Based on staff interviews, clinical record review, the facility's staff failed follow physician orders for one (1) of 35 residents in the survey sample, Resident #71. The findings include: Resident #71 was originally admitted to the facility 12/29/22 from the community. The current diagnoses included Atrial Fibrillation and Heart Disease. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 01/05/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #71 cognitive abilities for daily decision making were intact. The care plan dated 1/10/23 reads, FOCUS: The resident has Congestive Heart Failure. GOAL: The resident will remain free from symptoms of other cardiac complications. INTERVENTION: Administer diuretics. A review of physician orders for February 2023 read: Knee high Thrombo-Embolus Deterrent (TED). TED Hose to Bilateral Lower Extremitiesv (BLE) apply in the morning and remove at bedtime. Active 2/24/2023 20:00/8:00 PM. On 03/07/23 at approximately 1:17 PM., during the initial tour, Resident lower extremities were red and edematous. Thrombo-Embolus Deterrent (TED) hose were not observed on the Resident's lower extremities. Resident #71 said that she may have to order her stockings online because the staff stated they did not have any. An interview was conducted with Certified Nursing Assistant (CNA) #2 on 3/09/23 at approximately 12:50 PM., concerning Resident #71. She said that she was a floater on the floor for 3/9/23 (usually not assigned to Resident #71) but usually she would tell her supervisor if a resident's legs and feet are swollen and the supervisor would determine if the resident needed TED hose stockings. On 3/09/23 at approximately 12:55 PM., an interview was conducted with Licensed Practical Nurse (LPN) #1. She said that the resident wanted to order her own TED hose. She stated that the facility usually got an order from the provider, then measured the resident's extremities for the TED stockings once an order was obtained. 03/09/23 1:30 PM Resident #71 said, I am happy because I received my TED hose stockings this morning after all this time. TED hose may be prescribed to patients who are non-ambulatory, meaning they are not up and moving around on their own. For these patients, the risk of a blood clot developing in their legs is a main concern for health care providers, as clots can break free and travel through the bloodstream to the lungs and cause a pulmonary embolism. TED hose help reduce this risk by administering pressure on the lower part of the leg and feet - with the most compression occurring at the calf muscle. As patients lay in bed, blood is more likely to pool in the calf, creating the right environment for a clot to form. TED hose compression levels are measured in mmHg, or millimeters of mercury, just as we measure our blood pressure. TED hose compression levels are 20 mmHg or below. Patients may wear TED hose for up to three weeks, at which time they are mobile once again or have been prescribed a different treatment to reduce the risk of blood clots. https://hillcrestsouth.com/news/when-should-you-wear-ted-hose-or-compression-socks. An interview was conducted on 3/09/23 at approximately 3:30 PM., with the Assistant Director of Nursing (ADON) concerning TED hose stockings. She said that she would expect the CNA to report any swelling issues of the lower extremities or skin issues, but there was a physician's order in February that had not been implemented for TED hose to be applied to both of the resident's legs. On 03/09/2023 at approximately 5:00 PM., the above findings were shared with the Administrator, Director of Nursing (DON) and Corporate Consultant. The DON stated the resident should have had the TED hose per the physician's order.

Based on resident interview, staff interviews, clinical record review, and facility document review the facility staff failed to assess resident for self-administration of medication for 1 of 36 residents (Resident #184) in the survey sample. The findings included: The facility staff failed to assess Resident #184 for self-administration of Fluticasone nasal spray. Resident #184 was admitted to the nursing facility on 12/31/19. Diagnoses for Resident #184 included, but not limited to, seasonal allergies, rhinitis and Chronic Obstructive Pulmonary Disease (COPD). The resident's Minimum Data Set (MDS) assessment was not due. During the initial tour of the facility on 01/14/20 at approximately 11:29 a.m., a bottle of Fluticasone Proplonate nasal spray 50-mcg was observed at Resident #184's bedside; on her over bed table in direct view. The resident said she used the nasal spray this morning, one spray in each nostril because she has bad allergies. On 01/15/20 at approximately 9:10 a.m., the Fluticasone Proplonate nasal spray 50-mcg remained at Resident #184's bedside; on her over bed table in direct view. On the same day at approximately 12:30 p.m., the nasal Fluticasone nasal spray remains at bedside. Review of the Physician Order Sheet and Medication Administration Record (MAR) for January 2020 starting on 12/31/19, read: Fluticasone Proplonate nasal spray 50-mcg - 1 spray in each nostril as needed one time daily. On 01/15/20 at approximately 12:35 p.m., License Practical Nurse (LPN) #1 went to Resident #184's room. The LPN went into Resident #184's room while the surveyor remained outside the resident's door. The LPN came out of Resident #184's room with the Fluticasone Proplonate nasal spray 50-mcg. The nurse was asked, if Resident #184 had an order to self-administer medications, she replied, No. The surveyor asked, What is the facility's policy for a resident to self-administer medications. The LPN stated, The resident needs to be evaluated and the physician must be notified before a resident is allowed to self-administer medications. The LPN stated, (Resident #184) and her family need to be educated about bring medications being brought in for (Resident#184) to self-administer. A briefing was held with the Administrator, Director of Nursing (DON) and Cooperate staff on 01/16/20 at approximately 3:15 p.m. The DON said Resident #184 should have been assessed, if the resident passes the self-administration assessment than an order is obtained to leave at bedside. The facility's policy: Self-Administered Medications and Treatments (Last revised date - 12/2012). -Standard: Self-administered medications and treatments must be carefully monitored and recorded in the Medication Administration Record (MAR) and Treatment Record (TAR). -Policy: Self-administration of medications or treatments by residents is permitted by the physician order that includes dosage, route, and any special instructions. Procedures include but not limited to . -The head nurse manager or team leader assesses resident competency to self-administer. -A decision to permit self-administration is made in concert with the resident. -Obtain an order from physician. Record on MAR. -Explain procedure to resident. Definitions: Fluticasone Proplonate is used to relieve hay fever, and other allergy symptoms, or nonallergic rhinitis, it is usually sprayed in each nostril once daily (https://medlineplus.gov/druginfo/meds/a695002.html).