Based on observation, staff interviews and clinical record review the facility staff failed to provide the accommodation needed for 1 of 19 residents (Resident #2) in the survey sample. The findings included: The facility staff to ensure Resident #2's call bell remained within reach. Resident #2 was admitted to the nursing facility on 08/29/16. Diagnosis for Resident #2 included but not limited Anxiety disorder and muscle weakness. The current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/19/21 coded Resident #2 Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long term memory problems and with severe cognitive impairment - never/rarely made decisions. The MDS coded Resident #2 total dependence of two with transfer, toilet use, personal hygiene and bathing, total dependence of one with dressing and extensive assistance of one with eating with Activities of Daily Living (ADL) care. Resident #2's comprehensive care plan documented Resident #2 at risk for falls related to impaired mobility, dementia, bipolar and occasion pain from arthritis. The goal set for the resident by the staff will have interventions in place to minimize the risk of a serious injury. Some of the approaches to manage goal is to keep the call light within reach and to encourage the resident to use call bell or call out for assistance. On 02/02/22 at approximately 10:00 a.m., Resident was observed sitting up in the wheel chair with the call bell back behind the resident's bed. On the same day at approximately 3:09 p.m., Resident #2 was observed lying in bed; call bell remain in the same place (back behind the resident bed). License Practical Nurse (LPN) #1 went into Resident #2's room along with this surveyor. The LPN removed Resident #2's call light from back behind the resident's bed and attached it to the resident's covering. When asked, What is the purpose for keeping Resident #2's call light within her reach, The LPN stated, The call bell should be within reach so the resident can call for assistance. She said Resident #2 cannot use the call be all the time but at times she will put the call light when she needs help. An interview was conducted with the Director of Nursing on 02/03/22 at approximately 12:50 p.m. The DON said the resident's call bell should be within reach at all times. She said the call light should be attached/clipped to their shirt or blanket and for best practice to inform the staff of their needs and to help prevent falls. A pre-exit conference was conducted with the Administrator and Director of Nursing on 02/03/22 at approximately 3:30 p.m. The Administration team were informed of the above findings; no further information was provided prior to exit. The facility titled: Call Light board of approval date of 10/25/02. Policy statement: The purpose of this procedure is to respond to the resident's requests and needs. Key Procedural Points read in part: 5. When the resident is in bed or confined to a chair, be sure the call light is within reach of the resident.

Based on information gleamed during the antibiotic stewardship task, observation, staff interview, and clinical record review the facility staff failed to ensure a Resident who is prescribed an antibiotic has appropriate indication for use and receives the antibiotic timely for 1 of 19 residents (Resident #21), in the survey sample. The findings included: Resident #21 was originally admitted to the facility 1/24/20 and had not been discharged from the facility. The current diagnoses included; dementia and obstructive uropathy. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/11/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were moderately impaired. In section G (Physical functioning) the resident was coded as requiring supervision after set-up with bed mobility, transfers, and locomotion, limited assistance of one person personal hygiene, dressing, and toileting and physical help of one person in part of his bathing activity. In section H (Bladder and Bowel) the resident was coded for use of an indwelling catheter. The physician order summary included and order dated 9/1/21 which read; Urinary Catheter 16 french 30 cc balloon three times each day. The current care plan included a problem dated 1/24/20 read; (name of the resident) has a history of urinary tract infection with an indwelling urinary catheter and remains at risk for recurrent urinary tract infections. The goal read; (name of the resident) will have interventions in place to minimize the risk of urinary tract infections through next review, 5/5/21. The interventions included; Keep fluids next to the resident at all times. Provide cues/assist the resident to drink fluids with medications and between meals. Monitor the resident for burning/painful urination. Record Intake and Output. Monitor for bladder distention. On 2/2/22, the resident was observed in the activity area, an indwelling catheter bag was attached to his chair and bright yellow urine was observed in the catheter tubing. Resident #21 was identified as one of the residents requiring use of an antibiotic on the antibiotic stewardship report for December 2021. The Director of Nursing stated documentation revealed the resident presented with a new onset of confusion, acute meatus tenderness, purulent drainage and hematuria, therefore an assessment by the Nurse Practitioner (NP) was requested. Review of the clinical record revealed; a progress note dated 11/29/21 at 20:56 which read; Resident alert and oriented times three. Skin warm and dry to touch. Denies pain or discomfort. Indwelling catheter patent and draining yellow urine with bloody sediment. Resident had paper towels stuffed in his brief with yellowish color stain. He also had thrown a stained paper towel on the floor. Educated resident on use of trash can, not putting paper towels in brief and notifying staff of need to change brief. Resident noted to have redness noted to scrotum and groin. Peri care provided and Nystatin cream applied. Resident resting comfortably in bed with call bell in reach. On 11/30/21 the NP visited Resident #21 secondary to the above observations indicating a possible urinary tract infection. The NP ordered a Urine, Culture & Sensitivity to be collected One Time Daily for One Day (Starting 11/30/2021 Ending 11/30/2021 Anytime) Another progress note dated 12/1/21 at 6:17 read; Per Provider orders removed 16 French (Fr) catheter with 20 cubic centimeter (cm) balloon without issues. Inserted 16 Fr catheter with 30 cc balloon without issues with yellow color urine return. Used Lidocaine 2% Jelly Urojet for comfort. Resident tolerated the procedure without difficulty. There is some jelly bloody like substance leaking around the catheter, which is from the jelly which was injected into the penis prior to insertion of catheter. Will report to oncoming shift to continue to monitor. A note dated 12/2/21 read; Seen by NP order for new Foley to be placed. Order for Lidocaine with applicator to be applied before insertion, and a lab order to obtain a Urinalysis/Culture and Sensitivity (UA/CS) to be sent after placement of the new Foley catheter. A progress note dated 12/7/21 at 11:09 read; Resident seen by NP for results of the UA/CS. An order was obtained to start Macrobid on 