Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to administer medications per the physician order for one of 22 residents in the survey sample, Resident #38. The findings include: For Resident #38 (R38), the facility staff failed to remove a lidocaine patch per the physician orders. Observation was made of RN (registered nurse) #3, administering medications on 8/1/2023 at 8:42 a.m. to R38. RN #3 prepared the medications. She pulled out two Aspercreme Pad Lido (lidocaine) 4% pads. One was for the resident's neck, and one was for the resident's left knee. RN #3 entered the room and administered the oral medications. She then placed one of the Aspercreme Pads to the back of the resident's neck. She proceeded to the other side of the bed and pulled back the covers off the resident's left knee. The Aspercreme pad was still on the resident's left knee, dated 7/31/2023. RN #3 stated she could not just remove the patch and apply the new one as there was an order to remove it after 12 hours of being on. RN #3 went and spoke with the unit manager and left a message for the nurse practitioner. The physician orders dated, 7/17/2023, documented, Lidocaine External Patch 4% (Lidocaine) (1), Apply to L (left) knee topically one time a day for OA (osteoarthritis) and remove per schedule. The July 2023 MAR (medication administration record) documented the above order. The Lidocaine External Patch was to be applied at 9:00 a.m. and removed at 2059 (8:59 p.m.). An interview was conducted on 8/1/2023 at 3:38 p.m. with LPN (licensed practical nurse) #2, the unit manager. When asked the process for applying and removing a Lidocaine patch, LPN #2 stated they are applied in the mornings and removed after 12 hours. LPN #2 was asked why is that done that way, LPN #2 stated it's per the physician orders and to prevent irritation of the skin where the patch was applied. When asked if it is signed off as removed on the evening shift and the day shift nurse finds it still in place the next morning, is that following the physician orders, LPN #2 stated, no. An interview was conducted with LPN #4, the nurse that signed off the removal of the lidocaine patch on 7/31/2023, on 8/1/2023 at 3:34 p.m. The above MAR was reviewed with LPN #4. When asked if she took the patch off last night LPN #4 stated she did. It was reviewed with LPN #4 that the resident had two patches prescribed. LPN #4 stated she took one off of her neck. The observation made on 8/1/2023 at 8:42 a.m. was reviewed with LPN #4. LPN #4 stated, I guess I didn't take it off as I was so busy last night. The facility policy, Medication Administration, documented in part, 3. Medications will be administered in accordance with the orders, including any required time frame. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above findings on 8/1/2023 at 4:01 p.m. (1) Lidocaine External Patch 4% is in a class of medications called local anesthetics. It works by stopping nerves from sending pain signals. Never wear them for more than 12 hours per day (12 hours on and 12 hours off). This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a603026.html

Based on observations, staff interview, clinical record review, it was determined that the facility staff failed to implement fall interventions for one of 22 residents in the survey sample, Resident #242. The findings include: For Resident #242 (R242), the facility staff failed to place a fall mat on the floor to the left side of the bed while he was lying in bed. R242 was admitted to the facility with a diagnosis that included but was not limited to convulsion (1). R242's admission MDS (minimum data set) was not due at the time of the survey. On 08/01/23 at approximately 1:30 p.m., R242 was observed lying in bed asleep. Further observation failed to evidence a fall mat on the floor next to the bed. On 08/01/23 at approximately 3:20 p.m., R242 was observed lying in bed asleep. Further observation failed to evidence a fall mat on the floor next to the bed. The physician's order for R242 documented in part, Fall mat in place to left side of bed when resident is in bed. Order Date: 07/31/2023. The comprehensive care plan for R242 documented in part, Focus. (R242) is at risk for falls characterized by history of falls, CVA (cerebral vascular accident) with left sided weakness related to: impaired balance, poor coordination. Date Initiated: 07/24/2023. Under Interventions it documented in part, Fall mat in place to left side of bed when resident is in bed Date Initiated: 07/31/202. On 08/02/2023 at approximately 8:33 a.m., an interview was conducted with LPN (licensed practical nurse) #2. After informed of the above observations, review of the physician's orders and care plan LPN #2 stated that the fall matt should have been put in place. On 08/02/2023 at approximately 9:40 a.m., ASM (administrative staff member) #2, administrator, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) The term seizure is often used interchangeably with convulsion. A seizure is the physical findings or changes in behavior that occur after an episode of abnormal electrical activity in the brain. This information was obtained from the website: Seizures | MedlinePlus.