documented, Nurse practitioner in facility observed resident not at [their] baseline, observed right facial droop and slow to respond. Able to follow directions. Vitals BP-128/78 (blood pressure), P-96 (pulse), T-97.4 (temperature), R-17 (respirations), 02-97% RA (oxygen saturation on room air). Resident has been transported to [name of hospital] via stretcher with EMT's (emergency medical technicians) for an evaluation. Report called into ER (emergency room) by N.P. (nurse practitioner) Resident is [their] own RP (responsible party). Emergency contact, [name] has been updated. A nurse practitioner note dated 5/17/22 documented, Per staff pt (patient) has been acting unusual, having weakness, slow to respond. Today patient states Something is not right. Pt having unequal grip strength, right sided facial drooping, and slurring of speech. NP (nurse practitioner) sending out to ER (emergency room) for further workup pt having new onset right sided weakness, slurred speech, minimal right facial droop, pt being sent to ER for further evaluation of possible TIA/Stroke/UTI (transient ischemic attack (mini stroke), stroke, urinary tract infection.) A review of the clinical record revealed a Hospital Transfer form completed on 5/17/22 (but dated 2/11/22) that documented resident demographic information, vital signs (dated 5/17/22), reason for transfer (a fall, which was not accurate for 5/17/22) code status, and ongoing medical and care needs. Further review of the clinical record failed to reveal any evidence what documentation was provided to the hospital, including but not limited to comprehensive care plan goals, medication list, relevant progress notes or labs. On 6/14/22 at 3:00 PM an interview was conducted with LPN #4 (Licensed Practical Nurse). She stated that on a hospital transfer, the facility should send the hospital transfer form, face sheet, advance directives, medication list, progress notes, labs, bed hold and care plan. On 6/14/22 at approximately 4:00 PM ASM #1 (Administrative Staff Member) the Administrator, was provided a list of items needed, which included evidence of what documentation was provided to the hospital. On 6/15/22 at 9:40 AM, ASM #2, the Director of Nursing, stated there was no other documentation regarding what was sent to the hospital. She stated that the staff are supposed to document this information in the nurse's note. On 6/15/22 at 3:30 PM ASM #1 was provided with a list of policies requested, which included a request for one regarding admission, transfer, discharge, hospital transfer requirements. On 6/15/22 at 5:34 PM and 5:39 PM the facility sent emails with policies attached. None for admission, transfer, discharge, hospital transfer requirements was provided. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review it was determined that the facility staff failed to evidence that written notification of a hospital transfer was provided to the resident and/or responsible party for a hospital transfer for one of 59 residents in the survey sample; Resident #128. The findings include: Resident #128 was transferred to the hospital on 5/17/22. There was no evidence that written notification of a hospital transfer was provided to the resident and/or responsible party. Resident #128 was admitted to the facility on [DATE]. On the most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 5/30/22, the resident scored an 11 out of a possible 15 on the BIMS (Brief Interview for Mental Status) indicating the resident was moderately impaired cognitively in ability to make daily life decisions. The resident was coded as requiring extensive assistance for eating and total care for all other areas of activities of daily living. A review of the clinical record revealed a nurse's note dated 5/17/22 that documented, Nurse practitioner in facility observed resident not at [their] baseline, observed right facial droop and slow to respond. Able to follow directions. Vitals BP-128/78 (blood pressure), P-96 (pulse), T-97.4 (temperature), R-17 (respirations), 02-97% RA (oxygen saturation on room air). Resident has been transported to [name of hospital] via stretcher with EMT's (emergency medical technicians) for an evaluation. Report called into ER (emergency room) by N.P. (nurse practitioner) Resident is [their] own RP (responsible party). Emergency contact, [name] has been updated. A nurse practitioner note dated 5/17/22 documented, Per staff pt (patient) has been acting unusual, having weakness, slow to respond. Today patient states Something is not right. Pt having unequal grip strength, right sided facial drooping, and slurring of speech. NP (nurse practitioner) sending out to ER (emergency room) for further workup pt having new onset right sided weakness, slurred speech, minimal right facial droop, pt being sent to ER for further evaluation of possible TIA/Stroke/UTI (transient ischemic attack (mini stroke), stroke, urinary tract infection.) A review of the clinical record revealed a Hospital Transfer form completed on 5/17/22 (but for some reason dated 2/11/22) that documented resident demographic information, vital signs (dated 5/17/22), reason for transfer (a fall, which was not accurate for 5/17/22) code status, and ongoing medical and care needs. Further review of the clinical record failed to reveal any evidence of a written notification of a hospital transfer being provided to the resident and/or responsible party. On 6/14/22 at 3:00 PM an interview was conducted with LPN #4 (Licensed Practical Nurse). She stated that she was not sure about a written notification of a hospital transfer. On 6/14/22 at approximately 4:00 PM ASM #1 (Administrative Staff Member) the Administrator, was provided a list of items needed, which included evidence of a written notification of a hospital transfer being provided to the resident and/or responsible party. On 6/15/22 at 9:40 AM, ASM #2, the Director of Nursing, stated there was no evidence that a written notification of a hospital transfer was provided. On 6/15/22 at 3:30 PM ASM #1 was provided with a list of policies requested, which included a request for one regarding admission, transfer, discharge, hospital transfer requirements. On 6/15/22 at 5:34 PM and 5:39 PM the facility sent emails with policies attached. None for admission, transfer, discharge, hospital transfer requirements was provided. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to evidence a bed hold was provided when Resident #76 was transferred to the hospital on 4/20/22. The facility's Acute Care Transfer Document Checklist did not evidence bed hold on the check list. Resident #76 was admitted to the facility on [DATE]. Resident #76's diagnoses included but were not limited to: ESRD (end stage renal disease), COPD (chronic obstructive pulmonary disease, diabetes mellitus and dementia. Resident #76's most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 3/19/22, coded the resident as scoring 9 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the eINTERACT (INTerventions to Reduce Acute Care Transfers) form dated 4/20/22 at 4:28 PM, revealed the following, Mental confusion, weakness. Vital signs blood pressure-222/112, pulse-76, respirations-21, temperature-97.7, oxygen saturation-98% on room air. Emergency assistance arrived and transported resident to hospital. RP (responsible party) and NP (nurse practitioner) notified. On 6/13/22 at 3:32 PM, an interview was conducted with LPN (licensed practical nurse) #1. When asked what bed hold is provided when a resident is transferred to the hospital, LPN #1 stated, There is a form to check off, of what has been sent with the resident, there is a big envelope that we put the papers in. I do not know about the bed hold. On 6/13/22 at approximately 4:00 PM a request was made for the evidence of the bed hold policy when Resident #76 was transferred to the hospital on 4/20/22. On 6/14/22 at approximately 9:00 AM, SBAR (situation background assessment recommendation) form for Resident #76 was provided. On 6/14/22 at 4:00 PM, request made again for bed hold for Resident #76. On 6/15/22 at 1:40 PM, ASM (administrative staff member) #1, the administrator, stated, We do not have the bed hold for this resident. When ASM #1, the administrator and ASM #2, the director of nursing were asked who provides bed holds for residents, they stated, admissions does that but she is on vacation. On 6/15/22 at 3:40 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional clinical coordinator and ASM #4, the regional director of operations were informed of the above concern. A request was made on 6/15/22 on 3:30 PM for any facility bed hold policy. On 6/15/22 at 6:20 PM, ASM #1 and ASM #2 stated, we do not have any policy related to bed holds. No further information was provided prior to exit. Based on staff interview and clinical record review it was determined that the facility staff failed to evidence that written bed hold notice was provided to the resident and/or responsible party for a hospital transfer for 2 of 59 residents in the survey sample; Residents #128 and #76 The findings include: 1. Resident #128 was transferred to the hospital on 5/17/22. There was no evidence that written bed hold notice was provided to the resident and/or responsible party. Resident #128 was admitted to the facility on [DATE]. On the most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 5/30/22, the resident scored an 11 out of a possible 15 on the BIMS (Brief Interview for Mental Status) indicating the resident was moderately impaired cognitively in ability to make daily life decisions. A review of the clinical record revealed a nurse's note dated 5/17/22 that documented, Nurse practitioner in facility observed resident not at [their] baseline, observed right facial droop and slow to respond. Able to follow directions. Vitals BP-128/78 (blood pressure), P-96 (pulse), T-97.4 (temperature), R-17 (respirations), 02-97% RA (oxygen saturation on room air). Resident has been transported to [name of hospital] via stretcher with EMT's (emergency medical technicians) for an evaluation. Report called into ER (emergency room) by N.P. (nurse practitioner) Resident is [their] own RP (responsible party). Emergency contact, [name] has been updated. A review of the clinical record revealed a Hospital Transfer form completed on 5/17/22 (but for some reason dated 2/11/22) that documented resident demographic information, vital signs (dated 5/17/22), reason for transfer (a fall, which was not accurate for 5/17/22) code status, and ongoing medical and care needs. Further review of the clinical record failed to reveal any evidence of a written bed hold notice being provided to the resident and/or responsible party. On 6/14/22 at 3:00 PM an interview was conducted with LPN (Licensed Practical Nurse) #4 . She stated that on a hospital transfer, the facility should send the hospital transfer form, face sheet, advance directives, medication list, progress notes, labs, and bed hold. On 6/14/22 at approximately 4:00 PM ASM #1 (Administrative Staff Member) the Administrator, was provided a list of items needed, which included evidence of a written bed hold notice being provided to the resident and/or responsible party. On 6/15/22 at 9:40 AM, ASM #2, the Director of Nursing, stated there was no evidence that a written bed hold notice was provided. On 6/15/22 at 3:30 PM ASM #1 was provided with a list of policies requested, which included a request for one regarding admission, transfer, discharge, hospital transfer requirements. On 6/15/22 at 5:34 PM and 5:39 PM the facility sent emails with policies attached. None for admission, transfer, discharge, hospital transfer requirements was provided. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and in the course of a complaint investigation, it was determined that the facility staff failed to accurately code the MDS (minimum data set) resident assessment for 3 of 59 residents in the survey sample, Resident #46, #114 and #701. The findings include: 1. The facility staff failed to accurately code Resident #46's (R46) quarterly MDS with an ARD (assessment reference date) of 6/4/2022 for falls sustained at the facility since the previous assessment. On the most recent MDS, a quarterly assessment with an ARD of 6/4/2022, the resident scored 3 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is severely impaired for making daily decisions. Section J1800 documented R46 not having any falls since admission/entry or reentry or prior assessment. Review of the clinical record revealed a list of R46's MDS assessments. The list revealed the prior assessment was an End of PPS Part A Stay with an ARD of 4/21/2022 and a quarterly MDS with an ARD of 4/11/2022. Review of the clinical record for R46 revealed documented falls on 5/5/2022 and 5/21/2022. The progress notes documented in part: 5/5/2022 10:03 (10:03 a.m.) Resident was found on the floor at 0025 (12:25 a.m.) in her room facing the door by her aid, her bed was behind her and wheelchair within 5 ft (feet) to her left. Resident stated that she was going to get some fish. Neuro (neurological) assessment conducted and her vital signs were within normal limits, alert able to answer to her name speech clear and typical, PERRLA (pupils, equal, round, reactive to light and accommodation) and able to move all extremities and grasp. No injuries or complaints of pain or discomfort . 5/21/2022 20:23 (8:23 a.m.) Resident had an unwitnessed fall at 745 pm, resident was self propelling wheelchair in hallway and slid out of chair, resident noted with shoes intact. Resident was assessed with no injuries noted . On 6/15/2022 at 9:44 a.m., an interview was conducted with RN (registered nurse) #1, MDS nurse. RN #1 stated that they used the RAI manual for guidance in completing the MDS assessments. RN #1 stated that they reviewed the look-back period for any falls when completing the MDS assessments. RN #1 stated that they reviewed the clinical record for falls. RN #1 stated that they would review R46's quarterly MDS with the ARD of 6/4/2022 and see if it should have been coded for falls. On 6/15/2022 at 2:03 p.m., RN #1 stated that they had reviewed the quarterly MDS for R46 and that it should have been coded for falls. RN #1 stated that R46 had falls in May of 2022 which should have been reflected on the quarterly MDS with the ARD of 6/4/2022. According to the RAI Manual, Version 1.16, dated October 2018, section J1800 documented in the steps for assessment, .If this is not the first assessment/entry or reentry (A0310E = 0), the review period is from the day after the ARD of the last MDS assessment to the ARD of the current assessment. 3. Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Include medical records generated in any health care setting since last assessment . On 6/15/2022 at 2:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the southside regional clinical coordinator and ASM #4, the regional director of operations were made aware of the findings. No further information was provided prior to exit. 2. The facility staff failed to accurately code Resident #114's (R114) quarterly MDS with an ARD (assessment reference date) of 5/23/2022 for falls sustained at the facility since the previous assessment. On the most recent MDS, a quarterly assessment with an ARD of 5/23/2022, the resident scored 3 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is severely impaired for making daily decisions. Section J1800 documented R114 not having any falls since admission/entry or reentry or prior assessment. Review of the clinical record revealed a list of R114's MDS assessments. The list revealed the prior assessment was an End of PPS Part A Stay MDS with an ARD of 4/18/2022 and an admission assessment with an ARD of 3/1/2022. Review of the clinical record for R114 revealed documented falls on 4/29/2022 and 5/15/2022. The progress notes documented in part: 4/29/2022 18:08 (6:08 p.m.) Resident observe on bedroom via staff. On assessment, patient side lying lateral to bedroom with face down. Resident unable to note events leading up to fall .No injuries notied [sic] at this time . 5/15/2022 21:00 (9:00 p.m.) Approx. (approximately) 1930 (7:30 p.m.), writer was called to residents room by staff, writer observed resident laying on his right side, on the floor, next to bed, last observed 15 minutes prior by writer, resting in low bed quietly, eyes closed, call bell and bedside table within reach, wearing non skid socks and facility gown, clean and dry, resident unable to explain how he fell, related to dementia diagnosis, moves upper extremities without pain, lower extremities contracted unable to move, neurochecks wnl (within normal limits), no new injuries noted, no swelling noted, denies all pain and discomfort . On 6/15/2022 at 9:44 a.m., an interview was conducted with RN (registered nurse) #1, MDS nurse. RN #1 stated that they used the RAI manual for guidance in completing the MDS assessments. RN #1 stated that they reviewed the look-back period for any falls when completing the MDS assessments. RN #1 stated that they reviewed the clinical record for falls. RN #1 stated that they would review R114's quarterly MDS with the ARD of 5/23/2022 and see if it should have been coded for falls. On 6/15/2022 at 2:03 p.m., RN #1 stated that they had reviewed the quarterly MDS for R114 and that it should have been coded for falls. RN #1 stated that R46 had falls between the two MDS assessments which should have been reflected on the quarterly MDS with the ARD of 5/23/2022. On 6/15/2022 at 2:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the southside regional clinical coordinator and ASM #4, the regional director of operations were made aware of the findings. No further information was provided prior to exit. 3. For Resident #701, the facility staff failed to accurately complete the admission MDS for resident and staff interviews of sections C and D. Resident #701 was admitted to the facility on [DATE] and discharged to an assisted living facility on 9/25/21. The admission nursing assessment dated [DATE] documented the resident was alert and oriented to person only. On the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/21/21, the resident was coded as requiring supervision for eating and extensive assistance for all other areas of activities of daily living. On the above MDS, the resident interviews for Section C Cognition and Section D Mood were not attempted nor accurately completed. Each question response was documented with a dash. On 6/15/22 at 10:00 AM an interview was conducted with RN #1 (Registered Nurse) the MDS nurse. She stated that dashes are not encouraged and that resident interviews should be attempted, and if they could not be attempted, then that should have been documented. She stated that the staff member who was responsible for completing these sections was no longer at the facility. When asked what policy does the facility follow for completing the MDS, she stated the RAI manual (Resident Assessment Instrument). Section B Hearing, Speech, and Vision of the above MDS was coded as follows: -Section B 0700 Makes Self Understood (Ability to express ideas and wants, consider both verbal and non-verbal expression. 0. Understood. 1. Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time. 2. Sometimes understood - ability is limited to making concrete requests. 3. Rarely/never understood.) Resident #128 was coded as a 2. -Section B 0800 Ability to Understand Others (Understanding verbal content, however able (with hearing aid or device if used). 0. Understands - clear comprehension. 1. Usually understands - misses some part/intent of message but comprehends most conversation. 2. Sometimes understands - responds adequately to simple, direct communication only. 3. Rarely/never understands.) Resident #128 was coded as a 2. The coding of Section B as Sometimes understood and understands indicated that resident interviews for applicable sections below should have been attempted. Section C Cognitive Patterns was coded as follows: Section C 0100 Should Brief Interview for Mental Status (C0200-C0500) be Conducted? Attempt to conduct interview with all residents. -0. No (resident is rarely/never understood) Skip to and complete C0700-C1000, Staff Assessment for Mental Status. -1. Yes Continue to C0200, Repetition of Three Words. The box for both above responses was filled in with a dash (-). Neither response was selected. As the resident was coded in Section B as being sometimes understood and understands, Section C for a resident interview for cognitive patterns should have been attempted. A review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019 was conducted as follows: Page C-1 documented: Most residents are able to attempt the Brief Interview for Mental Status (BIMS). A structured cognitive test is more accurate and reliable than observation alone for observing cognitive performance. (1) Without an attempted structured cognitive interview, a resident might be mislabeled based on his or her appearance or assumed diagnosis. (2) Structured interviews will efficiently provide insight into the resident's current condition that will enhance good care And on page C-2 was documented: Code 0, no: if the interview should not be conducted because the resident is rarely/never understood; cannot respond verbally, in writing, or using another method; or an interpreter is needed but not available. Skip to C0700, Staff Assessment of Mental Status. Code 1, yes: if the interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. Proceed to C0200, Repetition of Three Words If the resident interview was not conducted within the look-back period (preferably the day before or the day of) the ARD, item C0100 must be coded 1, Yes, and the standard no information code (a dash -) entered in the resident interview items. A Yes was not coded for item C0100 as required by the RAI manual in order to dash out the interview responses. The resident interview was not attempted and item C0100 was not accurately completed. Section D Mood was coded as follows: D0100. Should Resident Mood Interview be Conducted? - Attempt to conduct interview with all residents. 0. No (resident is rarely/never understood) Skip to and complete D0500-D0600, Staff Assessment of Resident Mood. 1. Yes Continue to D0200, Resident Mood Interview. The box for both above responses was filled in with a dash (-). Neither response was selected. As the resident was coded in Section B as being sometimes understood and understands, Section D for a resident interview for mood should have been attempted. A review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019 was conducted as follows: Page D-1 documented: Most residents who are capable of communicating can answer questions about how they feel. Obtaining information about mood directly from the resident, sometimes called hearing the resident's voice, is more reliable and accurate than observation alone for identifying a mood disorder. And on page D-2 was documented: Code 0, no: if the interview should not be conducted because the resident is rarely/never understood or cannot respond verbally, in writing, or using another method, or an interpreter is needed but not available. Skip to item D0500, Staff Assessment of Resident Mood. Code 1, yes: if the resident interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. Continue to item D0200, Resident Mood Interview. And on page D-3 was documented: If the resident interview was not conducted within the look-back period (preferably the day before or the day of) the ARD, item D0100 must be coded 1, Yes, and the standard no information code (a dash -) entered in the resident interview items. A Yes was not coded for item D0100 as required by the RAI manual in order to dash out the interview responses. The resident interview was not attempted and item D0100 was not accurately completed. On 6/15/22 at approximately 4:00 PM, ASM #1 (Administrative Staff Member), the Administrator, ASM #2, the Director of Nursing, and ASM #4, the Regional Director of Operations were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate level I PASRR (preadmission screening and resident review) to determine if a level 2 PASRR was required for one of 59 residents in the survey sample, Resident #19. The facility staff failed to entirely complete section 2 of Resident #19's (R19) PASRR and inaccurately documented the resident as not having a serious mental illness. The findings include: On the most recent MDS (minimum data set), a five day Medicare assessment with an ARD (assessment reference date) of 4/18/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), which indicated the resident was not cognitively impaired for making daily decisions. R19's diagnoses included bipolar disorder (1), borderline personality disorder (2) and dissociative identity disorder (3). R19's level 1 PASRR, completed on 9/14/21 documented, 2. DOES THE INDIVIDUAL HAVE A CURRENT SERIOUS MENTAL ILLNESS (MI)? No was circled. 2.a. Is this major mental disorder diagnosable under DSM (Diagnostic and Statistical Manual of Mental Disorders) (e.g. schizophrenia, mood, paranoid, panic, or other serious anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or other mental disorder that may lead to a chronic disability)? Neither yes nor no was circled. The employee who completed R19's PASRR was not available for interview during the survey. On 6/14/22 at 9:03 a.m., an interview was conducted with OSM (other staff member) #1 (the social worker). OSM #1 stated the admissions department completes PASRRs but she has completed them and is familiar with the process. OSM #1 stated PASRRs are completed based on residents' medical records. OSM #1 stated she knew R19 had some psychiatric diagnoses including bipolar disorder and borderline personality disorder. OSM #1 reviewed R19's PASRR and stated the PASRR was not accurate and one wouldn't know if a level 2 PASRR was needed if the level 1 is not accurate. On 6/15/22 at 11:35 a.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing), ASM #3 (the regional clinical coordinator) and ASM #4 (the regional director of operations) were made aware of the above concern. On 6/15/22 at 6:20 p.m., ASM #1 and ASM #2 stated the facility did not have a policy regarding PASRRs. No further information was presented prior to exit. References: (1) Bipolar disorder is a mood disorder that can cause intense mood swings. This information was obtained from the website: https://medlineplus.gov/bipolardisorder.html (2) Borderline personality disorder (BPD) is a mental condition in which a person has long-term patterns of unstable or turbulent emotions. These inner experiences often result in impulsive actions and chaotic relationships with other people. This information was obtained from the website: https://medlineplus.gov/ency/article/000935.htm (3) Dissociative identity disorder. Formerly known as multiple personality disorder, this disorder is characterized by 'switching' to alternate identities. You may feel the presence of two or more people talking or living inside your head, and you may feel as though you're possessed by other identities. This information was obtained from the website: https://www.mayoclinic.org/diseases-conditions/dissociative-disorders/symptoms-causes/syc-20355215?p=1

Based on observation, resident interview, staff interview, clinical record review, facility document review and in the course of a complaint investigation it was determined that the facility staff failed to provide care and services to promote healing of a pressure ulcer for one of 59 residents in the survey sample, Resident #87. The findings include: The facility staff failed to evidence a treatment to the Stage 4 pressure ulcer between 1/7/2022-1/9/2022 and 1/11/2022-1/17/2022 for Resident #87 (R87). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/12/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was not cognitively impaired for making daily decisions. Section M documented R87 having 1 Stage 4 pressure ulcer and 1 Stage 3 pressure ulcer. On 6/14/2022 at 8:25 a.m., an interview was conducted with R87 in their room. R87 stated that the nurses had been in earlier that morning to change their wound dressing and had gotten better about doing the wound care as ordered. R87 stated that they had problems in the past with getting the wound dressing changed and their family had complained to the nurses about it. A request was made to ASM (administrative staff member) #2, the director of nursing, to observe wound care for R87 on 6/14/2022 at approximately 8:00 a.m. On 6/14/2022 at approximately 9:30 a.m., ASM #2 stated that R87's wound care had been completed for the day and they would arrange the observation for 6/15/2022. On 6/15/2022 at approximately 10:15 a.m., LPN (licensed practical nurse) #2, the wound nurse was observed performing wound care on another resident. LPN #2 stated that the assigned nurse for R87 had already completed the wound care that morning and it could not be observed. The physician orders reviewed from 1/1/2022 through 1/31/2022 documented in part; - Wound care: Sacral wound- clean with NS (normal saline)- apply flagyl and pack with 1/4 Dakins moistened gauze QD (every day) and PRN (as needed) - apply dry dressing every evening shift for wound related to pressure ulcer of sacral region unspecified stage. Order date: 12/14/2021. Start Date: 12/14/2021. End Date: 01/07/2022. - Wound care: Sacral wound- clean with 1/4 Dakins solution- pack with Silver Calcium Alginate QD (every day) and PRN (as needed)- cover with dry dressing. Order Date: 01/07/2022, End Date: 01/17/2022 . The order failed to evidence a start date. - Wound care: Sacral wound- clean with 1/4 Dakins solution- pack with Silver Calcium alginate QD and PRN- cover with Dry dressing in the morning for wound care. Order Date: 01/17/2022. Start Date: 01/18/2022. End Date: 01/18/2022. The eTAR (electronic treatment administration record) for R87 dated 1/1/2022-1/31/2022 failed to evidence documentation of a treatment provided to the sacral wound 1/7/2022 through 1/17/2022. The progress notes documented in part, - 1/10/2022 22:38 (10:38 p.m.) Note Text: Sacral wound care provided during shift. Yellow/reddish discharge noted. Foul odor noted. No c/o pain/discomfort while providing wound care. Pain meds offered, declined per resident. The progress notes failed to evidence documentation of treatment to the sacral wound 1/7/2022-1/9/2022 and 1/11/2022-1/17/2022. The wound evaluation & management summary dated 1/7/2022 documented in part, Stage 4 pressure wound sacrum full thickness .Wound progress: deteriorated, Additional wound detail: larger, d/c dakins packing, start Silver Alginate, dressing treatment plan, primary dressing(s), Sodium hypochlorite solution (dakins) apply once daily for 30 days: clean with 1/4 dakins solution; Alginate calcium w/silver apply once daily for 30 days. secondary dressing(s), gauze island (w/bdr) (with border) apply once daily for 30 days . The wound evaluation & management summary dated 1/14/2022 documented in part, Stage 4 pressure wound sacrum full thickness .Wound progress: improved, Additional wound detail: smaller, dressing treatment plan, primary dressing(s), Sodium hypochlorite solution (dakins) apply once daily for 23 days: clean with 1/4 dakins solution; Alginate calcium w/silver apply once daily for 23 days. secondary dressing(s), gauze island (w/bdr) apply once daily for 23 days . The wound evaluation & management summary dated 1/28/2022 documented in part, Stage 4 pressure wound sacrum full thickness .Wound progress: improved, Additional wound detail: shorter, no longer with exposed bone, dressing treatment plan, primary dressing(s), Sodium hypochlorite solution (dakins) apply once daily for 9 days: clean with 1/4 dakins solution; Alginate calcium w/silver apply once daily for 9 days. secondary dressing(s), gauze island (w/bdr) apply once daily for 9 days . The comprehensive care plan for R87 documented in part, Skin #2: [R87] has pressure ulcers to sacrum and right thigh. Stage 4, Being followed by wound doctor. Date Initiated: 07/17/2019. Revision on: 06/14/2022 . On 6/15/2022 at 9:56 a.m., a telephone interview was conducted with ASM (administrative staff member) #7, the wound physician. ASM #7 stated that R87 had a sacral wound they had been following for 956 days. ASM #7 stated that R87's wound was slow to heal due to medical comorbidities and noncompliance with offloading and turning and positioning. ASM #7 stated that there was a zinc barrier cream ordered for the skin around the wound but was not the primary treatment for the pressure ulcer. ASM #7 stated that there should be a continuous treatment in place for the Stage 4 pressure wound treatment. On 6/15/2022 at 10:54 a.m., an interview was conducted with LPN (licensed practical nurse) #3, unit manager. LPN #3 stated that treatments were evidenced as completed by documenting them on the eTAR. LPN #3 stated that if there was no documentation there was no evidence to support that anything was done. LPN #3 they were always taught that if it was not documented it was not done. LPN #3 reviewed the eTAR for R87 dated 1/1/2022-1/31/2022 and stated that they did not see any evidence that there was a treatment in place for the sacral pressure ulcer between 1/7/2022-1/17/2022. On 6/15/2022 at 1:29 p.m., an interview was conducted with LPN #2, the wound nurse. LPN #2 stated that they were new to the wound nurse position. LPN #2 stated that R87's pressure ulcer was slow to heal due to non-compliance with offloading and turning and positioning off of the wound. LPN #2 stated that they round with the wound doctor and make any changes to treatment orders as needed when the physician rounds. LPN #2 reviewed the physician orders and the eTAR for R87 dated 1/1/2022-1/31/2022 and stated that they did not see any evidence of a treatment in place for the pressure ulcer from 1/7/2022-1/17/2022. LPN #2 stated that R87 had the pressure ulcer during that time and there should have been a treatment in place. The facility policy, Skin Management dated 5/1/2010 documented in part, .Guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing . On 6/15/2022 at approximately 4:05 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the southside regional clinical coordinator and ASM #4, the regional director of operations were notified of the findings. No further information was provided prior to exit. Complaint deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to provide respiratory therapy as ordered for Resident #61. Resident #61 was observed with oxygen via nasal cannula at 3 liters per minute on 6/13/22 at 1:09 PM, 6/14/22 at 9:00 AM and 6/14/22 at 2:50 PM. Resident #61 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: COPD (chronic obstructive pulmonary disease). Resident #61's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/22/22, coded the resident as scoring 7 out of 15 on the BIMS (brief interview for mental status score), indicating the resident was severely cognitively impaired. Resident #61's care plan dated 4/24/21 with no revision date, revealed the following, Need: Resident has a potential for difficulty breathing and risk for respiratory complications related to: COPD. Interventions: Elevate head of bed, encourage cough & deep breathing, Oxygen as ordered via nasal cannula every shift for SOB (shortness of breath), COPD oxygen per order. A review of the physician's orders dated 4/4/22, revealed the following, Oxygen 2l/min via nasal cannula for SOB. every shift for SOB. Resident #61 was observed with oxygen via nasal cannula at 3 liters per minute on 6/13/22 at 1:09 PM, 6/14/22 at 9:00 AM and 6/14/22 at 2:50 PM. The oxygen concentrator is the Invacare Perfecto2. Resident #61 wa unable to be interviewed due to cognitive impairment. On 6/14/22 at 2:55 PM, LPN (licensed practical nurse) #3 was asked to observe the oxygen setting on Resident #61. An interview was conducted on 6/14/22 at 3:00 PM with LPN #3. When asked the oxygen setting observed, LPN #3 stated, it is set on 3 liters nasal cannula. I need to check the order. When asked how she read the level at 3 liters, LPN #3 stated, you read the number where the center of the ball is located. LPN #3 checked the order in the medical record and stated, the order is for 2 liters nasal cannula. I will go change it now. When asked if the oxygen being set at 3 liters nasal cannula, indicated that the oxygen was being monitored for correct therapy, LPN #3 stated, No, it is not. On 6/14/22 at 4:20 PM, ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional clinical coordinator were informed of the above concern. According to the instruction manual for the Invacare Perfecto2 oxygen concentrator, To properly read the flowmeter, locate the prescribed flowrate line on the flowmeter. Next, turn the flow know until the ball rises to the line. Now center the ball on the liters per minute line prescribed. According to the facility's Physician orders policy dated 6/24/21, which revealed the following, Treatment rendered to a guest/resident must be in accordance with the specific standing, written, verbal, or telephone order of a physician or other licensed health professional ordering within their scope of practice and clinical privileges. No further information was provided prior to exit. Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care and services for 3 of 59 residents in the survey sample, Residents #289, #94 and #61. The findings include: 1. The facility staff failed to store Resident # 289's (R289) nasal cannula (1) in a sanitary manner. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 06/05/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded (R289) for Oxygen Therapy while a resident. On 06/13/22 at approximately 1:09 p.m., an observation of (R289's) nasal cannula was observed hanging over the partially open drawer of the bedside dresser uncovered. On 06/14/22 at approximately 3:10 p.m., an observation of (R289's) nasal cannula was observed hanging over the partially open drawer of the bedside dresser uncovered. The physician's order for (R289) documented in part, Oxygen 2l/min (two liters per minute) via (by) nasal cannula as needed for SOB (shortness of breath). Order Date: 5/31/2022. Start Date: 06/03/2022. On 06/15/22 at approximately 8:06 a.m., an interview was conducted with LPN (licensed practical nurse) #7. When asked to describe the procedure for storing a resident's nasal cannula when it was not in use LPN #7 stated it should be wrapped up and placed inside a bag for infection control purposes. When informed of the observations described above LPN #7 stated that the nasal cannula should not have been stored that way. The facility's policy Use of Oxygen documented in part, III. The O2 cannula or mask, when not in use, should be stored in a clean bag. Bag should be changed weekly. On 06/15/2022 at approximately 11:35 a.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, ASM #4, regional director of operations. No further information was presented prior to exit. References: (1) Tubing used to deliver oxygen at levels from 1 to 6 L/min. The nasal prongs of the cannula extend approx. 1 cm into each naris and are connected to a common tube, which is then connected to the oxygen source. This information was obtained from the website: http://medical-dictionary.thefreedictionary.com/nasal+cannula. 2. For Resident #94 the facility staff failed to administer oxygen at the physician ordered rate. Resident #94 was admitted to the facility on [DATE]. On the most recent MDS (Minimum Data Set) an annual assessment with an ARD (Assessment Reference Date) of 5/10/22, Resident #94 scored an 11 out of a possible 15 on the BIMS (brief interview for mental status) indicating the resident was moderately impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living, except for eating which only required supervision. A review of the clinical record revealed a physician's order dated 1/25/22 for oxygen at 3 liters per minute continuously. On 6/13/22 at 1:13 PM and 6/14/22 at 9:04 AM, Resident #94 was observed in bed with oxygen on. The flow meter reflected an oxygen rate of 1.5 liters per minute as evidenced by the line for the 1.5 liter mark crossing through the middle of the flow meter ball. On 6/14/22 at 3:00 PM, an interview was conducted with LPN #4 (Licensed Practical Nurse). She stated that the resident's oxygen rate should be 3 liters per minute. When asked if the rate was set at 1.5 liters, was the oxygen being administered as ordered, she stated that it was not. A review of the comprehensive care plan revealed one dated 10/10/20 for [Resident #94] has a potential for difficulty breathing and risk for respiratory complications . This care plan included the intervention, dated 3/15/21 for Administer medication and treatments per physician orders oxygen per order . The facility policy, Use of Oxygen was reviewed. This policy did not document anything about verifying physician's orders for the use of and rate of oxygen. On 6/15/22 at approximately 4:00 PM, ASM #1 (Administrative Staff Member), the Administrator, ASM #2, the Director of Nursing, and ASM #4, the Regional Director of Operations were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview and employee record review, it was determined the facility staff failed to complete annual performance/competency reviews for two of five CNA (certified nursing assistant), CNA #7 and CNA #8. The findings include: Five CNA employee records were reviewed for their annual performance/competency reviews. On 6/13/2022 at approximately 5:00 p.m. a request was made for the annual performance/competency reviews completed on CNA #7 and CNA #8. CNA #7 was hired on 9/2/2020 and CNA #8 was hired on 3/17/2021. A second request for the annual performance/competency reviews was made on 6/15/2022 at approximately 10:30 a.m. At the end of the day meeting on 6/15/2022 at 2:34 p.m. A third request was made for the performance/competency reviews for CNA #7 and CNA #8. At that time ASM (administrative staff member) #1, the administrator, stated the facility did not have the annual performance/competency reviews for CNA #7 and CNA #8. An interview was conducted on 6/15/2022 at 2:45 p.m. with ASM #4, the regional director of operations. When asked the process for CNAs to get their annual performance/competency reviews, ASM #4 stated the payroll employee tracks who is due and gives the list to the department manager. ASM #4 stated the DON (director of nursing) has only been in the position for two months as well as the payroll employee. A policy on annual performance/competency reviews was requested on 6/15/2022 at approximately 4:00 p.m. ASM #1, ASM #2, the director of nursing, ASM #3, the regional clinical coordinator, and ASM #4, the regional director of operations, were made aware of the above concern on 6/15/2022 at 4:18 p.m. On 6/15/2022 at 6:20 p.m. ASM #1 and ASM #2, the director of nursing, informed the surveyors the facility did not have a policy on annual performance/competency reviews. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a medication error rate of less than 5%. The facility medication error rate was 10.71%, having made 3 identified medication errors out of 28 opportunities. The errors were for 2 of 3 residents in the Medication Administration task; Residents #14 and #96. The findings include: 1. For Resident #14, the facility staff failed to ensure the resident was free of medication errors. Resident #14 was admitted to the facility on [DATE]. On the annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 3/11/22, Resident #14 scored a 15 out of a possible 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact in ability to make daily life decisions. A review of the facility policy, Medication Administration was conducted. This policy documented, Medications are administered in accordance with written orders of the attending physician. On 6/14/22 at 8:17 AM, LPN #5 (Licensed Practical Nurse) was observed to prepare and administer the following medications for Resident #14: Methimazole (1) 5 mg (milligrams), 1 tab. Buspar (2) 10 mg, 1 tab Aspirin (3) 81 mg, 1 tab Magnesium Oxide (4) 400 mg, 1 tab On 6/14/22 at 11:16 AM, reconciliation of the medications was conducted compared with the physician's orders. An order dated 9/8/21 for a lidocaine 4% patch (5) to the left knee every morning was noted. It was noted that LPN #5 signed out for a lidocaine patch to left knee as being administered when it had not been administered. On 6/14/22 at 12:40 PM an interview was conducted with Resident #14. When asked if they received their pain patch on their knee this morning, they stated that they did not. On 6/14/22 at 12:40 PM an interview was attempted with LPN #5 regarding the missed medication. He refused to answer any questions, denied doing anything wrong and walked away from the surveyor. On 6/14/22 at 12:45 PM the above concern was reported to ASM #1 (Administrative Staff Member) the Administrator and ASM #4, the Regional Director of Operations. On 6/14/22 at 3:00 PM, an interview was conducted with LPN #4 (Licensed Practical Nurse) in regard to medication administration. LPN #4 stated that staff should not sign out for medications that were not given. A review of the comprehensive care plan revealed one dated 3/23/21 for [Resident #14] is at risk for constipation R/T (related to): decreased mobility, medications side effects. This care plan included the intervention, dated 3/23/21 for Administer medications as ordered and observe for ineffectiveness/side effects. Report abnormal findings to the physician. On 6/15/22 at approximately 4:00 PM, ASM #1 (Administrative Staff Member), the Administrator, ASM #2, the Director of Nursing, and ASM #4, the Regional Director of Operations were made aware of the findings. No further information was provided by the end of the survey. References: (1) Methimazole - is used to treat hyperthyroidism Information obtained from https://medlineplus.gov/druginfo/meds/a682464.html (2) Buspar - is used to treat anxiety Information obtained from https://medlineplus.gov/druginfo/meds/a688005.html (3) Aspirin - is used to treat pain, fever, prevent heart attacks and strokes Information obtained from https://medlineplus.gov/druginfo/meds/a682878.html (4) Magnesium Oxide - is used to treat indigestion Information obtained from https://medlineplus.gov/druginfo/meds/a601074.html (5) Lidocaine - is used to treat pain Information obtained from https://medlineplus.gov/druginfo/meds/a603026.html 2. For Resident #96, the facility staff failed to ensure the resident was free of medication errors. Resident #96 was admitted to the facility on [DATE]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/11/22, Resident #96 scored a 13 out of a possible 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact in ability to make daily life decisions. The resident was coded as supervision for eating and extensive to total care for other areas of activities of daily living. A review of the facility policy, Medication Administration was conducted. This policy documented, Medications are administered in accordance with written orders of the attending physician. On 6/14/22 at 8:28 AM, LPN #5 (Licensed Practical Nurse) was observed to prepare and administer the following medications for Resident #96: Dulera (1) 100 mcg (micrograms) / 5 mcg inhaler Aspirin (2) 325 mg (milligrams), 1 tab Vitamin D3 (3) 25 mcg, 1 tab Colace (4) 100 mg, 1 tab Glipizide (5) 5 mg, 1 tab Genvoya (6) 150 mg/150 mg/200 mg/10 mg, 1 tab Risperdone (7) 0.5 mg, 1 tab Prednisone (8) 10 mg, 1 tab Senna (9) 8.6 mg, 1 tab Acetaminophen (10) 325 mg, 1 tab Spiriva (11) 18 mcg On 6/14/22 at 11:15 AM, reconciliation of the medications was conducted compared with the physician's orders. An order dated 6/30/21 for Alaway (12) eye drops and an order dated 1/18/21 for Pepcid (13) were noted. It was noted that LPN #5 signed out these medications as being administered when they had not been administered. On 6/14/22 at 12:40 PM an interview was attempted with LPN #5 regarding the missed medication. He refused to answer any questions and denied doing anything wrong and walked away from the surveyor. On 6/14/22 at 12:45 PM the above concern was reported to ASM #1 (Administrative Staff Member) the Administrator and ASM #4, the Regional Director of Operations. On 6/14/22 at 3:00 PM, an interview was conducted with LPN #4 (Licensed Practical Nurse) regarding medication administration. She stated that staff should not sign out for medications that were not given. A review of the comprehensive care plan revealed one dated 5/12/21 for [Resident #96] is at risk for abnormal bleeding/bruising R/T (related to): medication use . This care plan included an intervention dated 5/12/21 for Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician. Another care plan, dated 7/22/21 was for [Resident #96] is at risk for constipation R/T: decreased mobility, diminished appetite, Hx (history) of constipation, medications side effects. This care plan included the intervention, dated 7/22/21 for Administer medications as ordered and observe for ineffectiveness/side effects. Report abnormal findings to the physician. On 6/15/22 at approximately 4:00 PM, ASM #1 (Administrative Staff Member), the Administrator, ASM #2, the Director of Nursing, and ASM #4, the Regional Director of Operations were made aware of the findings. No further information was provided by the end of the survey. References: (1) Dulera is used to treat asthma and COPD Information obtained from https://medlineplus.gov/druginfo/meds/a602023.html and from https://medlineplus.gov/druginfo/meds/a608035.html (2) Aspirin - is used to treat pain, fever, prevent heart attacks and strokes Information obtained from https://medlineplus.gov/druginfo/meds/a682878.html (3) Vitamin D3 is used to treat Vitamin D deficiency and to improve absorption of calcium Information obtained from https://medlineplus.gov/druginfo/meds/a620058.html (4) Colace is used for the treatment of constipation Information obtained from https://medlineplus.gov/druginfo/meds/a601113.html (5) Glipizide is used for the treatment of diabetes Information obtained from https://medlineplus.gov/druginfo/meds/a684060.html (6) Genvoya is used for the treatment of HIV Information obtained from https://medlineplus.gov/druginfo/meds/a612035.html (7) Risperdone is used to treat symptoms of schizophrenia, bipolar, and behavior. Information obtained from https://medlineplus.gov/druginfo/meds/a694015.html (8) Prednisone is used to reduce swelling and redness Information obtained from https://medlineplus.gov/druginfo/meds/a601102.html (9) Senna is used for the treatment of constipation Information obtained from https://medlineplus.gov/druginfo/natural/652.html (10) Acetaminophen is used to treat mild to moderate pain Information obtained from https://medlineplus.gov/druginfo/meds/a681004.html (11) Spiriva is used for the treatment of COPD Information obtained from https://medlineplus.gov/druginfo/meds/a604018.html (12) Alaway is used for the treatment of allergy symptoms of the eyes Information obtained from https://medlineplus.gov/druginfo/meds/a604033.html (13) Pepcid is used for the treatment of reflux and ulcers Information obtained from https://medlineplus.gov/druginfo/meds/a687011.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to ensure medication was stored in a safe and secure manner on one of 3 facility nursing units; the [NAME] unit. The findings include: During medication administration on the [NAME] unit, LPN #5 left a bottle of Folic Acid on top of the medication cart while in Resident #96's room, with the cart out of line of sight. Resident #96 was admitted to the facility on [DATE]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/11/22, Resident #96 scored a 13 out of a possible 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact in ability to make daily life decisions. On 6/14/22 at 8:28 AM, LPN #5 (Licensed Practical Nurse) was observed preparing medications on the [NAME] unit. A CNA (Certified Nursing Assistant) came and reported to LPN #5 that Resident #96 was asking for their inhaler. LPN #5 then began to prepare medications for Resident #96, by first pulling the resident's Dulera (1) and taking it to the resident. It was noted that while LPN #5 was in the room of Resident #96, a bottle of Folic Acid (2) was left on top of the medication cart, with the cart out of the line of sight of LPN #5 while he was in Resident #96's room. A staff member was observed to pass by the cart with the unsupervised medication on top. On 6/14/22 at 12:40 PM an interview was attempted with LPN #5 regarding the storage of medication. He refused to answer any questions, denied doing anything wrong and walked away from the surveyor. On 6/14/22 at 12:45 PM the above concern was reported to ASM #1 (Administrative Staff Member) the Administrator and ASM #4, the Regional Director of Operations. On 6/14/22 at 3:00 PM, an interview was conducted with LPN #4 (Licensed Practical Nurse). She stated that staff should not leave a medication cart unlocked and medications on top of it when the cart is unsupervised. The facility policy, Medication Administration was reviewed. This policy documented, Make sure that the medication cart is locked at all times when it is not in use or not within your constant vision. Store the locked medication cart in the appropriate storage area between med passes. The policy did not address not leaving medications out on top of the cart, unsupervised. On 6/15/22 at approximately 4:00 PM, ASM #1 (Administrative Staff Member), the Administrator, ASM #2, the Director of Nursing, and ASM #4, the Regional Director of Operations were made aware of the findings. No further information was provided by the end of the survey. References: (1) Dulera is used to treat asthma and COPD Information obtained from https://medlineplus.gov/druginfo/meds/a602023.html and from https://medlineplus.gov/druginfo/meds/a608035.html (2) Folic Acid is used to help the body make healthy new cells. Information obtained from https://medlineplus.gov/folicacid.html

