**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to administer pain medication to a resident who experienced pain and requested pain medication for one (1) of eight (8) residents in the survey sample, Resident #7. The findings include: For Resident #7 the facility staff failed to give pain medication when requested. The resident went without pain medication for approximately 38 hours. Resident #7 was admitted to the facility on [DATE] with diagnoses included but are not limited to left leg pain, peripheral vascular disease (PVD), right below the knee amputation (BKA), left heel unstageable pressure ulcer, and a stage three (3) sacrum pressure ulcer. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/8/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible score of 15 which indicated Resident #7 was cognitively intact. Section J Health Conditions/Pain Management was not assessed on the MDS. Resident #7 care plan dated 12/21/2023 included a focus on the risk for alteration in comfort related to PVD, left second toe amputation, right BKA, and pressure ulcers. Resident #7 order summary includes an order dated 12/29/23 for Oxycodone (oxycontin) 10mg every four (4) hours as needed for pain. An interview was conducted with Family Member (FM) #1 over the phone on 7/3/24 at approximately 4:15 PM. FM #1 shared that Resident #7 called her on 1/24/24 at approximately 1:00 AM and shared that he had been asking for pain medication for hours and that the nursing staff kept telling him that he was given medication already and that he was not due to get another dose. During this call FM #1 said she could hear staff in the background saying that Resident #7 was given Percocet (oxycodone/acetaminophen). FM #1 said that she informed nursing staff that Resident #7 was allergic to Percocet. FM #1 shared that after the nursing staff checked the medical records, they realized that it was another resident that received pain medication and not Resident #7. An interview was conducted with Resident #7 over the phone on 7/3/24 at approximately 4:25 PM. Resident #7 said that he suffered in pain for hours and that his pain on a scale of 0-10, with 10 being the worse was a 15. An interview was conducted over the phone with Licensed Practical Nurse (LPN) #5 on 7/3/24 at approximately 10:35 AM. LPN #5 shared that she was supervising on 1/24/24 and that Resident #7's daughter called and asked why her father could not get pain medication. LPN #5 said that she did not remember everything, but she remembers there being some confusion about Resident #7 getting pain medication and that the primary nurse had mixed up her residents. Progress note dated 1/24/24 at 1:57 AM written by LPN #4 indicated, Resident #7 requested pain medication and when the medication administration record (MAR) and narcotic book was checked she thought it noted that Resident #7 received pain pills at 12:00 AM. This note also indicates, the 3-11 PM nurse reported that Resident #7 received medication on previous shift and will receive next dose in 4 hours as ordered. The progress note read, Resident #7 insisted that he did not receive his pain medication and called daughter. The nursing supervisor visited the resident and explained to the resident and daughter that she would follow up on the administration time. The nursing supervisor and LPN #4 double checked the narcotic book and realized that the medication was not given to the resident. LPN #4 and the nursing supervisor apologized for the miscommunication. LPN #4 looked at the wrong charting in the narcotic book. LPN #4 administered pain medication to Resident #7 as prescribed. Progress note dated 1/24/24 at 1:58 AM written by the nursing supervisor supported the note written by LPN #4. Review of Resident #7's January MAR indicates prior to Resident #7 calling FM #1 due to pain on 1/24/24 at approximately 1:00 PM, his last dose of Oxycodone was on 1/22/24 at 11:46 AM. After nursing staff recognized their mistake Resident #7 was administered Oxycodone 10mg on 1/24/24 at 1:52 AM, 6:23 AM, 11:52 AM, and 4:56 PM. Review of the facilities Pain Management policy, reviewed and revised on 12/13/23 read, .The facility must ensure that pain management is provided to residents who require such services . An interview was conducted with the Director of Nursing (DON) on 7/8/2024 at approximately 11:30 AM. The DON shared that the expectation is that staff do a pain assessment on every resident every shift at least. The DON indicated that the electronic medical record (EMR) does not populate a pain assessment column if the provider does not order pain assessments. The DON said that the staff had to document their pain assessments otherwise manually. The above findings were shared with the Administrator, Corporate Nurse #1, DON, and Assistant Director of Nursing (ADON) on 7/8/2024 at approximately 5:22 PM. No further information was provided prior to the conclusion of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to document administered controlled medication on the medication administration record (MAR) for one (1) of eight (8) residents in the survey sample, Resident #7. The findings include: For Resident #7 the facility staff failed to document 50 doses of oxycodone on the Medication Administration Record (MAR) that were signed out on the medication monitoring control records for December 2023 and January 2024. Resident #7 was admitted to the facility on [DATE] with diagnoses included but are not limited to left leg pain, peripheral vascular disease (PVD), right below the knee amputation (BKA), left heel unstageable pressure ulcer, and a stage three (3) sacrum pressure ulcer. Resident #7 care plan dated 12/21/2023 included a focus on the risk for alteration in comfort related to PVD, left second toe amputation, right BKA, and pressure ulcers. Review of Resident #7's medication monitoring control records for the months December 2023 and January 2024 reflect oxycodone being signed out but not documented on the December 2023 and January 2024 MARs for the following dates and times: 12/12/23 at 9 PM, 12/13/23 at 6 PM, 12/13/23 at 11 PM, 12/18/23 at 7 AM, 12/18/23 at 6 PM, 12/19/23 at 6 PM, 12/20/23 at 5 PM, 12/21/23 at 6:30 AM, 12/21/23 at 6 PM, 12/22/23 at 5 AM, 12/22/23 at 1:40 PM, 12/22/23 at 8:40 PM, 12/23/23 at 4:30 PM, 12/25/23 at 2:15 AM, 12/26/23 at 9 AM, 12/27/23 at 10:30 AM , 12/28/23 at 7 PM, 12/29/23 at 6 AM, 12/29/23 at 4:56 PM, 12/30/23 at 6 AM, 12/30/23 at 10:00 AM, 12/31/23 at 3 AM, 1/1/24 at 4 PM, 1/1/24 at 10 PM, 1/3/24 at 7 PM, 1/5/24 at 4:30 AM, 1/6/24 at 6:30 PM, 1/15/24 at 5 PM, 1/15/24 at 10 PM, 1/20/24 at 5:30 PM, 1/20/24 at 11 PM, 1/21/24 at 11 AM, 1/21/24 at 3 PM, 1/21/24 at 7 PM, 1/21/24 at 11 PM, 1/22/24 at 7:15 AM, 1/22/24 at 11:15 AM, 1/22/24 at 6 PM, 1/22/24 at 11:46 PM, 1/24/24 at 11 PM, 1/25/24 at 6 AM, 1/25/24 at 10:45 AM, 1/25/24 at 4 PM, 1/25/24 at 10 PM, 1/26/24 at 3:03 PM, 1/27/24 at 4:15 AM, 1/27/24 at 9 AM, 1/27/24 at 4:15 PM, 1/27/24 at 11:45 PM, 1/28/24 at 9 AM, and 1/26/24 at 10 PM. An interview was conducted with the Director of Nursing (DON) on 7/8/2024 at approximately 11:30 AM. The DON shared that when administering a controlled as needed medication, staff should check the order, dispensed medication, sign it off on the narcotic sheet, and document it on the MAR. The DON shared that they did not have a process in place for auditing the controlled sheets but will be developing a process moving forward. An interview was conducted with Licensed Practical Nurse (LPN) #3 on 7/8/24 at approximately 12:00 PM. LPN #3 shared that she developed a bad habit of not always documenting her controlled medication in residents MAR because of feeling rushed at times and the fast-paced flow of her shifts. LPN #3 shared that she was educated on 6/5/24 by the Director of Nursing (DON) of the expectation of complete documentation of administered medications. The above findings were shared with the Administrator, Corporate Nurse #1, DON, and ADON on 7/8/2024 at approximately 5:22 PM. No further information was provided prior to the conclusion of the survey.

Based on information acquired while reviewing infections acquires in the facility and staff interviews the facility staff failed to have a qualified individual to perform the role of an Infection preventionist (IP). The findings included; On 7/3/24 at approximately 1:05 PM, an interview was conducted with the Registered Nurse identified as the IP. As the documentation was reviewed regarding urinary tract infections (UTI) for residents over a six month period two residents were identified with multiple UTIs. The IP stated staff education was provided without providing documentation of the curriculum. During the interview, the IP also stated that she had completed the training to become a qualified IP but, she did not have the certification because she had not completed the competency test. The IP stated based on information obtained from Human Resources the last qualified IP employed separated from the facility on 12/22/23 and currently she was wearing thehat as the current IP. On 7/8/24 at approximately 1:00 PM, a final interview was conducted with the Administrator, Director of Nursing and Regional Nurse Consultant. They had no comments and voiced no concerns regarding the above information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and in the course of a complaint investigation, it was determined the facility staff failed to notify the physician and/or responsible party (RP) of missed medication and a change in condition for 2 of 43 residents in the survey sample, Resident #427 and #50. The findings include: 1. The facility failed to notify the RP of Resident #427's thrush and abrasion on buttocks. Resident #427 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: atrial fibrillation, stroke, hypertension, end stage renal disease and coronary artery disease. The most recent MDS (minimum data set) assessment, a 5 day Medicare assessment, with an ARD (assessment reference date) of 11/18/21, 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. A review of the MDS Section G-functional status coded the resident as being totally dependent for bed mobility, transfer, locomotion, dressing, eating, hygiene and bathing. A review of the comprehensive care plan dated 11/16/21, which revealed, FOCUS: The resident has actual impairment MASD (moisture associated skin damage) to skin integrity of the right gluteal folds related to fragile skin, incontinence. INTERVENTIONS: Keep skin clean and dry. Use lotion on dry intact skin. Encourage good nutrition and hydration in order to promote healthier skin. A review of the physician orders dated 12/20/21, revealed, Nystatin Suspension 100000 UNIT/Milliliter Give 5 milliliter by mouth four times a day for Thrush for 5 Days swish and swallow. A review of the physician orders dated 12/29/21, revealed, Right buttocks: Cleanse with wound cleanser, apply skin prep to surrounding area, place Ca+ alginate (cut to fit) to wound bed, apply bordered dressing q 3 days. One time a day every 3 day(s) for open area. A review of Resident #427's MAR (medication administration record) revealed, Nystatin Suspension 100000 UNIT/Milliliter Give 5 milliliter by mouth four times a day for Thrush for 5 Days swish and swallow was administered December 21-December 25, 2021 at 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM. A review of Resident #427's TAR (treatment administration record) revealed, Right buttocks cleansed and dressed per physician orders every three days, administered per physician orders on 12/31/21, 1/3/22, 1/6/22, 1/9/22, 1/12/22 and 1/15/22. A review of the nursing progress note dated 12/28/21 at 10:59 PM, revealed, Residents daughter called and made aware about the residents open area to her buttocks. Also the resident's daughter voiced concerns about her mothers' throat maybe irritated, sore and her being unable to voice the discomfort. Daughter requested to see if her mother can see a doctor to get her throat checked and this writer notified her that the doctor will be notified. A review of the nursing progress note dated 12/29/21 at 4:04 PM, revealed, Spoke with resident RP addressed concerns regarding her decreased oral intake, resident completed 6 days of Nystatin for oral thrush on 12/26/21 oral cavity assessed by nurse practitioner and free of thrush at this time new order received for chlorhexadine twice daily. Reviewed labs and educated on resident baseline results and also reviewed current treatment to impaired skin integrity to right buttock with new order in place for calmoseptine and hydrocolloid change every 3 days and prn. RP (responsible party) verbalized understanding and was thankful for the updates at this time. An interview was conducted on 8/3/22 at 8:40 AM with LPN (licensed practical nurse) #4, the wound care nurse. When asked what the process is for notifying the family if an alteration in skin integrity is found, LPN #4 stated, the person that finds the wound, would call the doctor and the RP. As the wound nurse I would call the RP to double check and the RP would know within a 24 hour period. An interview was conducted on 8/4/22 at 7:29 AM with LPN #5, the unit manager. When asked the process for notifying a resident's RP or family regarding a change in condition or treatment, LPN #5 stated, they would call the family member and let them know there is an issue or change and you should do an incident report and put a progress note in the chart. An interview was conducted on 8/4/22 at 7:40 AM, with RN (registered nurse) #2. When asked the process for notification if a resident has a change in condition or change in treatment, RN #2 stated, we would notify the RP and document it in the progress note. When asked to look at Resident #427's chart to find RP notification notes, RN #2 stated, we have the order to treat thrush on 12/20/2. I have looked at the nursing progress note for 12/16/21, 12/18/21 and 12/20/21, there is not anything about family notification about this. An interview was conducted on 8/4/22 at 8:05 AM, with ASM (administrative staff member) #1, the administrator. When asked if there was evidence of RP notification for Resident #427's thrush and abrasion, ASM #1 stated, No, the proper documentation was not done for RP notification. The staff that were in place, were inefficient and there was not a lot of structure in place. We have replaced the staff and are putting structures in place. On 8/4/22 at approximately 12:20 PM, ASM (administrative staff member) #1, the administrator, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of clinical services were made aware of the findings. A review of the facilities' Notification of Changes policy dated 11/1/20, revealed the following: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification. Circumstances requiring notification include: 1. Accidents: Resulting in injury. Potential to require physician intervention. 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: Life-threatening conditions, or Clinical complications. Circumstances that require a need to alter treatment. This may include: New treatment. Discontinuation of current treatment due to: Adverse consequences. Acute condition. Exacerbation of a chronic condition. A transfer or discharge of the resident from the facility. A change of room or roommate assignment. A change in resident rights. Documentation of Notification: Record of the date, time, name of individual who received the notification and any pertinent response to the notice will be made in the clinical record in the resident's clinical record. No further information was provided prior to exit. Complaint deficiency. 2. The facility staff failed to notify the physician and the responsible party of a medication not given to Resident #50 (R50) on 8/3/2022 as observed during the medication administration observation. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 7/4/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is cognitively intact for making daily decisions. On 8/3/2022 at 8:26 a.m., an observation was made of LPN (licensed practical nurse) #7 administering medication to R50. LPN #7 prepared morning medication for R50 and stated that they did not have the scheduled 9:00 a.m. dose of Donepezil HCL 10 mg (milligram) to give to R50 because it was not on the cart. LPN #7 stated that the computer said that the medication was on order from the pharmacy. LPN #7 stated that they were going to call the pharmacy to check on the status of the medication after they finished the morning medications. The eMAR (electronic medication administration record) dated 8/1/2022-8/31/2022 for R50 documented in part, Donepezil HCl Tablet 10 MG, Give 1 tablet by mouth one time a day for dementia -Start Date- 06/28/2022 0900 (9:00 a.m.) The record for 8/3/2022 at 9:00 a.m. documented a 9 with the eMAR chart codes documenting .9=Other / See Nurse Notes . The eMAR failed to evidence administration of the 9:00 a.m. dose of Donepezil 10 mg on 8/3/2022. The progress notes for R50 documented in part, 8/3/2022 08:42 (8:42 a.m.) Donepezil HCl Tablet 10 MG, Give 1 tablet by mouth one time a day for dementia. Not available, will call pharmacy. The physician orders for R50 documented in part, Donepezil HCl Tablet 10 MG, Give 1 tablet by mouth one time a day for dementia. Order Date: 06/27/2022. On 8/03/2022 at 3:58 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that if a residents medication was not available they checked their cubex medication system (automated medication dispensing system) to see if there was a stock of the medication they could pull. LPN #5 stated that if not, they would reach out to the pharmacy to see if the medication could be sent that day. LPN #5 stated that if the medication was not able to be sent by the pharmacy they would notify the physician to get an order to hold the medication until the medication arrived and notify the responsible party. LPN #5 stated that there should be documentation in the progress notes of notification of the pharmacy, physician and the responsible party. On 8/04/2022 at 7:52 a.m., an interview was conducted with LPN #4. LPN #4 stated that if a residents medication was not available staff were to contact the pharmacy to see if it was in route to them. LPN #4 stated that if the medication was due to be administered and not available they should notify the physician to get an order to hold the medication until it arrived and document the notification of the physician and the responsible party. LPN #4 stated that they also have a cubex medication system in house that stores some medications that staff could pull from if needed. Review of the clinical record on 8/4/2022 at 9:30 a.m. failed to evidence documentation of notification of the physician or the responsible party for the missed dose of Donepezil HCL on 8/3/2022, or communication with the pharmacy. On 8/4/2022 at 11:40 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, facility document review, clinical record review, and in the course of a complaint allegation, it was determined the facility staff failed to report to the state agency an allegation of abuse for one of 43 residents in the survey sample, Resident #26 (R26); and failed to report an injury of unknown origin for one of 43 residents in the survey sample, Resident #5 (R5). The findings include: 1. The facility staff failed to file a report, of an allegation of abuse, to the State Agency as required after the resident made the statement of alleged abuse, for Resident #26 (R26) On the most recent MDS (minimum data set) assessment, with an ARD of 5/30/2022, the resident scored a 15 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. Diagnoses included but were not limited to: schizophrenia and dementia The Facility Reported Incident (FRI) dated, 11/4/2020, documented in part, Report date: 11/4/2020. Residents involved: Name of R26. Incident Type: Allegation of abuse/mistreat. Describe incident: (R26) report that a big black man had come into her room and threw her on the bed and they all jumped on her .Resident was fully assessed by nursing staff and bruises were all properly documented. Responsible party and physician were notified. Findings on investigation will be reported back in 5 working days. The Facility Reported Incident (FRI) dated, 11/11/2020, documented in part, All staff on 3-11 and 11-7 were interviewed on whether they had witnessed or had knowledge of the incident in question. Statements were collected from all staff that did indicate that they had knowledge of the incident. A thorough head to toe assessment was completed on both residents, injuries and or bruises were all documented at that time. APS (adult protective services) worker (name of APS worker) and (name of detective) interviewed each resident and took pictures of all injuries/bruises .(R26) was unable to accurately recall detailed of the event as well as the names of the alleged employees involved. She stated that she is very confused and has difficulties remembering things. (Name of a male CNA) called top speak with HR (human resources) on 11/10/2020 and informed her that they were resigning effective immediately and that he never works with female residents and does not know who (R26) is. Statement from the 3-11 CNA (certified nursing assistant) indicated that (R26) was sitting at the nurse's station at the end of the shift free of any injuries and or bruises .The facility has unsubstantiated the allegation against the male CNA. MD (medical doctor) and RP (responsible party) were made aware of the outcome of the investigation. The nurse's note dated, 11/1/2020 at 7:37 a.m., documented in part, Note Text: @ (at) 0255 (2:55 a.m.) resident noted to have bleeding and bruising above right eyelid at nursing station. Resident noted to have 2 shallow lacerations above right eye lid. Injury unwitnessed. Resident very poor historian. Injury was not noted earlier in shift. Resident came from room. Resident's floor noted to have blood on it. Resident clothes scattered on floor. Attempt to clean lacerations and measure them. Resident refused. Walking away from nursing staff. Resident noted to be agitated. No change in behavior when normally agitated. Resident refused vital signs and neuro check to be taken. ADON (assistant director of nursing) notified of above. (Name of physician group) call at 0330 (3:30 a.m.) awaiting callback. 0520 (5:20 a.m.) Received callback from (Name of physician group) notified of the above. 0540 (5:40 a.m.) Received callback from (name of physician group) (name of NP - nurse practitioner) to send resident to ER (emergency room) via 911 for evaluation. 0540 (5:40 a.m.) 911 called. 0555 (5:55 a.m.) EMS (emergency medical services) arrived and assessed resident. Resident refused to go to ER. ADON notified. Called and left VM (voice mail) to notify (name of physician group) of above. The Skin Condition Observation Sheet, dated 11/5/2020, five days after the initial reported incident, documented the following: 2 x 1 (in centimeters) bruising/black purple noted on right eye; two lacerations in the eyebrow area, scattered bruising on right forearm; swollen right hand; 0.3 x 0.1 area on left chest; 2x1.5 bruising on left antecubital area; 1 x 1.5 area on left arm below the elbow; 0.5 x 0.5 area on left wrist; 1.2 x 2 area noted on right abdomen. None of the staff that were involved in this incident were employed at the facility at the time of survey. This included the administrator, director of nursing, the nurse that wrote the above note, the CNAs documented in the FRI and the ADON. An interview was conducted with LPN (licensed practical nurse) #5, on 8/3/2022 at 10:42 a.m. When asked the process for when a resident makes a statement that they have been abused, LPN #5 stated you have to initiate an investigation immediately. An incident report must be made. LPN #5 stated a full body assessment must be completed, notify the MD and RP (responsible party). Interview the people that cared for the resident, if the roommate is alert and verbal, would interview them. LPN #5 stated that if the resident named a staff member then that staff member would be placed on suspension. When asked if you have to report an allegation of abuse to the director of nursing (DON) or the administrator, LPN #5 stated that a nurse should report it to the DON or administrator as soon as you are aware of it. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 8/4/2022 at 11:19 a.m. When asked what steps are to be taken when a resident stated they have been abused, ASM #1 stated everyone stops what they are doing. First make sure the resident is safe, no injuries, no harm. Report a FRI. We have two hours to report abuse, start an investigation depending on what it is, if staff is involved, suspend the staff member. Question the resident and roommate. ASM #1 stated she takes a census sheet and the staff assignment sheet and start interviews with everyone on that group assignment. ASM #1 stated she would interview the whole hall of residents. Make sure the doctor and family is aware. Complete the investigation, if the allegation is founded, then we notify the police. When asked when she should be notified of an allegation of abuse, ASM #1 stated as soon as it happens. The facility policy, Abuse, Neglect and Exploitation documented in part, VII. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of an alleged violations to the Administrator, state agency, adult protective services and to all other required agencies(e.g., law enforcement when applicable) within specified timeframes; a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or results in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .B. The Administrator will follow up government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. ASM (administrative staff member) # 1, the administrator, ASM #2, the director of nursing, and ASM #5, the director of clinical services, were made aware of the above concern on 8/4/2022 at 11:46 a.m. No further information was obtained prior to exit. 2. The facility staff failed to report to the State Agency, within 24 hours, an injury of unknown origin, a bruise, for Resident #5 (R5). On the most recent MDS assessment, a quarterly assessment, with an ARD of 5/4/2022, the resident scored a 0 out of 15 on the BIMS score, indicating the resident is severely cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance to being totally dependent upon the staff for all of their activities of daily living. The Facility Reported Incident (FRI) dated, 11/4/2020, documented in part, Report date: 11/4/2020. Residents involved: (Name of R5). Incident Type: Allegation of abuse/mistreat; injury of unknown origin. Describe incident: (R5) injury of unknown origin. Resident unable to inform staff how bruise to her chest occurred .Resident was fully assessed by nursing staff and bruises were all properly documented. Responsible party and physician were notified. Findings on investigation will be reported back in 5 working days. The Facility Reported Incident (FRI) dated, 11/11/2020, documented in part, All staff on 3-11 and 11-7 were interviewed on whether they had witnessed or had knowledge of the incident in question. Statements were collected from all staff that did indicate that they had knowledge of the incident. A thorough head to toe assessment was completed on both residents, injuries and or bruises were all documented at that time. APS (adult protective services) worker (name of APS worker) and (name of detective) interviewed each resident and took pictures of all injuries/bruises .(R5). (R5) was unable to recall details of the event or how she got her bruises .(Name of a male CNA) called top speak with HR (human resources) on 11/10/2020 and informed her that they were resigning effective immediately and that he never works with female residents and does not know who (R26) is. Statement from the 3-11 CNA (certified nursing assistant) indicated that (R5) was sitting at the nurse's station at the end of the shift free of any injuries and or bruises .The facility has unsubstantiated the allegation against the male CNA. MD (medical doctor) and RP (responsible party) were made aware of the outcome of the investigation. The nurse's note dated, 11/1/2022 at 8:10 a.m. documented, Note Text: CNA giving care requested this nurse to assess resident, upon assessment noted bruised area to left clavicular area, purple in color, non-tender to touch, skin tear to right upper arm, approximately 1.5 in length, purple in color, cleansed with DWC (wound cleanser), pat dry, applied bacitracin, then covered with dry dressing. MD made aware/RP (name of RP) notified. Treatment initiated. Will continue to monitor status. There were no skin assessments on or around the date above in the clinical record. There were no skin assessments documented in the FRI investigation folder. The only documentation, other than on the actual FRI of 11/4/2020, in the FRI investigation folder was related to the other resident documented on the FRI, not R5. An interview was conducted with LPN (licensed practical nurse) #5, on 8/3/2022 at 10:42 a.m. When asked the process for when a nurse finds an injury of unknown origin on a resident, LPN #5 stated you have to initiate an investigation as to where the injury came from. An incident report must be made. LPN #5 stated a full body assessment must be completed, notify the MD and RP (responsible party). Interview the people that cared for the resident, if the roommate is alert and verbal, would interview them. When asked if you have to report an injury of unknown origin to the director of nursing (DON) or the administrator, LPN #5 stated that a nurse should report it to the DON or administrator as soon as you are aware of it. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 8/4/2022 at 11:19 a.m. When asked what steps are to be taken when a resident stated they have been abused, ASM #1 stated everyone stops what they are doing. First make sure the resident is safe, no injuries, no harm. Report a FRI. We have two hours to report abuse, start an investigation depending on what it is, if staff is involved, suspend the staff member. Question the resident and roommate. ASM #1 stated she takes a census sheet and the staff assignment sheet and start interviews with everyone on that group assignment. ASM #1 stated she would interview the whole hall of residents. Make sure the doctor and family is aware. Complete the investigation, if r allegation is founded, then we notify the police. When asked when she should be notified of an allegation of abuse, ASM #1 stated as soon as it happens. When asked if this procedure is the same for an injury of unknown origin such as a bruise, ASM #1 stated, yes, because that could have been caused by abuse. ASM #1 stated she could not locate any further documentation related to the bruises found on R5. ASM (administrative staff member) # 1, the administrator, ASM #2, the director of nursing, and ASM #5, the director of clinical services, were made aware of the above concern on 8/4/2022 at 11:46 a.m. No further information was obtained prior to exit.