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide services to attempt to restore bladder and bowel continence for one of 22 residents in the survey sample, Resident #25. The findings include: For Resident #25 (R25), the facility staff failed to provide evidence of attempting to restore her bladder and bowel function after admission to the facility. R25 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/26/23, R25 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was coded as being frequently incontinent of both bowel and bladder. On the admission MDS (8/28/22) and the quarterly assessments (11/21/22 and 2/21/23) since her admission, she was also coded as being frequently incontinent of bowel and bladder. On all of these MDS assessments, R25 was coded as being independent for walking in her room. On 7/31/23 at 3:05 p.m., R25 was seated on the wheelchair in her room. When R25's incontinence was discussed and when asked if the facility staff had taken any steps to restore bladder or bowel continence since her admission, R25 stated: No, they haven't. She stated she takes herself to the bathroom, but she sometimes needs help changing her brief [due to bowel or bladder incontinence episodes]. On 8/1/23 at 8:48 a.m., R25 was observed independently walking in her room. A review of R25's clinical record failed to reveal evidence of the facility staff's attempt to restore R25's continence of bowel or bladder, or rationale of why it wasn't attempted. On 8/1/23 at 4:01 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. On 8/2/23 at 8:59 a.m., ASM #2 stated: We don't really have anything to provide. She stated the facility staff had focused more on the resident's mobility than on bowel and bladder incontinence. A review of the facility policy, Fecal Incontinence, revealed, in part: Residents with fecal incontinence will receive the appropriate treatment and services to restore as much normal bowel function as possible .Incontinence is not considered a normal part of the aging process .The resident will be evaluated for presence of fecal incontinence on admission/readmission and with each .MDS assessment. Consideration of factors impacting will be reviewed. A review of the facility policy, Assessment and Management of Urinary Function, revealed, in part: Policy: To ensure each resident has an evaluation of urinary function and if urinary incontinence is identified, a determination is made of the type of urinary incontinence and appropriate treatment and services are implemented to restore as much bladder function as possible .When urinary function evaluation identifies urinary incontinence, a further evaluation will be completed .to determine appropriate treatment and/or interventions. No further information was provided prior to exit.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in one of one kitchen areas. The findings include: The facility staff failed to date and/or dispose of opened food. On 7/31/23 at 9:15 AM, an observation was conducted in the main kitchen. In the freezer, one of two five-pound frozen hash browns packed in a plastic bag had been torn open. There was no label on the bag of the date it was opened or expiration date. An interview was conducted on 7/31/23 at 9:20 AM with OSM (other staff member) #1, the chef/dietary supervisor. When asked to review the opened hash brown bag, OSM #1 stated, They must have just opened this with breakfast service. It should not be open like this. I will remove it. The ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing was made aware of the finding on 8/1/23 at 4:15 PM. The facility's Infection Control Sanitation/Safety Guidelines policy dated 8/2013, revealed the following, Storage: The objective is to maintain high-quality food at approved temperatures and conditions to ensure retention of quality and safe conditions. No further information was provided prior to exit.

4. For Resident #35, the facility staff failed to implement the comprehensive care plan for dialysis care, specifically offering food prior to dialysis. Resident #35 was admitted with diagnosis that included but not limited to: ESRD (end stage renal disease). Resident #35's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/7/23, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of MDS Section O-Special Procedures: coded the resident as dialysis-yes. A review of the comprehensive care plan dated 12/12/19 and revised on 6/30/23, revealed, FOCUS: Resident has end stage renal disease and receives hemodialysis via left arm AV (arterio-venous) graft, 3 times a week on Monday, Wednesday and Friday. Resident is at increased nutritional risk related to requiring a therapeutic diet, food preferences for foods that contradict diet order, ESRD on hemodialysis, Heart Failure and Type 2 diabetes mellitus. Resident has nutritional risk related to related to heel pressure injury. INTERVENTIONS: Prepare and send meal with (Name) as well as any other items he may need. Encourage to follow ordered diet to reduce risks of fluid overload/deficit and nutritional concerns. Revised 6/17/20: Dialysis no longer allows resident to take food into the center. Resident usually has a big breakfast each morning, monitor for the need to offer food prior to going out at 10 am and immediately upon returning from dialysis. Revised on 10/13/20: Currently foods are not allowed