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #43 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Respiratory Failure and Heart Failure. Resident #43's Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 11/12/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 11 indicating moderate cognitive impairment. On 01/15/2020 a copy of Resident #43's Advance Directive was requested. On 01/15/2020 at 3:20 p.m., an interview was conducted with the Quality Improvement and Compliance Manager, when she was asked the process for reviewing Advance Directives with residents, new admissions, the Quality Improvement and Compliance Manager stated, The process we follow is admissions reviews resident rights with the resident and reviews how to formulate advance directives with the resident. The Surveyor requested evidence of what information the Admissions Director reviewed with the resident. An interview was conducted with Other Staff Member (OSM) #2, Admissions Director, on 01/15/2019 at 4:15 p.m. when asked to explain the process concerning Advanced Directives, the Admissions Director stated, We review the facility agreement with the resident and review resident rights, the right to request, refuse and / or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. If the resident has an advance directive we scan it into the medical record. If the resident does not have an advance directive we ask them if they would like to formulate an advance directive and speak with the Social Worker. When the Admissions Director was asked where it is documented that they review advance directives and ask if they would like to formulate an Advance Directive, the Admissions Director stated, We do not document anywhere. We just have the resident sign the Signature Form. When the Admissions Director was asked if the residents refusal to formulate an Advance Directive should have been documented, the Admissions Director stated, Yes I think they should have documented if the resident refused to formulate an Advance Directive. The Admissions Director stated, An Acknowledgement of Receipt form was just implemented after an audit was done this past Thursday. On 01/15/2020 the Surveyor received copy of Resident #43's Durable Do Not Resuscitate Order dated 07/31/2019 and copy of The [NAME] Center Westminister Canterbury on Chesapeake Bay Signature Form. The facility was unable to provide evidence that the facility had offered the resident an opportunity to formulate an advance directive. The Administrator and Director of Nursing was made aware of the finding during briefing on 01/16/2020 at approximately 6:45 p.m. No further information was provided. Based on clinical record reviews, staff interviews and facility documentation review, the facility staff failed to ensure 3 of 36 residents (#184, #185, and #43), in the survey sample were given the opportunity to formulate an advance directive The findings included: 1. Resident #184 was admitted to the nursing facility on 12/31/19. Diagnoses for Resident #184 included but not limited to, Transient cerebral ischemia attack (mini-stroke) and Heart Failure. Review of the clinical record revealed that there were no advance directive for Resident #184. Review of Resident #184's Physician Order Sheet (POS) for January 2020 revealed the following order: Full Code starting on 12/31/19. On 01/15/20 at approximately 4:18 p.m., an interview was conducted with the Admissions Director who said an Advanced Directive should have been completed upon admission. She said an audit was started last week because the Advanced Directive were not being done. The Admissions Director said she was not sure why Resident #184's advanced directive was not completed. On 01/16/20, the following document titled: Advanced Directives/Medical Treatment Decisions with an issue date of 01/15/20 was received. The document contained the following information: -Organ Donation -Full Code -Other Advanced Directives type (life support for organ donation). -Signed and dated by the resident and admission Director on 01/20/20. A briefing was held with the Administrator, Director of Nursing and Cooperate on 01/16/20 at approximately 3:15 p.m. The facility did not present any further information about the findings. 2. Resident #185 was admitted to the nursing facility on 01/07/20. Diagnoses for Resident #185 included but not limited to, Chronic Obstructive Pulmonary Disease (COPD). Review of the clinical record revealed that there were no advance directive for Resident #185. Review of Resident #185's Physician Order Sheet (POS) for January 2020 revealed the following order: Full Code starting on 01/07/20. On 01/15/20 at approximately 4:18 p.m., an interview was conducted with the Admissions Director who said an Advanced Directive should have been completed upon admission. She said an audit was started last week because the Advanced Directive were not being done. The Admissions Director said she was not sure why Resident #185's advanced directive was not completed. On 01/16/20, the surveyor was given the following document titled: Advanced Directives/Medical Treatment Decisions with an issue date of 01/15/20. The document contained the following information: -I do not choose to formulate or issue any Advanced Directives at this time. -Signed and dated the signed by the resident, legal representative and the Lead Social Worker. A briefing was held with the Administrator, Director of Nursing and Cooperate on 01/16/20 at approximately 3:15 p.m. The facility did not present any further information about the findings.

Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to report an injury of unknown origin that resulted in a serious bodily injury (right hip fracture) on 07/11/19, within 2 hours to the State Survey Agency, for 1 of 36 residents (Resident #183) in the survey sample. The findings included: Resident #183 was admitted to the nursing facility on 07/10/19 with a diagnosis of left hip fracture. Resident #183 was discharged to the (local hospital) on 07/11/19 with an admitting diagnosis of right hip fracture. The resident's Minimum Data Set (MDS) assessment was not due at the time of discharge. Review of Resident #183's Nursing admission Assessment Comprehensive completed on 07/10/19 included but not limited to: -Cognitive patterns/mental health: short-term memory problem, no issues with long term-memory problem. -Transfer ability: 2 assist chair bound. -Toilet use: assist with toileting. A phone interview was conducted with Certified Nursing Assistant (CNA) #2 on 01/15/20 at approximately 12:17 p.m., who stated, I'm sorry but I really don't remember Resident #183. CNA #2 was assigned to Resident #183 on 07/11/19, the night Resident #183 stated she had fallen. A statement written by CNA #2 on 07/11/19 included but not limited to: transferred Resident #183 to her wheel chair with the assistance from (Registered Nurse-RN #3). Resident #183 sat quietly by the doorway watching TV until the end of the shift. A phone call was placed to Registered Nurse (RN) #3 on 01/15/20 at approximately 12:08 p.m. The RN was assigned to Resident #183 on 07/10/19-07/11/19 (7 p.m.