Based on staff interivew, facility document review, clinical record review and in the course of a complaint investigation, it was detrmined the facility staff failed to investigate an injury of unknown origin for one of 43 residents in the survey sample, Resident #5 (R5). The findings include: On the most recent MDS assessment, a quarterly assessment, with an ARD of 5/4/2022, the resident scored a 0 out of 15 on the BIMS score, indicating the resident is severely cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance to being totally dependent upon the staff for all of their activities of daily living. The Facility Reported Incident (FRI) dated, 11/4/2020, documented in part, Report date: 11/4/2020. Residents involved: (Name of R5). Incident Type: Allegation of abuse/mistreat; injury of unknown origin. Describe incident: (R5) injury of unknown origin. Resident unable to inform staff how bruise to her chest occurred .Resident was fully assessed by nursing staff and bruises were all properly documented. Responsible party and physician were notified. Findings on investigation will be reported back in 5 working days. The Facility Reported Incident (FRI) dated, 11/11/2020, documented in part, All staff on 3-11 and 11-7 were interviewed on whether they had witnessed or had knowledge of the incident in question. Statements were collected from all staff that did indicate that they had knowledge of the incident. A thorough head to toe assessment was completed on both residents, injuries and or bruises were all documented at that time. APS (adult protective services) worker (name of APS worker) and (name of detective) interviewed each resident and took pictures of all injuries/bruises .(R5). (R5) was unable to recall details of the event or how she got her bruises .(Name of a male CNA) called top speak with HR (human resources) on 11/10/2020 and informed her that they were resigning effective immediately and that he never works with female residents. Statement from the 3-11 CNA (certified nursing assistant) indicated that (R5) was sitting at the nurse's station at the end of the shift free of any injuries and or bruises .The facility has unsubstantiated the allegation against the male CNA. MD (medical doctor) and RP (responsible party) were made aware of the outcome of the investigation. The nurse's note dated, 11/1/2022 at 8:10 a.m. documented, Note Text: CNA giving care requested this nurse to assess resident, upon assessment noted bruised area to left clavicular area, purple in color, non-tender to touch, skin tear to right upper arm, approximately 1.5 in length, purple in color, cleansed with DWC (wound cleanser), pat dry, applied bacitracin, then covered with dry dressing. MD made aware/RP (name of RP) notified. Treatment initiated. Will continue to monitor status. There were no skin assessments for around the date above in the clinical record. There were no skin assessments documented in the FRI investigation folder. The only documentation, other than on the actual FRI of 11/4/2020, in the FRI investigation folder was related to the other resident documented on the FRI, not R5. An interview was conducted with LPN (licensed practical nurse) #5, on 8/3/2022 at 10:42 a.m. When asked the process for when a nurse finds an injury of unknown origin on a resident, LPN #5 stated you have to initiate an investigation as to where the injury came from. An incident report must be made. LPN #5 stated a full body assessment must be completed, notify the MD and RP (responsible party). Interview the people that cared for the resident, if the roommate is alert and verbal, would interview them. When asked if you have to report an injury of unknown origin to the director of nursing (DON) or the administrator, LPN #5 stated that a nurse should report it to the DON or administrator as soon as you are aware of it. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 8/4/2022 at 11:19 a.m. When asked what steps are to be taken when a resident stated they have been abused, ASM #1 stated everyone stops what they are doing. First make sure the resident is safe, no injuries, no harm. Report a FRI. We have two hours to report abuse, start an investigation depending on what it is, if staff is involved, suspend the staff member. Question the resident and roommate. ASM #1 stated she takes a census sheet and the staff assignment sheet and start interviews with everyone on that group assignment. ASM #1 stated she would interview the whole hall of residents. Make sure the doctor and family is aware. Complete the investigation, if allegation is founded, then we notify the police. When asked when she should be notified of an allegation of abuse, ASM #1 stated as soon as it happens. When asked if this procedure is the same for an injury of unknown origin such as a bruise, ASM #1 stated, yes, because that could have been caused by abuse. When asked if the FRI investigation in the facility FRI folder was a complete investigation, ASM #1 stated, it wasn't the way she would have done the investigation. ASM #1 stated she could not locate any further documentation related to the bruises found on R5. The facility policy, Abuse, Neglect and Exploitation documented in part, IV - Identification of Abuse, Neglect and Exploitation: B. Possible indicators of abuse include; but are not limited to: 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body. 3. Physical injury of a resident, of unknown source V - Investigation of alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .Vii. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes; a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. ASM (administrative staff member) # 1, the administrator, ASM #2, the director of nursing, and ASM #5, the director of clinical services, were made aware of the above concern on 8/4/2022 at 11:46 a.m. No further information was obtained 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 the facility staff failed to provide evidence that all required information was provided to the hospital staff for 2 out of 43 residents in the survey sample that were transferred to the hospital; Residents #27 and #26. The findings include: 1. For Resident #27, the facility staff failed to evidence provision of required resident information to a receiving facility at the time of transfer to the hospital on 7/24/22. Resident #27 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: chronic respiratory failure, cerebrovascular accident and diabetes mellitus. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/29/22, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, transfer, locomotion, dressing and hygiene; total dependence for bathing and supervision for eating. Section O-special procedures/treatments coded the resident as oxygen yes. A review of the comprehensive care plan dated 12/5/20 and revised 3/8/21, revealed, FOCUS: The resident is at risk for alteration in respiratory distress/shortness of breath related to COPD (chronic obstructive pulmonary disease) and sarcoidosis of the lungs. INTERVENTIONS: Observe for difficulty breathing (Dyspnea) on exertion. Remind resident not to push beyond endurance. Head of bed elevated while in bed. A review of the facilities eINTERACT (Interventions To Reduce Acute Care Transfers) Change in Condition Evaluation V 5.1, Neurological Status Evaluation: sudden change in level of consciousness. A review of the nursing progress note dated 7/24/22 at 9:10 AM, revealed, Resident in bed, extremely confused, did not eat, normal cognitive level alert and oriented x 3. Resident does not know who she is or where she is at, cannot talk normal, babbling, pupil dilated. Physician notified requesting to send to emergency room. A review of the nursing progress note dated 7/24/22 at 10:03 AM, revealed, Received nursing order to send to emergency room for evaluation and treatment per on-call NP (nurse practitioner) at 9:40 AM. 911 arrived at 9:50 AM, transported resident to hospital. A review of the nursing progress note dated 7/24/22 at 4:34 PM, revealed, Resident admitted to hospital on [DATE] with an admitting diagnosis of: COPD exacerbation and Aspiration PNA (pneumonia). There was no evidence that any clinical documentation was sent with Resident #27 when transferred to the hospital on 7/24/22. An interview was conducted on 8/3/22 at 8:50 AM with LPN (licensed practical nurse) #3. When asked what information is sent with a resident to the hospital, LPN #3 stated, the care plan, medication list, change of condition form, any labs or orders and advance directives. When asked who sends this information, LPN #3 stated, the nurse sends this information. An interview was conducted on 8/4/22 at 8:05 AM with ASM (administrative staff member) #1, the administrator. ASM #1 stated, When I came the proper documentation was not done, the staff that were in place were inefficient and there was not a lot of structure in place. We have worked to change that and to hire staff that will follow what is needed. On 8/4/22 at 9:46 AM, there was an email from ASM #1, the administrator, confirming there is no evidence of clinical documentation sent with Resident #27 to the hospital on 7/24/22. On 8/4/22 at approximately 12:20 PM, ASM (administrative staff member) #1, the administrator, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of clinical services were made aware of the findings. A review of the facilities Transfer and Discharge (Including AMA-against medical advice) policy dated 10/2021, revealed the following: Emergency Transfers/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). Obtain physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. Complete and send with the resident (or provide as soon as practicable) a Transfer Form which documents: Resident status, including baseline and current mental, behavioral and functional status and recent vital signs; Current diagnosis, allergies and for transfer/discharge; Contact information of the practitioner responsible for the care of the resident; Resident representative information including contact information; Current medications (including when last received), treatments, most recent relevant lab and/or radiological findings and recent immunizations; Special instructions or precautions for ongoing care to include precautions such as isolation or contact; Special risks such as risk for falls, elopement, bleeding or pressure injury and/or aspiration precautions; Comprehensive care plan goals, and Any other documentation, as applicable, to ensure a safe and effective transition of care. A copy of any Advance Directive, Durable Power of Attorney, DNR or Withholding or Withdrawing of Life-Sustaining Treatment forms should be sent with the resident. The original copies of the transfer form and Advance Directive accompany the resident. Copies are retained in the medical record. No further information was provided prior to exit. 2. The facility staff failed to evidence the documentation of documents sent to the hospital for Resident #26 (R26) upon transfer to the hospital on 6/12/2022. On the most recent MDS (minimum data set) assessment, with an ARD of 5/30/2022, the resident scored a 15 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. The nurse's note dated 6/12/2022 at 5:07 a.m. documented in part, Resident sent to the ER (emergency room) to be evaluated due to c/o (complaint of) SOB (shortness of breath) and anxiety. Received order to send resident out from NP (nurse practitioner). Spoke with resident's son, he also stated that he would like for his mother to be sent to the ER. Review of the E-Interact form dated 6/12/2022 failed to evidence the care plan goals were sent with the resident upon transfer on 6/12/2022. An interview was conducted with LPN (licensed practical nurse) #2 on 8/3/2022 at 1:21 p.m. When asked the process for sending a resident to the hospital, LPN #2 stated they send an envelope with the documentation that is listed on the front of the envelope. The envelope documents, Resident name, date of birth , unit. It further documents; Please include the following: face sheet, E-interact change in condition & transfer, resident dashboard printable view, order summary, baseline care plan, bed hold, nurse, date of transfer and comments. When asked what happens to the white paper on the front of the envelope, LPN #2 stated she takes it off and keeps it here in the facility and stated that the nurse should also write a note in the chart as to what was sent. Clarified with LPN #2 the meaning of the baseline care plan, LPN #2 stated the nurse should print the care plan that is in the computer. An interview was conducted with LPN #5 on 8/3/2022 at 3:58 p.m. When asked when a resident goes to the hospital, what documents are sent with the resident upon transfer, LPN #5 stated they send the copy of the care plan, medication list, the change in condition transfer form, bed hold policy that is put in an envelope. On the front of the envelope is a paper to check off what is put in the envelope. LPN #5 stated they had the envelope to the EMTs (emergency medical technicians). When asked if the nurse documents the documents that were sent, LPN #5 stated she writes a note in the chart, theoretically there should be a note containing what you sent. ASM (administrative staff member) # 1, the administrator, ASM #2, the director of nursing, and ASM #5, the director of clinical services, were made aware of the above concern on 8/4/2022 at 11:46 a.m. No further information was obtained 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 the facility staff failed to provide evidence that written RP (responsible party) and/or ombudsman notification was provided for 3 of 43 residents who were transferred to the hospital, Residents #27, #26 and #29. The findings include: 1. The facility staff failed to evidence provision of written RP notification was provided for Resident #27. Resident #27 was transferred to the hospital on 7/24/22. Resident #27 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: chronic respiratory failure, cerebrovascular accident and diabetes mellitus. A closed record review was conducted. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/29/22, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the facilities eINTERACT (Interventions To Reduce Acute Care Transfers) Change in Condition Evaluation V 5.1, Neurological Status Evaluation: sudden change in level of consciousness. A review of the nursing progress note dated 7/24/22 at 9:10 AM, revealed, Resident in bed, extremely confused, did not eat, normal cognitive level alert and oriented x 3. Resident does not know who she is or where she is at, cannot talk normal, babbling, pupil dilated. Physician notified requesting to send to emergency room. A review of the nursing progress note dated 7/24/22 at 10:03 AM, revealed, Received nursing order to send to emergency room for evaluation and treatment per on-call NP (nurse practitioner) at 9:40 AM. 911 arrived at 9:50 AM, transported resident to hospital. A review of the nursing progress note dated 7/24/22 at 4:34 PM, revealed, Resident admitted to hospital on [DATE] with an admitting diagnosis of: COPD exacerbation and Aspiration PNA (pneumonia). There was no evidence of any written RP notification when Resident #27 was transferred to the hospital on 7/24/22. An interview was conducted on 8/3/22 at 8:50 AM with LPN (licensed practical nurse) #3. When asked who contacts the RP and ombudsman when a resident to the hospital, LPN #3 stated, the nurses call the RP/family. I do not know who informs the ombudsman. When asked who sends the written RP notification, LPN #3 stated, Maybe social services, I do not know. On 8/4/22 at 9:46 AM, email from ASM #1, the administrator, confirming evidence of ombudsman notification and the only evidence of RP notification is phone call to RP documented on the facilities eINTERACT (Interventions To Reduce Acute Care Transfers) Change in Condition Evaluation V 5.1, dated 7/24/22. On 8/4/22 at approximately 12:20 PM, ASM (administrative staff member) #1, the administrator, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of clinical services were made aware of the findings. A review of the facilities Transfer and Discharge (Including AMA-against medical advice) policy dated 10/2021, revealed the following: Emergency Transfers/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). Obtain physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. Provide transfer notice as soon as practicable to resident and representative. Social Services Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list. No further information was provided prior to exit. 3. The facility staff failed to evidence written notification was provided to (R29) and/or (R29's) responsible party for a facility-initiated transfer on 05/23/2022. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 06/06/2022, the resident scored 15 out of 14 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. The facility's progress noted for (R29) dated 05/23/2022 documented in part, Note Text: Resident had small amount bloody drainage under wheelchair. Assisted resident to bed to assess where blood was coming from. Resident had large bloody bowel movement. Unit manager notified MD immediately. Vitals taken. Order to send 911 to hospital. 911 called . Review of the clinical record and the EHR (electronic health record) for (R29) failed to evidence written notification of discharge was provided to (R29) and (R29's) representative for the facility-initiated transfer on 05/23/2022. On 08/04/22 at approximately 10:48 a.m., an interview was conducted with ASM (administrative staff member) # 2, director of nursing. When asked if a written notification is sent to the resident and the resident's responsible party when a resident is transferred to the hospital ASM # 2 stated that nothing is given to the resident and or the responsible in writing. On 08/03/2022 at approximately 5:21 p.m., ASM # 1, administrator ASM # 2, director of nursing, and ASM # 5, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. 2. The facility staff failed to provide a written notification to the resident and/or the responsible party upon transfer to the hospital on 6/11/2022 for Resident #26 (R26). On the most recent MDS (minimum data set) assessment, with an ARD of 5/30/2022, the resident scored a 15 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. The nurse's note dated 6/12/2022 at 5:07 a.m. documented in part, Resident sent to the ER (emergency room) to be evaluated due to c/o (complaint of) SOB (shortness of breath) and anxiety. Received order to send resident out from NP (nurse practitioner). Spoke with resident's son, he also stated that he would like for his mother to be sent to the ER. Review of the E-Interact form dated 6/12/2022 failed to evidence the care plan goals were sent with the resident upon transfer on 6/12/2022. An interview was conducted with OSM (other staff member) #1, the director of social services, on 8/4/2022 at 10:08 a.m. When asked if she plays a role in sending a written notice to the resident and/or responsible party regarding what a resident has been transferred to the hospital, OSM #1 stated she did not. When asked who is responsible for this, OSM #1 stated she thought maybe admissions. An interview was conducted with OSM #5, the admissions staff member, on 8/4 2022 at 10:13 a.m. When asked if she played a role in providing a written notification to the resident and/or family what a resident is transferred to the hospital, OSM #5 stated she believed it was in the package that is sent with them, she doesn't do that. OSM #5 stated she believes the nursing staff does that. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 8/4/2022 at 10:48 a.m. When asked who is responsible for providing the resident and/or the responsible party with a written notice why the resident went to the hospital, ASM #2 stated, the nurse usually document why they went to the hospital. When asked about the written notification, ASM #2 stated they just send the package. Nothing is given to the resident and/or responsible party in writing, we just call them. ASM (administrative staff member) # 1, the administrator, ASM #2, and ASM #5, the director of clinical services, were made aware of the above concern on 8/4/2022 at 11:46 a.m. No further information was obtained 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 the facility staff failed to provide evidence that bed hold notification was provided to one out of 43 residents in the survey sample who was transferred to the hospital; Residents #27. The findings include: The facility staff failed to evidence provision of bed hold notification for Resident #27. Resident #27 was transferred to the hospital on 7/24/22. Resident #27 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: chronic respiratory failure, cerebrovascular accident and diabetes mellitus. A closed record review was conducted. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/29/22, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the facilities eINTERACT (Interventions To Reduce Acute Care Transfers) Change in Condition Evaluation V 5.1, Neurological Status Evaluation: sudden change in level of consciousness. A review of the nursing progress note dated 7/24/22 at 9:10 AM, revealed, Resident in bed, extremely confused, did not eat, normal cognitive level alert and oriented x 3. Resident does not know who she is or where she is at, cannot talk normal, babbling, pupil dilated. Physician notified requesting to send to emergency room. A review of the nursing progress note dated 7/24/22 at 10:03 AM, revealed, Received nursing order to send to emergency room for evaluation and treatment per on-call NP (nurse practitioner) at 9:40 AM. 911 arrived at 9:50 AM, transported resident to hospital. A review of the nursing progress note dated 7/24/22 at 4:34 PM, revealed, Resident admitted to hospital on [DATE] with an admitting diagnosis of: COPD exacerbation and Aspiration PNA (pneumonia). There was no evidence of any bed hold documentation when Resident #27 was transferred to the hospital on 7/24/22. An interview was conducted on 8/3/22 at 8:50 AM with LPN (licensed practical nurse) #3. When asked who provides the bed hold information, LPN #3 stated, nursing sends the bed hold with the resident. When asked if there is a copy of the bed hold provided, LPN #3 stated, we do not keep a copy of the bed hold. On 8/4/22 at 9:46 AM, email from ASM #1, the administrator, read, behold policy was sent with discharge packet but was not documented. On 8/4/22 at approximately 12:20 PM, ASM (administrative staff member) #1, the administrator, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of clinical services were made aware of the findings. A review of the facilities Transfer and Discharge (Including AMA-against medical advice) policy dated 10/2021, revealed the following: Emergency Transfers/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). Obtain physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer. 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 review and revise the comprehensive care plan for the use of oxygen for Resident #26 (R26). The findings include: On the most recent MDS (minimum data set) assessment, with an ARD of 5/30/2022, the resident scored a 15 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. The physician order dated, 6/2/2022, documented, Oxygen at 2 L (liters per minute) for nocturnal dyspnea. The comprehensive care plan, dated, 3/22/2022, failed to evidence any documentation related to the use of oxygen. Observation was made on 8/3/2022 at 8:04 a.m. of R26 resting on their bed. An oxygen concentrator was located across from the foot of the bed. The oxygen tubing was laying over the concentrator with the nasal prongs touching the floor. When asked if she uses the oxygen, R26 stated they have been having shortness of breath and used it last night. An interview was conducted with LPN (licensed practical nurse) #5 on 8/3/2022 at 3:58 p.m. When asked who updates the care plan, LPN #5 stated it could be a nurse, the unit manager or MDS. When asked if oxygen should be on the care plan, LPN #5 stated, it should be. When asked the purpose of the care plan, LPN #5 stated it's so we can treat the patient according to their plan of care. The facility policy, Oxygen Administration documented in part, The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a. The type of oxygen delivery system. b. When to administer, such as continuous or intermittent and/or when to discontinue. c. Equipment setting for the prescribed flow rates. d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. e. Monitoring for complications associated with the use of oxygen. ASM (administrative staff member) # 1, the administrator, ASM #2, the director of nursing, and ASM #5, the director of clinical services, were made aware of the above concern on 8/3/2022 at 5:28 p.m. No further information was obtained prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, facility documentation review and in the course of a complaint investigation, it was determined that the facility staff failed to develop, with the resident or the resident representative, a discharge plan for one of 43 residents in the survey sample, Resident #428. Resident #428's RP (responsible party), was not provided education on insulin administration or wound care. DME (durable medical equipment) was not at resident's home upon her discharge from the facility. The findings included: Resident #428 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: osteomyelitis, cardiomyopathy, atrial fibrillation, hypertension, diabetes mellitus and pneumonia. Resident #428 was discharged from the facility on 2/21/22. The most recent MDS (minimum data set) assessment, a 5 day Medicare assessment, with an ARD (assessment reference date) of 2/2/22, coded the resident as scoring a 03 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, transfer, dressing, bathing and hygiene; supervision for eating. Walking and locomotion did not occur. Section H-bowel and bladder status coded as always incontinent. A review of the comprehensive care plan dated 2/8/22, which revealed, FOCUS: The resident has Diabetes Mellitus with hyperglycemia, foot ulcer also with neuropathy. INTERVENTIONS: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Monitor/document/report as needed any signs/symptoms of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Monitor/document/report as needed any signs/symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath (smells fruity), stupor and coma. A review of the physician orders dated 1/6/22, revealed, Humalog KwikPen Solution Pen-injector 100 UNIT/milliliter (Insulin Lispro (1 Unit Dial)) Inject 8 unit subcutaneously before meals for diabetes. Order revised on 1/27/22, revealed, Humalog KwikPen Solution Pen-injector 100 UNIT/milliliter (Insulin Lispro (1 Unit Dial)) Inject 5 unit subcutaneously before meals for diabetes. A review of the physician orders dated 1/6/22, revealed, Insulin Glargine 100 UNIT/milliliter Solution pen injector-Inject 40 unit subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS. Order revised 1/27/22, revealed, Insulin Glargine 100 UNIT/milliliters Solution pen injector Inject 20 unit subcutaneously every evening shift related to TYPE 2 DIABETES MELLITUS. A review of the physician orders dated 2/7/22, revealed, Clean area to lower back with wound cleanser, pat dry, apply medihoney and calcium alginate, then dry dressing daily and as needed every day shift for wound care. A review of the nurse practitioner orders dated 2/14/22, revealed, Please evaluate and treat patient for the following services, home health, occupational therapy and physical therapy. A review of the physician orders dated 2/16/22, revealed, Cleanse open area to left medial foot with wound cleanser, apply collagen foam, add calcium alginate, cover with dry dressing, every day and as needed for soil age every day shift. Cleanse open area to lumbar back with wound cleanser, apply medihoney, cover with dry dressing, daily and as needed for soil age every day shift. A review of the nurse practitioner orders dated 2/17/22, revealed, Standard manual wheelchair with elevated leg rests; walker with wheels, folding, adjustable or fixed height and commode chair. A review of the discharge planning progress note dated 2/17/22 at 4:39 PM, revealed Summary of Stay Most Recent admission: [DATE] 4:30 PM Recapitulation of Stay:: Resident admitted to SNF (skilled nursing facility) for IV ABT (intravenous antibiotic), wound care, PT/OT/ST (physical therapy/occupational therapy/speech therapy), medication management. IV ABT was completed, she remains on PO ABT (oral antibiotic) for the infection. She has had follow up with both infectious and ankle foot specialist. Follow up appointments has been scheduled. Transitional Services and Referrals Home Health Agency. DME (durable medical equipment) Ordered: Wheelchair, Walker, Bedside Commode. Social Services Summary: Mental and psychosocial Status: is independent with making her wants and needs met. Resident is to return to her private residence with supports from her family and Home Care to help maintain her overall health. Cognitive Status: Resident has modified independence when making decisions regarding tasks of daily life. Communication Deficits: not applicable. Physical Functional Status: Bed Mobility self-performance is Limited Assistance. Transfer self-performance is Extensive Assistance. Locomotion on unit self-performance is Total Dependence. Locomotion off unit was not assessed. Walk in Corridor was not assessed. Resident is always continent of urine. Resident is always continent of bowel. Sensory and Physical Impairments (i.e. vision, hearing, etc.): not applicable. Dental Condition: good. Special treatments and procedures: not applicable. Skin Condition/Wound Care: Left lateral foot-Cleanse with normal saline, apply collagen sheet/calcium alginate, and cover with dry dressing, daily. Lower back- cleanse open area with normal saline, apply medihoney, calcium alginate, and cover with dry dressing, daily. Summary of Nursing Services: Resident admitted to SNF for IV ABT, wound care, PT/OT/ST, medication management. IV ABT was completed, she remains on PO ABT for the infection. She has had follow up with both infectious and ankle foot specialist. Follow up appointments has been scheduled. Medication Reconciliation: A medication reconciliation has been completed. The post-discharge medication list has been discussed with the resident's family. The post-discharge medication list has been provided to the resident's family. The following received the post-discharge medication list: The responsible party will be provided with medication list on 02/20/2022. Medication list was also discussed on 02/19/2022. Therapy Referrals: A referral was made for Physical Therapy (PT). A referral was made for Occupational Therapy (OT). A referral was made for Speech Therapy (ST). Summary of Service Provided by SNF: Pt received OT services to address BUE (bilateral upper extremity) strengthening, ADL retraining and adaptive equipment/DME use. PT focused on balance training, bed mobility, and transfers. ST interventions for cognition, short term memory and orientation. Final Disposition: Resident discharged to Home. Resident left facility via wheelchair. Resident was accompanied by family. Resident will have a caregiver after discharge: Husband. Resident has home health. Reason for discharge: Condition Improvement. Comments: IV ABT completed. A review of the discharge note by social services dated 2/18/22 at 10:51 AM, revealed, Resident is scheduled to discharge from the facility on Sunday February 20, 2022 around 10am. She will be picked up by her husband and will received home health supports. Nurse Practitioner provided medication orders and DME (wheelchair and or walker, and bedside commode) ordered. A review of the nursing progress note dated 2/21/22 at 11:30 AM, revealed, Resident was discharged home via stretcher with medical staff, all paperwork and scripts sent with here. Also discharge summary was signed by the resident; all belongs were taken with her. Residents' skin noted to have no new open areas, bruising or redness noted, she just had two open areas she had, one to her foot and the one to her lower back. RP called when transportation arrived to make aware she was on her way. An interview was conducted on 8/2/22 at 4:02 PM with OSM (other staff member) #1, the social services director. When asked when she had started in the facility, OSM #1 stated, it was on February 9, 2022. There was another social worker before her and they are no longer employed. When asked to describe the discharge planning process for Resident #428, OSM #1 stated, she was to be discharged home with home health in place. The RP was in the loop with things. I documented that he was provided transportation time. I do not recall that the husband was unable to support his wife with medications. I ordered the DME: wheelchair, walker and bedside commode and sent the referral for home health/OT/PT. When asked what home health process was, OSM #1 stated, they come out and do an evaluation of services needed. When asked if the resident has wounds what is the process, OSM #1 stated, some of the nurse practitioners leave the order open for home health to decide. There was no specifics on wound care for this resident in the home health orders. An interview was conducted on 8/3/22 at 8:40 AM with LPN (licensed practical nurse) #4, the wound care nurse. When asked when she started in the facility, LPN #4 stated, it was February 2022 and she not know this resident. When asked the process for transitioning a resident home with wound care, LPN #4 stated, if they are going with home health, home health would get the orders for the wound care. When asked if education would be provided to the RP, if the orders were as needed, LPN #4 stated, We would educate the RP in that situation and document it in the progress note or discharge plan. An interview was conducted on 8/3/22 at 8:50 AM with LPN #3. When asked if she remembered Resident #428, LPN #3 stated, there is no memory of her or discharge planning with this resident. When asked if she had a resident on insulin discharging home with the RP as primary caregiver, what steps would be taken for a safe discharge, LPN #3 stated, education on insulin administration would be provide to the RP. An interview was conducted on 8/3/22 at 9:20 AM with ASM (administrative staff member) #3, the nurse practitioner. When asked if she remembered resident #428, ASM #3 stated, Yes, she had osteomyelitis on foot that would not heal and was receiving intravenous antibiotics. When asked if she was aware of the RP's concern regarding a safe discharge, ASM #3 stated, No I did not hear that the husband had any issues. I had never spoken with her husband. The facility said she was ready to discharge she had run out of money or was requesting a discharge, I am not sure which. I give the order to the social worker. The resident was on oral antibiotics and did not need wound care orders, just skilled nursing and they would evaluate through the physician they have for wound care orders. An interview was conducted on 8/4/22 at 7:29 AM, with LPN #5, the unit manager. When asked how long she had been employed and if she knew Resident #248, LPN #5 stated, since February 2022 and I do not know this resident. When asked what education would be provided to a RP who would be a resident's caregiver upon discharge, LPN #5 stated, if it is medication distribution then we would do education. They could come in for a training and we would do a tutorial. When asked where this would be documented, LPN #5 stated, In the past I would just do a progress note, here we have a discharge summary we can document on. An interview was conducted on 8/4/22 at 7:40 AM with RN (registered nurse) #2. When asked if he remembered Resident #248, RN #2 stated, A little bit. Let me look up her chart. When asked if there was documentation regarding education being provided to Resident #248's RP, RN #2 stated, There is a multidisciplinary discharge summary on 2/17/22, section 5 is vague regarding medication. There is no additional detail, is not explicit on how to administer insulin. I do not see any note but have not looked at notes past the week of 2/16/22. An interview was conducted on 8/4/22 at 10:29 AM with the home health agency Resident #248 was referred to. Home health agency confirmed that Resident #248 was not provided home health services from them until 5/25/22 and that no DME was at the resident's home during the initial assessment on 2/21/22. On 8/4/22 at approximately 12:20 PM, ASM (administrative staff member) #1, the administrator, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of clinical services were made aware of the findings. A review of the facilities' Discharge Planning Process policy dated 11/1/20, revealed the following: It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. 'Discharge planning' is a process that generally begins on admission and involves identifying each resident's discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure a successful discharge. If discharge to community is a goal, an active discharge care plan will be implemented and will involve the interdisciplinary team, including the resident and/or resident representative. The plan shall be documented on the resident medical records and comprehensive care plan. An active individualized discharge care plan will address, at a minimum: a. Discharge destination, with assurances the destination meets the resident's health/safety needs and preferences. b. Identified needs, such as medical, nursing, equipment, educational, or psychosocial needs. c. Caregiver/support person availability and the resident's or caregiver's/support person's capacity and capability to perform required care. d. Resident's goals of care and treatment preferences. The evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis in the clinical record. Education needs, as identified in the discharge plan, will be provided to the resident and/or family member prior to discharge. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to implement interventions to keep a resident safe for one of 43 residents in the survey sample, Resident #34 (R34). R34's care plan called for anti-roll back system to be placed on R34's wheelchair. No anti roll devices were observed on multiple occasions during the survey while R34 was in the wheelchair. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/9/22, R34 was coded as being severely impaired for making daily decisions, having scored four out of 15 on the BIMS (brief interview for mental status). R34 was coded as requiring a wheelchair for moving around the room and the unit. On the following dates and times, R34 was observed sitting in a wheelchair: 8/2/22 at 12:47 p.m. and 1:59 p.m.; 8/3/22 at 8:00 a.m. At no time did R34's wheelchair have anti roll/tip devices on the back to prevent R34's wheelchair from rolling or tipping over backwards. A review of R34's care plan dated 10/11/20 and revised 10/17/21 revealed, in part: The resident is at risk for fall R/T (related to): poor balance, unsteady gait, confusion, unaware of safety needs .dementia .antiroll back system to w/c (wheelchair). On 8/4/22 at 8:08 a.m., OSM (other staff member) #3, an occupational therapist and the director of rehab, was interviewed. She stated she was familiar with R34. When asked if R34's wheelchair needed any specialized adaptations, she stated R34 had sustained multiple falls. She stated she had worked extensively with R34, and R34 had no ability to control their own impulses to stand and try to walk. She stated R34 was unsafe to walk independently. She stated R34 needed anti-tippers on the wheelchair to prevent the wheelchair from falling backwards if the resident tried to stand independently. OSM #3 observed R34 in the wheelchair. OSM #3 stated: No, she does not have anything on the wheelchair for extra safety. No anti-tippers. On 8/4/22 at 12:05 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director for clinical services, were informed of these concerns. On 8/4/22 at 1:42 p.m., ASM #1 stated the facility did not have a policy related to wheelchair safety/safety equipment. No further information was provided prior to exit. Complaint deficiency.