Based on staff interview and employee record review, it was determined the facility staff failed to ensure two of five CNAs had their annual training in dementia and abuse, CNA #7 and CNA #8. The findings include: Five CNA employee records were reviewed for documentation of their annual training in abuse and dementia. On 6/13/2022 at approximately 5:00 p.m. a request was made for the annual training in abuse and dementia for CNA #7 and CNA #8. CNA #7 was hired on 9/2/2020 and CNA #8 was hired on 3/17/2021. A second request for documentation for the annual training in abuse and dementia for CNA #7 and CNA #8 was made on 6/15/2022 at approximately 10:30 a.m. At the end of the day meeting on 6/15/2022 at 2:34 p.m. A third request was made for the documentation of annual abuse and dementia training for CNA #7 and CNA #8. At this time ASM (administrative staff member) #1, the administrator, stated the facility did not have evidence of annual training in abuse and dementia for CNA #7 and CNA #8. An interview was conducted with LPN (licensed practical nurse) #8, the assistant director of nursing, on 6/15/2022 at 3:20 p.m. When asked the process for ensuring the staff receive their annual required educations, LPN #8 stated she had just started two days ago. Her understanding is that the facility goes through in-services. Every staff member just have abuse and dementia training. LPN #8 stated she is developing a calendar for educations. LPN #8 stated the facility also has an on-line education program where the staff are assigned educations that are due monthly. LPN #8 stated the abuse and dementia training is included in the on-line education program. When asked to provide documentation for CNA #7 and CNA #8's education for abuse and dementia. LPN #8 returned at 3:27 p.m. and stated they had looked at the on-line training for both of the CNAs and didn't find the documentation trainings. ASM #1, ASM #2, the director of nursing, ASM #3, the regional clinical coordinator, and ASM #4, the regional director of operations, were made aware of the above concern on 6/15/2022 at 4:18 p.m. A request was made for a policy regarding mandatory annual training at this time. On 6/15/2022 at 6:20 p.m. ASM #1 and ASM #2, the director of nursing, informed the surveyors the facility did not have a policy on annual mandatory trainings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to provide Resident #114 (R114) or R114's representative information on or an opportunity to formulate an advanced directive. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/23/2022, the resident scored 3 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is severely impaired for making daily decisions. Review of R114's clinical record failed to evidence documentation of advanced directive review or information on advanced directives provided to the responsible party. Review of the care plan meeting minutes dated 2/28/2022 and 3/8/2022 failed to evidence review of advanced directives. Review of the social service history evaluation dated 3/1/2022 failed to evidence review of advanced directives. On 6/14/2022 at approximately 8:00 a.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of information provided or an opportunity to formulate an advanced directive for R114. On 6/15/22 at 12:21 p.m., an interview was conducted with OSM (other staff member) #1, social worker. OSM #1 stated advance directives are reviewed with residents and/or their representatives by the admissions department upon admission to the facility. OSM #1 stated a review of resident's code status was periodically conducted during care plan meetings and sometimes other aspects of advance directives are reviewed. OSM #1 stated a review of advance directives may be checked off on care plan meeting minutes but she was not sure how a review could be evidenced if it was not documented or checked off. On 6/15/22 at approximately 2:00 p.m., an interview was conducted with OSM #10, the admissions coordinator. OSM #10 stated residents and/or their representatives fill out an advance directive notification/acknowledgment form upon admission and this form is included in the admission contract. OSM #10 stated the admission contract was sent to the business office and then sent to the medical records department after the admissions department was done with the contract. OSM #10 stated administrative staff were looking for the requested advance directive notification/acknowledgment forms. On 6/15/2022 at approximately 4:48 p.m., ASM (administrative staff member) #1, the administrator, was made aware of the findings. ADM #1 stated that they did not have any evidence of advance directive information provided or reviewed for R114 to provide. No further information was presented prior to exit. 4. The facility staff failed to offer Resident #16 (R16) information on or an opportunity to formulate an advanced directive. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/14/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is not cognitively impaired for making daily decisions. On 6/13/2022 at approximately 2:15 p.m., an interview was conducted with R16 in their room. When asked about advanced directive information, R16 stated that they did not recall receiving any information from anyone regarding advanced directives when they were admitted to the facility about 3 months ago. Review of R16's clinical record failed to evidence documentation of advanced directive review or information on advanced directives provided. Review of the care plan meeting minutes dated 3/22/2022 failed to evidence review of advanced directives. Review of the social service history evaluation dated 3/10/2022 failed to evidence review of advanced directives. On 6/14/2022 at approximately 8:00 a.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of information provided or an opportunity to formulate an advanced directive for R16. On 6/15/22 at 12:21 p.m., an interview was conducted with OSM (other staff member) #1, social worker. OSM #1 stated advance directives are reviewed with residents and/or their representatives by the admissions department upon admission to the facility. OSM #1 stated a review of resident's code status was periodically conducted during care plan meetings and sometimes other aspects of advance directives are reviewed. OSM #1 stated a review of advance directives may be checked off on care plan meeting minutes but she was not sure how a review could be evidenced if it was not documented or checked off. On 6/15/22 at approximately 2:00 p.m., an interview was conducted with OSM #10, the admissions coordinator. OSM #10 stated residents and/or their representatives fill out an advance directive notification/acknowledgment form upon admission and this form is included in the admission contract. OSM #10 stated the admission contract was sent to the business office and then sent to the medical records department after the admissions department was done with the contract. OSM #10 stated administrative staff were looking for the requested advance directive notification/acknowledgment forms. On 6/15/2022 at approximately 4:48 p.m., ASM (administrative staff member) #1, the administrator was made aware of the findings. ASM #1 stated that they did not have any evidence of advance directive information provided or review for R16 to provide. No further information was presented prior to exit. Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to evidence that residents and/or their RR (resident representative) were provided with written information and provided the opportunity to formulate advance directives at the time of admission and/or conduct a periodic review with the residents and/or their RRs if they wish to formulate one, or, if applicable, make changes to their existing advance directives or maintain them as written for 5 of 59 residents in the survey sample, Residents #90, #78, #114, #16, and #58. The findings include: 1. The facility staff failed to provide Resident #90 (R90) or the RR written information and the opportunity to formulate advance directives (1) upon admission, and failed to conduct a periodic review of advance directives in 2021 and 2022. R90 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 2/14/22, the resident scored 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. A review of R90's clinical record failed to reveal the resident and/or RR was provided with written information and provided the opportunity to formulate advance directives at the time of admission. Further review of R90's clinical record (to include social services notes, evaluations and care conference minutes for 2021 and 2022) failed to reveal evidence that the facility staff conducted a periodic review of all aspects of advance directives with R90 or the RR (excluding resuscitation status) during 2021 or 2022. On 6/15/22 at 12:21 p.m., an interview was conducted with OSM (other staff member) #1, the social worker. OSM #1 stated advance directives are reviewed with residents and/or their RRs by the admissions department upon admission to the facility. OSM #1 stated a review of residents' code (resuscitation) status is periodically conducted during care plan meetings and sometimes other aspects of advance directives are reviewed. OSM #1 stated a review of advance directives might be checked off on care plan meeting minutes but she wasn't sure how a review could be evidenced if it was not documented or checked off. On 6/15/22 at approximately 2:00 p.m., an interview was conducted with OSM (other staff member) #10, the admissions coordinator. OSM #10 stated residents and/or their RRs fill out an advance directive notification/acknowledgment form upon admission and this form is included in the admission contract. OSM #10 stated the admission contract is sent to the business office then sent to the medical records department after the admissions department is done with the contract. OSM #10 stated administrative staff were looking for requested advance directive notification/acknowledgment forms. On 6/15/22 at 2:32 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing), ASM #3 (the regional clinical coordinator) and ASM #4 (the regional director of operations) were made aware of the above concern. The facility policy titled, Federal & State- Guest/Resident Rights & Facility Responsibilities documented, 12. Advance Directives. The facility must comply with the requirements specified in 42 CFR (code of federal regulations) part 489, subpart I (Advance Directives) .i. These requirements include provisions to inform and provide written information to all adult guests/residents concerning the right to accept or refuse medical or surgical treatment and, at the guest's/resident's option, formulate an advance directive .iv. If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law . The facility policy titled, Code Status documented, 7. Review and Discussion of Advance Directives. i. Advance Directives and Code Status shall be reviewed with the resident, or the Patient Advocate/Health Care Representative (if properly invoked), or the Guardian/Conservator, or the patient surrogate (if the resident is terminally ill/permanently unconscious) at least once per year and documented in the medical record by Social Services . No further information was presented prior to exit. Reference: (1) What kind of medical care would you want if you were too ill or hurt to express your wishes? Advance directives are legal documents that allow you to spell out your decisions about end-of-life care ahead of time. They give you a way to tell your wishes to family, friends, and health care professionals and to avoid confusion later on. A living will tells which treatments you want if you are dying or permanently unconscious. You can accept or refuse medical care. You might want to include instructions on ·The use of dialysis and breathing machines ·If you want to be resuscitated if your breathing or heartbeat stops ·Tube feeding ·Organ or tissue donation A durable power of attorney for health care is a document that names your health care proxy. Your proxy is someone you trust to make health decisions for you if you are unable to do so. This information was obtained from the website: https://medlineplus.gov/advancedirectives.html 2. The facility staff failed to conduct a periodic review of advance directives with Resident #78 (R78) or the RR (resident representative) in 2021 and 2022. Resident #78 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 5/4/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. A review of R78's clinical record (including social services notes, evaluations and care conference minutes for 2021 and 2022) failed to reveal evidence that the facility staff conducted a periodic review of all aspects of advance directives with R78 or the RR (excluding resuscitation status) during 2021 or 2022. On 6/15/22 at 10:20 a.m., an interview was conducted with R78. The resident stated staff had not discussed advance directives with the resident. On 6/15/22 at 12:21 p.m., an interview was conducted with OSM (other staff member) #1 (the social worker). OSM #1 stated advance directives are reviewed with residents and/or their RRs by the admissions department upon admission to the facility. OSM #1 stated a review of residents' code (resuscitation) status is periodically conducted during care plan meetings and sometimes other aspects of advance directives are reviewed. OSM #1 stated a review of advance directives might be checked off on care plan meeting minutes but she wasn't sure how a review could be evidenced if it was not documented or checked off. On 6/15/22 at 2:32 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing), ASM #3 (the regional clinical coordinator) and ASM #4 (the regional director of operations) were made aware of the above concern. No further information was presented prior to exit. 5. The facility staff failed to obtain or discuss an advance directive upon admission for Resident # 58 (R58). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 04/17/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. A review of (R58's) clinical record failed to evidence an advance directive or discussion of an advance directive. The comprehensive care plan for (R58) dated 04/13/2022 failed to evidence documentation of an advance directive. The current physician's order sheet dated April 2022 documented, Code Status: Do Not Resuscitate. On 6/15/22 at 12:21 p.m., an interview was conducted with OSM (other staff member) #1, social worker. OSM #1 stated advance directives are reviewed with residents and/or their representatives by the admissions department upon admission to the facility. OSM #1 stated a review of residents' code status is periodically conducted during care plan meetings and sometimes other aspects of advance directives are reviewed. OSM #1 stated a review of advance directives might be checked off on care plan meeting minutes but she wasn't sure how a review could be evidenced if it was not documented or checked off. On 6/15/22 at approximately 2:00 p.m., an interview was conducted with OSM #10, admissions coordinator. OSM #10 stated residents and/or their representatives fill out an advance directive notification/acknowledgment form upon admission and this form is included in the admission contract. OSM #10 stated the admission contract is sent to the business office then sent to the medical records department after the admissions department is done with the contract. OSM #10 stated administrative staff were looking for (R58') advance directive notification/acknowledgment forms. On 06/15/22 at 3:40 p.m., an interview was conducted with (R58). When asked if the facility staff discussed or obtained an advance directive with them (R58) stated that they completed their own admission paperwork and that no one asked her about an advance directive. On 06/15/22 at approximately 4:48 p.m. ASM (administrative staff member) #1 stated that they did not have (R58's) advance directive notification/acknowledgment form. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. The facility staff failed to implement the comprehensive care plan for dialysis care for Resident #76. Resident #76 was admitted to the facility on [DATE]. Resident #76's diagnoses included, but were not limited to, ESRD (end stage renal disease) and dementia. Resident #76's most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 3/19/22, coded the resident as scoring 9 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of Resident #76's comprehensive care plan revised 9/9/21, revealed the following, NEED: Resident is at risk for complications related to needs for dialysis due to: End Stage Renal Disease. dialysis cath replaced 1/6/21. Hemodialysis Tuesday, Thursday, Saturday. INTERVENTIONS: Observe for signs/symptoms of infection to access site: Redness, Swelling, warmth or drainage/bleeding and other signs of infection: fever, generalized malaise, complaints of abdominal pain, chills. Document and report abnormal findings to the physician. For Hemodialysis: Facility will utilize the Dialysis Communication form to communicate with the dialysis center. Send the dialysis communication book to the dialysis center with each appointment. Upon return from the dialysis center review the communication book including any progress notes and provide an update to the physician and any staff member/disciplines as needed. A review of the physician's orders dated 8/9/21 renewed 5/2/22, revealed the following, Hemodialysis Tuesday, Thursday, Saturday. Monitor dialysis catheter Right Chest for signs/symptoms of infection. May reinforce dressing if needed. Monitor every shift. A review of the dialysis binder for Resident #76 on 6/14/22, revealed the following, the facility's Hemodialysis Communication Form was completed on the following dates, 6/14/22, 4/22/22, 4/7/22, 3/29/22, 3/26/22 and 3/24/22. The facility failed to provide communication to the dialysis facility for 10 of 14 visits in March 2022, the missing dates in March 2022 were: 3/1, 3/3, 3/8, 3/10, 3/12 3/15, 3/17, 3/19, 3/22 and 3/31. The facility failed to provide communication to the dialysis facility for 11 of 13 visits in April 2022, the missing dates in April 2022 were: 4/2, 4/5, 4/9, 4/12, 4/14, 4/16, 4/19, 4/23, 4/26, 4/28 and 4/30. The facility failed to provide communication to the dialysis facility for 13 of 13 visits in May 2022, the missing dates in May 2022 were: 5/3, 5/5, 5/7, 5/10 5/12, 5/14, 5/17, 5/19, 5/21, 5/24, 5/26, 5/28 and 5/31. The facility failed to provide communication to the dialysis facility for 5 of 5 visits in June 2022, the missing dates in June 2022 were: 6/2, 6/4, 6/7, 6/9 and 6/11. A review of the TAR (treatment administration record) for March 2022, revealed the following, Monitor dialysis catheter Right Chest for signs/symptoms of infection. May reinforce dressing if needed. Monitor every shift. The reviewed evidenced that 25 out of 93 shifts/opportunities were missing documentation. Missing dates were day shift: 3/1, 3/2, 3/4, 3/5, 3/6, 3/7, 3/12, and 3/15; evening shift 3/3, 3/6, 3/8, 3/9, 3/24 and 3/26 and night shift 3/1, 3/4, 3/6, 3/7, 3/9, 3/10, 3/11, 3/14, 3/15, 3/22 and 3/29. A review of the TAR for April 2022, revealed the following, Monitor dialysis catheter Right Chest for signs/symptoms of infection. May reinforce dressing if needed. Monitor every shift. The review evidenced that 6 out of 61 shifts/opportunities were missing documentation. Missing dates were day shift: 4/1, 4/9, 4/10 and 4/21; evening shift 4/8 and night shift 4/4. A review of the TAR for May 2022, revealed the following, Monitor dialysis catheter Right Chest for signs/symptoms of infection. May reinforce dressing if needed. Monitor every shift. The review evidenced that 8 out of 90 shifts/opportunities were missing documentation. Missing dates were day shift: 5/8, 5/17 and 5/23; evening shift: 5/23, 5/25, 5/26 and 5/28 and night shift 5/11. A review of the TAR for June 2022, revealed the following, Monitor dialysis catheter Right Chest for signs/symptoms of infection. May reinforce dressing if needed. Monitor every shift. The review evidenced that 6 of 42 shifts were missing documentation. Missing dates were day shift: 6/5, 6/8, 6/10 and 6/11; evening shift: 6/10 and night shift 6/8. On 6/13/22 at 3:25 PM, an interview was conducted with Resident #76. When asked if she had a dialysis binder, Resident #76 stated, I have one. I believe I left it at the dialysis center. When asked if they check the dialysis catheter site every shift, Resident #76 stated, I do not think so. An interview was conducted on 6/14/22 at 3:00 PM with LPN (licensed practical nurse) #3. When asked the purpose of the care plan, LPN #3 stated, the purpose of the care plan is to identify the needs of each resident and what actions need to be taken for those needs. When asked if not having the dialysis communication sheets sent with the resident indicated the care plan was being followed, LPN #3 stated, no, it would not be followed in that case. When asked if there were blanks on the TAR, what that indicated, LPN #3 stated, if there are blanks, then I have always been taught, if it was not documented it was not done. When asked if dialysis catheter care was not documented, was the care plan being followed, LPN #3 stated, no, it was not. On 6/14/22 at 4:20 PM, ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional clinical coordinator were informed of the above concern. A review of the facility's Care Planning policy dated 6/21, which reveals, In addition to care plans based on admission orders, goals for admission and desired outcomes, interdisciplinary team assessments, physician orders. No further information was provided prior to exit. 8. The facility staff failed to implement the comprehensive care plan for oxygen therapy for Resident #61. Resident #61 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, COPD (chronic obstructive pulmonary disease). Resident #61's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/22/22, coded the resident as scoring 7 out of 15 on the BIMS (brief interview for mental status score), indicating the resident was severely cognitively impaired. The resident was coded as requiring extensive assistance in bed mobility, transfers, dressing; total dependence with toileting, bathing and personal hygiene and supervision with eating. Resident #61's care plan dated 4/24/21 with no revision date, revealed the following, Need: Resident has a potential for difficulty breathing and risk for respiratory complications related to: COPD. Interventions: Elevate head of bed, encourage cough & deep breathing, Oxygen as ordered via nasal cannula every shift for SOB (shortness of breath), COPD oxygen per order. A review of the physician's orders dated 4/4/22, revealed the following, Oxygen 2l/min via nasal cannula for SOB. every shift for SOB. Resident #61 was observed with oxygen via nasal cannula at 3 liters per minute on 6/13/22 at 1:09 PM, 6/14/22 at 9:00 AM and 6/14/22 at 2:50 PM. The oxygen concentrator is the Invacare Perfecto2. An interview was unable to be conducted with Resident #61 due to cognitive impairment. On 6/14/22 at 2:55 PM, LPN (licensed practical nurse) #3 was asked to observe the oxygen setting on Resident #61. An interview was conducted on 6/14/22 at 3:00 PM with LPN (licensed practical nurse) #3. When asked the purpose of the care plan, LPN #3 stated, the purpose of the care plan is to identify the needs of each resident and what actions need to be taken for those needs. When asked the oxygen setting observed, LPN #3 stated, it is set on 3 liters nasal cannula. When asked if the oxygen being set at 3 liters nasal cannula, indicated that the care plan was being followed, LPN #3 stated, No, it is not. On 6/14/22 at 4:20 PM, ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional clinical coordinator were informed of the above concern. According to the instruction manual for the Invacare Perfecto2 oxygen concentrator, To properly read the flowmeter, locate the prescribed flowrate line on the flowmeter. Next, turn the flow know until the ball rises to the line. Now center the ball on the liters per minute line prescribed. The facility's Physician orders policy dated 6/24/21, revealed the following, Treatment rendered to a guest/resident must be in accordance with the specific standing, written, verbal, or telephone order of a physician or other licensed health professional ordering within their scope of practice and clinical privileges. No further information was provided prior to exit. 6. The facility staff failed to implement the comprehensive care plan for Resident #87 (R87) for (A) pressure ulcer treatments and (B) the use of hand splints. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/12/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is not cognitively impaired for making daily decisions. Section M documented R87 having 1 Stage 4 pressure ulcer and 1 Stage 3 pressure ulcer. A. On 6/14/2022 at 8:25 a.m., an interview was conducted with R87 in their room. R87 stated that the nurses had been in earlier that morning to change their wound dressing and had gotten better about doing the wound care as ordered. R87 stated that they had problems in the past with getting the wound dressing changed and their family had complained to the nurses about it. The comprehensive care plan for R87 documented in part, Skin #2: [R87] has pressure ulcers to sacrum and right thigh. Stage 4, Being followed by wound doctor. Date Initiated: 07/17/2019. Revision on: 06/14/2022 . Under Interventions it documented in part, .Treatments as ordered; . The eTAR (electronic treatment administration record) for R87 dated 1/1/2022-1/31/2022 failed to evidence documentation of a treatment provided to the sacral wound 1/7/2022 through 1/17/2022. The progress notes documented in part, - 1/10/2022 22:38 (10:38 p.m.) Note Text: Sacral wound care provided during shift. Yellow/reddish discharge noted. Foul odor noted. No c/o pain/discomfort while providing wound care. Pain meds offered, declined per resident. The progress notes failed to evidence documentation of treatment to the sacral wound 1/7/2022-1/9/2022 and 1/11/2022-1/17/2022. The physician orders reviewed from 1/1/2022 through 1/31/2022 documented in part, Wound care: Sacral wound- clean with 1/4 Dakins solution- pack with Silver Calcium Alginate QD (every day) and PRN (as needed)- cover with dry dressing. Order Date: 01/07/2022, End Date: 01/17/2022 . The order failed to evidence a start date. The wound evaluation & management summary dated 1/7/2022 documented in part, Stage 4 pressure wound sacrum full thickness .Wound progress: deteriorated, Additional wound detail: larger, d/c dakins packing, start Silver Alginate, dressing treatment plan, primary dressing(s), Sodium hypochlorite solution (dakins) apply once daily for 30 days: clean with 1/4 dakins solution; Alginate calcium w/silver apply once daily for 30 days. secondary dressing(s), gauze island (w/bdr) (with border) apply once daily for 30 days . The wound evaluation & management summary dated 1/14/2022 documented in part, Stage 4 pressure wound sacrum full thickness .Wound progress: improved, Additional wound detail: smaller, dressing treatment plan, primary dressing(s), Sodium hypochlorite solution (dakins) apply once daily for 23 days: clean with 1/4 dakins solution; Alginate calcium w/silver apply once daily for 23 days. secondary dressing(s), gauze island (w/bdr) apply once daily for 23 days . The wound evaluation & management summary dated 1/28/2022 documented in part, Stage 4 pressure wound sacrum full thickness .Wound progress: improved, Additional wound detail: shorter, no longer with exposed bone, dressing treatment plan, primary dressing(s), Sodium hypochlorite solution (dakins) apply once daily for 9 days: clean with 1/4 dakins solution; Alginate calcium w/silver apply once daily for 9 days. secondary dressing(s), gauze island (w/bdr) apply once daily for 9 days . On 6/14/2022 at 3:08 p.m., an interview was conducted with LPN (licensed practical nurse) #9. LPN #9 stated that the care plan was to guide the staff on how to care for the resident. LPN #9 stated that the staff use the care plan to know what to do for the residents and were not implementing the care plan if they were not following the interventions. On 6/15/2022 at 9:56 a.m., a telephone interview was conducted with ASM (administrative staff member) #7, the wound physician. ASM #7 stated that R87 had a sacral wound they had been following for 956 days. ASM #7 stated that R87's wound was slow to heal due to medical comorbidities and noncompliance with offloading and turning and positioning. ASM #7 stated that there was a zinc barrier cream ordered for the skin around the wound but was not the primary treatment for the pressure ulcer. ASM #7 stated that there should be a continuous treatment in place for the Stage 4 pressure wound treatment. On 6/15/2022 at 10:54 a.m., an interview was conducted with LPN #3, the unit manager. LPN #3 stated that treatments were evidenced as completed by documenting them on the eTAR. LPN #3 stated that if there was no documentation there was no evidence to support that anything was done. LPN #3 they were always taught that if it was not documented it was not done. LPN #3 reviewed the eTAR for R87 dated 1/1/2022-1/31/2022 and stated that they did not see any evidence that there was a treatment in place for the sacral pressure ulcer between 1/7/2022-1/17/2022. On 6/15/2022 at 1:29 p.m., an interview was conducted with LPN #2, wound nurse. LPN #2 stated that they were new to the wound nurse position. LPN #2 stated that R87's pressure ulcer was slow to heal due to non-compliance with offloading and turning and positioning off of the wound. LPN #2 stated that they round with the wound doctor and make any changes to treatment orders as needed when the physician rounds. LPN #2 reviewed the physician orders and the eTAR for R87 dated 1/1/2022-1/31/2022 and stated that they did not see any evidence of a treatment in place for the pressure ulcer from 1/7/2022-1/17/2022. On 6/15/2022 at approximately 4:05 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the southside regional clinical coordinator and ASM #4, the regional director of operations were notified of the findings. No further information was provided prior to exit. Complaint deficiency B. On 6/14/2022 at 8:25 a.m., an interview was conducted with R87 in their room. R87 stated that they used to wear hand splints to keep their hands from getting stiff but had not worn them in months. R87 stated that they wanted to wear the hand splints and had asked about them but the nurses had told them that therapy had to evaluate for them. R87 stated that they did not know if the staff knew where they were or not and no one ever offered to apply them anymore. Additional observations of R87 on 6/13/2022 at 2:45 p.m. and 4:30 p.m. and 6/14/2022 at 10:50 a.m., revealed them not wearing hand splints. The comprehensive care plan for R87 documented in part, [R87] is at risk for Contracture development, Date Initiated: 04/05/2022. Revision on: 04/05/2022 . Under Interventions it documented in part, Pt (patient) to wear hand splints to both hands daily for contracture mgmt (management). Apply after morning ADL (activities of daily living) care and remove in the evening or as requested by pt. Date Initiated: 04/05/2022 . The Occupational therapy OT discharge summary for R87 dated 12/7/2021 documented in part, .Pt (patient) to wear B (bilateral) hand splints daily, on after ADL morning routine and off after lunch/before dinner. Pt has been tolerating 4 hour wear and is able to communicate to staff when she wants splints removed .Restorative aide trained in splint program and PROM (passive range of motion) to BUE (bilateral upper extremities) and hands . On 6/14/2022 at 2:48 p.m., an interview was conducted with CNA (certified nursing assistant) #5. CNA #5 stated that they perform passive range of motion exercises on residents during ADL care. CNA #5 stated that they were not aware of any residents that had splints on their hallway. CNA #5 stated that they thought the nurses or the therapist applied the splints because the CNAs did not. On 6/14/2022 at 3:08 p.m., an interview was conducted with LPN (licensed practical nurse) #9. LPN #9 stated that therapy evaluated and recommended splint use for residents. LPN #9 stated that the nurses would follow up and make sure the splint is being applied by the CNAs or the nurse. LPN #9 stated that the care plan was to guide the staff on how to care for the resident. LPN #9 stated that the staff use the care plan to know what to do for the residents and were not implementing the care plan if they were not applying the splints as directed in the care plan. LPN #9 stated that they thought they remembered R87 having hand splints and that the CNAs should apply them after morning care. LPN #9 went to R87's room and found two hand splints in the drawer of the nightstand. R87 stated to LPN #9, Oh, you found them, I am glad because no one knew where they were. LPN #9 proceeded to apply the splints to R87's hands. On 6/15/2022 at approximately 4:05 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the southside regional clinical coordinator and ASM #4, the regional director of operations were notified of the findings. No further information was provided prior to exit. 5. Facility staff failed to implement Resident #58's (R58's) comprehensive care plan for attempting non-pharmacological interventions prior to the administration of a PRN [as needed] pain medication tramadol (1). (R58) was admitted to the facility with a diagnosis that included by not limited to: rheumatoid arthritis. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 04/17/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section J0300 Pain Presence coded (R58) as having frequent pain in the past 5 (five) days. Section J0600 Pain Intensity coded (R58) as having a pain level of five out of ten with tem being the worse pain. The physician's order for (R58) documented in part, Tramadol HCl (hydrochloride) Tablet 50 MG (milligram). Give 1 tablet by mouth every 6 (six) hours as needed for pain. Complete NPI (non-pharmacological interventions) with use. Order date: 4/18/2022. The eMAR (electronic medication administration record) for (R58) dated June2022 documented the physician's order as stated above and Pain-Non-Pharmacological Interventions: Document Non Pharmacological interventions used: 1)Massage. 2) Meditation/Relaxation. 3)Positioning. 4) Ice/cold pack. 5)Diversional Activity. 6) Guided Imagery. 7) Rest. 8)Social Interaction. as needed Document NonPharmacological interventions using the corresponding number. Start Date04/12/2022. Review of the eMAR failed to evidence documentation of non-pharmacological interventions as stated above from 06/01/2022 through 06/12/2022. The eMAR revealed that (R58) received 50 mgs of tramadol on the following dates and times, with no evidence of non-pharmacological interventions being attempted on: 06/01/2022 at 7:06 a.m., 06/02/2022 at 10:48 a.m. and at 6:29 p.m., 06/03/2022 at 11:07 a.m., 06/04/2022 at 12:21 p.m., 06/06/2022 at 8:24 a.m., 06/07/2022 at 10:19 a.m. and at 9:59 p.m., 06/08/2022 at 5:20 p.m. and at 9:43 p.m., 06/09/2022 at 8:46 a.m. and at 8:25 p.m., 06/10/2022 at 5:50 a.m., 06/11/2022 at 9:38 p.m. and on 06/12/2022 at 4:32 a.m. and at 9:33 p.m. The comprehensive care plan for (R58) documented in part, Focus. (R58) is at risk for pain and/or has acute/chronic pain r/t (related to) DX (diagnoses: RA (rheumatoid arthritis), DJD (degenerative joint disease), GERD (gastroesophageal reflux disease). Date Initiated: 04/13/2022. Under Interventions it documented in part, Evaluate the effectiveness of pain interventions as given. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition as needed. Date Initiated: 04/13/2022. Review of the facility's nurse's notes for (R58) dated 06/01/2022 through 06/12/2022 failed to evidence non-pharmacological interventions being attempted on the dates and times listed above. On 06/15/22 at 8:00 a.m., an interview was conducted with LPN (licensed practical nurse) #7. When asked to describe the procedure when administering as needed pain medication LPN #7 stated that the nurse assesses the resident's pain by obtaining the severity of the resident's pain on a scale of zero to ten, with ten being the worse pain, the location of the pain and the type of pain such as throbbing or stabbing. LPN #7 stated that the nurse would then start with non-pharmacological interventions such as repositioning, ice pack, or heat, and if that does not alleviate the resident's pain, they would administer the prescribe medication. When asked how often non-pharmacological interventions LPN #7 stated that it should be attempted each time before the as needed pain medication is administered. When asked where it would be documented that the location of pain, type of pain and non-pharmacological interventions were attempted LPN #7 stated that it would be documented in the nurse's notes or the eMAR. After review of the eMAR for non-pharmacological interventions LPN #7 was asked about the missing documentation. LPN #7 stated that they could not say non-pharmacological interventions were attempted because it was not documented. After reviewing (R58's) comprehensive care plan, LPN #7 was asked to explain the intervention for (R58's) pain care plan as stated above. LPN #7 stated that the intervention referred to implementing non-pharm interventions. When asked if (R58's) care was implemented for the use and documenting of non-pharm interventions LPN #7 stated no. On 06/15/2022 at approximately 11:35 a.m., ASM (administrative staff member) # 1, administrator, ASM # 2, director of nursing and ASM # 3, regional clinical coordinator, ASM# 4, regional director of operations. No further information was presented prior to exit. References: (1) Tramadol is used to relieve moderate to moderately severe pain. Tramadol extended-release tablets and capsules are only used by people who are expected to need medication to relieve pain around-the-clock. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a695011.html. Based on observation, resident interview, staff interview, facility document review, and in the course of a complaint investigation, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for 2 of 3 residents in the medication administration observation task (Residents #14 and #96); and for 6 of 59 residents in the survey sample (Residents #701, #94, #58, #87, #76, and #61). The findings include: 1. For Resident #14, the facility staff failed to implement the comprehensive care plan for administering medication as ordered. Resident #14 was admitted to the facility on [DATE]. On the annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 3/11/22, Resident #14 scored a 15 out of a possible 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact in ability to make daily life decisions. A review of the comprehensive care plan revealed one dated 3/23/21 for [Resident #14] is at risk for constipation R/T (related to): decreased mobility, medications side effects. This care plan included the intervention, dated 3/23/21 for Administer medications as ordered and observe for ineffectiveness/side effects. Report abnormal findings to the physician. On 6/14/22 at 8:17 AM, LPN #5 (Licensed Practical Nurse) was observed to prepare and administer the following medications for Resident #14: Methimazole 5 mg (milligrams), 1 tab. Buspar 10 mg, 1 tab Aspirin 81 mg, 1 tab Magnesium Oxide 400 mg, 1 tab On 6/14/22 at 11:16 AM, reconciliation of the medications was conducted compared with the physician's orders. An order dated 9/8/21 for a lidocaine 4% patch (1) to the left knee every morning was noted. It was noted that LPN #5 signed out for a lidocaine patch to left knee as being administered when it had not been administered. On 6/14/22 at 12:40 PM an interview was conducted with Resident #14. When asked if they received their pain patch on their knee this morning, they stated that they did not. On 6/14/22 at 12:40 PM an interview was attempted with LPN #5 regarding the missed medication. He refused to answer any questions, denied doing anything wrong and walked away from the surveyor. On 6/14/22 at 12:45 PM the above concern was reported to ASM #1 (Administrative Staff Member) the Administrator and ASM #4, the Regional Director of Operations. On 6/14/22 at 3:00 PM, an interview was conducted with LPN #4 (Licensed Practical Nurse) regarding medication administration. She stated that if a resident was not administered medications and there was no parameters to hold it, then the care plan to administer medications as ordered was not being followed. On 6/15/22 at 9:03 AM, an interview regarding the purpose of care plans was conducted with LPN #6. LPN #6 stated that the purpose of the care plan was so that staff know what the resident is doing and what staff need to do to care for the resident. A review of the facility policy, Care Planning was conducted. The policy documented, Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs identified in the comprehensive assessments and prepared by an interdisciplinary team who includes but not limited to; attending physician, a registered nurse who is responsible for the resident, a nurse aide, a member of food/nutrition services, the resident or resident representative, therapy staff as required and any other ancillary staff. Additional resources will also be utilized to ensure that any additional needs or risk areas are identified . On 6/15/22 at approximately 4:00 PM, ASM #1 (Administrative Staff Member), the Administrator, ASM #2, the Director of Nursing, and ASM #4, the Regional Director of Operations were made aware of the findings. No further information was provided by the end of the survey. References: (1) Lidocaine - is used to treat pain Information obtained from https://medlineplus.gov/druginfo/meds/a603026.html 2. For Resident #96, the facility staff failed to implement the comprehensive care plan for administering medication as ordered. Resident #96 was admitted to the facility on [DATE]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/11/22, Resident #96 scored a 13 out of a possible 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact in ability to make daily life decisions. The resident was coded as supervision for eating and extensive to total care for other areas of activities of daily living. A review of the comprehensive care plan revealed one dated 5/12/21 for [Resident #96] is at risk for abnormal bleeding/bruising R/T (related to): medication use . The care plan included an intervention dated 5/12/21 for Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician. Another care plan, dated 7/22/21 was for [Resident #96] is at risk for constipation R/T: decreased mobility, diminished appetite, Hx (history) of constipation, medications side effects. This care plan included the intervention, dated 7/22/21 for Administer medications as ordered and observe for ineffectiveness/side effects. Report abnormal findings to the physician. On 6/14/22 at 8:28 AM, LPN #5 (Licensed Practical Nurse) was observed to prepare and administer the following medications for Resident #96: Dulera 100 mcg (micrograms) / 5 mcg inhaler Aspirin 325 mg (milligrams), 1 tab Vitamin D3 25 mcg, 1 tab Colace 100 mg, 1 tab Glipizide 5 mg, 1 tab Genvoya 150 mg/150 mg/200 mg/10 mg, 1 tab Risperdone 0.5 mg, 1 tab Prednisone 10 mg, 1 tab Senna 8.6 mg, 1 tab Acetaminophen 325 mg, 1 tab Spiriva 18 mcg On 6/14/22 at 11:15 AM, reconciliation of the medications was conducted compared with the physician's orders. An order dated 6/30/21 for Alaway (1) eye drops and an order dated 1/18/21 for Pepcid (2) were noted. It was noted that LPN #5 signed out these medications as being administered when they had not been administered. On 6/14/22 at 12:40 PM an interview was attempted with LPN #5 regarding the missed medication. He refused to answer any questions, denied doing anything wrong and walked away from the surveyor. On 6/14/22 at 12:45 PM the above concern was reported to ASM #1 (Administrative Staff Member) the Administrator and ASM #4, the Regional Director of Operations. On 6/14/22 at 3:00 PM, an interview was conducted with LPN #4 (Licensed Practical Nurse) regarding medication administration. She stated that if a resident was not administered medications and there was no parameters to hold it, then the care plan to administer medications as ordered was not being followed. On 6/15/22 at 9:03 AM, an interview regarding the purpose of care plans was conducted with LPN #6. LPN #6 stated that the purpose of the care plan was so that staff know what the resident is doing and what staff need to do to care for the resident. A review of the facility policy, Care Planning was conducted. This policy documented, Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs identified in the comprehensive assessments and prepared by an interdisciplinary team who includes but not limited to; attending physician, a registered nurse who is responsible for the resident, a nurse aide, a member of food/nutrition services, the resident or resident representative, therapy staff as required and any other ancillary staff. Additional resources will also be utilized to ensure that any additional needs or risk areas are identified . On 6/15/22 at approximately 4:00 PM, ASM #1 (Administrative Staff Member), the Administrator, ASM #2, the Director of Nursing, and ASM #4, the Regional Director of Operations were made aware of the findings. No further information was provided by [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interview, clinical record review, facility document review and in the course of a complaint investigation it was determined that the facility staff failed to review and/or revise the comprehensive care plan for 4 of 59 residents in the survey sample, Resident #114, #87, #25, #336. The findings include: 1. The facility staff failed revise Resident #114's comprehensive care plan for (A) the use of a splint to the right upper arm and (B) the use of fall mats. On the most recent MDS, a quarterly assessment with an ARD of 5/23/2022, the resident scored 3 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section J1800 documented R114 not having any falls since admission/entry or reentry or prior assessment. A. On 6/13/2022 at 1:59 p.m., an observation was made of R114 in their room. R114 was observed lying in bed with a t-shirt on and asleep. R114 was observed not wearing a splint on the right upper arm. Additional observations of R114 in their room on 6/13/2022 at 3:41 p.m. and 4:24 p.m. and 6/14/2022 at 8:45 a.m. and 1:30 p.m. revealed R114 not wearing a splint on the right upper arm. The comprehensive care plan for R114 documented in part, [R114] is at risk for contracture development. Has contractures to all 4 extremities. Date Initiated: 03/10/2022. Revision on: 03/10/2022. The care plan failed to evidence an intervention for the right wrist extension brace. The physician orders for R114 documented in part, - Pt (patient) to wear R (right) wrist extension brace RUE (right upper extremity) during the day as tolerated. Perform skin inspections daily. one time a day. Order Date: 04/02/2022. The clinical record failed to evidence documentation of R114 refusing to wear the RUE wrist extension brace on 6/13/2022 or 6/14/2022. On 6/14/2022 at 2:48 p.m., an interview was conducted with CNA (certified nursing assistant) #5. CNA #5 stated that they perform passive range of motion exercises on residents during ADL care. CNA #5 stated that they were not aware of any residents that had splints on their hallway. CNA #5 stated that they thought the nurses or the therapist applied the splints because the CNAs did not. On 6/14/2022 at 3:08 p.m., an interview was conducted with LPN (licensed practical nurse) #9. LPN #9 stated that therapy evaluated and recommended splint use for residents. LPN #9 stated that the nurses would follow up and make sure the splint is being applied by the CNAs or the nurse. LPN #9 stated that the care plan was to guide the staff on how to care for the resident. LPN #9 stated that the staff use the care plan to know what to do for the residents and were not implementing the care plan if they were applying the splints as directed in the care plan. LPN #9 stated that they thought they remembered R114 having a splint on their arm when they were on the other unit. LPN #9 went to R114's room and found a splint in the closet. LPN #9 proceeded to apply the splint to R114 right arm. On 6/15/2022 at 9:44 a.m., an interview was conducted with RN (registered nurse) #1, MDS nurse. RN #1 stated that the care plan was used to guide the staff on how to care for the patient. RN #1 stated that anything that required a physician order was placed on the care plan. RN #1 stated that splints were placed on the care plan so the staff would know to use them. On 6/15/2022 at 11:31 a.m., RN #1 stated that they had reviewed R114's care plan and the splint was not included but should have been. RN #1 stated that they had corrected the care plan. The facility policy, Care Planning dated 9/1/2011 documented in part, .The care plan must be specific, resident centered, individualized and unique to each resident and may include: It should be oriented toward preventing avoidable declines. How to manage risk factors. Address/include resident strengths. Utilize current standards of practice .The care plan and resident [NAME] will be updated on Admission, Quarterly, Annually and with significant changes. This includes adding new focuses, goals, and interventions and resolving ones that are no longer applicable as needed . The facility policy, Brace and Splint Program dated 1/1/2012 documented in part, .a. A care plan will be developed that has measurable objectives and interventions and that include the following: b. Applying the brace/splint: Resident applies the brace with staff that provide verbal and physical guidance and direction that teaches the resident how to apply, manipulate, and care for the appliance. c. Staff has a scheduled program of applying and removing the appliance that includes: d. Scheduled hours to be worn and when skin will be inspected for signs and symptoms of pressure areas, irritations, rashes, etc. and will be reported to charge nurse and attending physician. e. Communicate individualized interventions to the direct care providers. Provide specific directions and training as needed (e.g., correct splint application, range of motion tech, skin integrity). Update Care plan and [NAME]. 