-7 a.m.); a message was left, RN #3 never called back. A statement written by RN #3 on 07/11/19 was reviewed and included but not limited to: Resident #183 wanted to swing her legs in out of bed, stating she did not belong here. Resident #183 complained of pain saying, I cannot move my leg. The RN explained that swinging her legs back and forth trying to get out of bed would only cause more pain; resident was non-complaint. The RN said she and the CNA assisted Resident #183 using a gait belt into wheel chair. Chair alarm placed and working properly. Review of Resident #183's clinical notes were reviewed and included but not limited to: -07/11/19, revealed the following information: Therapy in to evaluate, per therapy Resident #183 was complaining of right hip pain and unable to move/lift right leg on evaluation with severe pain 10/10 on pain scale. Therapy was concerned. -07/11/19, included but not limited to: physician in to see Resident #183 with new orders to get an x-ray of right hip and EKG, hold therapy for today and to send Resident #183 if x-ray shows right hip fracture. Review of Physical Therapy note dated 07/11/19 read in part . -Pain Assessment: Resident #183 confused but stating she fell on right hip last night or this morning. No report per nursing. Review of Resident #183's Radiology Report dated 07/11/19 included the following: -Examination: Hip UNI with or without pelvis - 1 view, right. -Results: There is an acute femoral next fracture with moderate displacement. Review of Resident #183's clinical note dated 07/12/19 included the following: Resident #183 admitted to the hospital for right hip fracture. A briefing was held with the Administrator, Director of Nursing (DON) and Cooperate staff on 01/16/20 at approximately 3:15 p.m. It was discussed that Resident #183 had an x-ray done on 07/11/19, which revealed a right hip fracture, first identified while at the nursing facility. The Administrator was asked if Resident #183's right hip fracture; a fracture of unknown origin; the Administrator replied, Yes. The Administrator was asked if a Facility Reported Incident (FRI) submitted to the State Survey Agency; the Administrator stated, No. The facility's policy titled: Abuse Prevention, Detection, Investigation and Reporting (Revised 04/2017) included: -Reporting a. The organization will maintain systems to ensure that all alleged violations involving abuse neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident properly, are reported immediately, but not later than 2 hours after the allegation is made, if the events causes allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that case the allegation do not involve abuse and do not result in serious body injury, to the administrator of the facility, or his or her designee, and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. b. Each covered individual/mandated reporter shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury or crime, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a closed record review and staff interviews the facility failed to ensure that care plan goals were sent upon discharge to the hospital for 1 of 36 Residents in the survey sample, Resident #85. The findings included: Resident #85 was admitted to the facility on [DATE] with diagnoses to include but not limited to Major Depressive Disorder and Left Acetabulum Fracture. The most recent comprehensive Minimum Data Set was an admission Assessment with and a Assessment Reference Date (ARD) of 10/7/19. The Brief Interview for Mental Status (BIMS) was an 8 out of a possible 15 which indicated Resident #85 was moderately cognitively impaired. Resident #85 also has a Discharge/Return Not Anticipated Assessment with an ARD date of 10/17/19 that was reviewed. Under Section A2100 Discharge Status the resident was coded: Acute Hospital. Resident #85's Comprehensive Care Plan was reviewed and is documented in part, as follows: Problems: Fall with fracture, Risk for bleeding secondary to anticoagulant use, Diagnosis of depression, Risk for pain, Needs assist for mobility and activities and mobility (toe touch weight-bearing to left lower extremity), Alteration in cardiac output due to hypertension and atrial fibrillation, Risk for aspiration/dysphagia, and Malnutrition. Resident #85's Clinical Notes were reviewed and are documented in part, as follows: 10/17/19 at 23:47 (11:47) P.M.: Received call from laboratory with critical results: K+ (potassium) 7.1. Called placed to Name (Medical Doctor) orders fro Kayexalate 30gm(grams) STAT and send to hospital via 911: Resident lethargic, follows commands, VSS (vital signs stable), NAD (no apparent distress). Son at bedside, this nurse explained orders received and next steps to be taken. Son voices understanding. Paramedics arrived, report given, departed with resident. On 1/16/20 at approximately 11:30 A.M. and interview was conducted with the Administrator regarding Resident #85's discharge on [DATE] to the hospital and if care plan goals were sent upon discharge. The Administrator stated, I don't have any documentation to support the care plan goals were sent with the resident. We have a new process that we are beginning and will include that. There was no facility policy for care plan goals to be sent with the resident upon discharge to the hospital per the Administrator. Prior to exit no further information was shared by the facility staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a closed record review and staff interviews the facility staff failed to ensure that a bed-hold notice was sent upon discharge to the hospital for 1 of 36 Resident's in the survey sample, Resident #85. The findings included: Resident #85 was admitted to the facility on [DATE] with diagnoses to include but not limited to Major Depressive Disorder and Left Acetabulum Fracture. The most recent comprehensive Minimum Data Set was an admission Assessment with and a Assessment Reference Date (ARD) of 10/7/19. The Brief Interview for Mental Status (BIMS) was an 8 out of a possible 15 which indicated Resident #85 was moderately cognitively impaired. Resident #85 also has a Discharge/Return Not Anticipated Assessment with an ARD date of 10/17/19 that was reviewed. Under Section A2100 Discharge Status the resident was coded: Acute Hospital. Resident #85's Physician Orders were reviewed and are documented in part, as follows: 10/17/19: Send to ER (emergency room) via 911. On 1/16/20 at approximately 11:30 A.M. and interview was conducted with the Administrator regarding Resident #85's discharge on [DATE] to the hospital and if a bed-hold notice was sent upon discharge. The Administrator stated, We called the family the following day and offered the bed-hold, but no, we did not send a bed-hold notice when the Resident was discharged . There was no documented evidence of the bed-hold notice. There was no facility policy for bed-hold notices to be sent with the resident upon discharge to the hospital per the Administrator. Prior to exit no further information was shared by facility staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview and clinical record review the facility staff failed to ensure that the assessment accurately reflected one of 36 residents in the survey sample (Resident #20). The findings included: Resident #20 was originally admitted to the facility on [DATE] with a readmission date of 05/10/2019. Diagnoses included but were not limited to, Parkinson's Disease and Unspecified Dementia With Behavioral Disturbance. Resident #20's current Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date of 10/27/2019. Resident #20 was coded with a BIMS (Brief Interview for Mental Status) score of 03 indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #20 as requiring extensive assistance of 1 with personal hygiene, extensive assistance of 2 with bed mobility, transfer, dressing and toilet use, total dependence of 1 with eating and total dependence of 2 with bathing. On 01/16/2020 review of Resident #20's clinical