2. The facility staff failed to obtain consent for and assess for the use of bed rails for Resident #4 (R4). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/29/2022, 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. On 8/2/2022 at 2:10 p.m., an interview was conducted with R4 in their room. R4 was observed in bed lying on top of the made bed. Bilateral upper quarter bed rails were observed to be in the up position on the bed. R4 stated that they did not really use the rails but sometimes pulled up on them. When asked if staff had discussed the bed rails with them, R4 stated that they may have when they first came in but they did not remember because they had changed rooms. The comprehensive care plan for R4 failed to evidence documentation of bed rail use. The Admission/re-admission screening dated 4/22/2022 for R4 documented in part, .Side rails, Sides: Neither, Not indicated at this time . The Bed Rail Safety Review dated 4/22/2022 for R4 documented in part, .Have alternative to bed rails been attempted? Yes .Continue current alternative measures . The bed rail safety review failed to evidence an indication for bed rail use or consent obtained. On 8/3/2022 at 3:58 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that residents were assessed for the use of bed rails to make sure that the rail would not be a restraint. LPN #5 stated that they assessed the resident to see if they were able to lift the rail or remove it and whether they needed the rail for mobility or repositioning. LPN #5 stated that if the bed rail was appropriate there should be a consent from the resident or the responsible party. LPN #5 stated that the consent could be a verbal consent but there should be documentation of the consent in the progress notes. On 8/3/2022 at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional director of clinical services and LPN (licensed practical nurse) #4, the director of clinical education/wound care were made aware of the findings. No further information was provided prior to exit. 3. The facility staff failed to obtain consent for the use of bed rails for Resident #23 (R23). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/26/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. On 8/2/2022 at 1:16 p.m., an interview was conducted with R23 in their room. R23 was observed in bed. The left upper bed rail was observed to be up on the bed. R23 stated that they used the bed rail to hold onto for positioning. When asked if staff had discussed the bed rails with them, R23 stated that they were not sure if anyone had asked, but they used them. The comprehensive care plan for R23 failed to evidence documentation of bed rail use. The Admission/re-admission screening dated 4/20/2022 for R23 documented in part, .Side rails, Sides: Both, Indicated to promote independence with bed mobility . The document failed to evidence a consent for bed rail use obtained. The Bed Rail Safety Review dated 5/16/2022 for R23 documented in part, .Have alternative to bed rails been attempted? Yes .Continue current alternative measures . The bed rail safety review failed to evidence a consent obtained for bed rail use. The Bed Rail Safety Review dated 6/16/2022 for R23 documented in part, .Have alternative to bed rails been attempted? Yes .Implement new bed rail(s) as indicated to promote independence and safety (Obtain informed consent) . The bed rail safety review failed to evidence a consent obtained for bed rail use. On 8/3/2022 at 3:58 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that residents were assessed for the use of bed rails to make sure that the rail would not be a restraint. LPN #5 stated that they assessed the resident to see if they were able to lift the rail or remove it and whether they needed the rail for mobility or repositioning. LPN #5 stated that if the bed rail was appropriate there should be a consent from the resident or the responsible party. LPN #5 stated that the consent could be a verbal consent but there should be documentation of the consent in the progress notes. On 8/3/2022 at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional director of clinical services and LPN (licensed practical nurse) #4, the director of clinical education/wound care were made aware of the findings. No further information was provided prior to exit. Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for 3 of 43 residents in the survey sample, Residents #73, #4, and #23. The findings include: 1. The facility staff failed to assess Resident #73 (R73) for the necessity of bed rails, and failed to evidence education of the resident regarding risks and benefits of implementing bed rails. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/13/22, R73 was coded as being moderately impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). On the following dates and times, R73 was observed lying in bed with the top quarter side rails up on both sides of the bed: 8/2/22 at 12:35 p.m. and 3:00 p.m.; 8/3/22 at 8:02 a.m. and 10:37 a.m. A review of R73's clinical record, including facility assessments, failed to reveal a bed rail assessment or any evidence the resident/RP (responsible party) received education regarding the risks and benefits of utilizing bed rails. A review of R73's care plan dated 1/14/22 revealed, in part: The resident needs a safe environment with .rails for mobility. On 8/3/2022 at 3:58 p.m., LPN (licensed practical nurse) #5, a unit manager, was interviewed. LPN #5 stated that residents were assessed for the use of bed rails to make sure that the rail would not be a restraint. LPN #5 stated the facility staff assessed the resident to determine the resident's ability to lift the rail or to remove it. Additionally, the resident should be assessed to determine whether the bed rails are needed for mobility or repositioning. On 8/3/22 at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director for clinical services, were informed of these concerns. A review of the facility policy, Proper Use of Side Rails, revealed, in part: It is the policy of this facility to utilize a person-centered approach when determining the use of side rails .1. As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of side/bed rails meets those needs: a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms b. Size and weight c. Sleep habits d. Medication(s) e. Acute medical or surgical interventions f. Underlying medical conditions g. Existence of delirium h. Ability to toilet self safely i. Cognition j. Communication k. Mobility (in and out of bed) l. Risk of falling 3. If after an attempted alternative to side/bed rails has been made, and the alternatives do not meet the resident's needs, the facility shall: a. Evaluate the alternatives and document how these alternatives failed to meet the resident's assessed needs. If there is no appropriate alternative, document reason. b. Assess the resident for risks of entrapment, and other risks associated with the use of side/bed rails. The following are examples of potential risks: i. Accident hazards (i.e., falls, entrapment, injuries sustained from attempts to climb over, around, between, or through the rails) ii. Barrier from safely getting out of bed iii. Physical restraint (i.e., hinders from independently getting out of bed or performing routine activities) iv. Decline in function, such as muscle functioning/balance v. Skin integrity issues vi. Decline in other areas of daily living, such as using the bathroom, continence, eating, hydration, walking, and mobility vii. Negative psychosocial outcomes, such as altered self-esteem, feelings of isolation, or agitation/anxiety c. Obtain informed consent from the resident, or the resident representative for the use of bed rails, prior to installation/use .5. The use of side rails will be specified in the resident's plan of care. a. Side rails that are permanently installed on the bed frame shall not be used, even incidentally, without proper assessment, informed consent, and physician orders. b. Once side/bed rails are installed, the facility will ensure side rail/bed rail usage does not prohibit necessary treatments and resident care. Care and treatments will continue to be provided in accordance with professional standards of practice and resident choices. c. Parameters for use shall be clearly defined, such as half rails or at certain times. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to store medications in a safe manner on 1 of 2 nursing units, [NAME] Garden Unit. 1. RN #1 left medications on top of a medication cart, unsupervised, on the [NAME] Garden unit. 2. LPN #2 left the medication cart unlocked during medication administration, while it was unsupervised, on the [NAME] Garden unit. The findings include: 1. RN #1 left medications on top of a medication cart, unsupervised, on the [NAME] Garden unit. Resident #42 was admitted to the facility on [DATE]. On the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], the resident was coded as being cognitively intact in ability to make daily life decisions. Resident #19 was admitted to the facility on [DATE]. On the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], Resident #19 was coded as being severely cognitively impaired in ability to make daily life decisions. On 8/3/22 at 7:43 AM, while waiting for Medication Administration observations, LPN #1 (Licensed Practical Nurse) was preparing to begin medications and had to briefly leave her cart. While she was away from her cart, at 7:45 AM, RN #1 (Registered Nurse) came to the cart and left 2 medication cards of new medications that were delivered, under the computer on top of the medication cart. These medications were Lipitor (1) for Resident #42 and Crestor (2) for Resident #19. At 7:47 AM, LPN #1 returned to her cart, identified that medications were left on top of her cart unsupervised and took the medications and went to speak to RN #1 about leaving the medications on top of the cart unsupervised. On 8/3/22 at 8:48 AM, an interview was conducted with LPN #1. She stated that RN #1 was the night shift nurse and had left for the day. She stated that they should not have left the medications on top of her cart unsupervised when she was away from the cart, and that she addressed it with them immediately. She stated she was upset that they had done that. A review of the facility policy Medication Storage was conducted. This policy documented, A. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls C. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. On 8/3/22 at approximately 6:00 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #4, the Regional Director of Clinical Services, were made aware of the findings. No further information was provided by the end of the survey. (1) Lipitor is used to reduce cholesterol. Information obtained from https://medlineplus.gov/druginfo/meds/a600045.html (2) Crestor is used to reduce cholesterol. Information obtained from https://medlineplus.gov/druginfo/meds/a603033.html 2. LPN #2 left the medication cart unlocked during medication administration, while it was unsupervised, on the [NAME] Garden unit. Resident #38 was admitted to the facility on [DATE]. On the most recent MDS (Minimum Data Set), an admission assessment dated [DATE], the resident was coded as being severely cognitively impaired in ability to make daily life decisions. On 8/3/22 at 8:36 AM, LPN #2 was preparing medications for Resident #38. She had to leave the medication cart to attend to a resident in another room. At 8:37 AM, LPN #2 left the medication cart in front of Resident #38's room, with the cart facing to the inside of the doorway to the room. She left the cart unlocked when she stepped away from the cart to attend to the other resident in another room. Two staff members passed by the cart, and a staff member entered the room with the breakfast tray At 8:38 AM, LPN #2 returned to the cart. On 8/3/22 at 8:43 AM after preparing medications for Resident #38, LPN #2 entered the room to administer the medications. The resident's bed was the one furthest from the doorway (by the window) and the curtain was pulled around the bed. LPN #2 was behind the curtain to administer the medications, leaving the medication cart unlocked and out of line of sight while she was behind the pulled curtain. Other staff were in the room tending to the resident in the bed closest to the doorway and the cart, which was unlocked and unsupervised by LPN #2. At 8:45 AM, LPN #2 returned to the cart. On 8/3/22 at 8:45 AM an interview was conducted with LPN #2. She stated that when staff leave a medication cart, they should leave the cart locked and computer screen closed. When asked if she locked it every time she walked away from it, she stated that she thought she had, that she tried to. When told of the observations of the cart unlocked she stated, I need to push it (the lock) in more. A review of the facility policy Medication Storage was conducted. This policy documented, A. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls C. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. On 8/3/22 at approximately 6:00 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #4, the Regional Director of Clinical Services, were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to obtain laboratory tests per physician's order for one of 43 residents in the survey sample, Resident #276. The facility staff failed to obtain multiple lab tests per Resident #276's (R276) nephrologist's (kidney doctor) orders. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/12/21, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. R276's diagnoses included acute renal failure and cystic kidney disease. A review of R276's clinical record revealed a note from the nephrologist (kidney doctor) dated 4/6/21 that documented, Follow-up in 6 months. H&H (hemoglobin and hematocrit), protein creatinine ratio, renal panel, vitamin D25, PTH. The note documented future lab orders for: 10/01/2021: SPOT URINE CREATININE (1). 10/01/2021: VITAMIN D 25 LEVEL (2). 10/01/2021: HCT (HEMATOCRIT) (3). 10/01/2021: HBG (HEMOGLOBIN) (4). 10/01/2021: PTH INTACT (5). 10/01/2021: RENAL FUNCTION PANEL (6). 10/01/2021 SPOT PROTEIN URINE (7). Further review of R276's clinical record failed to reveal any lab results for October 2021 until after the resident's follow-up nephrology appointment on 10/5/21. On 8/4/22 at 8:06 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated that when lab orders are received from a consulting physician, the orders are placed into the facility computer system to make sure the labs get done then the requisitions are placed into the electronic lab system so someone from the laboratory will come in and obtain the labs. LPN #4 reviewed R276's lab orders. LPN #4 stated she would enter the lab orders into the facility computer system and electronic lab system and set the labs up to be done about a month before the scheduled follow-up appointment. On 8/4/22 at 11:58 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Laboratory Services and Reporting documented, 1. The facility must provide or obtain laboratory services to meet the needs of its residents. 2. The facility is responsible for the timeliness of the services. No further information was presented prior to exit. Complaint deficiency. References: (1) A spot creatinine test, Measures creatinine levels in blood and/or urine. Creatinine is a waste product made by your muscles as part of regular, everyday activity. Normally, your kidneys filter creatinine from your blood and send it out of the body in your urine. If there is a problem with your kidneys, creatinine can build up in the blood and less will be released in urine. This information was obtained from the website: https://medlineplus.gov/lab-tests/creatinine-test/ (2) A Vitamin D 25 level measures how much vitamin D is in your body. This information was obtained from the website: https://medlineplus.gov/ency/article/003569.htm (3) A hematocrit test is a blood test that measures how much of your blood is made up of red blood cells. Red blood cells carry oxygen from your lungs to the rest of your body. This information was obtained from the website: https://medlineplus.gov/lab-tests/hematocrit-test/ (4) A hemoglobin test measures the levels of hemoglobin in your blood. Hemoglobin is a protein in your red blood cells that carries oxygen from your lungs to the rest of your body. This information was obtained from the website: https://medlineplus.gov/lab-tests/hemoglobin-test/ (5) A PTH (parathyroid hormone) test, Measures the level of parathyroid hormone in the blood. PTH, also known as parathormone, is made by your parathyroid glands. These are four pea-sized glands in your neck. PTH controls the level of calcium in the blood. This information was obtained from the website: https://medlineplus.gov/lab-tests/parathyroid-hormone-pth-test/ (6) A renal function panel is a series of tests that measures the function of your kidneys. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3afile=viv_xncpDV&server=pvlb7srch13&v%3astate=root%7croot&url=https%3a%2f%2fmedlineplus.gov%2fkidneytests.html&rid=Ndoc0&v%3aframe=redirect&v%3aredirect-hash=93448cb06446aa2e60807d26615c5671& (7) A spot protein urine test measures the amount of protein in your urine. This information was obtained from the website: https://pubmed.ncbi.nlm.nih.gov/32058809/#:~:text=A%20spot%20urine%20P%2FC,%2Fmg)%20confirms%20nephrotic%20proteinuria.

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to obtain a diagnostic test per physician's request for one of 43 residents in the survey sample, Resident #276. The facility staff failed to obtain a renal ultrasound (1) per Resident #276's (R276) nephrologist's (kidney doctor) request. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/12/21, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. R276's diagnoses included acute renal failure and cystic kidney disease. A review of R276's clinical record revealed a note from the nephrologist (kidney doctor) dated 4/6/21 that documented, Follow-up in 6 months .Renal ultrasound prior to the next visit .Future Procedures: 4/12/20/21: RENAL ULTRASOUND . Further review of R276's clinical record failed to reveal any renal ultrasound results. On 8/4/22 at 8:06 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated that when diagnostic requests are received from a consulting physician, the nurses should place the request into the facility computer system as an order to make sure the test is done and call an outside company to come in and complete the test. On 8/4/22 at 11:58 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Diagnostic Testing Services documented, This facility will provide the appropriate diagnostic services (laboratory and radiology) required to maintain the overall health of its residents and in accordance with State and Federal guidelines. No further information was presented prior to exit. Complaint deficiency. Reference: (1) A renal ultrasound uses sound waves to make images of the kidneys, ureters, and bladder. This information was obtained from the website: https://kidshealth.org/en/parents/renal-ultrasound.html

Based on staff interview, facility document review, employee record review, and in the course of a complaint investigation, it was determined the facility staff failed to complete criminal background checks on 7 out of 25 employee records reviewed. The findings include: Twenty five employee records were reviewed. Seven of the twenty five employee records failed to evidence the completion of a criminal background check, OSM (other staff member) #14, central supply clerk; OSM #15, physical therapist; LPN (licensed practical nurse) #9; OSM #17, dietary aide; LPN #12; CNA (certified nursing assistant) #10; and OSM #6, the business office manager/human resources staff member. Two of the seven employees were still employed at the facility, LPN #9 and OSM #6. An interview was conducted with OSM #6 on 8/4/2022 at 7:58 a.m. When asked the process for a new hire, OSM #6 stated in the beginning after the new employee has their interview, we get their identification information, social security number, and vaccination card is submitted to us. Then we run the background check using their ID and social security number. When all information is back, we set them up for orientation. When asked why there are missing criminal background checks, OSM #6 stated she gave us all the documents she could find. OSM #6 stated, she couldn't run her own criminal background check. The previous human resources person had not completed it prior to her starting employment at the facility. The facility policy, Abuse, Neglect and Exploitation documented in part, The components of the facility abuse prohibition plan are discussed herein: 1. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation or misappropriation of resident property; 1. Background, reference and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers and consultants .3. The facility will maintain documentation of proof that the screening occurred. ASM (administrative staff member) # 1, the administrator, ASM #2, the director of nursing, and ASM #5, the director of clinical services, were made aware of the above concern on 8/4/2022 at 11:46 a.m. No further information was obtained prior to exit. Complaint deficiency.

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to implement their policies for the investigation of an allegation of abuse for one of 43 residents in the survey sample, Resident #26; and failed to implement their policies for the investigation of an injury of unknown origin for one of 43 residents in the survey sample, Resident #5 (R5); and failed to implement their policies for the completion of criminal background checks for 7 of 25 employee record reviews. The findings include: 1. The facility staff failed to implement their policies for the investigation of an allegation of abuse, at the time the allegation was made by the resident, for Resident #26 (R26). On the most recent MDS (minimum data set) assessment, with an ARD of 5/30/2022, the resident scored a 15 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. Diagnoses included but were not limited to: schizophrenia and dementia The Facility Reported Incident (FRI) dated, 11/4/2020, documented in part, Report date: 11/4/2020. Residents involved: (Name of R26). Incident Type: Allegation of abuse/mistreat. Describe incident: (R26) report that a big black man had come into her room and threw her on the bed and they all jumped on her .Resident was fully assessed by nursing staff and bruises were all properly documented. Responsible party and physician were notified. Findings on investigation will be reported back in 5 working days. The Facility Reported Incident (FRI) dated, 11/11/2020, documented in part, All staff on 3-11 and 11-7 were interviewed on whether they had witnessed or had knowledge of the incident in question. Statements were collected from all staff that did indicate that they had knowledge of the incident. A thorough head to toe assessment was completed on both residents, injuries and or bruises were all documented at that time. APS (adult protective services) worker (name of APS worker) and (name of detective) interviewed each resident and took pictures of all injuries/bruises .(R26) was unable to accurately recall detailed of the event as well as the names of the alleged employees involved. She stated that she is very confused and has difficulties remembering things. (Name of a male CNA) called top speak with HR (human resources) on 11/10/2020 and informed her that they were resigning effective immediately and that he never works with female residents and does not know who (R26) is. Statement from the 3-11 CNA (certified nursing assistant) indicated that (R26) was sitting at the nurse's station at the end of the shift free of any injuries and or bruises .The facility has unsubstantiated the allegation against the male CNA. MD (medical doctor) and RP (responsible party) were made aware of the outcome of the investigation. The nurse's note dated, 11/1/2020 at 7:37 a.m., documented in part, Note Text: @ (at) 0255 (2:55 a.m.) resident noted to have bleeding and bruising above right eyelid at nursing station. Resident noted to have 2 shallow lacerations above right eye lid. Injury unwitnessed. Resident very poor historian. Injury was not noted earlier in shift. Resident came from room. Resident's floor noted to have blood on it. Resident clothes scattered on floor. Attempt to clean lacerations and measure them. Resident refused. Walking away from nursing staff. Resident noted to be agitated. No change in behavior when normally agitated. Resident refused vital signs and neuro check to be taken. ADON (assistant director of nursing) notified of above. (Name of physician group) call at 0330 (3:30 a.m.) awaiting callback. 0520 (5:20 a.m.) Received callback from (Name of physician group) notified of the above. 0540 (5:40 a.m.) Received callback from (name of physician group) (name of NP - nurse practitioner) to send resident to ER (emergency room) via 911 for evaluation. 0540 (5:40 a.m.) 911 called. 0555 (5:55 a.m.) EMS (emergency medical services) arrived and assessed resident. Resident refused to go to ER. ADON notified. Called and left VM (voice mail) to notify (name of physician group) of above. The Skin Condition Observation Sheet, dated 11/5/2020, five days after the initial reported incident, documented the following: 2 x 1 (in centimeters) bruising/black purple noted on right eye; two lacerations in the eyebrow area, scattered bruising on right forearm; swollen right hand; 0.3 x 0.1 area on left chest; 2x1.5 bruising on left antecubital area; 1 x 1.5 area on left arm below the elbow; 0.5 x 0.5 area on left wrist; 1.2 x 2 area noted on right abdomen. None of the staff that were involved in this incident were employed at the facility at the time of survey. This included the administrator, director of nursing, the nurse that wrote the above note, the CNAs documented in the FRI and the ADON. An interview was conducted with LPN (licensed practical nurse) # 5, on 8/3/2022 at 10:42 a.m. When asked the process for when a resident makes a statement that they have been abused, LPN #5 stated you have to initiate an investigation immediately. An incident report must be made. LPN #5 stated a full body assessment must be completed, notify the MD and RP (responsible party). Interview the people that cared for the resident, if the roommate is alert and verbal, would interview them. LPN #5 stated that if the resident named a staff member then that staff member would be placed on suspension. When asked if you have to report an allegation of abuse to the director of nursing (DON) or the administrator, LPN #5 stated that a nurse should report it to the DON or administrator as soon as you are aware of it. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 8/4/2022 at 11:19 a.m. When asked what steps are to be taken when a resident stated they have been abused, ASM #1 stated everyone stops what they are doing. First make sure the resident is safe, no injuries, no harm. Report a FRI. We have two hours to report abuse, start an investigation depending on what it is, if staff is involved, suspend the staff member. Question the resident and roommate. ASM #1 stated she takes a census sheet and the staff assignment sheet and start interviews with everyone on that group assignment. ASM #1 stated she would interview the whole hall of residents. Make sure the doctor and family is aware. Complete the investigation, if the allegation is founded, then we notify the police. When asked when she should be notified of an allegation of abuse, ASM #1 stated as soon as it happens. The facility policy, Abuse, Neglect and Exploitation, documented in part, V. Investigation of Alleged Abuse, and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in the handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause and 6. Providing complete and thorough documentation of the investigation. ASM (administrative staff member) # 1, the administrator, ASM #2, the director of nursing, and ASM #5, the director of clinical services, were made aware of the above concern on 8/4/2022 at 11:46 a.m. No further information was obtained prior to exit. 2. The facility staff failed to implement their policies for the investigation of an injury of unknown origin for Resident #5 (R5). On the most recent MDS assessment, a quarterly assessment, with an ARD of 5/4/2022, the resident scored a 0 out of 15 on the BIMS score, indicating the resident is severely cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance to being totally dependent upon the staff for all of their activities of daily living. The Facility Reported Incident (FRI) dated, 11/4/2020, documented in part, Report date: 11/4/2020. Residents involved: (Name of R5). Incident Type: Allegation of abuse/mistreat; injury of unknown origin. Describe incident: (R5) injury of unknown origin. Resident unable to inform staff how bruise to her chest occurred .Resident was fully assessed by nursing staff and bruises were all properly documented. Responsible party and physician were notified. Findings on investigation will be reported back in 5 working days. The Facility Reported Incident (FRI) dated, 11/11/2020, documented in part, All staff on 3-11 and 11-7 were interviewed on whether they had witnessed or had knowledge of the incident in question. Statements were collected from all staff that did indicate that they had knowledge of the incident. A thorough head to toe assessment was completed on both residents, injuries and or bruises were all documented at that time. APS (adult protective services) worker (name of APS worker) and (name of detective) interviewed each resident and took pictures of all injuries/bruises .(R5). (R5) was unable to recall details of the event or how she got her bruises .(Name of a male CNA) called top speak with HR (human resources) on 11/10/2020 and informed her that they were resigning effective immediately and that he never works with female residents and does not know who (R26) is. Statement from the 3-11 CNA (certified nursing assistant) indicated that (R5) was sitting at the nurse's station at the end of the shift free of any injuries and or bruises .The facility has unsubstantiated the allegation against the male CNA. MD (medical doctor) and RP (responsible party) were made aware of the outcome of the investigation. The nurse's note dated, 11/1/2022 at 8:10 a.m. documented, Note Text: CNA giving care requested this nurse to assess resident, upon assessment noted bruised area to left clavicular area, purple in color, non-tender to touch, skin tear to right upper arm, approximately 1.5 in length, purple in color, cleansed with DWC (wound cleanser), pat dry, applied bacitracin, then covered with dry dressing. MD made aware/RP (name of RP) notified. Treatment initiated. Will continue to monitor status. There were no skin assessments for around the date above in the clinical record. There were no skin assessments documented in the FRI investigation folder. The only documentation, other than on the actual FRI of 11/4/2020, in the FRI investigation folder was related to the other resident documented on the FRI, not R5. An interview was conducted with LPN (licensed practical nurse) #5, on 8/3/2022 at 10:42 a.m. When asked the process for when a nurse finds an injury of unknown origin on a resident, LPN #5 stated you have to initiate an investigation as to where the injury came from. An incident report must be made. LPN #5 stated a full body assessment must be completed, notify the MD and RP (responsible party). Interview the people that cared for the resident, if the roommate is alert and verbal, would interview them. When asked if you have to report an injury of unknown origin to the director of nursing (DON) or the administrator, LPN #5 stated that a nurse should report it to the DON or administrator as soon as you are aware of it. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 8/4/2022 at 11:19 a.m. When asked what steps are to be taken when a resident stated they have been abused, ASM #1 stated everyone stops what they are doing. First make sure the resident is safe, no injuries, no harm. Report a FRI. We have two hours to report abuse, start an investigation depending on what it is, if staff is involved, suspend the staff member. Question the resident and roommate. ASM #1 stated she takes a census sheet and the staff assignment sheet and start interviews with everyone on that group assignment. ASM #1 stated she would interview the whole hall of residents. Make sure the doctor and family is aware. Complete the investigation, if allegation is founded, then we notify the police. When asked when she should be notified of an allegation of abuse, ASM #1 stated as soon as it happens. When asked if this procedure is the same for an injury of unknown origin such as a bruise, ASM #1 stated, yes, because that could have been caused by abuse. ASM #1 stated she could not locate any further documentation related to the bruises found on R5. The facility policy, Abuse, Neglect and Exploitation documented in part, IV - Identification of Abuse, Neglect and Exploitation: B. Possible indicators of abuse include; but are not limited to: 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body. 3. Physical injury of a resident, of unknown source V - Investigation of alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .Vii. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes; a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. ASM (administrative staff member) # 1, the administrator, ASM #2, the director of nursing, and ASM #5, the director of clinical services, were made aware of the above concern on 8/4/2022 at 11:46 a.m. No further information was obtained prior to exit. 3. The facility staff failed to implement their policies for the completion of criminal background checks for 7 of 25 employee record reviews. Twenty five employee records were reviewed. Seven of the twenty five employee records failed to evidence the completion of a criminal background check, OSM (other staff member) #14, central supply clerk; OSM #15, physical therapist; LPN (licensed practical nurse) #9; OSM #17, dietary aide; LPN #12; CNA (certified nursing assistant) #10; and OSM #6, the business office manager/human resources staff member. Two of the seven employees were still employed at the facility, LPN #9 and OSM #6. An interview was conducted with OSM #6 on 8/4/2022 at 7:58 a.m. When asked the process for a new hire, OSM #6 stated in the beginning after the new employee has their interview, we get their identification information, social security number, and vaccination card is submitted to us. Then we run the background check using their ID and social security number. When all information is back, we set them up for orientation. When asked why there are missing criminal background checks, OSM #6 stated she gave us all the documents she could find. OSM #6 stated, she couldn't run her own criminal background check. The previous human resources person had not completed it prior to her starting employment at the facility. The facility policy, Abuse, Neglect and Exploitation documented in part, The components of the facility abuse prohibition plan are discussed herein: 1. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation or misappropriation of resident property; 1. Background, reference and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers and consultants .3. The facility will maintain documentation of proof that the screening occurred. ASM (administrative staff member) # 1, the administrator, ASM #2, the director of nursing, and ASM #5, the director of clinical services, were made aware of the above concern on 8/4/2022 at 11:46 a.m. No further information was obtained prior to exit.

7. The facility staff failed to develop the comprehensive care plan for the use of bed rails for Resident #4 (R4). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/29/2022, 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. On 8/2/2022 at 2:10 p.m., an interview was conducted with R4 in their room. R4 was observed in bed lying on top of the made bed. Bilateral upper quarter bed rails were observed to be in the up position on the bed. R4 stated that they did not really use the rails but sometimes pulled up on them. When asked if staff had discussed the bed rails with them, R4 stated that they may have when they first came in but they did not remember because they had changed rooms. The comprehensive care plan for R4 failed to evidence documentation of bed rail use. The Admission/re-admission screening dated 4/22/2022 for R4 documented in part, .Side rails, Sides: Neither, Not indicated at this time . The Bed Rail Safety Review dated 4/22/2022 for R4 documented in part, .Have alternative to bed rails been attempted? Yes .Continue current alternative measures . On 8/3/2022 at 3:58 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that the care plan was updated by the nurse, the unit manager or the MDS staff. LPN #5 stated that the care plan purpose was for the staff to treat the patient according to the plan of care. LPN #5 stated that bed rails should be addressed on the care plan so the staff know that they were a part of their plan of care. On 8/3/2022 at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional director of clinical services and LPN (licensed practical nurse) #4, the director of clinical education/wound care were made aware of the findings. No further information was provided prior to exit. 8. The facility staff failed to develop the comprehensive care plan for the use of bed rails for Resident #23 (R23). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/26/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is cognitively intact for making daily decisions. On 8/2/2022 at 1:16 p.m., an interview was conducted with R23 in their room. R23 was observed in bed. The left upper bed rail was observed to be up on the bed. R23 stated that they used the bed rail to hold onto for positioning. When asked if staff had discussed the bed rails with them, R23 stated that they were not sure if anyone had asked, but they used them. The comprehensive care plan for R23 failed to evidence documentation of bed rail use. The Bed Rail Safety Review dated 6/16/2022 for R23 documented in part, .Have alternative to bed rails been attempted? Yes .Implement new bed rail(s) as indicated to promote independence and safety (Obtain informed consent). List bed rail(s) to be implemented: Quarter rail. List side(s): Both . On 8/3/2022 at 3:58 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that the care plan was updated by the nurse, the unit manager or the MDS staff. LPN #5 stated that the care plan purpose was for the staff to treat the patient according to the plan of care. LPN #5 stated that bed rails should be addressed on the care plan so the staff know that they were a part of their plan of care. On 8/3/2022 at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional director of clinical services and LPN (licensed practical nurse) #4, the director of clinical education/wound care were made aware of the findings. No further information was provided prior to exit. 9. The facility staff failed to develop a comprehensive care plan to include (1) the use of bed rails and (2) address activities of daily living for Resident #14 (R14). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/19/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section G documented R14 requiring extensive assistance of one person for dressing, bathing, personal hygiene and toileting. On 8/2/2022 at 3:45 p.m., an interview was conducted with R14 in their room. R14 was observed lying on top of their bed with bilateral upper bed rails up on the bed. R14 stated that they used the bed rails to grab on to when turning. R14 stated that the facility staff were very helpful and assisted them with bathing and personal hygiene. The comprehensive care plan for R14 failed to evidence documentation of bed rail use or address ADL requirements. The Bed Rail Safety Review dated 3/22/2021 for R14 documented in part, .Have alternative to bed rails been attempted? Yes .Implement new bed rail(s) as indicated to promote independence and safety (Obtain informed consent). List bed rail(s) to be implemented: Half rail. List side(s): Both . On 8/3/2022 at 3:58 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that the care plan was updated by the nurse, the unit manager or the MDS staff. LPN #5 stated that the care plan purpose was for the staff to treat the patient according to the plan of care. LPN #5 stated that all residents should have a care plan regarding their ADL's (activities of daily living). LPN #5 reviewed R14's care plan and stated that they did not see a care plan regarding the bed rails or the ADL's and that these areas should be addressed. On 8/3/2022 at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional director of clinical services and LPN (licensed practical nurse) #4, the director of clinical education/wound care were made aware of the findings. No further information was provided prior to exit. 4. The facility staff failed to follow Resident 73's (R73's) care plan for the administration of oxygen. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/13/22, R73 was coded as being moderately impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). R73 was coded as having received oxygen at the facility during the look back period. R73's diagnoses included COPD (chronic obstructive pulmonary disease) and COVID-19. On the following dates and times, R73 was observed lying in bed, with oxygen being delivered at 3 lpm (liters per minute) via nasal cannula per oxygen concentrator: 8/2/22 at 12:35 p.m. and 3:00 p.m.; 8/3/22 at 8:02 a.m. and 10:37 a.m. A review of R73's care plan dated 1/14/22 and revised on 7/14/22 revealed, in part: [R73] has orders for oxygen therapy - on 2L/NC (two liters per minute via nasal cannula). A review of R73's clinical record revealed no evidence of a provider's order for oxygen administration. On 8/3/22 at 10:21 a.m., LPN (licensed practical nurse) #2 was interviewed. When asked how a nurse knows at what rate to administer oxygen to a resident, she stated she checks the provider's order for the rate. When asked why oxygen administration requires a provider's order, she stated: Because it is a drug. On 8/3/22 at 1:54 p.m., LPN #5, a unit manager, was asked to verify the rate at which R73 should be receiving oxygen. She stated she needed to check the physician's orders. LPN #5 stated she did not see an order, and would need to check with R73's nurse. On 8/3/22 at 1:55 p.m., LPN #2, who was caring for R73 on that shift, was asked to verify the rate at which R73 should be receiving oxygen. LPN #2 checked R73's orders, and stated: I don't see any orders for oxygen. But I'm sure it's two liters [per minute]. LPN #2 re-checked the orders, but found none for the administration of oxygen for R73. LPN #2 checked R73's oxygen rate, and turned the rate on the concentrator from three lpms to two lpms. LPN #2 stated the purpose of a resident's care plan is to tell the staff how best to take care of a resident. She stated everyone is responsible for implementing each resident's care plan. She stated the facility staff had not been following R73's care plan for oxygen administration. On 8/3/22 at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director for clinical services, were informed of these concerns. No further information was provided prior to exit. 5. The facility failed to follow R6's care plan to evidence coordination of hospice services with the hospice provider. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/29/22, R6 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). R6 was coded as receiving hospice services during the look-back period. A review of R6's clinical record revealed the following provider's order dated 4/22/22: Admit to [name of hospice company]. A review of R6's care plan dated 5/17/22 revealed, in part: Resident admitted to hospice services .Encourage support system of family and friends .Work with [hospice] nursing staff to provide maximum comfort for the resident. Further review of R6's clinical record failed to reveal a care plan, progress notes, or any other documentation by R6's hospice services provider. On 8/3/22 at 1:54 p.m., LPN (licensed practical nurse) #5, a unit manager, was asked to provide notes and/or other evidence of coordination with R6's hospice provider. LPN #5 stated there was no such documentation. She stated this particular hospice company does not provide notes to the facility. She stated she would need to call the company and asked the company to send the notes by fax. She stated she was aware of the facility's requirement to coordinate care with R6's hospice provider, but stated the company did not comply with that requirement regarding paperwork. On 8/3/22 at 1:55 p.m., LPN (licensed practical nurse) #2 was interviewed. LPN #2 stated the purpose of a resident's care plan is to tell the staff how best to take care of a resident. She stated everyone is responsible for implementing each resident's care plan. On 8/3/22 at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director for clinical services, were informed of these concerns. No further information was provided prior to exit. 6. For Resident #34 (R34), the facility staff failed to follow the care plan for anti-tippers to be placed on R34's wheelchair. No anti-tippers were observed on multiple occasions during the survey while R34 was in the wheelchair. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/9/22, R34 was coded as being severely impaired for making daily decisions, having scored 4 out of 15 on the BIMS (brief interview for mental status). R34 was coded as requiring a wheelchair for moving around the room and the unit. On the following dates and times, R34 was observed sitting in a wheelchair: 8/2/22 at 12:47 p.m. and 1:59 p.m.; 8/3/22 at 8:00 a.m. At no time did R34's wheelchair have anti-tip devices on the back to prevent R34's wheelchair from tipping over backwards. A review of R34's care plan dated 10/11/20 and revised 10/17/21 revealed, in part: The resident is at risk for fall R/T (related to): poor balance, unsteady gait, confusion, unaware of safety needs .dementia .antiroll back system to w/c (wheelchair). On 8/3/22 at 1:55 p.m., LPN (licensed practical nurse) #2 was interviewed. LPN #2 stated the purpose of a resident's care plan is to tell the staff how best to take care of a resident. She stated everyone is responsible for implementing each resident's care plan. On 8/4/22 at 8:08 a.m., OSM (other staff member) #3, an occupational therapist and the director of rehab, was interviewed. She stated she was familiar with R34. When asked if R34's wheelchair needed any specialized adaptations, she stated R34 had sustained multiple falls. She stated she had worked extensively with R34, and R34 had no ability to control their own impulses to stand and try to walk. She stated R34 was unsafe to walk independently. She stated R34 needed anti-tippers on the wheelchair to prevent the wheelchair from falling backwards if the resident tried to stand independently. OSM #3 observed R34 in the wheelchair. OSM #3 stated: No, she does not have anything on the wheelchair for extra safety. No anti-tippers. She stated if R34's care plan contained anti-tippers on the wheelchair, then the care plan was not being followed. On 8/4/22 at 12:05 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director for clinical services, were informed of these concerns. 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 develop and/or implement the comprehensive care plan for 9 of 43 residents in the survey sample, Residents #276, #36, #38, #73, #6, #34, #4, #23 and #14. The findings include: 1. The facility staff failed to implement Resident #276's (R276) comprehensive care plan for wound care treatments per physician's orders. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/12/21, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. R276's comprehensive care plan dated 6/11/21 documented, (Name) has Venous Ulcer r/t (related to) PVD (peripheral vascular disease) to Left medial bunion. Administer treatment/medication as per MD (medical doctor) order. (Name) has Venous Ulcer r/t PVD to Right medial foot. Administer treatment/medication as per MD order. A review of R276's clinical record revealed a note signed by the wound care nurse practitioner on 1/26/22 that documented, Treatment Recommendations: #2 Venous ulcer Hallux left medial- Instructions: Clean with wound cleaner. collagen (1), silver alginate (1), dry dressing and Ace wrap QD (every day) and prn (as needed). #1 Venous ulcer Foot right medial- Freq (Frequency): Daily (QD) & prn. Instructions: Clean with dakins (wound cleansing solution). Santyl (1) (medihoney (1) until avail [available]), calcium alginate (1), skin prep to peri, dry dressing and wrap with Ace, QD/prn). A review of R276's January 2022 and February 2022 physician's orders and TARs (treatment administration records) revealed the following orders: 1/26/22-Clean (L) (left) bunion (venous ulcer hallux left medial) with wound cleaner, apply silver alginate/collagen, skin prep around the wound and cover with dry dressing, and wrap with ace wrapping up to below knees QD and PRN every night shift every other day for wound care. 1/27/22-Clean (R) (right) bunion (venous ulcer foot right medial) with Dakins, apply medihoney and calcium alginate to wound bed, skin prep around the wound and cover with dry dressing, and wrap with ace wrapping up to below knee QD and PRN every night shift every other day for venous ulcer every day. The treatment to the left bunion was only initialed as completed every other day on 1/26/22, 1/28/22, 1/30/22 and 2/1/22 (the other days were blocked off with an X). The treatment to the right bunion was only initialed as completed every other day on 1/27/22, 1/29/22 and 1/31/22 (the other days were blocked off with an X). R276 discharged from the facility on 2/2/22. On 8/4/22 at 8:06 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated the wound care doctors and nurse practitioners email their notes to the nurses and the nurses create orders that are based on the notes in the facility computer system. LPN #4 stated the orders carry over to the TARs and nurses complete treatments based on the TARs. LPN #4 stated there is a specific tab in the computer system to block off days on the TARs to instruct nurses to not complete treatments on those days. LPN #4 reviewed the above wound care nurse practitioner note and the above TARs. LPN #4 stated the nurse who entered the order into the computer system set the frequency for treatment as every other day and that is why every other day was blocked off on the TARs. LPN #4 stated that according to the wound care note and the orders, the treatments should have been completed every day but were not. On 8/4/22 at 9:32 a.m., another interview was conducted with LPN #4. LPN #4 stated the comprehensive care plan is the plan of care for the resident and interventions are documented so that all clinicians or anyone working with the resident knows what care the resident needs. LPN #4 stated care plans are implemented on admission and can be reviewed. On 8/4/22 at 11:58 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Care Planning-Resident and/or Resident Representative participation documented, 6. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. The policy failed to document specific information regarding care plan implementation. No further information was presented prior to exit. Complaint deficiency. Reference: (1) Collagen, silver alginate, Santyl, medihoney and calcium alginate are all products used to treat wounds. 2. The facility staff failed to develop a comprehensive care plan for treatment and care of (R36's) pressure ulcer. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/10/2022, the resident scored 0 (zero) out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired of cognition for making daily decisions. The physician's order for (R36) DATED 08/06/2022 documented in part, Sacral: Cleanse with wound cleanser, pat dry, apply hydrogel and foam dressing every other day, and prn. Review of the comprehensive care plan for (R36) dated 07/23/2022 failed to evidence documented for care and services for (R36's) sacral pressure ulcer. On 08/04/22 at approximately 11:24 a.m., an interview was conducted with LPN (licensed practical nurse) #5. When asked if there was a care plan that addressed (R36's) sacral pressure ulcer and the use of pressure reducing boots LPN #5 review (R36's) current comprehensive care plan and stated that there was no care plan for (R36's) pressure ulcer or the boots. When asked to describe the procedure for developing a care plan for (R36's) pressure ulcer LPN #5 stated that nursing or the MDS coordinator should have developed the care plan from the physician's orders. On 08/04/2022 at approximately 11:24 a.m., LPN #5 provided page 16 of (R36's) comprehensive care plan that documented, Focus: (R36) actual impairment of the skin integrity r/t left heel open area , open area to sacrum. Date Initiated: 07/23/2022. Revision on: 08/04/2022. On 08/0/2022 at approximately 11:40 a.m., ASM # 1, administrator ASM # 2, director of nursing, and ASM # 5, regional director of clinical services, were made aware of the above findings. No further information was presented prior to exit. 3. The facility staff failed to develop a comprehensive care plan for (R38's) use of oxygen. (R38) was admitted to the facility with diagnoses that included but were not limited to: lobar pneumonia (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 06/15/2022, the resident scored 6 (six) out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded (R38) for Oxygen Therapy while not a resident. On 08/02/22 at approximately 12:58 p.m., an observation of (R38) revealed they were sitting in their room in a wheelchair receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between two and two-and-a-half liters per minute. On 08/02/22 at approximately 2:58 p.m., an observation of (R38) revealed they were sitting in their room in a wheelchair receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between two and two-and-a-half liters per minute. On 008/03/22 approximately 8:14 a.m., an observation of (R38) revealed they were lying in their bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between two and two-and-a-half liters per minute. The physician's order for (R38) dated 07/26/2022 documented, O2 @ 2lpm (oxygen at two liters per minute) via (by) n/c (nasal cannula), prn (as needed) for sats (saturation). Review of the (R38's) comprehensive care plan dated 06/09/2022 failed to evidence care and services for oxygen administration. On 08/04/22 at approximately 8:03 a.m., an observation of (R38's) oxygen flow rate on the oxygen concentrator was conducted with LPN (licensed practical nurse) #5. When asked if there was a care plan for the use of oxygen for (R38) LPN # 5 review (R38's) current comprehensive care plan and stated that there was not care plan for (R38's) use of oxygen. When asked to describe the procedure for developing a care plan for (R38's) oxygen LPN #5 stated that nursing or the MDS coordinator should have developed the care plan from the physician's orders. On 08/04/2022 at approximately 8:20 a.m., LPN #5 provided page 14 of (R38's) comprehensive care plan that documented, Focus: The resident has oxygen therapy r/t (related to) Ineffective gas exchange. Date Initiated: 08/04/2022. Under interventions it documented, Monitor for s/sx (signs and symptoms) of respiratory distress and report to MD (medical doctor) PRN (as needed): Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. Date Initiated: 08/04/2022; OXYGEN SETTINGS: O2 via nasal cannula @ 2L as needed. Date Initiated: 08/04/2022. Revision on: 08/04/2022; Promote lung expansion and improve air exchange by positioning with proper body alignment. If tolerated, head of bed elevated to 30 degrees. Date Initiated: 08/04/2022. Revision on: 08/04/2022 On 08/0/2022 at approximately 11:40 a.m., ASM # 1, administrator ASM # 2, director of nursing, and ASM # 5, regional director of clinical services, were made aware of the above findings. No further information was presented prior to exit.