at dialysis due to COVID precautions. Provide snacks upon return as requested. Revised 6/30/23: Educate Resident / Representative regarding nutritional needs and requirements. Offer Juven supplement twice daily to promote wound healing. A review of the physician's order dated 1/20/22, revealed, Dialysis every Mon-Wed-Fri at 11:00am pick up at 10:30am. An interview was conducted on 7/31/23 at approximately 10:00 AM, with Resident #35. Resident #35 was sitting in a wheelchair in his room, waiting for dialysis transport. When asked if he had a bagged lunch from the facility or if food was provided by the dialysis center, Resident #35 stated, No, they do not give us food at the dialysis center. I have only been given lunch from this place once. Two sandwiches, since then no food. I do not get back till close to supper time and I have missed my lunch completely. Inside the resident's dialysis bag were one bag of hard candy and one bag of gummy candy. When asked about the candy, Resident #35 stated, That is all I have to take to eat during dialysis. An interview was conducted on 8/2/23 at 8:40 AM, with LPN (licensed practical nurse) #2. When asked the purpose of the care plan, LPN #2 stated, it is their life and it is used to identify a plan of care, it should be followed. When asked who is responsible for implementing the care plan, LPN #2 stated, any aspect of the care plan is to be implemented by the nurse, aides and the interdisciplinary team. When asked if the care plan had been followed regarding Resident #35's nutrition related to dialysis, LPN #2 stated, no, it has not been implemented. We are sending a bag lunch with him today and will revise the care plan today. On 8/1/23 at approximately 4:15 PM, ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing was made aware of the findings. According to the facility's Baseline Care Assessment and Comprehensive Care Plan policy, The care plan must describe the services that are furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well being in accordance with the comprehensive assessment. No further information was provided prior to exit. 3. For Resident #242 (R242), the facility staff failed to implement the care plan to place a fall mat on the floor to the left side of the bed while he was lying in bed. R242 was admitted to the facility with a diagnosis that included but was not limited to convulsion (1). R242's admission MDS (minimum data set) was not due at the time of the survey. The facility's admission assessment for R242 dated 07/24/2023 documented in part, Mental Status: Alert & (and) Oriented x3 (times three - person, place, time). On 08/01/23 at approximately 1:30 p.m., R242 was observed lying in bed asleep. Further observation failed to evidence a fall mat on the floor next to the bed. On 08/01/23 at approximately 3:20 p.m., R242 was observed lying in bed asleep. Further observation failed to evidence a fall mat on the floor next to the bed. The physician's order for R242 documented in part, Fall mat in place to left side of bed when resident is in bed. Order Date: 07/31/2023. The comprehensive care plan for R242 documented in part, Focus. (R242) is at risk for falls characterized by history of falls, CVA (cerebral vascular accident) with left sided weakness related to: impaired balance, poor coordination. Date Initiated: 07/24/2023. Under Interventions it documented in part, Fall mat in place to left side of bed when resident is in bed Date Initiated: 07/31/202. On 08/02/23 at approximately 8:33 a.m., an interview was conducted with LPN (licensed practical nurse) #2. When asked to describe the purpose of a resident's care plan she stated that it is the resident's life, the resident's plan of care. After reviewing R242's care plan for the use of the fall mat and informed of the above observations, she was asked if the care plan was being followed. LPN #2 stated no. On 08/02/2023 at approximately 9:40 a.m., ASM (administrative staff member) #2, administrator, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) The term seizure is often used interchangeably with convulsion. A seizure is the physical findings or changes in behavior that occur after an episode of abnormal electrical activity in the brain. This information was obtained from the website: Seizures | MedlinePlus. Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for four of 22 residents in the survey sample, Residents #38, #39, #242 and #35. The findings include: 1. For Resident #38, the facility staff failed to implement the comprehensive care plan for administering pain medications per the physician orders. The comprehensive care plan dated, 5/27/2023 documented in part, Focus: (R38) is at risk for acute pain due to her osteoarthritis, limited ROM (range of motion) to her neck and kidney stones. The Interventions documented in part, Pain patches to neck and knee per MD (medical doctor) order. Observation was made of RN (registered nurse) #3, administering medications on 8/1/2023 at 8:42 a.m. to R38. RN #3 prepared the medications. She pulled out two Aspercreme Pad Lido (lidocaine) 4% pads. One was for the resident's neck, and one was for the resident's left knee. RN #3 entered the room and administered the oral medications. She then placed one of the Aspercreme Pads to