record revealed that Section G0400 - Functional Limitation in Range of Motion on the Quarterly Assessment was coded with a coding of 2 impairment on both sides as A. Upper extremity and B. Lower extremity. On 01/16/2019 at 1:00 p.m., Resident #20 was observed in a wheelchair in his room and the nurse in his room provide verbal cues to the resident to lift his arms and straighten them. Resident #20 complied. The nurse provided verbal cues to Resident #20 to straighten his legs. Resident #20 complied with assistance from nurse. No limitations noted in upper extremities or left lower extremity. Minimal limitation noted in right knee. An interview was conducted with Registered Nurse (RN) #1, MDS Coordinator, on 01/16/2020 at approximately 1:30 p.m. When asked if the Range of Motion section of the MDS dated [DATE] was correct, RN #1 stated, I will check and get back with you. On 01/16/2020 at approximately 2:05 p.m., RN #1 stated, The MDS dated [DATE] is incorrect but the Nurse Progress Note dated 10/28/2019 is correct. RN #1 provided a copy of the Clinical Note Entry dated 10/28/2019 and the note read as follows: Per resident interview of 10/28. Has adequate hearing with hearing aides, has highly impaired vision without glasses but able to identify pen. Has no visible teeth. Has adequate ROM (Range of Motion). BIMS 3/15. Denies any pain or SOB (Shortness of Breath). RN #1 stated, I can't explain, obviously it is a two (2) and should be a zero (0). I will do a modification. When RN #1 was asked if the MDS dated [DATE] was an inaccurate assessment, RN #1 stated, Yes it is. RN #1 provided a modified copy of the MDS with Attestation date of completion, 01/16/2020, and a copy of CMS (Centers for Medicare and Medicaid Services) Submission Report on 01/16/2020 at approximately 3:00 p.m. The Administrator and Director of Nursing was informed of the finding at a briefing on 01/16/2020 at approximately 6:45 p.m. The facility did not present any further information about the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to develop a care plan for Resident #190 who was on isolation precautions due to a diagnosis of Clostridium Difficile Colitis (C-Diff). Resident #109 was admitted to the nursing facility on 01/02/20. Diagnosis included but not limited to, Entercolitis due to C-Diff. The resident's Minimum Data Set (MDS) assessment was not due. The review of Resident #190's comprehensive care plan did not include a care plan for the diagnosis of C-Diff. An interview was conducted with the Director of Nursing (DON) on 01/15/20 at approximately 4:35 p.m. The DON reviewed Resident #190's care plan then stated, Yes, Resident #190 should have a C-Diff care plan. On 01/16/20, a C-Diff care plan was given to the surveyor that was created on 01/15/20, but only after, it was requested. The review of the C-Diff care plan included but not limited to the following information: Resident #190 was admitted with recurrent C-Diff-antibiotic infection. Goal: isolation for C-Diff, monitor bowel frequency and consistency, transmission precautions as indicated per Infectious Diseases and GI until fecal transplant, provide teaching to resident, family and staff related to infection, good handwashing, precautions every shift as needed and resident on contact transmission based precautions for diagnosis of C-Diff. A briefing was held with the Administrator, Director of Nursing and Cooperate on 01/16/20 at approximately 3:15 p.m. The facility did not present any further information about the findings. The facility's policy: Life Care-Comprehensive Person Centered Care Planning (Revision 04/2020). Policy: A Preliminary (interim) care plan to meet the resident's immediate needs shall be developed for each resident with (48) hours of admission. Definitions: -C-Diff is a bacterium that causes diarrhea and colitis - an inflammation of the colon (https://www.cdc.gov). Based on observation, staff interview, clinical record review and facility document review, it was determined that facility staff failed to develop a comprehensive care plan for two of 36 residents in the survey sample (Residents #22 and #190). The findings included: 1. Resident #22 was admitted to the facility on [DATE] with diagnoses that include but were not limited to, chronic obstructive pulmonary disease and pneumonia. Resident #22's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 11/2/19. Resident #22 was coded as being moderately impaired in cognitive function scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #22 was coded in Section O Special Equipment as receiving oxygen therapy. On 1/14/20 at 11:30 a.m. and at 12:46 p.m., observations were made of Resident #22. Resident #22 was sitting in her recliner with her nasal cannula in place receiving 2 liters of oxygen. Review of Resident #22's January 2020 POS (physician order summary) revealed the following order dated 8/9/19 (admission order): Continuous oxygen at HS (at night) as ordered (specify in notes) .notes 02@(at) 2 L (liters)/min (minute) via nasal cannula at HS. Resident #22's admission assessment dated [DATE] documented that Resident #22 was receiving oxygen therapy upon admission to the facility. Review of Resident #22's comprehensive care plan dated 8/10/19, failed to evidence a care plan for oxygen therapy or a respiratory care plan. On 1/16/2020 an interview was conducted with LPN (Licensed Practical Nurse) #2, Resident #22's nurse. When asked if Resident #22 was on oxygen, LPN #2 stated that she was. LPN #2 stated that Resident #22 was admitted with oxygen to wear at night. LPN #2 stated that Resident #22 desated (oxygen desaturated) at night. When asked the purpose of the care plan, LPN #2 stated that the purpose of the care plan was to outline the plan of care to all clinical staff. When asked if she would expect to see the comprehensive care plan to reflect the resident's use of oxygen, LPN #2 stated that she would. When asked the typical nursing interventions for a resident on oxygen, LPN #2 stated that the care plan should address checking pulse oximetry, oxygen safety, changing tubing etc. LPN #2 confirmed that she could not find a care plan for oxygen on Resident #22's comprehensive care plan. On 1/16/2020 at 3:45 p.m., ASM (administrative staff member) #1, the Administrator and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. No further information was presented prior to exit. Facility policy titled, Comprehensive Person Centered Care Planning, documents in part, the following: The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process .each residents comprehensive care plan will describe the following: a. Services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to ensure the comprehensive care plan was revised based on changing goals, preferences and needs of the resident for 2 of 36 residents in the survey sample, Resident # 38, and #22. The findings included: 1. For Resident #38, the facility staff failed to revise the care plan when the residents Stage 4 pressure area was healed on the left heel. Resident #38 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Pressure Ulcer of Left Heel, Stage 4 and Paroxysmal Atrial Fibrillation. Resident #38's Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 11/21/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. On 01/16/2020 at approximately 6:00 p.m., the Wound Physicians Wound Evaluation and Management Summary for Resident #38 was reviewed and