3. The facility staff failed to consistently assess and monitor Resident #8 (R8) after they tested positive for COVID-19 and during their COVID-19 isolation period. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/5/2022, the resident scored 7 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. The progress notes for R8 documented in part, 6/10/2022 19:15 (7:15 p.m.) Note Text: This writer spoke with the RP (responsible party), [name of responsible party] regarding res (resident) COVID test results were positive and that the res was being moved to the COVID unit at this time. The physician orders for R8 documented in part, - Isolation in private room related to Covid positive (+) diagnosis every shift, every shift for Covid positive diagnosis for 10 Days. Order Date: 06/10/2022. - Respiratory Interview: ask Do you have a cough? Do you have a sore throat? Do you have SOB (shortness of breath)? Are you experiencing aches/weakness? every shift for 14 Days Respiratory Interview: ask Do you have a cough? Do you have a sore throat? Do you have SOB? Are you experiencing aches/weakness? If yes, initiate a respiratory UDA (user defined assessment) (assessment completed in electronic medical record). Order Date: 06/11/2022. - VITAL SIGNS Q 6 (every six) HOURS four times a day for COVID + for 10 Days. Order Date: 06/14/2022. The eMAR (electronic medication administration record) for R8 documented in part, - Respiratory Interview: ask Do you have a cough? Do you have a sore throat? Do you have SOB? Are you experiencing aches/weakness? every shift for 14 Days Respiratory Interview: ask Do you have a cough? Do you have a sore throat? Do you have SOB? Are you experiencing aches/weakness? If yes, initiate a respiratory UDA. -Start Date- 06/11/2022 0700. The eMAR documented staff answering yes to the interview questions on 6/11/2022 night shift, 6/12/2022 day and evening shift, 6/13/2022 day and evening shift, 6/14/2022 night shift and 6/17/2022 evening and night shift. The clinical record for R8 documented a UDA respiratory assessment completed on 6/12/2022 at 1:58 a.m. The record failed to evidence UDA respiratory assessments completed on 6/11/2022 night shift, 6/12/2022 day and evening shift, 6/13/2022 day and evening shift, 6/14/2022 night shift and 6/17/2022 evening and night shift. On 8/03/2022 at 3:58 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that any resident who tested positive for COVID had vital signs completed twice a shift. LPN #5 stated that they also completed respiratory assessments during the quarantine period. LPN #5 stated that they did the respiratory assessments to make sure the resident did not have any symptoms and to treat any symptoms that came up. LPN #5 stated that the respiratory assessments were full assessments, were completed at least once a day and were documented in the electronic medical record. The facility policy Coronavirus Prevention and Response dated 7/18/2022 documented in part, Policy: This facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of the virus . According to The Centers for Disease Control Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, Nursing Homes & Long-Term Care Facilities, Updated Feb. 2, 2022 it documented in part, Manage Residents with Suspected or Confirmed SARS-CoV-2 Infection .Increase monitoring of residents with suspected or confirmed SARS-CoV-2 infection, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to identify and quickly manage serious infection. This information was obtained from the website: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_1631030962190 On 8/3/2022 at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional director of clinical services and LPN (licensed practical nurse) #4, the director of clinical education/wound care were made aware of the findings. No further information was provided prior to exit. 4. The facility staff failed to administer Donepezil to Resident #50 (R50) during the medication administration observation on 8/3/2022 that was available in the cubex medication system (automated medication dispensing system) in the facility. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 7/4/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. On 8/3/2022 at 8:26 a.m., an observation was made of LPN (licensed practical nurse) #7 administering medication to R50. LPN #7 prepared morning medication for R50 and stated that they did not have the scheduled 9:00 a.m. dose of Donepezil HCL 10 mg (milligram) to give to R50 because it was not on the cart. LPN #7 stated that the computer said that the medication was on order from the pharmacy. LPN #7 stated that they were going to call the pharmacy to check on the status of the medication after they finished the morning medications. The eMAR (electronic medication administration record) dated 8/1/2022-8/31/2022 for R50 documented in part, Donepezil HCl Tablet 10 MG, Give 1 tablet by mouth one time a day for dementia -Start Date- 06/28/2022 0900 (9:00 a.m.) The record for 8/3/2022 at 9:00 a.m. documented a 9 with the eMAR chart codes documenting .9=Other / See Nurse Notes . The eMAR failed to evidence administration of the 9:00 a.m. dose of Donepezil 10 mg on 8/3/2022. The progress notes for R50 documented in part, 8/3/2022 08:42 (8:42 a.m.) Donepezil HCl Tablet 10 MG, Give 1 tablet by mouth one time a day for dementia. Not available, will call pharmacy. The physician orders for R50 documented in part, Donepezil HCl Tablet 10 MG, Give 1 tablet by mouth one time a day for dementia. Order Date: 06/27/2022. On 8/03/2022 at 3:58 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that if a residents medication was not available they checked their cubex medication system to see if there was a stock of the medication they could pull. LPN #5 stated that if not, they would reach out to the pharmacy to see if the medication could be sent that day. LPN #5 stated that if the medication was not able to be sent by the pharmacy they would notify the physician to get an order to hold the medication until the medication arrived and notify the responsible party. LPN #5 stated that there should be documentation in the progress notes of notification of the pharmacy, physician and the responsible party. On 8/04/2022 at 7:52 a.m., an interview was conducted with LPN #4. LPN #4 stated that if a residents medication was not available staff were to contact the pharmacy to see if it was in route to them. LPN #4 stated that if the medication was due to be administered and not available they should notify the physician to get an order to hold the medication until it arrived and document the notification of the physician and the responsible party. LPN #4 stated that they also have a cubex medication system in house that stores some medications that staff could pull from if needed. LPN #4 stated that they were not sure if Donepezil was kept in the cubex system but staff could pull medication from it if needed. On 8/4/2022 at 1:45 p.m., ASM (administrative staff member) #1, the administrator, provided a listing of the medications that were available to staff in the cubex automated medication system which documented in part, .Item Description: Donepezil Tab (tablet) 5 mg . It documented 7 tablets on hand. On 8/4/2022 at 11:40 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit. 2. The facility failed to evidence coordination of hospice services with the hospice provider for Resident #6 (R6). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/29/22, R6 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). R6 was coded as receiving hospice services during the look-back period. A review of R6's clinical record revealed the following provider's order dated 4/22/22: Admit to [name of hospice company]. A review of R6's care plan dated 5/17/22 revealed, in part: Resident admitted to hospice services .Encourage support system of family and friends .Work with [hospice] nursing staff to provide maximum comfort for the resident. Further review of R6's clinical record failed to reveal a care plan, progress notes, or any other documentation by R6's hospice services provider. On 8/3/22 at 1:54 p.m., LPN (licensed practical nurse) #5, a unit manager, was asked to provide notes and/or other evidence of coordination with R6's hospice provider. LPN #5 stated there was no such documentation. She stated this particular hospice company does not provide notes to the facility. She stated she would need to call the company and asked the company to send the notes by fax. She stated she was aware of the facility's requirement to coordinate care with R6's hospice provider, but stated the company did not comply with that requirement regarding paperwork. On 8/3/22 at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director for clinical services, were informed of these concerns. A review of the facility policy, Hospice Services Facility Agreement, revealed, in part: It is the policy of this facility to provide and/or arrange for hospice services .A written agreement with the hospice sets out the following .a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day .ensure documentation from hospice that addresses .the most recent hospice plan of care specific to each resident .hospice election form .physician certification and recertification of the terminal illness specific to each resident. No further information was provided prior to exit. Based on observation, staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to provide services to maintain residents' highest level of well-being for 4 of 43 residents in the survey sample, Residents #276, #6, #8 and #50. The findings include: 1. The facility staff failed to provide Resident #276's (R276) wound care treatments every day per physician's orders from 1/26/22 through 2/2/22. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/12/21, the resident scored 13 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 R276's clinical record revealed a note signed by the wound care nurse practitioner on 1/26/22 that documented, Treatment Recommendations: #2 Venous ulcer Hallux left medial- Instructions: Clean with wound cleaner. collagen (1), silver alginate (1), dry dressing and Ace wrap QD (every day) and prn (as needed). #1 Venous ulcer Foot right medial- Freq (Frequency): Daily (QD) & prn. Instructions: Clean with dakins (wound cleansing solution). Santyl (1) (medihoney (1) until avail [available]), calcium alginate (1), skin prep to peri, dry dressing and wrap with Ace, QD/prn). A review of R276's January 2022 and February 2022 physician's orders and TARs (treatment administration records) revealed the following orders: 1/26/22-Clean (L) (left) bunion (venous ulcer hallux left medial) with wound cleaner, apply silver alginate/collagen, skin prep around the wound and cover with dry dressing, and wrap with ace wrapping up to below knees QD and PRN every night shift every other day for wound care. 1/27/22-Clean (R) (right) bunion (venous ulcer foot right medial) with Dakins, apply medihoney and calcium alginate to wound bed, skin prep around the wound and cover with dry dressing, and wrap with ace wrapping up to below knee QD and PRN every night shift every other day for venous ulcer every day. The treatment to the left bunion was only initialed as completed every other day on 1/26/22, 1/28/22, 1/30/22 and 2/1/22 (the other days were blocked off with an X). The treatment to the right bunion was only initialed as completed every other day on 1/27/22, 1/29/22 and 1/31/22 (the other days were blocked off with an X). R276 discharged from the facility on 2/2/22. R276's comprehensive care plan dated 6/11/21 documented, (Name) has Venous Ulcer r/t (related to) PVD (peripheral vascular disease) to Left medial bunion. Administer treatment/medication as per MD (medical doctor) order. (Name) has Venous Ulcer r/t PVD to Right medial foot. Administer treatment/medication as per MD order. On 8/4/22 at 8:06 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated the wound care doctors and nurse practitioners email their notes to the nurses and the nurses create orders that are based on the notes in the facility computer system. LPN #4 stated the orders carry over to the TARs and nurses complete treatments based on the TARs. LPN #4 stated there is a specific tab in the computer system to block off days on the TARs to instruct nurses to not complete treatments on those days. LPN #4 reviewed the above wound care nurse practitioner note and the above TARs. LPN #4 stated the nurse who entered the order into the computer system set the frequency for treatment as every other day and that is why every other day was blocked off on the TARs. LPN #4 stated that according to the wound care note and the orders, the treatments should have been completed every day but were not. On 8/4/22 at 11:58 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Wound Treatment Management documented, 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. No further information was presented prior to exit. Complaint deficiency. Reference: (1) Collagen, silver alginate, Santyl, medihoney and calcium alginate are all products used to treat wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to administer oxygen in a safe, sanitary manner for 4 of 43 residents in the survey sample, Residents #73, #69, #26, and #38. The findings include: 1. For Resident #73 (R73), the facility staff failed to obtain an order to administer oxygen, and failed to change the oxygen tubing in a timely manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], R73 was coded as being moderately impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). R73 was coded as having received oxygen at the facility during the look back period. R73's diagnoses included COPD (chronic obstructive pulmonary disease) and COVID-19. On the following dates and times, R73 was observed lying in bed, with oxygen being delivered at 3 lpm (liters per minute) via nasal cannula per oxygen concentrator: [DATE] at 12:35 p.m. and 3:00 p.m.; [DATE] at 8:02 a.m. and 10:37 a.m. At each observation, a sticker was located close to the concentrator. The sticker stated: CHANGE SUNDAY 7/31. A review of R73's clinical record revealed no evidence of a provider's order for oxygen administration. A review of R73's care plan dated [DATE] and revised on [DATE] revealed, in part: [R73] has orders for oxygen therapy - on 2L/NC (two liters per minute via nasal cannula). On [DATE] at 10:21 a.m., LPN (licensed practical nurse) #2 was interviewed. When asked how a nurse knows at what rate to administer oxygen to a resident, she stated she checks the provider's order for the rate. When asked why oxygen administration requires a provider's order, she stated: Because it is a drug. She stated oxygen tubing should be changed regularly, and stated she believed the tubing needed to be changed at least weekly, and more frequently if needed. She stated oxygen is being delivered into the lungs, and the tubing should be as clean as possible to prevent infection. On [DATE] at 1:54 p.m., LPN #5, a unit manager, was asked to verify the rate at which R73 should be receiving oxygen. She stated she needed to check the physician's orders. LPN #5 stated she did not see an order, and would need to check with R73's nurse. On [DATE] at 1:55 p.m., LPN #2, who was caring for R73 on that shift, was asked to verify the rate at which R73 should be receiving oxygen. LPN #2 checked R73's orders, and stated: I don't see any orders for oxygen. But I'm sure it's two liters [per minute]. LPN #2 re-checked the orders, but found none for the administration of oxygen for R73. LPN #2 checked R73's oxygen rate, and turned the rate on the concentrator from three lpms to two lpms. LPN #2 checked the sticker on R73's oxygen tubing. She stated: Well, this should have been changed on Sunday. I'll take care of it. She located new tubing, and replaced R73's expired tubing with the new tubing. On [DATE] at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director for clinical services, were informed of these concerns. A review of the facility policy, Oxygen Administration, revealed, in part: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences .Oxygen is administered under orders of a physician, except in the case of an emergency .Other infection control measures include: .Change oxygen tubing and mask/cannula weekly and as needed if it becomes contaminated. No further information was provided prior to exit. 3. Facility staff failed to maintain Resident #38's (R38's) oxygen flow rate at two liters per minute according to the physician's orders. (R38) was admitted to the facility with diagnoses that included but were not limited to: lobar pneumonia (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of [DATE], the resident scored 6 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded (R38) for Oxygen Therapy while not a resident. On [DATE] at approximately 12:58 p.m., an observation of (R38) revealed they were sitting in their room in a wheelchair receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between two and two-and-a-half liters per minute. On [DATE] at approximately 2:58 p.m., an observation of (R38) revealed they were sitting in their room in a wheelchair receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between two and two-and-a-half liters per minute. On [DATE] approximately 8:14 a.m., an observation of (R38) revealed they were lying in their bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between two and two-and-a-half liters per minute. The physician's order for (R38) dated [DATE] documented, O2 @ 2lpm (oxygen at two liters per minute) via (by) n/c (nasal cannula), prn (as needed) for sats (saturation). Review of the (R38's) comprehensive care plan dated [DATE] failed to evidence care and services for oxygen administration. On [DATE] at approximately 8:03 a.m., an observation of (R38's) oxygen flow rate on the oxygen concentrator was conducted with LPN (licensed practical nurse) #5. After reading the flow meter LPN #5 stated that it was two-and-a-half liters per minute. When asked what the flow rate should be LPN #5 stated that they needed to check the physician's orders. After looking up the physician's order in (R38's) EHR (electronic health record) LPN #5 stated that the flow rate was ordered for two liters per minute. When asked to describe how to read the oxygen flow rate on an oxygen concentrator and how often a resident's oxygen flow rate should be checked LPN #5 stated that the liter line should pass through the middle of the float ball inside the flow meter and the flow rate should be checked at the beginning of each shift and whenever the nurse goes into the room. When informed of the observations stated above LPN #5 stated that (R38's) oxygen flow rate was not being checked. On [DATE] at approximately 5:21 p.m., ASM #1, administrator ASM #2, director of nursing, and ASM #5, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. References: (1) Affects one or more sections (lobes) of the lungs. This information was obtained from the website: https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=85&contentid=P01321. 2. The facility staff failed to store a nebulizer mask in a sanitary manner for Resident #69 (R69). On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of [DATE], the resident scored a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately, cognitively impaired for making daily decision. Observation was made on [DATE] at approximately 12:00 p.m. of R69 in bed. A nebulizer mask was observed to be sitting on the night stand not within a bag or covered. A second observation was made on [DATE] at 3:41 p.m., the nebulizer mask was noted to be sitting on the night stand, uncovered. The physician order dated, [DATE], documented, Pratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML (milligram per milliliter)3 ml inhale orally via nebulizer two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE The medication was scheduled for 9:00 a.m. and 5:00 p.m. The review of the August MAR (medication administration record) documented the administration of the medication above for the month of August. The comprehensive care plan dated [DATE] documented in part, Focus: At risk for respiratory distress r/t (related to) COPD (Chronic obstructive pulmonary disease). The Interventions documented in part, Give medications as ordered. Observe/document any side effects and effectiveness. An interview was conducted with LPN (licensed practical nurse) #5, on [DATE] at 10:42 a.m. When asked how a nebulizer masks is to be stored when not in use, LPN #5 stated it should be stored in a plastic bag and labels with the resident's name and date. The facility policy, Nebulizer Therapy documented in part, g. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. ASM (administrative staff member) # 1, the administrator, ASM #2, the director of nursing, and ASM #5, the director of clinical services, were made aware of the above concern on [DATE] at 5:28 p.m. No further information was obtained prior to exit. 3. The facility staff failed to store oxygen tubing in a sanitary manner for Resident #26 (R26). On the most recent MDS (minimum data set) assessment, with an ARD of [DATE], the resident scored a 15 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. Observation was made on [DATE] at 8:04 a.m. of R26 resting on their bed. An oxygen concentrator was located across from the foot of the bed. The oxygen tubing was laying over the concentrator with the nasal prongs touching the floor. When asked if she uses the oxygen, R26 stated they have been having shortness of breath and used it last night. R26 stated the staff moved the concentrator to where it is at. The physician order dated, [DATE], documented, Oxygen at 2 L (liters per minute) for nocturnal dyspnea. The comprehensive care plan, dated, [DATE], failed to evidence any documentation related to the use of oxygen. An interview was conducted with LPN #5 on [DATE] at 10:42 a.m. When asked where oxygen tubing should be stored when not in use, LPN #5 stated, not on the floor, but should be contained in a bag that is labeled with a date. The facility policy, Oxygen Administration, documented in part, 7. Cleaning and care of equipment shall be in accordance with facility policies for such equipment. The policy failed to document the storage of the tubing when not in use. In Fundamentals of Nursing 7th edition, 2009: [NAME] A. [NAME] and [NAME]: Mosby, Inc; Page 648. Box 34-2 Sites for and Causes of Health Care-Associated Infections under Respiratory Tract -- Contaminated respiratory therapy equipment. ASM (administrative staff member) # 1, the administrator, ASM #2, the director of nursing, and ASM #5, the director of clinical services, were made aware of the above concern on [DATE] at 5:28 p.m. No further information was obtained prior to exit.

**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 maintain a clean deli slicer and store dishware in a clean and sanitary manner in one of one kitchen; and failed to label and date resident food stored in the refrigerator in one of two nourishment rooms in accordance with professional standards for food service safety. The findings include: 1. The facility failed to maintain a clean blade on the deli slicer that was available for use; and failed to fully dry dishware in the kitchen prior to stacking. On 8/2/2022 at 11:57 a.m., an observation was made of the kitchen in the facility with OSM (other staff member) #2, the dietary manager. Observation of the deli slicer on the counter top in the kitchen revealed it covered with a plastic bag. OSM #2 stated that it was available for use and removed the bag. Observation of the blade on the deli slicer revealed debris that could be scraped off of the edge. When asked about the blade, OSM #2 stated that the blade needed to be cleaned. OSM #2 stated that the deli slicer blade was washed after every use and dried prior to being put back on the slicer. OSM #2 stated that the blade should not have any debris on it. Observation of the kitchen revealed a stack of six small bowls. OSM #2 stated that the bowls were clean and available for use. Two of the bowls were observed to have visible debris stuck onto them and six of the bowls were observed to have visible water droplets on them. The bowls were observed to be stacked on top of each other with the water droplets between the bowls. OSM #2 stated that the bowls should be dried completely before they were stacked on top of each other. Beside the bowls were two stacks of small saucers. One stack of 18 saucers were observed to be visibly wet with water droplets on them. The second stack of 21 saucers was observed to be visibly wet with water droplets on them and two of the saucers were observed to have dried debris on them. OSM #2 stated that they should be dried before they were stacked on top of each other and the bowls and saucers with the debris needed to be washed again. The facility policy Food Safety Requirements dated 10/1/2021 documented in part, Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared and served in accordance with professional standards for food service safety .All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. a. Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment. b. Clean dishes shall be kept separate from dirty dishes. On 8/3/2022 at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional director of clinical services and LPN (licensed practical nurse) #4, the director of clinical education/wound care were made aware of the findings. No further information was provided prior to exit. 2. The facility staff failed to label and date resident food stored in the refrigerator in the nourishment room on the [NAME] Garden unit. On 8/3/2022 at approximately 12:30 p.m., an observation was made of the nourishment room on the [NAME] Garden unit. Observation of the refrigerator in the nourishment room revealed a canvas lunch box containing a peanut butter and jelly sandwich and prepackaged pickles. No name or date was observed on the lunchbox. A plastic shopping bag was observed with a half of a sandwich inside with no name or date on the bag. On 8/3/2022 at approximately 12:35 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that everything in the refrigerator belonged to residents on the unit. LPN #1 observed the lunchbox with the peanut butter and jelly sandwich and prepackaged pickles and stated that they did not know who it belonged to. LPN #1 observed the plastic shopping bag with a half of a sandwich inside and stated that there was no name or date on it but they knew which resident it belonged to. LPN #1 stated that the staff member who put the food in the refrigerator for the resident was responsible for dating and labeling the food with the residents name. LPN #1 stated that food was kept for three days and then thrown away. LPN #1 stated that they would try to find out who the lunchbox belonged to. On 8/03/2022 at 12:44 p.m., an interview was conducted with OSM (other staff member) #2, dietary manager. OSM #2 stated that dietary stocked the nourishment rooms with puddings, sandwiches, ice cream, juices, milk and filled the snack bins. OSM #2 stated that the nursing staff handled the resident food stored in the refrigerator. OSM #2 stated that any food should be labeled and have a date so they knew who it belonged to and when to discard it. The facility policy Use and storage of food brought in by family or visitors dated 10/1/2021 documented in part, Policy: It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident .2. All food items that are already prepared by the family or visitor [NAME] in must be labeled with content and dated . On 8/3/2022 at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional director of clinical services and LPN (licensed practical nurse) #4, the director of clinical education/wound care were made aware of the findings. No further information was provided prior to exit.

Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide education and offer the COVID-19 immunization for 4 of 5 residents reviewed during the immunization record reviews, Residents #3 (R3), #73 (R73), #18 (R18) and #42 (R42). The facility staff failed to provide Residents R3, R73, R18 and R42 (or their representatives) education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine, or offer the vaccine. The findings include: 1. For R3, on the most recent MDS (minimum data set), a five day Medicare assessment with an ARD (assessment reference date) of 4/29/22, R3 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. A review of the immunization tab in R3's clinical record revealed the resident had received one dose of the Pfizer COVID-19 vaccine on 4/19/22. Further review of R3's clinical record failed to reveal evidence that R3 was provided education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine or was offered the second dose of the vaccine. On 8/3/22 at 10:26 a.m., an interview was conducted with R3. R3 stated the resident received one dose of the COVID-19 vaccine at the hospital. R3 stated the resident had repeatedly asked facility staff for the second dose of the vaccine but had not received it. R3 stated this upset the resident because the resident contracted COVID-19 while at the facility. 2. For R73, on the most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 7/13/22, R73 scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. A review of the immunization tab in R73's clinical record failed to reveal documentation regarding the resident's COVID-19 immunization status. Further review of R73's clinical record failed to reveal evidence that R73 or the resident's representative was provided education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine or was offered the vaccine. 3. For R18, on the most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 5/20/22, R18 scored 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. A review of the immunization tab in R18's clinical record failed to reveal documentation regarding the resident's COVID-19 immunization status. Further review of R18's clinical record failed to reveal evidence that R18 or the resident's representative was provided education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine or was offered the vaccine. 4. For R42, on the most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 6/20/22, R42 scored 13 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 the immunization tab in R42's clinical record failed to reveal documentation regarding the resident's COVID-19 immunization status. Further review of R42's clinical record failed to reveal evidence that R42 was provided education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine or was offered the vaccine. On 8/3/22 at approximately 10:30 a.m., an interview was attempted with R42 but the resident was unavailable. On 8/3/22 at 1:49 p.m., an interview was conducted with LPN (licensed practical nurse) #4 (the infection control nurse). LPN #4 stated the admissions department is supposed to notify all department heads (including her), the unit managers and the admitting nurses of residents' COVID-19 vaccination status. LPN #4 stated the admitting floor nurses and any managers that follow up on the admission can ascertain a residents' COVID-19 vaccine status, provide education regarding the vaccine and offer the vaccine. LPN #4 stated the former infection control nurse was supposed to follow up to make sure this was being done and did not do so. On 8/3/22 at 5:39 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Coronavirus Prevention and Response documented, 11. Vaccination Planning a. All facility staff and residents will be encouraged to get vaccinated against SARS-CoV-2. The policy failed to document any further information regarding the process for education and offering the vaccine. No further information was presented prior to exit.