12/08/21. Macrobid is an antibiotic used to treat bladder infections (acute cystitis). It works by stopping the growth of bacteria. This antibiotic treats only bacterial infections. On 2/2/22 at 12:30 p.m., review of the laboratory report revealed the urine specimen was received by the laboratory on 12/1/21, the results were received from the laboratory by the nursing facility 12/6/21 which revealed the urine specimen contained 100,000 colonies of klebsiella oxytoca and was susceptible to the antibiotic Macrobid. The results were reported to the Practitioner on 12/7/21. The NP ordered Macrobid 100 milligrams by mouth every 12 hours for 7 days for urinary retention. The laboratory report revealed the resident had a urinary tract infection and the bacterias were susceptible to an antibiotic not to administer an antibiotic for urinary retention. The antibiotic Macrobid was first administered to Resident #21 on 12/8/21, therefore from the observation of Resident #21's onset of confusion, acute meatus tenderness, purulent drainage and hematuria it took eight since the changes were An interview was conducted with the Director of Nursing/Infection Preventionist on 2/3/22 at approximately 1:30 p.m. The Director of Nursing stated the delay in processing the specimen is related to the backup in the lab secondary to COVID-19 test; that information was confirmed by lab technician at the local laboratory. The DON further stated there was no reason for the delay in initiating the antibiotic for the medication was available in their in house supply. The Director of Nursing further stated when the nurse obtained the order a starting dose should have been administered and all other doses scheduled thereafter. On 2/3/22 at approximately 3:15 p.m., the above findings were shared with the Administrator and Director of Nursing. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and no concerns were voiced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure that a 1 of 15 residents in the survey sample was free from administration of an unnecessary psychotropic medication. (Resident #16) The findings included: The facility staff failed to have a 14 day stop date on the use of Ativan that was ordered by the physician for Resident #16. Resident #16 was readmitted to the facility on [DATE] with the following diagnosis of, but not limited to anemia, cancer, atrial fibrillation, blood clot, cirrhosis, anxiety disorder and urinary tract infection. On the admission, MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/1/19 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 14 out of a possible score of 15. Resident #16 was also coded as requiring extensive assistance of 1 staff member for dressing, personal hygiene and bathing. During the clinical record review on 8/29/19 by the surveyor, it was noted that the physician ordered Ativan 2 mg/ml (milligram/milliliter) 0.25 ml as needed every four hours for anxiety. This ordered was written on 7/29/19. There was not a stop date provided for the medication to be given for 14 days and then be re-evaluated by the physician to assess if the resident would need continued need of this medication or if this needed to be discontinued. The surveyor notified the DON (Director of Nursing) of the above documented findings on 8/29/19 at 11:13 am. The DON stated that the order for the Ativan was received when the resident was admitted to hospice services and the thinking of not having a stop date for the Ativan was OK because the resident was in Hospice. No further information was provided to the surveyor prior to the exit conference on 8/29/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility documentation review, clinical record review, the facility staff failed to: 1. The facility staff failed to ensure that documentation dates were included in section V of the MDS for 1 Resident (Resident #6) of 14 Residents in the survey sample. The findings included: 1. Resident #6 was admitted to the facility on [DATE]. Diagnoses for Resident #6 included but are not limited to Non-Alzheimer's Dementia* (1). Resident #6's Annual Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 5/8/17 coded Resident #6 with a BIMS (Brief Interview for Mental Status) score of 12 of 15, indicating a moderate cognitive impairment. Section V of the Annual MDS coded Resident #6 with the following CAA (Care Area Assessment) trigger areas: Cognition Urinary Incontinence ADL (Activity of Daily Living) functioning Continence Falls Dental Care Pressure Ulcer Section V of the Annual MDS (Minimum Data Set) did not include a notation of date and location for documentation related to the decision making process for the triggered areas listed above. The Facility provided a copy of pages (4-6 to 4-7) taken from the CMS's RAI (Resident Assessment Instrument) Version 3.0 Manual Chapter 4 that documented the following guidance: CAA documentation. CAA documentation helps to explain the basis for the care plan by showing how the IDT (Interdisciplinary Team) determined that the underlying causes, contributing factors, and risk factors were related to the care area condition for a specific resident: for example, the documentation should indicate the basis for these decisions, why the finding(s) require(s) an intervention, and the rational(s) for selecting specific interventions. Based on the review of the comprehensive assessment, the IDT and the resident and/or the resident's representative determine the areas that require care plan intervention(s) and develop, revise, or continue the individualized care plan. Relevant documentation for each triggered CAA describes: causes and contributing factors; The nature of the issue or condition (may include presence or lack of objective data and subjective complaints). In other words, what exactly is the issue/problem for this resident and why it is a problem; Complications affecting or caused by the care area for this resident; Risk factors related to the presence of the condition that affects the staff's decision to proceed to care planning; Factors that must be considered in developing individualized care plan interventions, including the decision to care plan or not to care plan various findings for the individual resident; The need for additional evaluation by the attending physician and other health professionals, as appropriate; The resource(s), or assessment tool(s) used for decision-making, and conclusions that arose from performing the CAA; Use the Location and Date of CAA Documentation column on the CAA Summary (Section V of the MDS 3.0) to note where the CAA information and decision making documentation can be found in the resident's record. Also indicate in the column Care Planning Decision whether the triggered care area is addressed in the care plan. The Acting MDS Coordinator on 11/15/17 at approximately 2:30 p.m., stated: Yes, there should be a date. when asked if there should be a corresponding note and date for Section V of the Annual MDS with ARD of 5/8/17 The facility administration was informed of the findings during a briefing on 11/14/17 at approximately 2:26 p.m. The facility did not present any further information about the findings.