revealed the following: Summarized Wound Care Assessment And Individualized Treatment Plan - (Site 1) Stage 4 Pressure Wound Of The Left heel (Resolved on 10/14/2019). On 01/16/2020 at approximately 6:15 p.m., review of Resident #38's Comprehensive Care Plan with an effective date of 08/31/2019 - Present revealed the following problems and goals and are documented in part, as follows: At Risk For Falls R/T (Related To) decreased mobility r/t non-healing L (Left) heel Stage 4 pressure ulcer, DM (Diabetes Mellitus) 2, OP, CHF (Congestive Heart Failure), CAD (Coronary Heart Disease) and use of antidepressants. STATUS: Active (Current) Goals: Resident will transfer safely with assistance. STATUS: Active (Current) GOAL DATE: 3/4/2020; Self care deficit R/T advanced age, decreased mobility r/t nonhealing L heel Stage 4, DM 2, CHF, and HX (History) of CAD. STATUS: Active (Current) Goals: Will safely perform to maximal ability self care activities. STATUS:Active (Current) GOAL DATE: 3/4/2020; Risk for alteration in skin integrity R/T Stage 4 left heel; 09/3/19. Currently using air mattress and Prevalon boots. STATUS: Active (Current). Goals: (Resident Name) alteration area will resolve without complications and no other areas will occur. STATUS:Active (Current) GOAL Date: 3/4/2020; Pain R/T chronic pain and nonhealing L heel Stage 4 pressure ulcer. STATUS: Active (Current) Goals: Resident will state / demonstrate relief or reduction in pain intensity after receiving interventions. STATUS: Active (Current) GOAL DATE: 3/4/2020. An interview was conducted with the Director of Nursing (DON) on 01/16/2020 at 6:30 p.m., when asked if Resident #38 currently had a wound on her left heel, the DON stated, No, it is healed. When the DON was asked if the care plan should have been updated that the Stage 4 wound is healed on the left heel, the DON stated, Yes. When the DON was asked what her expectations are of the nurses and documenting in the care plans, the DON stated, I expect that they update the care plans. The Administrator and Director of Nursing was informed of the finding during a briefing on 01/16/2020 at approximately 6:45 p.m. The facility did not present any further information about the finding. 2. For Resident #22, facility staff failed to revise the care plan while she was receiving antibiotics for her recent diagnosis of pneumonia. Resident #22 was admitted to the facility on [DATE] with diagnoses that include but were not limited to chronic obstructive pulmonary disease and pneumonia. Resident #22's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 11/2/19. Resident #22 was coded as being moderately impaired in cognitive function scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. On 1/14/20 at 12:46 p.m., an interview was conducted with Resident #22. Resident #22 was sitting in he recliner with oxygen in place via nasal cannula at 2 liters/minute. Resident #22 stated that she had been sick for almost a week with pneumonia. Resident #22 stated that she was still receiving a shot for her pneumonia. Review of Resident #22's clinical record revealed that a chest x-ray had been performed on 1/7/2020. The following result documented in part: There is slight pneumonia involving the right lower lobe . Review of Resident #22's January 2020 POS (physician order summary) documented the following antibiotic orders for treatment of Resident #22's pneumonia: Rocephin (1) 1 gram solution for injection (2 gm) Vial intramusclar Hour of sleep for seven days. Starting 1/8/20 - Pneumonia. Azithromycin (2) 500 mg (milligrams) tablet (500 mg) Tablet Oral for One day starting 1/9/20 - Pneumonia Azithromycin 250 mg for four days starting 1/10/20 - Pneumonia. Review of Resident #22's comprehensive care plan dated 8/10/19 with revisions; failed to evidence a care plan reflecting Resident #22's pneumonia and antibiotic therapy. Review of Resident #22's January 2020 MAR (medication administration record) revealed Resident #22 was to receive her last dose of Rocephin on 1/14/20 night shift. On 1/16/20 at 10:36 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #2, Resident #22's nurse. When asked who was responsible for revising the care plan, LPN #2 stated that the interdisciplinary team updated the care plan as things change with the residents care. LPN #2 stated that floor nurses can also revise the care plan. When asked the purpose of the care plan, LPN #2 stated that the purpose of the care plan was to outline the plan of care to all clinical staff. When asked if a resident has a new infection and placed on antibiotics, if the care plan should be revised to reflect the new infection, LPN #2 stated that she would expect the care plan to be revised. LPN #2 confirmed that she could not find a current care plan for Resident #22's infection. LPN #2 stated that maybe Resident #22's pneumonia care plan had been resolved because her last dose of antibiotics was the night of the 14th (1/14/2020). This writer made LPN #2 aware that on 1/14/20 a care plan could not be found. On 1/16/2020 at 3:45 p.m., ASM (administrative staff member) #1, the Administrator and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. No further information was presented prior to exit. Facility policy titled, Comprehensive Person Centered Care Plan documents in part the following: The Care Planning/Interdisciplinary team is responsible for the review and updating of care plans: a. When requested by the resident/resident representative. b. When there has been a significant change in the resident's condition; c. When the desired outcome is not met; d. When the resident has been readmitted to the facility from the hospital stay; and e. At least quarterly and after each OBRA MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review the facility staff failed to meet professional standards of practice by incorrectly transcribing a medication order for Lasix (a diuretic) for one of 36 residents in the survey sample ( Resident #41). The findings included: Resident #41 was originally admitted to the facility on [DATE]. Diagnoses included but were not limited to, Acute on Chronic Systolic (Congestive) Heart Failure, Chronic Atrial Fibrillation and Unspecified Dementia without Behavioral Disturbance. Resident #41's Annual Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 11/24/2019 was coded with a BIMS (Brief Interview for Mental Status) of 06 indicating severe cognitive impairment. On 01/15/2020 a copy of a Medication Error/Incident Report dated 02/05/2019 was obtained and reviewed. Review of report revealed and was documented in part, the following: Description of incident: Lasix 60 mg. (Milligram) Q (Every) a.m. X (Times) 2 (Two) days with BNP, CBC (Complete Blood Count), BMP (Basic Metabolic Panel) 2/7/18 was written on M.D. (Medical Doctor) communication log - next to (Resident Name) but in communication with provider orders were meant for resident above (another Resident's Name) . An interview was conducted with the Medical Director on 01/15/2020 at 5:20 p.m. and he stated, The PA (Physician Assistant) wrote the order for Lasix 60 mg on the communication log for another resident. The Medical Director stated, I was made aware of of the med error on 02/05/2019 and I ordered to hold the evening dose and the next a.m. dose, each 20 mg doses of Lasix. The Medical Director stated, (Resident Name) already had an order for Lasix 20 mg twice a day. The Medical Director also stated, (Resident