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain an operational call bell system for four of 43 residents in the survey sample, Residents #29 (R29), #46 (R46), #60 (R60), and #36 (R36), The findings include: 1. The facility staff failed to ensure (R29's) call bell was operational on 08/02/2022. (R29) was admitted to the facility with diagnoses that included but were not limited to: muscle weakness. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 06/06/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 08/02/22 at 1:11 p.m., an observation of (R29) revealed they were in their room sitting in a wheelchair. When asked to activate their call bell, (R29) pressed the call bell button and an observation revealed that the light in the hallway outside of (R29's) room did not light up. On 08/02/22 at 1:09 p.m., an interview was conducted with (R29) regarding their call bell. (R29) stated that their call bell was not working. When asked if they notified any of the facility staff about their call bell (R29) stated that they told a nurse, CNA (certified nursing assistant). On 08/02/22 at 3:00 p.m., an observation of (R29) revealed they were in their room sitting in a wheelchair. When asked to activate their call bell, (R29) pressed the call bell button and an observation revealed that the light in the hallway outside of (R29's) room did not light up. On 08 03/2022 at approximately 3:40 a.m., an interview was conducted with OSM (other staff member) #13, maintenance director. When asked about call bell inspections OSM #13 stated that they test all the resident's call bells monthly. When asked what the testing consisted of OSM #13 stated that they activate the resident's call bell in the their room, make sure the panel above the resident's bed lights up, the light in the hallway outside the resident's room is illuminated and that the call bell panel at the nurse's station also is illuminated. When informed of the above observation OSM #13 stated that they were not aware that the call bell was not working. On 08/03/2022 at approximately 5:21 p.m., ASM # 1, administrator ASM #2, director of nursing, and ASM #5, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. 2. The facility staff failed to ensure (R46's) call bell was operational on 08/02/2022 and on 08/03/2022. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/29/2022, 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. On 08/02/22 at 4:46 p.m., an observation of (R46) revealed they were in their room lying on their bed. When asked to activate their call bell, (R46) pressed the call bell button and an observation revealed that the light in the hallway outside of (R46's) room did not light up. On 08/03/22 at 8:17 a.m., an observation of (R46) revealed they were in their room lying on their bed. When asked to activate their call bell, (R46) pressed the call bell button and an observation revealed that the light in the hallway outside of (R46's) room did not light up. On 08/03/2022 at approximately 3:40 a.m., an interview was conducted with OSM (other staff member) #13, maintenance director. When asked about call bell inspections OSM #13 stated that they test all the resident's call bells monthly. When asked what the testing consisted of OSM #13 stated that they activate the resident's call bell in the their room, make sure the panel above the resident's bed lights up, the light in the hallway outside the resident's room is illuminated and that the call bell panel at the nurse's station also is illuminated. When informed of the above observation OSM #13 stated that they were not aware that the call bell was not working. On 08/03/2022 at approximately 5:21 p.m., ASM #1, administrator ASM #2, director of nursing, and ASM #5, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. 3. The facility staff failed to ensure (R60's) call bell was operational on 08/02/2022. (R60) was admitted to the facility with diagnoses that included but were not limited to: dementia (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/07/2022, the resident scored 3 (three) out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired of cognition for making daily decisions. On 08/02/22 at approximately 1:15 p.m., an observation of (R60) was observed lying in their bed. When asked to activate their call bell (R60) was confused and could not follow the request. The surveyor pressed (R60's) call bell next to the bed and observation of the call light in the hallway next to (60's) room failed to light up. Observation of (R60's) room failed to evidence a hand bell or any other device to notify staff. On 08/02/22 at approximately 3:10 p.m., (R60's) call bell was tested by the surveyor. The surveyor pressed (R60's) call bell next to the bed and observation of the call light in the hallway next to (60's) room failed to light up. Observation of (R60's) room failed to evidence a hand bell or any other device to notify staff. On 08/03/2022 at approximately 3:40 a.m., an interview was conducted with OSM (other staff member) # 13, maintenance director. When asked about call bell inspections OSM # 13 stated that they test all the resident's call bells monthly. When asked what the testing consisted of OSM # 13 stated that they activate the resident's call bell in the their room, make sure the panel above the resident's bed lights up, the light in the hallway outside the resident's room is illuminated and that the call bell panel at the nurse's station also is illuminated. When informed of the above observation OSM # 13 stated that they were not aware that the call bell was not working. On 08/03/2022 at approximately 5:21 p.m., ASM # 1, administrator ASM # 2, director of nursing, and ASM # 5, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. References: (1) 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. 4. The facility staff failed to ensure (R36's) call bell was operational on 08/02/2022 and on 08/03/2022. (R36) was admitted to the facility with diagnoses that included but were not limited to: dementia (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/10/2022, the resident scored 0 (zero) out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired of cognition for making daily decisions. On 08/02/22 at approximately 1:02 p.m., an observation of (R36) was observed lying in their bed. When asked to activate their call bell (R36) was confused and could not follow the request. The surveyor pressed (R60's) call bell next to the bed and observation of the call light in the hallway next to (36's) room failed to light up. Observation of (R36's) room failed to evidence a hand bell or any other device to notify staff. On 08/03/22 at approximately 9:00 a.m., (R36's) call bell was tested by the surveyor. The surveyor pressed (R36's) call bell next to the bed and observation of the call light in the hallway next to (36's) room failed to light up. Observation of (R36's) room failed to evidence a hand bell or any other device to notify staff. On 08/03/2022 at approximately 3:40 a.m., an interview was conducted with OSM (other staff member) #13, maintenance director. When asked about call bell inspections OSM #13 stated that they test all the resident's call bells monthly. When asked what the testing consisted of OSM #13 stated that they activate the resident's call bell in the their room, make sure the panel above the resident's bed lights up, the light in the hallway outside the resident's room is illuminated and that the call bell panel at the nurse's station also is illuminated. When informed of the above observation OSM #13 stated that they were not aware that the call bell was not working. On 08/03/2022 at approximately 5:21 p.m., ASM #1, administrator ASM #2, director of nursing, and ASM #5, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. References: (1) 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.

Based on staff interview, employee record review and facility documentation review, it was determined that the facility staff failed to ensure that 5 of 5 certified nursing assistants (CNAs) during annual performance reviews received dementia training (CNAs #2, #3, #4, #5 and #6). The findings include: On 08/04/2022 at approximately 8:45 a.m., a review of the annual competency trainings for CNA (certified nursing assistant) #2 with a hire date of 05/13/2005, CNA #3 with a hire date of 07/22/2020, CNA #4 with a hire date of 07/05/2017, CNA #5 with a hire date of 07/06/2016 and CNA #6 with a hire date of 11/20/1990 was conducted. The review failed to evidence dementia training for CNA # 2 from 05/13/2021 through 05/13/2022, , CNA #3 from 07/22/2021 through 07/22/2022, CNA #4 from 07/05/2021 through 07/05/2022, CNA# 5 from 07/06/2021 through 07/06/2022 and CNA #6 from 11/20/2020 through 11/20/2021. On 08/04/22 at approximately 9:19 a.m., an interview was conducted with ASM (administrative staff member) #2 , director of nursing and ADON regarding the annual competency training for the CNAs listed above. When asked who was responsible for tracking the CNA's annual competency training ASM #2 stated that it was the ADON. When informed that there was no evidence of dementia training for the CNAs listed above ASM #2 stated that when they were reviewing the competency trainings for the CNAs listed above they did not find evidence of dementia training. ADON stated that the dementia training is part of the CNA's annual competency training and also agreed that it was not evidenced for the CNAs listed above. The facility's policy Competency Evaluation documented in part, It is the policy of this facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents. On 08/04/2022 at approximately 11:40 a.m., ASM #1, administrator ASM #2, director of nursing, and ASM #5, regional director of clinical services, were made aware of the above findings. No further information was presented prior to exit.

Based on staff interview and facility document review, the facility staff failed to maintain a complete infection control surveillance program. The facility staff failed to maintain a complete surveillance system with enough data collection to properly track infections. The findings include: A review of the facility infection control surveillance program for January 2022 through June 2022 revealed the following: -Folders for January 2022 through April 2022 only contained a list of residents that were prescribed an antibiotic and information regarding the antibiotic prescription, lab tests results related to various infections for various residents and a color coded facility floor plan that tracked infections by categories of urinary infections, respiratory infections, gastrointestinal infections skin infections and other infections. -A folder for May 2022 only contained a log that tracked infection type, a list of residents that were prescribed an antibiotic and information regarding the antibiotic prescription. -No documentation for June 2022. On 8/3/22 at 4:14 p.m., an interview was conducted with LPN (licensed practical nurse) #4 (the infection control nurse who had been employed in that position for two weeks). LPN #4 stated each day she pulls a list of residents receiving antibiotics, including residents who are newly prescribed antibiotics. LPN #4 stated she also pulls any related lab test results related to the infection the antibiotic is prescribed for. LPN #4 stated she then tracks the types of infections based on the color coded floor plan. On 8/4/22 at 10:58 a.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated that every morning the team looks at residents who are newly prescribed antibiotics. ASM #2 stated the surveillance program should include a list of residents who have an infection, what infection the resident is diagnosed with, labs, diagnostics, whether the infection is hospital acquired or facility acquired, a facility tracking map and a formula to calculate the percentage of facility acquired infections. ASM #2 stated the purpose of infection surveillance is to see if there is a trend of infections so interventions can be implemented to prevent outbreaks. On 8/3/22 at 5:39 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. The facility policy titled, Infection Surveillance documented, A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. Definitions: 'Infection surveillance' refers to an ongoing systematic collection, analysis, interpretation, and dissemination of infection-related data .6. Monthly time periods will be used for capturing and reporting data. Line charts will be used to show data comparisons over time and will be monitored for trends. 10. Formulas used in calculating infection rates will remain constant for a minimum of one calendar year . No further information was presented prior to exit.

Based on staff interview and facility document review, the facility staff failed to conduct COVID-19 testing in a manner consistent with professional standards of practice. The facility staff failed to conduct complete COVID-19 testing during a facility outbreak that began on 6/10/22. The findings include: A review of facility documentation revealed the facility began COVID-19 outbreak status on 6/10/22 because a resident tested positive. A review of facility testing documentation revealed the following: On 6/10/22, all residents were tested and eight residents were positive for COVID-19. No staff were tested. On 6/13/22, only residents who were symptomatic or exposed were tested. Ten residents were positive. On 6/14/22, one staff member was tested and the results of the test were not documented. On 6/17/22, seven staff were tested and one was positive. On 6/20/22, eight staff were tested and all were negative. On 6/29/22, seven staff were tested and all were negative. On 7/1/22, one resident was symptomatic, tested and was positive. The resident's roommate was also tested and was negative. On 7/7/22, four staff were tested. Three were negative and one staff member's results were not documented. On 7/8/22 one staff was tested and was negative. On 7/10/22, five residents were symptomatic, tested and were positive. On 7/11/22, seven staff were tested and one was positive. On 7/18/22, four staff were tested and were negative. On 7/20/22, one resident was symptomatic, tested and was positive. One staff was tested and was negative. Two other residents were exposed, tested and were negative. On 7/24/22, one resident was symptomatic, tested and was positive. On 7/25/22, seven staff were tested. Six were negative and one staff member's results were not documented. On 8/3/22 at 1:49 p.m., an interview was conducted with LPN (licensed practical nurse) #4 (the infection control nurse who was employed in that positon for two weeks). LPN #4 stated she was informed to conduct COVID-19 testing once a week for staff who were not vaccinated or had not received a booster vaccine. LPN #4 stated that only residents who were symptomatic were being tested and no outbreak testing had been completed. On 8/3/22 at 2:18 p.m., an interview was conducted with ASM (administrative staff member) #1 (the administrator). ASM #1 stated that symptomatic residents and staff, anyone who had been at risk of being exposed, and staff who were exempted from the COVID-19 vaccine were being tested during the facility outbreak. On 8/3/22 at 3:23 p.m., an interview was conducted with ASM #2 (the director of nursing). ASM #2 stated the outbreak began on 6/10/22, when a resident was tested and was positive. ASM #2 stated the resident's family member was positive and had been all over the building so broad based testing was completed on 6/10/22. On 8/3/22 at 4:29 p.m., a telephone interview was conducted with OSM (other staff member) #9 (the local health department representative), in regards to COVID-19 outbreak testing. OSM #9 stated a facility can do either contact tracing or broad based testing but if a facility begins with broad based testing then they have to continue with broad based testing. OSM #9 stated that with broad based testing, all residents and staff should initially be tested at the beginning of the outbreak, then all staff and residents should be tested at least every seven days until there is a 14 day period with no new positive cases. OSM #9 stated the facility administrator had contacted her regarding positive cases but she requested additional information and did not receive a response. On 8/3/22 at 5:39 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. On 8/4/22 at 11:23 a.m., an interview was conducted with ASM #5 (the regional director of clinical services). ASM #5 stated that if a facility begins with broad based testing during an outbreak then all residents should initially be tested, then all residents who have not been positive in the last 90 days should be tested every five to seven days until there are no positive cases for two weeks. ASM #5 stated staff should be tested based on the community based cadence unless someone is symptomatic. ASM #5 stated the facility should also follow the local health department recommendations. The CDC (Centers for Disease Control) website documents the following: New Infection in Healthcare Personnel or Residents When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority .Alternative, broad-based approach: If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-level or group-level (e.g., unit, floor, or other specific area(s) of the facility). Broader approaches might also be required if the facility is directed to do so by the jurisdiction's public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission. Perform testing for all residents and HCP (health care personnel) on the affected unit(s), regardless of vaccination status, immediately (but generally not earlier than 24 hours after the exposure, if known) and, if negative, again 5-7 days later. This information was obtained from the website: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Fnursing-homes-facility-wide-testing.html#anchor_1631031062858 The facility policy titled, Coronavirus Prevention and Response documented, 5. When COVID-19 is suspected or confirmed the facility will: e. Implement procedures, including, but not limited to, contact testing and tracing, to identify and monitor others who may have been exposed if COVID-19 is confirmed .9.a. Any staff or resident with symptoms of COVID-19, regardless of vaccination status, should receive a viral test immediately. b. Asymptomatic HCP (health care personnel) with a higher-risk exposure and residents with close contact with someone with SARS-CoV-2 infection, regardless of vaccination status, should have a series of two viral tests. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 5-7 days after the exposure . No further information was presented 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 facility staff failed to provide written bed hold notification at the time of an acute transfer to the hospital for one of 37 residents in the survey sample, Resident #42. The findings included: Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to Type 2 diabetes mellitus, and hemiplegia (left side paralysis following stroke). Resident #42's most recent MDS (minimum data set) assessment was an admission assessment with an ARD (assessment reference date) of 9/19/19. Resident #42 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #42's clinical record revealed that she had been sent out to the hospital on 5/23/19. There was no evidence in the clinical record that written bed hold notification was sent with Resident #42 at the time of transfer. Further review of Resident #42's clinical record revealed that she returned to the facility on 5/28/19 and was admitted to the same room. On 11/21/19 at 1:11 p.m., an interview was conducted with OSM (Other Staff Member) #9, in admissions. When asked at the time of an acute care transfer, who was responsible for sending written bed hold notification with the resident, OSM #9 stated that the nurses were responsible for sending the notice. OSM #9 stated that she will follow up the next day with the resident and/or responsible party regarding the bed hold. OSM #9 stated a lot of the times she will visit the resident the following day at the hospital. OSM #9 stated that she could not find a copy of the signed bed hold notice for Resident #42 for her 5/23/19 transfer. On 11/21/19 at 1:30 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #1, the unit manager. When asked what documents nurses were supposed to send with the resident at the time of an acute care transfer to the hospital, LPN #1 stated that nurses were supposed to send the face sheet, list of medications/treatments, and the discharge summary. When asked if bed hold notification should be sent, LPN #1 stated that bed hold notification was usually attached to the discharge summary. When asked how to determine if the bed hold notice was sent if it was not attached to the discharge summary, LPN #1 stated that a nursing note should be documented reflecting the paperwork that was sent at the time of transfer. On 11/22/19 at 12:26 p.m., ASM #1, the Administrator, ASM #2, the ADON (Assistant Director of Nursing), ASM #3, the Corporate Nurse Consultant, and ASM #4, the [NAME] President of Operations were made aware of the above concerns. Facility policy titled, Bed hold Prior to Transfer, documents in part, the following: Prior to transferring a resident to the hospital, the facility will provide written information to the resident and/or the resident representative regarding bed hold. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #2 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Compression of Brain and Aphasia. Resident #2's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 07/05/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 12 indicating moderate cognitive impairment. In addition, the Minimum Data Set coded Resident #2 as requiring supervision with set up help only with bed mobility, transfer, dressing, eating and toilet use, supervision with 1 person assist with personal hygiene and physical help of 1 in part of bathing activity. On 11/22/2019 review of Resident #2's clinical record revealed that the last MDS completed was an admission assessment dated [DATE]. Review of Resident #2's Face Sheet revealed that he was discharged from the facility on 07/30/2019. An interview was conducted with the MDS Coordinator on 11/22/2019 at 2:00 p.m., and she stated, (Residents Name) was discharged and a Discharge Assessment was not completed until 10/03/2019. The MDS Coordinator provided a copy of the Discharge Assessment with a completion date of 10/03/2019. The MDS Coordinator explained that during this time period the facility did not have a MDS Coordinator and the corporate staff were coming in and assisting and the resident had been missed. The MDS Coordinator stated that she was new to the position and facility. The MDS Coordinator was asked, What is the process for completing the discharge assessment? MDS Coordinator stated, The facility must complete a discharge assessment within 14 days after the discharge date . It must be transmitted within 14 days after completing the MDS Discharge Assessment. The MDS Coordinator was asked to provide evidence that the Discharge Assessment was sent to CMS (Centers for Medicare and Medicaid Services). On 11/22/2019 at 2:40 p.m., the MDS Coordinator stated, I checked and the Discharge Assessment completed on 10/03/2019 was not submitted to CMS, I submitted it today. The MDS Coordinator provided the Surveyor a copy of the Final Validation Report with a submission date of 11/22/2019. The Administrator, Assistant Director of Nursing, [NAME] President of Operations and Corporate Nurse Consultant were informed of the findings at the exit meeting on 11/22/2019 at approximately 3:45 p.m. The facility did not present any further information about the findings. Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to transmit a discharge assessment within the required time frame for two of 37 residents in the survey sample, Residents #1 and #2. The findings included: 1. Resident #1 was admitted to the facility on [DATE] and discharged on 6/21/19 with diagnoses that included but were not limited to Hemiplegia (paralysis on left side). Resident #1's most recent MDS (Minimum Data Set) assessment was a discharge assessment with an ARD (assessment reference date) of 6/21/19. Resident #1 was coded as being severely impaired in cognitive function scoring 00 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #1's clinical record revealed that she was transferred to the hospital on 6/21/19 due to altered mental status. Resident #1 did not return to the facility. Further review of Section Z (assessment administration) of her discharge MDS assessment revealed that her discharge MDS was not completed until 11-7-19 (over 4 months after discharge). Review of Transmission Results Summary revealed that her MDS was not transmitted to CMS (Centers for Medicaid/Medicare) until 11/15/19. On 11/22/19 at 2:05 p.m., an interview was conducted with OSM (other staff member) #1, the MDS coordinator. When asked when a discharge assessment should be completed for a discharged resident, OSM #1 stated that a discharge assessment should be completed 14 days after the discharge date . When asked why Resident #1's discharge assessment was not completed until 11/7/19, OSM #1 stated that the facility did not have an MDS coordinator back in June and staff from corporate were coming in and helping out with MDS assessments. OSM #1 stated that her MDS was missed. When asked when the MDS should be transmitted to CMS, OSM #1 stated that the MDS should be transmitted 14 days after the assessment completion date. OSM #1 stated that since the MDS assessment was late than the transmit date was also be late. OSM #1 stated that she used the RAI (resident assessment instrument) manual as a reference when completing the MDS. On 11/22/19 at approximately 2:30 p.m., OSM #1 brought documentation from the RAI 3.0 MDS manual. The following was documented: P 2-17: Assessment Type/Item set: Discharge Assessment; MDS completion Date: No later than discharge date + (plus) 14 calendar days .Transmission date no later than MDS completion date + 14 calendar days. On 11/22/19 at 12:26 p.m., ASM #1, the Administrator, ASM #2, the ADON (Assistant Director of Nursing), ASM #3, the Corporate Nurse Consultant, and ASM #4, the [NAME] President of Operations were made aware of the above concerns. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility documentation review and clinical record review the facility staff failed to develop a complete comprehensive care plan to include Diabetes Mellitus and that the resident was a smoker, for 1 of 37 residents in the survey sample, Resident #5. The findings included: 1a. Resident #5 was admitted to the facility on [DATE]. Resident #5 was discharged from the facility on 07/26/2019 and readmitted to the facility on [DATE]. Diagnoses included but were not limited to, Diabetes Mellitus and Hypertension. Resident #5's Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 08/06/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. On 11/21/2019 review of Resident #5's clinical record revealed the following: The Face Sheet listed Type 2 Diabetes Mellitus without complications under Additional Current Diagnosis. Review of Resident #5's Physician Orders revealed an order for Lantus 100 Unit/ML (Milliliter) vial - Administer 5u (Units) SQ (Subcutaneous) Q (Every) HS (Hour of Sleep). DX (Diagnosis) - DM2 (Diabetes Mellitus Type 2). Order Date: 07/30/2019. Review of Resident #5's comprehensive care plan on 11/21/2019 did not reveal a care plan for Diabetes Mellitus. On 11/22/2019 at 3:30 p.m., an interview was conducted with the MDS Coordinator. When asked if the resident received insulin, MDS Coordinator stated, Yes. When asked if Resident #5 had a diagnosis of Diabetes, MDS Coordinator stated, Yes. When asked if Diabetes Mellitus was addressed in the residents care plan, MDS Coordinator stated, No. When asked if Diabetes Mellitus should be included in the residents care plan, MDS Coordinator stated, Yes. When asked what the purpose of the care plan was, MDS Coordinator stated, The care plan is a summary of what we are doing for the resident. The Administrator, Assistant Director of Nursing, Corporate Nurse Consultant and [NAME] President of Operations was informed of the findings at the pre-exit meeting on 11/22/2019 at 12:30 p.m. The facility did not present any further information about the findings. 1b. On 11/19/2019 at approximately 6:45 p.m., a list of residents in the facility that smoke was requested. During the initial tour of the facility on 11/19/2019 at approximately 7:15 p.m., Resident #5 was sitting in his wheel chair and he stated, I just came back inside, I've been outside smoking. On 11/20/2019 at approximately 9:00 a.m., a list of the residents in the facility who smoke was received along with the facility Smoking Policy and Smoking Schedule. Review of the list revealed Resident #5 was on the list. On 11/22/2019 review of Resident #5's comprehensive care plan revealed a problem that read as follows: Res. (Resident) continues to use code to exit building to smoke - Family provides code; Res. watches staff. The care plan did not include a goal or approaches for smoking. On 11/22/2019 at approximately 3:00 p.m., an interview was conducted with Resident #5. When asked if he kept cigarettes in his room, Resident #5 stated, No, the staff keep the cigarettes and lighter at the nurses desk. When asked if he went outside and smoked by himself, Resident #5 stated, No, they have set smoking times and the staff supervise. The Administrator, Assistant Director of Nursing, Corporate Nurse Consultant and [NAME] President of Operations were informed of the findings on 11/22/2019 at approximately 3:45 p.m. The facility did not present any further information about the findings. On 11/22/2019 at approximately 4:00 p.m., an interview was conducted with the MDS Coordinator. When asked if the resident smoked, MDS Coordinator stated, Yes. When asked where the resident gets his cigarettes from, MDS Coordinator stated, He gets cigarettes from his friends that visit and uses the code to exit the building to smoke. When asked if the resident's care plan problem addressing smoking was complete, MDS Coordinator stated, No, it needs interventions.

**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 facility staff failed to revise the care plan for one of 37 residents in the survey sample, Resident #4. The findings included: Resident #4 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Alzheimer's disease, Delusional disorders, lack of coordination. Resident #4's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 8/2/19. Resident #4 was coded as being severely impaired in cognitive function scoring 09 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #4's fall risk care plan dated 11/1/19 documented the following intervention: Wear clip alarms as ordered. On 11/19/19 through 11/20/19 several observations were made of Resident #4; she did not have a clip alarm in place. Review of Resident #4's November 2019 POS (physician order summary) revealed that she did not have a current order for a clip alarm. Further review of Resident #4's POS revealed an order for a clip alarm that was discontinued on 11/6/19. On 11/21/19 at 1:40 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #1, the unit manager. When asked who was responsible for revising the care plan, LPN #1 stated that any nurse could revise the care plan with any new changes in the resident's care and with new orders. When asked the purpose of the care plan, LPN #1 stated that the purpose of the care plan was to serve as a guide of care for each resident. LPN #1 confirmed that Resident #4's clip alarm was discontinued and should have been removed from the care plan. On 11/22/19 at 12:26 p.m., ASM #1, the Administrator, ASM #2, the ADON (Assistant Director of Nursing), ASM #3, the Corporate Nurse Consultant, and ASM #4, the [NAME] President of Operations were made aware of the above concerns. Facility policy titled, Care Plan- Comprehensive documents in part, the following: The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans .

**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 facility staff failed to obtain orders for the use of a catheter for one of 37 residents in the survey sample, Resident #83. The findings included: Resident #83 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to Hydronephrosis with renal and ureteral obstruction. Resident #83's most recent MDS (Minimum Data Set) assessment was an admission assessment with an ARD (assessment reference date) of 10/28/19. Resident #83 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #83 was coded in section H (Bowel and Bladder) as having an indwelling catheter. Review of Resident #83's elimination care plan dated 10/21/19 documented the following: Alteration in elimination Indwelling catheter and ileostomy related to: Dx (diagnosis) of Hydrourterinephrosis (1), wounds, rectal/colon cancer .change catheter and drainage bag as per order. Review of Resident #83's October 2019 POS (physician order summary) revealed the following orders for her urinary catheter: - 16 Fr (french) foley catheter. Dx: Hydrourterinephrosis - Change 16 french foley catheter PRN (as needed) - Change foley catheter bag the 1st and 15th of every month. - Foley catheter care Q (every) shift -Flush foley catheter PRN. All the above orders were discontinued on 11/11/19 when Resident #83 was sent to the hospital. Review of a nursing note dated 11/15/19 revealed that Resident #83 was admitted back to the facility with a foley catheter. The following in part, was documented: Foley cath intact and patient draining 50 ml (milliliters) amber colored urine no sediments or foul odor present . An order for the use of Resident #83's Foley catheter could not be found on her November 2019 POS. The only catheter order that was re-instated on the November 2019 POS was the following: Change foley catheter bag the 1st and 15th of every month. On 11/21/19 at 1:37 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #1, the unit manager. When asked what orders she would expect to see for a resident with a Foley catheter, LPN #1 stated that there should first be an order for the catheter documenting size, how often to change the bag, how often to replace the catheter (once a month), an irrigation order and orders for foley catheter care every shift. When asked who was responsible for providing catheter care every shift, LPN #1 stated that the nurses provide catheter care every shift. When asked if nurses would know to provide catheter care if there was not a current order for a urinary catheter or to provide care every shift; LPN #1 stated that catheter care was a nursing standard of practice and should be performed on every resident with a catheter. When asked how staff would know how often to change the catheter and provide flushes, LPN #1 stated that those instructions would have to be on the TAR (treatment administration record) and that orders would have to be in place in order for it to show up on the TAR. LPN #1 reviewed Resident #83's November 2019 orders and confirmed that not all of her catheter orders were reinstated when she arrived back to the facility on [DATE]. LPN #1 stated that she was going to re-activate all of Resident #83's catheter orders. On 11/21/19 at 1:53 p.m., an interview was conducted with Resident #83. Resident #83 stated that staff performed catheter care a few times a day along with Hospice staff. Resident #83 stated that she had no concerns related to her catheter. On 11/22/19 at 12:26 p.m., ASM #1, the Administrator, ASM #2, the ADON (Assistant Director of Nursing), ASM #3, the Corporate Nurse Consultant, and ASM #4, the [NAME] President of Operations were made aware of the above concerns. Facility policy titled, Catheter Care did not address the above concerns. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation review, the facility staff failed to ensure that 1 opened bottle of house stock calcium tablets 500 mcg (micrograms) with the expiration date of 09/2019 was discarded. The findings included: On [DATE] at approximately 10:15 AM, an inspection of the medication cart on the [NAME] unit was conducted with Licensed Practical Nurse (LPN) #1. An opened bottle of Calcium tablets was stored on a medication cart with an expiration of 09/19. LPN #1 was asked what should have been done with the expired bottle of medication; she stated, They should have discarded and replaced the medication. The Facility Policy titled, Storage of Medications Reads as follows: The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The above findings were shared with the Administrator, the Acting Director of Nursing and the Corporate Nurse Consultant during the pre-exit meeting conducted on [DATE] at 12:30 PM. No further information was presented by the facility staff.

Based on observation and staff interview the facility staff failed to ensure the garbage storage area was maintained in a sanitary condition. The findings included: On 11/21/19 at approximately 9:40 AM the garbage and refuse containers were observed with the Dietary Director. The ground area surrounding the two trash dumpsters were observed to have a small amount of scattered debris of glass fragments, cigarette butts, coffee filter grounds and two small trash bags located in front of the dumpsters on the ground. A cat was seen walking away from the dumpsters. The Dietary Director stated that the garbage disposal truck was here earlier and left debris on the ground. The Dietary Director was asked what should have been done concerning the debris left on the ground; she stated, We should keep the gate closed and check the dumpster after the garbage truck comes to pick up trash. The above findings was shared with the Administrator, the Acting Director of Nursing and the Corporate Nurse Consultant during the pre-exit meeting conducted on 11/22/19 at 12:30 PM. No further information was provided by facility staff.