Based on clinical record review, staff interviews, the facility staff failed to develop a psychoactive care plan for 1 of 16 residents (Resident #1) in the survey sample. The facility staff failed to develop a care plan for a Resident #1 who was receiving a psychoactive medication *Zoloft. The findings include: Resident #1 was admitted to the nursing facility on 08/18/2017. Diagnosis for included but not limited to *Adjustment disorder with depressed mood. *Zoloft is used to treat depression, obsessive-compulsive disorder (bothersome thoughts that won't go away and the need to perform certain actions over and over), panic attacks (sudden, unexpected attacks of extreme fear and worry about these attacks), posttraumatic stress disorder (disturbing psychological symptoms that develop after a frightening experience), and social anxiety disorder (extreme fear of interacting with others or performing in front of others that interferes with normal life) (https://medlineplus.gov/ency/article/007365.htm). *Adjustment disorder with depressed mood is a group of symptoms, such as stress, feeling sad or hopeless, and physical symptoms that can occur after you go through a stressful life event (https://medlineplus.gov/ency/article/007365.htm). The current Minimum Data Set (MDS) a 30-day assessment with an Assessment Reference Date (ARD) of 09/15/17 coded the resident with a 08 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The residents MDS was coded for the usage of antianxiety and antidepressant medication. The section N on the MDS under medications read as follows: Indicate the number of DAYS the resident receiving the medication during the last 7 days, the MDS was coded for receiving an antidepressant for 7 days. The review of Resident #1's comprehensive care did not include a care plan for psychoactive medication. An interview was conducted with the MDS Coordinator on 11/15/17 at approximately 2:15 p.m., who stated Psychoactive medications are to be care planned but under the drug class and not the medication. The surveyor asked, is Zoloft a psychoactive medication and she it be care planned, the MDS Coordinator replied, Yes - it's a psychoactive medication and it should have been care planned. On the same day at approximately 4:10 p.m., the MDS Coordinator reviewed Resident #1's entire care planned then stated, It's not here, it wasn't care planned. On 11/16/17 at approximately 11:20 a.m., and interview was conducted with the Director of Nursing (DON) who stated, psychoactive medications should be care planned but under the drug class and not the medication. The facility administration was informed of the finding during a briefing on 11/17/17 at approximately 2:30 p.m. The facility did not present any further information about the findings. The facility's policy: Comprehensive Person-Centered Care Planning Guidelines (Revised 5/31/17). -Incorporate identified problem areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews and review of the facility documentations, the facility failed ensure the necessary treatment was provided to prevent infection and promote healing for 1 of 16 Residents (Resident #1) in the survey sample. The facility staff failed to ensure infection control practice were followed during a sacral wound *stage 2 *pressure ulcer dressing for Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE]. Diagnosis for Resident #1 included but are not limited to Right *femur fracture and *Anemia. The current Minimum Data Set (MDS) a 30-day assessment with an Assessment Reference Date (ARD) of 09/15/17 coded the resident with a 08 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. In addition, the MDS coded Resident #1 requiring total dependence of one with bathing, extensive assistance of two with transfers and mobility, extensive assistance of one with dressing, hygiene and toilet use, and limited assistance of one with eating. Resident #1 was coded frequently incontinent of bowel and bladder. In section M (Skin Conditions) of MDS 09/15/17 coded Resident #1 at risk for developing pressure ulcers, having a stage 1 or higher. Resident #1 was also coded 0 if resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher. *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 (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). *Pressure Injury - Stage 2 (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 (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ *Right femur fracture is a hip fracture is a break in the upper part of the thigh bone(femur) where the thighbone joins the pelvis to form the hip joint (www.webmd.com/osteoporosis/hip-fracture). *Anemia is condition when blood does not carry enough oxygen to the rest of your body (Source: NIH U.S. National Library of Medicine: Medline Plus). Resident #1's care plan documented Resident #1 at risk for impaired skin integrity related to impaired mobility, incontinence and poor tissue perfusion. The goals: the resident will remain free of skin breakdown over the next 90 days. Some of the interventions include but not limited to: Pressure reducing mattress, check skin for redness, skin tears, swelling, or pressure areas. Report and signs of skin breakdown. The current treatment as of 11/10/17 is to cleanse sacrum with normal saline, apply barrier ointment, apply *mepilex foam pad, cover with mepilex dressing, off load area when every possible and change daily until resolved. *Mepilex is a foam dressing suitable for a wide range of wounds like venous leg ulcers, pressure ulcers or diabetic ulcers (www.molnlycke.us/advanced-wound-care-products/foam-dressings/mepilex/). On 11/15/17 at approximately 10:00 a.m., the resident was observed lying in bed on a specialty mattress; in a supine position. LPN #2 performed wound care with the assistance of LPN #3. Both LPN's washed her hands then donned a pair of gloves prior to starting sacral wound care dressing change, LPN #2 removed the dressing from the sacral wound, placed the soiled dressing inside a clear plastic bag, removed her gloves then went into the bathroom, got a pair of clean gloves from the glove holder on the bathroom wall, donned the new gloves, returned to the bedside, proceeded to clean the wound with normal saline, applied barrier cream to the wound followed with mepilex the covered with a foam dressing. On 11/15/17 at approximately 2:35 p.m., and interview was conducted with LPN #2 who stated, I should have removed my gloves after I removed the soiled dressing, washed my hands then put on another pair of gloves, cleaned the wound, remove my gloves, finish wound care then wash may hands again. An interview was conducted with the Director of Nursing (DON) on 11/16/17 at approximately 11:20 a.m., who stated, The nurse should have washed her hands before starting wound care, after removing the soiled dressing, remove gloves, wash hands, donned a new pair of gloves, clean the wound, remove gloves, wash hands again then put on another pair of gloves. The facility administration was informed of the finding during a briefing on 11/16/17 at approximately 2:30 p.m. The facility did not present any further information about the findings. The facility's policy: Skin Care - Wound Care (Revised 10/22/14) Policy Statement: -The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Policy Interpretation and