6. Documentation: a. Document resident daily participation, including actual number of minutes participating in Point of Care . On 6/15/2022 at approximately 4:05 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the southside regional clinical coordinator and ASM #4, the regional director of operations were notified of the findings. No further information was provided prior to exit. B. On 6/13/2022 at 1:59 p.m., an observation was made of R114 in their room. R114 was observed lying in bed with a t-shirt on and asleep. R114's bed was observed to be pushed against the wall in the room with a fall mat placed on the floor to the right side of the bed. Additional observations of R114 in their room on 6/13/2022 at 3:41 p.m. and 4:24 p.m. and 6/14/2022 at 8:45 a.m. and 1:30 p.m. revealed the fall mat in place to the right side of the bed. The physician orders for R114 documented in part, - Fall mat at bedside- check placement and function every shift for safety. Order Date: 05/16/2022. The progress notes documented in part: - 4/29/2022 18:08 (6:08 p.m.) Resident observe on bedroom via staff. On assessment, patient side lying lateral to bedroom with face down. Resident unable to note events leading up to fall .No injuries notied [sic] at this time . - 5/15/2022 21:00 (9:00 p.m.) Approx. (approximately) 1930 (7:30 p.m.), writer was called to residents room by staff, writer observed resident laying on his right side, on the floor, next to bed, last observed 15 minutes prior by writer, resting in low bed quietly, eyes closed, call bell and bedside table within reach, wearing non skid socks and facility gown, clean and dry, resident unable to explain how he fell, related to dementia diagnosis, moves upper extremities without pain, lower extremities contracted unable to move, neurochecks wnl (within normal limits), no new injuries noted, no swelling noted, denies all pain and discomfort .nsg (nursing) intervention bedside mat . On 6/14/2022 at 3:08 p.m., an interview was conducted with LPN (licensed practical nurse) #9. LPN #9 stated that fall mats were on the care plans for residents. LPN #9 stated that the care plan was to guide the staff on how to care for the resident. LPN #9 stated that the staff use the care plan to know what to do for the residents and that the care plan should be reviewed after a fall. LPN #9 stated that the care plan was reviewed to determine if any new interventions were needed or if the current plan was adequate and it should be done as soon as possible after a fall. LPN #9 stated that the interventions were updated so that all staff were able to see what needed to be in place. On 6/15/2022 at 9:44 a.m., an interview was conducted with RN (registered nurse) #1, MDS nurse. RN #1 stated that the care plan was used to guide the staff on how to care for the patient. RN #1 stated that the unit manager brought any resident falls to the daily meetings and they would update the care plans then. RN #1 stated that after a fall the care plan was updated with any new interventions that were added. RN #1 stated that anything that required a physician order was placed on the care plan. RN #1 stated that fall mats were placed on the care plan so the staff would know to use them. On 6/15/2022 at 11:31 a.m., RN #1 stated that they had reviewed R114's care plan and the fall mats were not included but should have been. RN #1 stated that they had corrected the care plan. On 6/15/2022 at 2:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the southside regional clinical coordinator and ASM #4, the regional director of operations were made aware of the findings. No further information was provided prior to exit. 2. The facility staff failed to review and/or revise the comprehensive care plan for Resident #87 (R87) after a resident to resident incident with their roommate on 11/10/2021. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/12/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was not cognitively impaired for making daily decisions. On 6/14/2022 at 8:25 a.m., an interview was conducted with R87 in their room. When asked about any incident with their previous roommate on 11/10/2021, R87 stated that they got along well with their current roommate. R87 stated that they had hallucinations at times and did not remember any problems with a previous roommate. R87 stated that they felt safe at the facility. A FRI (facility reported incident) dated 11/10/2021 for R87 was reviewed. The follow up and summary dated 11/17/2021 documented in part, This is a follow-up and summary to Facility Reported Incident in which it was reported that Resident [R25] got out of bed on November 10, 2021 and placed a pillow over her roommates [R87]'s head .A little after midnight on November 10, 2021 [R87] was heard calling out for nurse who immediately responded and found [R25] at [R87]'s bedside with a pillow over [R87]'s face. The nurse immediately removed the pillow and directed [R25] back to bed and placed certified nursing assistant [Name of CNA] at the door of the room to monitor [R25] for the rest of the night. [CNA] provided comfort to [R87] who reported that she was fine .[R25] was sent to the hospital for psychiatric evaluation on November 10, 2021 .Upon her return she was transferred to a private room [Room number]. [R25] was seen by the nurse practitioner, [Name of NP] upon return .Resident was also seen by psychiatric nurse practitioner, [Name of NP] who agreed with these changes in medication. [R87] continues to receive supportive care and continues to state that she is fine. Impression and findings: The incident did occur . The progress notes for R87 documented in part, - 11/10/2021 09:40 (9:40 a.m.) Note Text: made call to rp (responsible party) and made her aware of resident confusion during the night , made rp aware that roommate was removed to a different room, skin check is in progress, writer spoke with resident this morning and resident stated that she was fine no c/o (complaints of) pain or discomfort noted will cont (continue) to monitor. - 11/10/2021 10:08 (10:08 a.m.) Note Text: Guest noted talking to people who are not there. Guest stating, stop sticking me with needles before I call my son. No one is in the room at this time. Writer was standing in the doorway observing guest. Guest observed saying, I'm not ready yet Jesus. - 11/10/2021 10:30 (10:30 a.m.) Nurse Practitioner note: CC (chief complaint): smothered by roommate, Seeing patient for recent altercation with roommate, patient states that her roommate attempted to smother her with a pillow last night , she states the pillow was not on her face for long because she moved the pillow away and screamed for help and then nursing came in and removed the pillow from the roommate. She states she feels fine , no Diff (difficulty) breathing, no pain, VSS (vital signs stable), oxygen stable. She does state that she is scared to sleep sec (secondary) to incident. No s/s (signs or symptoms) of acute distress, patient up in her wheelchair, following commands .Plan of care d/w (discussed with) staff on the floor: roommate removed , psych consult . - 11/10/2021 13:03 (1:03 p.m.) Psychiatric Nurse practioner note: .CC: shock from being assaulted during the previous night by roommate placing a pillow over her face. Information source: Resident, staff, records . Interval History: Severely frightened and currently anxious following assault previous night by her roommate. She states the roommate told her to be quiet then came to her bedside and placed a pillow over her face. She was able to push against it with her functional arm while shouting Jesus help me! I'm not ready to go! and nursing staff came to her rescue. States that this roommate has shouted at her before, and is relieved that she has been permanently removed from being her roommate . Impression: Resident had a scare which her faith is helping her resolve quickly. No change in medication deemed appropriate at this time as the threatening situation was promptly dealt with to her satisfaction. Plan: Monitor for residual signs and symptoms of anxiety / PTSD (post traumatic stress disorder) for which medication would be appropriate . - 11/17/2021 13:56 (1:56 p.m.) Swk (social worker) check with guest to see how she was doing since the incident with her room mate. Guest voiced she was fine she has another roommate and she is enjoying her company. Guest voiced she does not have any issues at this time. The comprehensive care plan for R87 failed to evidence a review and/or revision regarding the resident to resident incident on 11/10/2021. On 6/15/2022 at 12:20 p.m., an interview was conducted with OSM (other staff member) #1, social worker. OSM #1 stated that they were not in the building when the incident happened between R87 and R25 but spoke with R87 afterwards. OSM #1 stated that they had reviewed and updated R25's care plan after the incident but had not updated R87's care plan. OSM #1 stated that they normally would only review the care plan of the aggressor in a resident to resident incident. On 6/15/2022 at 2:07 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that the care plan was used to tell the staff how to care for the resident and was a person centered care directive for each resident in the facility. LPN #7 stated that any altercation between two guests required both care plans to be updated. LPN #7 stated that both residents should have their care plan updated and reviewed even if only one was the aggressor. On 6/15/2022 at 2:14 p.m., a follow up interview was conducted with OSM #1, social worker. OSM #1 stated that the purpose of the care plan was to ensure that the nursing could follow what was going on with the guest. OSM #1 stated that nursing would need to monitor both residents after a resident to resident altercation. OSM #1 stated that R87 should be monitored for mood changes after an incident like the one on 11/10/2021 and the care plan probably should have been updated to reflect that. On 6/15/2022 at approximately 4:05 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the southside regional clinical coordinator and ASM #4, the regional director of operations were notified of the findings. No further information was provided prior to exit. Complaint deficiency 3. The facility staff failed to review and/or revise the comprehensive care plan in a timely manner for Resident #25 (R25) after a resident to resident incident with their roommate on 11/10/2021. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/25/2022, the resident scored 5 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is severely impaired for making daily decisions. On 6/14/2022 at 12:30 p.m., an observation was made of R25 in their room. R25 was observed in their private room sitting in a wheelchair. R25 was not observed displaying any aggressive behaviors during the dates of the survey. A FRI (facility reported incident) dated 11/10/2021 for R25 was reviewed. The follow up and summary dated 11/17/2021 documented in part, This is a follow-up and summary to Facility Reported Incident in which it was reported that Resident [R25] got out of bed on November 10, 2021 and placed a pillow over her roommates [R87]'s head .A little after midnight on November 10, 2021 [R87] was heard calling out for nurse who immediately responded and found [R25] at [R87]'s bedside with a pillow over [R87]'s face. The nurse immediately removed the pillow and directed [R25] back to bed and placed certified nursing assistant [Name of CNA] at the door of the room to monitor [R25] for the rest of the night. [CNA] provided comfort to [R87] who reported that she was fine .[R25] was sent to the hospital for psychiatric evaluation on November 10, 2021 .Upon her return she was transferred to a private room [Room number]. [R25] was seen by the nurse practitioner, [Name of NP] upon return .Resident was also seen by psychiatric nurse practitioner, [Name of NP] who agreed with these changes in medication. [R87] continues to receive supportive care and continues to state that she is fine. Impression and findings: The incident did occur . The progress notes for R25 documented in part; - 11/10/2021 00:30 (12:30 a.m.) Late Entry: Note Text: Noted that resident got up and placed a pillow on her roommate's head. She kept getting out of her bed to try and place a pillow over [R87] head. Agency CNA (certified nursing assistant) had to sit in the door way to keep [R25] away from [R87] the entire shift. Nurse assumed responsibility until next shift. - 11/10/2021 00:48 (12:48 a.m.) Late Entry: Note Text: Guest was Not admitted To [Name and phone number of Hospital]. She was transported back to the [Name of facility] this evening shift at approx. (approximately) 2130 (9:30 p.m.) via Ambulance. She appeared to be rested and no signs of distress . - 11/10/2021 08:03 (8:03 a.m.) Note Text: Guest transferred to [Room number] from [Room number] with all belongings. - 11/10/2021 09:54 (9:54 a.m.) Note Text: spoke with resident rp (responsible party) r/t (related to) confusion and agitation during the night, notified rp that np (nurse practitioner) was made aware and resident has been placed in a different room temporarily until a permanent room can be determined, made rp aware that resident has calm down no distress noted at this time, will cont (continue) to monitor. - 11/10/2021 10:32 (10:32 a.m.) Note Text: notified rp (responsible party) of transfer to [Name of hospital] for a psych (psychiatric) eval (evaluation). - 11/10/2021 10:50 (10:50 a.m.) Nurse practitioner note: . Seeing patient per nursing patient found attempting trying to smother roommate with pillow, patient stated all she remembers is waking up to go pee, she doesn't remember anything else. No s/s (signs/symptoms) of acute distress, RP daughter notified. Pysch to see patient today. Plan of care d/w (discussed with) staff on the floor: now in different room, stat CMP (comprehensive metabolic panel) . - 11/10/2021 12:07 (12:07 p.m.) Note Text: Call placed to [name and number of county non-emergency]. Spoke with dispatcher who took information. Per dispatcher, [name of county] officers is coming to facility to speak with DON (director of nursing) in reference to incident. And per dispatcher, someone is to return call to facility with how guest is going to be transported to [Name of hospital]. Waiting to be notified. The comprehensive care plan for R25 documented in part, [R25] has a actual behavior problem R/T (related to): trying to smother her roommate with a pillow. Episodes of yelling/screaming out, physical behavioral symptoms directed towards others .Date Initiated: 03/17/2022. Revision on: 04/06/2022. The care plan failed to evidence a review or revision prior to 3/17/2022. On 6/15/2022 at 12:20 p.m., an interview was conducted with OSM (other staff member) #1, social worker. OSM #1 stated that they were not in the building when the incident happened between R87 and R25 but spoke with R87 afterwards. OSM #1 stated that R25 had behaviors of yelling out at times but had not had any aggressive behaviors prior to 11/10/2021. OSM #1 stated that R25 had not had any further aggressive behaviors towards any residents and remained in a private room. OSM #1 stated that they thought they had reviewed and updated R25's care plan after the incident. OSM #1 stated that they normally would only review the care plan of the aggressor in a resident to resident incident. OSM #1 reviewed the care plan for R25 dated 3/17/2022 and stated that they thought that it was reviewed/revised right after the incident on 11/10/2021 and was not sure where the 3/17/2022 date came from. OSM #1 stated that they would ask another staff member to review and see if they could pull the history on it. OSM #1 stated that the care plan should have been reviewed prior to 3/17/2022. On 6/15/2022 at 2:07 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that the care plan was used to tell the staff how to care for the resident and was a person centered care directive for each resident in the facility. LPN #7 stated that any altercation between two guests required both care plans to be updated as soon as possible. On 6/15/2022 at approximately 4:05 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the southside regional clinical coordinator and ASM #4, the regional director of operations were notified of the findings. No further information was provided prior to exit. Complaint deficiency. 4. The facility staff failed to review or revise Resident #336's (R336) comprehensive care plan for falls the resident sustained on 8/16/21 and 9/16/21. On the most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 8/29/21, the resident scored 9 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately cognitively impaired for making daily decisions. A review of R336's clinical record (nurses' notes) revealed the resident sustained falls on 8/16/21 and 9/16/21. A review of post fall evaluations dated 8/16/21 and 9/16/21 revealed a check box beside the words, Care Plan/[NAME] Updated. The check box was not marked. A review of R336's comprehensive care plan initiated on 3/16/21 failed to reveal evidence that the resident's care plan was reviewed or revised regarding those falls. On 6/15/22 at 8:02 a.m., an interview was conducted with RN (registered nurse) #2, regarding the purpose of the care plan. RN #2 stated the care plan is something to follow that kind of gives staff the guideline of what's going on with the resident and what the resident needs. RN #2 stated she does not review or revise care plans. On 6/15/22 at 10:14 a.m., an interview was conducted with RN #1 (the MDS coordinator). RN #1 stated she updates residents' care plans usually within 24 hours of being made aware of a resident's fall or when a new order for an intervention is obtained. RN #1 reviewed R336's care plan. The care plan documented for therapy to evaluate for proper fitting of shoes. The initiation date was 9/11/21 and the creation date was 9/22/21. RN #1 stated this was probably documented due to a new order and not from a review or revisions from R336's falls. RN #1 stated she would further review R336's care plan for any review or revisions for the 8/16/21 and 9/16/21 falls. On 6/15/22 at 1:56 p.m., RN #1 stated she could not find evidence that R336's care plan was reviewed or revised for either fall. On 6/15/22 at 2:32 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing), ASM #3 (the regional clinical coordinator) and ASM #4 (the regional director of operations) were made aware of the above concern. The facility policy titled, Fall Management documented, 3. When a fall occurs, the licensed nurse will evaluate the guest/resident for injury .4. The licensed nurse will complete: Review and /or revise care plan and guest/resident [NAME] . No further information was presented prior to exit. COMPLAINT DEFICIENCY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to follow medication administration standards of practice during medication administration to Resident #87 (R87). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/12/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is not cognitively impaired for making daily decisions. On 6/14/2022 at 10:55 a.m., an interview was conducted with R87 in their room. During the interview with R87, at 10:59 a.m., an observation was made of LPN (licensed practical nurse) #5 entering R87's room. LPN #5 entered the room with two medication cups, one in the right hand and one in the left hand. LPN #5 proceeded to R87's roommate's (Resident 113) side of the room and placed the cup on the overbed table and stated, Here are your meds to Resident #113 (R113) who was in the bed. LPN #5 proceeded to come over to R87 and stated, Here are your meds handing a cup of medication to R87. LPN #5 assisted R87 to place the pills in their mouth and then left the room at that time leaving R113 with the cup of pills still sitting on the overbed table. On 6/14/2022 at approximately 11:08 a.m., an interview was attempted with LPN #5. LPN #5 stated that the medications were the residents morning meds and that they always gave two residents medications at the same time and had never made a mistake doing it this way. LPN #5 stated that they put A bed medications in the left hand and B bed medications in the right hand. LPN #5 stated that they did not work at the facility normally and had already been followed by a surveyor that morning and did not have time to talk. On 6/14/2022 at approximately 3:08 p.m., an interview was conducted with LPN #9. LPN #9 stated that medications were administered to one resident at a time. LPN #9 stated that errors could be made by administering to multiple residents at the same time and there were also infection control concerns. LPN #9 stated, You just don't do that. During the entrance conference on 6/13/2022 at approximately 1:30 p.m., ASM (administrative staff member) #1, the administrator stated the facility used [NAME] as their nursing standard of practice. The facility policy Medication Administration dated 3/1/2013 documented in part, .Guest/resident medications are administered in an accurate, safe, timely, and sanitary manner . Fundamentals of Nursing, [NAME], [NAME] & [NAME] 5th edition; page 557 under the section Nurse Practice Acts, Nurses are also expected to practice in a safe and prudent manner it is the nurse's legal domain to administer medications in a safe and timely manner. Page 568, Procedure 29-1; Administering Oral Medications. Procedure: 1. Wash hands. 2. Arrange MAR next to medication supply. 3. Prepare medications for only one client at a time. 4. Remove ordered medications from supply 5. Calculate correct drug dosage 6. Prepare selected medications .7. Take medication directly to client's room. Do not leave medication unattended . On 6/14/2022 at 4:15 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the southside regional clinical coordinator and ASM #4, the regional director of operations were made aware of the findings. No further information was presented prior to exit. 4. The facility staff failed to follow medication administration standards of practice during medication administration to Resident #113 (R113). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/21/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is not cognitively impaired for making daily decisions. On 6/14/2022 at 10:59 a.m., during an interview with another resident (Resident #87), an observation was made of LPN (licensed practical nurse) #5 entering R113's room. LPN #5 entered the room with two medication cups, one in the right hand and one in the left hand. LPN #5 proceeded to R113's side of the room and placed the cup on the overbed table stating here are your meds to R113 who was in the bed. LPN #5 proceeded to come over to R87 and stated here are your meds, handing a cup of medication to R87. LPN #5 assisted R87 to place the pills in their mouth and then left the room at that time leaving R113 with the cup of pills still sitting on the overbed table. At this time, R113 was observed to get out of bed and get in the wheelchair stating that the nurse forgot their pain pills. R113 was observed to exit the room and go to LPN #5 at the medication cart to request pain medication. R113 returned to the room with a second medication cup with two tablets inside. On 6/14/2022 at approximately 11:08 a.m., an interview was attempted with LPN #5. LPN #5 stated that the medications were the residents morning meds and that they always gave two residents medications at the same time and had never made a mistake doing it this way. LPN #5 stated that they put A bed medications in the left hand and B bed medications in the right hand. LPN #5 stated that they did not work at the facility normally and had already been followed by a surveyor that morning and did not have time to talk. LPN #5 stated that they thought they had watched both residents swallow their medication in the room, stated that they do not leave medications at the bedside and walked away from the surveyor into a residents room. On 6/14/2022 at approximately 3:08 p.m., an interview was conducted with LPN #9. LPN #9 stated that medications were administered to one resident at a time. LPN #9 stated that errors could be made by administering to multiple residents at the same time and there were also infection control concerns. LPN #9 stated, You just don't do that. LPN #9 stated that medications were not left at the bedside and that the nurse stayed to make sure the resident swallowed the medication. LPN #9 stated that anyone could come in and take the medication or they could get lost. On 6/13/2022 at approximately 1:30 p.m., during entrance ASM (administrative staff member) #1, the administrator stated the facility used [NAME] as their nursing standard of practice. The facility policy Medication Administration dated 3/1/2013 documented in part, .Observe that the guest/resident swallows the oral medications. Do not leave medications with the guest/resident to self-administer unless the guest/resident is approved for self-administration of the medication . On 6/14/2022 at 4:15 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the southside regional clinical coordinator and ASM #4, the regional director of operations were made aware of the findings. No further information was presented prior to exit. Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to follow professional standards of practice for 2 of 3 residents in the Medication Administration observation task, Residents #14 and #96; and for 2 of 59 residents in the survey sample; Residents #87 and #113. The findings include: 1. For Resident #14, the facility staff failed to follow professional standards of practice when LPN #5 signed out for medication as given that was not administered. Resident #14 was admitted to the facility on [DATE]. On the annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 3/11/22, Resident #14 scored a 15 out of a possible 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact in ability to make daily life decisions. On 6/14/22 at 8:17 AM, LPN #5 (Licensed Practical Nurse) was observed to prepare and administer the following medications for Resident #14: Methimazole 5 mg (milligrams), 1 tab. Buspar 10 mg, 1 tab Aspirin 81 mg, 1 tab Magnesium Oxide 400 mg, 1 tab On 6/14/22 at 11:16 AM, reconciliation of the medications was conducted and compared with the physician's orders. An order dated 9/8/21 for a lidocaine 4% patch (1) to the left knee every morning was noted. It was noted that LPN #5 signed out for a lidocaine patch to left knee as being administered when it had not been administered. On 6/14/22 at 12:40 PM an interview was conducted with Resident #14. When asked if they received their pain patch on their knee this morning, they stated that they did not. On 6/14/22 at 12:40 PM an interview was attempted with LPN #5 regarding the missed medication. He refused to answer any questions and denied doing anything wrong and walked away from the surveyor. On 6/14/22 at 12:45 PM the above concern was reported to ASM #1 (Administrative Staff Member) the Administrator and ASM #4, the Regional Director of Operations. On 6/14/22 at 3:00 PM, an interview was conducted with LPN #4 (Licensed Practical Nurse) and medication administration was discussed. She stated that staff should not sign out for medications that were not given. A review of the comprehensive care plan revealed one dated 3/23/21 for [Resident #14] is at risk for constipation R/T (related to): decreased mobility, medications side effects. This care plan included the intervention, dated 3/23/21 for Administer medications as ordered and observe for ineffectiveness/side effects. Report abnormal findings to the physician. A review of the facility policy, Medication Administration was conducted. This policy documented, Medications are administered in accordance with written orders of the attending physician .Record the dose, route, and time of the medication on the Medication/Treatment Administration Record. Document if the guest/resident refused. The policy did not address not signing out for medications that were not given. According to Fundamentals of Nursing, 5th edition, [NAME], [NAME] & [NAME], page 577, The most common medication errors include documentation errors charting medication that was not given. On 6/15/22 at approximately 4:00 PM, ASM #1 (Administrative Staff Member), the Administrator, ASM #2, the Director of Nursing, and ASM #4, the Regional Director of Operations were made aware of the findings. No further information was provided by the end of the survey. References: (1) Lidocaine - is used to treat pain Information obtained from https://medlineplus.gov/druginfo/meds/a603026.html 2. For Resident #96, the facility staff failed to follow professional standards of practice when LPN #5 signed out for medication as given that was not administered. Resident #96 was admitted to the facility on [DATE]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/11/22, Resident #96 scored a 13 out of a possible 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact in ability to make daily life decisions. On 6/14/22 at 8:28 AM, LPN #5 (Licensed Practical Nurse) was observed to prepare and administer the following medications for Resident #96: Dulera 100 mcg (micrograms) / 5 mcg inhaler Aspirin 325 mg (milligrams), 1 tab Vitamin D3 25 mcg, 1 tab Colace 100 mg, 1 tab Glipizide 5 mg, 1 tab Genvoya 150 mg/150 mg/200 mg/10 mg, 1 tab Risperdone 0.5 mg, 1 tab Prednisone 10 mg, 1 tab Senna 8.6 mg, 1 tab Acetaminophen 325 mg, 1 tab Spiriva 18 mcg On 6/14/22 at 11:15 AM, reconciliation of the medications was conducted and compared with the physician's orders. An order dated 6/30/21 for Alaway (1) eye drops and an order dated 1/18/21 for Pepcid (2) were noted. It was noted that LPN #5 signed out these medications as being administered when they had not been administered. On 6/14/22 at 12:40 PM an interview was attempted with LPN #5 regarding the missed medication. He refused to answer any questions and denied doing anything wrong and walked away from the surveyor. He displayed a hostile attitude. On 6/14/22 at 12:45 PM the above concern was reported to ASM #1 (Administrative Staff Member) the Administrator and ASM #4, the Regional Director of Operations. On 6/14/22 at 3:00 PM, an interview was conducted with LPN #4 (Licensed Practical Nurse). She stated that staff should not sign out for medications that were not given. A review of the comprehensive care plan revealed one dated 5/12/21 for [Resident #96] is at risk for abnormal bleeding/bruising R/T (related to): medication use . This care plan included an intervention dated 5/12/21 for Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician. Another care plan, dated 7/22/21 was for [Resident #96] is at risk for constipation R/T: decreased mobility, diminished appetite, Hx (history) of constipation, medications side effects. This care plan included the intervention, dated 7/22/21 for Administer medications as ordered and observe for ineffectiveness/side effects. Report abnormal findings to the physician. A review of the facility policy, Medication Administration was conducted. This policy documented, Medications are administered in accordance with written orders of the attending physician .Record the dose, route, and time of the medication on the Medication/Treatment Administration Record. Document if the guest/resident refused. The policy did not address not signing out for medications that were not given. According to Fundamentals of Nursing, 5th edition, [NAME], [NAME] & [NAME], page 577, The most common medication errors include documentation errors charting medication that was not given. On 6/15/22 at approximately 4:00 PM, ASM #1 (Administrative Staff Member), the Administrator, ASM #2, the Director of Nursing, and ASM #4, the Regional Director of Operations were made aware of the findings. No further information was provided by the end of the survey. References: (1) Alaway is used for the treatment of allergy symptoms of the eyes Information obtained from https://medlineplus.gov/druginfo/meds/a604033.html (2) Pepcid is used for the treatment of reflux and ulcers Information obtained from https://medlineplus.gov/druginfo/meds/a687011.html

2. The facility staff failed to provide showers per the resident's preference for Resident #10 (R10). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/8/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) indicating the resident is not cognitively impaired for making daily decisions. Section G documented R10 being totally dependent on one person for personal hygiene and totally dependent on one person for bathing. On 6/13/2022 at 3:44 p.m., an interview was conducted with R10 in their room. R10 stated that they were supposed to get showers on Tuesdays and Thursdays but were lucky to get one every 3 weeks. R10 stated that they preferred to have at least one shower a week because it made them feel cleaner than a bed bath. R10 stated that the staff often gave bed baths on their shower days and never offered a shower. R10 stated that the staff often told them that they were short staffed or gave no reason why they could not give the shower. On 6/15/2022 at 12:00 p.m., a follow up interview was conducted with R10. R10 stated that they did not receive their shower on 6/14/2022 as scheduled. R10 stated that they did not refuse it and was not offered a shower. R10 stated that the CNA (certified nursing assistant) just came in and gave them a bed bath. The physician orders for R10 documented in part, If patient refuses shower or is agitated call daughter to calm patient and encourage patient do not let pt (patient) miss shower days. Order Date: 3/25/2022. The progress notes dated 4/1/2022-6/15/2022 failed to evidence documentation of R10 refusing showers. The Shower/Bath documentation for 4/1/2022-4/30/2022 documented a shower/bath/bed bath given on 4/15/2022. The document failed to evidence documentation of a shower/bath/bed bath given on 4/5/2022, 4/8/2022, 4/22/2022, 4/26/2022 and 4/29/2022. The document contained an NA in the area for the shower/bath/bed bath on 4/1/2022, 4/4/2022, 4/12/2022 and 4/19/2022. The Shower/Bath documentation for 5/1/2022-5/31/2022 documented a shower/bath/bed bath given on 5/6/2022, 5/13/2022, 5/24/2022 and 5/27/2022. The document failed to evidence documentation of a shower/bath/bed bath given on 5/3/2022, 5/10/2022, and 5/17/2022. The document contained an NA in the area for the shower/bath/bed bath on 5/31/2022. The document contained evidence of R10's refusal of a shower/bath/bed bath on 5/20/2022. The Shower/Bath documentation for 6/1/2022-6/30/2022 documented a shower/bath/bed bath given on 6/3/2022, 6/7/2022 and 6/10/2022. The document failed to evidence documentation of a shower/bath/bed bath given on 6/14/2022. The comprehensive plan for R10 documented in part, [R10] has an ADL (activities of daily living) self care performance deficit and requires assistance with ADL's and mobility r/t (related to): limited mobility and weakness. Date Initiated: 07/18/2020. Revision on: 07/21/2020. On 6/15/2022 at approximately 8:30 a.m., a request was made to ASM (administrative staff member) #1 for the shower sheets for R10 from 4/1/2022-6/15/2022. On 6/15/2022 at approximately 1:30 p.m., ASM #2, the director of nursing provided a Shower/Skin Observation document for R10 dated 6/14/2022 which documented in part, Bed bath given . On 6/14/2022 at 2:48 p.m., an interview was conducted with CNA (certified nursing assistant) #5. CNA #5 stated that showers were given twice a week. CNA #5 stated that they had a schedule they followed with certain room numbers to receive showers on certain days. CNA #5 stated that if the resident refused their shower they let the nurse know and attempted later in the day. CNA #5 stated if the resident continued to refuse the shower they offered a bed bath or documented the refusal. CNA #5 stated that they did not have any problems getting their scheduled showers completed during their shift. CNA #5 stated that resident preferences regarding showers or bed baths should be honored and they were asked which they wanted on their shower days. CNA #5 stated that showers/bed baths were documented in the computer as completed or refused. On 6/14/2022 at 3:08 p.m., an interview was conducted with LPN (licensed practical nurse) #9. LPN #9 stated that resident showers were given twice a week. LPN #9 stated that the CNA's documented the showers in the computer and on shower sheets in a book. LPN #9 stated that if a resident refused their shower the CNA notified the nurse and they spoke to the resident to try to convince them. LPN #9 stated that if they still refused they notified the responsible party and documented it in the medical record. On 6/15/2022 at 8:15 a.m., an interview was conducted with CNA #2. CNA #2 stated that showers/bed baths were documented in the computer and on shower sheets. CNA #2 stated that there should not be any blank areas in the shower/bath/bed bath documentation because you could not say whether it was done or not and if there was an NA it meant not applicable so it did not happen. On 6/15/2022 at 10:54 a.m., an interview was conducted with LPN #3. LPN #3 stated that showers were given twice a week and documented in the shower book and in the computer. LPN #3 stated that if a resident refused the shower it was documented in the medical record and the family was notified. LPN #3 stated that they always learned that if it was not documented it was not done and could not say that showers were given if there was no documentation to support it. The facility policy Routine Guest/Resident Care dated 3/1/2013 documented in part, .Showers, tub baths, and/or shampoos are scheduled according to person centered care or state specific guidelines [sic]; Bed linens are changed at this time. Additional showers are given as requested . On 6/15/2022 at 2:40 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the southside regional clinical coordinator and ASM #4, the regional director of operations were made aware of the findings. No further information was provided prior to exit. 3. The facility staff failed to provide bathing/showers, incontinence care, personal hygiene and ADL (activities of daily living) care to Resident #87 (R87). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/12/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section E documented no rejections of care observed. Section G documented R87 requiring extensive assistance from one staff member for bed mobility, transfers, personal hygiene and toilet use and totally dependent on one person for bathing. On 6/14/2022 at 10:50 a.m., an interview was conducted with R87. R87 stated that there were times when there was a delay getting their brief changed when soiled but they knew the staff were busy with other residents. R87 stated that there were days when they did not get their bath until after lunch and they preferred to get washed up in the morning so they could get out of bed between 10:00 a.m. and 12:00 p.m. R87 stated that there were days when they did not get washed up at all but the staff did come in and change their brief. The complaint allegations related to 12/2021-1/2022 timeframe, clinical records and ADL records for those dates were reviewed. The Documentation survey report for R87 dated 12/1/2021-12/31/2021 failed to evidence toilet use and incontinence care for R87 on day shift on 12/5/2021, 12/6/2021, 12/10/2021, 12/11/2021, 12/18/2021, 12/20/2021-12/24/2021, and 12/26/2021-12/31/2021. The report failed to evidence toilet use and incontinence care for R87 on evening shift on 12/5/2021, 12/6/2021, 12/9/2021, 12/16/2021, 12/23/2021, 12/24/2021, 12/26/2021, 12/30/2021 and 12/31/2021. The report failed to evidence toilet use and incontinence care for R87 on night shift on 12/7/2021-12/12/2021 and 12/15/2021-12/31/2021. The report failed to evidence a shower or bath on 12/10/2021, 12/14/2021, 12/21/2021, 12/24/2021, 12/28/2021 and 12/31/2021. The report failed to evidence ADL care for R87 on day shift on 12/5/2021, 12/6/2021, 12/10/2021, 12/11/2021, 12/13/2021, 12/14/2021, 12/18/2021, 12/20/2021-12/24/2021, 12/26/2021-12/31/2021. The report failed to evidence ADL care for R87 on evening shift on 12/5/2021, 12/6/2021, 12/9/2021, 12/11/2021, 12/16/2021, 12/23/2021, 12/24/2021, 12/26/2021, 12/30/2021, and 12/31/2021. The report failed to evidence ADL care for R87 on night shift on 12/7/2021-12/12/2021, and 12/15/2021- 12/31/2021. The report failed to evidence personal hygiene for R87 on day shift on 12/5/2021, 12/6/2021, 12/10/2021, 12/11/2021, 12/13/2021, 12/14/2021, 12/18/2021, 12/20/2021-12/24/2021, and 12/26/2021-12/31/2021. The report failed to evidence personal hygiene for R87 on evening shift for R87 for 12/5/2021, 12/6/2021, 12/9/2021, 12/16/2021, 12/23/2021, 12/24/2021, 12/26/2021, 12/30/2021 and 12/31/2021. The report failed to evidence personal hygiene for R87 on night shift for 12/7/2021-12/12/2021, and 12/15/2021- 12/31/2021. The Documentation survey report for R87 dated 1/1/2022-1/31/2022 failed to evidence toilet use and incontinence care for R87 on day shift on 1/2/2022 and 1/3/2022, 1/6/2022, 1/8/2022, 1/11/2022-1/13/2022, 1/15/2022-1/23/2022, 1/25/2022-1/27/2022 and 1/30/2022. The report failed to evidence toilet use and incontinence care for R87 on evening shift on 1/2/2022-1/6/2022, 1/9/2022-1/11/2022, 1/14/2022 and 1/15/2022, 1/18/2022 and 1/19/2022, 1/21/2022-1/24/2022, 1/28/2022 and 1/31/2022. The report failed to evidence toilet use and incontinence care for R87 on night shift on 1/1/2022-1/12/2022, 1/14/2022-1/25/2022 and 1/28/2022-1/31/2022. The report failed to evidence a shower or bath on 1/11/2022, 1/18/2022, 1/21/2022 and 1/25/2022. The report failed to evidence ADL care for R87 on day shift on 1/1/2022-1/3/2022, 1/6/2022, 1/8/2022, 1/11/2022-1/13/2022, 1/15/2022-1/23/2022, 1/25/2022-1/27/2022 and 1/30/2022. The report failed to evidence ADL care for R87 on evening shift on 1/2/2022-1/6/2022, 1/9/2022-1/11/2022, 1/14/2022 and 1/15/2022, 1/18/2022 and 1/19/2022, 1/21/2022-1/24/2022, 1/28/2022 and 1/31/2022. The report failed to evidence ADL care for R87 on night shift on 1/1/2022-1/12/2022, 1/14/2022-1/25/2022 and 1/28/2022-1/31/2022. The report failed to evidence personal hygiene for R87 on day shift on 1/1/2022-1/3/2022, 1/6/2022, 1/8/2022, 1/11/2022-1/13/2022, 1/15/2022-1/23/2022, 1/25/2022-1/27/2022 and 1/30/2022. The report failed to evidence personal hygiene for R87 on evening shift for R87 for 1/2/2022-1/6/2022, 1/9/2022-1/11/2022, 1/14/2022 and 1/15/2022, 1/18/2022 and 1/19/2022, 1/21/2022-1/24/2022, 1/28/2022 and 1/30/2022. The report failed to evidence personal hygiene for R87 on night shift for 1/1/2022-1/12/2022, 1/14/2022-1/26/2022 and 1/28/2022-1/31/2022. The comprehensive care plan for R87 documented in part, Incontinence: [R87] is incontinent of bowel. Needs assistance in incontinent care r/t (related to) functional deficit and underlying comorbidity. Use of indwelling foley r/t neurogenic bladder. Date Initiated: 07/17/2019. Revision on: 08/19/2021. The care plan further documented, Adl: [R87] has an ADL Self Care Performance Deficit and requires assistance with ADL's and mobility r/t dx (diagnoses) of MS (multiple sclerosis), gerd (gastro-esophageal reflux disease), htn (hypertension), ams (altered mental status), paraplegic, and blindness. Date Initiated: 07/17/2019. Revision on: 08/19/2021 . Under Interventions it documented in part, BED MOBILITY: Resident requires extensive assistance of one staff to reposition and turn in bed. Date Initiated: 08/02/2019 . The care plan further documented, [R87] chooses not to follow treatment regimen R/T: declines to have wedge removed. Declines to have to of the bed to be lowered. Declines to be repositioned in the bed. Date Initiated: 05/19/2022, Revision on: 05/19/2022. On 6/14/2022 at 2:48 p.m., an interview was conducted with CNA (certified nursing assistant) #5. CNA #5 stated that showers were given twice a week. CNA #5 stated that they had a schedule they followed with certain room numbers to receive showers on certain days. CNA #5 stated that if the resident refused their shower they let the nurse know and attempted later in the day. CNA #5 stated if the resident continued to refuse the shower they offered a bed bath or documented the refusal. CNA #5 stated that showers/bed baths were documented in the computer as completed or refused. CNA #5 stated that incontinence care was provided every 2 hours and as needed and personal hygiene was completed every shift. CNA #5 stated that all residents were given a bed bath each day in the morning to get them ready for the day. CNA #5 stated that the bed bath included the full body. CNA #5 stated that these were documented in the computer. CNA #5 stated that R87 had a catheter and they emptied the catheter bag each shift. CNA #5 stated that they turned and repositioned R87 every two hours and used a wedge to help position them and provided incontinence care at that time. CNA #5 stated that R87 liked to stay on their back most of the time and often refused to turn off of their back and use the wedge for positioning but often let them use pillows. CNA #5 stated that R87 got out of the bed most days and there were days when they refused to get out of bed. CNA #5 stated that they informed the nurse when R87 refused turning and positioning and getting out of bed. On 6/15/2022 at 8:15 a.m., an interview was conducted with CNA #2. CNA #2 stated that showers/bed baths were documented in the computer and on shower sheets. CNA #2 stated that there should not be any blank areas in the shower/bath/bed bath documentation because you could not say whether it was done or not and if there was an NA it meant not applicable so it did not happen. CNA #2 stated that all residents were given a bed bath each day in the morning prior to getting up and dressed. On 6/15/2022 at 10:54 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that showers were given twice a week and documented in the shower book and in the computer. LPN #3 stated that if a resident refused the shower it was documented in the medical record and the family was notified. LPN #3 stated that they always learned that if it was not documented it was not done and could not say that the care was provided if there was no documentation to support it. On 6/15/2022 at 4:05 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the southside regional clinical coordinator and ASM #4, the regional director of operations were made aware of the findings. No further information was provided prior to exit. Complaint deficiency. Based on observation, resident interview, staff interview, facility document review and in the course of a complaint investigation, the facility staff failed to provide ADL (activities of daily living) care for 3 of 59 residents in the survey sample, Residents #40, #10 and #87. The findings include: 1.a. The facility staff failed to trim Resident #40's (R40) fingernails. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/6/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. Section G coded R40 as being totally dependent on one staff with personal hygiene. On 6/14/22 at 3:10 p.m., an observation of R40's fingernails was conducted with LPN (licensed practical nurse) #8. R40's fingers were contracted and bent in towards the resident's palms; however, LPN #8 was able to move the resident's fingers out from the palms for the observation. R40's right thumb nail was approximately one forth inch long. All nails on R40's left hand, excluding the pinky finger, were approximately one half inch long. R40 stated staff had not trimmed the resident's nails in two to three months. R40's comprehensive care plan last reviewed on 4/15/22 documented, (R40) requires assistance with adl's r/t (related to) impaired mobility diagnosis of quadriplegia, muscle weakness, chronic pain. Guest will state that he needs his nails trimmed and then decline when offered by staff. BATHING: Check nail length and trim and clean on bath day and as necessary . However, a review of R40's clinical record (including nurses' notes and ADL records for March 2022 through June 2022) failed to reveal documentation that R40 was offered a fingernail trim and refused. On 6/15/22 at 8:02 a.m., an interview was conducted with CNA (certified nursing assistant) #2 and RN (registered nurse) #2 (a CNA and nurse who has cared for R40). CNA #2 stated she recently wanted to cut R40's fingernails but it was difficult to get the clippers under the resident's nails and she didn't know how to do so. CNA #2 stated she had not reported this to any other facility employee. CNA #2 stated she was going to ask the podiatrist if there was anything that could be done but the podiatrist was busy during the last visit. RN #2 stated she had recognized R40's fingernails and how his hands were formed (contracted fingers). RN #2 stated she had not attempted to trim R40's fingernails because she wasn't comfortable doing so. RN #2 stated had not found out what could be done to trim the resident's nails. On 6/15/22 at 8:54 a.m., an interview was conducted with LPN #6 (a unit manager). LPN #6 stated she observed R40's fingernails Wednesday or Thursday of the previous week. LPN #6 stated R40's fingers were hard to open. LPN #6 stated she was now trying to see how R40's nails could be trimmed and maybe a hand towel could be rolled into the resident's hands. LPN #6 stated she spoke with someone from the therapy department regarding this two weeks ago but she could not remember who she spoke to. On 6/15/22 at 10:27 a.m., R40 was observed lying in bed. A palm protector was on the resident's right hand. The fingernails on both of R40's hands were trimmed. R40 stated a therapist, nurse and CNA had been in the room and trimmed the resident's nails. On 6/15/22 at 10:44 a.m., an interview was conducted with OSM (other staff member) #8 (the rehab therapy director). OSM #8 stated no employee had come to him or the therapy staff regarding R40's fingernails until this morning when the unit manager asked if he could evaluate the resident. On 6/15/22 at 11:35 a.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing), ASM #3 (the regional clinical coordinator) and ASM #4 (the regional director of operations) were made aware of the above concern. The facility policy titled, Routine Guest/Resident Care documented, Guests/residents receive the necessary assistance to maintain good grooming and personal/oral hygiene .3. Daily personal hygiene minimally includes assisting or encouraging guests/residents with washing their face and hands, shaving, nail care, combing their hair each morning, and brushing their teeth and/or providing denture care. Any concerns will be reported to the nurse. No further information was presented prior to exit. Complaint Deficiency. 1.b. The facility staff failed to assist Resident #40 (R40) with eating assistance on 8/30/21 and 8/31/21. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/6/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. Section G coded R40 with requiring extensive assistance of one staff with eating. R40's comprehensive care plan last reviewed on 4/15/22 documented, (R40) requires assistance with adl's r/t (related to) impaired mobility diagnosis of quadriplegia, muscle weakness, chronic pain. EATING: Resident requires extensive set-up one staff assistance to eat. A complaint submitted to the SA (state agency) on 9/9/21 documented concern that R40 was not assisted with eating on either 8/30/21 or 8/31/21. A review of R40's point of care ADL (activities of daily living) records for 8/30/21 and 8/31/21 failed to reveal documentation of R40's meal intake or documentation that the resident was assisted with eating breakfast and lunch on those dates. On 6/13/22 at 3:12 p.m., an interview was conducted with R40. R40 stated there are times when the resident does not receive a meal tray. R40 stated the staff keeps the feeders meal trays on the cart and feeds them after they pass the other meal trays. R40 stated the facility contracts agency staff and sometimes they forget to assist the resident with meals. On 6/15/22 at 8:02 a.m., an interview was conducted with CNA (certified nursing assistant) #2 (a CNA who has cared for R40.) CNA #2 stated the CNAs are supposed to document meal assistance and intake in the point of care system. CNA #2 stated R40 must be fed and has voiced concerns about not being fed. CNA #2 stated meal trays for the residents who require assistance stay on the tray cart until the residents can be fed. CNA #2 stated sometimes R40 gets irritated by the time he is fed and then states he does not want the tray. A review of R40's clinical record (including ADL records and nurses' notes) for 8/30/21 and 8/31/21 failed to reveal documentation that R40 was offered assistance with eating and refused breakfast and lunch. On 6/15/22 at 11:35 a.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing), ASM #3 (the regional clinical coordinator) and ASM #4 (the regional director of operations) were made aware of the above concern. The facility policy titled, Routine Guest/Resident Care failed to reveal documentation regarding assistance with feeding. No further information was presented prior to exit. Complaint Deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to follow physician orders for a mammogram for Resident #15. Resident #15 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), diabetes mellitus, CHF (congestive heart failure) and dementia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/14/22, coded the resident as scoring a 4 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the comprehensive care plan dated 12/1/21 documented in part, NEED: Resident is at risk for impaired skin integrity/pressure injury. Resident is at risk for decline in condition. INTERVENTIONS: Observe and report to physician any changes in condition. Conduct weekly head to toe skin assessments. A review of the nurse practitioner's orders dated 10/12/21, revealed the following, Set up ASAP (as soon as possible) appointment with Breast cancer center one time only for hx (history) of left breast cancer, new mass to right breast for 2 Days. A review of the nurse practitioner's orders dated 10/18/21, revealed the following, Set up ASAP (as soon as possible) appointment for mammogram right breast mass/lump hx (history) of breast cancer. Call daughter and notify and see if able to set up and take to appointment one time only for right lump for 3 Day. A review of the nurse practitioner's orders dated 10/27/21, revealed the following, If not already done set up appointment for ASAP (as soon as possible) MAMMOGRAM FOR MASS TO RIGHT BREAST WITH HX (history) OF BREAST CANCER -NEED DONE ASAP one time only for MAMMOGRAM ASAP for 2 Days. A review of the nurse practitioner's orders dated 11/3/21, revealed the following, If not already done set up ASAP (as soon as possible) APPOINTMENT FOR MAMMOGRAM , RIGHT BREAST HARD MASS ORDER PLACED MULTIPLE TIMES IN OCC one time only for HX (history) BREAST CANCER, RIGHT BREAST MASS for 2 Days. A review of the nurse practitioner's orders dated 11/6/21, revealed the following, If not already done set up ASAP (as soon as possible) APPOINTMENT FOR MAMMOGRAM , RIGHT BREAST HARD MASS ORDER PLACED MULTIPLE TIMES IN OCC one time only for HX (history) BREAST CANCER, RIGHT BREAST MASS for 2 Days. A review of the nurse practitioner's orders dated 1/4/22, revealed the following, Please schedule patient to see surgeon ASAP (as soon as possible) for right breast mass, hx (history) left breast cancer s/p (status/post) mastectomy. Try to schedule appointment on Wed, Thu, or Fri. Patient will need transport provided as daughter unable to transport. Notify daughter of date/time of appointment for her to be present. A review of the nurse practitioner's orders dated 2/4/22, revealed the following, Referral to Breast surgeon for right breast mass/ hx (history) of breast cancer. A review of the nursing progress note dated 10/13/21 at 4:30 PM, revealed the following, Dynamic mobile notified of US ultrasound to right breast. Lump noted to right breast. Guest denied pain/discomfort. Order/face sheet/and paper work has been completed. Someone is to call facility from Dynamic mobile with date and time of US. MD/RP aware. A review of the nursing progress note dated 10/14/21 at 3:29 PM, revealed the following, Dynamic mobile notified facility that they would not be able to obtain US ultrasound to right breast, due 2 lumps. NP in facility and made aware. A review of the nurse practitioner's note dated 11/3/21 at 10:50 AM, revealed the following, Mass found to right breast patient has hx of breast cancer -order placed twice for appointment to be set up for mammogram ,patient denies pain on palpation, no s/s of acute distress. A review of the physician's note dated 1/4/22 at 10:15 AM, revealed the following, Follow up right breast mass, history left breast cancer. Nursing documents on 10/14/21 that Dynamic mobile not able to obtain ultrasound to right breast due to 2 lumps. Nurse practitioner recertification 11/3 mention order placed twice for appointment to be set up for mammogram. No result found in miscellaneous or results section in PCC (point click care). Spoke to daughter on phone, she was unaware of situation. Discussed whether or not she wishes to proceed with work up given patient's advance age and debility and would not be able to stand for mammogram. Daughter does want to pursue evaluation of right breast mass and indicated for preference to stay within Hospital system and previous doctor. She was unable to provide name of patient's treating doctors for her left breast cancer. A review of the physician's note dated 1/21/22 at 11:59 AM, revealed the following, Right breast mass found around Oct/[DATE]; history left breast cancer post mastectomy 2017. No work up done so far. A review of the nurse practitioner's note dated 2/3/22 at 7:11 PM, revealed the following, Right breast mass found around Oct/[DATE]. History left breast cancer post mastectomy 2017. No work up done so far. Spoke to RP (responsible party) who would like further evaluation. Will refer to breast surgeon, daughter aware she will need to be present at appointment for decision making/consent. A review of the nurse practitioner's note dated 3/11/22 at 12:20 PM, revealed the following, Appointment with breast cancer surgeon- patient s/p biopsy right breast cancer with possible mets per consult -patient to have PET scan on 3/24 at 8am -appointment placed in book for secretary. A review of the nurse practitioner's note dated 3/22/22 at 8:52 PM, revealed the following, Patient post right breast biopsy 3/1, patient has breast cancer with Mets she is scheduled for pet scan 3/24. A review of the nurse practitioner note dated 3/28/22 at 2:12 PM, revealed the following, Post right breast biopsy 3/1, + mets. Was scheduled for PET on 3/24, canceled due to Blood sugar on high side. A review of the physician note on dated 5/11/22 at 6:23 PM, revealed the following, Discussed PET (positon emission tomography) scan result stage 3 CA (cancer), chemo was offered but family decided no chemo due to age/dementia. Due to above patient will not be a candidate for any cardiac procedure as well, we will manage HF (heart failure) in the facility. Per oncology, prognosis 6-18 months. Family agreeable for comfort/hospice once she will significantly decline. The nurse practitioners and nurses who documented notes are no longer employed at the facility. An interview was conducted on 6/14/22 at 8:58 AM, with CNA (certified nursing assistant) #1. When ask her role in scheduling appointments for the residents, CNA #1 stated, I make appointments for the whole house except some residents might make their own. I have been here for 4-5 years. I round twice a day at 9:00 AM and 2:00 PM. I may get pulled to the floor to do AM care. I have an appointment book on all 3 units. On one side of the book, I have the appointment papers. I keep a copy and put on their unit, the resident name, date and time, who is picking up and time, doctors address. In that book, there is a piece of paper that is printed off from PCC and put on the left side of the book. The nurses let me know if there is an order in PCC and print off copy of the order. I go around every morning and check off all 3 books. If it is an agency nurse they do not make me aware of appointments. I have an email and the nurse practitioners sometimes email me. Some nurse practitioners will come up to me in the hall and give me appointments to make. Sometimes I schedule mammograms and they are so hard to get in. The nurse practitioner tells me where to call, sometimes they have the number. I do not document the follow up, I tell the nurses and I do not know if they write a note or not. Sometimes transportation does not show up at all and then we try to find out what happens. I call a day ahead of time to make sure they are coming, I will take the resident to the door myself and the transportation does not show up at times. When CNA #1 was asked for evidence of the appointments being made for the mammogram for Resident #15, CNA #1 stated, the previous administrator and DON (director of nursing) said to shred all the information monthly. I do not have any written or documented evidence. When asked if she had discussed this process with the current administrator (started April 2022) or director of nursing (started May 2022), CNA #1 stated, no, I have not. An interview was conducted on 6/14/22 at 11:20 AM, with ASM (administrative staff member) #5, the physician. When asked if she knew the mammogram situation with Resident #15, ASM #5 stated, Yes I do. We have changed our process, so that the physician spends more time with the long term care residents. When asked about the delay in implementation of orders for mammograms, ASM #5 stated, If it's an outside procedure like a mammogram, we put the order in and let the nurses know and the agency nurses know. We try to let the unit manager know. It sometimes gets lost with the agency nurse. The CNA (CNA #1) schedules the test, each situation is unique. Some procedure are multiple calls back and forth. The family is notified, if patients cannot make decisions, we let them know. Family involved and sometimes wants to go with the resident, or to make sure they will go for the procedure. When asked if the delay in obtaining the mammogram for Resident #15 could have impacted the prognosis for the resident, ASM #5 stated, I cannot say for 100%. I honestly believe that the prognosis was probably not impacted. Her dementia, comorbid conditions and functional status would all impact the prognosis. An interview was conducted on 6/14/22 at 3:00 PM with LPN (licensed practical nurse) #3. When asked if physician orders for appointments or tests are not completed as ordered, has the quality of care been maintained, LPN #3 stated, no, if we have not followed physician orders, we are not maintaining quality of care. On 6/15/22 at 3:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional clinical coordinator and ASM #4, the regional director of operations were informed of the above concern. According to the facility's Physician Orders policy dated 6/24/21, which revealed the following, Treatment rendered to a guest/resident must be in accordance with the specific standing, written, verbal, or telephone order of a physician or other licensed health professional ordering within their scope of practice and clinical privileges. No further information was provided prior to exit. Complaint Deficiency. 3. The facility staff failed to follow physician orders for a physician appointment with the surgeon for Resident #436. Resident #436 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: dementia, falls, atrial fibrillation, chronic kidney disease. The most recent MDS (minimum data set) assessment, a Medicare 5 day admission assessment, with an ARD (assessment reference date) of 5/19/21, coded the resident as scoring a 5 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the comprehensive care plan dated 12/1/21 documented in part, NEED: Resident has Actual impairment to skin integrity related to surgical wound. INTERVENTIONS: Treatment to skin impairment per order. A review of the physician's orders dated 5/17/21, revealed the following, Patient has an appointment with surgeon on 5/18/21 at 11 am. A review of the physician's note dated 5/17/21 at 12:32 PM, revealed the following, He has an appointment on 18th of May with his surgeon. No progress note on 5/18/21 documenting the surgeon appointment. An interview was conducted on 6/14/22 at 8:58 AM, with CNA (certified nursing assistant) #1. When ask her role in scheduling appointments for the residents, CNA #1 stated, I make appointments for the whole house except some residents might make their own. I have been here for 4-5 years. I round twice a day at 9:00 AM and 2:00 PM. I may get pulled to the floor to do AM care. I have an appointment book on all 3 units. On one side of the book, I have the appointment papers. I keep a copy and put on their unit, the resident name, date and time, who is picking up and time, doctors address. In that book, there is a piece of paper that is printed off from PCC and put on the left side of the book. The nurses let me know if there is an order in PCC and print off copy of the order. I go around every morning and check off all 3 books. If it is an agency nurse they do not make me aware of appointments. I have an email and the nurse practitioners sometimes email me. Some nurse practitioners will come up to me in the hall and give me appointments to make. The nurse practitioner tells me where to call, sometimes they have the number. I do not document the follow up, I tell the nurses and I do not know if they write a note or not. Sometimes transportation does not show up at all and then we try to find out what happens. I call a day ahead of time to make sure they are coming, I will take the resident to the door myself and the transportation does not show up at times. When CNA #1 was asked for evidence of the transportation being made for the surgeon appointment on 5/18/21 for Resident #436, CNA #1 stated, the previous administrator and DON (director of nursing) said to shred all the information monthly. I do not have any written or documented evidence. When asked if she had discussed this process with the current administrator (started April 2022) or director of nursing (started May 2022), CNA #1 stated, no, I have not. An interview was conducted on 6/14/22 at 11:20 AM, with ASM (administrative staff member) #5, the physician. When asked if she remembered Resident #436, ASM #5 stated, I believe my partner cared for him When asked if they knew he had missed his follow up surgical appointment, ASM #5 stated, I do not see any documentation of that. An interview was conducted on 6/14/22 at 3:00 PM with LPN (licensed practical nurse) #3. When asked if physician orders for appointments or tests are not completed as ordered, has the quality of care been maintained, LPN #3 stated, no, if we have not followed physician orders, we are not maintaining quality of care. On 6/15/22 at 3:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional clinical coordinator and ASM #4, the regional director of operations were informed of the above concern. According to the facility's Physician Orders policy dated 6/24/21, which revealed the following, Treatment rendered to a guest/resident must be in accordance with the specific standing, written, verbal, or telephone order of a physician or other licensed health professional ordering within their scope of practice and clinical privileges. No further information was provided prior to exit. Complaint Deficiency. Based on observation, resident interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to maintain residents' highest level of well-being for 4 of 59 residents in the survey sample, Residents #19, #15, #436, #701. The findings include: 1. The facility staff failed to schedule a mammogram per Resident #19's (R19) plan of care. On the most recent MDS (minimum data set), a five day Medicare assessment with an ARD (assessment reference date) of 4/18/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. On 6/13/22 at 1:21 p.m., an interview was conducted with R19. R19 stated that about a year ago, the resident's sister was diagnosed with breast cancer and the resident had not had a mammogram in approximately 15 years so R19 requested to have a mammogram scheduled at that time. R19 stated she spoke to two nurse practitioners and still had not had a mammogram. A note signed by a nurse practitioner on 5/27/21 documented, Patient concerned about her sister being dx (diagnosed) with breast cancer and would like to schedule a mammogram .ASSESSMENT/PLAN OF CARE/MEDICAL DECISION-MAKING: Family hx (history) of breast cancer- will schedule mammogram . A review of R19's clinical record failed to reveal a physician's order for a mammogram at this time. Further review of R19's clinical record revealed a physician's order signed by another nurse practitioner and dated 5/12/22 for a mammogram but failed to reveal a mammogram had ever been scheduled or completed. The nurse practitioner who signed the 5/27/21 note and the nurse practitioner who signed the 5/12/22 physician's order were no longer employed at the facility and were not available for interview. On 6/14/22 at 8:47 a.m., an interview was conducted with CNA (certified nursing assistant) #1 (the ward clerk responsible for scheduling appointments). CNA #1 stated she keeps a book on all three units and the nurses and nurse practitioners are supposed to communicate needed appointments via those books. CNA #1 stated that sometimes, nurses and the nurse practitioners will email her with appointment needs but sometimes she isn't notified of needed appointments at all (via the communication book or email). CNA #1 stated R19 makes her own appointments most of the time then writes them down along with a confirmation number and gives the paper to CNA #1. CNA #1 stated she could not provide any documentation to evidence why R19 had not received the mammogram. On 6/14/22 at 9:41 a.m., another interview was conducted with R19. R19 stated that sometimes she does schedule appointments but she asked the nurse practitioners to schedule the mammogram appointment because R19 did not know who to contact to make the appointment. On 6/15/22 at 9:13 a.m., another interview was conducted with CNA #1. CNA #1 stated R19 has a lot of appointments and she was not aware of the nurse practitioner's documentation on 5/27/21 or the physician's order on 5/11/22. CNA #1 stated one of the nurse practitioners used to make the statement that R19 makes her own appointments so she's going to let her do it. CNA #1 could not provide any further information. On 6/15/22 at 11:35 a.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing), ASM #3 (the regional clinical coordinator) and ASM #4 (the regional director of operations) were made aware of the above concern. The facility policy titled, Physician's Order documented, Physician orders are obtained to provide a clear direction in the care of the guest/resident. On 6/15/22 at 6:20 p.m., ASM #1 and ASM #2 stated the facility did not have a policy for mammograms or scheduling appointments. No further information was presented prior to exit. 4. For Resident #701 the facility staff failed to follow physician's orders and standards of practice for medication administration, by administering another resident's medications to Resident #701. Resident #701 was admitted to the facility on [DATE] and discharged to an assisted living facility on 9/25/21. The admission nursing assessment dated [DATE] documented the resident was alert and oriented to person only. On the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/21/21, the resident was coded as requiring supervision for eating and extensive assistance for all other areas of activities of daily living. A review of the facility policy, Medication Administration was conducted. This policy documented, Medications are administered in accordance with written orders of the attending physician Verify the medication label against the medication administration record for the guest/resident name, time, drug, dose, and route Never administer medications supplied for one guest/resident to another guest/resident A review of the comprehensive care plan for Resident #701 revealed one dated 9/2/21 for [Resident #701] is at risk for abnormal bleeding/bruising R/T: medication use . The interventions included one dated 9/2/21 for Administer medications as ordered A review of the clinical record revealed a nurse's note dated 9/20/21 at 7:20 AM (note actually created on 9/22/21 at 3:05 PM) that documented, [Resident #701] and another resident was put to bed in the wrong beds. on med pass [Resident #701] received the medication of the resident of who bed (they) was put into during the night. (They) received Levothyroxine (1). (They) was monitored and (their) brother was notified about the medication error. [Resident #701] ate (their) breakfast and responded back when being talked to. No S/S (signs or symptoms) of an (sic, a) reaction noted. A nurse's note dated 9/21/21 documented, notified brother of med event on 9-21-21, also notified np (nurse practitioner) and md (medical doctor) of med event n.n.o (no new orders) at this time will cont (continue) to monitor. A review of the Incident Report about the medication error, dated 9/20/21, included a written statement dated 9/21/21 from the nurse that made the medication error, documented, On 9/21/21 I administered to [Resident #701] two Tylenol (2) and synthroid (same as 1); When I administered [Resident #701] (their) medication I did not ask (their) name, I looked at (their) picture in the electronic record and thought it was the person laying in the bed. I was asked by the aide why [Resident #701] wasn't in (their) bed approximately seven in the morning. I then went to the computer and, identified in the computer the picture and calling out the guest name to clearly identify the MD. the aide (name) stated that she placed [Resident #701] in the wrong room around approximately three A.M. Vital signs were taken and no distress noted - same level of cognitive level. The nurse who made the medication error was no longer at the facility and could not be interviewed. On 6/14/22 at 3:00 PM, an interview was conducted with LPN #4 (Licensed Practical Nurse). She stated that the rights of medication administration were right resident, right medication, right dose, right route and right time. She stated that staff should not administer medications for one resident to another resident. On 6/15/22 at approximately 4:00 PM, ASM #1 (Administrative Staff Member), the Administrator, ASM #2, the Director of Nursing, and ASM #4, the Regional Director of Operations were made aware of the findings. No further information was provided by the end of the survey. References: (1) Levothyroxine - is used to treat hypothyroidism Information obtained from https://medlineplus.gov/druginfo/meds/a682461.html (2) Tylenol - is used to treat mild to moderate pain Information obtained from https://medlineplus.gov/druginfo/meds/a681004.html Complaint Deficiency.

Based on resident interview, staff interview clinical record review and in the course of a complaint investigation, the facility staff failed to provide condom catheter care and services per professional standards for one of 59 residents in the survey sample, Resident #40. The facility staff failed to change Resident #40's (R40) condom catheter every other day. The findings include: URINARY INCONTINENCE DEVICES: The systems for men most often consist of a pouch or condom-like device. This device is securely placed around the penis. This is often called a condom catheter. A drainage tube is attached at the tip of the device to remove urine. This tube empties into a storage bag, which can be emptied directly into the toilet. Condom catheters are most effective when applied to a clean, dry penis. You may need to trim the hair around the pubic area for better grip of the device. You must change the device at least every other day to protect the skin and prevent urinary tract infections. This information was obtained from the website: https://medlineplus.gov/ency/article/003974.htm On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/6/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. On 6/13/22 at 3:12 p.m., an interview was conducted with R40. R40 stated the condom catheter is supposed to be changed right much but nurses are currently changing it about every 10 days. R40 stated the nurses say they forgot to change it or don't know how to change it so the resident has to wait until a good nurse comes in. A review of R40's clinical record failed to reveal a physician's order to routinely change R40's condom catheter. A physician's order dated 6/29/21 documented to change the resident's condom catheter as needed and another physician's order dated 3/31/22 documented to change the resident's condom catheter as needed. R40's comprehensive care plan last reviewed on 4/15/22 documented, (R40) is at risk for urinary tract infection and catheter-related trauma: has Condom Catheter r/t (related to) paraplegia. Change catheter and tubing per facility policy . A review of TARs (treatment administration records) for August 2021 through Jun 2022 revealed R40's condom catheter was changed on the following dates: 8/5/21, 8/26/21, 9/16/21, 1/24/22, 2/6/22, 2/13/22, 3/29/22, 4/7/22, 4/18/22, 4/29/22, 5/9/22, 5/15/22, 5/25/22, 6/4/22, 6/12/22 and 6/14/22. There was no documentation to evidence the catheter was changed on any other dates. On 6/15/22 at 12:11 p.m., an interview was conducted with ASM (administrative staff member) #6 (the nurse practitioner). ASM #6 stated it is a professional standard and best practice to change a condom catheter every day. ASM #6 stated she was not aware R40's condom catheter change was only ordered as needed. On 6/15/22 at 3:10 p.m. a telephone interview was conducted with ASM #5 (Resident #40's physician). ASM #5 stated a condom catheter should be changed every 24 to 48 hours to check the skin for irritation/pressure ulcers and to prevent UTIs (urinary tract infections). ASM #5 stated she could not explain why R40 only had an as needed order for the condom catheter change. ASM #5 stated maybe this was per R40's request or the routine order got lost. R40 stated she tries to go through residents' orders when completing recertifications but she cannot review every resident's orders every day. Further review of R40's clinical record revealed antibiotic medication treatment was initiated for UTIs on 9/16/21 and 6/15/22. On 6/15/22 at 3:35 a.m., ASM #1 (the administrator), ASM #2 (the director of nursing), ASM #3 (the regional clinical coordinator) and ASM #4 (the regional director of operations) were made aware of the above concern. On 6/15/22 at 6:20 p.m., ASM #1 and ASM #2 stated the facility did not have a policy or standard of practice for condom catheters. No further information was presented prior to exit. Complaint Deficiency.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for one of 59 residents in the survey sample, Resident #58 (R58). The findings include: Facility staff failed to conduct complete pain assessments and attempt non-pharmacological interventions prior to the administration of a PRN [as needed] pain medication, tramadol (1). (R58) was admitted to the facility with a diagnosis that included by not limited to: rheumatoid arthritis. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 04/17/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section J0300 Pain Presence coded (R58) as having frequent pain in the past 5 (five) days. Section J0600 Pain Intensity coded (R58) as having a pain level of five out of ten with tem being the worse pain. The physician's order for (R58) documented in part, Tramadol HCl (hydrochloride) Tablet 50 MG (milligram). Give 1 tablet by mouth every 6 (six) hours as needed for pain. Complete NPI (non-pharmacological interventions) with use. Order date: 4/18/2022. The eMAR (electronic medication administration record) for (R58) dated June 2022 documented the physician's order as stated above and Pain-Non-Pharmacological Interventions: Document Non Pharmacological interventions used: 1)Massage. 2) Meditation/Relaxation. 3)Positioning. 4) Ice/cold pack. 5)Diversional Activity. 6) Guided Imagery. 7) Rest. 8)Social Interaction. as needed Document NonPharmacological interventions using the corresponding number. Start Date 04/12/2022. Review of the eMAR failed to evidence documentation of non-pharmacological interventions as stated above from 06/01/2022 through 06/12/2022. The eMAR revealed that (R58) received 50 mgs of tramadol on the following dates and times, with no evidence of the location of pain, type of pain and non-pharmacological interventions being attempted on: 06/01/2022 at 7:06 a.m., 06/02/2022 at 10:48 a.m. and at 6:29 p.m., 06/04/2022 at 12:21 p.m., 06/06/2022 at 8:24 a.m., 06/07/2022 at 10:19 a.m. and at 9:59 p.m., 06/08/2022 at 5:20 p.m., 06/09/2022 at 8:25 p.m., 06/10/2022 at 5:50 a.m., 06/11/2022 at 9:38 p.m. and on 06/12/2022 at 4:32 a.m. and at 9:33 p.m. Further review of the eMAR failed to evidence non-pharmacological interventions being attempted on: 06/03/2022 at 11:07 a.m., 06/08/2022 at 9:43 p.m. and on 06/09/2022 at 8:46 a.m. The comprehensive care plan for (R58) documented in part, Focus. (R58) is at risk for pain and/or has acute/chronic pain r/t (related to) DX (diagnoses: RA (rheumatoid arthritis), DJD (degenerative joint disease), GERD (gastroesophageal reflux disease). Date Initiated: 04/13/2022. Under Interventions it documented in part, Evaluate the effectiveness of pain interventions as given. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition as needed. Date Initiated: 04/13/2022. Review of the facility's nurse's notes for (R58) dated 06/01/2022 through 06/12/2022 failed to evidence the location of pain, type of pain and non-pharmacological interventions being attempted on the dates and times listed above and failed to evidence non-pharmacological interventions being attempted on the dates and times listed above. On 06/13/22 at approximately 12:52 p.m., an interview was conducted with (R58). When asked if they receive as needed pain medication (R58) stated yes. When asked of the nurse attempts to alleviate their pain by other means before administering their pain medication (R58) stated that nurse just gives them their medication. On 06/15/22 at 8:00 a.m., an interview was conducted with LPN (licensed practical nurse) # 7. When asked to describe the procedure when administering as needed pain medication LPN # 7 stated that the nurse assesses the resident's pain by obtaining the severity of the resident's pain on a scale of zero to ten, with ten being the worse pain, the location of the pain and the type of pain such as throbbing or stabbing. LPN # 7 stated that the nurse would then start with non-pharmacological interventions such as repositioning, ice pack, or heat, and if that does not alleviate the resident's pain, they would administer the prescribe medication. When asked how often non-pharmacological interventions LPN # 7 stated that it should be attempted each time before the as needed pain medication is administered. When asked where it would be documented that the location of pain, type of pain and non-pharmacological interventions were attempted LPN # 7 stated that it would be documented in the nurse's notes or the eMAR. When asked why it is important to attempt non-pharmacological interventions prior to the administration of as needed pain medication LPN # 7 stated that it could decrease use of pain medication. After review of the eMAR for non-pharmacological interventions LPN # 7 was asked about the missing documentation. LPN # 7 stated that they could not say non-pharmacological interventions were attempted because it was not documented. After reviewing the facility's nurse's notes for (R58) dated 06/01/2022 through 06/12/2022 and the eMAR for the administration of Tramadol LPN # 7 was asked if the location of pain, type of pain and non-pharmacological interventions were documented for the dates listed above. LPN # 7 stated, No. The facility's policy Pain Management documented in part, 6. Ask the guest/resident and observe to determine the intensity of pain: Mild pain - if a guest/resident indicates his or her pain is mild. Moderate pain - if a guest/resident indicates his or her pain is moderate. Severe Pain- if a guest/resident indicates his or her pain is severe. Very severe or Horrible - if a guest/resident indicates his or her pain is very severe or horrible. 7. Ask the guest/resident and observe to determine the location of pain .14. The staff will implement the care plan, monitor the guest/resident, and administer therapeutic interventions for pain, if ordered. On 06/15/2022 at approximately 11:35 a.m., ASM (administrative staff member) # 1, administrator, ASM # 2, director of nursing and ASM # 3, regional clinical coordinator, ASM# 4, regional director of operations. No further information was presented prior to exit. References: (1) Tramadol is used to relieve moderate to moderately severe pain. Tramadol extended-release tablets and capsules are only used by people who are expected to need medication to relieve pain around-the-clock. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a695011.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, clinical record review, and facility document review, it was determined the facility staff failed to provide dialysis care and services for two of 59 residents in the survey sample, Resident #76 and Resident #116. The findings include: 1. For Resident #76, the facility failed to provide communication to the dialysis facility for 10 of 14 visits in March 2022, 11 of 13 visits in April 2022, 13 of 13 visits in May 2022 and 4 of 5 visits in June 2022 and failed to monitor the catheter site for signs of infection and bleeding. Resident #76 was admitted to the facility on [DATE]. Resident #76's diagnoses included but were not limited to: ESRD (end stage renal disease) and dementia. Resident #76's most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 3/19/22, coded the resident as scoring 9 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of Resident #76's comprehensive care plan revised 9/9/21, revealed the following, NEED: Resident is at risk for complications related to needs for dialysis due to: End Stage Renal Disease. dialysis cath replaced 1/6/21. Hemodialysis Tuesday, Thursday, Saturday. INTERVENTIONS: Observe for signs/symptoms of infection to access site: Redness, Swelling, warmth or drainage/bleeding and other signs of infection: fever, generalized malaise, complaints of abdominal pain, chills. Document and report abnormal findings to the physician. For Hemodialysis: Facility will utilize the Dialysis Communication form to communicate with the dialysis center. Send the dialysis communication book to the dialysis center with each appointment. Upon return from the dialysis center review the communication book including any progress notes. Provide an update to the physician and any staff member/disciplines as needed. A review of the physician's orders dated 8/9/21 renewed 5/2/22, revealed the following, Hemodialysis Tuesday, Thursday, Saturday. Monitor dialysis catheter Right Chest for signs/symptoms of infection. May reinforce dressing if needed. Monitor every shift. A review of the dialysis binder for Resident #76 on 6/14/22, revealed the following, the facility's Hemodialysis Communication Form was completed on the following dates, 6/14/22, 4/22/22, 4/7/22, 3/29/22, 3/26/22 and 3/24/22. The facility failed to provide communication to the dialysis facility for 10 of 14 visits in March 2022, the missing dates in March 2022 were: 3/1, 3/3, 3/8, 3/10, 3/12 3/15, 3/17, 3/19, 3/22 and 3/31. The facility failed to provide communication to the dialysis facility for 11 of 13 visits in April 2022, the missing dates in April 2022 were: 4/2, 4/5, 4/9, 4/12, 4/14, 4/16, 4/19, 4/23, 4/26, 4/28 and 4/30. The facility failed to provide communication to the dialysis facility for 13 of 13 visits in May 2022, the missing dates in May 2022 were: 5/3, 5/5, 5/7, 5/10, 5/12, 5/14, 5/17, 5/19, 5/21, 5/24, 5/26, 5/28 and 5/31. The facility failed to provide communication to the dialysis facility for 5 of 5 visits in June 2022, the missing dates in June 2022 were: 6/2, 6/4, 6/7, 6/9 and 6/11. A review of the TAR (treatment administration record) for March 2022, revealed the following, Monitor dialysis catheter Right Chest for signs/symptoms of infection. May reinforce dressing if needed. Monitor every shift evidenced that 24 out of 93 shifts were missing documentation. Missing dates were day shift: 3/1, 3/2, ¾, 3/5, 3/6, 3/7, 3/12, and 3/15; evening shift 3/3, 3/6, 3/8, 3/9, 3/24 and 3/26 and night shift 3/1, ¾, 3/6, 3/7, 3/9, 3/10 3/11, 3/14, 3/15, 3/22 and 3/29. A review of the TAR for April 2022, revealed the following, Monitor dialysis catheter Right Chest for signs/symptoms of infection. May reinforce dressing if needed. Monitor every shift evidenced that 6 out of 61 shifts were missing documentation. Missing dates were day shift: 4/1, 4/9, 4/10 and 4/21; evening shift 4/8 and night shift 4/4. A review of the TAR for May 2022, revealed the following, Monitor dialysis catheter Right Chest for signs/symptoms of infection. May reinforce dressing if needed. Monitor every shift evidenced that 8 out of 90 shifts were missing documentation. Missing dates were day shift: 5/8, 5/17 and 5/23; evening shift: 5/23, 5/25, 5/26 and 5/28 and night shift 5/11. A review of the TAR for June 2022, revealed the following, Monitor dialysis catheter Right Chest for signs/symptoms of infection. May reinforce dressing if needed. Monitor every shift evidenced that 6 of 42 shifts were missing documentation. Missing dates were day shift: 6/5, 6/8, 6/10 and 6/11; evening shift: 6/10 and night shift 6/8. On 6/13/222 at 3:25 PM, an interview was conducted with Resident #76. When asked if she had a dialysis binder, Resident #76 stated, I have one. I believe I left it at the dialysis center. When asked if they (nursing staff) check the dialysis catheter site every shift, Resident #76 stated, I do not think so. An interview was conducted on 6/13/22 at 3:30 PM with LPN (licensed practical nurse) #1. When asked for the dialysis binder for Resident #76, LPN #1 stated, It is not up here, it may be in the resident's room. When asked the purpose of the dialysis communication form, LPN #1 stated, It is to provide information to the dialysis center about the resident's vital signs, weight and any additional important information. The dialysis center sends us information back about weight changes or orders. When asked the frequency of sending the communication form to the dialysis center, LPN #1 stated, it is sent with every visit. When asked what specific care is provided to a resident with hemodialysis, LPN #1 stated, We check the dialysis catheter or fistula site for bleeding or infection. If there is a fistula, we check for a bruit or thrill. When asked the frequency of these checks, LPN #1 stated, it is every shift. When asked where this is documented, LPN #1 stated, it is documented on the TAR. When asked if there are blanks in the TAR, what does that indicate, LPN #1 stated, it means that it was not done. A request was made on 6/14/22 at 12:15 PM for the dialysis communication forms from 3/1/22 through 6/14/22 for Resident #76. The dialysis binder was provided on 6/14/22 at 2:09 PM. On 6/14/22 at 4:20 PM, ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional clinical coordinator were informed of the above concern. A review of the facility's Hemodialysis policy dated 10/19, which reveals, The facility completes the appropriate section of the hemodialysis communication form prior to the guest/resident receiving each dialysis session and again when the resident returns. Evaluate the resident daily for dialysis access site and possible complications, including, but not limited to: bleeding, stenosis, infection, steel syndrome or aneurysms. No further information was provided prior to exit. 2. The facility staff failed to provide dialysis communication forms for (R116's) to the dialysis center on 05/20/2022, 05/23/2022, 05/25/2022, 05/27/2022, 05/30/2022, 06/01/2022, 06/10/2022 and 06/13/2022 and failed to complete dialysis communication forms on 05/13/2022, 05/16/2022, 05/18/2022, 06/03/2022, 06/06/2022 and 06/08/2022. (R116) was admitted to the facility with diagnoses included but were not limited to: acute kidney failure. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 05/15/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded (R116) for Dialysis while a resident. The physician's order for (R116) documented in part, Hemodialysis Monday, Wednesday, Friday. [Name of Dialysis Center and Phone Number] chairtime (chair time) 1200p (12:00 p.m.). Order Date: 05/12/2022. Check vital signs prior to dialysis (T,P,R,BP) (temperature, pulse, respiration, blood pressure) post (after) dialysis Monday, Wednesday, Friday. Every day shift Mon, Wed, Fri. (Monday, Wednesday, Friday). Order Date: 05/12/2022. The comprehensive care plan for (R116) dated 05/12/2022 documented in part, (R116) is at risk for complications R/T (related to) needs dialysis due to: ESRD (end stage renal disease). Date Initiated: 05/12/2022. Under Interventions it documented in part, Resident receives dialysis Monday, Wednesday, Friday. Date Initiated: 05/12/2022. The facility's Hemodialysis Communication Forms for (R116) documented in part, COMPLETED BY THE FACILITY BEFORE DEPARTURE. VS (vital signs): BP: T: P: R:, Mental Status:, Medication Dialysis:, Medication Changes:, Pertinent Labs: Condition of Shunt:, Special Instructions to Dialysis Unit:, Nurse Signature:. Under COMPLETED BY THE FACILITY UPON RETURN it documented, VS: BP: T: P: R:, Mental Status:, Condition of Access Site:, Nurse Signature:. Review of (R116's) dialysis communication book failed to evidence the facility's Hemodialysis Communication Forms for 05/20/2022, 05/23/2022, 05/25/2022, 05/27/2022, 05/30/2022, 06/01/2022, 06/10/2022 and 06/13/2022. Further review of (R116's) dialysis communication book revealed blanks under VS: BP: T: P: R:, Mental Status:, Medication Dialysis:, Medication Changes:, Pertinent Labs: Condition of Shunt: and Nurse Signature: on 06/03/2022 under the heading COMPLETED BY THE FACILITY BEFORE DEPARTURE. Under COMPLETED BY THE FACILITY UPON RETURN there were blanks under VS: BP: T: P: R:, Mental Status:, Condition of Access Site:, Nurse Signature: on 05/13/2022, 05/16/2022, 05/18/2022, 06/03/2022, 06/06/2022 and on 06/08/2022. On 06/14/2022 at approximately 10:10 a.m., an interview was conducted with LPN (licensed practical nurse) #7. When asked why it was important to complete the dialysis communication forms prior the resident going to the dialysis center LPN # 7 stated that it provided a baseline and the nurse could compare the resident's medical status before and after dialysis and with dialysis. When asked why it was important to complete the dialysis communication forms when the resident comes back to the facility from the dialysis center LPN # 7 stated that it directed the nurse to put eyes on the resident, gauges how well the resident was doing, see any recommendations from the dialysis center and check the resident's dialysis access site. After reviewing the dialysis communications sheets dated 05/13/2022, 05/16/2022, 05/18/2022, 06/03/2022, 06/06/2022 and on 06/08/2022 for (R116) LPN # 7 stated that if it wasn't documented then it wasn't done. When asked about (R116's) missing dialysis communication sheets for 05/20/2022, 05/23/2022, 05/25/2022, 05/27/2022, 05/30/2022, 06/01/2022, 06/10/2022 and 06/13/2022, LPN # 7 stated that they did not have them. The facility's policy Hemodialysis documented in part, 4. The facility completes the appropriate section of the hemodialysis communication form prior to guest/resident receiving each dialysis session and again when the guest/resident returns from hemodialysis. On 06/14/2022 at approximately 4:13 a.