**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 facility staff failed to ensure an accurate clinical record for one of 37 residents in the survey sample, Resident #19. The findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses that included but were not limited to type two diabetes mellitus. Resident #19's most recent MDS (Minimum Data Set) assessment was a quarterly assessment with an ARD (assessment reference date) of 8/21/19. Resident #19 was coded as moderately impaired in cognitive function scoring 13 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #19 was coded in section N (Medications) as receiving insulin injections. Review of Resident #19's November POS (physician order summary) revealed the following order for insulin: Novolog (1) 100 units/mL (milliliters) Flexpen AC/HS (before meals)/at bedtime) Novolog per sliding scale FBG (fasting blood sugar) less then 90 = 0U (units) 91-120 = 20U 121-130 = 30U 131-180 = 35U 181-220 = 40U 221- 300 = 50U 301 OR> (greater) = 60 Review of Resident #19's November 2019 MAR (Medication Administration Record) revealed that incorrect amount of insulin was documented as administered on 11/13/19, 11/14/19, 11/15/19, 11/18/19, 11/19/19, and 11/20/19. The following was documented: 11/13/19 11:30 AM Bld_Glu: 242; SubQ inj: RLQ (right lower quadrant) (abdomen); Units: 5. (50 was supposed to be given). 11/14/19 11:30 AM Bld_Glu: 237; SubQ inj: LLQ (left lower quadrant) (abdomen); Units: 5. (50 was supposed to be given). 11/15/19 11:30 AM Bld_Glu: 305; SubQ inj: LLQ; Units: 6. (60 was supposed to be given). 11/18/19 11:30 AM Bld_Glu: 369; SubQ inj: LLQ; Units: 6. (60 was supposed to be given). 11/19/19 11:30 AM Bld_Glu: 204; SubQ inj: LLQ; Units: 4. (40 was supposed to be given). 11/20/19 11:30 AM Bld_Glu: 329; SubQ inj: LLQ; Units: 6. (60 was supposed to be given). Further review of Resident #19's November MAR revealed that one nurse Licensed Practical Nurse (LPN) #2 was the nurse who documented all six administrations of the above insulin. On 11/21/19 at 3:22 p.m., an interview was conducted with LPN #2. When asked how to properly administer sliding scale insulin, LPN #2 stated that she would test the resident's blood sugar using the glucometer and then administer insulin per physician's order. When asked if the order should be followed, LPN #2 stated that it should. This writer showed LPN #2 Resident #19's MAR. LPN #2 stated that she left the zero off her number when documenting and charted so fast, she did not catch it. LPN #2 stated that the MAR should have said 60 instead of 6 and 40 instead of 4 etc. On 11/22/19 at 12:26 p.m., ASM #1, the Administrator, ASM #2, the ADON (Assistant Director of Nursing), ASM #3, the Corporate Nurse Consultant, and ASM #4, the [NAME] President of Operations were made aware of the above concerns. No further information was presented prior to exit. Facility policy titled, Documentation, documented in part, the following: Documentation in the medical record will be objective .complete, and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #57 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis for Resident #57 included but not limited to Alzheimer's disease and anxiety disorder. The current Minimum Data Set (MDS), an annual assessment with an Assessment Reference Date (ARD) of 08/03/19 coded the resident with a BIMS summary score of 99 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. C0600-Staff assessment for mental status was conducted because resident was unable to complete the interview coding the resident as having short-term and long-term memory problems. On 11/20/19 at approximately, 9:55 AM wound care observation was made. Initially, the wound care nurse sanitized the resident's bedside table, allowed it to dry, placed a drape on the table, added wound care items etc. After removing the soiled dressings from the Resident's sacrum with a cotton tip applicator and gloved hands. LPN #6 donned gloves without performing hand hygiene and proceeded with cleaning Resident #57's sacrum with clean gauze. After the completion of wound care Licensed Practical Nurse (LPN) #6 removed her scissors and marker from the drape placed on the resident's bedside table then placed the items (scissors and markers) on the uncovered table while discarding the soiled items and drape into the biohazard bag. She disinfected the marker and scissors after she had placed them on the bedside table. She performed hand hygiene and placed Resident #57's water pitcher on his bedside table without disinfecting the table. On 11/20/19 at approximately, 10:43 AM an interview was conducted with LPN #6 concerning the above issues observed during wound care. She stated, Yes, I would usually clean the table but was a little nervous. I started off cleaning my hands with the foam disinfectant but it got too sticky and creamy. LPN #6 stated For infection control measures I should have washed my hands and disinfected the table. The above findings was shared with the Administrator, the Acting Director of Nursing and the Corporate Nurse Consultant during the pre-exit meeting conducted on 11/22/19 at 12:30 PM. No further information was presented by facility staff. Based on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to maintain infection control practices during the dining room observation for two of 37 residents, Resident #46 and #73; and failed to practice infection control measures while performing wound care for one of 37 residents, Resident #57. The findings included: 1. Resident #46 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dysphagia (difficulty swallowing), and anomaly of jaw size. Resident #46's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 9/25/19. Resident #46 was coded as being severely impaired in cognitive function scoring 03 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #46 was coded in Section G (Functional Status) as requiring extensive assistance with one staff member with meals. 2. Resident #73 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dysphagia and left sided paralysis. Resident #73's most recent MDS assessment was a quarterly assessment with an ARD (assessment reference date) of 10/16/19. Resident #73 was coded as being severely impaired in cognitive function scoring 08 out of 15 on the BIMS. Resident #73 was coded in Section G (Functional Status) as requiring limited assistance with one staff member with meals. On 11/20/19 at 12:08 p.m., an observation was made in the restorative dining room. CNA (Certified Nursing Assistant) #2 was observed assisting Resident #46 with her meal. At 12:13 p.m., Resident #73 started coughing and CNA #2 stopped assisting Resident #46 and went over to assist Resident #73. CNA #2 then gave Resident #73 a sip of his drink, and starting to wipe food off the residents clothes with her bare hands. CNA #2 then moved his tray out of they way and wiped his mouth with his clothing protector. CNA #2 was then observed to put on one glove to the right hand and cleaned the rest of the food crumbs off the resident's shirt. CNA #2 then threw the glove away and proceeded to assist Resident #46 with her meal. CNA #2 did not wash or sanitize her hands prior to assisting Resident #46. On 11/22/19 at 1:00 p.m. a phone interview was attempted with CNA #2. She could not be reached. On 11/22/19 at 1:46 p.m., an interview was conducted with CNA #3, a CNA on [NAME] unit. When asked if she ever assists residents with meals, CNA #3 stated that she did. When asked how to maintain infection control practices while assisting with meals, CNA #3 stated that staff should wash or sanitize their hands prior to and after assisting a resident with their meal. When asked if hands should be washed or sanitized in-between assisting residents with meals; CNA #3 stated that hands should be washed to prevent the spread of germs. On 11/22/19 at 1:35 p.m., ASM (Administrative Staff Member) #1, the facility administrator was made aware of the above concerns. Facility policy titled, Assistance with Meals, did not address the above concerns. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to follow professional standards of practice and document the amount of insulin actually given for three of 37 residents in the survey sample, Resident #42, #19 and #53. The findings included: For Resident #42, #19 and #53, Licensed Practical Nurse (LPN) #3 was identified as the nurse who inaccurately documented insulin administration. On 11/21/19 at 5:22 p.m., an interview was conducted with LPN #3. When asked if she had ever experienced glitches when documenting in the eMAR (electronic medication record), LPN #3 stated that she was a new nurse to the facility and has only been working at the facility for approximately 2.5 weeks. LPN #3 stated that she was still adjusting to the new computer system. LPN #3 stated that she requested an additional nine more days of training due to the computer system. LPN #3 stated at first when documenting blood sugars; she was entering in the blood sugar amount/reading underneath the section for the amount of units of insulin administered. LPN #3 stated that she was re-educated by administration. LPN #3 stated that she had started employment on 10/29/19 and thought was evaluated on 11/4/19. LPN #3 stated that she had requested 9 more days of additional training on the computer system shortly after that. This writer showed LPN #3 the November MAR for Resident #42. LPN #3 stated that she has never administered the wrong amount of insulin and was always double checking the order with the amount if insulin prepared and administered. LPN # 3 stated she was always verifying the right dose. When asked if it was important that the MAR reflected the amount of insulin actually administered, LPN #3 stated that it was. LPN #3 stated that it sometimes gets hectic on the nursing floor and that sometimes she will forgot to sign off the medications after they were administered. LPN #3 stated that sometimes she will have to go back later and sign off that the medications were given. On 11/21/19 at 5:42 p.m., an interview was conducted with ASM (Administrative Staff Member) #2 , the ADON (Assistant Director of Nursing). When asked if LPN #3 had any recent medication errors with insulin, ASM #2 stated, Not that I am aware of. ASM #2 stated that LPN #3 was a brand new nurse to their facility and that she had recently got off orientation. When asked how the facility monitors for medication errors, ASM #2 stated that in morning meetings facility staff will go over new orders and make sure MARS/TARS match the orders but that they did not check all MARS and TARS for medication errors. ASM #2 stated that she thought there was a way to see if a medication was given too early, or the wrong dose administered. ASM #2 stated that she would find out what had happened. When asked if LPN #3 had requested additional training, ASM #2 stated that LPN #3 at first thought she could take on more; but then started to feel overwhelmed with the computer system that she requested additional training with documentation. ASM #2 stated that LPN #3 was evaluated by nursing staff for medication pass before she took on an assignment on her own. On 11/22/19 at 10:45 a.m., further interview was conducted with ASM #2. ASM #2 stated that she looked into the above dates of insulin administration, as well as interviewed LPN #3 and determined that LPN #3 was not signing off her medication right after administration. ASM #2 stated that by the time LPN #3 was ready to sign off on her medications, she had forgot how much insulin was administered to her residents and would just enter in any number to just get it signed off. ASM #2 stated that LPN #3 was even called at home on a few occasions to come back into the facility to sign off her medications that were showing up late. ASM #2 stated that on 11/21/19 LPN #3 was removed from the medication cart until this situation was investigated and she was in-serviced on documentation that you must sign off at that moment. ASM #2 stated that medications should be signed off immediately after administration. ASM #2 stated that she had also started education for the rest of her nurses on documentation after medication administration. Review of LPN #3's annual competency skill review, revealed that she was signed off on medication administration; including subcutaneous injections and the use of the glucometer on 11/5/19. A witness statement documented by LPN #3 dated 11-21-19 documented the following: I (Name of LPN #3) LPN new hire on October 29, 2019 currently on our state survey review. There was /are some discrepancies found on many patient's MAR record for incorrect data entry for insulin administration. Moreover, for the patients that incorrect documentation of insulin presented this writer provided and administered the correct dose of insulin per sliding scale as directed. However the patient's MAR was in fact signed off yet not confirmed by my signature as the nurse. On the other hand, due to not being familiar with this current computer format in the beginning of usage with data entry, failure to confirm all medications given provided with lock signature of this writer presented with many data entry errors of patients insulin administration. So late entry of data with confirmation of my signature presented as incorrect documentation. Lastly, I want to take full responsibility for my incorrect documentation and from this day forward it will be my duty to review, verify, and confirm all insulin/all medication data entry. Specific documentation errors are as follows: 1. Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to Type 2 diabetes mellitus. Resident #42's most recent MDS (minimum data set) assessment was an admission assessment with an ARD (assessment reference date) of 9/19/19. Resident #42 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #42 was coded in section N (Medications) as receiving insulin injections. Review of Resident #42's November POS (physician order summary) revealed the following order for insulin: Accucheck AC/HS (before meals)/at bedtime) W/ (with) humalog (1) 100 units/mL (milliliters) vial SSI (sliding scale insulin) BS (blood sugar) 0-60, notify provider (physician) BS 61-200 = 0 units BS 201-250 = 2 units BS 251-300 = 4 units BS 301-350 = 6 units BS 351- 400 = 8 units BS > (greater than) 401, give 10 units and notify provider. Review of Resident #42's November 2019 MAR (Medication Administration Record) revealed that incorrect amount of insulin was documented as administered on 11/2/19, 11/6/19, 11/15/19, 11/17/19, 11/18/19, and 11/20/19. The following was documented: 11/2/19 11:30 AM Bld_Glu (blood glucose): 334; SubQ (subcutaneous) inj (injection): LLQ (left lower quadrant) (abdomen); Units: 10. 11/6/19 11:30 AM Bld_Glu: 410; SubQ inj: LLQ; Units: 6. 11/15/19 4:30 PM Bld_Glu: 451; SubQ inj: RLQ (right lower quadrant) (abdomen); Units: 6. 11/17/19 11:30 AM Bld_Glu: 322; SubQ inj: RLQ; Units: 8. 11/18/19 8:30 PM Bld_Glu: 402; SubQ inj: LLQ; Units: 6. 11/20/19 4:30 PM Bld_Glu: 392; SubQ inj: LLQ; Units: 6. There was no evidence in Resident #42's clinical record of any adverse outcomes related to the incorrect amount of insulin administered. Further review of Resident #42's November 2019 MAR revealed that one nurse (LPN (Licensed Practical Nurse) #3), was responsible for documenting the incorrect dose of insulin administered on all six occasions. On 11/21/19 at 3:40 p.m., an observation was conducted of LPN #3 obtaining blood sugars and administering insulin on five residents. There were no concerns related to the above findings. Review of the medication administration reports to Resident #42's November MAR revealed that on multiple occasions, there was no evidence of when LPN #3 had administered insulin to Resident #42. Further review of these reports revealed late administration times of the above insulin. On 11/22/19 at 12:26 p.m., ASM #1, the Administrator, ASM #2, the ADON (Assistant Director of Nursing), ASM #3, the Corporate Nurse Consultant, and ASM #4, the [NAME] President of Operations were made aware of the above concerns. ASM #2 at approximately 1 p.m., presented evidence that LPN #3 was re-educated on the Administering Medications policy on 11/21/19. Facility policy titled, Administering Medications documents in part, the following: The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. No further information was presented prior to exit. 2. Resident #19 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Type two diabetes mellitus. Resident #19's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 8/21/19. Resident #19 was coded as moderately impaired in cognitive function scoring 13 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #19 was coded in section N (Medications) as receiving insulin injections. Review of Resident #19's November POS (physician order summary) revealed the following order for insulin: Novolog 100 units/mL (milliliters) Flexpen AC/HS (before meals)/at bedtime) Novolog per sliding scale FBG (fasting blood sugar) less then 90 = 0U (units) 91-120 = 20U 121-130 = 30U 131-180 = 35U 181-220 = 40U 221- 300 = 50U 301 OR> (greater) = 60 Review of Resident #19's November 2019 MAR (Medication Administration Record) revealed that incorrect amount of insulin was documented as administered on 11/1/19 at 430 p.m. and 8:30 p.m., and 11/2/19 at 11:30 a.m The following was documented: 11/1/19 4:30 PM Bld_Glu (blood glucose): 181; SubQ (subcutaneous) inj (injection): LLQ (left lower quadrant) (abdomen); Units: 165. 11/1/19 8:30 PM Bld_Glu: 165; SubQ inj: LLQ; Units: 181. 11/2/19 11:30 AM Bld_Glu: 352; SubQ inj: LLQ; Units: 35. There was no evidence in Resident #19's clinical record of any adverse outcomes related to the incorrect amount of insulin administered. Further review of Resident #19's November 2019 MAR revealed that one nurse (LPN (Licensed Practical Nurse) #3), was responsible for documenting the incorrect dose of insulin administered on all three occasions. On 11/21/19 at 3:40 p.m., an observation was conducted of LPN #3 obtaining blood sugars and administering insulin on five residents. There were no concerns related to the above findings. Review of the medication administration reports to Resident #19's November MAR revealed that on multiple occasions, there was no evidence of when LPN #3 had administered insulin to Resident #19. On 11/22/19 at 12:26 p.m., ASM #1, the Administrator, ASM #2, the ADON (Assistant Director of Nursing), ASM #3, the Corporate Nurse Consultant, and ASM #4, the [NAME] President of Operations were made aware of the above concerns. ASM #2 at approximately 1 p.m., presented evidence that LPN #3 was re-educated on the Administering Medications policy on 11/21/19. No further information was presented prior to exit. 3. Resident #53 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Type 2 diabetes mellitus. Resident #53's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 9/29/19. Resident #53 was coded as being severely impaired in cognitive function scoring 07 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #53 was coded in section N (Medications) as receiving insulin injections. Review of Resident #53's November POS (physician order summary) revealed the following order for insulin: Novolog 100 units/mL (milliliters) Flexpen Accuchecks before meals with SSI (sliding scale insulin): 200-249 = 1U (unit) 250- 299 = 2U 300- 349 = 3U 350- 399 = 4U 400-449 = 5U 450-499 = 6U 500-549 = 7U Dx (diagnosis) DM2 (Diabetes Mellitus type 2). Review of Resident #53's November 2019 MAR (Medication Administration Record) revealed that incorrect amount of insulin was documented as administered on 11/3/19 at 11:30 a.m., 11/8/19 at 11:30 a.m. and 11/19/19 at 4:30 p.m. and 8:30 p.m. The following was documented: 11/3/19 11:30 AM Bld_Glu (blood glucose): 411; SubQ (subcutaneous) inj (injection): LLQ (left lower quadrant) (abdomen); Units: 2. 11/8/19 11:30 AM Bld_Glu: 281; SubQ inj: LLQ; Units: 6. 11/19/19 4:30 PM Bld_Glu: 402; SubQ inj: LLQ; Units: 6. 11/19/19 8:30 PM Bld_Glu: 427; SubQ inj: LLQ; Units: 1. Further review of Resident #53's November 2019 MAR revealed that one nurse (LPN (Licensed Practical Nurse) #3), was responsible for documenting the incorrect dose of insulin administered on all four occasions. On 11/21/19 at 3:40 p.m., an observation was conducted of LPN #3 obtaining blood sugars and administering insulin on five residents. There were no concerns related to the above findings. Review of the medication administration reports to Resident #53's November MAR revealed that on multiple occasions, there was no evidence of when LPN #3 had administered insulin to Resident #53. On 11/22/19 at 12:26 p.m., ASM #1, the Administrator, ASM #2, the ADON (Assistant Director of Nursing), ASM #3, the Corporate Nurse Consultant, and ASM #4, the [NAME] President of Operations were made aware of the above concerns. ASM #2 at approximately 1 p.m., presented evidence that LPN #3 was re-educated on the Administering Medications policy on 11/21/19. No further information was presented prior to exit.

Based on observation, staff interview, and facility document review, it was determined that facility staff failed to apply hair restraints before entering the food preparation area in the facility kitchen. On 11/19/19 at 6:20 PM during the initial tour of the kitchen there were no hair restraints available upon entrance into the kitchen and food prep area. On the floor before entering into the kitchen and food prep area was a yellow and black strip with unreadable lettering. There were staff observed throughout the survey crossing the unreadable yellow and black line on the floor entering the kitchen without hair restraints. In order to get a hairnet you had to enter the kitchen, turn right and go past the food prep area to open a drawer that housed the hair restraints. On 11/20/19 at approximately 11:15 AM a tour of the kitchen was made with the Dietary Director. She was asked how would someone entering the kitchen obtain a hairnet? She stated, They would stop at this line and someone would bring them a hairnet. She was then asked how would someone know to stop at this yellow line. She stated, The yellow line has caution written on it. She was then asked how would someone make out the wording of these letters because it's hard reading the lettering; no comment was made. On 11/21/19 at approximately, 9:35 AM a sign was observed placed between the entrance doors reading: PLEASE DO NOT CROSS THE YELLOW LINE WITHOUT A HAIRNET, THANKS. Located below the sign were hair restraints. The Dietary Manager stated, The sign was put up yesterday. The above findings were shared with the Administrator, the Acting Director of Nursing and the Corporate Nurse Consultant during the pre-exit meeting conducted on 11/22/19 at 12:30 PM. No further information was presented by the facility staff.

Based on staff interview and facility document review, the facility staff failed to obtain a criminal record background check through the Virginia State Police for 1 of 25 employees (employee #25). The findings included: The facility staff failed to obtain a criminal record background check through the Virginia State Police for employee #25-a contracted physical therapist. The surveyor reviewed 25 newly hired employee personnel files on 4/11/18. Employee #25 was hired on 3/10/17 as a physical therapist (PT). Employee #25's personnel file did not contain a criminal record background check. The surveyor interviewed the human resources director on 4/11/18 at 9:55 a.m. and asked the human resources director to review the file for the completion of the criminal record background check. The HR director stated she didn't see one and then stated contracted staff are responsible for completing their records. The surveyor informed the administrator and the administrator stated the concern would be addressed with the contracted staff. The surveyor requested the facility policy on hiring /screening of new employees on 4/11/18. The surveyor reviewed the facility policy titled Background Screening Investigations on 4/12/18. The policy read in part 1. The Personnel/Human Resources Director, or other designee, will conduct employment background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on persons making application for employment with this facility. Such investigation will be initiated within two days of employment or offer of employment. The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above finding in the end of the day meeting on 4/11/18 at 5:15 p.m. No further information was provided prior to exit on 4/12/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to review and revise the Comprehensive Resident Centered Care Plan for 2 of 25 residents in the survey sample (Resident #67 and #10). The findings included: 1. The facility staff failed to review and revise the Comprehensive Resident Centered Care Plan for Resident #67. Resident #67 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, heart failure, high blood pressure, Alzheimer's disease, dementia, Parkinson's disease, anxiety disorder, depression, manic depression and Chronic Obstructive Pulmonary Disease. On the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/22/18 coded the resident with a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #67 was also coded as requiring limited assistance of 1 staff member for dressing and extensive assistance of 1 staff member for personal hygiene. Resident #67 was as being totally dependent on 1 staff member for bathing. The surveyor performed a review of Resident #67's clinical record on 4/10 and 4/11/18. During this review, it was noted by the surveyor that on the comprehensive care plan the following areas of the care plan did not have a revise and review date. There were: Impaired Vision with a Problem Onset date of 8/12/15 Allergic to Iodine, Iron salts, Toprol, has intolerance to Ultram, and Remeron, Codeine, Fish with a 'Problem Onset of 8/19/14 ADL (Activities of Daily Living) r/t (related to) inability to maintain ADLs at satisfactory level as evidenced by need of staff assist d/t (due to) dx. (disease) of Dementia, Pain, Depression, Parkinson's', Depression, Anxiety, .Anemia, .Poor Vision, and hx (history of) Pleural Effusion .with a Problem Onset of 12/31/13 and has a revision date of 3/17/17 At risk for Falls . with a Problem Onset of 8/19/14 High risk for increase bleeding and bruising r/t use of Blood thinning agent . with a Problem Onset of 8/19/14 The surveyor interviewed MDS nurse #1 and notified her of the above documented findings on 4/11/18 at 10:15 am. MDS nurse #1 stated, I will have to go and see if there is another care plan that has been revised after this one. On 4/12/18 at 3:12 pm, the surveyor notified the administrative team of the above documented findings. The surveyor asked the director of nursing if there were any more updates or revisions to the care plan for Resident #67. The director of nursing stated she would look into this and get back to the surveyor. No further information was provided to the surveyor prior to the exit conference on 4/12/18. 2. The facility staff failed to review and revise Resident #10's current comprehensive care plan when a scoop plate was ordered. The clinical record of Resident #10 was reviewed 4/9/18 through 4/12/18. Resident #10 was admitted to the facility 1/12/17 and readmitted [DATE] with diagnoses that included but not limited to non-traumatic intracerebral hemorrhage, gastrostomy, gastro-esophageal reflux disease, hypertension, chronic rhinitis, Type 2 diabetes mellitus, long term use of insulin, hyperlipidemia, gastrointestinal hemorrhage, dysphagia, pain, and respiratory failure. Resident #10's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/10/18 assessed the resident with short-term memory problems, long-term memory problems, and modified independence for daily decision-making. The clinical record of Resident #10 had a physician order dated 3/12/18 that read Pt (patient) to have scoop plate @ (at) meals. The tray ticket dated 4/11/18 had scoop dish under feeding assistance devices. The surveyor observed Resident #10 during lunch on 4/10/18 at 12:14 p.m. The plate was a divided plate. Resident #10 had a fork in the left hand eating potatoes. The surveyor reviewed the current comprehensive care plan dated 1/12/17. One problem identified 7/5/17 read At risk for unplanned wt. (weight) loss as evidenced by dx (diagnoses) dysphagia, diabetic, PEG tube, nausea/vomiting. Approaches included: Serve diet as ordered, RD (registered dietician) to review residents medical records and make recommendations-nursing to follow-up, supplements as ordered, accuchecks as ordered, meds as ordered-monitor for side effects and effectiveness, and PEG tube as ordered. The care plan was not revised to include the order for the scoop dish. The surveyor interviewed the minimum data set licensed practical nurse #1 on 4/11/18 at 2:53 p.m. After reviewing the care plan, MDS/LPN #1 stated the scoop plate should be added as specialized equipment to the care plan. The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above finding on 4/11/18 at 5:15 p.m. and again on 4/12/18 at 3:12 p.m. No further information was provided prior to the exit conference on 4/12/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility document review the facility staff failed to follow professional standards of practice for administering medications. The findings included: The facility staff failed to follow professional standards of nursing practice during a medication pass and pour observation, resulting in a medication error for Resident #30. Resident #30 was admitted to the facility on [DATE]. Diagnoses included but not limited to anemia, thrombocytopenia, hyperlipidemia, dementia, depression, insomnia, tachycardia, chronic obstructive pulmonary disease, dysphagia, and osteoporosis. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/09/18 coded the Resident as 15 of 15 in section C, cognitive status. This is a quarterly MDS. On 04/10/18 at approximately 0920, surveyor observed LPN #1 (licensed practical nurse) administering Resident #30's Flonase nasal spray. LPN #1 administered 1 spray of the Flonase into each of Resident #30's nostrils. Resident #30's medications were reconciled with the clinical record on 04/10/18 at approximately 0930. The clinical record contained a physician's order summary, which read in part Flonase allergy RLF 50 mcg spr 2 sprays in both nares daily. The Resident's eMAR was reviewed and contained an entry, which read in part Flonase allergy RLF 50 mcg spr 2 sprays in both nares daily. Surveyor spoke with LPN #1 on 04/10/18 at approximately 0935 regarding Resident #30's Flonase. Surveyor asked LPN #1 how many sprays of the Flonase she had administered and she stated 1 in each nostril. Surveyor asked LPN #1 to pull the order and look at it. LPN #1 did so, and then stated, I guess I owe her one. The surveyor requested the facility standards of practice for administering medications from the DON (director of nursing) on 04/10/18 at approximately 1035 and was provided with a copy of a policy entitled Administering Medications. This policy read in part Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame. 7. The individual administering the medication must check the label THREE (3) times to verify the right Resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. The concern of the incorrect dose of medication being administered was discussed with the administrative team during a meeting on 04/10/18 at approximately 1655. 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 the facility staff failed to follow physician's orders for 1 of 25 Residents, #24. The findings included: For Resident #24 the facility staff failed to administer the medication Neurontin as ordered by the physician. Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to coronary artery disease, hypertension, diabetes mellitus, hyperlipidemia, cerebrovascular accident, dementia, hemiplegia, depression and psychotic disorder. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/01/18 coded the Resident as 3 out of 15 in section C, cognitive status. This is an annual MDS. Resident #24's clinical record was reviewed on 04/10/18. It contained a physician's order summary for the month of April which read in part Neurontin 100mg capsule give one cap po (by mouth) BID (twice daily) for pain. The Resident's eMAR (electronic medication administration record) for April was reviewed and contained an entry which read in part Neurontin 100mg capsule give one cap po (by mouth) BID (twice daily) for pain. This entry had been coded N on 04/02/18 for the 5pm dose. The surveyor spoke with RN (registered nurse) #1 on 04/10/18 at approximately 1515 regarding the coding on Resident #24's eMAR. RN #1 stated that she does not know what N stands for and does not remember why the medication was not administered, and that it might have been because it was not available in the medication cart. Surveyor asked RN #1 what she would do if medications were not available and she stated, Wait for pharmacy to deliver, call the pharmacy to deliver, or check the stat box. The surveyor spoke with the QA nurse (quality assurance) on 04/10/18 at approximately 1530. Surveyor asked QA nurse what N on the eMAR stood for, and she stated N means the medication was not administered. The concern of the medications not being available was discussed with the administrative team during a meeting on 04/10/18 at approximately 1655. On 04/11/18 at approximately 0945, the DON provided the surveyor with a copy of a medication error report, which read in part 5pm dose of medication was not given to Resident; nurse states medication was not found. DON also provided surveyor with a copy of an inservice training form, which read in part 1. Topics to be discussed: importance of checking stat box overflow, calling pharmacy when a medication is not available and if medication cannot be given calling MD + notify RP (responsible party) + document. DON and RN #1 signed this form. The surveyor requested and was provided with a policy entitled Medication Shortage/Unavailable Medications, which read in part Procedure 1. Upon discovery that facility has an inadequate supply of a medication to administer to a Resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication shortage is discovered at the time of medication administration, facility staff should immediately take the action specified in Sections 2 or 3 of the policy 7.0, as applicable. 2. If a medication shortage is discovered during normal pharmacy hours: 2.1 Facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order or reorder for the next scheduled delivery. 2.2 If the next available delivery causes delay or a missed dose in the Resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery. The surveyor requested and was provided with a copy of the emergency medication supply. The medication Neurontin 100 mg was listed as being available in the emergency medication supply. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to maintain respiratory equipment for Resident #67. Resident #67 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, heart failure, high blood pressure, Alzheimer's disease, dementia, Parkinson's disease, anxiety disorder, depression, manic depression and Chronic Obstructive Pulmonary Disease. On the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/22/18 coded the resident with a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #67 was also coded as requiring limited assistance of 1 staff member for dressing and extensive assistance of 1 staff member for personal hygiene. Resident #67 was also coded as being totally dependent on 1 staff member for bathing. On 4/10/18 at 9:30 am, the surveyor went into the resident's room and noted that Resident #67 had O2 (oxygen) at 2 l/min (liters per minute) by nasal cannula. The oxygen tubing was dated with a date of 4/8/18. The O2 concentrator's filter was observed to have dust and particles of debris on it that was visible to the surveyor's eye. LPN #1 was notified of the filter being dirty with dust and particles of debris visible to the eye. She stated she would have this taken care of right now. The surveyor asked LPN #! When she would expect staff to clean the oxygen concentrator's filter. LPN #1 stated she would expect staff to clean the filter when the oxygen tubing was changed on a weekly basis. The surveyor notified the administrative team of the above documented findings on 4/12/18 at 3:12 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 4/12/18. Based on observation, resident interview, facility document review and clinical record review, the facility staff failed to ensure respiratory care equipment was maintained for 3 of 25 residents (Resident #50, Resident #136, and Resident #67) to include cleaning of the concentrator, following the physician order for amount of oxygen to be delivered and infection control for nebulizers. The findings included: 1. The facility staff failed to ensure Resident #50's oxygen concentrator was clean. The clinical record of Resident #50 was reviewed 4/9/18 through 4/12/18. Resident #50 was admitted to the facility 5/6/09 and readmitted [DATE] with diagnoses that included but not limited to hemiplegia following cerebral vascular accident affecting unspecified side, adult failure to thrive, B12 nutritional deficiency, cognitive communication deficit, depressive disorder, adrenocortical insufficiency, aphasia, hypertension, nontoxic multinodal goiter, hypothyroidism, bilateral deep vein thrombosis, hypoxia, dementia, and anemia. Resident #50's 60 day minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/7/18 assessed the resident with short-term memory problems, long-term memory problems and moderately impaired cognitive skills for daily decision making. No indicators of delirium, behaviors or psychosis. During the initial tour on 4/9/18, the surveyor observed Resident #50 in bed with an oxygen concentrator positioned at the bedside. The oxygen concentrator was set on 2 liters/nasal cannula. The surveyor noted an accumulation of dust on the concentrator. Resident #50's April 2018 physician's order were reviewed. Orders read O2 at 2 LPM (liters per minute) to decrease work of breathing and keep SpO2> (oxygen saturation) (greater than) 93%, change oxygen tubing qweek (every week), and change nebulizer tubing and mask q week (every week). The surveyor observed Resident #50 again on 4/10/18 at 8:42 a.m. Resident #50 was in bed with the oxygen concentrator set on 2 liters. Once again, the surveyor observed a fair amount of dust and debris on the concentrator, especially both air filters. A lint like substance greyish in color was observed on both filters. The oxygen tubing was dated 4/8/18. The surveyor interviewed the unit manager licensed practical nurse #1 on 4/10/18. The unit manager L.P.N. #1 stated the dated tubing indicated the date the tubing was changed. The surveyor and the unit manager L.P.N. #1 observed the oxygen concentrator together. The unit manager LPN #1 agreed with the surveyor that there was a large amount of accumulated dust on both filters. The unit manager L.P.N. #1 removed the air filters and stated she would take care of the issue. UM LPN #1 stated she would expect staff to clean the filters when the tubing was changed. The surveyor informed the administrator and the director of nursing of the above concern on 4/10/18 at 4:55 p.m. and requested the facility policy on oxygen maintenance. The administrator stated the facility did not have a policy that specified cleaning of the oxygen equipment. The surveyor reviewed the facility policy titled Oxygen Administration on 4/11/18. The policy read in part Steps in the Procedure 6. Check the face mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. 10. Oxygen tubing, cannula/mask should be stored in a clean, clear plastic bag when not in use. No further information was provided prior to the exit conference on 4/12/18. 2. The facility staff failed to failed to ensure the nebulizer facemask was clean, failed to ensure the oxygen concentrator was clean, failed to date the oxygen tubing when changed, and failed to follow the physician order for oxygen administration for Resident #136. The surveyor reviewed Resident #136's clinical record 4/9/18 through 4/12/18. Resident #136 was admitted to the facility 4/1/18 with diagnoses that included but not limited to hypertension, urinary tract infection, chronic obstructive pulmonary disease, radiculopathy, trochanteric bursitis, morbid obesity, right artificial hip joint, osteoarthritis, gastrointestinal hemorrhage, sleep apnea, depressive disorder, iron deficiency anemia, and venous thrombosis and embolus. Resident #136's admission minimum data set (MDS) had not yet been completed. The surveyor observed Resident #136 during the initial tour on 4/9/18 at 6:15 p.m. The resident was observed in bed, watching television. On the nightstand, the surveyor observed a nebulizer machine with a facemask attached. The facemask was lying on top of the machine. The surveyor also observed the oxygen concentrator had dust and debris along the front of the machine and the air filters, located on each side of the machine, had a layer of dust that appeared powdery. The oxygen tubing did not have a date when the tubing had been changed. The oxygen concentrator was turned off but the resident had the nasal cannula in both nostrils. The surveyor informed the unit manager licensed practical nurse #1 that the resident's oxygen concentrator was not turned on. The resident stated she thought she felt air going through the tubing but when checked by the unit manager LPN #1 the machine was off. The unit manager LPN #1 was asked what liter the resident was ordered. The UM LPN #1 stated 2 and promptly turned the oxygen concentrator to 2 liter. Resident #136's April 2018 physician's order were reviewed. Orders read O2 at 2 liters (liters) via NC (nasal cannula) continuous and change oxygen tubing weekly. The surveyor observed Resident #136 on 4/10/18 at 8:35 a.m. Resident #136 was observed in bed, oxygen on at 2 liters per nasal cannula. The oxygen concentrator was noted to have dust and debris on the front and the air filters had an accumulation of dust. The oxygen tubing did not have a date when the tubing was last changed. The surveyor informed the unit manager LPN #1 of the above concerns on 4/10/18 at 8:36 a.m. The unit manager LPN #1 removed the air filters, washed them with water, and placed the filters back in the concentrator. The UM LPN #1 also stated the oxygen tubing should be dated when changed weekly. The tubing should have been changed 4/8/18. The UM LPN #1 stated she would expect the nursing staff to clean the filters and date the tubing weekly. In addition, the surveyor did not observe a No Smoking sign on the door. The surveyor informed the administrator and the corporate registered nurse of the above concerns on 4/10/18 at 10:38 a.m. The surveyor informed the administrator and the director of nursing of the above concern on 4/10/18 at 4:55 p.m. and requested the facility policy on oxygen maintenance. The administrator stated the facility did not have a policy that specified cleaning of the oxygen equipment. The surveyor reviewed the facility policy titled Oxygen Administration on 4/11/18. The policy read in part Steps in the Procedure 6. Check the facemask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. 10. Oxygen tubing, cannula/mask should be stored in a clean, clear plastic bag when not in use. No further information was provided prior to the exit conference on 4/12/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation the facility staff failed to ensure medications were available for administration for 2 of 25 Residents, #41 and #65. The findings included: 1. For Resident #41 the facility staff failed to ensure the medication methocarbamol was available for administration. Resident #41 was admitted to the facility on Diagnoses included but not limited to morbid obesity, spinal stenosis, chronic obstructive pulmonary disease, hypokalemia, congestive heart failure, sleep apnea, hypertension, and depression. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/16/18 coded the Resident as 15 of 15 in section C, cognitive status. This is a quarterly MDS. Resident #41's clinical record was reviewed on 04/11/18. It contained a physician's order summary for the month of March, which read in part Methocarbamol 500mg tablet give two tabs (1,000 mg total) po (by mouth) QID (four times a day) DX (diagnosis): muscle spasms. The Resident's eMAR (electronic medication record) was reviewed and contained an entry, which read in part Methocarbamol 500mg tablet give two tabs (1,000 mg total) po (by mouth) QID (four times a day) DX (diagnosis): muscle spasms. This entry was coded with N for 03/29/18 at 1 pm. The comments section of the eMAR had a note, which read in part 3:02 PM, 3/39/18 (Scheduled: 1:00PMm 3/28/18; Methocarbamol 500 mg tablet) Methocarbamol 500 mg give two ta .scheduled for 03/29/2018 1:00 PM.mediciation in route //03/29/2018 3:02 PM. The surveyor spoke with the QA nurse (quality assurance) on 04/10/18 at approximately 1530. Surveyor asked QA nurse what N on the eMAR stood for, and she stated N means the medication was not administered. The surveyor requested and was provided with a policy entitled Medication Shortage/Unavailable Medications, which read in part Procedure 1. Upon discovery that facility has an inadequate supply of a medication to administer to a Resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication shortage is discovered at the time of medication administration, facility staff should immediately take the action specified in Sections 2 or 3 of the policy 7.0, as applicable. 2. If a medication shortage is discovered during normal pharmacy hours: 2.1 Facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order or reorder for the next scheduled delivery. 2.2 If the next available delivery causes delay or a missed dose in the Resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery. The surveyor requested and was provided with a copy of the emergency medication supply. The medication Methocarbamol was not listed as being available. The surveyor spoke with the administrator on 04/11/18 at approximately 1530 regarding Resident #41. The concern of the medication not being available for administration was brought to her attention at this time. Administrator stated that she might possibly have some information regarding this. The concern of the medication not being available for administration was discussed with the administrative team during a meeting on 04/11/18 at approximately 1715. No further information was provided prior to exit. This is a complaint deficiency. 2. The facility failed to ensure that a physician ordered medication was available for administration to Resident #65. Resident #65 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to diabetes, Multiple Sclerosis, Manic Depression and Psychotic Disorder. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/28/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #65 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent on 1 staff member for bathing. The surveyor conducted a clinical record review on 4/11/18 for Resident #65. During this review, the surveyor noted in the nurses' notes dated and timed for 2/7/18 at 8:07 am that stated, 6 am Resident MS (MS Contin) was not in stock. RX (Pharmacy) was called & staff stated that the insurance would not allow it to be sent. Resident was given a oxycodone tab 1 & effective. 7 am On coming charge nurse made aware of the above to f/u (follow up) with supervisor. The surveyor reviewed the physician order sheet for February 2018 and noted the following order: MS Contin 30 mg (milligram) Tablet take 1 tab po (by mouth) Q (every) 8 hrs (hours) . The surveyor also reviewed the MAR (Medication Administration Record) for Resident #65 for the month of February 2018. In the box for 2/6/18 at 10:00 pm for the medication of MS Contin an N with the nurses' initials were present. On 2/7/18 at 6 am, in the box for the medication MS Contin there was a N with the initials of the nurse documented on the resident's MAR. The surveyor reviewed the above documented findings with the director of nursing (DON) on 4/11/18 at approximately 10:45 am. The DON stated, I will have to look into this a little deeper and find out why this medication was not available. The surveyor asked the DON what the N stood for in the documentation on the resident's MAR concerning the above documented date and times for the medication of MS Contin. The DON stated, The N means that the medication was not given. The DON returned to the surveyor at 1:30 pm and stated that she had looked over the manifest from the pharmacy and the facility had called the pharmacy on 2/5/18 and again on 2/6/18. The DON stated that she had spoken to _______ (Name of contact at pharmacy facility uses) and that the person there would be glad to speak to the surveyor. The DON gave the surveyor the phone number of this contact person at the pharmacy. At 2 pm, the surveyor called Pharmacy contact #1 at the phone number supplied by the DON. According to the Pharmacy contact #1 that stated, The facility had called the pharmacy on 2/5/18 and reported to the pharmacy that they were needing a refill on the resident's MS Contin. The pharmacy technician had contacted the insurance of the resident and it had been denied to have this refill. The facility called again on 2/6/18 and spoke to a pharmacy technician concerning the need for the refill on the resident's medication. Instead of the pharmacy technician going ahead and pushing thru the channels here at the pharmacy and asking for an emergency fill on this medication which would had changed the delivery date to 2/6/18 this was not done until later in the day on 2/6/18 and the delivery date was not changed and it was delivered to the facility on the run on 2/7/18. In my opinion, the ball was dropped within the pharmacy on this. On 4/12/18 at 3:12 pm, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 4/12/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure the director of nursing signed the drug regimen review for one of 25 Residents in the survey sample (Resident #34). The findings included: Resident #34 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to Peripheral Vascular Disease, diabetes, hyperlipidemia (high cholesterol), stroke, Alzheimer's disease, and depression. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/23/18, the resident was coded as having short and long term memory problems with being moderately impaired in daily decision-making. Resident #34 was also coded as requiring extensive assistance of 1 staff member for dressing and personal care and being totally dependent on 1 staff member for bathing. The surveyor conducted a review of Resident #34's clinical record on 4/11/18. During this review, the surveyor noted a Consultation Report .January 1, 2018 through January 16, 2018 from the pharmacist. This recommendation was signed and acknowledged by the medical director and was dated 2 1 18. The surveyor also noted that the physician had marked a response with a check mark in the box that stated, I have re-evaluated this therapy and DO NOT wish to implement any changes due to the reasons below. Rationale: Will f/u (follow up) @ (at) next recert (recertification). It was noted by the surveyor that on this Consultation Report, there was no signature on this by the director of nursing. At approximately 3 pm, the surveyor showed this Consultation Report to the director of nursing and notified her of the missing signature on this by her. The director of nursing did not reply after looking at this with the surveyor. At 5:15 pm, the surveyor notified the administrative team of the above documented findings on Resident #34. No further information was provided to the surveyor prior to the exit conference on 4/12/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to provide non-pharmacological interventions prior to administering pain medications for 2 of 25 residents in the survey sample (Resident #67 and #184). The findings included: 1. The facility staff failed to provide non-pharmacological interventions prior to administrating pain medications to Resident #67. Resident #67 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, heart failure, high blood pressure, Alzheimer's disease, dementia, Parkinson's disease, anxiety disorder, depression, manic depression and Chronic Obstructive Pulmonary Disease. On the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/22/18 coded the resident with a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #67 was also coded as requiring limited assistance of 1 staff member for dressing and extensive assistance of 1 staff member for personal hygiene. Resident #67 was as being totally dependent on 1 staff member for bathing. The surveyor performed a review of Resident #67's clinical record on 4/10/18. During this review, it was noted by the surveyor that on the MAR (Medication Administration Record) for the month of April 2018, the resident received the following prn (as needed) pain medication: Norco 5-325 Tablet Take one tablet every 4 hours as needed for pain. This medication was administrated to the resident on the following dates and times: 4/2 at 9:48 am and 4:02 pm, 4/3 at 9:15 am, 2:56 pm, 4/6 at 7:53 am, 4/7 at 5:37 am and 8:05 pm, and 4/8 at 5:39 am. The surveyor reviewed the Administration Record at the end of the MAR and the only non-pharmacological intervention documented for the above administration times of the prn pain medication was Assessed for pain. The surveyor reviewed the resident's care plan and under the problem of Alteration of comfort r/t (related to) pain the interventions read in part: Monitor for worsening pain or pain not responding to current therapy, notify MD (medical doctor) for increase in strength or change in med. Offer quiet environment and assist with positioning for comfort . Attempt non-pharmacologic pain relief measures such as repositioning, back rubs. Document effectiveness . Provide diversional activities, if applicable . On 4/10/18 at approximately 1:45 pm, the surveyor reviewed the above documented findings with the director of nursing (DON). The surveyor asked if assess for pain was considered a non-pharmacological intervention to be used prior to the administration of a prn pain medicine. The DON stated that assess for pain was a non-pharmacological intervention to be used by her staff. The surveyor asked the DON if that was the only non-pharmacological intervention that she would expect her nurses to use prior to them administrating a prn pain medication to a resident. The DON stated, It is one that the staff can use. The surveyor asked the DON if there were any other interventions that the staff could use before administrating prn pain medicine to a resident and she stated, Yes I see where you are coming from but assessing for pain is one of them. The surveyor notified the administrative team of the above documented findings on 4/10/18 at 4:58 pm in the conference room. The surveyor again notified the administrative team on 4/11/18 at 5:15 pm of the above documented findings on Resident #67 regarding no non-pharmacological interventions except for assess for pain used prior to the administration of a prn pain medication. No further information was provided to the surveyor prior to the exit conference on 4/12/18. 2. The facility staff failed to provide non-pharmacological interventions prior to administering pain medication to Resident #184. Resident #184 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to sepsis, cerebral aneurysm, enterocolitis related to C-Diff, malignant neoplasm of lung, high blood pressure and malignant neoplasm of the brain. The admission MDS (Minimum Data Set) had not been completed at the time of this survey in the nursing facility. According to the admission nursing assessment dated for 4/6/18, it was documented that the resident is alert and oriented. It was also documented that Resident #184 requires extensive assistance of 1 staff member for transfers, walking, personal hygiene and bathing. During the clinical record review performed by the surveyor on 4/11 and 4/12/18. It was noted that the resident had a physician order for the following pain medication: Tramadol HCL 50 mg (milligram) tablet - take 1 tab by mouth every 6 hours as needed DX (diagnosis) pain. The surveyor reviewed the MAR (Medication Administration Record) for April 2018 and noted that Resident #184 was given Tramadol for pain on the following dates and times: 4/8 at 9:04 am and 4/9 at 1:35 am. The non-pharmacological intervention that was documented on the Administration Record for each time the Tramadol was given for pain was Assessed for pain. The surveyor notified the administrative team of the above documented findings on 4/12/18 at 3:15 pm. No further information was provided to the surveyor prior to the exit conference on 4/12/18.