the back of the resident's neck. She proceeded to the other side of the bed and pulled back the covers off the resident's left knee. The Aspercreme pad was still on the resident's left knee, dated 7/31/2023. RN #3 stated she could not just remove the patch and apply the new one as there was an order to remove it after 12 hours of being on. RN #3 went and spoke with the unit manager and left a message for the nurse practitioner. The physician orders dated, 7/17/2023, documented, Lidocaine External Patch 4% (Lidocaine) (1), Apply to L (left) knee topically one time a day for OA (osteoarthritis) and remove per schedule. The July 2023 MAR (medication administration record) documented the above order. The Lidocaine External Patch was to be applied at 9:00 a.m. and removed at 2059 (8:59 p.m.). An interview was conducted with LPN #2, the unit manager, on 8/2/2023 at 8:33 a.m. When asked the purpose of the care plan, LPN #2 stated, It's their life, their plan of care. LPN #2 was asked if it should be followed, LPN #2 stated, yes. When asked who is responsible for implementing the care plan, LPN #2 stated, it's everyone that is responsible for implementing the care plan. The facility policy, Baseline Care Assessment and Comprehensive Care Plan, documented in part, 6. The interdisciplinary team, in conjunction with the resident, resident's family, surrogate or representative should develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment .7. The care plan must describe the services that are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment .11. The care plan includes treatment objective that have measurable outcomes with timetables and specific approaches to meet the defined needs. The policy did not address the implementation of the care plan. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM # 4, the vice president of post-acute services, were made aware of the above concern on 8/2/2023 at 9:58 a.m. No further information was provided prior to exit. 2. For Resident #39 (R39), the facility staff failed to develop a care plan for the use of side rails. Observation was made of R39 on 8/1/2023 at 8:21 a.m. The resident was in bed, with both side rails up. The Side Rail and Entrapment Evaluation dated 7/6/2023 documented in part, Resident's care plan addresses use of side rails and interventions to minimize injury or entrapment. A Y, indicating, yes, was documented. The comprehensive care plan dated, 7/7/2023, failed to evidence documentation for the use of side rails. An interview was conducted with LPN #2, the unit manager, on 8/2/2023 at 8:33 a.m. When asked the purpose of the care plan, LPN #2 stated, It's their life, their plan of care. LPN #2 was asked if it should be followed, LPN #2 stated, yes. When asked who is responsible for implementing the care plan, LPN #2 stated, it's everyone that is responsible for implementing the care plan. When asked if a resident uses side rails, should that be on the care plan, LPN #2 stated, yes, and after reviewing R39's care plan LPN #2 stated she didn't see the use of side rails on the care plan. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM # 4, the vice president of post-acute services, were made aware of the above concern on 8/2/2023 at 9:58 a.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 22 residents in the survey sample, Resident #35. The findings include: The facility failed to provide a bagged lunch for Resident #35 to take with him to the dialysis appointment or offer additional food prior to going to dialysis. Resident #35 was admitted with diagnoses that include but are not limited to: ESRD (end stage renal disease. Resident #35's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/7/23, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of MDS Section O-Special Procedures: coded the resident as dialysis-yes. A review of the comprehensive care plan dated 12/12/19 and revised on 6/30/23, revealed, FOCUS: Resident has end stage renal disease and receives hemodialysis via left arm AV (arterio-venous) graft, 3 times a week on Monday, Wednesday and Friday. Resident is at increased nutritional risk related to requiring a therapeutic diet, food preferences for foods that contradict diet order, ESRD on hemodialysis, Heart Failure and Type 2 diabetes mellitus. Resident has nutritional risk related to related to heel pressure injury. INTERVENTIONS: Prepare and send meal with [NAME] as well as any other items he may need. Encourage to follow ordered diet to reduce risks of fluid overload/deficit and nutritional concerns. Revised 6/17/20: Dialysis no longer allows resident to take food into the center. Resident usually has a big breakfast each morning, monitor for the need to offer food prior to going out at 10 am and immediately upon returning from dialysis. Revised on 10/13/20: Currently foods are not allowed at dialysis due to COVID precautions. Provide snacks upon return as requested. Revised 6/30/23: Educate Resident / Representative regarding nutritional needs and requirements. Offer Juven supplement twice daily to promote wound healing. A review of the physician's order dated 1/20/22, revealed, Dialysis every Mon-Wed-Fri at 11:00am pick up at 10:30am. A review of the nursing progress note dated 7/7/23 at 4:27 PM, revealed, Last