Name) was monitored for hypotension and no problems were noted. (Resident Name) labs - BUN went from 25 on 01/21/2019 to 23 on 2/15/2019 which was better - not significant but still better. When the Medical Director was asked if Resident #41 had any side effects from receiving the extra 40 mg. of Lasix on 02/05/2019, the Medical Director stated, No, none what so ever. On 01/16/2020 review of Resident #41's February 2019 Medication Administration Record revealed the following: Order for - Lasix 20 mg tablet (40 mg) Tablet Oral One Time Daily for Two Days Starting 02/05/2019 and an Order for - Lasix 20 mg tablet (20 mg) Tablet Oral Two Times Daily Starting 01/16/2019 - Nurse initialed boxes on 02/05/2019 indicating medications were administered as ordered. The nurse who transcribed the order no longer worked at the facility. On 01/16/2020, the facility policy titled - Medication Management Plan was reviewed and included: Purpose: To ensure that the right resident receives the right drug, in the right dose and dosage form, at the right time, via the correct rout, and to ensure the resident has the right response to the medication. To ensure that all staff responsible for medication administration are qualified and fully informed of all policies and procedures in medication management and the pharmacy operating procedures. The Administrator and Director of Nursing was made aware of the finding during briefing on 01/16/2020 at approximately 6:45 p.m. No further information was provided. Complaint Deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility record review, it was determined that facility staff failed to follow a physician's order for oxygen for one of 36 residents in the survey sample, Resident #22. The findings included: Resident #22 was admitted to the facility on [DATE] with diagnoses that include but were not limited to chronic obstructive pulmonary disease and pneumonia. Resident #22's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 11/2/19. Resident #22 was coded as being moderately impaired in cognitive function scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #22 was coded in Section O Special Equipment as receiving oxygen therapy. On 1/14/20 at 11:30 a.m. and at 12:46 p.m., an observation was made of Resident #22. Resident #22 was sitting in her recliner with her nasal cannula in place receiving 2 liters of oxygen. Resident #22 had stated that she was not sure why she needed her oxygen on; that she usually received oxygen at night. Resident #22 stated that staff tell her she needs it (oxygen). Resident #22 could not elaborate on who told her to wear her oxygen during the day. Review of Resident #22's January 2020 POS (physician order summary) revealed the following order dated 8/9/19 (admission order): Continuous oxygen at HS (at night) as ordered (specify in notes) .notes 02@(at) 2 L (liters)/min (minute) via nasal cannula at HS. On 1/16/20 at 10:36 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #2, Resident #22's nurse. When asked if Resident #22 needed oxygen, LPN #2 stated that Resident #22 had orders to wear 2 liters of oxygen at night. LPN #2 stated that Resident #22's oxygen desaturated at night. LPN #2 stated that her oxygen sometimes dropped below 90 percent on room air while sleeping. LPN #2 also stated that Resident #22 had prn (as needed) orders for oxygen. When asked if she could pull up the as needed orders, LPN #2 looked through Resident #22's clinical record and stated, I don't even see one. LPN #2 stated that Resident #22 should just be wearing oxygen at night if there are no active orders for PRN. When told LPN #2 about the above observations, LPN #2 stated that her oxygen should not have been in place during the day. On 1/16/2020 at 3:45 p.m., ASM (administrative staff member) #1, the Administrator and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. No further information was presented prior to exit. Facility policy titled, Oxygen Therapy, documents in part, the following: Oxygen administration requires a physician order that includes: 1. Medical Reason or Diagnosis 2. Flow Rate 3. Frequency of 02 saturation levels 4. Continuous or PRN administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review the facility staff incorrectly transcribed a medication order for one of 36 residents in the survey sample ( Resident #41), which resulted in the resident receiving an unnecessary dose of Lasix (a diuretic). The findings included: Resident #41 was originally admitted to the facility on [DATE]. Diagnoses included but were not limited to, Acute on Chronic Systolic (Congestive) Heart Failure, Chronic Atrial Fibrillation and Unspecified Dementia without Behavioral Disturbance. Resident #41's Annual Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 11/24/2019 was coded with a BIMS (Brief Interview for Mental Status) of 06 indicating severe cognitive impairment. On 01/15/2020 a copy of a Medication Error/Incident Report dated 02/05/2019 was obtained and reviewed. Review of report revealed and was documented in part, the following: Description of incident: Lasix 60 mg. (Milligram) Q (Every) a.m. X (Times) 2 (Two) days with BNP, CBC (Complete Blood Count), BMP (Basic Metabolic Panel) 2/7/18 was written on M.D. (Medical Doctor) communication log - next to (Resident Name) but in communication with provider orders were meant for resident above (another Resident's Name) . An interview was conducted with the Medical Director on 01/15/2020 at 5:20 p.m. and he stated, The PA (Physician Assistant) wrote the order for Lasix 60 mg on the communication log for another resident. The Medical Director stated, I was made aware of of the med error on 02/05/2019 and I ordered to hold the evening dose and the next a.m. dose, each 20 mg doses of Lasix. The Medical Director stated, (Resident Name) already had an order for Lasix 20 mg twice a day. The Medical Director also stated, (Resident Name) was monitored for hypotension and no problems were noted. (Resident Name) labs - BUN went from 25 on 01/21/2019 to 23 on 2/15/2019 which was better - not significant but still better. When the Medical Director was asked if Resident #41 had any side effects from receiving the extra 40 mg. of Lasix on 02/05/2019, the Medical Director stated, No, none what so ever. On 01/16/2020 review of Resident #41's February 2019 Medication Administration Record revealed the following: Order for - Lasix 20 mg tablet (40 mg) Tablet Oral One Time Daily for Two Days Starting 02/05/2019 and an Order for - Lasix 20 mg tablet (20 mg) Tablet Oral Two Times Daily Starting 01/16/2019 - Nurse initialed boxes on 02/05/2019 indicating medications were administered as ordered. The nurse who transcribed the order no longer worked at the facility. On 01/16/2020, the facility policy titled - Medication Management Plan was reviewed and included: Purpose: To ensure that the right resident receives the right drug, in the right dose and dosage form, at the right time, via the correct rout, and to ensure the resident has the right response to the medication. To ensure that all staff responsible for medication administration are qualified and fully informed of all policies and procedures in medication management and the pharmacy operating procedures. The Administrator and Director of Nursing was made aware of the finding during briefing on 01/16/2020 at approximately 6:45 p.m. No further information was provided. Complaint Deficiency.