Based on staff interview and clinical record review, the facility staff failed to ensure 1of 25 residents was free of an unnecessary psychotropic medication (Resident #70). The findings included: The facility staff failed to ensure Resident #70 was free of an unnecessary medication. The facility staff failed to offer/provide non-pharmacologic interventions prior to the use of Xanax on five (5) different occasions. The clinical record of Resident #70 was reviewed 4/9/18 through 4/12/18. Resident #70 was admitted to the facility 2/19/18 with diagnoses that included but not limited to atrial fibrillation, bradycardia, hypokalemia, long QT syndrome, enterocolitis due to Clostridium difficle, anxiety disorder, chronic obstructive pulmonary disease, hyperlipidemia, pulmonary hypertension, Takotsubo syndrome, diverticulum of the esophagus, left ventricular failure, acute on chronic systolic heart failure, and anorexia. Both the 5 day and 14 day MDS coded the resident with a brief interview for mental status as a 15. Both anxiety and depression were coded in Section I Active Diagnoses. Resident #70's March 2018 physician order sheet included an order for Xanax 0.25 mg (milligrams) po (by mouth) q (every) 12 hours prn (as needed) for sleep/anxiety. The surveyor reviewed the March 2018 electronic medication administration record (eMAR) and the eMAR notes. Resident #70 was administered Xanax 0.25 mg on 3/10/18 at 9:19 p.m. per resident request. Xanax 0.25 mg was administered 3/21/18 at 5:50 p.m. No reason documented for the administration of the prn Xanax. Xanax 0.25 mg was administered 3/23/18 at 12:10 a.m. The 3/23/18 notes stated per resident request. Resident #70 was administered Xanax 0.25 mg on 3/24/18 at 6:26 p.m. No reason for the administration of the medication was identified. Resident #70 received Xanax 0.25 mg on 3/26/18 at 8:21 p.m. No reason for the administration was documented. The surveyor reviewed the Departmental Notes for March 2018. The notes did not have evidence of non-pharmacologic interventions prior to the administration or a reason for the administration other than resident request. Departmental Notes dated 3/10/18 (6:13 a.m. and 1:09 p.m.) did not have any reasons for the administration of the Xanax or any non-pharmacologic use prior to the administration of the medication. Departmental Note dated 3/21/18 (1:49 a.m.) did not reference any non-pharmacologic intervention prior to the use of Xanax. The note read in part sleep habits are good. The departmental note dated 3/23/18 at 6:51 a.m. or the 3/24/18 note of 12:55 a.m. did not reference any non-pharmacologic intervention prior to administration. There was not a departmental note written 3/24/18 after 12:55 a.m. The note written 3/25/18 at 12:22 a.m. did not reference any type of non-pharmacologic intervention or reason for the administration of Xanax. The surveyor informed the administrator and the director of nursing of the lack of non-pharmacologic interventions prior to the use of Xanax or the lack of documentation for the use of Xanax in the end of the day meeting on 4/11/18 at 5:15 p.m. The DON stated she wanted to review the information provided. No further information was provided prior to the exit conference on 4/12/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to coordinate hospice services for Resident #86. Resident #86 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, high blood pressure, stroke, dementia, seizure disorder and anxiety disorder. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/26/17, the resident was coded as having short term and long term memory problems. The resident was also coded as being moderately impaired in making daily decisions. Resident #86 was totally dependent on 1 staff member for dressing, personal hygiene and bathing. During the clinical record review on 4/11 and 4/12/18 that was performed by the surveyor. It was noted by the surveyor a physician order dated for 10/24/17, which stated, Hospice Care. The surveyor reviewed the clinical record and noted the only documentation in the record from Hospice was a Plan of Care dated for 10/21/17. According to the Plan of Care, the resident was to receive the following: Skilled Nursing visits 2 times a week for 14 weeks, Medical Social Worker visits 10/22/17 then 1 time a week for 1 week, then 1 time a week for 11 weeks, and Hospice aide visits 10/22/17 then 3 times a week for 12 weeks, then decrease to 2 times a week for 1 week. There was no documentation of these visits from each of the disciplines in the clinical record when reviewed by the surveyor. On 4/12/18 at 3:12 pm, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 4/12/18. Based on staff interview, facility document review and clinical record review, the facility staff failed to coordinate hospice services for 2 of 25 residents (Resident #48 and Resident #86). The findings included: 1. The facility staff failed to ensure hospice documentation was in the clinical record of Resident #48. The clinical record of Resident #48 was reviewed 4/9/18 through 4/12/18. Resident #48 was admitted to the facility 11/28/17 with diagnoses, that included but not limited to Alzheimer's disease, dementia with behavioral disturbances, major depressive disorder, anxiety, adult failure to thrive, and history of falling. Resident #48's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/5/18 assessed the resident with long-term memory problems, short-term memory problems, and moderately impaired cognitive skills for daily decision-making. No identified indicators of psychosis, delirium, or behaviors. Section O Special Treatments, Procedures and Programs was coded for hospice care. The December 2017 through April 2018 had orders that read Resident under hospice care upon admission-dated 12/28/17). Resident #48's current comprehensive care plan had the problem of hospice but the entry did not have a date when implemented, goals or approaches. The surveyor reviewed the hospice contract on 4/11/18. The hospice contract read in part 1.6 Hospice Services means those services and items provided to a Hospice Patient , either directly or under arrangements that are reasonable and necessary for the palliation and management of the Hospice's patient's terminal illness and related conditions, as specified in the Plan of Care. 2. Duties and Obligations of Hospice-Coordination of Services- Hospice shall ensure the continuity of care for Hospice patients and their families in all care settings. Hospice will be responsible for coordinating patient care conferences, periodic patient and family assessments and evaluations, discharge planning and bereavement follow-up for all Hospice patients and their families. Hospice shall designate a member of each Interdisciplinary Group who is responsible for a hospice patient at the facility. Hospice shall provide Facility with the following information specific to each Hospice Patient residing at facility: (i) The most recent Hospice Plan of Care; (ii) The Hospice election form and any advanced directives; (iii) The Physician Certification and recertification (s) of the terminal illness; (iv) The names and contact information for Hospice staff involved in the care of the Hospice Patient; (v) Instructions on how to access Hospice's 24 hour-on-call system; (vi) Hospice medication information; and (vii) Hospice Physician and attending physician orders. 4. Coordination of Services-4.4 Clinical records Facility and Hospice shall each prepare and maintain complete and detailed clinical records concerning each Hospice patient receiving Facility services and Hospice services under this agreement in accordance with prudent record-keeping procedures, their own policies and procedures, and applicable federal and state law and regulations and applicable Medicare and Medicaid program guidelines. Facility and Hospice will each maintain and subject to applicable laws and regulations regarding confidentiality of patient information, make available to each other for inspection and copying, detailed such clinical records concerning each Hospice Patient as necessary for the proper evaluation, screening, and provision of services to Hospice patient under this agreement. The clinical record contained a copy of the Recertification of Terminal Illness-60 -Day Benefit Period was dated 1/19/18 and ending 3/19/18. The surveyor found no current hospice orders for care-frequency of skilled nurse visits, frequency of certified nursing aides visits, social worker frequency and chaplain frequency visits. The surveyor was unable to locate any certified nursing aide visits, chaplain visits and social worker visits in the clinical record. The surveyor interviewed the unit manager licensed practical nurse #1 on 4/10/18 at 2:58 p.m. about the aide visits. The unit manager LPN #1 stated the facility staff provided the resident baths/care. The unit manager LPN #1 stated she would call the hospice agency and get Resident #48's visit information. The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above concern with lack of documentation from the hospice agency during the end of the day meeting on 4/10/18 at 4:55 p.m. No further information was provided prior to the exit conference on 4/12/18.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to follow infection control guidelines for 2 of 25 residents (Resident #34 and Resident #136). The findings included: 1. The facility staff failed to ensure the nebulizer facemask was clean for Resident #136. The surveyor reviewed Resident #136's clinical record 4/9/18 through 4/12/18. Resident #136 was admitted to the facility 4/1/18 with diagnoses that included but not limited to hypertension, urinary tract infection, chronic obstructive pulmonary disease, radiculopathy, trochanteric bursitis, morbid obesity, right artificial hip joint, osteoarthritis, gastrointestinal hemorrhage, sleep apnea, depressive disorder, iron deficiency anemia, and venous thrombosis and embolus. Resident #136's admission minimum data set (MDS) had not yet been completed. The surveyor observed Resident #136 during the initial tour on 4/9/18 at 6:15 p.m. The resident was observed in bed, watching television. On the nightstand, the surveyor observed a nebulizer machine with a facemask attached. The facemask was lying on top of the machine. The facemask was not secured in a clean plastic bag. The surveyor informed the unit manager LPN #1 of the above concerns on 4/10/18 at 8:36 a.m. The unit manager LPN #1 stated the nebulizer mask should be stored in a clean plastic bag. The surveyor informed the administrator and the corporate registered nurse of the above concerns on 4/10/18 at 10:38 a.m. The surveyor informed the administrator and the director of nursing of the above concern on 4/10/18 at 4:55 p.m. and requested the facility policy on equipment maintenance. The administrator stated the facility did not have a policy that specified cleaning of the equipment. The surveyor reviewed the facility policy titled Oxygen Administration on 4/11/18. The policy read in part Steps in the Procedure 6. Check the facemask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. 10. Oxygen tubing, cannula/mask should be stored in a clean, clear plastic bag when not in use. No further information was provided prior to the exit conference on 4/12/18. 2. The facility staff failed to ensure infection control guidelines were maintained on the [NAME] Garden unit. Resident #34 was observed removing clean linen from the linen cart. The surveyor observed Resident #34 at the linen cart on 4/11/18 at 4:29 p.m. Resident #34 was observed removing linen from the linen cart. The observation was seen by the unit manager licensed practical nurse #1 who intervened. The UM LPN #1 stated the resident never messes with the linen cart. The UM LPN #1 removed the resident from the linen cart. The UM LPN #1 informed the surveyor the linens from the cart had been removed and washed, the cart cleaned and the cart replaced with clean linens. The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above infection control concerns during the end of the day meeting on 4/11/18 at 5:15 p.m. and again on 4/12/18 at 3:12 p.m. The surveyor reviewed the infection control program with the director of nursing on 4/12/18. Resident #34 was admitted to the facility 12/4/14 with diagnoses that included but not limited to Alzheimer's disease, peripheral vascular disease, hyperlipidemia, diabetes mellitus, depression, and cerebrovascular accident. Quarterly minimum data set (MDS) with an assessment reference date assessed the resident with short-term memory problem, long-term memory problem, and moderately impaired cognitive skills for daily decision-making. No further information was provided prior to the exit conference on 4/12/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility staff failed to ensure handrails were firmly affixed and in good repair on one of two units. The rose garden unit. The findings included. On 04/11/18, the surveyor observed that the handrails (two) between room [ROOM NUMBER] and the nurse's station were missing a brace. Thus allowing the handrails to be pushed in when resting or pushing on the handrail. The handrail between the laundry room and barber/beauty shop was cracked in two areas. On 04/11/18, the surveyor leaned against a handrail between room [ROOM NUMBER] and the nurse's station. This handrail bent in toward the wall. When looking at the handrail the surveyor observed that some of the braces between the handrail and the wall were missing. A second handrail in the same area was also missing braces and was able to be pushed in toward the wall. Maintenance employee #1 was shown the handrails. On 04/12/18 at 10:07 a.m., the surveyor checked the handrails to see if they had been fixed. No modifications had been made to either handrail. When checking other handrails the surveyor observed the handrail between the laundry room and the barber/beauty shop was cracked in two places. The surveyor was able to observe Residents in the hallway where the issues with the handrails were noted. The nurse consultant was notified of the issues with the handrails on 0412/18 at 10:10 a.m. The administrative staff was notified of the issues regarding the handrails on 04/12/18 at approximately 3:12 p.m. No further information regarding his issue was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. For Resident #30 the facility staff failed to code diagnoses in Section I of the MDS. Resident #30 was admitted to the facility on [DATE]. Diagnoses included but not limited to anemia, thrombocytopenia, hyperlipidemia, dementia, depression, insomnia, tachycardia, chronic obstructive pulmonary disease, dysphagia, and osteoporosis. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/09/18 coded the Resident as 15 of 15 in section C, cognitive status. Section I of the MDS listed diagnoses as depression and asthma. This is a quarterly MDS. Resident #30's clinical record was reviewed on 04/10/18 at approximately 1000. It contained a physician's order summary for the month of April, which read in part Memantine HCl 10mg tablet- 1 tab by mouth 2 times a day dx (diagnosis) dementia and Aricept 10 mg tablet PO (by mouth) at bedtime Dx: dementia. The physician's order summary had diagnoses listed as dysphagia, chronic obstructive pulmonary disease, thrombocytopenia, hyperlipidemia, and mood disorder. The surveyor requested and was provided with a diagnosis list for Resident #30. Diagnoses were listed as thrombocytopenia, hyperlipidemia, unspecified dementia without behavioral disturbance, major depressive disorder, recurrent, mild, insomnia, unspecified, chronic obstructive pulmonary disease w acute lower resp infc (respiratory infection), and dysphagia. The surveyor spoke with MDS coordinator on 04/10/18 at approximately 1030 regarding Resident #30's diagnoses. Surveyor asked MDS coordinator specifically if the diagnosis of dementia should have been coded on the MDS, and MDS coordinator stated that it should have. The concern of the inaccurate MDS was discussed with the administrative team during a meeting on 04/10/18 at approximately 1655. No further information was provided prior to exit. 8. For Resident #41 the facility staff failed to code diagnoses in Section I of the MDS. Resident #41 was admitted to the facility on Diagnoses included but not limited to morbid obesity, spinal stenosis, chronic obstructive pulmonary disease, hypokalemia, congestive heart failure, sleep apnea, hypertension, and depression. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/16/18 coded the Resident as 15 of 15 in section C, cognitive status. Section I, active diagnoses, of this MDS listed diagnoses as depression and asthma with additional diagnoses listed as morbid obesity, spinal stenosis, spondylosis and muscle weakness. This is a quarterly MDS. The Resident's clinical record was reviewed on 04/11/18. It contained a physician's order summary for the month of April, which read in part furosemide 40 mg tablet 1 tab PO (by mouth) daily -CHF (congestive heart failure) and Lisinopril 10 mg tablet-take one tab PO QD (every day), DX (diagnosis): HTN (hypertension). Diagnoses on the physician's order summary were listed as spinal stenosis, morbid obesity, arthropathy, unspecified asthma, hypokalemia, acute on chronic systolic (congestive) heart failure, and major depressive disorder. Surveyor spoke with MDS coordinator on 04/12/18 at approximately 0935 regarding Resident #41's MDS. Surveyor asked MDS coordinator should the diagnoses listed on the physician's order summary be coded on the MDS and MDS coordinator stated Let me investigate before I answer that. On 04/12/18 at approximately 1015 the MDS coordinator provided the surveyor with a copy of section I of the Resident's MDS depression and asthma with additional diagnoses listed as morbid obesity, spinal stenosis, spondylosis and muscle weakness and stated that she had made a correction. The diagnoses listed on the corrected MDS were depression and asthma with additional diagnoses listed as morbid obesity, spinal stenosis, spondylosis and muscle weakness. This was the same as the original MDS. The concern of the incorrect MDS was discussed with the administrative team during a meeting on 04/12/18 at approximately 1510. No further information was provided prior to exit. Based on staff interview and clinical record review, the facility staff failed to maintain accurate MDS assessments for 11 of 25 Residents (Residents #8, #26, #46, #85, #76, #79, #30, #41, #48, #50, and #70). The findings included. 1. For Resident #8, the facility staff failed to maintain an accurate MDS (minimum data set) assessment in regards to alarms. The record review revealed that Resident #8 had been admitted to the facility 10/02/17. Diagnoses included, but were not limited to, dementia without behavioral disturbances, diabetes, hyperlipidemia, and chronic kidney disease. Section C (cognitive patterns) of the Residents quarterly MDS assessment with an ARD (assessment reference date) of 01/08/18 was coded 1/1/1 to indicate the Resident had problems with long and short term memory and had modified independence in cognitive skills for daily decision making. Section P (restraints) was not coded to indicate the Resident used a chair and/or bed alarm. The most current POS (physician order summary) included an order for bed/chair alarms the date of this order was documented as 10/29/17. The comprehensive care plan included the problem area of falls. Interventions included, but were not limited to Bed/chair alarm as ordered. On 4/10/18 at approximately 3:45 p.m., the surveyor interviewed the MDS coordinator. After reviewing the MDS, the coordinator verbalized to the surveyor that the MDS had been inaccurately coded in regards alarms. On 04/10/18 at approximately 4:00 p.m., the surveyor and an employee from the activity department checked the Residents chair alarm. The chair alarm was observed to be in working order. The administrative staff were notified of the issue regarding the MDS assessment during a meeting with the survey team on 04/12/18 at 3:12 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #26, the facility staff failed to accurately code the MDS (minimum data set) assessment in regards to the medications aspirin and plavix, falls, and in regards to the Residents flu vaccine. The record review revealed that Resident #26 had been admitted to the facility 02/01/17. Diagnoses included but were not limited to, cerebral infarction, adult failure to thrive, essential hypertension, constipation, chronic rhinitis, and aphasia. Section C (cognitive patterns) of the Residents quarterly MDS assessment with an ARD (assessment reference date) of 02/02/18 included a BIMS (brief interview for mental status) summary score of 15. Section J (health conditions) had been coded to indicate the Resident has one fall. Section N (medications) had been coded to indicate the Resident was receiving anticoagulant medications. Section O (special treatments, procedures, and programs) had been coded to indicate the Resident was not offered a flu vaccine at the facility. A review of the Residents current physician orders revealed that the Resident was receiving the medications aspirin and plavix. Per the RAI (resident assessment instrument) manual aspirin and clopidogrel (plavix) are antiplatelet medications and were not to be coded as anticoagulant medications. When reviewing the nursing notes the surveyor was able to find evidence of two falls one on 12/02/17 and another on 01/11/18. On 04/11/18 at approximately 8:20 a.m., the surveyor spoke with DON (director of nursing) regarding the flu vaccine. The DON verbalized to the surveyor that the flu vaccine information was sent to the family and at the time the MDS was completed and it had not been returned to the facility. So, the MDS was coded incorrectly. The DON stated a correction had been completed. The administrative staff were notified of the issue regarding the MDS assessment during a meeting with the survey team on 04/12/18 at 3:12 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #46, the facility inaccurately coded the Residents MDS (minimum data set) assessment in regards to insulin. The clinical record review revealed that Resident #46 had been admitted to the facility 12/06/10. Diagnoses included, but were not limited to, multiple sclerosis, Alzheimer's disease, depression, generalized anxiety disorder, and diabetes. Section C (cognitive patterns) of the Residents quarterly MDS assessment with an ARD (assessment reference date) of 03/02/18 included a BIMS (brief interview for mental status) summary score of 12 out of a possible 15 points. Section N (medications) had been coded to indicate the Resident had received insulin injections for 3 out of the last 7 days. A review of the Residents eMARs (electronic medication administration records) revealed that the Resident had received insulin for 7 of 7 the days coded on the MDS assessment. On 4/10/18 at approximately 12:10 p.m., the surveyor and the MDS coordinator reviewed the Residents MDS assessment and eMARs. After this review the MDS coordinator verbalized to the surveyor that the MDS had been miscoded in regards to insulin injections. The administrative staff were notified of the issue regarding the MDS assessment during a meeting with the survey team on 04/12/18 at 3:12 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference. 4. For Resident #85, the facility staff to accurately code the Residents MDS (minimum data set) assessment in regards to the Residents discharge from the facility. The record review revealed that Resident #85 had been admitted to the facility 02/16/18 and was discharged to an acute care hospital on [DATE]. Diagnoses included, but were not limited to, atrial fibrillation, coronary artery disease, chronic obstructive pulmonary disease, and hypertension Section C (cognitive patterns) of the Residents discharge MDS assessment with an ARD (assessment reference date) of 02/20/18 included a BIMS (brief interview for mental status) summary score of 0 out of a possible 15 points and had been coded to indicate the Resident had been discharged to the community. The discharge summary signed by the physician (02/22/18) revealed that Resident #85's discharge diagnosis was septic shock and he had been admitted to an ICU (intensive care unit). On 04/12/18 at 10:38 a.m., the surveyor reviewed this MDS with the MDS coordinator. After reviewing this MDS, the MDS coordinator verbalized to the surveyor that it had been coded inaccurately. The administrative staff were notified of the issue regarding the MDS assessment during a meeting with the survey team on 04/12/18 at 3:12 p.m. Prior to the exit conference the MDS coordinator provided the surveyor with a corrected copy of the MDS indicating the Resident had been discharged to an acute hospital. No further information regarding this issue was provided to the survey team prior to the exit conference. 5. The facility staff failed to maintain an accurate MDS (Minimum Data Set) assessment for Resident #76. Resident #76 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, high blood pressure, dementia, seizure disorder and depression. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/26/18; the resident was coded as having short term and long-term memory loss and being moderately impaired in making daily decisions. Resident #76 was also coded as being totally dependent on 1 staff member for dressing, personal hygiene and bathing. The surveyor performed a review of Resident #76's clinical record on 4/10/18. During this review, it was noted by the surveyor that Resident #76 had the following physician order: .Resident to wear clip alarm while in bed and in wc (wheelchair) . The resident's care plan was updated with a date of 12/26 which had the intervention of .alarms as ordered . for the problem of At risk for falls with injury . The resident's MDS with ARD of 2/26/18 coded the resident under Section P, P0200, Alarms, as a 0 for bed and chair alarms being used. On 4/10/18 at approximately 2 pm, the surveyor asked MDS nurse #1 if bed and chair alarms should be coded on Resident #76 when the resident has an order as documented above. The MDS nurse #1 stated, I will have to check and get back to you on this. The surveyor notified the administrative team of the above documented findings on 4/10/18 at 4:58 pm. On 4/11/18 at 7:45 am, the surveyor was provided a copy of the corrected MDS with bed and chair alarms being coded as 2 which means that the device was used daily. No further information was provided to the surveyor prior to the exit conference on 4/13/18. 6. The facility staff failed to maintain an accurate MDS (Minimum Data Set) assessment for Resident #79. Resident #79 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to high blood pressure, diabetes, stroke, depression and Chronic Obstructive Pulmonary Disease. On the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/24/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 5 out of a possible score of 15. Resident #79 was also coded as requiring extensive assistance of 1 staff member for dressing and personal care and being totally dependent on 1 staff member for bathing. The surveyor went into the resident's room on 4/11/18 at approximately 11:30 am. The surveyor observed the resident to be sitting up in his wheelchair with a lap belt tied around the resident's waist to the back of the wheelchair. The resident's representative was also in the room at the time this observation was made. The surveyor asked the representative if the resident could untie the lap belt. The representative stated in a whisper, He can't get to it. It's done that way so that he can't wander off anymore. The surveyor asked the resident if he could undo the lap belt that was around his waist and he looked puzzled as to what the surveyor had asked him to do. The resident did not respond to the surveyor. The surveyor performed a review of Resident #79's clinical record on 4/11/18. During this review, the surveyor noted on the MDS with ARD of 3/24/18, documented the resident's weight, under Section K, as 50 pounds. Also on the same MDS, the resident was not coded for the use of a restraint, under Section P, P0100. The surveyor reviewed the vital signs tab in the electronic clinical record and the weight documented on 3/12/18 was 150.2 pounds. At 3:15 pm, the surveyor notified the MDS nurse #1 of the above documented findings. On 4/11/18 at 5:15 pm, the surveyor notified the administrative team of the above documented findings of the incorrect weight on the MDS. The surveyor was provided copies of the corrected MDS which had the resident's weight documented as 154 pounds in Section K and also had a trunk restraint coded in Section P as being used daily. These copies were left lying on the conference room table when the surveyor arrived to the facility on 4/12/18 at 7:45 am. No further information was provided to the surveyor prior to the exit conference on 4/12/18. 9. The facility staff failed to accurately code Section O (Special Treatment, Procedures, and Programs) and Section P (Restraints) on Resident #48's quarterly minimum data set (MDS) assessment. The clinical record of Resident #48 was reviewed 4/9/18 through 4/12/18. Resident #48 was admitted to the facility 11/28/17 with diagnoses, that included but not limited to Alzheimer's disease, dementia with behavioral disturbances, major depressive disorder, anxiety, adult failure to thrive, and history of falling. Resident #48's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/5/18 assessed the resident with long-term memory problems, short-term memory problems, and moderately impaired cognitive skills for daily decision-making. No identified indicators of psychosis, delirium, or behaviors. (a) The facility staff failed to accurately code Section O Special Treatment, Procedures, and Programs on Resident #48's quarterly MDS. Section O Special Treatment, Procedures, and Programs was reviewed. Influenza Vaccine (O0250 A, B, and C) was reviewed. Section A read Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? The question was answered No with instructions to skip to O0250C, If influenza vaccine not received, state reason. Section C was marked 5. Not offered. Information about the influenza vaccinations were kept with the director of nurses. The surveyor requested information when Resident #48's influenza vaccination had been administered. The Immunization List for Resident #48 documented the resident had the influenza vaccination on 10/1/17 prior to admission to the facility. Section C options also included: 1. Resident not in this facility during this year's influenza vaccination season. 2. Resident received outside of this facility. 3. Not eligible-medical contraindication 4. Offered and declined. 5. Not offered. 6. Inability to obtain influenza vaccine due to a declared shortage. 9. None of the above. Resident #48 received the influenza vaccination outside of the facility; therefore, option 2 should have been marked/coded. The surveyor interviewed minimum data set (MDS) assessment licensed practical nurse #1 on 4/11/18. MDS/LPN #1 stated the information in Section O about the influenza vaccination was incorrect and stated a correction would be done. (b). The facility staff failed to accurately code Section P Restraints on Resident #48's quarterly MDS with ARD of 3/5/18. Resident #48's December 2017 through April 2018 physician's order sheets had an order dated 12/5/17 that resident was to wear a clip alarm at all times for safety. A review of Section P Restraints and specifically P0200 Alarms did not have any type of alarm coded-bed, chair, floor mat, motion sensor, wander/elopement, and other alarm. The surveyor did observe Resident #48 on the morning of 4/10/18 at 8:53 a.m. sitting in a high back wheelchair in the TV area with a clip alarm attached from the back of the wheelchair to the resident's clothing. The unit manager licensed practical nurse #1 checked the alarm to ensure the alarm was working and the alarm sounded when activated. The surveyor interviewed the minimum data set (MDS) licensed practical nurse #1 on 4/10/18 at 3:53 p.m. regarding the coding of the clip alarm on the MDS. MDS/LPN #1 stated she had no documentation in the 7-day look back period to support the coding for the alarms. MDS/LPN #1 stated a correction of the quarterly MDS would be done. The surveyor informed the administrator and the director of nursing of the inaccurate coding on Resident #48's quarterly MDS in the end of the day meeting on 4/10/18 at 4:55 p.m., again on 4/11/18 at 5:15 p.m. and on 4/12/18 at 3:12 p.m. No further information was provided prior to the exit conference on 4/12/18. 