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, ASM #4, regional director of operations. No further information was presented prior to exit. References: (1) Dialysis treats end-stage kidney failure. It removes waste from your blood when your kidneys can no longer do their job. Hemodialysis (and other types of dialysis) does some of the job of the kidneys when they stop working well. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000707.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility document review it was determined facility staff failed to store food in one of one kitchens in accordance with professional standards for food service safety. The findings include: The facility failed to properly store plastic scoops in the dry good area, properly store opened, available for use frozen foods in the walk in freezer, and discard milk past it's expiration date in the walk in refrigerator. On 6/13/2022 at 10:44 a.m., an observation was made of the facility kitchen with OSM (other staff member) #11, the dietary aide. Observation of the dry goods area revealed three 18 quart plastic bins. One of the plastic bins was labeled Salt and was approximately 1/2 full. A blue plastic scoop was located inside the bin resting on top of the salt. Another plastic bin labeled Powdered milk was observed to be approximately 3/4 full. A plastic gallon sized zipper closure bag was observed laying on top of the lid to the bin with a plastic scoop sitting on top of the bag exposed to air. OSM #11 stated that the plastic scoops were supposed to be stored in the plastic bags when not in use and should not be stored on top of the bag exposed to air or in the bin touching the food product. OSM #11 stated that the plastic scoops were stored in the bags to keep them clean. OSM #11 stated that the plastic scoops were not stored on the food to prevent potential contamination. Observation of the walk in refrigerator revealed a gallon of whole milk approximately 1/4 full with a date on the outside of the container of Jun 08. OSM #11 stated that the date meant that it expired on 6/8/2022 and should have been discarded. OSM #11 agreed that it was available for use in the refrigerator. Observation of the walk in freezer revealed a box labeled as french petit rolls-unbaked. The inner plastic bag in the box was observed to be approximately 3/4 full and open with rolls exposed to air. One 3.5 lb bag of hashbrown patties was observed to be opened with hashbrowns exposed to air. One 3 ounce bag in a 10 pound box of battered [NAME] wedges was observed to be approximately 1/4 full with [NAME] wedges exposed to air. OSM #11 stated that products in the freezer should be dated and closed in plastic wrap after opening to keep them fresh. OSM #11 stated that it appeared someone had dated the products but had not closed the bags like they were supposed to. The facility policy Food purchasing and storage dated 8/1/2011 documented in part, .Dry Storage: .Containers with tight fitting covers or sealed plastic bags will be use for storing foods that have been removed form their original container. Scoops will be provided for items stored in bulk, kept covered near the containers and sanitized at least daily .Perishable Food Storage: .All frozen food will be dated, labeled and wrapped or sealed. Moisture-proof, tight-fitting materials will be used to prevent freezer burn . On 6/14/2022 at 4:15 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the southside regional clinical coordinator, and ASM #4, the regional director of operations were made aware of the findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence that the required information was provided to the receiving provider upon transfer to the hospital for two of 38 residents in the survey sample, Residents #71 and #333. The facility failed to evidence the comprehensive care plan goals were provided to the hospital for Resident #71's hospital transfer on 4/16/21, and for Resident #333's hospital on 3/9/21. The findings include: 1. Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of but not limited to acute respiratory failure, gastrostomy, below knee amputation (right), end stage renal disease, chronic obstructive pulmonary disease, deep vein thrombosis, dialysis, chronic kidney disease, dysphagia, aphasia, diabetes, depression, dementia, osteomyelitis, and COVID-19. The 5-day MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 4/28/21 coded the resident as severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing and toileting; extensive assistance for transfers, dressing, eating, and hygiene; and was incontinent of bowel and bladder. A review of the clinical record revealed a nurse's note dated 4/16/21 at 3:32 PM, which documented in part, resident tolerated her medications this morning; about 15 minutes later, CNA (Certified Nursing Assistant) notified nurse that resident was c/o (complaining of) trouble breathing; brought resident her inhaler and it helped for a few minutes; CNA put pulse ox (oxygen) on resident on monitored, she notified nurse that resident's PO2 (pulse oxygen saturation) went down to 86%; put resident on 2lpm (two liters per minute) of O2 (oxygen); MD (medical doctor) was called and notified, MD said to send resident out to hospital; notified niece, (name) also 146/62 96.8 79 16 86%y (Blood pressure 146/62, temperature 96.8, pulse 79, respirations 16, and oxygen saturation 86%). There were no further nurse's notes written about this event prior to hospital transfer. A review of the clinical record for Resident #71, revealed a SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer Form that was completed on 4/16/21. This form included resident demographic, medical, code status, functional status, and family contact, treatments, precautions, devices, allergies, and risk alert information. The form did not document any references to comprehensive care plan goals being provided. As part of the above form was a page titled Acute Care Transfer Document Checklist that listed various documents to be sent with the resident. Each item contained a line next to it, to be checked off as being provided. Nothing was checked off. Also, the checklist did not contain reference for the provision of comprehensive care plan goals as an item to be sent to the hospital. On 5/12/21 at 8:37 AM an interview was conducted with RN #4 (Registered Nurse) a unit manager. She stated that staff should send a facesheet, medication list, copy of the resident's code status, the care plan, and a bed hold policy. RN #4 stated it should be documented in the nurses note what all was sent. RN #4 reviewed the above identified transfer form and stated that it does not contain this information. She stated that if it was not documented in the nurse's note, then assume there is no evidence it was done. On 5/12/21 at 10:58 AM an interview was conducted with LPN #1 (Licensed Practical Nurse), who wrote the above note. LPN #1 stated that at the time of this resident's transfer she was new to the facility and was not aware of all the process. She stated that she should have sent a bed hold, facesheet, medication list, recent labs [laboratory tests], code status, and care plan. LPN #1 stated, I know now there was more stuff I was supposed to send but that was my second or third day on the unit. She stated that the unit manager who assisted with the transfer and paperwork was not there anymore. LPN #1 stated that there is a checklist but she did not see one. When asked how staff evidence what is sent, LPN #1 stated, Document it. When asked if the nurse's note or transfer form evidenced that the care plan goals were sent, LPN #1 stated, There is nothing in the note evidencing what was sent. There is a check list. When asked if the care plan goals was listed on the form, LPN #1 reviewed it and stated, It is not on it. When asked, how do you know what all to send each time if it is not on the check list, LPN #1 stated, The unit manager or person in charge are usually involved with the transfers. A review of the facility's admission / Transfer / Discharge policies that were provided did not address transfers/discharges in an emergent situation to the hospital and any associated procedures and requirements. On 5/12/21 at 11:13 AM, ASM (Administrative Staff Member) #1, #2, #3, and #5 (the Administrator, the Director of Nursing, the Regional Director of Operations, and the Senior Clinical Transition Specialist) were made aware of the findings. No further information was provided. 2. Resident #333 was admitted to the facility on [DATE] and discharged to the hospital on 3/9/21 and did not return to the facility. The resident was admitted with the diagnoses of but not limited to left tibia fracture, pneumonia, obesity, diabetes, glaucoma, high blood pressure, chronic kidney disease, heart failure, end stage renal disease, dislocation of ankle joint, and dialysis. The 5-day MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 2/19/21 coded the resident as cognitively intact in ability to make daily life decisions. Resident #333 was coded as requiring total care for bathing; extensive assistance for transfers, dressing, toileting and hygiene; independent for eating; and was coded as occasionally incontinent of bowel and bladder. A review of the clinical record for Resident #333 revealed the following notes in part: - A nurse's note dated 3/9/21 at 2:00 PM documented, Called MD (medical doctor) to notify him of the vital signs (temperature) 98.8, (blood pressure) 82/46, (pulse) 107, (oxygen saturation) level 89% on oxygen as ordered. Non- rebreather applied. Repeat (oxygen) level at 2:10pm is 75%. MD notified. Send patient out 911. RP (responsible party), daughter is aware. - A nurse's note dated 3/9/21 at 3:09 PM documented, This nurse observed guest as having a BS (blood sugar) of 57 nurse encouraged guest to drink some orange juice the aide assisted guest with her drink. upon getting a second set of BS it increased to 72. However guest was observed as having sob (shortness of breath) her O2 (oxygen) sats (saturation) were 89, oxygen was given at 5 liters and no improvement her vs (vital signs) (blood pressure) 82/46 (pulse) 107 O2 (oxygen saturation) 89 (temperature) 98.8. Patient primary was called Dr (doctor) (name) and he recommended that she be sent out to (name of) hospital verbal report was given, (Hospital nurse) the ER (Emergency Room) nurse stated she did not want the e-change of condition and e-interact transfer form to be faxed. A review of the clinical record for Resident #333 revealed a SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer Form that was completed on 3/9/21. This form included resident demographic, medical, code status, functional status, and family contact, treatments, precautions, devices, allergies, and risk alert information. The form did not document any references to comprehensive care plan goals being provided. As part of the above form was a page titled Acute Care Transfer Document Checklist that listed various documents to be sent with the resident. Each item contained a line next to it, to be checked off as being provided. Nothing was checked off. Also, the checklist did not contain reference for the provision of comprehensive care plan goals as an item to be sent to the hospital. On 5/12/21 at 8:37 AM an interview was conducted with RN #4 (Registered Nurse) a unit manager. She stated that staff should send a facesheet, medication list, copy of the resident's code status, the care plan, and a bed hold policy. She stated it should be documented in the nurses note what all was sent. RN #4 reviewed the above identified transfer form and stated that it does not contain this information. She stated that if it was not documented in the nurse's note, then assume there is no evidence it was done. The nurses involved in this hospital transfer were no longer at the facility and therefore could not be interviewed. A review of the facility's admission / Transfer / Discharge policies that were provided did not address transfers/discharges in an emergent situation to the hospital and any associated procedures and requirements. On 5/12/21 at 11:13 AM, ASM (Administrative Staff Member) #1, #2, #3, and #5 (the Administrator, the Director of Nursing, the Regional Director of Operations, and the Senior Clinical Transition Specialist) were made aware of the findings. No further information was provided. References: 1. Levaquin - is an antibiotic. Information obtained from https://medlineplus.gov/druginfo/meds/a697040.html 2. Albuterol - is a bronchodilator used to treat symptoms of lung diseases such as asthma and chronic obstructive pulmonary disease. Information obtained from https://medlineplus.gov/druginfo/meds/a607004.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #138 was admitted to the facility on [DATE]. Resident #138's diagnoses included but were not limited to congestive heart failure, high blood pressure and acute respiratory failure. Resident #138's annual and five day Medicare minimum data set assessment with an assessment reference date of 1/11/21, coded the resident's cognition as severely impaired. Resident #138 was discharged to the hospital on 2/24/21 for shortness of breath and a low oxygen level. Review of Resident #138's clinical record failed to reveal evidence that notification of the discharge was provided to the ombudsman. On 5/12/21 at 10:01 a.m., an interview was conducted with OSM (other staff member) #4 (the director of social services). OSM #4 stated she did not notify the ombudsman of resident hospital discharges but the administrator did. On 5/12/21 at 10:10 a.m., an interview was conducted with ASM (administrative staff member) #1, the administrator. ASM #1 stated the director of social services faxed a monthly list of resident hospital discharges to the ombudsman. ASM #1 was asked to provide evidence that notification of Resident #138's hospital discharge on [DATE] was provided to the ombudsman. On 5/12/21 at 11:28 a.m., ASM #1 stated she could not provide the requested document and was made aware that this was a concern. No further information was presented prior to exit. Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence that the Ombudsman was notified of a hospital transfer for three of 38 residents in the survey sample, Residents #71, #333, and #138. The facility staff failed to evidence that notification of the transfer was provided to the ombudsman for Resident #71, transferred to the hospital on 4/16/21, Resident #33, transferred to the hospital on 3/9/21 and Resident #138, transferred to the hospital on 2/24/21. The findings include: 1. Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of but not limited to acute respiratory failure, gastrostomy, below knee amputation (right), end stage renal disease, chronic obstructive pulmonary disease, deep vein thrombosis, dialysis, chronic kidney disease, dysphagia, aphasia, diabetes, depression, dementia, osteomyelitis, and COVID-19. The 5-day MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 4/28/21 coded the resident as being severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing and toileting; extensive assistance for transfers, dressing, eating, and hygiene; and was incontinent of bowel and bladder. A review of the clinical record for Resident #71 revealed a nurse's note dated 4/16/21 at 3:32 PM that documented in part, resident tolerated her medications this morning; about 15 minutes later, CNA (Certified Nursing Assistant) notified nurse that resident was c/o (complaining of) trouble breathing; brought resident her inhaler and it helped for a few minutes; CNA put pulse ox (oxygen) on resident on monitored, she notified nurse that resident's PO2 (pulse oxygen saturation) went down to 86%; put resident on 2lpm (two liters per minute) of O2 (oxygen); MD (medical doctor) was called and notified, MD said to send resident out to hospital; notified niece, (name) also 146/62 96.8 79 16 86%y (Blood pressure 146/62, temperature 96.8, pulse 79, respirations 16, and oxygen saturation 86%). There were no further nurse's notes written about this event prior to hospital transfer. A review of the clinical record for Resident #71 revealed a SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer Form that was completed on 4/16/21. This form included resident demographic, medical, code status, functional status, and family contact, treatments, precautions, devices, allergies, and risk alert information. The form did not document any references to a written Ombudsman notice being provided. On 5/12/21 at 8:37 AM an interview was conducted with RN #4 (Registered Nurse) a unit manager. She stated that nurses do not notify the Ombudsman. On 5/12/21 at 10:02 in an interview with OSM #4 (Other Staff Member, the Social Worker), she stated that the Administrator does the Ombudsman notifications. On 5/12/21 at 10:09 AM in an interview with ASM #1 (Administrative Staff Member, the Administrator), she stated that the social worker does the Ombudsman notifications. A review of the facility's admission / Transfer / Discharge policies that were provided did not address transfers/discharges in an emergent situation to the hospital and any associated procedures and requirements. On 5/12/21 at 11:13 AM, ASM (Administrative Staff Member) #1, #2, #3, and #5 (the Administrator, the Director of Nursing, the Regional Director of Operations, and the Senior Clinical Transition Specialist) were made aware of the findings. No further information was provided. 2. Resident #333 was admitted to the facility on [DATE] and discharged to the hospital on 3/9/21 and did not return to the facility. The resident was admitted with the diagnoses of but not limited to left tibia fracture, pneumonia, obesity, diabetes, glaucoma, high blood pressure, chronic kidney disease, heart failure, end stage renal disease, dislocation of ankle joint, and dialysis. The 5-day MDS (Minimum Data Set), assessment with an ARD (Assessment Reference Date) of 2/19/21 coded the resident as being cognitively intact in ability to make daily life decisions. A review of the clinical record revealed in part the following notes: - A nurse's note dated 3/9/21 at 2:00 PM documented, Called MD (medical doctor) to notify him of the vital signs (temperature) 98.8, (blood pressure) 82/46, (pulse) 107, (oxygen saturation) level 89% on oxygen as ordered. Non- rebreather applied. Repeat (oxygen) level at 2:10pm is 75%. MD notified. Send patient out 911. RP (responsible party), daughter is aware. - A nurse's note dated 3/9/21 at 3:09 PM documented, This nurse observed guest as having a BS (blood sugar) of 57 nurse encouraged guest to drink some orange juice the aide assisted guest with her drink. upon getting a second set of BS it increased to 72. However guest was observed as having sob (shortness of breath) her O2 (oxygen) sats (saturation) were 89, oxygen was given at 5 liters and no improvement her vs (vital signs) (blood pressure) 82/46 (pulse) 107 O2 (oxygen saturation) 89 (temperature) 98.8. Patient primary was called Dr (doctor) (name) and he recommended that she be sent out to (name of) hospital verbal report was given, (Hospital nurse) the ER (Emergency Room) nurse stated she did not want the e-change of condition and e-interact transfer form to be faxed. A review of the clinical record for Resident #333 revealed a SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer Form that was completed on 3/9/21. This form included resident demographic, medical, code status, functional status, and family contact, treatments, precautions, devices, allergies, and risk alert information. The form did not document any references to a written Ombudsman notice being provided. On 5/12/21 at 8:37 AM an interview was conducted with RN #4 (Registered Nurse) a unit manager. She stated that nurses do not notify the Ombudsman. On 5/12/21 at 10:02 in an interview with OSM #4 (Other Staff Member, the Social Worker), she stated that the Administrator does the Ombudsman notifications. On 5/12/21 at 10:09 AM in an interview with ASM #1 (Administrative Staff Member, the Administrator), she stated that the social worker does the Ombudsman notifications. A review of the facility's admission / Transfer / Discharge policies that were provided did not address transfers/discharges in an emergent situation to the hospital and any associated procedures and requirements. On 5/12/21 at 11:13 AM, ASM (Administrative Staff Member) #1, #2, #3, and #5 (the Administrator, the Director of Nursing, the Regional Director of Operations, and the Senior Clinical Transition Specialist) were made aware of the findings. No further information was provided. References: 1. Levaquin - is an antibiotic. Information obtained from https://medlineplus.gov/druginfo/meds/a697040.html 2. Albuterol - is a bronchodilator used to treat symptoms of lung diseases such as asthma and chronic obstructive pulmonary disease. Information obtained from https://medlineplus.gov/druginfo/meds/a607004.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence that a written bed hold notice was provided to the resident and/or responsible party upon a hospital transfer for 2 of 38 residents in the survey sample; Residents #71 and #333. The facility staff failed to evidence that a written bed hold notice was provided to the resident and/or responsible party upon a hospital transfer for Resident #71 on 4/16/21, and for Resident #333 on 3/9/21. The findings include: 1. Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of but not limited to acute respiratory failure, gastrostomy, below knee amputation (right), end stage renal disease, chronic obstructive pulmonary disease, deep vein thrombosis, dialysis, chronic kidney disease, dysphagia, aphasia, diabetes, depression, dementia, osteomyelitis, and COVID-19. The 5-day MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 4/28/21 coded the resident as being severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing and toileting; extensive assistance for transfers, dressing, eating, and hygiene; and was incontinent of bowel and bladder. A review of the clinical record for Resident #71 revealed a nurse's note dated 4/16/21 at 3:32 PM that documented in part, resident tolerated her medications this morning; about 15 minutes later, CNA (Certified Nursing Assistant) notified nurse that resident was c/o (complaining of) trouble breathing; brought resident her inhaler and it helped for a few minutes; CNA put pulse ox (oxygen) on resident on monitored, she notified nurse that resident's PO2 (pulse oxygen saturation) went down to 86%; put resident on 2lpm (two liters per minute) of O2 (oxygen); MD (medical doctor) was called and notified, MD said to send resident out to hospital; notified niece, (name) also 146/62 96.8 79 16 86%y (Blood pressure 146/62, temperature 96.8, pulse 79, respirations 16, and oxygen saturation 86%). There were no further nurse's notes written about this event prior to hospital transfer. A review of the clinical record for Resident #71 revealed a SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer Form that was completed on 4/16/21. This form included resident demographic, medical, code status, functional status, and family contact, treatments, precautions, devices, allergies, and risk alert information. The form did not document any references to a written bed hold notice being provided. As part of the above form was a page titled Acute Care Transfer Document Checklist that listed various documents to be sent with the resident. Each item contained a line next to it, to be checked off as being provided. Nothing was checked off. Also, the checklist did not contain reference for the provision of a written bed hold notice as an item to be sent to the hospital. On 5/12/21 at 8:37 AM an interview was conducted with RN #4 (Registered Nurse) a unit manager. She stated that staff should send a facesheet, medication list, copy of the resident's code status, the care plan, and a bed hold policy. She stated it should be documented in the nurses note what all was sent. RN #4 reviewed the above identified transfer form and stated that it does not contain this information. She stated that if it was not documented in the nurse's note, then assume there is no evidence it was done. On 5/12/21 at 10:58 AM an interview was conducted with LPN #1 (Licensed Practical Nurse), who wrote the above note. She stated that at the time of this resident's transfer she was new to the facility and was not aware of all the process. She stated that she should have sent a bed hold, facesheet, medication list, recent labs, code status, and care plan. LPN #1 stated, I know now there was more stuff I was supposed to send but that was my second or third day on the unit. She stated that the unit manager who assisted with the transfer and paperwork was not there anymore. LPN #1 stated that there is a checklist but she did not see one. When asked how staff evidence what was sent, LPN #1 stated, Document it. When asked if the nurse's note or transfer form evidenced that the bed hold notice was sent, LPN #1 stated, There is nothing in the note evidencing what was sent. There is a check list. When asked if the bed hold notice was included on the checklist, LPN #1 reviewed it and stated, It is not on it. When asked, how staff know what to send each time if it is not on the check list, LPN #1 stated, The unit manager or person in charge are usually involved with the transfers. On 5/12/21 at 10:02 in an interview with OSM #4 (Other Staff Member, the Social Worker), she stated that the Admissions department handles Bed Holds. On 5/12/21 at 10:09 AM in an interview with ASM #1 (Administrative Staff Member, the Administrator), she stated that a Bed Hold notice goes in the discharge packet upon transfer. On 5/12/21 at 10:24 AM in an interview with OSM #5, the Admissions staff member, she stated that when a resident is sent to the hospital, she calls the emergency room and checks on the resident's status. OSM #5 stated she then calls the family to offer the Bed Hold. She stated that if they do want to do one there is a form they fill out and sign and for how many days. She stated that most decline it. OSM #5 stated that she thought they we were only to do it if they want the bed hold and sign the form. She stated that she does not maintain documentation that those who did not want it were offered. OSM #5 stated she calls every family for hospital transfers. A review of the facility's admission / Transfer / Discharge policies that were provided did not address transfers/discharges in an emergent situation to the hospital and any associated procedures and requirements. On 5/12/21 at 11:13 AM, ASM (Administrative Staff Member) #1, #2, #3, and #5 (the Administrator, the Director of Nursing, the Regional Director of Operations, and the Senior Clinical Transition Specialist) were made aware of the findings. No further information was provided. 2. Resident #333 was admitted to the facility on [DATE] and discharged to the hospital on 3/9/21 and did not return to the facility. The resident was admitted with the diagnoses of but not limited to left tibia fracture, pneumonia, obesity, diabetes, glaucoma, high blood pressure, chronic kidney disease, heart failure, end stage renal disease, dislocation of ankle joint, and dialysis. The 5-day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/19/21 coded the resident as being cognitively intact in ability to make daily life decisions. The resident was coded as requiring total care for bathing; extensive assistance for transfers, dressing, toileting and hygiene; independent for eating; and was occasionally incontinent of bowel and bladder. Resident #333 was admitted to the facility on [DATE] and discharged to the hospital on 3/9/21 and did not return to the facility. The resident was admitted with the diagnoses of but not limited to left tibia fracture, pneumonia, obesity, diabetes, glaucoma, high blood pressure, chronic kidney disease, heart failure, end stage renal disease, dislocation of ankle joint, and dialysis. The 5-day MDS (Minimum Data Set), assessment with an ARD (Assessment Reference Date) of 2/19/21 coded the resident as being cognitively intact in ability to make daily life decisions. A review of the clinical record revealed in part the following notes: - A nurse's note dated 3/9/21 at 2:00 PM documented, Called MD (medical doctor) to notify him of the vital signs (temperature) 98.8, (blood pressure) 82/46, (pulse) 107, (oxygen saturation) level 89% on oxygen as ordered. Non- rebreather applied. Repeat (oxygen) level at 2:10pm is 75%. MD notified. Send patient out 911. RP (responsible party), daughter is aware. - A nurse's note dated 3/9/21 at 3:09 PM documented, This nurse observed guest as having a BS (blood sugar) of 57 nurse encouraged guest to drink some orange juice the aide assisted guest with her drink. upon getting a second set of BS it increased to 72. However guest was observed as having sob (shortness of breath) her O2 (oxygen) sats (saturation) were 89, oxygen was given at 5 liters and no improvement her vs (vital signs) (blood pressure) 82/46 (pulse) 107 O2 (oxygen saturation) 89 (temperature) 98.8. Patient primary was called Dr (doctor) (name) and he recommended that she be sent out to (name of) hospital verbal report was given, (Hospital nurse) the ER (Emergency Room) nurse stated she did not want the e-change of condition and e-interact transfer form to be faxed. A review of the clinical record for Resident #333 revealed a SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer Form that was completed on 3/9/21. This form included resident demographic, medical, code status, functional status, and family contact, treatments, precautions, devices, allergies, and risk alert information. The form did not document any references to a written bed hold notice being provided. As part of the above form was a page titled Acute Care Transfer Document Checklist that listed various documents to be sent with the resident. Each item contained a line next to it, to be checked off as being provided. Nothing was checked off. Also, the checklist did not contain reference for the provision of a written bed hold notice as an item to be sent to the hospital. The nurses involved in this hospital transfer were no longer at the facility and therefore could not be interviewed. On 5/12/21 at 8:37 AM an interview was conducted with RN #4 (Registered Nurse) a unit manager. She stated that staff should send a facesheet, medication list, copy of the resident's code status, the care plan, and a bed hold policy. She stated it should be documented in the nurses note what all was sent. RN #4 reviewed the above identified transfer form and stated that it does not contain this information. She stated that if it was not documented in the nurse's note, then assume there is no evidence it was done. On 5/12/21 at 10:02 in an interview with OSM #4 (Other Staff Member, the Social Worker), she stated that the Admissions department handles Bed Holds. On 5/12/21 at 10:09 AM in an interview with ASM #1 (Administrative Staff Member, the Administrator), she stated that a Bed Hold notice goes in the discharge packet upon transfer. On 5/12/21 at 10:24 AM in an interview with OSM #5, the Admissions staff member, she stated that when a resident is sent to the hospital, she calls the emergency room and checks on the resident's status. OSM #5 stated she then calls the family to offer the Bed Hold. She stated that if they do want to do one there is a form they fill out and sign and for how many days. She stated that most decline it. OSM #5 stated that she thought they we were only to do it if they want the bed hold and sign the form. She stated that she does not maintain documentation that those who did not want it were offered. OSM #5 stated she calls every family for hospital transfers. A review of the facility's admission / Transfer / Discharge policies that were provided did not address transfers/discharges in an emergent situation to the hospital and any associated procedures and requirements. On 5/12/21 at 11:13 AM, ASM (Administrative Staff Member) #1, #2, #3, and #5 (the Administrator, the Director of Nursing, the Regional Director of Operations, and the Senior Clinical Transition Specialist) were made aware of the findings. No further information was provided. References: 1. Levaquin - is an antibiotic. Information obtained from https://medlineplus.gov/druginfo/meds/a697040.html 2. Albuterol - is a bronchodilator used to treat symptoms of lung diseases such as asthma and chronic obstructive pulmonary disease. Information obtained from https://medlineplus.gov/druginfo/meds/a607004.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to code the annual MDS [minimum data set], with an ARD [assessment reference date] of 03/16/2021, for the use of oxygen for one of 38 residents in the survey sample, Resident # 58. The findings include: Resident # 58 was admitted to the facility with diagnoses that included but were not limited to: acute and chronic respiratory failure [1] and chronic obstructive pulmonary disease [2]. Resident # 58's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 03/16/2021, coded Resident # 58 as scoring an 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. Under section O0100 Special Treatments, Procedures and Programs it documented in part, C. Oxygen therapy. 2. While a Resident. Further review of this section revealed the box under 2. While a Resident, was not checked. On 05/10/21 at 1:46 p.m., 05/11/21 at 7:57 a.m., and on 05/11/21 at 2:17 p.m., observations of Resident # 58 revealed the resident lying in bed receiving oxygen by nasal cannula from an oxygen concentrator. Observation of the flow meter on the oxygen concentrator revealed that Resident # 58 was receiving oxygen at three liters per minute. The POS [physician's order sheet' dated May 2021 for Resident # 58 documented, O2 [oxygen] 4L [four liters] via [by] NC [nasal cannula] continuously. Start Date: 12/16/2019. On 05/11/2021 at 4:12 p.m. an interview was conducted with RN [registered nurse] # 3, MDS coordinator. When asked about the coding for Resident # 58's use of oxygen on their annual MDS assessment dated [DATE], RN # 3 stated they would review the MDS. On 05/12/2021 at 9:29 a.m., RN # 3 stated that Resident # 58's annual MDS was not coded for oxygen. When asked to describe the procedure for completing the MDS, RN # 3 stated that they follow the RAI [resident assessment manual. CMS's (Centers of Medicare/Medicaid) RAI (resident assessment instrument) Version 3.0 Manual CH 3: MDS documented, SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS. Intent: The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received during the specified time periods. O0100: Special Treatments, Procedures, and Programs. Facilities may code treatments, programs and procedures that the resident performed themselves independently or after set-up by facility staff. Do not code services that were provided solely in conjunction with a surgical procedure or diagnostic procedure, such as IV medications or ventilators. Surgical procedures include routine pre- and post-operative procedures. On 05/12/2021 at approximately 11:15 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, regional director of operations and ASM # 4, senior clinical transition specialist, were made aware of the above findings. No further information was provided prior to exit. References: [1] When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. [2] Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, facility staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement a resident's initial baseline care plan for one of 38 residents reviewed, Resident #337. The facility staff failed to administer oxygen at the physician-prescribed rate, according to Resident #337's baseline care plan. The findings include: Resident #337 was admitted to the facility on [DATE] with diagnoses including COPD (1) and lung cancer. She had not been a resident of the facility long enough to have a completed MDS (minimum data set) assessment. On the Resident #337's admission nursing assessment dated [DATE], she was coded as being oriented to person, place, and time, and as receiving oxygen at the rate of two liters per minute. On 5/11/21 at 9:53 a.m., Resident #337 was observed sitting up in bed. Her eyes were closed. Oxygen was being delivered to her from a concentrator through a nasal cannula. The middle of the ball on the concentrator flowmeter was observed between 3.5 and 4 liters per minute. During the observation, Resident #337 awoke and participated in an interview. She stated her oxygen rate should be four liters per minute, and that is the rate her doctor had ordered for her both at home, and after she was admitted to the facility. Resident #337 stated she had been receiving oxygen at 4 liters per minute ever since she was admitted . She stated she did not adjust the oxygen concentrator herself, and that a staff member had mentioned that the knob on the oxygen concentrator for adjusting the flow rate was broken. On 5/11/21 at 12:15 p.m., Resident #337 was observed sitting in a wheelchair eating lunch. Oxygen was being delivered to her from a concentrator through a nasal cannula. The middle of the ball on the oxygen concentrator flowmeter was observed between 3.5 and 4 liters per minute. On 5/11/21 at 2:50 p.m., Resident #337 was observed sitting in a wheelchair in her room. LPN #12 came into the room. When asked to state the rate of Resident #337's oxygen, LPN #1 stated, Well, the top of the ball is on 4. The bottom of the ball is on 3.5. There is no knob to adjust it. LPN #12 was observed manipulating the knobs on the oxygen concentrator, and finally stated, I fixed it. I moved it to 4. The line should go through the middle of the ball. A review of Resident #337's clinical record revealed the following oxygen orders: - 4/27/21 Oxygen cont. (continuous) 2LPM (two liters per minute) via NC (nasal cannula) to keep sats (saturations) >92% (greater than 92%) every shift. This order was discontinued by LPN #12 at 3:00 p.m. on 5/11/21. - 5/11/21 (at 3:00 p.m.) Oxygen cont. at 4 LPM via NC to keep sats >92% every shift. This order was entered by LPN #12. A review of Resident #337's initial baseline care plan dated 4/26/21, revealed, in part: [Resident #337] has a potential for difficulty breathing and risk for respiratory complications .Administer medications and treatments per physician orders .Oxygen. On 5/11/21 at 2:11 p.m., RN (registered nurse) #3, the MDS nurse, was interviewed. When she asked the purpose of a resident's care plan, RN #3 stated the care plan tells the staff how to take care of a resident, and raises any issues that should be addressed while the resident is in the facility's care. On 5/11/21 at 3:19 p.m., LPN #1 was interviewed. When asked the purpose of the care plan, she stated the care plan contains different tools that are in place to help the resident, and different interventions to assist the resident and keep the resident safe. She stated the care plan contains goals that can be set, measured, and evaluated. LPN #1 stated the goals are set in place in order for the resident to have the optimal outcome. When asked how she makes sure the care plan interventions are implemented, LPN #1 stated that many of the interventions pop up on the TAR for the staff to sign off as being completed. On 5/11/21 at 4:45 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing (DON), and ASM #3, the regional director of operations, were informed of these concerns. On 5/12/21 at 10:34 a.m., LPN #4, a unit manager, was interviewed. When asked how a resident's oxygen rate is determined, LPN #4 stated, I will talk to the resident, then look through the orders. She stated an order from a physician, which includes the rate and method of delivery, is required to administer oxygen. On 5/12/21 at 10:58 a.m., ASM #2, the director of nursing was interviewed. She stated the physician's ordered rate should be followed. No further information was provided prior to exit. REFERENCES (1) COPD is a general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review it was determined that the facility staff failed to revise the comprehensive care plan for one of 38 residents in the survey sample, Resident #57. Resident #57's comprehensive care plan was not revised to address a significant weight loss. The findings include: Resident #57 was admitted to the facility with diagnoses that included but were not limited to metabolic encephalopathy (1), dementia (2) and osteoarthritis (3). Resident #57's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/15/2021, coded Resident #57 as scoring a 3 (three) on the staff assessment for mental status (BIMS) with a score of 0 - 15, 3- being severely impaired for making daily decisions. Section G coded Resident #57, as requiring extensive assistance of two or more staff for bed mobility, transfers and dressing. Section K coded Resident #57 as having a swallowing disorder and receiving a mechanically altered diet while at the facility. The clinical record for Resident #57 documented an admission weight of 209 lbs (pounds) on 3/11/2021 and a weight of 195.0 lbs on 3/25/2021 for a 14 pound weight loss in 14 days. The clinical record further documented the most current weight of 176.4 lbs on 5/7/2021, for a 32.6 pound weight loss from 3/11/2021 to 5/7/2021. The physician orders for Resident #57 documented in part, - Regular diet, Pureed texture, Nectar consistency. Order Date: 3/12/2021. - Magic Cups (dietary supplement) two times a day with lunch and dinner daily. Order Date: 4/13/2021. - Med Pass 2.0 (dietary supplement) three times a day 120ml (milliliter) TID (three times a day) for supplement. Order Date: 3/26/2021. The progress notes for Resident #57 documented in part, - 3/26/2021 10:05 (10:05 a.m.) Reviewed Clinical Indicator: Reviewed in RAR (resident at risk) for weight loss, down 14# (14 pounds) this week. Remains obese with BMI (body mass index) of 30.5 (4). Dysphagia (5), requires puree texture with nectar thick liquids. ST (speech therapy) following for swallowing. PO (by mouth) intake is poor, <50% (less than fifty percent) most meals. Guest also on Lasix daily (diuretic medication). Action Taken: Will increase Med Pass supplement to TID, staff assist with meals as needed, encourage intake of meals and supplements. Response to Previous Actions Taken: Continue to monitor weekly weight trends. - 4/13/2021 09:30 (9:30 a.m.) Reviewed Clinical Indicator: Reviewed in RAR d/t (due to) weight loss. Current weight 185#, down 23# since admission. BMI = 29 remains above IBW (ideal body weight). Diet: Puree with nectar liquids. Intake is variable, <75% (less than seventy-five percent) most meals. ST following for swallowing fxn (function). He receives Med Pass supplement TID. Action Taken: Will add Magic cup with lunch and dinner meals. Staff encourage intake of meals and supplements. Response to Previous Actions Taken: Continue to monitor weekly weights in RAR. The nutritional evaluation for Resident #57 dated 3/15/2021 documented in part, .Med Pass added daily d/t (due to) risk for weight loss. No pressure areas noted. Weekly weights will be monitored in RAR for at least 4 (four) weeks . The comprehensive care plan for Resident #57 dated 3/22/2021 documented in part, [Resident #57] is at nutritional and/or dehydration . Date Initiated: 03/22/2021; Revision on: 03/22/2021. Under Interventions it documented in part, .Follow in RAR (resident at risk) per protocol. Date Initiated: 03/22/2021 and .Obtain weight at a minimum of monthly. Report significant weight changes of 5% x 1 month (five percent in one month), 7.5% x 3 months (seven and a half percent in three months) or 10% x 6 months (ten percent in six months) to the physician and dietician. Date Initiated: 3/22/2021. The care plan failed to evidence revision or documentation to address the resident's significant weight loss documented on 3/26/2021. On 5/12/2021 at approximately 10:33 a.m., an interview was conducted with LPN (licensed practical nurse) #4, the unit manager. When asked the purpose of the comprehensive care plan, LPN #4 stated that it notified everyone what was going on with the resident at that time. LPN #4 stated that other staff were able to review the care plan to get an idea of the care that the resident required. LPN #4 stated that weekly RAR meetings were conducted on each unit to discuss any residents who had weight loss. LPN #4 stated that the dietician would request weekly weights to monitor residents and add supplements as needed. LPN #4 stated that when they had the RAR meetings to discuss residents with weight loss they also revised the care plan to include any interventions to address the significant weight loss. On 5/12/2021 at approximately 11:15 a.m., a request was made to ASM #1 for the facility policy on developing and implementing the care plan. The facility policy, Interdisciplinary Care Plan dated 06/17 documented in part, .4. Care plans are revised as dictated by change(s) in the guest's condition. Reviews are done at least quarterly . On 5/10/21 at approximately 9:50 a.m., during survey entrance ASM #1, the administrator and ASM #2, the director of nursing stated that the facility used [NAME] as their standard of practice. According to Fundamentals of Nursing [NAME] and [NAME] 2007 pages 65-77 documented, A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care .expect to review, revise and update the care plan regularly, when there are changes in condition, treatments, and with new orders . (6) On 5/12/2021 at approximately 11:15 a.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of operations and ASM #5, the senior clinical transition specialist were made aware of the findings. No further information was provided prior to exit. Reference: 1. Encephalopathy: Encephalopathy is a general term describing a disease that affects the function or structure of your brain. This information is taken from the website https://www.healthline.com/health/hepatic-encephalopathy. 2. Dementia: A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. 3. Osteoarthritis: Osteoarthritis occurs when cartilage, the tissue that cushions the ends of the bones within the joints, breaks down and wears away. This information was obtained from the website: https://www.nia.nih.gov/health/osteoarthritis 4. BMI is body mass index (BMI). This information was obtained from the website: https://medlineplus.gov/ency/article/007196.htm 5. Dysphagia: A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. 6. Fundamentals of Nursing [NAME] & [NAME] 2007, [NAME] Company Philadelphia pages 65-77.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and clinical record review, the facility staff failed to follow professional standards of practice for one of 32 residents in the survey sample, Resident #128. The facility staff failed to clarify two different dose orders for Tylenol which were both prescribed as needed for pain for Resident #128, to determine which and when each dose of the medication should be administered based on pain level parameters. The findings include: Resident #128 was admitted to the facility on [DATE] with diagnoses including, but not limited to, COPD (Chronic Obstructive Pulmonary Disease) (1) and heart failure. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/25/21, Resident #128 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was coded as experiencing occasional pain at a maximum level of eight out of ten during the look back period. On 5/11/21 at 11:34 a.m., Resident #128 was observed lying in bed. When asked if she experiences pain, she stated she does. She stated sometimes it is severe. When asked if the facility staff brings pain medications to her in a timely manner, Resident #128 stated, Usually. When asked if the pain medications she receives are strong enough to allow her to manage the pain, Resident #128 stated, Usually. A review of Resident #128's clinical record revealed the following physician's orders, both dated 4/22/21: - Tylenol (2) Extra Strength Tablet 500 mg (milligrams). Acetaminophen. Give 1000 mg by mouth every 8 hours as needed for pain. - Tylenol Tablet 325 mg (Acetaminophen) Give 2 tablets by mouth every 6 hours as needed for pain NTE (not to exceed) 3 G (grams)/24 HRS (hours). A review of Resident #128's TARs (treatment administration records) revealed she received a dose of 650 mg of Tylenol on 5/2/21, 5/9/21, and 5/10/21. She did not receive a dose of 1000 mg of Tylenol in May 2010. A review of Resident #128's comprehensive care plan, dated 4/22/21 and updated 5/3/21, revealed, in part: [Resident #128] is at risk for pain/or has pain .Administer medications as ordered. On 5/11/21 at 3:19 p.m., LPN (licensed practical nurse) #1 was shown the above two orders for Tylenol and asked how she would determine which order for Tylenol to administer to a resident. LPN #1 stated the orders were very similar. She stated she would check both orders to make sure they were still valid. She stated she would check to see if either order had been administered recently. LPN #1 stated, [Order] clarification is always a plus. LPN #1 stated she would probably ask for clarification of this order before administering either order. On 5/11/21 at 4:45 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing (DON), and ASM #3, the regional director of operations, were informed of these concerns. On 5/12/21 at 10:34 a.m., LPN #4 was shown the above two orders for Tylenol. LPN #4 stated, These should have been clarified. She stated a nurse would not know which order to give in which setting for a resident. On 5/12/21 at 10:58 a.m., ASM #2 was interviewed. ASM #2 stated, The manager clarified the order yesterday. A review of the facility policy, Medication Administration, contained no information related to clarification of orders. On 05/10/2021 at approximately 9:50 a.m., during the entrance conference with ASM [administrative staff member] # 1, administrator and ASM # 2, director of nursing stated that the standard of practice the nursing staff follows was [NAME]. According to Lippincott Manual Of Nursing Practice, Eighth Edition: by [NAME] & [NAME], pg. 87 read: Nursing Alert: Unusual dosages or unfamiliar drugs should always be confirmed with the health care provider and pharmacist before administration. On pg. 15, the following is documented in part, Inappropriate Orders: 2. Although you cannot automatically follow an order you think is unsafe, you cannot just ignore a medical order, either. b. Call the attending physician, discuss your concerns with him, obtain appropriate orders. c. Notify all involved medical and nursing personnel d. Document clearly. No further information was provided prior to exit. REFERENCES (1) COPD is a general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. (2) Acetaminophen is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of osteoarthritis (arthritis caused by the breakdown of the lining of the joints). Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). It works by changing the way the body senses pain and by cooling the body. This information is taken from the website https://medlineplus.gov/druginfo/meds/a681004.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, clinical record review, and facility policy review, it was determined the facility staff failed to provide wound care in a manner to promote healing and prevent infection of a pressure wound for two of 38 residents in the survey sample, Residents # 64 and # 18. 1. The facility staff failed to administer a wound treatment in a manner to promote healing and prevent infection for Resident #64. The facility staff failed to wash their hands before and after glove use and failed to wash their hands for a minimum of 15-20 seconds during Resident # 64's wound care. 2. The facility staff failed to administer a wound treatment in a manner to promote healing and prevent infection for Resident #18. LPN (licensed practical nurse) #4, failed to disinfect scissors removed from their uniform pocket before cutting dressings applied directly to Resident #18's wound, failed to wash their hands before and after glove use and failed to ensure handwashing for a minimum of 20 seconds during Resident # 18's wound care. The findings include: 1. Resident # 64 was admitted to the facility with diagnoses that included but were not limited to: heart disease, pressure ulcer and arthritis. Resident # 64's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/21/2021, coded Resident # 64 as scoring a 13 on the brief interview for mental status (BIMS) of a score of 0 - 15, 13 - being cognitively intact for making daily decisions. Section M Skin Conditions) coded Resident # 64 as having a pressure ulcer upon admission. The facility's Nursing Comprehensive Evaluation for Resident # 64 dated 03/17/2021 documented in part, admission: [DATE]. Under section K. Skin it documented, Right Buttock. Stage 2 [1]. The facility's Braden Scale [2] for Resident # 64 documented, Effective Date: 03/17/2021. Score: 15. At Risk. The comprehensive care plan for Resident # 64 dated 03/17/2021 documented in part, Need. [Resident # 64] is at risk for impaired skin integrity/pressure ulcer. Admit to the facility with skin breakdown. Date Initiated: 03/17/2021. Under Interventions it documented in part, Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician. Date Initiated: 03/17/2021. The most current physician's wound care order dated 05/02/2021 for Resident # 64 documented, Wound Care: Sacral Wound - clean with NS - pack loosely with ¼ [one quarter] DAKINS [3] moistened gauze and PRN [as needed] - cover with dry dressing. On 05/11/2021 at approximately 10:20 a.m., an observation was conducted of LPN [licensed practical nurse] # 4 conducting a dressing change on Resident # 64's sacrum [4]. Prior to the start of the wound care this surveyor introduced themselves to Resident # 64 and asked permission to have one of the female nurses of the survey team observe their wound care. Resident # 64 stated that it was ok with them that this surveyor conduct the observation because their doctor was a male. The wound care was observed by this surveyor in the presence of a female nurse of the survey team. Resident # 64 was positioned on her left side with the assistance of CNA [certified nursing assistant] # 4 and a clean barrier sheet was set up over Resident # 64's over-the-bed-table after disinfecting it. LPN # 4 then placed the clean dressings and treatments on the over-the-bed-table. After donning a clean pair of gloves, LPN # 4 removed the old dressing, placed it in a trash bag, then removed their gloves, went to the sink and washed their hands. Observation revealed LPN #4's hand washing was completed in five seconds. LPN # 4 then put on a clean pair of gloves, cleaned the wound with normal saline, removed gloves, and immediately donned a clean pair of gloves without sanitizing or washing their hands. LPN #4 then applied the treatment and dressing, removed gloves, and donned a new pair of gloves without sanitizing or washing their hands. LPN # 4 then assisted CNA # 4 in repositioning and covering Resident # 64, removed gloves, went to the sink and washed their hands. The hand washing was observed to be completed in five seconds. On 05/11/2021 at 11:35 a.m., an interview was conducted with LPN # 4. When asked to describe the procedure for hand washing LPN # 4 stated, Turn on the water, wet hands, apply soap, suds hands and wash for 15 to 30 seconds, rinse hands, dry them with a paper towel then use it to turn the water off. When asked about the time frame of washing their hands, LPN # 4 stated, I'm not sure. When asked to describe the procedure for washing hands when changing gloves, LPN # 4 stated that hands should be washed or sanitized before donning gloves and after removing them. LPN #4 was informed of the above observations of hand washing during Resident # 64's wound care procedure. LPN # 4 stated that they didn't use proper hand hygiene when washing their hands and before donning gloves and after removing them. LPN # 4 further stated, I rushed through it. The facility's policy Hand Washing documented in part, I. C. Wash well under running water for a minimum of 20 seconds, using a rotary motion and friction. The facility's policy Using Gloves documented in part, II. E. Perform hand hygiene after removing gloves. On 05/11/2021 at approximately 4:45 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional director of operations, were made aware of the above findings. No further information was provided prior to exit. References: [1]. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis.Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions. This information was obtained from: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ [2] The Braden Scale is a standardized tool to assess pressure ulcer risk. This information was obtained from the website: https://pubmed.ncbi.nlm.nih.gov/28512923/ [3] Used to prevent and treat skin and tissue infections that could result from cuts, scrapes and pressure sores. It is also used before and after surgery to prevent surgical wound infections. Dakin's solution is a type of hypochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine, the active ingredient in Dakin's solution, is a strong antiseptic that kills most forms of bacteria and viruses. This information was obtained from the website: https://www.webmd.com/drugs/2/drug-62261/dakins-solution/details. [4] A shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis. The sacrum forms the posterior pelvic wall and strengthens and stabilizes the pelvis. Joined at the very end of the sacrum are two to four tiny, partially fused vertebrae known as the coccyx or tail bone. The coccyx provides slight support for the pelvic organs but actually is a bone of little use. This information was obtained from the website: https://medlineplus.gov/ency/imagepages/19464.htm 2. Resident # 18 was admitted to the facility with diagnoses that included but were not limited to: pressure ulcer and multiple sclerosis [1]. Resident # 18's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/12/2021, coded Resident # 18 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section M Skin Conditions) coded Resident # 18 as having a pressure ulcer upon admission. Under M0300 it documented, Stage 3 - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of the tissue loss. May include undermining and tunneling [3]. The facility's Nursing Comprehensive Evaluation for Resident # 18 dated 07/17/2019 documented in part, admission: [DATE]. Under section K. Skin it documented, Right Buttock. Stage 2. Left Buttock. Stage 2. The facility's Braden Scale for Resident # 18 documented, Effective Date: 03/17/2021. Score: 16. At Risk. The comprehensive care plan for Resident # 18 with a revision date of 11/13/2020 documented in part, Need. [Resident # 18] has actual impairment to skin integrity r/t [related to] sage 3 to sacrum. Date Initiated: 07/17/2019. Revision on: 11/13/2020. Under Interventions it documented, Observe location, size and treatment of skin injury. Report abnormalities, failure to heal, s/s [signs/symptoms] of infection, maceration, etc. to physician. Date Initiated: 07/17/2019. The current physician's wound care order dated 03/05/2021 for Resident # 18 documented, cleanse sacral wound with NS apply hydrofera [2] blue dressing then dry dressing everyday. On 05/11/2021 at approximately 10:35 a.m., an observation was conducted of LPN [licensed practical nurse] # 4 conducting a dressing change on Resident # 18's sacrum. Prior to the start of the wound care this surveyor introduced themselves to Resident # 18 and asked permission to have one of the female nurses of the survey team observe their wound care. Resident # 18 stated that it was ok with them that this surveyor conduct the observation because their doctor was a male. The wound care was observed by this surveyor in the presence of a female nurse of the survey team. Resident # 18 was positioned on her left side with the assistance of CNA [certified nursing assistant] # 4 and a clean barrier sheet was set up over Resident # 18's over-the-bed-table after disinfecting it. LPN # 4 then placed the clean dressings and treatments on the over-the-bed-table. LPN # 4 reached into her lab coat and took out a pair of scissors and placed them on the over-the-bed-table without disinfecting the scissors. After donning a clean pair of gloves, LPN # 4 removed the old dressing, placed it in a trash bag and removed their gloves, went to the sink and washed their hands. Observation revealed LPN #4 completed handwashing in five seconds. LPN # 4 then put on a clean pair of gloves, cleaned the wound with normal saline, removed gloves, and immediately donned a clean pair of gloves without sanitizing or washing their hands. LPN # 4 then asked CNA # 4 to retrieve a bottle of peri wash. CNA # 4 removed their gloves, placed them in the trash bag, opened the door to the resident's room without washing their hands, and left the room. CNA # 4 then returned to the room with the bottle of peri wash and donned a clean pair of gloves. LPN #4 used the bottle of peri wash obtained by CNA #4, who was not observed washing their hands, and completed the procedure. LPN #4 then applied the treatment to the wound wearing the same gloves worn when handling the peri wash. LPN # 4 used the scissors they removed from their pocket, to cut the dressing to size without disinfecting them, and applied the dressing to Resident #18's sacral wound. LPN #4 then removed gloves, donned a new pair of gloves without sanitizing or washing their hands. LPN # 4 then assisted CNA # 4 in repositioning and covering Resident # 18, removed gloves, went to the sink and washed their hands. The hand washing was observed to be completed in five seconds. On 05/11/2021 at 11:30 a.m., an interview was conducted with CNA # 4. When asked to describe the procedure for hand washing, CNA # 4 stated, Turn on the water, wet hands, apply soap, rub hands together, wash the backs of your hands and between the fingers, rinse hands, dry them with a paper towel then use it to turn the water off. When asked to describe the procedure for washing hands when changing gloves, CNA # 4 stated that hands should be washed or sanitized before donning gloves and after removing them. CNA #4 was informed of the above observations of them removing their gloves and leaving the resident's room without washing their hands to retrieve [NAME] wash used during the wound care by LPN #4. CNA # 4 stated that they should have washed or sanitized their hands after removing the gloves before leaving the room. On 05/11/2021 at 11:35 a.m., an interview was conducted with LPN # 4. When asked to describe the procedure for hand washing, LPN # 4 stated, Turn on the water, wet hands, apply soap, suds hands and wash for 15 to 30 seconds, rinse hands, dry them with a paper towel then use it to turn the water off. When asked about the time frame of washing their hands, LPN # 4 stated, I'm not sure. When asked to describe the procedure for washing hands when changing gloves, LPN # 4 stated that hands should be washed or sanitized before donning gloves and after removing them. LPN #4 was informed of the above observations of hand washing during Resident # 18's wound care procedure. LPN # 4 stated that they didn't use proper hand hygiene when washing their hands and before donning gloves and after removing them. LPN # 4 further stated, I rushed through it. When asked if they disinfected the scissors used before cutting the dressing applied to Resident #18's wound, LPN # 4 stated that they disinfected them before placing them in their pocket. When asked if the scissor were still disinfected after having them in their pocket, LPN # 4 stated, I should have cleaned them when I took them out of my pocket. On 05/10/2021 at approximately 9:50 a.m., during the entrance conference with ASM [administrative staff member] # 1, administrator and ASM # 2, director of nursing stated that the standard of practice the nursing staff follows was [NAME]. Disinfection, noncritical patient care equipment. Introduction .reusable noncritical patient care equipment should be disinfected after use, before use on another patient. Lippincott procedures - Disinfection, noncritical patient care equipment. Revised: November 20, 2020. In a study conducted by the International Conference on Nosocomial and Healthcare related Infections in Atlanta Georgia, March 2000 showed that ordinary items can make your patients sick. In one study, a researcher gathered scissors that nurses and physicians kept in their pockets, as well as communal scissors left on dressing carts and tables. Three-quarters of the scissors carried microorganisms, including Staphylococcus aureus, Groups A and B streptococcus, and gram-negative bacilli. The solution is quite simple. If health care workers swab the scissors with alcohol after each use, they will virtually eliminate the risk of transmission of microorganisms. In the study, contaminated scissors were effectively disinfected after swabbing the scissors with alcohol. Reference: Embil JM, [NAME] B, [NAME] J, et al. Scissors as a potential source of nosocomial infection? Presented at the 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections. Atlanta; March 8, 2000. On 05/11/2021 at approximately 4:45 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional director of operations, were made aware of the above findings. No further information was provided prior to exit. [1] A nervous system disease that affects your brain and spinal cord. It damages the myelin sheath, the material that surrounds and protects your nerve cells. This damage slows down or blocks messages between your brain and your body, leading to the symptoms of MS. This information was obtained from the website: https://medlineplus.gov/multiplesclerosis.html. [2] Hydrofera Blue is a type of wound dressing. This information was obtained from the website: https://hydrofera.com/hydrofera-blue/

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, it was determined that facility staff failed to provide appropriate treatment and services for the care of a Foley catheter to prevent infection for one of 38 residents in the survey sample, Residents # 18. Separate observations revealed Resident #18's Foley catheter tubing directly on the floor. The findings include: Resident # 18 was admitted to the facility with diagnoses that included but were not limited to: neuromuscular dysfunction of the bladder [1] and multiple sclerosis [2]. Resident # 18's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/12/2021, coded Resident # 18 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 18 was coded as requiring extensive assistance of one staff member for activities of daily living. Section H Bladder and Bowel coded Resident # 18 as having an indwelling catheter. On 05/10/21 at 3:14 p.m., an observation of Resident # 18 revealed the resident sitting in their room in a wheelchair. Further observation revealed the tubing of the resident's catheter under the wheelchair resting directly on the floor. On 05/11/21 at 1:04 p.m., an observation of Resident # 18 revealed the resident sitting in a wheelchair in their room. Further observation revealed the tubing of the resident's catheter under the wheelchair resting directly on the floor. On 05/11/21 at 3:43 p.m., an observation of Resident # 18 was conducted with LPN [licensed practical nurse] # 4, unit manager. Resident # 18 was observed in their room sitting in a wheelchair. Observation of the catheter tubing revealed it was under the wheelchair resting on the floor. LPN # 4 stated that the tubing should not be on the floor and that it was an infection control concern. The POS [physician's order sheet] for Resident # 18 dated 05/2021 documented in part, Foley Catheter care every shift for neurogenic bladder. Start Date: 07/02/2020. The comprehensive care plan for Resident # 18 dated 07/09/2020 documented in part, Need: [Resident # 18] is at risk for urinary tract infection and catheter related trauma: has indwelling catheter r/t [related to] Neurogenic bladder, Date Initiated: 07/09/2020. Under Interventions it documented in part, Position catheter bag and tubing below the level of the bladder. Check tubing for kinks each shift. Date Initiated: 07/09/2020. On 05/10/2021 at approximately 9:50 a.m., during the entrance conference with ASM [administrative staff member] # 1, administrator and ASM # 2, director of nursing stated that the standard of practice the nursing staff follows was [NAME]. According to Fundamentals of Nursing [NAME] and [NAME] Eighth Edition 2006, [NAME] Company, page 757, titled Renal and Urinary Disorders, under the heading Management of a Patient with an Indwelling Catheter and Closed Drainage System the subheading: Maintaining a closed drainage system: 2. Maintain an unobstructed urine flow. b. Urine should not be allowed to collect in tubing because free flow of urine must be maintained to prevent urinary tract infection. Improper drainage occurs when the tubing is kinked or twisted, allowing pools of urine to collect in the tubing. c. Keep the bag off the floor to prevent bacterial contamination. On 05/11/2021 at approximately 4:45 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional director of operations, were made aware of the above findings. No further information was provided prior to exit. References: [1] A problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition. This information was obtained from the website: https://medlineplus.gov/ency/article/000754.htm. [2] A nervous system disease that affects your brain and spinal cord. It damages the myelin sheath, the material that surrounds and protects your nerve cells. This damage slows down or blocks messages between your brain and your body, leading to the symptoms of MS. This information was obtained from the website: https://medlineplus.gov/multiplesclerosis.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure the appropriate treatment and services to prevent complications of enteral feeding per the physicians orders for one of 38 residents in the survey sample, Resident #115. The facility staff failed to administer water flushes, and failed to record the total intake for the resident daily, per the physician's order. The findings include: Resident #115 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (1), dementia (2), and history of a stroke requiring the placement of a feeding tube (3). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/13/21, Resident #115 was coded as being severely cognitively impaired for making daily decisions, having scored three out of 15 on the BIMS (brief interview for mental status). She was coded as receiving greater than 51% of her total calories through a feeding tube. On the following dates and times, 5/11/21 at 9:58 a.m., 12:26 p.m., and 3:00 p.m., Resident #115 was observed lying in bed with the head her bed elevated. A tube feeding solution bag and a bag of water were hanging on a pole. Both feeding solution and the water were threaded through an automatic pump. The pump settings were 60 mls/hour (milliliters per hour) continuous for the tube feeding solution, and 40 mls of water one time flush each hour. A review of Resident #115's clinical record revealed the following physician's orders, dated 4/21/21: Jevity 1.2 (tube feeding solution) @ (at) 60 ml per hour .Jevity 1.2 at 60 ml per hour. Total amount taken in every night shift. The clinical record also contained the following physician's order: Enteral (tube feeding) Feed Order Four times a day for Maintenance Flush PEG tube with 120 cc (cubic centimeters) of water. A review of Resident #115's MARs (medication administration records) and TARs (treatment administration records) revealed staff signatures for all dates in May 2021 for these orders, indicating the feedings and water were administered per the order. However, none of the night shift records contained a total amount of tube feeding solution taken in by the resident. A review of Resident #115's comprehensive care plan, dated 4/14/21 and revised 4/19/21, revealed, in part: [Resident #115] is unable to tolerate nutritionally adequate food and/or fluids by mouth requiring the use of a feeding tube .Administer tube feeding as ordered. On 5/11/21 at 3:00 p.m., LPN (licensed practical nurse) #6 was accompanied to Resident #115's room and the residents the feeding tube pump settings were observed. When asked to describe the settings, LPN #6 stated it was set to deliver 60 mls of Jevity each hour to the resident via the resident's feeding tube. She stated it was set to deliver a once-an-hour flush of 40 mls of water. When asked if she knew if these settings matched the physician's order, LPN #6 stated she thought so, but would need to verify. LPN #6 checked Resident #115's physician's orders, and stated, I can't tell. She stated she thought that when the pump was programmed for the tube feeding solution, the pump automatically provided the 40 mls of water flush each shift. LPN #6 stated, No - the orders don't match what the pump is doing. She stated she did not know how to prevent the pump from delivering the 40 mls of water flush each hour. On 5/11/21 at 4:45 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing (DON), and ASM #3, the regional director of operations, were informed of these concerns. On 5/12/21 at 10:34 a.m., LPN #4, a unit manager, was interviewed. She stated she was very familiar with the programming and operations of the feeding tube pumps. She stated the pumps are programmed according to the physician's orders. She stated the pump requires a nurse to program both the tube feeding solution amount and rate as well as the water flush amount and rate. LPN #4 stated the pumps automatically deliver the amount that a nurse has programmed. She stated the tube feeding pumps do not have an intrinsic automatic setting for water flushes of any kind. LPN #4 stated, We always have to set the tube feeding and water amounts manually. She stated the tube feeding and flush amounts vary for each resident, and are adjusted as the resident's needs or conditions change. When asked to review Resident #115's TARs for the total amount of intake each night shift, LPN #4 stated, They are missing a prompt. There should be an amount each shift. You can't just sign it off. On 5/12/21 at 10:58 a.m., ASM #2 was interviewed. She verified that the tube feeding pumps must be manually programmed for both the tube feeding and the water amounts and rates, and that Resident #115's pump had been incorrectly programmed. ASM #2 stated the night shift staff should have been recording the total amount of tube feeding and water taken in by the resident for each preceding 24 hour period. A review of the tube feeding pump instructions revealed steps to be followed to manually program the pump for both the tube feeding solution and the water flushes. The instructions contained no information about the pump automatically being set to deliver water flushes prior to a nurse programming it to do so. A review of the facility policy, Enteral Nutrition, revealed, in part: The nurse obtains an order for placement of an enteral feeding tube. Order should include the following information: the formula to be used .The rate and/or timing of administration .Total volume to be given per 24-hour period .Method of administration .Volume of water given as water flush .Once the tube has been placed and tube placement confirmed, the nurse administers the enteral feeding regimen according to formula, system type, and method of delivery ordered by the physician .The nurse irrigates the feeding tube with the prescribed amount of water and frequency to maintain or restore patency of the feeding tube and to provide free water. No further information was provided prior to exit. REFERENCES (1) Parkinson's disease (PD) is a type of movement disorder. It happens when nerve cells in the brain don't produce enough of a brain chemical called dopamine. Sometimes it is genetic, but most cases do not seem to run in families. This information is taken from the website https://medlineplus.gov/parkinsonsdisease.html. (2) Dementia is a gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information is taken from the website https://medlineplus.gov/ency/article/000746.htm. (3) A PEG (percutaneous endoscopic gastrostomy) feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. PEG feeding tube insertion is done in part using a procedure called endoscopy. Feeding tubes are needed when you are unable to eat or drink. This may be due to stroke or other brain injury, problems with the esophagus, surgery of the head and neck, or other conditions. This information is taken from the website https://medlineplus.gov/ency/patientinstructions/000900.htm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to provide dialysis services, consistent with professional standards of practice, the comprehensive person-centered care plan two of 38 residents, Resident #22 and Resident #439. The facility staff failed to evidence consistent assessments of Resident #22 and Resident #439's dialysis access sites per the comprehensive plan of care. Resident #22 had no documented assessment of the residents dialysis access site for a bruit and thrill on multiple dates in March, April and May, 2021. Resident #439 had no documented assessment of the residents dialysis access site for a bruit and thrill from 12/1/20 through 1/15/21, (47 days). The findings include: 1. Resident #22 was admitted to the facility on [DATE]. Resident #22's diagnoses included but were not limited to: ESRD [end stage renal disease] (inability of the kidneys to excrete wastes and function in the maintenance of electrolyte balance (1), diabetes mellitus (inability of insulin to function normally in the body) (2), atrial fibrillation (rapid and random contraction of the atria of the heart) (2) and peripheral vascular disease (abnormal conditions affecting blood vessels outside of the heart) (3). Resident #22's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/28/21, coded that the resident's BIMS (brief interview for mental status) a score of 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is moderately impaired cognitively. A review of the MDS Section G-functional status coded the resident as extensive assistance for bed mobility, transfers, dressing, hygiene; limited assistance with locomotion and eating total dependence for bathing. Walking did not occur. A review of MDS Section H- bowel and bladder coded the resident as frequently incontinent for bowel and for bladder. A review of the comprehensive care plan dated 2/22/20, documented in part, NEED-at risk for complications related to dialysis due to ESRD. INTERVENTIONS-resident is receiving hemodialysis: palpate for presence of thrill and listen for bruit as needed. Observe for redness or swelling at the site. Report abnormal observations to physician as needed. A review of the TAR (treatment administration record) Check bruit and thrill left upper arm shunt every shift. The TAR 3/1/31 failed to evidence bruit and thrill checks for the dialysis shunt for 16 of 93 shifts, the 4/1/21-4/30/21 TAR failed to evidence bruit and thrill checks for the dialysis shunt for 11 of 90 shifts and the 5/1/21-5/10/21 TAR failed to evidence bruit and thrill checks for 1 of 30 shifts. An interview was conducted on 5/10/21 at 3:05 PM with LPN (licensed practical nurse) #12. When asked about the care for a resident with a dialysis shunt, LPN #12 stated, We check for a bruit and thrill. We should check it every shift. When asked if this was documented, LPN #12 stated, Yes it is on the TAR. An interview was conducted on 5/10/21 at 3:25 PM with LPN #15, the unit manager. When asked about the care for a resident with a dialysis shunt, LPN #15 stated, We check for a bruit and thrill. When asked the frequency of these checks, LPN #15 stated, We should check it on days of dialysis. We probably should check it every day. When asked if this was documented, LPN #15 stated, Yes it is documented on the TAR. When asked if it not documented, what that means, LPN #15 stated, It means that it wasn't documented, not that it wasn't done. 2. Resident #439 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes mellitus (inability of insulin to function normally in the body) (2), atrial fibrillation (rapid and random contraction of the atria of the heart) (4), renal failure (inability of the kidneys to excrete waste and function in the maintenance of electrolyte balance) (5), and bipolar (mental disorder characterized by periods of mania and depression) (6). The most recent MDS (minimum data set) assessment, a five day admission Medicare assessment, with an ARD (assessment reference date) of 1/6/21, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, transfer, hygiene, bathing and dressing; independence for eating, locomotion and walking did not occur. A review of MDS Section H- bowel and bladder coded the resident as always frequently incontinent for bowel and occasionally incontinent for bladder. A review of the comprehensive care plan dated 2/20/20, documented in part, NEED-at risk for complications related to dialysis. INTERVENTIONS-resident is receiving hemodialysis: palpate for presence of thrill and listen for bruit as needed. Observe for redness or swelling at the site. Report abnormal observations to physician as needed. A review of the TAR (treatment administration record) from 12/1/20-1/15/21 failed to evidence bruit and thrill checks for Resident #439's dialysis shunt. There was no documentation of bruit and thrill checks for 47 days. An interview was conducted on 5/11/21 at 8:50 AM with LPN (licensed practical nurse) #5. When asked the care for a resident with a dialysis shunt, LPN #5 stated, You should check for a bruit and thrill. We check it every shift. When asked if this was documented, LPN #5 stated, Yes it is on the TAR. On 5/11/21 at 4:54 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of operations, were informed of the finding. According to ASM #2, the director of nursing, the standard of practice followed is [NAME], the on line version. According to Medical Surgical Nursing made Incredibly Easy, [NAME] & [NAME] copyright 2004 page 565 Dialysis Monitoring and Aftercare: At least four times per day, assess circulation at the access site by auscultating for the presence of bruits and palpating for thrills. Unlike most other circulatory assessments, bruits and thrills should be present here. Lack of a bruit at a venous access site .may indicate a blood clot requiring immediate surgical attention. No further information was provided prior to exit. Complaint Deficiency References: (1) Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 498. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 160. (3) Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 445. (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 54. (5) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 498. (6) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 71

Based on staff interview and facility document review, it was determined that the facility staff failed to complete the required annual performance review for two of five CNA (certified nursing assistant) records reviewed, CNAs #1 and #3. For CNA #1, no performance evaluation was completed between 3/7/20 and 3/7/21, and for CNA #3, no performance evaluation was completed between 6/11/19 and 6/11/20. The findings include: A review of performance evaluations was performed for CNA #1 and #3. On 5/11/21 at 9:45 a.m., ASM (administrative staff member) #1, the administrator, stated she had not located the annual performance review for CNA #1, but believed the review for CNA #3 was on her desk. On 5/11/21 at 4:45 p.m., ASM #1 was asked about the status of the performance reviews for both CNA #1 and CNA #3. She stated ASM #2, the director of nursing, was responsible for these reviews, and should be interviewed. On 5/12/21 at 10:58 a.m., ASM #2, the director of nursing, was interviewed about the missing performance reviews for CNAs #1 and #3. She stated the payroll department prints out a list of which reviews are due for a particular month. ASM #2 stated, We try to complete those first. She stated unit managers and the assistant director of nursing are responsible for helping her complete the required annual performance reviews. She could not state a reason for these two performance reviews not being completed. ASM #2 stated the reviews are important to give staff feedback, to determine if a performance improvement plan is needed, and are an effective means of one-on-one communicating with an employee. On 5/12/21 at 11:14 a.m., ASM #1 and ASM #3, the regional director of operations spoke about the evaluations that were not completed. ASM #1 stated there was no facility policy regarding the evaluations. ASM #3 stated the timing of the evaluations, per company practice, was linked to staff wage increases. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to evidence a complete and accurate medical record for two of 38 residents in the survey sample, Resident #71 and Resident #333. The findings include: 1. For Resident #71, the facility staff failed to (A) ensure the comprehensive care plan goals for dialysis did not contain goals that were not appropriate for the type of dialysis access site the resident had in place; and (B) failed to ensure all medications and treatments were documented on the March 2021 and April 2021 Medication Administration Record (MAR). Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of but not limited to acute respiratory failure, gastrostomy, below knee amputation (right), end stage renal disease, chronic obstructive pulmonary disease, deep vein thrombosis, dialysis, chronic kidney disease, dysphagia, aphasia, diabetes, depression, dementia, osteomyelitis, and COVID-19. The 5-day MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 4/28/21 coded the resident as severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing and toileting; extensive assistance for transfers, dressing, eating, and hygiene; and was incontinent of bowel and bladder. (A) The facility staff failed to ensure the comprehensive care plan goals for dialysis did not contain goals that were not appropriate for the type of dialysis site the resident had. A review of the clinical record revealed a physician's order dated 4/28/21 for Check Right chest dialysis port for bleeding post dialysis every day shift every Tue (Tuesday), Thu (Thursday), Sat (Saturday). This order indicated the resident had a venous catheter (1) site for dialysis. A review of the comprehensive care plan revealed one dated 1//6/21 for (Resident #71) is at risk for complications R/T (related to) needs dialysis due to: End Stage Renal Disease. The interventions included one dated 3/22/21 for Do not draw blood or take B/P (blood pressure) in arm with graft (2) and another one dated 3/22/21 for For Hemodialysis: Check bruit/thrill (3) every shift. Notify physician if not detected. (Note: A bruit and thrill are not checked for catheter sites in the neck or chest. This procedure is for graft sites in the arm, which was not the type the resident had.) On 5/12/21 at 8:45 AM an interview was conducted with RN #3 (Registered Nurse), the MDS nurse. She reviewed the care plan and stated that these interventions were not appropriate for the resident's type of dialysis access and should not be on the care plan. She stated that the care plan is the plan of care of the patient needs so staff know how to care for the resident. RN #3 stated that a fill-in MDS nurse from another facility used a generic care plan and put in the wrong thing for this resident. (B) The facility staff failed to ensure all medications and treatments were documented on the March 2021 and April 2021 Medication Administration Record (MAR). A review of the clinical record revealed the following: The March 2021 Medication Administration Record with the following medications that were not documented as being administered: • Contact and Droplet Isolation COVID-19, every shift for preventative for 14 days. This order was dated 3/21/21. The night shift (11PM to 7AM) failed to document this care on 3/24/21, 3/25/21, 3/28/21, 3/29/21, and 3/30/21. • Check Peg Tube for placement This order was dated 3/21/21 and was scheduled for every shift. The night shift (11PM to 7AM) failed to document this care on 3/24/21, 3/25/21, 3/28/21, 3/29/21, and 3/30/21. • Elevate head of bed at least 30 degrees during feeding (tube feeding) This order was dated 3/21/21. The night shift (11PM to 7AM) failed to document this care on 3/24/21, 3/25/21, 3/28/21, 3/29/21, and 3/30/21. • Enteral Feed Order, every shift, give Nepro 1.8 cal (calories) via peg tube at 45ml/hr (45 milliliters per hour) . This order was dated 3/22/21 and was scheduled for every shift. The night shift (11PM to 7AM) failed to document this care on 3/23/21, 3/24/21, 3/25/21, 3/28/21, 3/29/21, and 3/30/21. • Humalog (4) per sliding scale .before meals for diabetes. This order was dated 3/22/21 and was scheduled for 6:30AM, 11:30AM, and 4:30PM. The night shift (11PM to 7AM) failed to document the blood sugar and dose of Humalog administered at 6:30AM on 3/23/21, 3/24/21, 3/25/21, 3/26/21, 3/28/21, 3/29/21, 3/30/21, and 3/31/21. • Hydralazine (5) .50 mg (milligrams) via Peg (Percutaneous endoscopic gastrostomy) -tube every 8 hours for HTN (high blood pressure). This order was dated 3/21/21 and was scheduled for 6:00AM, 2:00PM, and 10:00PM. The night shift (11PM to 7AM) failed to document the Hydralazine was administered at 6:00AM on 3/23/21, 3/25/21, 3/26/21, 3/28/21, 3/29/21, 3/30/21, and 3/31/21. • Sevelamer Carbonate (6) Give 1 packet via Peg-tube before meals for renal disorder This order was dated 3/21/21 and was scheduled for 6:30AM, 11:30AM, and 4:30PM. The night shift (11PM to 7AM) failed to document the Sevelamer was administered at 6:00AM on 3/23/21, 3/24/21, 3/25/21, 3/26/21, 3/28/21, 3/29/21, 3/30/21, and 3/31/21. • Respiratory Screen every shift for 14 days document Yes or No for symptoms of COVID-19. This order was dated 3/21/21. The night shift (11PM to 7AM) failed to document this care on 3/23/21, 3/24/21, 3/25/21, 3/28/21, 3/29/21, and 3/30/21. • Enteral Feed Order every 4 hours Flush Peg tube with 30 cc (equivalent to milliliters) of water. This order was dated 3/21/21. This was scheduled for 1:00AM, 5:00AM, 9:00AM, 1:00PM, 5:00PM, and 9:00PM. The night shift (11PM to 7AM) failed to document this care for the 1:00AM time on 3/30/21; and for the 5:00AM time on 3/23/21, 3/26/21, 3/28/21, 3/29/21, and 3/30/21. The April 2021 Medication Administration Record with the following medications that were not documented as being administered: • Nepro, 50c (sic - cc) (equivalent of millimeters) per hour from 7PM to 7AM daily. This order was dated 4/2/21 and was documented as being administered every evening. However, the night shift (11PM to 7AM shift) failed to document the Nepro was stopped around 7:00 AM on 3/2/21, 3/5/21, 3/6/21, 3/8/21, and 3/14/21. • Check Peg Tube for placement This order was dated 3/21/21 and was scheduled for every shift. The night shift (11PM to 7AM) failed to document this care on 4/5/21, 4/6/21, 4/8/21, and 4/14/21. • Elevate head of bed at least 30 degrees during feeding (tube feeding) This order was dated 3/21/21. The night shift (11PM to 7AM) failed to document this care on 4/2/21, 4/5/21, 4/6/21, 4/8/21, and 4/14/21. • Humalog per sliding scale .before meals for diabetes. This order was dated 3/22/21 and was scheduled for 6:30AM, 11:30AM, and 4:30PM. The night shift (11PM to 7AM) failed to document the blood sugar and dose of Humalog administered at 6:30AM on 4/2/21, 4/3/21, 4/6/21, 4/7/21, 4/9/21, 4/11/21, and 4/15/21. • Hydralazine .50 mg (milligrams) via Peg-tube every 8 hours for HTN (high blood pressure). This order was dated 3/21/21 and was scheduled for 6:00AM, 2:00PM, and 10:00PM. The night shift (11PM to 7AM) failed to document the Hydralazine was administered at 6:00AM on 4/2/21, 4/3/21, 4/6/21, 4/7/21, 4/9/21, 4/11/21, and 4/15/21. • Sevelamer Carbonate Give 1 packet via Peg-tube before meals for renal disorder This order was dated 3/21/21 and was scheduled for 6:30AM, 11:30AM, and 4:30PM. The night shift (11PM to 7AM) failed to document the Sevelamer was administered at 6:00AM on 3/2/21, 3/6/21, and 3/7/21. On 5/12/21 at 12:04 PM in a phone interview with LPN #9, who works the night shift with Resident #71, she stated that she checks the resident's blood sugars and sliding scale insulin, and the other identified medications and treatments. She stated that she forgot to document but that she always administers the medications/care/treatment. On 5/12/21 at 11:13 AM, ASM (Administrative Staff Member) #1, #2, #3, and #5 (the Administrator, the Director of Nursing, the Regional Director of Operations, and the Senior Clinical Transition Specialist) were made aware of the findings. No further information was provided. References: There are three types of dialysis access: temporary catheter (1) and AV graft (2). (1) Temporary Catheter: During this procedure, a thin flexible tube called a catheter is placed into a large vein in the neck. This catheter can be used a maximum of 3 months, so long term dialysis patients will require something else eventually. Also, because this catheter is placed directly into the bloodstream, there is a high risk of infection. (2) AV graft: During this procedure, two small incisions are made in the arm and a cylinder like tube called a graft is inserted under the skin. One end of the graft is sewn to the artery and the other end to the vein. Again, this increases the size of the vein and it becomes tougher and thicker, with rapid blood flow from the artery to the vein. (3) How Do I Know If the Graft Is Functioning Effectively? There are two signs that indicate a dialysis access site is functioning well. When you slide your fingertips over the site you should feel a gentle vibration, which is called a thrill. Another sign is when listening with a stethoscope a loud swishing noise will be heard called a bruit. If both of these signs are present and normal, the graft is still in good condition. If not, there may be a narrowing within the graft as a result of blood clot collection. If there is bruising or discoloration close to the graft site, this could indicate that part of the graft wall was punctured and may require repair as well. The site may need to be reopened and repaired, or it may be possible to insert a thin flexible tube called a catheter through the site and use a balloon to widen the opening of the graft and improve blood flow. Information obtained from https://www.vascularhealthclinics.org/institutes-divisions/vascular-surgery-and-medicine/dialysis-access/ (4) Humalog - is an insulin product used to treat diabetes. Information obtained from https://medlineplus.gov/druginfo/meds/a697021.html (5) Hydralazine - is used to treat high blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a682246.html (6) Sevelamer - is used to control high blood levels of phosphorous in people with chronic kidney disease who are on dialysis. Information obtained from https://medlineplus.gov/druginfo/meds/a601248.html 2. For Resident #333, the facility staff failed to ensure that another resident's information was not filed in Resident #333's medical record. Resident #333 was admitted to the facility on [DATE] and discharged to the hospital on 3/9/21 and did not return to the facility. The resident was admitted with the diagnoses of but not limited to left tibia fracture, pneumonia, obesity, diabetes, glaucoma, high blood pressure, chronic kidney disease, heart failure, end stage renal disease, dislocation of ankle joint, and dialysis. The 5-day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/19/21 coded the resident as cognitively intact in ability to make daily life decisions. The resident was coded as requiring total care for bathing; extensive assistance for transfers, dressing, toileting and hygiene; independent for eating; and was occasionally incontinent of bowel and bladder. A nurse's note dated 3/9/21 at 2:00 PM documented, Called MD (medical doctor) to notify him of the vital signs (temperature) 98.8, (blood pressure) 82/46, (pulse) 107, (oxygen saturation) level 89% on oxygen as ordered. Non- rebreather applied. Repeat (oxygen) level at 2:10pm is 75%. MD notified. Send patient out 911. RP (responsible party), daughter is aware. Further review of the clinical record for the requirements related to hospital transfers revealed an item under the Misc (miscellaneous) tab where scanned documents are uploaded, that was dated 3/9/21 and titled Written Notification sent, indicating this was the required written notification to the responsible party that was sent upon a hospital transfer. When clicking on the above item to open it, the attached document was actually a Screening for Mental Illness, Mental Retardation/Intellectual Disability, or Related Conditions form that was completed for a different resident and uploaded into Resident #333's electronic medical record. On 5/12/21 at 9:15 AM an interview was conducted with OSM #3 (Other Staff Member) the Medical Records person. She stated that the item was not the transfer notice and should not have been in Resident #333's medical record. On 5/12/21 at 11:13 AM, ASM (Administrative Staff Member) #1, #2, #3, and #5 (the Administrator, the Director of Nursing, the Regional Director of Operations, and the Senior Clinical Transition Specialist) were made aware of the findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to follow infection control practices during wound care for two of 38 residents in the survey sample, Residents # 64 and # 18. 