Implementation -This procedure may involve potential and/or direct exposure to blood, body fluids, infectious diseases, air contaminants, and hazardous chemicals. Steps in the Procedure include but not limited to: -Wash your hands thoroughly before beginning the procedure. -Tape plastic bag to bedside table for waste. Clean bedside table with chemical wipe. -Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. Wash hands or use hand sanitizer. -Use new, clean gloves. Loosen tape and remove dressing. -Pull glove over dressing and discard both into appropriate receptacle. Wash hands or use hand sanitizer. -Use new, clean gloves. -Pour liquid solutions directly on gauze sponges on their papers. -Use new, clean gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. -Clean wound as ordered. Discard gloves. Wash hands or use sanitizer. -Use new, clean gloves. Apply treatment as indicated. -Dress wound as ordered. -Place barrier cloth and soiled items into designated container. Remove gloves and discard into designated container. Wash your hands. -Use new, clean gloves. Clean over bed table with chemical wipe. -Wash your hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and facility documentation review the facility staff failed to ensure one treatment cart was stored in a secured location, accessible to designated staff only. The facility staff failed to ensure treatment cart containing medication in the hallway was locked when not in direct site of the nurse. The findings include: On 11/15/17 at approximately 9:55 a.m., LPN #2 removed wound care supplies from the back hall treatment cart located in the hallway; then went into room [ROOM NUMBER]B to perform wound care on Resident #1. At approximately 10:15 a.m., the surveyor came out of the room and noticed the treatment cart was left unlocked. The nurse came out of room [ROOM NUMBER], walked pass the unlocked treatment cart over to the medication cart. The surveyor informed the LPN that she had left her treatment cart unlocked after she had removed wound supplies. The surveyor asked, Should your medication cart have been locked with not in direct site, the LPN stated, My cart should have locked my cart. An interview was conducted with the Director of Nursing (DON) on 11/15/17 at approximately 11:25 a.m., who stated, I expect for all nurses to lock their treatment and medication cart when not in direct view of the nurse. The facility administration was informed of the finding during a briefing on 11/17/17 at approximately 2:30 p.m. The facility did not present any further information about the findings. The facility's policy: Medications - Storage of Medications (Revised 09/18/15). Policy Statement: The purpose of this procedure is to ensure that medications are stored in a safe, secure, and orderly manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to implement appropriate hand hygiene during a sacral wound *stage 2*pressure ulcer dressing change in addition to disinfect the over bed table after being used for wound care for Resident #1. Resident #1 was admitted to the nursing facility on 08/18/2017. Diagnosis for included but not limited to Right *femur fracture. The current Minimum Data Set (MDS) a 30-day assessment with an Assessment Reference Date (ARD) of 09/15/17 coded the resident with a 08 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. In addition, the MDS coded Resident #1 requiring total dependence of one with bathing, extensive assistance of two with transfers and mobility, extensive assistance of one with dressing, hygiene and toilet use, and limited assistance of one with eating. Resident #1 was coded frequently incontinent of bowel and bladder. In section M (Skin Conditions) of MDS 09/15/17 coded Resident #1 at risk for developing pressure ulcers, having a stage 1 or higher. Resident #1 was also coded 0 if resident have one or more unhealed pressure ulcer (s) at Stage 1 or higher. *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 (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). *Pressure Injury - Stage 2 (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 (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ *Right femur fracture - a hip fracture is a break in the upper part of the thigh bone (femur) where the thigh bone joins the pelvis to form the hip joint (www.webmd.com/osteoporosis/hip-fracture). Resident #1's care plan documented Resident #1 at risk for impaired skin integrity related to impaired mobility, incontinence and poor tissue perfusion. The goals: the resident will remain free of skin breakdown over the next 90 days. Some of the interventions include but not limited to: Pressure reducing mattress, check skin for redness, skin tears, swelling, or pressure areas. Report and signs of skin breakdown. The current treatment as of 11/10/17 is to cleanse sacrum wound with normal saline, apply barrier ointment, apply *mepilex foam pad, cover with mepilex dressing, off load area when every possible and change daily until resolved. *Mepilex is a foam dressing suitable for a wide range of wounds like venous leg ulcers, pressure ulcers or diabetic ulcers (www.molnlycke.us/advanced-wound-care-products/foam-dressings/mepilex/). On 11/15/17 at approximately 10:00 a.m., the resident was observed lying in bed on a specialty mattress; in a supine position, resident was position to his left side with assistance of LPN #3. LPN #2 placed a clear plastic bag over the over bed table as the table barrier then placed all wound care supply items on the plastic bag covering the over bed table. LPN #2 performed wound care with the assistance of LPN #3. LPN #2 removed the dressing from the sacral wound, placed the soiled dressing inside a clear plastic bag, removed her gloves, went into the bathroom, got a pair of clean gloves from the glove holder on the bathroom wall, donned the new gloves, returned to the bedside, proceeded to clean the wound with normal saline, applied barrier cream to the wound followed with mepilex the covered with a foam dressing. The wound nurse washed her hands using soap x 10 seconds then put her hands under the running water, rinsing off all the soap but continued to rub her hands together for 5 minutes. LPN #2 removed the clean plastic bag from the over bed table and dispose in the trash can. The surveyor if she was finished with completing her wound care, she replied, Yes I'm done, then walked out the room. On 11/15/17 at approximately 2:15 p.m., and interview was conducted with LPN #2 who stated, I should have removed my gloves after I removed the soiled dressing, washed my hands then put on another pair of gloves, cleaned the wound, remove my gloves, finish wound care then wash may hands again. The surveyor asked if the over bed table should have been disinfected after use, she replied No, I don't see why, I put the supplies in the plastic bag covering the table, the table was never touch, so I had no reason to clean it. The surveyor then asked, How long do you wash your hands after wound care, she replied 20 seconds, the surveyor informed LPN #2, she actually washed her hands using soap x 10 seconds then put her hands under the running water, rinsing off all the soap but continued to rub her hands together for 10 minutes with just