meal eaten: breakfast. Meal / snack was sent with the Resident. A review of the progress notes from 4/1/23-7/31/23 revealed no additional documentation of meal sent with resident. An interview was conducted on 7/31/23 at approximately 10:00 AM with Resident #35. Resident #35 was sitting in a wheelchair in his room, waiting for dialysis transport. When asked if he had a bagged lunch from the facility or if food was provided by the dialysis center, Resident #35 stated, No, they do not give us food at the dialysis center. I have only been given lunch from this place once. Two sandwiches, since then no food. I do not get back till close to supper time and I have missed my lunch completely. Inside Resident #35's dialysis bag were one bag of hard candy and one bag of gummy candy. When asked about the candy, Resident #35 stated, That is all I have to take to eat during dialysis. An interview was conducted on 7/31/23 at 10:30 AM with OSM (other staff member) #3, the chef/manager and OSM #4, the dining services manager. When asked if brown bag lunch was provided to Resident #35 for his dialysis appointments, OSM #3 stated, No, we do not provide a brown bag lunch. OSM #4 stated, Our process is to provide him with food when he returns from dialysis. When asked about the timing of his return and supper time, OSM #4 stated, he gets back around 4:30-4:45 PM, it is close to when we are serving supper. When asked if he had missed a meal for his dialysis days, OSM #4 stated, yes. An interview was conducted on 8/1/23 at 8:20 AM, with LPN (licensed practical nurse) #3. When asked if a lunch was provided to Resident #35 for his dialysis appointment, LPN #3 stated, No, we are not sending a lunch with him. On 8/1/23 at approximately 4:15 PM, ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing was made aware of the findings. On 8/2/23 at 8:00 AM, ASM #2 stated, they have talked with the dialysis facility and they will be sending a brown bag lunch with him starting today. According to the facility's Care of Resident with End Stage Renal Disease policy, Residents with end-stage renal disease (ESRD) will be cared for according to current recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff may include: The nature and clinical management of ESRD, including infection prevention and nutritional needs. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide written notice of hospital transfer for one of 31 residents in the survey sample, Resident #45. Resident #45 transferred to the hospital on [DATE]. The facility staff failed to provide written notice of the transfer to the resident representative or ombudsman. The findings include: Resident #45 was admitted to the facility on [DATE]. Resident #45's diagnoses included but were not limited to high blood pressure, heart disease and major depressive disorder. Resident #45's quarterly minimum data set assessment with an assessment reference date of 11/22/21 coded the resident's cognition as severely impaired. Review of Resident #45's clinical record revealed a nurse's note that documented the resident was transferred to the hospital on [DATE] for a left knee wound. Further review of Resident #45's clinical record failed to reveal evidence that written notice of the transfer was provided to Resident #45's representative or the ombudsman. On 1/26/22 at 2:11 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the nurses notify residents' representatives of hospital transfers via phone but not via written notice. On 1/26/22 at 2:03 p.m., an interview was conducted with OSM (other staff member) #3 (the social services director) in regards to providing written notice of transfer to the ombudsman. OSM #3 stated she populates the facility discharge list and faxes it to the ombudsman each month. OSM #3 stated that Resident #45's 10/11/21 transfer was not classified as a discharge because the resident returned on 10/12/21 so the resident's name was not on the list faxed to the ombudsman. In regards to written notice to the representative, OSM #3 stated she provides written notice of transfer to the representative via certified mail but she only started this process in November 2021. On 1/26/22 at 5:33 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, Facility Initiated Transfer and Discharge documented, H. Before a facility transfers or discharges a resident, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand .8. The facility will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman . No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility document review and staff interviews it was determined that the facility staff failed to evidence a bed hold notice was provided to 1 of 31 residents in the survey sample, Resident #254. Written bed hold notice was not provided to Resident #254 or their responsible party after admission to the hospital on [DATE]. The findings include: Resident #254 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included but were not limited to malignant neoplasm of bladder (1) and end stage renal disease (2). Resident #254's most recent MDS (minimum data set), an admission five-day assessment with an ARD (assessment reference date) of 10/22/2022, coded Resident #254 as scoring a 12 on the brief interview for mental status (BIMS) assessment, 