10. The facility staff failed to accurately code Section O Special Treatments, Procedures and Programs on Resident #70's admission minimum data set (MDS) assessment with assessment reference date (ARD) of 2/26/18 and the 14 day MDS with an ARD of 3/3/18. The clinical record of Resident #70 was reviewed 4/9/18 through 4/12/18. Resident #70 was admitted to the facility 2/19/18 with diagnoses that included but not limited to atrial fibrillation, bradycardia, hypokalemia, long QT syndrome, enterocolitis due to Clostridium difficle, anxiety disorder, chronic obstructive pulmonary disease, hyperlipidemia, pulmonary hypertension, Takotsubo syndrome, diverticulum of the esophagus, left ventricular failure, acute on chronic systolic heart failure, and anorexia. Both the 5 day and 14 day MDS coded the resident with a brief interview for mental status as a 15. The Resident Immunization Record for Resident #70 documented that the resident received the influenza vaccination on 12/17/17 per the daughter (dated 3/8/18). A review of Section O on the 5-day and 14 day MDS was coded with a 1. 1 read Resident not in this facility during this year's influenza vaccination season. The surveyor interviewed the director of nursing on 4/10/18 at 11:22 a.m. regarding what the influenza season was for the facility. The DON stated the flu season was October 1st through March 31st. The surveyor interviewed the minimum data set assessment licensed practical nurse #1 on 4/10/18 at 1:59 p.m. regarding the coding of Section O on the 5-day and 14 day MDS. MDS/LPN #1 stated, I'll modify it. Flu season ends in December 2017. Daughter brought evidence of flu during a care plan meeting on 3/8/18. Will do modifications. The surveyor informed the administrator and the director of nursing of the above coding issue during the end of the day meeting on 4/10/18 at 4:55 p.m., 4/11/18 at 5:15 p.m. and again on 4/12/18 at 3:15 p.m. No further information was provided prior to the exit conference on 4/12/18. 11. The facility staff failed to accurately code Section M and Section O on Resident #50's 60 day minimum data set MDS) assessment with an assessment reference date (ARD) of 3/7/18. The clinical record of Resident #50 was reviewed 4/9/18 through 4/12/18. Resident #50 was admitted to the facility 5/6/09 and readmitted [DATE] with diagnoses that included but not limited to hemiplegia following cerebral vascular accident affecting unspecified side, adult failure to thrive, B12 nutritional deficiency, cognitive communication deficit, depressive disorder, adrenocortical insufficiency, aphasia, hypertension, nontoxic multinodal goiter, hypothyroidism, bilateral deep vein thrombosis, hypoxia, dementia, and anemia. Resident #50's 60 day minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/7/18 assessed the resident with short-term memory problems, long-term memory problems and moderately impaired cognitive skills for daily decision making. No indicators of delirium, behaviors or psychosis. (a). The facility failed to accurately code a stage 2 pressure ulcer in Section M Skin Conditions on the 60 day MDS with ARD of 3/7/18. The surveyor reviewed the wound care doctor's progress note dated 2/28/18. The note read Pressure Wound of the Right Heel pressure stage 2 duration greater than 1 day, healing, manage pain and Pressure Ulcer sacrum pressure stage 2 duration greater than 1 day, healing manage pain. Section M Skin Conditions and specifically Section M0150 Risk of Pressure Ulcers was coded resident was at risk of developing pressure ulcers. M0210 Unhealed pressure ulcer(s) was coded with a 0-does this resident have one or more unhealed pressure ulcer (s) at stage 1 or higher. The code was 0 with instructions to skip to M0900, Healed Pressure Ulcers. The surveyor interviewed the minimum data set (MDS) assessment licensed practical nurse #1 on 4/12/18. MDS/LPN #1 stated the area was coded as moisture associated skin damage. MDS/LPN #1 stated she would do a correction as Section M was not accurately coded. (b). The facility failed to accurately code the influenza vaccine in Section O Special Treatments, Procedures and Programs. Section O Special Treatments, Procedures and Programs was reviewed. Section O0250 Influenza Vaccine was coded 0 and instructions to skip to O0250C, If influenza vaccine not received, state reason. Section C was coded 5-not offered. The surveyor was unable to locate immunization record for Resident #50. The facility provided the discharge summary notes from Resident #50's discharge date d 12/5/17. The discharge summary read Influenza Vaccine-Patient refused. Section C options also included: 1. Resident not in this facility during this year's influenza vaccination season. 2. Resident received outside of this facility. 3. Not eligible-medical contraindication 4. Offered and declined. 5. Not offered. 6. Inability to obtain influenza vaccine due to a declared shortage. 9. None of the above. The surveyor interviewed MDS/LPN on 4/11/18 at 4:56 p.m. regarding coding for the influenza vaccine. MDS/LPN #1 stated she would correct Section O. The surveyor informed the administrator, the director of nursing, and the corporate registered nurse in the end of the day meeting on 4/11/18 at 5:15 p.m. and again on 4/12/18 at 3:15 p.m. No further information was provided prior to the exit conference on 4/12/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 12. For Resident #284, the facility staff failed to provide a written copy of the baseline care plan. Resident #284 was admitted to the facility 04/07/18. Diagnoses included but not limited to cerebral infarction, hypertension and aphasia. The Resident was a new admit and had not had a MDS (minimum data set) completed, but was assessed to be alert and oriented. The surveyor spoke with the MDS coordinator and requested a copy of the Resident's baseline care plan on 04/10/18 at approximately 0915. The surveyor could not locate any evidence that a written summary of the care plan had been provided to the Resident or the Resident's representative. Surveyor spoke with the MDS coordinator on 04/101/8 at approximately 0945 regarding providing a summary of the baseline care plan. MDS coordinator stated the Resident/representative had not been provided a summary of the care plan. Also stated that she had heard about this, but had not read about it thoroughly. The concern of not providing the Resident with a copy of the baseline care plan was discussed with the administrative team during a meeting on 04/101/8 at approximately 1655. No further information was provided prior to exit. 10. For Resident #45, the facility staff failed to provide the Resident and/or representative with a summary of the baseline care plan. The record review revealed that Resident #45 had been admitted to the facility 01/31/18. Diagnoses included, but were not limited to, diabetes, depression, hypertension, and chronic obstructive pulmonary disease. Section C (cognitive patterns) of the Residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/07/18 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. During an interview with the MDS coordinator on 04/12/18 at approximately 9:25 a.m., the MDS coordinator verbalized to the surveyor that she had not provided the Resident and/or representative with a summary of the baseline care plan, as she was not aware that she needed to. The administrative staff was notified of the issues regarding the Residents baseline care plan on 04/12/18 at approximately 3:12 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference. 11. For Resident #234, the facility staff failed to provide the Resident and/or representative with a summary of the baseline care plan. The record review revealed that Resident #234 had been admitted to the facility 03/28/18. Diagnoses included, but were not limited to, atrial fibrillation, osteoarthritis, functional quadriplegia, and hypertension. There was no MDS (minimum data set) assessment information completed on this Resident. During an interview with the MDS coordinator on 04/11/18 at approximately 10:35 a.m., the MDS coordinator verbalized to the surveyor that she had not provided the Resident and/or representative with a summary of the baseline care plan, as she was not aware that she needed to. The administrative staff was notified of the issues regarding the Residents baseline care plan on 04/12/18 at approximately 3:12 p.m. No further information regarding his issue was provided to the survey team prior to the exit conference. Based on staff interview and clinical record review, the facility staff failed to provide the resident and/or their representative with a summary of the baseline care plan for 12 of 25 Residents in the survey sample (Resident #65, #67, #76, #184, #79, #50, #70, #134, #136, #45, #234 and #284). The findings included: 1. The facility staff failed to provide the resident and representative with a summary of the baseline care plan for Resident #65. Resident #65 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to diabetes, Multiple Sclerosis, Manic Depression and Psychotic Disorder. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/28/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #65 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent on 1 staff member for bathing. The surveyor performed a clinical record review on 4/11and 4/12/18 on Resident #65. It was noted by the surveyor that no documentation was in the clinical record that stated the baseline care plan for Resident #65 was given to the resident and representative when the resident was readmitted to the facility on [DATE]. The surveyor notified MDS nurse #1 of the above documented findings on 4/12/18 at 2 pm. The MDS nurse #1 stated, I didn't know that I should had been doing them. The surveyor notified the administrative team of the above documented findings on 4/12/18 at 3:12 pm. No further information was provided to the surveyor prior to the exit conference on 4/12/18. 2. The facility failed to provide the resident and representative with a summary of the baseline care plan for Resident #67. Resident #67 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, heart failure, high blood pressure, Alzheimer's disease, dementia, Parkinson's disease, anxiety disorder, depression, manic depression and Chronic Obstructive Pulmonary Disease. On the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/22/18 coded the resident with a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #67 was also coded as requiring limited assistance of 1 staff member for dressing and extensive assistance of 1 staff member for personal hygiene. Resident #67 was also coded as being totally dependent on 1 staff member for bathing. The surveyor performed a clinical record review on Resident #67 on 4/10/18. It was noted by the surveyor that no documentation was in the clinical record that stated the baseline care plan for Resident #67 was given to the resident and representative when the resident was readmitted to the facility on [DATE]. During the resident interview conducted by the surveyor on 4/10/18 at 9:57 am, the resident stated when asked by the surveyor if she was given a copy of the baseline care plan when she was readmitted to the facility in January, I don't remember. The surveyor notified MDS nurse #1 of the above documented findings on 4/10/18 at approximately 11:15 am in the conference room. The MDS nurse #1 stated, I didn't know that I should had been doing them. I was notified of the change but I didn't thoroughly understand it at the time. The surveyor notified the administrative team on 4/10/18 at 4:58 pm and on 4/12/18 at 3:12 pm of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 4/12/18. 3. The facility failed to provide the resident and representative with a summary of the baseline care plan for Resident #76. Resident #76 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, high blood pressure, dementia, seizure disorder and depression. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/26/18; the resident was coded as having short term and long-term memory loss and being moderately impaired in making daily decisions. Resident #76 was also coded as being totally dependent on 1 staff member for dressing, personal hygiene and bathing. The surveyor performed a review of Resident #76's clinical record on 4/10/18. During the clinical record review, the surveyor did not find any documentation that the baseline care plan was given to the resident and representative at the time of readmission to the facility on 2/14/18. The surveyor notified MDS nurse #1 of the above documented findings on 4/10/18 at approximately 11:15 am in the conference room. The MDS nurse #1 stated, I didn't know that I should had been doing them. I was notified of the change but I didn't thoroughly understand it at the time. The surveyor notified the administrative team on 4/10/18 at 4:58 pm and on 4/12/18 at 3:12 pm of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 4/12/18. 4. The facility failed to provide the resident and representative with a summary of the baseline care plan for Resident #184. Resident #184 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to sepsis, cerebral aneurysm, enterocolitis related to C-Diff, malignant neoplasm of lung, high blood pressure and malignant neoplasm of the brain. The admission MDS (Minimum Data Set) had not been completed at the time of this survey in the nursing facility. According to the admission nursing assessment dated for 4/6/18, it was documented that the resident is alert and oriented. It was also documented that Resident #184 requires extensive assistance of 1 staff member for transfers, walking, personal hygiene and bathing. During the clinical record review performed by the surveyor on 4/11 and 4/12/18, it was noted that there was no documentation of the baseline care plan being given to the resident and representative when the resident was admitted to the facility on [DATE]. The surveyor had previously notified MDS nurse #1 on 4/10/18 at approximately 11:15 am in the conference room of no documentation concerning baseline care plans being given to the resident and representative when a resident was admitted or readmitted to the facility. At that time the MDS nurse #1 stated, I didn't know that I should had been doing them. I was notified of the change but I didn't thoroughly understand it at the time. The surveyor notified the administrative team on 4/12/18 at 3:12 pm of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 4/12/18. 5. The facility failed to provide the resident and representative with a summary of the baseline care plan for Resident #79. Resident #79 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to high blood pressure, diabetes, stroke, depression and Chronic Obstructive Pulmonary Disease. On the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/24/18 the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 5 out of a possible score of 15. The resident was also coded as requiring extensive assistance of 1 staff member for dressing and personal care and being totally dependent on 1 staff member for bathing. The surveyor performed a review of Resident #79's clinical record on 4/11/18. During this review, it was noted by the surveyor that there was no documentation of the baseline care plan being given to the resident and representative when the resident was readmitted to the facility on [DATE]. The surveyor had previously notified MDS nurse #1 on 4/10/18 at approximately 11:15 am in the conference room of no documentation concerning baseline care plans being given to the resident and representative when a resident was admitted or readmitted to the facility. At that time the MDS nurse #1 stated, I didn't know that I should had been doing them. I was notified of the change but I didn't thoroughly understand it at the time. The surveyor notified the administrative team on 4/12/18 at 3:12 pm of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 4/12/18. 6. The facility staff failed to provide Resident #70 or Resident #70's representative with a copy of the baseline care plan. The clinical record of Resident #70 was reviewed 4/9/18 through 4/12/18. Resident #70 was admitted to the facility 2/19/18 with diagnoses that included but not limited to atrial fibrillation, bradycardia, hypokalemia, long QT syndrome, enterocolitis due to Clostridium difficle, anxiety disorder, chronic obstructive pulmonary disease, hyperlipidemia, pulmonary hypertension, Takotsubo syndrome, diverticulum of the esophagus, left ventricular failure, acute on chronic systolic heart failure, and anorexia. Both the 5 day and 14 day MDS coded the resident with a brief interview for mental status as a 15. The surveyor interviewed Resident #70 on 4/10/18 at 11:00 a.m. The surveyor asked the resident if the facility gave her a copy of her admission or baseline care plan. Resident #70 didn't recall getting one. The surveyor interviewed the minimum data set (MDS) assessment licensed practical nurse #1 4/10/18. MDS/LPN #1 stated she had not done any baseline care plans on any residents and stated she had heard about doing them but had not read about it thoroughly. The surveyor informed the administrator and the director of nursing of the above concern during the end of the day meeting on 4/11/18 at 5:15 p.m. and again on 4/12/18 at 3:15 p.m. No further information was provided prior to the exit conference on 4/12/18. 7. The facility staff failed to provide Resident #134 or Resident #134's representative a copy of the baseline care plan. The clinical record of Resident #134 was reviewed 4/9/18 through 4/12/18. Resident #134 was admitted to the facility 6/29/10 and readmitted [DATE] with diagnoses that included but not limited to status-post left above the knee amputation due to infected left knee hardware, chronic non-ambulation, osteoarthritis of knee, asthma, hypothyroidism, Alzheimer's disease, hyperlipidemia, glaucoma, chronic obstructive pulmonary disease, dementia without behavioral disturbances, hypertension, angina pectoris, cardiac pacemaker, blindness right eye, urine retention, and coronary artery disease. Resident #134's 5 day admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 4/2/18 assessed the resident with short-term memory problems, long-term memory problems, and moderately impaired cognitive skills for daily decision making. The surveyor reviewed the current comprehensive care plan dated 3/26/18 found in the clinical record; however, the baseline care plan was unable to be located. The surveyor interviewed Resident #134's daughter on 4/11/18 at 10:47 a.m. The daughter stated a baseline care plan was not given to her when her mom was readmitted [DATE]. The surveyor interviewed the minimum data set (MDS) licensed practical nurse #1 on 4/11/18 at 4:56 p.m. MDS/LPN #1 stated she did not do any baseline care plans for any of the residents. The surveyor informed the administrator and the director of nursing of the above concern during the end of the day meeting on 4/11/18 at 5:15 p.m. and again on 4/12/18 at 3:15 p.m. No further information was provided prior to the exit conference on 4/12/18. 8. The facility staff failed to provide Resident #136 or Resident #136's representative a copy of the baseline care plan. The surveyor reviewed Resident #136's clinical record 4/9/18 through 4/12/18. Resident #136 was admitted to the facility 4/1/18 with diagnoses that included but not limited to hypertension, urinary tract infection, chronic obstructive pulmonary disease, radiculopathy, trochanteric bursitis, morbid obesity, right artificial hip joint, osteoarthritis, gastrointestinal hemorrhage, sleep apnea, depressive disorder, iron deficiency anemia, and venous thrombosis and embolus. Resident #136's admission minimum data set (MDS) had not yet been completed. The clinical record contained a baseline care plan dated 4/2/18. Instructions at the top of the baseline care plan read The Baseline Care Plan must be developed within the first 48 hours of admission to the facility. The Baseline Care Plan must reflect the resident's stated goals and preferences and include interventions that address his/her current needs. Complete all sections. Signatures are required as designated. The baseline care plan did not have a signature of the resident or the resident representative. The only signature was that of the minimum data set licensed practical nurse #1 and dated 4/3/18. The surveyor interviewed Resident #136 on 4/10/18 at 4:00 p.m. Resident #136 stated she did not recall receiving a care plan when first admitted . The surveyor interviewed the minimum data set (MDS) assessment licensed practical nurse #1 on 4/10/18 at 4:56 p.m. MDS/LPN #1 stated she did not complete a baseline care plan on any of the residents. The surveyor informed the administrator, the director of nursing, and the corporate registered nurse of the above concern on 4/11/18 at 5:15 p.m. and again on 4/12/18 at 3:12 p.m. No further information was provided prior to the exit conference on 4/12/18. 9. The facility staff failed to provide Resident #50 or Resident #50's representative a copy of the baseline care plan. The clinical record of Resident #50 was reviewed 4/9/18 through 4/12/18. Resident #50 was admitted to the facility 5/6/09 and readmitted [DATE] with diagnoses that included but not limited to hemiplegia following cerebral vascular accident affecting unspecified side, adult failure to thrive, B12 nutritional deficiency, cognitive communication deficit, depressive disorder, adrenocortical insufficiency, aphasia, hypertension, nontoxic multinodal goiter, hypothyroidism, bilateral deep vein thrombosis, hypoxia, dementia, and anemia. Resident #50's 60 day minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/7/18 assessed the resident with short-term memory problems, long-term memory problems and moderately impaired cognitive skills for daily decision making. No indicators of delirium, behaviors or psychosis. The surveyor reviewed the current comprehensive care plan dated 1/10/18. However, the surveyor was unable to locate a copy of the baseline care plan in the clinical record. The surveyor interviewed the minimum data set (MDS) assessment licensed practical nurse #1 on 4/10/18 at 4:56 p.m. MDS/LPN #1 stated she did not complete a baseline care plan on any of the residents. The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above concern on 4/11/18 at 5:15 p.m. and again on 4/12/18 at 3:15 p.m. No further information was provided prior to the exit conference on 4/12/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to maintain complete and accurate clinical records for five of 25 Residents. Residents #45, #57, #234, #48, and #87. The findings included. 1. For Resident #45, the facility staff failed to file a consultation report from the pharmacist for the month of February in the Residents clinical record. The record review revealed that Resident #45 had been admitted to the facility 01/31/18. Diagnoses included, but were not limited to, diabetes, depression, hypertension, and chronic obstructive pulmonary disease. Section C (cognitive patterns) of the Residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/07/18 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. The clinical record included a progress note transcribed by the pharmacist on 02/14/18 at 1:05 p.m.See report for any noted irregularities and/or recommendation. When reviewing the clinical record the surveyor was unable to find the results of this consult. The facility provided the surveyor a copy of this consult on 04/12/18. No explanation was provided as to why it was not in the clinical record. The administrative staff was notified of this issue on 04/12/18 at approximately 3:12 p.m. Prior to the exit conference, the facility staff provided the surveyor with a copy of their policy/procedure titled Charting and Documentation. This policy/procedure read in part, All services provided to the resident .or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #57, the DON (director of nursing) failed to sign the pharmacy consultation report for January 2018. The record review revealed that Resident #57 was admitted to the facility 09/26/13. Diagnoses included but were not limited to, cerebral infarction, Alzheimer's disease, and dysphagia. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 03/07/18 included a BIMS (brief interview for mental status) summary score of 9 of 15 points. The clinical record included a pharmacy consultation report for January 2018. This report included recommendations from the consulting pharmacy. The physician had signed this report on 01/22/18. The line for the DON to sign had been left blank. During an interview with the DON on 04/11/18 at approximately 10:05 a.m., the DON verbalized to the surveyor that she had reviewed the pharmacy consult but had not signed it. The administrative staff was notified of this issue on 04/12/18 at approximately 3:12 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #234, the facility staff failed to document for the administration of medications and supplements on 04/06/18. The record review revealed that Resident #234 was admitted to the facility 03/28/18. Diagnoses included, but were not limited to, chest pain, atrial fibrillation, osteoarthritis, functional quadriplegia, and essential hypertension. There was no completed MDS (minimum data set) assessment on this Resident. However, the Resident was alert and orientated. A review of the Residents eMARs (electronic medication administration records) for the month of 04/2018 revealed that for 04/06/18 the nursing staff failed to document for the administration of miralax powder, colace, klor-con, furosemide, zyrtec, fluticasone, cardizem, protonix, lopressor, flovent, alum-mag hydroxide, pro-stat, and med pass. On 04/11/18 at approximately 2:25 p.m., the surveyor and the unit manager reviewed the eMARs for 04/06/18. After this review, the unit manager stated she would review the clinical record further. On 4/11/18 at approximately 3:10 p.m., LPN (licensed practical nurse) #1 verbalized to the surveyor that she had not felt well on 04/06/18 and had to leave work. LPN #1 stated she had not hit the final button but the medicines were administered and prepared. During an interview with Resident #234 on 04/11/18 at approximately 3:45 p.m., the Resident stated she had received all her medications. The administrative staff was notified of this issue on 04/12/18 at approximately 3:12 p.m. Prior to the exit conference, the facility staff provided the surveyor with a copy of their policy/procedure titled Charting and Documentation. This policy/procedure read in part, All services provided to the resident .or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .The following information is to be documented in the resident medical record .medication administered . No further information regarding this issue was provided to the survey team prior to the exit conference. 4. The facility staff failed to document the clip alarm that was ordered to be worn at all times for safety on the December 2017 through April 2018 medication administration record/treatment administration record for Resident #48. The clinical record of Resident #48 was reviewed 4/9/18 through 4/12/18. Resident #48 was admitted to the facility 11/28/17 with diagnoses, that included but not limited to Alzheimer's disease, dementia with behavioral disturbances, major depressive disorder, anxiety, adult failure to thrive, and history of falling. Resident #48's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/5/18 assessed the resident with long-term memory problems, short-term memory problems, and moderately impaired cognitive skills for daily decision-making. No identified indicators of psychosis, delirium, or behaviors. The surveyor reviewed the December 2017 physician order sheet. The physician order dated 12/5/17 read Resident to wear a clip alarm at all times for safety. The surveyor reviewed the December 2017 through April 2018 electronic treatment administration records (eTAR) but found no evidence the treatment had been documented as done. The entry on the December 2017 eTAR read Resident to wear a clip alarm at all times for safety. However, December 1 through December 4 had **** (asterisks) for documentation. After 12/4/17, each box was blank from 12/5/17 through 12/31/17. The same for January 2018 through April 2018. The surveyor informed the corporate registered nurse on 4/10/18 at 3:53 p.m. of the surveyor's inability to locate documentation of the order for the clip alarm. The corporate RN stated the clip alarm was ancillary and it would be charted in an alarm book. The surveyor informed the administrator and the director of nursing of the above concern on 4/10/18 at 4:55 p.m. On 4/11/18, the surveyor was provided a Medication Error Report dated 4/10/18 from the director of nursing. The DON stated the order was entered on the eTAR but a time interval or time code was not. The DON stated there was no negative outcome to the resident. The surveyor reviewed the facility policy on documentation titled Charting and Documentation on 4/12/18. The policy read in part 2. The following information is to be documented in the resident medical record: c. Treatments or services performed. No further information was provided prior to the exit conference on 4/12/18. 5. The facility staff failed to document physician ordered treatments to the right inner thigh of Resident #87 on 6/26/17 and 6/27/17. The clinical record of Resident #87 was reviewed 4/11/18 through 4/12/18. Resident #87 was admitted to the facility 10/9/14, readmitted [DATE] and discharged [DATE]. Resident #87's diagnoses included but not limited to morbid obesity, acute embolism and thrombosis of lower extremity, hypertension, dysphagia, hyperlipidemia, transient cerebral ischemic attacks, flaccid hemiplegia, pain, Type 2 diabetes mellitus, chronic kidney disease, vascular dementia, aphasia, vitamin D deficiency, urinary tract infection, cognitive communication deficit, expressive language disorder and severe stress. Resident #87's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 5/22/17 assessed the resident with a BIMS score of 5/15 in Section C. There were no indicators of delirium, psychosis, or behaviors affecting others. Resident #87 was totally dependent on 2 persons for bed mobility, transfers, dressing, toilet use, personal hygiene, locomotion on and off the unit. Resident #87 required extensive assistance of 1 person for eating. Functional limitation in range of motion was assessed in both upper and lower extremities on one side. Resident #87 was frequently incontinent of bladder and always incontinent of bowel. Resident #87 was identified to be at risk for the developing of pressure ulcers. No pressure ulcers were currently identified. Resident #87's current comprehensive care plan dated 10/9/14 identified a problem with onset date of 10/9/14 that read Potential for impaired skin integrity r/t (related to) dx (diagnosis) of CVA, rt (right) sided weakness, decrease in mobility, incontinence of B&B (bowel and bladder), obesity, and hx (history) of sheared area, fungal infections, moisture associated skin damage, refuses all showers. Approaches: Monitor for incont. (incontinence) q (every) 2 hrs (hours) and prn (as needed)-change promptly-provide cream care and barrier cream as ordered/needed, assist with repositioning q 2 hrs and prn, encourage po and fluid intake, monitor skin integrity daily and weekly, treatment as ordered, apply protective oint (ointment)/powder to skin as ordered/needed, apply specialty mattress as ordered, off load heels while in bed. The visual body map completed 6/23/17 shows 99 at right inner thigh front. Legend on the visual body map for 99=other. Wound Assessment Report Drainage=serous, small. No pain, no edema, measured 0.5 centimeters (length) x 2.50 cm (width) x 0.00 cm (depth). MD (medical doctor) and responsible party notified 6/23/17. Current weight 322 pounds. Orders dated 6/23/17 read Cleanse R (right) inner thigh with DWC (dermal wound cleanser) pat dry, apply skin prep to surrounding area, apply wound gel to wound bed and cover with allevyn foam, change dressing qd (every day) and prn. The June 2017 and July 2017 treatment administration records were reviewed. The June 2017 entries from 6/23/17 through 6/30/17 were reviewed and 7/1/17 through 7/2/17. There were 2 days (6/26/17 and 6/27/17) where there is no documentation that care was provided. The Departmental Notes from 6/1/17 through 7/5/17 were reviewed. There was not a note for 6/26/17 or 6/27/17 for wound care provided. The surveyor requested the facility policy on pressure ulcer care from the administrator and the director of nursing on 4/12/18. The policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol read in part 2. In addition, the nurse shall describe and document/report the following: d. Current treatments, including support surfaces. The surveyor reviewed the facility policy on documentation titled Charting and Documentation on 4/12/18. The policy read in part 2. The following information is to be documented in the resident medical record: c. Treatments or services performed. No further information was provided prior to the exit conference on 4/12/18.