Based on observation and staff interview the facility staff failed to ensure one multi dose vial of Tuberculin Purified Solution was properly dated when opened on one of four nursing units, Stone Rehab Unit A. The findings included: On 01/16/2020 at approximately 10:30 a.m., an inspection of the refrigerator in the Medication Storage Room on Stone Rehab Unit A with Licensed Practical Nurse (LPN) #1 was conducted. A plastic bag labeled Aplisol 10 Test (Mantoux), Stock Supply, Store in Refrigerator, Date Opened (not dated) Do Not Use 30 Days After Above Date. QTY (Quaintly) 5 was observed. Inside of the plastic bag were 2 multidose vials of Tuberculin Purified Solution 5TU / 0.1 ml, 1 unopened vial and 1 opened vial which was not dated when it was opened. When LPN #1 was asked if the vial should be dated when opened, LPN #1 stated, Yes, everything gets dated because after 30 days it gets thrown out. It's not dated. LPN #1 discarded the opened, undated vial of solution. The Administrator and Director of Nursing were made aware of the finding during a briefing on 01/16/2020 at approximately 6:45 p.m. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and facility documentation review, the facility staff failed to ensure reasonable accommodation of needs for 2 of 41 residents (Resident #55 and #12) in the survey sample. 1. The facility staff failed to ensure Resident #55 had reasonable accommodation of needs, specifically to have interior bathroom door handles. 2. The facility staff failed to ensure Resident #12 had reasonable accommodation of needs, specifically to have interior bathroom door handles. The findings included: 1. Resident #55 was admitted to the facility on [DATE]. Diagnosis for Resident #55 included but not limited to Dementia with Behavioral Disturbance, Difficulty in Walking, and Muscle Weakness. Resident #55's Minimum Data Set (MDS) with an Assessment Reference Date of 10/1/18 coded Resident #55 Brief Interview for Mental Status (BIMS) score of 4 out of a possible score of 15 indicating moderate cognitive impairment. During the initial tour on 11/28/18 at approximately 1:30 PM, Resident #12 was observed in her wheelchair in her room accompanied by her daughter. Resident #12 daughter stated, I am concerned there is no door handle inside mom's bathroom. It was observed there was no door handle to interior bathroom sliding door. During a follow up tour on 11/29/18 at approximately 12:00 PM, it was observed there was still no handle on inside of Resident #12's bathroom door. Interior sliding bathroom doors of 15 rooms on Resident #55's unit were inspected on 11/29/18 for presence of door handles. An interview was conducted on 11/29/18 at approximately 4:00 PM with Director of Maintenance who stated, It is the expectation that each bathroom door has an exterior and interior door handle for entering and exiting the bathroom. On 11/30/18 at approximately 1:00 PM the above findings were shared with the facility Administrator and the Director of Nursing during a pre-exit conference. The facility Administrator stated, (Resident #12) handle was removed at resident request and (Resident #55 room) was also removed because they were a friend to (Resident #12) and wanted it done too. We forgot to put the handle back in the room of (Resident #55) when a new resident moved in there. Documentation of resident request to remove door handle was requested, no documentation was available from facility. A policy and procedure for resident room set-up and/or room hardware installation was requested and the facility was unable to provide any policy. The facility shared an email from contractors showing pictures of initial bathroom door hardware installation but did not provide any documentation for removal of interior door handles for Resident #55. No additional information was shared. 2. Resident #12 was admitted to the facility on [DATE]. Diagnosis for Resident #12 included but not limited to Tremor, Osteoporosis, Asthma, Mild Cognitive Impairment, Legal Blindness, and Diabetes. Resident #12 Minimum Data Set (MDS) with an Assessment Reference Date of 10/1/18 coded Resident #12 Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15 indicating cognitively intact at assessment. During a tour of unit on 11/29/18 at approximately 12:00 PM, interior bathroom sliding doors of 15 resident rooms were inspected for presence of bathroom door handles. At that time it was noted that Resident #12's room was without a bathroom door handle. An interview was conducted on 11/29/18 at approximately 4:00 PM with Director of Maintenance. The Director of Maintenance and surveyor entered bathroom of Resident #12, sliding bathroom door was closed. The Director of Maintenance stated, It is the expectation that each bathroom door has an exterior and interior door handle for entering and exiting the bathroom. On 11/30/18 at approximately 1:00 PM the above findings were shared with the facility Administrator and the Director of Nursing during a pre-exit conference. The facility Administrator stated, (Resident #12) handle was removed at resident request and (Resident #55 room) was also removed because they were a friend to (Resident #12) and wanted it done too. We forgot to put the handle back in the room of (Resident #55) when a new resident moved in there. Documentation of resident request to remove door handle was requested, no documentation was available from facility. A policy and procedure for resident room set-up and/or room hardware installation was requested and the facility was unable to provide any policy. The facility shared an email from contractors showing pictures of initial bathroom door hardware installation but did not provide any documentation for removal of interior door handles for Resident #12. No additional information was shared.

Based on observations, resident interviews and staff interview the facility staff failed to ensure resident equipment was maintained in a sanitary manner for 2 of 41 residents (Residents #57 and #6), in the survey sample. 1. The facility staff failed to ensure Resident # 57's motorized chair was without a white substance to the front of the seat and on the footrest. 2. The facility staff failed to ensure Resident #6's tube feeding pole was without a dried yellow substance to the base of the pole. The finding included: 1. Resident #57 was originally admitted to the facility 2/8/17 and has never been discharged from the facility. The current diagnoses included; coronary artery disease, heart failure, diabetes and high blood pressure. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/29/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #57's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 2 people with bed mobility, transfers, and dressing, as well as limited assistance of 1 person with wheel chair mobility on the unit and supervision of 1 person with wheel chair mobility off the unit. On 11/28/18, at approximately 1:15 p.m., during the initial screening, Resident #57 was observed in his room listening to a book on tape; his wheel chair was observed parked in the room. A white substance was observed on the seat and the footrest (approximately the size of a dollar bill) of the motorized chair. On 11/29/18 Resident #57 was observed in his room and the motorized wheel chair still had a white substance on the seat and footrest of his wheel chair. On 11/29/18 at approximately 11:30 a.m., Resident #57 stated because of his visual problems he hadn't noticed the white substance until it was brought to his attention but he would talk to the staff about cleaning it. At approximately 3:00 p.m., on 11/29/18, Resident #57 was observed on the motorized wheel chair in the main lobby, the white substance was visible to the front of the wheel chair and the footrest. The facility's policy for wheel chair cleaning was requested but the Director of Nursing stated they didn't have a policy therefore; a wheel chair, walkers and Hoyer sling cleaning schedule was presented. Resident #57's was scheduled for Saturdays. On 11/30/18 at approximately 1:45 p.m., during the pre-exit briefing the above information was given to the Administrator, Director of Nursing and Corporate [NAME] President. The Director of Nursing stated the nursing staff reported it was likely the cream which is applied to the resident's legs that was visible on the wheel chair. She further stated Resident #57's wheel chair requires cleaning usually twice weekly. 2. Resident #6 was originally admitted to the facility 3/9/18. The resident had an unplanned discharge from the facility and re-entered the facility 5/24/18. The current diagnoses included; Parkinson's disease and reflux. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/23/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated Resident #6's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of 1 person with eating. At MDS section K0510 the resident was coded for receiving nutrition via a feeding tube. On 11/28/18, at approximately 1:35 p.m., during the initial screening, Resident #6 was observed in his room seated at bedside. The tube feeding pole was observed with a dried pale yellow substance on all legs of the base of the pole. Resident #6 was also visited in his room on 11/29/18 at approximately 3:50 p.m. The feeding was in progress and the pole was again observed with a dried pale yellow substance on the base. The facility's policy for cleaning resident equipment was requested; the Director of Nursing stated they had no policy for cleaning of tube feeding poles and the policy titled Tube Feeding didn't address cleaning of tube feeding equipment. On 11/30/18 at approximately 1:45 p.m., during the pre-exit briefing the above information was given to the Administrator, Director of Nursing and Corporate [NAME] President. The Director of Nursing stated the pole which held the tube feeding should be cleaned when needed.