12- being moderately impaired for making daily decisions. The progress notes for Resident #254 documented in part, - 11/9/2021 07:52 (7:52 a.m.) Note Text: resident appears shaky this morning. Vital signs normal. Blood sugar 100. Lips and tongue appear dry. Resident barely interacting with staff. Low output from Foley last night. Per report, resident did not drink or sleep well. Juice given. Resident became more alert as he drank. Resident left for dialysis as scheduled. - 11/9/2021 08:36 (8:36 a.m.) Note Text: This writer was transporting resident to the front of the building to take resident to his transport van for Dialysis. This writer noticed that the resident was not responding well to voice or touch as well as shaking. Called on the overhead for the charge nurse and floor nurse to come assist. Pulse and BS (blood sugar) taken. Resident still was not responding well, thicken apple juice was given and resident started to perk up more. Before leaving the facility, he was asked again if anything was hurting and he stated his stomach, appropriate staff notified. 0750 (7:50 a.m.) - 11/9/2021 11:31 (11:31 a.m.) Note Text: This nurse informed that resident was transferred from dialysis to ER (emergency room) via EMS (emergency medical services) for altered mental status and low oxygen saturation. RP (responsible party) already aware. - 11/9/2021 13:11 (1:11 p.m.) Note Text: This nurse informed that resident will be admitted to [Name of hospital]. Resident ADT out. - 11/11/2021 23:30 (11:30 p.m.) Note Text: Patient re-admitted to facility at approx. (approximately) 2230 (10:30 p.m.) via stretcher from [Name of hospital] . The clinical record failed to evidence documentation of a bed hold notice being provided to Resident #254's responsible party for the admission to the hospital on [DATE]. On 1/27/2022 at 11:05 a.m., an interview was conducted with OSM (other staff member) #1, the social services director. When asked about resident transfers, OSM #1 stated that when residents were transferred from the facility a packet was sent with the resident which included a transfer notice, a bed hold notice and other required documents. OSM #1 stated that when a resident was transferred from the doctor's office or dialysis center to the hospital they did not receive the packet because they were not aware the resident was going to the hospital. OSM #1 stated that they had not been enforcing the bed hold policy because of the abundance of beds in the facility and the pandemic but did not have documentation of this practice being in place. OSM #1 stated that they would check with the finance staff to see if the previous finance person had sent a bed hold notice or contacted the family. On 1/27/2022 at 12:45 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that the social worker handled bed hold notices. ASM #2 stated that since the facility did not transfer Resident #254 to the hospital the bed hold notice would be sent by certified mail the day after admission to the hospital. On 1/27/2022 at approximately 1:35 p.m., a request was made to ASM #1, the administrator for the facility policy for bed hold notice. On 1/27/2022 at 2:46 p.m., ASM #1 provided via email the policy Bed Hold Policy dated 5/2019. It documented in part, Whenever a resident leaves the facility overnight or is discharged to the hospital, the resident's bed may be reserved. The following procedures are to be followed upon the discharge of any resident form this facility .During normal business hours, the Admissions staff or designee will be responsible for contacting the responsible party to determine if the bed will be held . On 1/27/2022 at approximately 1:30 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. References: 1. malignant neoplasm The term malignancy refers to the presence of cancerous cells that have the ability to spread to other sites in the body (metastasize) or to invade nearby (locally) and destroy tissues. Malignant cells tend to have fast, uncontrolled growth and DO NOT die normally due to changes in their genetic makeup. Malignant cells that are resistant to treatment may return after all detectable traces of them have been removed or destroyed. This information was obtained from the website: https://medlineplus.gov/ency/article/002253.htm. 2. end-stage kidney disease The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/000500.htm.

Based on clinical record review and staff interview, it was determined that the facility staff failed to accurately code a Resident's MDS (minimum data set) assessment for 1 of 31 residents in the survey sample, Resident #8. For Resident #8, the facility staff failed to accurately code the 11/01/2021 MDS for hospice care. The findings include: Resident # 8 was admitted to the facility with diagnoses that included but were not limited to: high blood pressure, low iron and breast cancer. Resident # 8's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 11/01/2021, coded Resident # 8 as scoring a 0 (zero) out of 15 on the brief interview for mental status (BIMS), with 0 indicating the resident is severely impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs failed to code Resident # 8 as receiving hospice. The POS (physician's order sheet) for Resident # 8 documented in