water. An interview was conducted with the Director of Nursing (DON) on 11/16/17 at approximately 11:20 a.m., who stated, The nurse should have washed her hands before starting wound care, after removing the soiled dressing, remove gloves, wash hands, donned a new pair of gloves, clean the wound, remove gloves, wash hands again then put on another pair of gloves. The DON also stated, After removing the supplies from the over bed table, she should have clean the over bed table also. The facility administration was informed of the finding during a briefing on 11/17/17 at approximately 2:30 p.m. The facility did not present any further information about the findings. The facility's Policy - Personal Protective Measures - Handwashing (Last Revision - 6/23/16). Policy Statement -The purpose of this procedure is to provide guidelines to employees for proper and appropriate handwashing techniques that will aid in the prevention of the transmission of infections. Policy Interpretation and Implementation (Objectives) -To prevent the spread of infectious diseases. When to Wash Hands: Appropriate handwashing must be performed for a minimum of 20 seconds under the following conditions include but not limited to: - After having prolonged contact with resident. -After handling used dressings, specimen's containers, contaminated tissues, linen, etc. -After contact with blood, body fluids, secretions excretions, mucous membranes, or broken skin. -After handling potential contaminated with a resident's blood, body fluids, excretions or secretions. After removing gloves Procedure Guidelines: -Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds under a moderate stream of water, at a comfortable temperature. Based on observation, resident interview, staff interview, facility documentation review, clinical record review,the facility staff failed to: 1. The facility staff failed to ensure infection control measures of hand hygiene and allowing santi wipe to dry for a full 2 minutes were followed during a glucometer check to prevent potential infections for 1 Resident (Resident #14) in the survey sample of 14 Residents. 2. The facility staff failed to implement appropriate hand hygiene during a sacral wound care dressing change in addition to disinfect the over bed table after being used for wound care for Resident #1 in the survey sample of 14 Residents. The findings included: 1. Resident #14 was admitted to the facility on [DATE]. Diagnoses for Resident #14 included but are not limited to Diabetes Mellitus*(1). Resident #'s Initial Minimum Data Set (MDS - an assessment protocol) had not been completed. Resident #14 was observed on 11/15/17 at approximately 5:00 p.m. to require the assistance of one staff member for transfers. Resident #14 was alert and oriented to name only at this time. Resident #14's 11/8/17 to present active/current Care Plan documented the following: Problem: Risk for unstable blood glucose levels Interventions included but were not limited to: Monitor for signs and symptoms of hypoglycemia and hyperglycemia Resident #14's 11/9/17 Physician order documented the following: Humalog 100 unit/milliliter subcutaneous solution (slide scale) two times a day 2 Units Blood Sugar is 251-300 4 Units Blood Sugar is 301-350 6 Units Blood Sugar is 351-400 8 Units Blood Sugar is 401-450 During an observation of medication pass on 11/14/17 at approximately 5:14 p.m., LPN (Licensed Practical Nurse) #1 was observed preparing to obtain a blood sugar check on Resident #14. LPN #1 was observed to wash her hands for approximately 20 seconds. LPN #1 then walked to her equipment that she had placed on a paper towel on Resident #14's table and donned non sterile gloves. LPN #1, wiped down the glucometer meter with a disinfecting wipe and immediately walked to Resident #14's bed. LPN #1, explained to the Resident that she was going to obtain a finger stick for blood and asked if it was ok. LPN #1, wiped Resident #14's finger tip with an alcohol pad and used a lancet to prick Resident #14's finger tip. As LPN #1 went to place the drop of blood on the glucose strip, she stated, Oh, I didn't cut the machine on, I'll have to do this again. LPN #1 removed her gloves and washed her hands for approximately 10 seconds. LPN #14 donned clean gloves and wiped Resident #14's finger tip with alcohol and this time dried finger tip with paper towel. LPN #14 cut glucometer on and inserted strip into the meter. LPN #14 then using a lancet pricked Resident #14's finger tip, obtained a drop of blood, wiped the first drop away using a paper towel and applied the second drop of blood to the glucose strip. The results read 140. LPN #1 stated, He will not get insulin coverage as he is under 251. LPN #1 removed her gloves and then washed her hands for approximately 20 seconds. The Facility Policy and Procedure, titled, Personal Protective Measures Handwashing with a revision date of 6/23/16, documented the following: Appropriate handwashing must be performed for a minimum of 20 seconds under the following conditions: Before performing invasive procedures Before preparing or handling medications After contact with blood, After removing gloves The Facility provided a one page documented (page 55), titled, Infection Prevention and Control Manual for Long Term Care from Patient Care Guidelines. It documented the following: The meter will be disinfected after each use, according to the manufacturer's instructions. Visible debris will be removed with soap and water prior to disinfection. The glucometer will be disinfected with Sani-wipes containing a hypochloric solution. The Facility provided a copy of the printed information on the Sanitizing wipes container that LPN #1 used to clean the glucometer. It documented the following: TO DISINFECT AND DEODORIZE: To disinfect nonfood contact surfaces only; Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two (2) minutes. Let air dry. For heavily soiled surfaces sue a wipe to pre-clean prior to disinfecting. The Center for Disease Control (https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines.pdf) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 documented the following: The choice of disinfectant, concentration, and exposure time is based on the risk for infection associated with use of the equipment and other factors discussed in this guideline. However, for these processes to be effective, health-care workers should adhere strictly to the cleaning, disinfection, and sterilization recommendations in this document and to instructions on product labels. Disinfection describes a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects (Tables 1 and 2). In health-care settings, objects usually are disinfected by liquid chemicals or wet pasteurization. Each of the various factors that affect the efficacy of disinfection can nullify or limit the efficacy of the process. Interview:--------------------------------------- The facility administration was informed of the findings during a briefing on 11/14/17 at approximately 2:26 p.m. The facility did not present any further information about the findings. Definitions: 1. Diabetes Mellitus: Medline Plus documented: Diabetes is a disease in which your blood glucose, or blood sugar, levels are too high. Glucose comes from the foods you eat. Insulin is a hormone that helps the glucose get into your cells to give them energy. With type 1 diabetes, your body does not make insulin. With type 2 diabetes, the more common type, your body does not make or use insulin well. Without enough insulin, the glucose stays in your blood. You can also have prediabetes. This means that your blood sugar is higher than normal but not high enough to be called diabetes. Having prediabetes puts you at a higher risk of getting type 2 diabetes.