Based on clinical record review and staff interviews the facility staff failed to complete the required initial comprehensive assessment timely for 1 of 41 residents (Resident #132), in the survey sample. The facility's staff failed to complete Resident #132's admission Minimum Data Set (MDS) assessment within 14 calendar days after admission to the facility. The findings included: Resident #132 was originally admitted to the facility 11/15/18 and he has not been discharged . The current diagnoses included; cancer, an infected left 2nd toe and diabetes. No MDS assessment was observed in the facility's computer system for Resident #132; therefore a copy of the admission MDS assessment was requested. An incomplete admission MDS assessment was provided by the facility's staff on 11/29/18 at approximately 4:15 p.m. The MDS Coordinator stated they were short staffed and unable to get to Resident #132's MDS assessment within the required timeframe. She stated it should have been completed 11/28/18, and she was working on getting it completed. The uncompleted admission MDS assessment with an assessment reference date (ARD) of 11/22/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #132's cognitive abilities for daily decision making were moderately impaired. Upon arrival to the facility 11/30/18 at 9:00 a.m., Resident #132's MDS assessment had been completed and left for viewing. It was signed 11/29/18. The CMS guidelines for Comprehensive Assessments are as follows: OBRA-required comprehensive assessments include the completion of both the MDS and the Care Area Assessments (CAA) process, as well as care planning. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred or a significant correction to a prior comprehensive assessment is required. They consist of: admission Assessment, Annual Assessment, Significant Change in Status Assessment, Significant Correction to Prior Comprehensive Assessment. The ARD (Item A2300) is the last day of the observation/look back period, and day 1 for purposes of counting back to determine the beginning of observation/look back periods. For example, if the ARD is set for day 14 of a resident's admission, then the beginning of the observation period for MDS items requiring a 7-day observation period would be day 8 of admission (ARD + 6 previous calendar days), while the beginning of the observation period for MDS items requiring a 14-day observation period would be day 1 of admission (ARD + 13 previous calendar days). (CMS' RAI Version 3.0 Manual, October 2018 Page 2-19). On 11/30/18 at 1:45 p.m., the above findings were shared with the Administrator, Director of Nursing and the Corporate [NAME] President. The Director of Nursing stated they have no policy because they follow the RAI (Resident Assessment Instrument) manual for MDS completion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility document review and staff interviews the facility staff failed to ensure a Level I PASARR (Preadmission Screening and Resident Review which is a pre-admission screening for a mental disorder (MD) or intellectual disability) was completed prior to admission or within 30 days of admission for 2 of 41 Residents in the survey sample, Resident #24 and #29. 1. The facility staff failed to ensure a Level I PASARR (a pre-admission screening for a mental disorder (MD) or intellectual disability) was completed prior to admission for Resident #24. 2. The facility staff failed to ensure a Level I PASARR was completed prior to admission for Resident #29. The findings included: 1. Resident #24 was admitted to the facility on [DATE] with diagnoses to include Anxiety Disorder and Bipolar Disorder. The most recent comprehensive Minimum Data Set (MDS) was an Annual assessment with an Assessment Reference Date (ARD) of 1/26/18. The Brief Interview for Mental Status was coded as a 6 out of a possible 15 indicating Resident #24 was cognitively impaired and incapable of daily decision making. On 11/28/18 at approximately 4:00 P.M. the facility was asked for for Resident #24's PASARR that was completed prior to admission of 7/14/14 or within 30 days of admission. On 11/29/18 at approximately 1:00 P.M. the Director of Social Services presented a Level I PASARR for Resident #24 that she completed on 11/28/18. The Director of Social Services stated, I could not find a Level I PASARR for Name (Resident #24) so I did one yesterday. 2. Resident #29 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include Major Depressive Disorder and Bipolar Disorder. The most recent comprehensive Minimum Data Set (MDS) was an admission with an Assessment Reference Date (ARD) of 1/26/18. The Brief Interview for Mental Status was coded as a 99 (resident unable to complete the interview). However, the Resident #29 was coded has having short and long term memory recall and was severely impaired in cognition for daily decision making. On 11/28/18 at approximately 4:00 P.M. the facility was asked for for Resident #29's PASARR that was completed prior to admission of 2/26/13 or within 30 days of admission. On 11/29/18 at approximately 1:00 P.M. the Director of Social Services presented a Level I PASARR for Resident #29 that she completed on 11/28/18. The Director of Social Services stated, I could not find a Level I PASARR for Name (Resident #29) so I did one yesterday. On 11/29/18 at approximately 2:00 P.M. The Administrator presented a policy and procedure titled Preadmission Screening and Resident Review (PASARR) original date November 29, 2018 to the surveyor and stated, This is our new PASARR policy and it is effective today. The facility policy titled Preadmission Screening and Resident Review (PASARR) original date: November 29, 2018 was reviewed and is documented in part, as follows: PURPOSE/POLICY: The facility observes pre-admission screening requirements: *To ensure that people with known or suspected mental illness or intellectual disabilities are not inappropriately institutionalized or marginalized; to make sure that every individual receives the services and supports that will optimize their success in the least restrictive setting. *To ensure that residents with these specific types of disabilities are admitted or allowed to remain in the facility; only if the facility can provide them with the services they need. PROCEDURE: 1. Preadmission-Level I Screening a. Admissions from a hospital or another provider. i. The Admissions Coordinator will review each prospective resident's medical record for documentation of a Level I (DMAS 95) screening. 1. If the Level I screening does not identify the presence or suspicion of a condition of disability, no further action is necessary. 2. If there has been no Level I screening, the Admissions Coordinator will request that the provider complete the screen and provide a copy to the facility. 3. In the event that the hospital or other provider cannot perform the Level I screening, the facility will complete the screen within the first 30 days of a resident's stay. 6. The results of the Level I screen and the Level II PASARR evaluation will be maintained as part of the resident's medical record. Prior to exit no further information was provided by the facility.