part, Admit to LTC (long term care) for hospice service - [Name of Hospice Organization]. Date Order: 07/29/2021. The comprehensive care plan for Resident # 8 dated 08/03/2021 documented. FOCUS: [Resident # 8] has chosen [Name of Hospice Organization] services for end of life care. Date Initiated: 07/29/2021. Under Interventions it documented in part, Work with nursing staff to provide maximum comfort for the resident. Date Initiated: 07/29/2021. On 01/326/2022 at approximately 4:03 p.m., an interview was conducted with LPN (licensed practical nurse) # 3, MDS coordinator. After reviewing Resident # 8's MDS assessment with an ARD of 11/01/2021 and the comprehensive care plan dated 07/29/2021, and the physician's order for Resident # 8's hospice, LPN # 3 stated, stated, The MDS should have been coded for hospice. It wasn't put in. When asked what she uses as guidance for completing the MDS LPN # 3 stated she uses the RAI (Resident Assessment Instrument) manual. CMS's (Centers for Medicare/Medicaid Services) Long-Term Care RAI (Resident Assessment Instrument) Version 3.0 Manual documented, O0100: Special Treatments, Procedures, and Programs (cont.) O0100C, Oxygen therapy. Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. Code oxygen used in Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP) here. Do not code hyperbaric oxygen for wound therapy in this item. This item may be coded if the resident places or removes his/her own oxygen mask, cannula. On 01/27/2022 at approximately 1:30 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and facility document review, it was determined that the facility staff failed to provide a written summary of the baseline care plan after a readmission to the facility for 1 of 31 residents in the survey sample, Resident #254. There is no evidence to support that Resident #254 and/or the responsible party were provided a written summary of the care plan after the readmission to the facility on [DATE]. The findings include: Resident #254 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included but were not limited to malignant neoplasm of bladder (1) and end stage renal disease (2). Resident #254's most recent MDS (minimum data set), an admission five-day assessment with an ARD (assessment reference date) of 10/22/2021, coded Resident #254 as scoring a 12 on the brief interview for mental status (BIMS) assessment, 12- being moderately impaired for making daily decisions. The progress notes for Resident #254 documented in part, - 11/9/2021 07:52 (7:52 a.m.) Note Text: resident appears shaky this morning. Vital signs normal. Blood sugar 100. Lips and tongue appear dry. Resident barely interacting with staff. Low output from Foley last night. Per report, resident did not drink or sleep well. Juice given. Resident became more alert as he drank. Resident left for dialysis as scheduled. - 11/9/2021 08:36 (8:36 a.m.) Note Text: This writer was transporting resident to the front of the building to take resident to his transport van for Dialysis. This writer noticed that the resident was not responding well to voice or touch as well as shaking. Called on the overhead for the charge nurse and floor nurse to come assist. Pulse and BS (blood sugar) taken. Resident still was not responding well, thicken apple juice was given and resident started to perk up more. Before leaving the facility, he was asked again if anything was hurting and he stated his stomach, appropriate staff notified. 0750 (7:50 a.m.) - 11/9/2021 11:31 (11:31 a.m.) Note Text: This nurse informed that resident was transferred from dialysis to ER (emergency room) via EMS (emergency medical services) for altered mental status and low oxygen saturation. RP (responsible party) already aware. - 11/9/2021 13:11 (1:11 p.m.) Note Text: This nurse informed that resident will be admitted to [Name of hospital]. Resident ADT out. - 11/11/2021 23:30 (11:30 p.m.) Note Text: Patient re-admitted to facility at approx. (approximately) 2230 (10:30 p.m.) via stretcher from [Name of hospital] . - 11/12/2021 13:04 (1:04 p.m.) Note Text: Care Plan meeting: Resident, Spouse, Son-in-law, NP (nurse practitioner), Therapy, Care Manager, and this SW (social worker) present for this meeting . Medications and care plan were discussed . The clinical record failed to evidence a written summary of the baseline care plan for the readmission on [DATE] being offered and/or provided to the resident and/or responsible party. On 1/27/2022 at 11:05 a.m., an interview was conducted with OSM (other staff member) #1, the social services director. OSM #1 stated that the MDS (minimum data set) staff managed the care plans and each department documented their specific areas on the care plan. OSM #1 stated that they did not create baseline care plans for readmissions because the comprehensive care plan was reactivated when they were readmitted . OSM #1 stated that they offered a copy of the care plan to the resident or responsible party when they had the comprehensive care plan meetings. On 1/27/2022 at 11:15 a.m., an interview was conducted with LPN (licensed practical nurse) #3, MDS coordinator. LPN #3 stated that the comprehensive care plan was updated for readmissions to include any new needs identified from the hospitalization. LPN #3 stated