Based on observation, resident interview, staff interview and facility documentation review the facility staff failed to ensure a complete and accurate clinical record for 1 of 16 residents (Resident #1) in the survey sample. The facility staff failed to ensure the Treatment Administration Record (TAR) for November 2017 was accurate for the application of *ted hose for Resident #1. The findings include: Resident #1 was admitted to the nursing facility on 08/18/2017. Diagnosis included but not limited to Right *femur fracture. The current Minimum Data Set (MDS) a 30-day assessment with an Assessment Reference Date (ARD) of 09/15/17 coded the resident with a 08 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. *Ted hose are stockings that help prevent blood clots and swelling in your legs (https://www.drugs.com/cg/ted-hose.html). *Right femur fracture - a hip fracture is a break in the upper part of the thigh bone (femur) where the thigh bone joins the pelvis to form the hip joint (www.webmd.com/osteoporosis/hip-fracture). On 11/14/17 at 12:20 p.m., during the initial tour, Resident #1 was observed lying in bed with his left leg hanging off the side of the bed; ted hose was not present to left lower extremity. During the review of Resident #1's Treatment Administration Record (TAR) on 11/14/17 at approximately 2:15 p.m., indicated the following order written on 08/28/17: ted hose to be donned in A.M. (morning) and removed every H.S. (night). On the same day at approximately 3:30 p.m., Resident #1 was sitting on the side of the bed without ted hose to bilateral lower extremities. The review of November 2017 Treatment Administration Record (TAR), the nurse had signed off on 11/14/17 that Resident #1's ted hose had been applied. An interview was conducted with Resident #1 on 11/14/17 approximately 3:30 p.m., the surveyor asked if his ted hose had been applied to his lower extremities today, he replied No, they haven't been on at all today. On 11/14/17 at approximately 5:00 p.m., Resident #1 was in the dining room waiting for his dinner tray. The surveyor observed the resident was not wearing his ted hose. On the same day at 5:20 p.m., the surveyor and the Director of Nursing (DON) walked to the dining room; the DON observed Resident #1 was not wearing his ted hose then stated, I expect for the nurse to follow physician orders as they are written and to call the physician in advance why the resident is not wearing his ted hose. The surveyor asked if Resident #1 has edema to his lower extremities, she replied, Yes, that's more reason for him to have his ted hose on. The facility administration was informed of the finding during a briefing on 11/17/17 at approximately 2:30 p.m. The facility did not present any further information about the findings. The facility's policy: Charting (Revised 02/28/17). Policy Statement: -All services provided to the resident, or any changes in the resident's condition, she be recorded in the resident's medical record. Policy Interpretation and Implementation: -Entries must be recorded by the person rendering the service just after it was performed. -All unanticipated occurrences or changes in the resident's condition must be recorded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, clinical recorded review and facility documentation, the facility staff failed to follow physician orders for 1 out 16 (Resident #1) in the survey sample. The facility staff failed to notify the physician that the following medications were not administered as ordered: *Phoslo 667 capsule for Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE]. Diagnosis for Resident #1 included but are not limited to *End Stage Renal Disease (ESRD) and Right *Femur Fracture. The current Minimum Data Set (MDS) a 30-day assessment with an Assessment Reference Date (ARD) of 09/15/17 coded the resident with a 08 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. In addition, the MDS coded Resident #1 requiring total dependence of one with bathing, extensive assistance of two with transfers and mobility, extensive assistance of one with dressing, hygiene and toilet use, and limited assistance of one with eating. Resident #1 was coded frequently incontinent of bowel and bladder. *Phoslo is used to prevent high blood phosphate levels in patients who are on dialysis due to severe kidney disease (www.webmd.com). *End Stage Renal Disease is the last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs(https://medlineplus.gov/ency/article/000500.htm). *Hip Fracture is a hip fracture is a break in the upper part of the thigh bone(femur) where the thighbone joins the pelvis to form the hip joint (www.webmd.com/osteoporosis/hip-fracture). Review of Resident #1's Physician orders and Medication Administration Record (MAR) for September, October and November 2017 indicated the following medication orders: 1). Phoslo 667 mg capsule - oral three times daily scheduled to be administered at 8 a.m., 11:30 a.m., and 5:00 p.m. for ESRD. During the review of Resident #1's Medication Administration Audit Record for September, October and November 2017 revealed the following medication were not administered due to resident out of facility at dialysis: 1). Phoslo 667 was document as not being administered at 11:30 a.m., in September 2017 on the following days: 9/4, 9/8, 9/11, 9/13/ 9/15, 9/18, 9/20, 9/22, 9/25, 9/27 and 9/29/2017. 2). Phoslo 667 was document as not being administered at 11:30 a.m., in October 2017 on the following days: 10/2, 10/4, 10/6, 10/9, 10/11, 10/16, 10/20, 10/23, 10/25 and 10/27/17. 3). Phoslo 667 was document as not being administered at 11:30 a.m., in November 2017 on the following days: 11/1, 11/3, 11/6 and 11/13/17. The review of Resident #1's clinical record did not indicate that the physican was notified that the resident missed multiple doses of Phoslo due to resident being out to dialysis. On 11/16/17 at appropriately 1:40 p.m., and interview was conducted with the NP who stated, Resident #1 was under another provider until October 20, 2017 but the nurses should have contacted the physician to have his medication times adjusted; the times should have been adjusted. The surveyor asked, why is Phoslo given to dialysis patients, the NP stated, Phoslo is a supplement that helps to prevent high phosphate levels with dialysis patients, their kidneys don't work so the Phoslo helps to maintain that low phosphate level. The NP proceeded to say, I do have concerns that Resident #1's medication wasn't administered because he was out to dialysis, the medication should to be administered appropriately; they should have contacted someone to have his medications adjusted to fit his dialysis days. The facility administration was