1. The facility staff failed to follow infection control practices by washing their hands before and after glove use and for a minimum of 20 seconds during Resident # 64's wound care. 2. The facility staff failed to disinfect scissors before use, wash their hands before and after glove use and failed to ensure handwashing for a minimum of 20 seconds during Resident # 18's wound care. The findings include: 1. Resident # 64 was admitted to the facility with diagnoses that included but were not limited to: heart disease, pressure ulcer and arthritis. Resident # 64's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/21/2021, coded Resident # 64 as scoring a 13 on the brief interview for mental status (BIMS) of a score of 0 - 15, 13 - being cognitively intact for making daily decisions. Section M Skin Conditions) coded Resident # 64 as having a pressure ulcer upon admission. The facility's Nursing Comprehensive Evaluation for Resident # 64 dated 03/17/2021 documented in part, admission: [DATE]. Under section K. Skin it documented, Right Buttock. Stage 2 [1]. The facility's Braden Scale [2] for Resident # 64 documented, Effective Date: 03/17/2021. Score: 15. At Risk. The most recent physician's order dated 05/02/2021 for Resident # 64 documented, Wound Care: Sacral Wound - clean with NS - pack loosely with ¼ [one quarter] DAKINS [3] moistened gauze and PRN [as needed] - cover with dry dressing. On 05/11/2021 at approximately 10:20 a.m., an observation was conducted of LPN [licensed practical nurse] # 4 conducting a dressing change on Resident # 64's sacrum [4]. Prior to the start of the wound care this surveyor introduced themselves to Resident # 64 and asked permission to have one of the female nurses of the survey team observe their wound care. Resident # 64 stated that it was ok with them that this surveyor conduct the observation because their doctor was a male. The wound care was observed by this surveyor in the presence of a female nurse of the survey team. Resident # 64 was positioned on her left side with the assistance of CNA [certified nursing assistant] # 4 and a clean barrier sheet was set up over Resident # 64's over-the-bed-table after disinfecting it. LPN # 4 then placed the clean dressings and treatments on the over-the-bed-table. After donning a clean pair of gloves, LPN # 4 removed the old dressing, placed it in a trash bag, then removed their gloves, went to the sink and washed their hands. Observation revealed LPN #4's hand washing was completed in five seconds. LPN # 4 then put on a clean pair of gloves, cleaned the wound with normal saline, removed gloves, and immediately donned a clean pair of gloves without sanitizing or washing their hands. LPN #4 then applied the treatment and dressing, removed gloves, and donned a new pair of gloves without sanitizing or washing their hands. LPN # 4 then assisted CNA # 4 in repositioning and covering Resident # 64, removed gloves, went to the sink and washed their hands. The hand washing was observed to be completed in five seconds. On 05/11/2021 at 11:35 a.m., an interview was conducted with LPN # 4. When asked to describe the procedure for hand washing LPN # 4 stated, Turn on the water, wet hands, apply soap, suds hands and wash for 15 to 30 seconds, rinse hands, dry them with a paper towel then use it to turn the water off. When asked about the time frame of washing their hands, LPN # 4 stated, I'm not sure. When asked to describe the procedure for washing hands when changing gloves, LPN # 4 stated that hands should be washed or sanitized before donning gloves and after removing them. LPN #4 was informed of the above observations of hand washing during Resident # 64's wound care procedure. LPN # 4 stated that they didn't use proper hand hygiene when washing their hands and before donning gloves and after removing them. LPN # 4 further stated, I rushed through it. The facility's policy Hand Washing documented in part, I. C. Wash well under running water for a minimum of 20 seconds, using a rotary motion and friction. The facility's policy Using Gloves documented in part, II. E. Perform hand hygiene after removing gloves. Per the CDC [Center for Disease Control and Prevention], Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an Alcohol-Based Hand Sanitizer: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, immediately after glove removal. Wash with Soap and Water When hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea and after known or suspected exposure to spores (e.g. B. anthracis, C difficile outbreaks). The CDC Guideline for Hand Hygiene in Healthcare Settings recommends: When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. Glove Use: When and How to Wear Gloves: Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves. Change gloves and perform hand hygiene during patient care, if gloves become damaged, gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. Never wear the same pair of gloves in the care of more than one patient. Carefully remove gloves to prevent hand contamination. This information was obtained from the website: https://www.cdc.gov/handhygiene/providers/index.html. On 05/11/2021 at approximately 4:45 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional director of operations, were made aware of the above findings. No further information was provided prior to exit. References: [1]. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis.Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions. This information was obtained from: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ [2] The Braden Scale is a standardized tool to assess pressure ulcer risk. This information was obtained from the website: https://pubmed.ncbi.nlm.nih.gov/28512923/ [3] Used to prevent and treat skin and tissue infections that could result from cuts, scrapes and pressure sores. It is also used before and after surgery to prevent surgical wound infections. Dakin's solution is a type of hypochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine, the active ingredient in Dakin's solution, is a strong antiseptic that kills most forms of bacteria and viruses. This information was obtained from the website: https://www.webmd.com/drugs/2/drug-62261/dakins-solution/details. [4] A shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis. The sacrum forms the posterior pelvic wall and strengthens and stabilizes the pelvis. Joined at the very end of the sacrum are two to four tiny, partially fused vertebrae known as the coccyx or tail bone. The coccyx provides slight support for the pelvic organs but actually is a bone of little use. This information was obtained from the website: https://medlineplus.gov/ency/imagepages/19464.htm 2. Resident # 18 was admitted to the facility with diagnoses that included but were not limited to: pressure ulcer and multiple sclerosis [1]. Resident # 18's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/12/2021, coded Resident # 18 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section M Skin Conditions) coded Resident # 18 as having a pressure ulcer upon admission. Under M0300 it documented, Stage 3 - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of the tissue loss. May include undermining and tunneling. The facility's Nursing Comprehensive Evaluation for Resident # 18 dated 07/17/2019 documented in part, admission: [DATE]. Under section K. Skin it documented, Right Buttock. Stage 2. Left Buttock. Stage 2. The facility's Braden Scale for Resident # 18 documented, Effective Date: 03/17/2021. Score: 16. At Risk. The current physician's wound care order dated 03/05/2021 for Resident # 18 documented, cleanse sacral wound with NS apply hydrofera blue dressing [2] then dry dressing everyday. On 05/11/2021 at approximately 10:35 a.m., an observation was conducted of LPN [licensed practical nurse] # 4 conducting a dressing change on Resident # 18's sacrum. Prior to the start of the wound care this surveyor introduced themselves to Resident # 18 and asked permission to have one of the female nurses of the survey team observe their wound care. Resident # 18 stated that it was ok with them that this surveyor conduct the observation because their doctor was a male. The wound care was observed by this surveyor in the presence of a female nurse of the survey team. Resident # 18 was positioned on her left side with the assistance of CNA [certified nursing assistant] # 4 and a clean barrier sheet was set up over Resident # 18's over-the-bed-table after disinfecting it. LPN # 4 then placed the clean dressings and treatments on the over-the-bed-table. LPN # 4 reached into her lab coat and took out a pair of scissors and placed them on the over-the-bed-table without disinfecting the scissors. After donning a clean pair of gloves, LPN # 4 removed the old dressing, placed it in a trash bag and removed their gloves, went to the sink and washed their hands. Observation revealed LPN #4 completed handwashing in five seconds. LPN # 4 then put on a clean pair of gloves, cleaned the wound with normal saline, removed gloves, and immediately donned a clean pair of gloves without sanitizing or washing their hands. LPN # 4 then asked CNA # 4 to retrieve a bottle of peri wash. CNA # 4 removed their gloves, placed them in the trash bag, opened the door to the resident's room without washing their hands, and left the room. CNA # 4 then returned to the room with the bottle of peri wash and donned a clean pair of gloves. LPN #4 used the bottle of peri wash obtained by CNA #4, who was not observed washing their hands, and completed the procedure. LPN #4 then applied the treatment to the wound wearing the same gloves worn when handling the peri wash. LPN # 4 used the scissors they removed from their pocket, to cut the dressing to size without disinfecting them, and applied the dressing to Resident #18's sacral wound. LPN #4 then removed gloves, donned a new pair of gloves without sanitizing or washing their hands. LPN # 4 then assisted CNA # 4 in repositioning and covering Resident # 18, removed gloves, went to the sink and washed their hands. The hand washing was observed to be completed in five seconds. On 05/11/2021 at 11:30 a.m., an interview was conducted with CNA # 4. When asked to describe the procedure for hand washing, CNA # 4 stated, Turn on the water, wet hands, apply soap, rub hands together, wash the backs of your hands and between the fingers, rinse hands, dry them with a paper towel then use it to turn the water off. When asked to describe the procedure for washing hands when changing gloves, CNA # 4 stated that hands should be washed or sanitized before donning gloves and after removing them. CNA #4 was informed of the above observations of them removing their gloves and leaving the resident's room without washing their hands. CNA # 4 stated that they should have washed or sanitized their hands after removing the gloves before leaving the room. On 05/11/2021 at 11:35 a.m., an interview was conducted with LPN # 4. When asked to describe the procedure for hand washing, LPN # 4 stated, Turn on the water, wet hands, apply soap, suds hands and wash for 15 to 30 seconds, rinse hands, dry them with a paper towel then use it to turn the water off. When asked about the time frame of washing their hands, LPN # 4 stated, I'm not sure. When asked to describe the procedure for washing hands when changing gloves, LPN # 4 stated that hands should be washed or sanitized before donning gloves and after removing them. LPN #4 was informed of the above observations of hand washing during Resident # 18's wound care procedure. LPN # 4 stated that they didn't use proper hand hygiene when washing their hands and before donning gloves and after removing them. LPN # 4 further stated, I rushed through it. When asked if they disinfected the scissors used before cutting the dressing, LPN # 4 stated that they disinfected them before placing them in their pocket. When asked if the scissor were still disinfected after having them in their pocket, LPN # 4 stated, I should have cleaned them when I took them out of my pocket. On 05/10/2021 at approximately 9:50 a.m., during the entrance conference with ASM [administrative staff member] # 1, administrator and ASM # 2, director of nursing stated that the standard of practice the nursing staff follows was [NAME]. Disinfection, noncritical patient care equipment. Introduction .reusable noncritical patient care equipment should be disinfected after use, before use on another patient. Lippincott procedures - Disinfection, noncritical patient care equipment. Revised: November 20, 2020. In a study conducted by the International Conference on Nosocomial and Healthcare related Infections in Atlanta Georgia, March 2000 showed that ordinary items can make your patients sick. In one study, a researcher gathered scissors that nurses and physicians kept in their pockets, as well as communal scissors left on dressing carts and tables. Three-quarters of the scissors carried microorganisms, including Staphylococcus aureus, Groups A and B streptococcus, and gram-negative bacilli. The solution is quite simple. If health care workers swab the scissors with alcohol after each use, they will virtually eliminate the risk of transmission of microorganisms. In the study, contaminated scissors were effectively disinfected after swabbing the scissors with alcohol. Reference: Embil JM, [NAME] B, [NAME] J, et al. Scissors as a potential source of nosocomial infection? Presented at the 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections. Atlanta; March 8, 2000. On 05/11/2021 at approximately 4:45 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional director of operations, were made aware of the above findings. No further information was provided prior to exit. [1] A nervous system disease that affects your brain and spinal cord. It damages the myelin sheath, the material that surrounds and protects your nerve cells. This damage slows down or blocks messages between your brain and your body, leading to the symptoms of MS. This information was obtained from the website: https://medlineplus.gov/multiplesclerosis.html. [2] Hydrofera Blue is a type of wound dressing. This information was obtained from the website: https://hydrofera.com/hydrofera-blue/

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident #57 was admitted to the facility with diagnoses that included but were not limited to metabolic encephalopathy (1), dementia (2) and osteoarthritis (3). Resident #57's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/15/2021, coded Resident #57 as scoring a 3 (three) on the staff assessment for mental status (BIMS) with a score of 0 - 15, 3- being severely impaired for making daily decisions. Section G coded Resident #57 as requiring extensive assistance of two or more staff for bed mobility, transfers and dressing. On 5/10/2021 at approximately 11:50 a.m., Resident #57 was observed in bed with bilateral upper bed rails in place on the bed. The bed rails were observed up and Resident #57 was observed grasping the bed rail when turning to the side in bed. An interview was attempted with Resident #57, however Resident #57 failed to answer questions appropriately. Additional observations of Resident #57 on 5/10/2021 at approximately 4:15 p.m. and 5/11/2021 at approximately 8:30 a.m. revealed the resident in bed with bilateral bed rails up. The physician orders for Resident #57 failed to evidence an order for the use of bed rails. The comprehensive care plan for Resident #57 dated 3/11/2021 failed to evidence documentation for use of bed rails. Review of Resident #57's clinical record failed to evidence a physical device assessment or consent for use of bed rails. On 5/11/2021 at approximately 11:30 a.m., ASM (administrative staff member) #1, the administrator provided via email, documentation of bed rail inspections completed in the facility for the past twelve months. The document provided documented the bed in Resident #57's room having bed rails being inspected by maintenance staff on Week 4 June 2020. On 5/12/2021 at approximately 7:45 a.m., a request was made via a written list to ASM #1, for the physical device assessment, consent for bed rail use and care plan for use of bed rails for Resident #57. On 5/12/2021 at approximately 9:30 a.m., ASM #1 stated that there was no order, consent or assessment for the bed rails for Resident #57. ASM #1 stated that Resident #57 should not have had the bed rails and they had no documentation to provide. On 5/12/2021 at approximately 10:33 a.m., an interview was conducted with LPN (licensed practical nurse) #4, the unit manager. LPN #4 stated that residents were evaluated for the use of bed rails to determine if they were able to use them for repositioning or turning in bed. LPN #4 stated that if a resident were assessed as eligible for bed rails they discussed the risks and benefits of the use and if they agreed to have them, they would sign a consent to authorize them. LPN #4 stated that if the resident were unable to make the decision for bed rails they discussed them with the responsible party and had them sign the consent for use. LPN #4 stated that after the assessment was completed and the consent was obtained they obtained a physician order for the bed rails and had the bed rails put into use. LPN #4 stated that they would care plan the bed rails at that time. When asked the purpose of the comprehensive care plan, LPN #4 stated that it notified everyone what was going on with the resident at that time. LPN #4 stated that other staff were able to review the care plan to get an idea of the care that the resident required. On 5/12/2021 at approximately 11:15 a.m., a request was made to ASM #1 for the facility policy on use of bed rails. The facility policy, Restraint Management dated Revised: 10/2019 documented in part, . 1. Whenever a guest/resident is admitted with an order for a restraint (including side rails), the staff may accept the order for up to 72 hours pending completion of the Physical Device Evaluation. 2. When a guest's/resident's condition necessitates consideration for a restraint, alternative interventions must be attempted and documented on the Physical Device Evaluation and in the care plan .5. Any guest/resident using a physical restraint or side rails must have a current, signed restraint consent in the medical record . The policy further documented, .10. Any guest using side rails will have a current order with the following components: Type of side rails (1/2, 3/4, full, assist bars); Number of side rails to be raised; Reason for use/medical symptom; Guest/resident request for use of side rails (If applicable) . On 5/12/2021 at approximately 11:15 a.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of operations and ASM #5, the senior clinical transition specialist were made aware of the findings. No further information was provided prior to exit. Reference: 1. Encephalopathy- Encephalopathy is a general term describing a disease that affects the function or structure of your brain. This information is taken from the website https://www.healthline.com/health/hepatic-encephalopathy. 2. Dementia is a loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. 3. Osteoarthiris- Osteoarthritis occurs when cartilage, the tissue that cushions the ends of the bones within the joints, breaks down and wears away. In some cases, all of the cartilage may wear away, leaving bones that rub up against each other. This information was obtained from the website: https://www.nia.nih.gov/health/osteoarthritis. Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for six of 38 residents in the survey sample, Residents #128, #115, #15, #58, #63, and #57. The facility staff failed to implement the comprehensive care plan for: 1. Resident #128, for the administration of oxygen and a CPAP per a physician's order, 2. Resident #115, facility staff failed to implement her comprehensive care plan for her feeding tube, 3a. Resident # 15's, for the use of non-pharmacological interventions prior to the use of as needed pain medication of oxycodone [1]. b. The facility staff failed to develop a comprehensive care plan for Resident # 15's the use of physician ordered oxygen. 4a. The facility staff failed to implement Resident # 58's comprehensive care plan for the use of non-pharmacological interventions prior to the use of as needed pain medication of oxycodone [1]. b. The facility staff failed to implement the comprehensive care plan for Resident # 58's the use of physician ordered oxygen. 5. The facility staff failed to implement Resident # 63's comprehensive care plan for the use of non-pharmacological interventions prior to the use of as needed pain medication of acetaminophen [1]. 6. The facility staff failed to develop a comprehensive care plan which included the use of bed rails for Resident #57. The findings include: 1. Resident #128 was admitted to the facility on [DATE] with diagnoses including, but not limited to, COPD (Chronic Obstructive Pulmonary Disease) (2) and heart failure. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/25/21, Resident #128 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was coded as receiving oxygen both before and while a resident at the facility. On 5/10/21 at 12:20 p.m., Resident #128 was observed sitting up in bed. She was receiving oxygen from a concentrator through a nasal cannula. The oxygen flowrate was set at 2 lpm (liters per minute). The oxygen tubing running from the concentrator to the resident did not have a date. When asked about the tubing, Resident #128 stated the tubing had not been changed since she had been admitted to the facility. On 5/10/21 at 4:00 p.m., Resident #128 was observed sitting up in bed. She was receiving oxygen from a concentrator through a nasal cannula. The oxygen flowrate was set at 2 lpm (liters per minute). On 5/11/21 at 9:18 a.m., Resident #128 was again asked about her oxygen tubing. She stated the tubing had still not been changed. At this time, LPN (licensed practical nurse) #12 entered the room. LPN #12 was asked to identify the date the oxygen tubing had been changed. LPN #1 stated, There is no date on the tubing. She stated since there was no date, she could not say when or if the tubing had been changed. Resident #128 stated, The tubing hasn't been changed since I was admitted , and [the tubing] is hard. LPN #12 stated the tubing should be changed weekly, and it is usually changed on the weekends. On 5/11/21 at 11:34 a.m., Resident #128 was observed lying in bed. She was wearing a CPAP device. She removed the device, replaced the nasal cannula so she could receive oxygen, and participated in an interview. She stated she has been receiving oxygen since before she was admitted to the facility, and has been receiving it ever since her admission to the facility. She further stated she uses the CPAP all the time, including daytime naps as well as overnight sleep. When asked if the staff was providing any supervision or cleaning for the CPAP, she stated they were not. Review of Resident #128's clinical record revealed an admission nursing assessment dated [DATE]. The assessment documented: Have you been told by a doctor that you have sleep apnea? Yes. Do you use a .CPAP? Yes. Do you use your machine regularly? Yes .Oxygen therapy? Yes. Oxygen therapy liter/min (liters per minute) and frequency? 2L (2 liters per minute). Review of Resident #128's clinical record revealed no physician's order for oxygen prior to 5/10/21, and no order at all for the sure of a CPAP. The review revealed the following order for oxygen, dated 5/10/21at 11:00 p.m.: Continuous oxygen @ (at) 2 liters every shift for sob (shortness of breath). A review of Resident #128's comprehensive care plan dated 4/22/21, revealed, in part: [Resident #128] has a potential for difficulty breathing and risk for respiratory complications .Administer medications and treatments per physician orders .Oxygen, CPAP . On 5/11/21 at 2:11 p.m., RN (registered nurse) #3, the MDS nurse, was interviewed. When she asked the purpose of a resident's comprehensive care plan, RN #3 stated the care plan tells the staff how to take care of a resident, and raises any issues that should be addressed while the resident is in the facility's care. On 5/11/21 at 3:10 p.m., LPN #6 was asked to verify Resident #128's oxygen rate set on the concentrator with her physician's order for oxygen. LPN #6 stated the oxygen rate matched the order. When asked when the oxygen order had been initially written, LPN #6 stated, It looks like it was just written this morning. When asked if Resident #128 had been receiving oxygen prior to the morning of 5/11/21, LPN #6 stated, Yes. She has had it the whole time. When asked if she could locate an order for oxygen for Resident #128 prior to 5/10/21, she stated she could not. When asked to locate the orders for Resident #128's CPAP, LPN #6 looked and stated, An order for that does not pop up. When asked if a resident needed an order for a CPAP, she stated yes. When asked how often CPAP equipment needs cleaning, she stated she was not sure. LPN #6 stated, Not every night, I don't think. Maybe every shift. I just really don't know. On 5/11/21 at 3:19 p.m., LPN #1 was interviewed. When asked the purpose of the comprehensive care plan, she stated the care plan contains different tools that are in place to help the resident, and different interventions to assist the resident and keep the resident safe. She stated the care plan contains goals that can be set, measured, and evaluated. She stated the goals are set in place in order for the resident to have the optimal outcome. When asked how she makes sure the care plan interventions are implemented, LPN #1 stated that many of the interventions pop up on the TAR for the staff to sign off as being completed. On 5/11/21 at 4:45 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing (DON), and ASM #3, the regional director of operations, were informed of these concerns. On 5/12/21 at 10:58 a.m., ASM #2, the director of nursing, was interviewed. She stated an order is required to administer oxygen to a resident. She stated an order is also required for a resident's CPAP usage. She stated the order should specify the settings on the machine. A review of the facility policy, Interdisciplinary Care Plan, revealed, in part, the following: The Interdisciplinary Care Plan Team, in accordance with the guest, his/her family, or representative, develops and maintains a comprehensive care plan for each guest. The interdisciplinary care plan will: .Reflect treatment goals and objectives in measurable outcomes .Identify the professional services that are responsible for each element of care and frequency of services provided .Reflect the medical regimen and physician's plan of treatment. 2. Resident #115 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (1), dementia (2), and history of a stroke requiring the placement of a feeding tube (3). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/13/21, she was coded as being severely cognitively impaired for making daily decisions, having scored three out of 15 on the BIMS (brief interview for mental status). Resident #115 was coded as receiving greater than 51% of her total calories through a feeding tube. On the following dates and times, 5/11/21 at 9:58 a.m., 12:26 p.m., and 3:00 p.m., Resident #115 was observed lying in bed with the head her bed elevated. A tube feeding solution bag and a bag of water were hanging on a pole. Both feeding solution and the water were threaded through an automatic pump. The pump settings were 60 mls/hour (milliliters per hour) continuous for the tube feeding solution, and 40 mls of water one time flush each hour. A review of Resident #115's clinical record revealed the following physician's orders, dated 4/21/21: Jevity 1.2 (tube feeding solution) @ (at) 60 ml per hour .Jevity 1.2 at 60 ml per hour. Total amount taken in every night shift. The clinical record also contained the following physician's order: Enteral (tube feeding) Feed Order Four times a day for Maintenance Flush PEG tube with 120 cc (cubic centimeters) of water. A review of Resident #115's MARs (medication administration records) and TARs (treatment administration records) revealed staff signatures for all dates in May 2021 for these orders, indicating the feedings and water were administered per the order. However, none of the night shift records contained a total amount of tube feeding solution taken in by the resident. A review of Resident #115's comprehensive care plan, dated 4/14/21 and revised 4/19/21, revealed, in part: [Resident #115] is unable to tolerate nutritionally adequate food and/or fluids by mouth requiring the use of a feeding tube .Administer tube feeding as ordered. On 5/11/21 at 2:11 p.m., RN (registered nurse) #3, the MDS nurse, was interviewed. When she asked the purpose of a resident's comprehensive care plan, she stated the care plan tells the staff how to take care of a resident, and raises any issues that should be addressed while the resident is in the facility's care. On 5/11/21 at 3:00 p.m., LPN (licensed practical nurse) #6 was accompanied to observe Resident #115's feeding tube pump settings. When asked to describe the settings, LPN #6 stated it was set to deliver 60 mls of Jevity each hour to the resident via the resident's feeding tube. She stated it was set to deliver a once-an-hour flush of 40 mls of water. When asked if she knew if these settings matched the physician's order, LPN #6 stated she thought so, but would need to verify. LPN #6 checked Resident #115's physician's orders, and stated, I can't tell. She stated she thought that when the pump was programmed for the tube feeding solution, the pump automatically provided the 40 mls of water flush each shift. She stated: No - the orders don't match what the pump is doing. She stated she did not know how to prevent the pump from delivering the 40 mls of water flush each hour. On 5/11/21 at 3:19 p.m., LPN #1 was interviewed. When asked the purpose of the comprehensive care plan, she stated the care plan contains different tools that are in place to help the resident, and different interventions to assist the resident and keep the resident safe. She stated the care plan contains goals that can be set, measured, and evaluated. She stated the goals are set in place in order for the resident to have the optimal outcome. When asked how she makes sure the care plan interventions are implemented, LPN #1 stated that many of the interventions pop up on the TAR for the staff to sign off as being completed. On 5/11/21 at 4:45 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing (DON), and ASM #3, the regional director of operations, were informed of these concerns. On 5/12/21 at 10:34 a.m., LPN #4, a unit manager, was interviewed. She stated she was very familiar with the programming and operations of the feeding tube pumps. She stated the pumps are programmed according to the physician's orders. LPN #4 stated, We always have to set the tube feeding and water amounts manually. She stated the tube feeding and flush amounts vary for each resident, and are adjusted as the resident's needs or conditions change. When asked to review Resident #115's TARs for the total amount of intake each night shift, LPN #4 stated, They are missing a prompt. There should be an amount each shift. You can't just sign it off. On 5/12/21 at 10:58 a.m., ASM #2 was interviewed. She verified that the tube feeding pumps must be manually programmed for both the tube feeding and the water amounts and rates, and that Resident #115's pump had been incorrectly programmed. ASM #2 stated the night shift staff should have been recording the total amount of tube feeding and water taken in by the resident for each preceding 24 hour period. No further information was provided prior to exit. REFERENCES (1) Parkinson's disease (PD) is a type of movement disorder. It happens when nerve cells in the brain don't produce enough of a brain chemical called dopamine. Sometimes it is genetic, but most cases do not seem to run in families. This information is taken from the website https://medlineplus.gov/parkinsonsdisease.html. (2) Dementia is a gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information is taken from the website https://medlineplus.gov/ency/article/000746.htm. (3) A PEG (percutaneous endoscopic gastrostomy) feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. PEG feeding tube insertion is done in part using a procedure called endoscopy. Feeding tubes are needed when you are unable to eat or drink. This may be due to stroke or other brain injury, problems with the esophagus, surgery of the head and neck, or other conditions. This information is taken from the website https://medlineplus.gov/ency/patientinstructions/000900.htm 3a. Resident # 15 was admitted to the facility with diagnoses that include but not limited to: spinal stenosis [2]. Resident # 15's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 02/05/2021, coded Resident # 15 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 15 as not having pain in the past five days`. The physician's order for Resident # 15 dated 02/02/2021 documented, Oxycodone Tablet 5 MG [five milligrams]. Give 1 [one] tablet by mouth every 6 [six] hours as needed for pain, pain scale 6-10 [six to ten]. Order Date: 2/2/2021. Resident # 15's eMAR [electronic medication administration record] dated April 2021 documented the physician's order above. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of oxycodone on: 04/01/2021 at 12:13 p.m. with a level of six, 04/02/2021 at 12:42 p.m. with a pain level of seven, 04/04/2021 at 8:38 a.m. with a pain level of seven, 04/05/2021 at 1:03 p.m. with a pain level of six and at 10:10 p.m. with a pain level of seven, 04/06/2021 at 1:19 p.m. with a pain level of seven, 04/07/2021 at 12:44 p.m. with a pain level of six, 04/10/2021 at 12:57 p.m. with a pain level of seven and at 9:41 p.m. with a pain level of seven, 04/14/2021 at 12:46 p.m. with a pain level of six, 04/15/2021 at 4:13 p.m. with a pain level of ten, 04/18/2021 at 3:45 a.m. with a pain level of six, 04/21/2021 at 5:55 a.m. with a pain level of eight, 04/24/2021 at 10:28 a.m. with a pain level of seven and at 10:14 p.m. with a pain level of eight, 04/25/2021 at 4:03 p.m. with a pain level of seven and on 04/27/2021 at 10:28 p.m. with a pain level of eight. Resident # 15's eMAR [electronic medication administration record] dated May 2021 documented the above physician's order. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of oxycodone on: 05/04/2021 at 3:15 p.m. with a pain level of seven, 05/05/2021 at 10:20 p.m. with a pain level of six and on 05/09/2021 at 4:15 p.m. with a pain level of eight and at 10:11 p.m. with a pain level of seven. The comprehensive care plan for Resident # 15 dated 07/16/2020 documented in part, Need: [Resident # 15 is at risk for pain and/or has acute/chronic pain r/t [related to] Arthritis, spinal stenosis. Date Initiated: 07/16/2020. Under Interventions it documented in part, Offer Non-Pharmacological Interventions: 1) Massage. 2) Meditation/Relaxation. 3) Positioning. 4) Ice/cold pack. 5) Diversional Activity. 6) Guided Imagery. 7) Rest. 8) Social Interaction. 9) Other. Date Initiated: 07/16/2020 On 05/10/21 at 1:56 p.m., an interview was conducted with Resident # 15. When asked if they received pain medication when needed, Resident # 15 stated yes. When asked if the nurses try to alleviate the pain before administering the medication, Resident # 15 stated, Sometimes they do. On 05/11/21 at 2:27 p.m., an interview was conducted with LPN [licensed practical nurse] # 4, unit manager about implementing Resident # 15's comprehensive care plan for non-pharmacological interventions. When asked where a nurse documents that non-pharmacological interventions were attempted prior to administering an as needed pain medication, LPN # 4 stated, Should be documented on the ear. After reviewing Resident # 15's April 2021 and May 2021 ears, LPN # 4 stated that there was missing documentation of non-pharmacological interventions on the dates and times documented above. LPN # 4 further stated that they couldn't say that the interventions were being attempted. When asked to review Resident # 15's comprehensive care plan, LPN # 4 stated that they didn't need to because they knew that the non-pharmacological interventions were on the care plan. LPN # 4 further stated that if the non-pharmacological interventions were not being done the care plan was not being followed. On 05/11/2021 at approximately 4:45 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional director of operations, were made aware of the above findings. No further information was provided prior to exit. References: [1] Indicated for the management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f2137f1a-b49a-40bd-97ac-cd6b36e295f4. [2] A narrowing of the spinal column that causes pressure on the spinal cord, or narrowing of the openings (called neural foramina) where spinal nerves leave the spinal column. This information was obtained from the website: https://medlineplus.gov/ency/article/000441.htm. 3b. Resident # 15's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 02/05/2021, coded Resident # 15 for Oxygen Therapy while a resident in Section O Special Treatments, Procedures and Programs. On 05/10/21 at 11:02 a.m., and at 1:58 p.m., observation of Resident # 15 revealed they were sitting in their wheelchair receiving oxygen by nasal cannula from an oxygen concentrator. Observation of the flow meter on the oxygen concentrator revealed that Resident # 15 was receiving oxygen at two-and-a-half liters per minute. On 05/11/21 at 7:58 a.m., an observation of Resident # 15 revealed the resident lying in bed receiving oxygen by nasal cannula connected to an oxygen concentrator. Observation of the flow meter on the oxygen concentrator revealed that Resident # 15 was receiving oxygen at two-and-a-half liters per minute. The physician's order dated 02/01/2021 for Resident # 15 documented, Oxygen 2l/m [two liters per minute] via [by] nasal cannula [1] as needed for SOB [shortness of breath]. The comprehensive care plan for Resident # 15 with a revision date of 02/01/2021 failed to evidence documentation for the use of oxygen. On 05/11/2021 at 4:12 p.m. an interview was conducted with RN [registered nurse] # 3, MDS coordinator. When asked about the comprehensive care plan for Resident # 15's use of oxygen, RN # 3 stated they would review the care plan. On 05/12/2021 at 9:29 a.m., RN # 3 stated that care plan was developed for Resident # 15's use of oxygen. On 05/11/2021 at 12:00 p.m. an interview was conducted with RN [registered nurse] # 3, MDS coordinator. When asked to describe the procedure for developing a resident's comprehensive care plan, RN # 3 stated that at the time of admission they look at the resident's diagnoses codes, the hospital history & physical, and physician's orders to develop the care plan. When asked how they maintain an accurate comprehensive care plan after admission, RN # 3 stated that they check the resident's physician's orders daily to develop, revise or update the care plan. On 05/12/2021 at approximately 11:15 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, regional director of operations and ASM # 4, senior clinical transition specialist, were made aware of the above findings. No further information was provided prior to exit. 4a. Resident # 58 was admitted to the facility with diagnoses that included but were not limited to: lower back pain. Resident # 58's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 03/16/2021, coded Resident # 58 as scoring an 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 58 as having frequent pain at a level four based on a zero to ten pain scale, with ten being the worse pain they could imagine. The physician's order for Resident # 58 dated 01/14/2020 documented, Oxycodone Tablet 5 MG [five milligrams]. Give 5 mg by mouth every 6 [six] hours as needed for severe pain. Order Date: 1/14/2020. The comprehensive care plan for Resident # 58 dated 07/16/2020 documented in part, Need: [Resident # 58] has the potential for pain and general discomfort. Dx [diagnosis] of arthritis. Date initiated 05/04/2020. Under Interventions it documented in part, Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Date initiated 05/04/2020. Resident # 58's eMAR [electronic medication administration record] dated April 2021 documented the above physician's order for pain medication. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of oxycodone on: 04/09/2021 at 5:49 a.m. with a pain level of ten and on 04/19/2021 at 9:17 p.m. with a pain level of five. Resident # 58's eMAR [electronic medication administration record] dated May 2021 documented the above physician's order for pain medication. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of oxycodone on: 05/04/2021 at 9:20 p.m. with a pain level of seven and on 05/08/2021 at 10:02 p.m. with a pain level of seven. On 05/10/21 at 1:44 p.m., an interview was conducted with Resident # 58. When asked if they received pain medication when needed, Resident # 58 stated yes. When asked if the nurses try to alleviate the pain before administering the medication, Resident # 58 stated, Sometimes they do sometimes they don't. On 05/11/21 at 2:27 p.m., an interview was conducted with LPN [licensed practical nurse] # 4, unit manager about implementing Resident # 15's comprehensive care plan for non-pharmacological interventions. When asked where a nurse documents that non-pharmacological interventions were attempted prior to administering a as needed pain medication, LPN # 4 stated, Should be documented on the eMAR. After reviewing Resident # 15's April 2021 and May 2021 eMARs, LPN # 4 stated that there was missing documentation of non-pharmacological interventions on the dates and times documented above. LPN # 4 further stated that they couldn't say that the interventions were being attempted. When asked to review Resident # 15's care plan LPN # 4 stated that they didn't need to because they knew that the non-pharmacological interventions were on the care plan. LPN # 4 further stated that if the non-pharmacological interventions were not being done the care plan was not being followed. On 05/11/2021 at approximately 4:45 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional director of operations, were made aware of the above findings. No further information was provided prior to exit. References: [1] Indicated for the management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f2137f1a-b49a-40bd-97ac-cd6b36e295f4. 4b. On 05/10/21 at 1:46 p.m., 05/11/21 at 7:57 a.m., and at 2:17 p.m., observations of Resident # 58 revealed the resident lying in bed receiving oxygen by nasal cannula from an oxygen concentrator. Observation of the flow meter on the oxygen concentrator revealed that Resident # 58 was receiving oxygen at three liters per minute. The POS [physician's order sheet' dated May 2021 for Resident # 58 documented, O2 [oxygen] 4L [four liters] via [by] NC [nasal cannula] continuously. Start Date: 12/16/2019. The comprehensive care plan for Resident # 58 dated 12/24/2019 documented in part, Need: [Resident # 58] has a potential for difficulty breathing and risk for respiratory complications R/T [related to]: Chronic Obstruc[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Resident #6 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: Chronic respiratory failure (chronic inability of the heart and lungs to maintain an adequate gas exchange) (1), trach (surgically created opening into the trachea with a tube inserted to create an airway) (2) and Parkinson's disease (slowly progressive neurological disorder characterized by tremors) (3). Resident #6's most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 2/2/21, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status score), indicating the resident was severely cognitively impaired. The resident was coded as being totally dependent in bed mobility, transfers, dressing, toileting, bathing, personal hygiene and eating; walking/locomotion did not occur. A review of the physician orders dated 2/9/21, documented in part, Change inner cannula of disposable trach one time a day. Clean inner cannula every shift. A review of the TAR (treatment administration record) from 4/1/21-5/12/21 documented in part, Change inner cannula of disposable trach one time a day. Clean inner cannula every shift. The TAR documented that the treatment was completed 100% of days. Resident #6's care plan dated 6/5/20 and revised 1/6/21, documented in part, NEED: Has a potential for difficulty breathing and risk for respiratory complications related to history of respiratory failure. Guest has trach. INTERVENTIONS: Change disposable trach cannula as ordered and as needed. Observe for signs/symptoms of acute respiratory insufficiency. Report abnormal findings to the physician. Oxygen at 2 liters nasal cannula for shortness of breath. Trach humidity set up with oxygen bleed to keep oxygen saturation greater than 90%. On 5/11/21 at 8:20 AM, trach care was observed. LPN (licensed practical nurse) #5 changed the inner cannula of Resident #6's disposable trach, and cleaned the inner cannula. LPN #5 then changed dressing and suctioned the resident. An interview was conducted on 5/11/21 at 8:50 AM with LPN #5. When asked what supplies were needed for a resident with a trach, LPN #5 stated, We should have the inner cannula, extra trach, trach ties, dressing, trach kit, oxygen tubing and an ambu bag. When asked to observe the additional disposable trach, inner cannula and ambu bag, LPN #5 stated, They are in his closet. I will show you. LPN #5 opened the closet and stated, There is not an ambu bag in this closet. I thought there was one. When asked where the ambu bags were located, LPN #5 stated, in the supply room and on the code cart. An interview was conducted on 5/11/21 at 1:15 pm with LPN #12. When asked if an ambu bag should be kept in the room of a resident with a trach, LPN #12 stated, Yes, there should be one in the room for emergencies. On 5/11/21 at 4:54 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of operations, were informed of the finding. According to ASM #2, the director of nursing, the standard of practice followed is [NAME], the on line version. A review of the [NAME]'s Tracheostomy suctioning procedure documents Equipment: handheld resuscitation bag. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 502. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 574. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 435. (4). Ambu bag: A self-refilling bag-valve-mask unit with a 1-1.5 litre capacity, used for artificial respiration which, while suboptimal for the non-intubated patient, is effective for ventilating and oxygenating intubated patients, allowing both spontaneous and artificial respiration. This information was obtained from the website: https://medical-dictionary.thefreedictionary.com/Ambu+bag#:~:text=Ambu%20bag%20A%20self-refilling%20bag-valve-mask%20unit%20with%20a,respiration.%20Segen%27s%20Medical%20Dictionary.%20%C2%A9%202012%20Farlex 3. Resident #128 was admitted to the facility on [DATE] with diagnoses including, but not limited to, COPD (Chronic Obstructive Pulmonary Disease) (2) and heart failure. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/25/21, Resident #128 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was coded as receiving oxygen both before and while a resident at the facility. On 5/10/21 at 12:20 p.m., Resident #128 was observed sitting up in bed. She was receiving oxygen from a concentrator through a nasal cannula. The oxygen rate was set at 2 lpm (liters per minute). The oxygen tubing running from the concentrator to the resident did not have a date. When asked about the tubing, Resident #128 stated the tubing had not been changed since she had been admitted to the facility. On 5/10/21 at 4:00 p.m., Resident #128 was observed sitting up in bed. She was receiving oxygen from a concentrator through a nasal cannula. The oxygen rate was set at 2 lpm (liters per minute). On 5/11/21 at 9:18 a.m., Resident #128 was again asked about her oxygen tubing. She stated the tubing had still not been changed. At this time, LPN (licensed practical nurse) #12 entered the room. LPN #12 was asked to identify the date the oxygen tubing had been changed. LPN #12 stated, There is no date on the tubing. She stated since there was no date, she could not say when or if the tubing had been changed. Resident #128 stated, The tubing hasn't been changed since I was admitted , and [the tubing] is hard. LPN #12 stated the tubing should be changed weekly, and it is usually changed on the weekends. On 5/11/21 at 11:34 a.m., Resident #128 was observed lying in bed. She was wearing a CPAP device. She removed the device, replaced the nasal cannula so she could receive oxygen, and participated in an interview. She stated she has been receiving oxygen since before she was admitted to the facility, and has been receiving it ever since her admission to the facility. Resident #128 further stated she uses the CPAP all the time, including daytime naps as well as overnight sleep. When asked if the staff was providing any supervision or cleaning for the CPAP, she stated they were not. Review of Resident #128's clinical record revealed an admission nursing assessment dated [DATE]. The assessment documented: Have you been told by a doctor that you have sleep apnea? Yes. Do you use a .CPAP? Yes. Do you use your machine regularly? Yes .Oxygen therapy? Yes. Oxygen therapy liter/min (liters per minute) and frequency? 