informed of the finding during a briefing on 11/17/17 at approximately 2:30 p.m. The facility did not present any further information about the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The findings included: 3. Resident #1 was admitted to the facility on [DATE]. Diagnosis for Resident #1 included but are not limited to *End Stage Renal Disease (ESRD) and Right *femur fracture. The current Minimum Data Set (MDS) a 30-day assessment with an Assessment Reference Date (ARD) of 09/15/17 coded the resident with a 08 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. In addition, the MDS coded Resident #1 requiring total dependence of one with bathing, extensive assistance of two with transfers and mobility, extensive assistance of one with dressing, hygiene and toilet use, and limited assistance of one with eating. Resident #1 was coded frequently incontinent of bowel and bladder. *Phoslo is used to prevent high blood phosphate levels in patients who are on dialysis due to severe kidney disease (www. com). *ESRD is the last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs (https://medlineplus.gov/ency/article/000500.htm). *Hip Fracture is a hip fracture is a break in the upper part of the thigh bone (femur) where the thigh bone joins the pelvis to form the hip joint (www.webmd.com/osteoporosis/hip-fracture). Review of Resident #1's Physician orders and Medication Administration Record (MAR) for September, October and November 2017 indicated the following medication orders: 1). Phoslo 667 mg capsule -oral three times daily scheduled to be administered at 8 a.m., 11:30 a.m., and 5:00 p.m. for ESRD. During the review of Resident #1's Medication Administration Audit Record for September, October and November 2017 revealed the following medication were not administered due to resident out of facility at dialysis: 1). Phoslo 667 was document as not being administered at 11:30 a.m., in September 2017 on the following days: 9/4, 9/6, 9/8, 9/11, 9/13/ 9/15, 9/18, 9/20, 9/22, 9/25, 9/27/2017. 2). Phoslo 667 was document as not being administered at 11:30 a.m., in October 2017 on the following days: 10/2, 10/4, 10/6, 10/9, 10/11, 10/16, 10/20, 10/23, 10/25, 10/27 and 10/30/17. 3). Phoslo 667 was document as not being administered at 11:30 a.m., in November 2017 on the following days: 11/1, 11/3, 11/6, 11/8 and 11/13/17. The facility administration was informed of the finding during a briefing on 11/17/17 at approximately 2:30 p.m. The facility did not present any further information about the findings. 4. Resident #1 was admitted to the facility on [DATE]. Diagnosis for Resident #1 included but are not limited to Right *Femur Fracture. The current Minimum Data Set (MDS) a 30-day assessment with an Assessment Reference Date (ARD) of 09/15/17 coded the resident with a 08 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. In addition, the MDS coded Resident #1 requiring total dependence of one with bathing, extensive assistance of two with transfers and mobility, extensive assistance of one with dressing, hygiene and toilet use, and limited assistance of one with eating. Resident #1 was coded frequently incontinent of bowel and bladder. **Hip Fracture is a hip fracture is a break in the upper part of the thigh bone (femur) where the thigh bone joins the pelvis to form the hip joint (www.webmd.com/osteoporosis/hip-fracture). Resident #1 received an order for *Tylenol Extra Strength 500 mg tablet (2 tabs) by oral as needed three times daily starting on 08/19/2017. *Tylenol is used to relieve mild to moderate pain and to reduce fever (https://medlineplus/gov/drugingfo/meds/a682514.html). Review of the Medication Administration Record (MAR) indicated that Resident # 1 received Tylenol Extra Strength 500 mg tablet (2 tabs) on the following days without any non-pharmacological intervention prior to the administration of as needed pain medication: In September 2017: 5th, 8th, 9th, 11th, 12th, 13th, 14th, 16th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 26th, 27th, 28th and 30th. In October 2017: 5th, 13th, 25th, 29th and 30th. In November 2017: 4th,5th, 7th, 11th, 12th,13th and 14th. An interview was conducted with Director of Nursing (DON) on 11/16/17 at 1:15 p.m., who stated she expect for the nurses to assess residents for their pain level but to try non-pharmacological interventions prior to the administration of prn pain medications; if non-pharmacological interventions are not effective then give prn pain mediation but to document the pain level and the effectiveness of the pain medication after being administered. The DON reviewed Resident #1's clinical record for documentation that non-pharmacological interventions were tried prior to the administration of prn Tylenol then replied, I was unable to locate non-pharmacological intervention prior to the administration of Resident #1's prn Tylenol. The facility administration was informed of the finding during a briefing on 11/17/17 at approximately 2:30 p.m. The facility did not present any further information about the findings. Based on observation, resident interview, staff interview, facility documentation review, clinical record review the facility staff failed to: 1. The facility staff failed to ensure non-pharmacological interventions were attempted prior to the administration of analgesics for 1 Resident (Resident #4) of 14 residents in the survey sample. 2. The facility staff failed to ensure non-pharmacological interventions were attempted prior to the administration of analgesics for 1 Resident (Resident #8) of 14 residents in the survey sample. 3. The facility staff failed to follow physician orders for the following medications: *Phoslo 667 capsule for Resident #1. 4. The facility staff failed to ensure non-pharmacological interventions were attempted prior the administration of prn (as needed) pain medication *Tylenol for Resident #1 of 14 residents in the survey sample. The findings included: 1. Resident #4 was admitted to the facility on [DATE]. Diagnoses for Resident #4 included but are not limited to Rhabdomyolysis* (1). Resident #4's Quarterly Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 9/25/17 coded Resident #4 with a BIMS (Brief Interview for Mental Status) of 13 of 15 indicating no cognitive impairment. In addition, the Quarterly MDS coded Resident #4 as requiring extensive assistance with one staff person assistance for hygiene and bathing. Resident #4 was coded as requiring supervision with one staff person assistance for transfers, eating and toileting. Resident #4's Active/Current 1/10/17 to Present Care Plan documented the following problem: Problem: Requires pain management monitoring secondary to prior TKR (Total Knee Replacement), arthropathy/arthritis joint pain and back pain. Interventions included but were not limited to: Implement the following nonpharmacological* (2) pain management program, specifically: distraction, massage, imagery, relaxation, aromatherapy, and application of heat or cold. Resident #4's Physician orders documented the following: 1/4/17 Acetaminophen 500 mg (milligrams) (1 tab) Tablet Oral as needed three times a day Resident #4's Clinical Record MAR (Medication Administration Record) for November 2017 documented the following administration times for Acetaminophen 500 mg (1) Tablet Oral as needed three times a day: Medline Plus documented: Acetaminophen is used to relieve mild to moderate pain 11/5/17 administered 9:58 a.m. 11/5/17 administered 16:27 (4:27 p.m.) 11/5/17 administered 21:19 (9:19 p.m.) 11/8/17 administered 10:00 a.m. 11/9/17 administered 17:25 (5:25 p.m.) 11/12/17 administered 8:27 a.m. All of the above administered doses were documented as being effective for Resident #4. On 11/16/17 at approximately 10:00 a.m., the Facility was requested to provide any documentation showing use of non-pharmacological interventions were completed prior to the use of the analgesic Acetaminophen. The facility did not provide any documentation. The Director of Nursing (DON) on 11/16/17 at approximately 3:00 p.m. stated there was no documentation for non pharmacological measures prior to the administration of analgesics. The Facility did not present a Policy for use of non pharmacological measures prior to the administration of pain medications. The facility administration was informed of the findings during a briefing on 11/14/17 at approximately 2:26 p.m. The facility did not present any further information about the findings. 2. Resident #8 was admitted to the facility on [DATE]. Diagnoses for Resident #8 included but are not limited to Fracture of Femur (leg bone) . Resident #8's admission Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 8/29/17 coded Resident #8 a BIMS (Brief Interview for Mental Status) of 01 of 15 indicating a severe cognitive impairment. In addition, the admission MDS coded Resident #8 as requiring extensive assistance with one staff person assistance for transfers, bed mobility, dressing, toilet use, hygiene and bathing. Resident #8's current/active Care Plan did not include a problem for pain. Resident #8's Physician orders documented the following: 8/22/17 Oxycodone -acetaminophen 5 mg - 325 mg tablet; 1 tab as needed every four hours Medline Plus documented: Oxycodone is used to relieve moderate to severe pain Resident #8's October 2017 MAR (Medication Administration Record) documented the following Oxycodone -acetaminophen 5 mg - 325 mg tablet administration times: 10/5/17 administered 16:35 (4:35 p.m.) 10/25/17 administered 18:04 (6:04 p.m.) All of the above administered doses were documented as being effective for Resident #4. On 11/16/17 at approximately 10:00 a.m., the Facility was requested to provide any documentation showing use of non-pharmacological interventions were completed prior to the use of the analgesic Acetaminophen. The facility did not provide any documentation. The Director of Nursing (DON) on 11/16/17 at approximately 3:00 p.m. stated there was no documentation for non pharmacological measures prior to the administration of analgesics. The Facility did not present a Policy for use of non pharmacological measures prior to the administration of pain medications. The facility administration was informed of the findings during a briefing on 11/14/17 at approximately 2:26 p.m. The facility did not present any further information about the findings. Definitions: 1. Rhabdomyolysis: ([NAME]-doe-my-OL-ih-sis) Mayoclinic.org documented: a rare condition that causes muscle cells to break down. The most common signs and symptoms of rhabdomyolysis include: Severe muscle aching throughout the entire body . 2. Non-Pharmacological: Non medicine measures such as relaxation, aromatherapy, massage: the National Institute of Health documented: The guidelines recommend that practitioners consider these non-pharmacologic interventions as appropriate options when treating patients whose low-back pain does not improve with more conservative self-care. 3. Non-Alzheimer's Dementia: Medline Plus documented: Dementia is the name for a group of symptoms caused by disorders that affect the brain. It is not a specific disease. People with dementia may not be able to think well enough to do normal activities, such as getting dressed or eating. They may lose their ability to solve problems or control their emotions. Their personalities may change. They may become agitated or see things that are not there. A type of dementia not associated with Alzheimer's Disease.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and staff interviews the facility staff failed to store and prepare food with professional standards for food service safety. The findings included: During the initial kitchen tour on 11/14/17 at 12: 18 P.M. An uncovered bowl of cake mix, with blender blades which had cake mix on them were observed on a cart. In the ice cream freezer two of four five gallon ice cream containers had lids inside the ice cream containers touching the ice cream There was one un-covered bowel of [NAME] slaw observed sitting on the serving line. There were four uncovered bowls of berry's observed sitting on the serving line. One bag of puree turkey sausage was observed sitting on top of a tray of bacon on a food cart in the middle of the floor leading into the refrigerator. A review of the menu for November 14, 2017 indicated: [NAME] slaw was to be served during the lunch meal and a mixed berry salad was to be served during the dinner meal A Dietary Food Storage Policy indicated: Food storage areas shall be maintained in a clean, safe and sanitary manner. 3. Cold foods shall be maintained at temperatures of 40 degrees or below. 5. All foods stored in walk-in refrigerators and freezers shall be stored in the kitchen area or in storerooms for food or food preparation. The Dietary Manager stated during the tour on 11/14/17 at 12: 24 P.M. that new ice cream container tops were on order. A dietary aide stated, The cake mix was to be discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and staff interviews, the facility staff failed to provide a safe, sanitary and comfortable environment. The findings included: During the General Observations of the environment on 11/16/17 at 11:14 A.M. the following areas were noted: In the shower room an old battery charger was observed on the floor the shower. The shower room floor drain was observed to have trash and debris. In the Electrical Room that also housed the copier and fax machine was observed paper. trash and debris on the floor. In the Mechanical Room mold and mildew like substance was observed on the vent cover of an air duct. The Maintenance Director stated, the air goes all over the residential area. In the Soiled Utility Room a 2 x 3 foot board was observed sitting on top of a small refrigerator used for storing laboratory samples. In the Medication storage room dead bugs and cob webs were observed on the counter where the Stat Medication box was stored. The light bulbs in the Laundry chemical storage room were not functioning. The outside Bi-Hazard Room was observed to have trash and debris. There were two old container tops used to cover laundry carts stored in the room. Two five gallon containers of sand with cigarette butts were observed in the room along with an old cigarette [NAME]. During an interview with the Maintenance Director he stated, some areas are to be cleaned on a routine bases and others on a monthly schedule. The facility staff failed to provide a safe, sanitary and comfortable environment.