2L (2 liters per minute). Review of Resident #128's clinical record revealed no physician's order for oxygen prior to 5/10/21, and no order at all for the use of a CPAP. The review revealed the following order for oxygen, dated 5/10/21 at 11:00 p.m.: Continuous oxygen @ (at) 2 liters every shift for sob (shortness of breath). A review of Resident #128's comprehensive care plan dated 4/22/21, revealed, in part: [Resident #128] has a potential for difficulty breathing and risk for respiratory complications .Administer medications and treatments per physician orders .Oxygen, CPAP . On 5/11/21 at 3:10 p.m., LPN #6 was asked to verify Resident #128's oxygen rate set on the concentrator with her physician's order for oxygen. LPN #6 stated the rate matched the order. When asked when the oxygen order had been initially written, LPN #6 stated, It looks like it was just written this morning. When asked if Resident #128 had been receiving oxygen prior to the morning of 5/11/21, LPN #6 stated, Yes. She has had it the whole time. When asked if she could locate an order for oxygen for Resident #128 prior to 5/10/21, she stated she could not. When asked to locate the orders for Resident #128's CPAP, LPN #6 looked and stated, An order for that does not pop up. When asked if a resident needed an order for a CPAP, she stated yes. When asked how often CPAP equipment needs cleaning, LPN #6 stated she was not sure. LPN #6 stated, Not every night, I don't think. Maybe every shift. I just really don't know. On 5/11/21 at 3:19 p.m., LPN #1 was interviewed. When asked if an order is required for a resident to receive oxygen and for the use of a CPAP, she stated yes. She stated because oxygen is a medication, it requires an order. She stated the oxygen tubing is supposed to be changed weekly, and should be labeled with the date and the initials of the staff member who changed it. She stated the CPAP order should include the time of use, the rate, and any other maintenance or cleaning needs. When asked if she knew how often CPAP equipment should be cleaned, LPN #1 stated, I feel like it is every month or so. On 5/11/21 at 4:45 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing (DON), and ASM #3, the regional director of operations, were informed of these concerns. On 5/12/21 at 10:34 a.m., LPN #4, a unit manager, was interviewed. When asked how a resident's oxygen rate is determined, LPN #4 stated, I will talk to the resident, then look through the orders. She stated an order from a physician, which includes the rate and method of delivery, is required to administer oxygen. She stated an order is also needed for a resident's CPAP usage. She stated it is her practice to clean the CPAP mask with soap and water every day. On 5/12/21 at 10:58 a.m., ASM #2 was interviewed. She stated an order is required to administer oxygen to a resident. ASM #2 stated an order is also required for a resident's CPAP usage. She stated the order should specify the settings on the machine. A review of the facility policy, Use of Oxygen, revealed, in part: The O2 (oxygen) cannula or mask should be changed weekly and dated. It should be changed when soiled or dry. A review of the facility policy, Continuous Positive Airway Pressure (CPAP) Use, revealed, in part: Cleaning of non-invasive respiratory equipment: Wash tubing and mask weekly with soap and water, rinse and let air dry .Verify the practitioner's order . No further information was provided prior to exit. REFERENCES (1) CPAP (Continuous Positive Airway Pressure) is a treatment that uses mild air pressure to keep your breathing airways open .It involves using a CPAP machine that includes a mask or other device that fits over your nose or your nose and mouth, straps to position the mask, a tube that connects the mask to the machine's motor, and a motor that blows air into the tube. CPAP is used to treat sleep-related breathing disorders including sleep apnea. This information is taken from the website https://www.nhlbi.nih.gov/health-topics/cpap. (2) COPD is a general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. 4. Resident #337 was admitted to the facility on [DATE] with diagnoses including COPD (1) and lung cancer. She had not been a resident of the facility long enough to have a completed MDS (minimum data set) assessment. On the resident's admission nursing assessment dated [DATE], she was coded as being oriented to person, place, and time, and as receiving oxygen at the rate of two liters per minute. On 5/11/21 at 9:53 a.m., Resident #337 was observed sitting up in bed. Her eyes were closed. Oxygen was being delivered to her from a concentrator through a nasal cannula. The middle of the ball on the concentrator flowmeter was observed between 3.5 and 4 liters per minute. During the observation, Resident #337 awoke and participated in an interview. Resident #337 stated her oxygen rate should be four liters per minute, and that is the rate her doctor had ordered for her both at home, and after she was admitted to the facility. She stated she had been receiving oxygen at 4 liters per minute ever since she was admitted . She stated she did not adjust the oxygen concentrator herself, and that a staff member had mentioned that the knob on the oxygen concentrator for adjusting the flow rate was broken. On 5/11/21 at 12:15 p.m., Resident #337 was observed sitting in a wheelchair eating lunch. Oxygen was being delivered to her from a concentrator through a nasal cannula. The middle of the ball on the concentrator was observed between 3.5 and 4 liters per minute. On 5/11/21 at 2:50 p.m., Resident #337 was observed sitting in a wheelchair in her room. LPN #12 came into the room. When asked to state the rate of Resident #337's oxygen, LPN #12 stated, Well, the top of the ball is on 4. The bottom of the ball is on 3.5. There is no knob to adjust it. LPN #12 manipulated the knobs on the oxygen concentrator, and finally stated, I fixed it. I moved it to 4. The line should go through the middle of the ball. A review of Resident #337's clinical record revealed the following oxygen orders: - 4/27/21 Oxygen cont. (continuous) 2LPM (two liters per minute) via NC (nasal cannula) to keep sats (saturations) >92% (greater than 92%) every shift. This order was discontinued by LPN #12 at 3:00 p.m. on 5/11/21. - 5/11/21 (at 3:00 p.m.) Oxygen cont. at 4 LPM via NC to keep sats >92% every shift. This order was entered by LPN #12. A review of Resident #337's initial care plan dated 4/26/21, revealed, in part: [Resident #337] has a potential for difficulty breathing and risk for respiratory complications .Administer medications and treatments per physician orders .Oxygen. On 5/11/21 at 3:19 p.m., LPN #1 was interviewed. When asked if an order is required for a resident to receive oxygen, she stated yes. She stated because oxygen is a medication, it requires an order. On 5/11/21 at 4:45 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing (DON), and ASM #3, the regional director of operations, were informed of these concerns. On 5/12/21 at 10:34 a.m., LPN #4, a unit manager, was interviewed. When asked how a resident's oxygen rate is determined, LPN #4 stated, I will talk to the resident, then look through the orders. She stated an order from a physician, which includes the rate and method of delivery, is required to administer oxygen. On 5/12/21 at 10:58 a.m., ASM #2 was interviewed. She stated an order is required to administer oxygen to a resident. No further information was provided prior to exit. REFERENCES (1) COPD is a general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory services according to the physician's orders and professional standards for seven of 38 residents in the survey sample, Residents #15, #58, #128, #337, #71, #333 and #6. The facility staff failed to administer oxygen at the oxygen flow rate according to the physician's orders for Resident # 15, Resident #58 and Resident #337. For Resident #128, the facility staff, the facility failed to obtain an order for oxygen and the used of a CPAP (continuous positive airway pressure) machine prior to survey team entrance on 5/10/21. The facility staff failed to change the oxygen tubing between 4/21/21 and 5/11/21. The facility staff failed to ensure an order for the use of oxygen was written following an emergent event and obtaining the verbal order from the physician, for Resident #6 on 4/16/21 and Resident #333 on 3/9/21. The facility staff failed to provide tracheostomy [trach] care in a safe manner for Resident #6. During Resident #6's trach care on 5/11/21 at 8:20 AM there was no ambu bag (4) in his room. The findings include: 1. Resident # 15 was admitted to the facility with diagnoses that include but are not limited to: congestive heart failure. Resident # 15's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 02/05/2021, coded Resident # 15 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 15 for Oxygen Therapy while a resident. On 05/10/21 at 11:02 a.m., and at 1:58 p.m., observation of Resident # 15 revealed the resident in their room sitting in a wheelchair and receiving oxygen by nasal cannula from an oxygen concentrator. Observation of the flow meter on the oxygen concentrator revealed that Resident # 15 was receiving oxygen at two-and-a-half liters per minute. On 05/11/21 at 7:58 a.m., an observation of Resident # 15 revealed the resident lying in bed and receiving oxygen by nasal cannula from an oxygen concentrator. Observation of the flow meter on the oxygen concentrator revealed that Resident # 15 was receiving oxygen at two-and-a-half liters per minute. The physician's order dated 02/01/2021 for Resident # 15 documented, Oxygen 2l/m [two liters per minute] via [by] nasal cannula [1] as needed for SOB [shortness of breath]. The comprehensive care plan for Resident # 15 with a revision date of 02/01/2021 failed to evidence documentation for the use of oxygen. On 05/11/21 at 2:11 p.m., an interview was conducted with LPN [licensed practical nurse] # 4, unit manager. When asked to describe how to read the flow meter on an oxygen concentrator to determine the amount of oxygen being delivered to a resident, LPN # 4 stated, The liter line should pass through the middle of the ball [float ball]. At 2:20 p.m., LPN # 4 was accompanied to Resident #115's room and was asked to read the oxygen flow rate on Resident # 15's oxygen concentrator. After entering Resident # 15 room and reading the flow meter LPN # 4 stated, It's at two-and-a-half liters. When asked what the physician ordered the oxygen flow rate to be set at LPN # 4 referred to the physician's orders and stated that it should set at two liters per minute. The Operating Instructions provided by the facility for the oxygen concentrators documented in part, Note: To properly read the flowmeter, locate the prescribed flowrate line on the flowmeter. Next, turn the flow knob until the ball rises to the line. Now, center the ball on the L/min line prescribed. On 05/11/2021 at approximately 4:45 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional director of operations, were made aware of the above findings. No further information was provided prior to exit. References: [1] Tubing used to deliver oxygen at levels from 1 to 6 L/min. The nasal prongs of the cannula extend approx. 1 cm into each naris and are connected to a common tube, which is then connected to the oxygen source. This information was obtained from the website: http://medical-dictionary.thefreedictionary.com/nasal+cannula. 2. Resident # 58 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: acute and chronic respiratory failure [1] and chronic obstructive pulmonary disease [2]. Resident # 58's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 03/16/2021, coded Resident # 58 as scoring an 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. Under section O0100 Special Treatments, Procedures and Programs it documented in part, C. Oxygen therapy. 2. While a Resident. Further review of this section revealed the box under 2. While a Resident, was not checked. On 05/10/21 at 1:46 p.m., 05/11/21 at 7:57 a.m., and at 2:17 p.m., observation of Resident # 58 revealed the resident lying in bed and receiving oxygen by nasal cannula from an oxygen concentrator. Observation of the flow meter on the oxygen concentrator revealed that Resident # 58 was receiving oxygen at three liters per minute. The POS [physician's order sheet' dated May 2021 for Resident # 58 documented, O2 [oxygen] 4L [four liters] via [by] NC [nasal cannula] continuously. Start Date: 12/16/2019. The comprehensive care plan for Resident # 58 dated 12/24/2019 documented in part, Need: [Resident # 58] has a potential for difficulty breathing and risk for respiratory complications R/T [related to]: Chronic Obstructive Pulmonary Disease, COPD, Requires the use of: O2 @ [at] 4 liters. Date Initiated: 12/24/2019. Under Intervention it documented in part, Administer medication & [and] treatments per physician's orders. Monitor for ineffectiveness, side effects and adverse reactions, report abnormal finds to the physician. Guest to use Oxygen via nasal cannula. Date Initiated: 12/24/2019. On 05/11/21 at 2:11 p.m., an interview was conducted with LPN [licensed practical nurse] # 4, unit manager. When asked to describe how to read the flow meter on an oxygen concentrator to determine the amount of oxygen being delivered to a resident, LPN # 4 stated, The liter line should pass through the middle of the ball [float ball]. At 2:17 p.m., LPN # 4 was accompanied to Resident #58's room and was asked to read the oxygen flow rate on Resident # 58's oxygen concentrator. After entering Resident # 58's room and reading the flow meter LPN # 4 stated, It's at three liters. When asked what the physician ordered the oxygen flow rate to be set at LPN # 4 referred to the physician's orders and stated that it should set at four liters per minute. On 05/11/2021 at approximately 4:45 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional director of operations, were made aware of the above findings. No further information was provided prior to exit. References: [1] When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. [2] Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 5. Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of but not limited to acute respiratory failure, gastrostomy, below knee amputation (right), end stage renal disease, chronic obstructive pulmonary disease, deep vein thrombosis, dialysis, chronic kidney disease, dysphagia, aphasia, diabetes, depression, dementia, osteomyelitis, and COVID-19. The 5-day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/28/21 coded the resident as severely cognitively intact in ability to make daily life decisions. The resident was coded as requiring total care for bathing and toileting; extensive assistance for transfers, dressing, eating, and hygiene; and was incontinent of bowel and bladder. A review of the clinical record revealed a nurse's note dated 4/16/21 at 3:32 PM documented, resident tolerated her medications this morning; about 15 minutes later, CNA (Certified Nursing Assistant) notified nurse that resident was c/o (complaining of) trouble breathing; brought resident her inhaler and it helped for a few minutes; CNA put pulse ox (oxygen) on resident on monitored, she notified nurse that resident's PO2 (pulse oxygen saturation) went down to 86%; put resident on 2lpm (two liters per minute) of O2 (oxygen); MD (medical doctor) was called and notified, MD said to send resident out to hospital; notified niece, (name) also 146/62 96.8 79 16 86%y (Blood pressure 146/62, temperature 96.8, pulse 79, respirations 16, and oxygen saturation 86%). A review of the physician's orders failed to reveal any evidence that there was an order to administer the oxygen that was documented in the above note. On 5/12/21 at 8:37 AM an interview was conducted with RN #4 (Registered Nurse) a unit manager. She checked the system for orders and stated that she does not see it was written. She stated that after the emergency, they should have put the order in. Oxygen requires an order because it is considered to be a medication. On 5/12/21 at 10:58 AM an interview was conducted with LPN #1 (Licensed Practical Nurse), who wrote the above note. She stated that she was in the resident's room at the time of the emergency situation and that the unit manager was in the room as well and was on the phone with the physician. She stated she did not hear the physician's side of the conversation but that the unit manager repeated what the physician was saying, and that the unit manager stated the resident was to get oxygen and that the rate was to be two liters. LPN #1 stated that she went and got the concentrator and hooked her up and the unit manager said she was going to put in the order. When asked to review the orders for oxygen, LPN #1 stated, I do not see an order for oxygen. It should have been in there. LPN #1 stated that Oxygen requires an order. It is a medication. On 5/12/21 at 11:13 AM, ASM (Administrative Staff Member) #1, #2, #3, and #5 (the Administrator, the Director of Nursing, the Regional Director of Operations, and the Senior Clinical Transition Specialist) were made aware of the findings. No further information was provided. 6. Resident #333 was admitted to the facility on [DATE] and discharged to the hospital on 3/9/21 and did not return to the facility. The resident was admitted with the diagnoses of but not limited to left tibia fracture, pneumonia, obesity, diabetes, glaucoma, high blood pressure, chronic kidney disease, heart failure, end stage renal disease, dislocation of ankle joint, and dialysis. The 5-day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/19/21 coded the resident as cognitively intact in ability to make daily life decisions. The resident was coded as requiring total care for bathing; extensive assistance for transfers, dressing, toileting and hygiene; independent for eating; and was occasionally incontinent of bowel and bladder. A review of the clinical record revealed the following notes: - A nurse's note dated 3/8/21 at 10:14 AM documented, Noted that guest complained of shortness of breath and abdominal pain. A set of vitals was obtained which was within normal limit except for her oxygen sats (saturation) which was 78% on room air. Oxygen administered briefly She stated that she wanted to skip dialysis for today but nurse encouraged her to go. A second set of vitals obtained which was within normal limits and oxygen sats was 95%. Will continue to monitor. - A physician's note dated 3/9/21 at 2:52 PM documented, S/P (status post) dialysis today, overall feeling week and C/O (complains of) some SOB (shortness of breath) noted she has low grade fever BP (blood pressure) is high this morning B/L (bilateral) mild exp. (expiratory) wheezing, no rhonchi with new fever we check CXR (chest x-ray) if have more fever or CXR is abnormal-will need to start antibiotics discussed with daughter in detail - A physician's note dated 3/9/21 at 11:25 AM documented, received call from nurse about CXR (chest x-ray) shows RUL (right upper lobe) pneumonia noted low grade fever oxygen saturation 92% with oxygen, Bp (blood pressure) is ok as per nurse feel week and low appetite plan: Levaquin (1) 750 (milligrams) now then Q 48 H (every 48 hours) after each dialysis, albuterol (2) MDI (metered dose inhaler) schedule and PRN (as needed), labs tomorrow morning, speech eval (evaluation), discuss with daughter (name) in detail, discuss with nurse and unit incharge. - A nurse's note dated 3/9/21 at 12:22 PM documented, Unit Manager talked with md (medical doctor) in reference to pts (patient's) status vital signs, abt (antibiotic) for pneunmonia (sic) He stated that he spoke with (name), the next of kin which is her daughter in reference to the new antibiotic for pneumonia and pt [patient] is on oxygen. - A nurse's note dated 3/9/21 at 12:26 PM documented, (Name of), daughter called today and wanted the md (Medical Doctor) to update. I spoke with the md and he had given (name of another daughter) the update, and she would be the contact family member. I spoke with her via phone and she stated she had been updated on her mothers status about oxygen and antibiotic for pneumonia. - A nurse's note dated 3/9/21 at 2:00 PM documented, Called MD (medical doctor) to notify him of the vital signs (temperature) 98.8, (blood pressure) 82/46, (pulse) 107, (oxygen saturation) level 89% on oxygen as ordered. Non- rebreather applied. Repeat (oxygen) level at 2:10pm is 75%. MD notified. Send patient out 911. RP (responsible party), daughter is aware. - A nurse's note dated 3/9/21 at 3:09 PM documented, This nurse observed guest as having a BS (blood sugar) of 57 nurse encouraged guest to drink some orange juice the aide assisted guest with her drink. upon getting a second set of BS it increased to 72. However guest was observed as having sob (shortness of breath) her O2 (oxygen) sats (saturation) were 89, oxygen was given at 5 liters and no improvement her vs (vital signs) (blood pressure) 82/46 (pulse) 107 O2 (oxygen saturation) 89 (temperature) 98.8. Patient primary was called Dr (doctor) (name) and he recommended that she be sent out to (name of) hospital verbal report was given, (Hospital nurse) the ER (Emergency Room) nurse stated she did not want the e-change of condition and e-interact transfer form to be faxed. A review of the physician's orders failed to reveal any evidence that there was an order to administer the oxygen that was documented in the above notes. The nurses involved in this change of condition were no longer at the facility and therefore could not be interviewed. On 5/12/21 at 8:37 AM an interview was conducted with RN #4 (Registered Nurse) a unit manager. She checked the system for orders and stated that she does not see it was written. RN #4 stated that after the emergency, they should have put the order in. Oxygen requires an order because it is considered to be a medication. On 5/12/21 at approximately 12:15 PM, a phone interview was conducted with ASM #6 (Administrative Staff Member), the physician. He stated that he ordered the oxygen as the resident was having difficulties, and did not improve, so he sent the resident out to the hospital. ASM #6 stated the nurses were keeping him notified of the resident's status and the use of the oxygen and its effectiveness. On 5/12/21 at 11:13 AM, ASM (Administrative Staff Member) #1, #2, #3, and #5 (the Administrator, the Director of Nursing, the Regional Director of Operations, and the Senior Clinical Transition Specialist) were made aware of the findings. No further information was provided. References: 1. Levaquin - is an antibiotic. Information obtained from https://medlineplus.gov/druginfo/meds/a697040.html 2. Albuterol - is a bronchodilator used

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interviews, staff interviews, clinical record reviews and facility document reviews it was determined that the facility staff failed to implement bed rail requirements for four of 38 residents in the survey sample, Residents #57, #132, #58 and #64. The facility staff failed to perform a physical device assessment, obtain a physician's order, obtain a consent for bed rails and evidence documentation of the use of bed rails on the comprehensive care plan for Resident #57, and Resident #58, and failed to obtain a consent prior to the use of bed rails for Resident #132, and failed to evidence an assessment for the use of bed rails [also referred to as side rails] for Resident # 64. The findings include: 1. Resident #57 was admitted to the facility with diagnoses that included but were not limited to metabolic encephalopathy (1), dementia (2) and osteoarthritis (3). Resident #57's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/15/2021, coded Resident #57 as scoring a 3 (three) on the staff assessment for mental status (BIMS) with a score of 0 - 15, 3- being severely impaired for making daily decisions. Section G coded Resident #57 requiring extensive assistance of two or more staff for bed mobility, transfers and dressing. On 5/10/2021 at approximately 11:50 a.m., Resident #57 was observed in bed with bilateral upper bed rails in place on the bed. The bed rails were observed up and Resident #57 was observed to grasp the bed rail when turning to the side in bed. An interview was attempted with Resident #57, however Resident #57 failed to answer questions appropriately. Additional observations of Resident #57 on 5/10/2021 at approximately 4:15 p.m. and 5/11/2021 at approximately 8:30 a.m. revealed the resident in bed with the bilateral bed rails up. The physician orders for Resident #57 failed to evidence an order for the use of bed rails. The comprehensive care plan for Resident #57 dated 3/11/2021 failed to evidence documentation for use of bed rails. Review of Resident #57's clinical record failed to evidence a physical device assessment or consent for use of bed rails. On 5/11/2021 at approximately 11:30 a.m., ASM (administrative staff member) #1, the administrator provided via email, documentation of bed rail inspections completed in the facility for the past twelve months. The document provided documented the bed in Resident #57's room having bed rails being inspected by maintenance staff on Week 4 June 2020. On 5/12/2021 at approximately 7:45 a.m., a request was made via a written list to ASM #1, for the physical device assessment, consent for bed rail use and care plan for use of bed rails for Resident #57. On 5/12/2021 at approximately 9:30 a.m., ASM #1 stated that there was no order, consent or assessment for the bed rails for Resident #57. ASM #1 stated that Resident #57 should not have had the bed rails and they had no documentation to provide. On 5/12/2021 at approximately 10:33 a.m., an interview was conducted with LPN (licensed practical nurse) #4, the unit manager. LPN #4 stated that residents were evaluated for the use of bed rails to determine if they were able to use them for repositioning or turning in bed by the physical device assessment. LPN #4 stated that if a resident were assessed as eligible for bed rails they discussed the risks and benefits of the use and if they agreed to have them, they would sign a consent to authorize them. LPN #4 stated that if the resident were unable to make the decision for bed rails they discussed them with the responsible party and had them sign the consent for use. LPN #4 stated that after the physical device assessment was completed and the consent was obtained from the resident or the responsible party, they obtained a physician order for the bed rails and had the bed rails put into use. LPN #4 stated that they would also care plan the bed rails at that time. On 5/12/2021 at approximately 11:15 a.m., a request was made to ASM #1 for the facility policy on use of bed rails. The facility policy, Restraint Management dated Revised: 10/2019 documented in part, . 1. Whenever a guest/resident is admitted with an order for a restraint (including side rails), the staff may accept the order for up to 72 hours pending completion of the Physical Device Evaluation. 2. When a guest's/resident's condition necessitates consideration for a restraint, alternative interventions must be attempted and documented on the Physical Device Evaluation and in the care plan .5. Any guest/resident using a physical restraint or side rails must have a current, signed restraint consent in the medical record . The policy further documented, .10. Any guest using side rails will have a current order with the following components: Type of side rails (1/2, 3/4, full, assist bars); Number of side rails to be raised; Reason for use/medical symptom; Guest/resident request for use of side rails (If applicable) . On 5/12/2021 at approximately 11:15 a.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of operations and ASM #5, the senior clinical transition specialist were made aware of the findings. No further information was provided prior to exit. Reference: 1. Encephalopathy: Encephalopathy is a general term describing a disease that affects the function or structure of your brain. This information is taken from the website https://www.healthline.com/health/hepatic-encephalopathy. 2. Dementia: A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. 3. Osteoarthiris- Osteoarthritis occurs when cartilage, the tissue that cushions the ends of the bones within the joints, breaks down and wears away. In some cases, all of the cartilage may wear away, leaving bones that rub up against each other. This information was obtained from the website: https://www.nia.nih.gov/health/osteoarthritis. 2. Resident #132 was admitted to the facility with diagnoses that included but were not limited to sepsis (1) and cardiomyopathy (2). Resident #132's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/25/2021, coded Resident #132 as scoring a 14 on the staff assessment for mental status (BIMS) with a score of 0 - 15, 14- being cognitively intact for making daily decisions. Section G coded Resident #132 requiring extensive assistance of two or more staff for bed mobility and total dependence of two or more staff for transfers. On 5/10/2021 at approximately 11:40 a.m., Resident #132 was observed in bed asleep with bilateral upper bed rails in place on the bed. The bed rails were observed up. On 5/11/2021 at approximately 11:45 a.m., an interview was conducted with Resident #132. Resident #132 was observed in bed with bilateral upper bed rails up. Resident #132 stated that they used the bed rails to hold onto when staff provided care and to assist in repositioning themselves in the bed. Resident #132 stated that they did not recall signing a consent for the bed rails but they wanted them on the bed and used them. The physician orders for Resident #132 documented in part, Two 1/2 (half) side rails up as an enabler when in bed. Order Date: 4/21/2021. The physical device assessment for Resident #132 dated 4/21/2021 documented in part, .Reason for enabler device use, 1. Repositioning/Support 2. Enable/Increase bed mobility. 7. New or Revised Order Two 1/2 side rails up as an enabler when in bed. 8. Care plan updated, Yes . The comprehensive care plan for Resident #132 dated 4/21/2021 documented in part, [Resident #132] is at risk for fall related injury and falls R/T (related to) limited mobility and weakness, use of antidepressant. Date Initiated: 04/21/2021. Revision on: 05/03/2021. Under Interventions it documented in part, .two 1/2 siderails [also know as bedrails] up in bed as an enabler. Date Initiated: 04/22/2021. On 5/11/2021 at approximately 11:30 a.m., ASM (administrative staff member) #1, the administrator provided via email, documentation of bed rail inspections completed in the facility for the past twelve months. The document provided documented the bed in Resident #132's room having bed rails being inspected by maintenance staff on Week 4 June 2020. On 5/12/2021 at approximately 7:45 a.m., a request was made via a written list to ASM #1, for the consent for use of bed rails for Resident #132. On 5/12/2021 at approximately 9:30 a.m., ASM #1 stated that they were emailing the bed rail documentation for Resident #132. On 5/12/2021 at approximately 10:07 a.m., ASM #1 provided the physical device assessment dated [DATE] and the physician's order for bed rails dated 4/21/2021. The email documents failed to evidence a consent for the use of bed rails. On 5/12/2021 at approximately 10:33 a.m., an interview was conducted with LPN (licensed practical nurse) #4, the unit manager. LPN #4 stated that residents were evaluated for the use of bed rails to determine if they were able to use them for repositioning or turning in bed. LPN #4 stated that if a resident were assessed as eligible for bed rails they discussed the risks and benefits of the use and if they agreed to have them, they would sign a consent to authorize them. LPN #4 stated that if the resident were unable to make the decision for bed rails they discussed them with the responsible party and had them sign the consent for use. LPN #4 stated that after the assessment was completed and the consent was obtained they obtained a physician order for the bed rails and had the bed rails put into use. On 5/12/2021 at approximately 11:15 a.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of operations and ASM #5, the senior clinical transition specialist were made aware of the findings. No further information was provided prior to exit. Reference: 1. Sepsis: An illness in which the body has a severe, inflammatory response to bacteria or other germs. The symptoms of sepsis are not caused by the germs themselves. Instead, chemicals the body releases cause the response. This information was obtained from the website: <https://medlineplus.gov/ency/article/000666.htm>. 2. Cardiomyopathy: Disease in which the heart muscle becomes weakened, stretched, or has another structural problem. It often occurs when the heart cannot pump or function well. Most people with cardiomyopathy have heart failure. This information was obtained from the website: https://medlineplus.gov/ency/article/001105.htm. 3. Resident # 58 was admitted to the facility with diagnoses that included but were not limited to: acute and chronic respiratory failure [1] and chronic obstructive pulmonary disease [2] and muscle weakness. Resident # 58's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 03/16/2021, coded Resident # 58 as scoring an 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. Under section G Functional Status coded Resident # 58 as requiring extensive assistance of one staff member for bed mobility. On 05/10/2021 at 1:52 p.m., and 05/11/2021 at 7:58 a.m., observation revealed Resident # 58 lying in bed with right and left upper bed rails raised. The comprehensive care plan for Resident # 58 dated 07/16/2020 failed to evidence documentation for the use of bedrails. Review of the EHR (electronic health record) for Resident # 58 failed to evidence documentation of an assessment for the use of bedrails. On 05/12/2021 at 10:15 a.m., an interview was conducted with Resident # 58. When asked if they could reposition themselves in the bed, Resident # 58 stated, No, I need help. On 05/12/2021 at 10:45 a.m., an interview was conducted with LPN (licensed practical nurse) #4, unit manager, regarding Resident # 58's use of bedrails. LPN #4 stated that Resident # 58 was unable to reposition themselves and the bedrails should not be in the raised position. LPN # 4 further stated that they had contacted the maintenance department and earlier in the day [OSM -other staff member # 7, director of maintenance] secured the bedrails in the down position so they could not be raised. On 05/12/2021 at 11:00 a.m., an observation of Resident # 58's bedrails was conducted with OSM # 7. Observation of the bedrails revealed they were in the down position and secure with cable ties [3]. Attempts made to raise the bedrails were unsuccessful evidencing that they were secured in the down position. On 05/12/2021 at approximately 11:15 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, regional director of operations and ASM # 4, senior clinical transition specialist, were made aware of the above findings. No further information was provided prior to exit. References: [1] When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. [2] Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. [3] A cable tie, also known as a zip tie or tie-wrap, is a type of fastener, designed for bunching electric cables or wires and to organize cables and wires, but with a wide variety of other applications. In its common form, the nylon cable tie consists of a tape section with triangular teeth that slope in one direction. The head of the cable tie has a slot with a flexible [NAME] that irreversibly rides up the slope of these teeth when the tape is inserted. The [NAME] engages the backside of these teeth to stop removal of the tape. This information was obtained from the website: https://www.definitions.net/definition/CABLE+TIE 4. Resident # 64 was admitted to the facility with diagnoses that included but were not limited to: heart disease, pressure ulcer and arthritis. Resident # 64's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/21/2021, coded Resident # 64 as scoring a 13 on the brief interview for mental status (BIMS) of a score of 0 - 15, 13 - being cognitively intact for making daily decisions. Section G coded Resident # 64 as being totally dependent of two staff members for bed mobility. On 05/10/2021 at 3:38 p.m., and 05/11/2021 at 8:10 a.m., observation revealed Resident # 64 lying in bed with right and left upper bed rails raised. On 05/11/21 at 10:20 a.m., an observation of Resident # 64's wound care was conducted. During the observation Resident # 64 was observed holding onto the left upper bedrail to stabilize herself on their left side, with the assistance of a certified nursing assistant, while wound care was conducted. The physician's orders for Resident # 64 documented in part, Resident to have bilat [bilateral] ½ [half] side rails to aide in turning and repositioning. The comprehensive care plan for Resident # 64 dated 03/17/2021 documented in part, Need: [Resident # 64] has an ADL [activities of daily living] Self Care Performance Deficit and requires assistance with ADL's and mobility. Date Initiated: 03/17/2021. Under Interventions it documented in part, 'Half bilateral side rails to aide in turning and repositioning. Date Initiated: 03/17/2021. Review of the EHR (electronic health record) for Resident # 64 failed to evidence an assessment for the use of bedrails. On 05/12/2021 at 10:45 a.m., an interview was conducted with LPN (licensed practical nurse) #4, unit manager, regarding Resident # 64's assessment for the use of bedrails. After reviewing Resident # 64's HER [electronic health record] LPN # 4 stated that an assessment was not completed. On 05/12/2021 at approximately 11:15 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, regional director of operations and ASM # 4, senior clinical transition specialist, were made aware of the above findings. No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review, and facility document review it was determined the facility staff failed to ensure the drug regimens for three of 38 residents in the survey sample, (Residents #15, #58 and # 63), were free from unnecessary medications. The facility staff failed to implement and attempt non-pharmacological interventions per the physician's orders and plan of care prior to administering as needed (prn) pain medications to Resident #15, Resident #58 and Resident #63 on multiple dates during April and May 2001. The findings include: 1. Resident # 15 was admitted to the facility with diagnoses that include but not limited to: spinal stenosis [2]. Resident # 15's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 02/05/2021, coded Resident # 15 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 15 as not having pain in the past five days`. The physician's order for Resident # 15 dated 02/02/2021 documented, Oxycodone Tablet 5 MG [five milligrams]. Give 1 [one] tablet by mouth every 6 [six] hours as needed for pain, pain scale 6-10 [six to ten]. Order Date: 2/2/2021. Pain-Non-Pharmacological Interventions: Document Non Pharmacological interventions used: 1) Massage. 2) Meditation/Relaxation. 3) Positioning. 4) Ice/cold pack. 5) Diversional Activity. 6) Guided Imagery. 7) Rest. 8) Social Interaction. 9) Other _______________. Document Non-Pharmacological interventions using the corresponding number. Order Date: 2/2/2021. Resident # 15's eMAR [electronic medication administration record] dated April 2021 documented the physician's order as stated above. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of oxycodone on: 04/01/2021 at 12:13 p.m. with a level of six, 04/02/2021 at 12:42 p.m. with a pain level of seven, 04/04/2021 at 8:38 a.m. with a pain level of seven, 04/05/2021 at 1:03 p.m. with a pain level of six and at 10:10 p.m. with a pain level of seven, 04/06/2021 at 1:19 p.m. with a pain level of seven, 04/07/2021 at 12:44 p.m. with a pain level of six, 04/10/2021 at 12:57 p.m. with a pain level of seven and at 9:41 p.m. with a pain level of seven, 04/14/2021 at 12:46 p.m. with a pain level of six, 04/15/2021 at 4:13 p.m. with a pain level of ten, 04/18/2021 at 3:45 a.m. with a pain level of six, 04/21/2021 at 5:55 a.m. with a pain level of eight, 04/24/2021 at 10:28 a.m. with a pain level of seven and at 10:14 p.m. with a pain level of eight, 04/25/2021 at 4:03 p.m. with a pain level of seven and on 04/27/2021 at 10:28 p.m. with a pain level of eight. Resident # 15's eMAR [electronic medication administration record] dated May 2021 documented the physician's order as stated above. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of oxycodone on: 05/04/2021 at 3:15 p.m. with a pain level of seven, 05/05/2021 at 10:20 p.m. with a pain level of six and on 05/09/2021 at 4:15 p.m. with a pain level of eight and at 10:11 p.m. with a pain level of seven. The comprehensive care plan for Resident # 15 dated 07/16/2020 documented in part, Need: [Resident # 15 is at risk for pain and/or has acute/chronic pain r/t [related to] Arthritis, spinal stenosis. Date Initiated: 07/16/2020. Under Interventions it documented in part, Offer Non-Pharmacological Interventions: 1) Massage. 2) Meditation/Relaxation. 3) Positioning. 4) Ice/cold pack. 5) Diversional Activity. 6) Guided Imagery. 7) Rest. 8) Social Interaction. 9) Other. Date Initiated: 07/16/2020 On 05/10/21 at 1:56 p.m., an interview was conducted with Resident # 15. When asked if they received pain medication when needed Resident # 15 stated yes. When asked if the nurses try to alleviate the pain before administering the medication, Resident # 15 stated, Sometimes they do. On 05/11/21 at 2:27 p.m., an interview was conducted with LPN [licensed practical nurse] # 4, unit manager regarding as needed pain and the implementation of non-pharmacological interventions. When asked where a nurse documents that non-pharmacological interventions were attempted prior to administering a as needed pain medication, LPN # 4 stated, Should be documented on the eMAR. After reviewing Resident # 15's April 2021 and May 2021 eMARs, LPN # 4 stated that there was missing documentation of non-pharmacological interventions on the dates and times documented above. LPN # 4 further stated that they couldn't say that the interventions were being attempted. When asked why they should try non-pharmacological interventions prior to administering a pain medication LPN stated, They may not need the pain medication. The facility's policy Pain Management documented in part, Procedure: 14. The staff will implement the care plan, monitor the guest/resident, and administer therapeutic interventions for pain, if ordered. On 05/11/2021 at approximately 4:45 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional director of operations, were made aware of the above findings. No further information was provided prior to exit. References: [1] Indicated for the management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f2137f1a-b49a-40bd-97ac-cd6b36e295f4. [2] A narrowing of the spinal column that causes pressure on the spinal cord, or narrowing of the openings (called neural foramina) where spinal nerves leave the spinal column. This information was obtained from the website: https://medlineplus.gov/ency/article/000441.htm. 2. The facility staff failed attempt non-pharmacological interventions prior to the administration of the prescribed as needed pain medication, oxycodone [1] to Resident # 58. Resident # 58 was admitted to the facility with diagnoses that included but were not limited to: lower back pain. Resident # 58's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 03/16/2021, coded Resident # 58 as scoring an 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 58 as having frequent pain at a level four based on a zero to ten pain scale, with ten being the worse pain they could imagine. The physician's order for Resident # 58 dated 01/14/2020 documented, Oxycodone Tablet 5 MG [five milligrams]. Give 5 mg by mouth every 6 [six] hours as needed for severe pain. Order Date: 1/14/2020. Pain-Non-Pharmacological Interventions: Document Non Pharmacological interventions used: 1) Massage. 2) Meditation/Relaxation. 3) Positioning. 4) Ice/cold pack. 5) Diversional Activity. 6) Guided Imagery. 7) Rest. 8) Social Interaction. Document Non-Pharmacological interventions using the corresponding number. Order Date: 2/12/2020. The comprehensive care plan for Resident # 58 dated 07/16/2020 documented in part, Need: [Resident # 58] has the potential for pain and general discomfort. Dx [diagnosis] of arthritis. Date initiated 05/04/2020. Under Interventions it documented in part, Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Date initiated 05/04/2020. Resident # 58's eMAR [electronic medication administration record] dated April 2021 documented the physician's order as stated above. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of the prescribed as needed pain medication oxycodone on: 04/09/2021 at 5:49 a.m. with a pain level of ten and on 04/19/2021 at 9:17 p.m. with a pain level of five. Resident # 58's eMAR [electronic medication administration record] dated May 2021 documented the physician's order as stated above. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of the prescribed as needed pain medication oxycodone on: 05/04/2021 at 9:20 p.m. with a pain level of seven and on 05/08/2021 at 10:02 p.m. with a pain level of seven. On 05/10/21 at 1:44 p.m., an interview was conducted with Resident # 58. When asked if they received pain medication when needed, Resident # 58 stated yes. When asked if the nurses try to alleviate the pain before administering the medication, Resident # 58 stated, Sometimes they do sometimes they don't. On 05/11/21 at 2:27 p.m., an interview was conducted with LPN [licensed practical nurse] # 4, unit manager regarding as needed pain and the implementation of non-pharmacological interventions. When asked where a nurse documents that non-pharmacological interventions were attempted prior to administering a as needed pain medication LPN # 4 stated, Should be documented on the eMAR. After reviewing Resident # 58's April 2021 and May 2021 eMARs LPN # 4 stated that there was missing documentation of non-pharmacological interventions on the dates and times documented above. LPN # 4 further stated that they couldn't say that the interventions were being attempted. When asked why they should try non-pharmacological interventions prior to administering a pain medication, LPN stated, They may not need the pain medication. On 05/11/2021 at approximately 4:45 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional director of operations, were made aware of the above findings. No further information was provided prior to exit. References: [1] Indicated for the management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f2137f1a-b49a-40bd-97ac-cd6b36e295f4. 3. The facility staff failed attempt non-pharmacological interventions prior to the administration of as needed pain medication of acetaminophen [1] to Resident # 63. Resident # 63 was admitted to the facility with diagnoses that included but were not limited to: fracture of the tibia [2]. Resident # 63's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/21/2021, coded Resident # 63 as scoring an 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 13 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 63 as having frequent pain at a level seven based on a zero to ten pain scale, with ten being the worse pain they could imagine. The physician's order for Resident # 63 dated 03/16/2021 documented, Acetaminophen Tablet 325 MG [five milligrams]. Give 2 [two] tablets by mouth every 4 [four] hours as needed for severe pain and Give 2 tablets by mouth every 4 hours as needed for Temp [temperature 100F [One hundred degrees Fahrenheit] or above Order Date: 3/16/2021 . Pain-Non-Pharmacological Interventions: Document Non Pharmacological interventions used: 1) Massage. 2) Meditation/Relaxation. 3) Positioning. 4) Ice/cold pack. 5) Diversional Activity. 6) Guided Imagery. 7) Rest. 8) Social Interaction. Document Non-Pharmacological interventions using the corresponding number. Order Date: 3/16/2021. The comprehensive care plan for Resident # 63 dated 03/16/2021 documented in part, Need: [Resident # 63] is at risk for pain and/or has acute/chronic pain r/t [related to] recent falls, tibia fracture. Date Initiated: 03/16/2021. Under Interventions in documented in part, Offer Non-Pharmacological Interventions: 1) Massage. 2) Meditation/Relaxation. 3) Positioning. 4) Ice/cold pack. 5) Diversional Activity. 6) Guided Imagery. 7) Rest. 8) Social Interaction. 9) Other. Date Initiated: 03/16/2021. Resident # 63's eMAR [electronic medication administration record] dated April 2021 documented the physician's order as stated above. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of Acetaminophen on: 04/02/2021 at 6:04 p.m. with a pain level of eight, 04/04/2021 at 11:23 a.m. with a pain level of six and at 8:40 p.m. with a pain level of five, 04/08/2021 at 9:14 a.m. with a pain level of eight, 04/10/2021 at 9:38 a.m. with a pain level of six and at 3:51 p.m. with a pain level of six, 04/11/2021 at 5:25 p.m. with a pain level of five, 04/13/2021 at 1:39 p.m. with a pain level of eight, 04/ 14/2021 at 8:17 a.m. with a pain level of six, 04/15/2021 at 10:38 a.m. with a pain level of five, 04/16/2021 at 9:15 p.m. with a pain level of five, 04/19/2021 at 9:21 a.m. with a pain level of seven, 04/22/2021 at 4:38 p.m. with a pain level of three, 04/ 23/2021 at 10:47 a.m. with a pain level of four and at 6:22 p.m. with a pain level of seven, 04/24/2021 at 10:55 a.m. with a pain level of seven. Further review of the eMAR revealed that Resident # 63 did not receive acetaminophen for temperature over 100 degrees. On 05/10/21 at 11:16 a.m., an interview was conducted with Resident # 63. When asked if they received pain medication when needed Resident # 63 stated yes. When asked if the nurses try to alleviate the pain before administering the medication, Resident # 63 stated, No they just give me the medication. On 05/11/21 at 2:27 p.m., an interview was conducted with LPN [licensed practical nurse] # 4, unit manager regarding as needed pain and the implementation of non-pharmacological interventions. When asked where a nurse documents that non-pharmacological interventions were attempted prior to administering a as needed pain medication LPN # 4 stated, Should be documented on the eMAR. After reviewing Resident # 63's April 2021 eMAR LPN # 4 stated that there was missing documentation of non-pharmacological interventions on the dates and times documented above. LPN # 4 further stated that they couldn't say that the interventions were being attempted. When asked why they should try non-pharmacological interventions prior to administering a pain medication LPN stated, They may not need the pain medication. On 05/11/2021 at approximately 4:45 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional director of operations, were made aware of the above findings. No further information was provided prior to exit. References: [1] Used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of osteoarthritis (arthritis caused by the breakdown of the lining of the joints). This information was obtained from the website: https: https://medlineplus.gov/druginfo/meds/a681004.html. [2] The tibia is the larger of two long bones in the lower leg. It is sometimes called the shin bone. This information was obtained from the website: https://medlineplus.gov/ency/article/002335.htm.