that Resident #254 was sent to the hospital from the dialysis center and his readmission was anticipated so they did not discontinue the comprehensive care plan. LPN #3 stated that they reviewed the care plan on readmission and used that as the baseline care plan. At this time, a request was made for evidence of a written summary of the care plan being offered and/or provided to the resident and/or responsible party. On 1/27/2022 at 12:00 p.m., LPN #3 provided a copy of the care plan meeting note dated 11/12/2021 and stated that it documented the care plan being discussed with the family. When asked if the note evidenced a written summary being offered and/or provided to the resident and/or responsible party, LPN #3 stated, No. On 1/27/2022 at 12:50 p.m., an interview was conducted with LPN #1, unit manager. LPN #1 stated that residents readmitted to the facility had their existing comprehensive care plan reviewed on admission. LPN #1 stated that a written copy of the care plan was offered and provided on request to the resident and/or responsible party during the care plan meetings. LPN #1 stated that the social worker documented the meetings and the evidence would be in the note. On 1/27/2022 at approximately 1:35 p.m., a request was made to ASM #1, the administrator for the facility policy for baseline care planning. On 1/27/2022 at 2:46 p.m., ASM #1 provided via email the policy Baseline Care Assessment and Comprehensive Care Plan dated 7/2019. It documented in part, All residents admitted to [Name of facility] are required to have a baseline care plan assessment completed within 48 hours of admission .Review of baseline care plan and medication list, with a printed summary is provided to the resident and/or residentts [sic] responsible party prior to completion of the comprehensive care plan. Documentation of this conversation/review is completed is in the EMR (electronic medical record) . On 1/27/2022 at approximately 1:30 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. References: 1. malignant neoplasm The term malignancy refers to the presence of cancerous cells that have the ability to spread to other sites in the body (metastasize) or to invade nearby (locally) and destroy tissues. Malignant cells tend to have fast, uncontrolled growth and DO NOT die normally due to changes in their genetic makeup. Malignant cells that are resistant to treatment may return after all detectable traces of them have been removed or destroyed. This information was obtained from the website: https://medlineplus.gov/ency/article/002253.htm. 2. end-stage kidney disease The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/000500.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for one of 31 residents in the survey sample, Resident #45. The facility staff failed to review and revise Resident #45's comprehensive care plan for anticoagulant (blood thinning) medication use. The findings include: Resident #45 was admitted to the facility on [DATE]. Resident #45's diagnoses included but were not limited to high blood pressure, heart disease and major depressive disorder. Resident #45's quarterly minimum data set assessment with an assessment reference date of 11/22/21, coded the resident's cognition as severely impaired. Review of Resident #45's clinical record revealed a physician's order dated 8/10/21 for Xarelto (1) 20 mg (milligrams) - one tablet by mouth in the evening for a right lower extremity deep vein thrombosis (blood clot). Review of Resident #45's January 2022 medication administration record revealed the resident was administered Xarelto 20 mg each evening during the month. Resident #45's comprehensive care plan dated 9/14/16 failed to reveal the care plan was reviewed and revised to include anticoagulant use. On 1/26/22 at 1:56 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the purpose of the care plan is to have a patient's plan of care in place so everyone knows how to care for someone and what their needs are. LPN #1 stated anticoagulant use should be included on residents' care plans. On 1/26/22 at 2:11 p.m., RN (registered nurse) #1 stated Resident #45's anticoagulant use was not included on the resident's care plan. On 1/26/22 at 5:33 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, Baseline Care Assessment and Comprehensive Care Plan documented, 12. The care plan is evaluated and changed in reference to the resident's response to treatment and whenever there is a change in the resident. All disciplines participate in maintaining the care plan so that it reflects the current status of the resident . No further information was presented prior to exit. Reference: (1) Xarelto is a blood thinning medication used to treat blood clots. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a611049.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for the clarification of physician orders for pain medications for one of 31 residents in the survey sample, Resident #51. The findings include: Resident #51 was admitted to the facility on [DATE] with diagnoses that included but not limited to: stroke (abnormal condition in which hemorrhage or blockage of the blood vessels of the brain leads to oxygen lack and resulting symptoms - sudden loss of ability to move a body part [as an arm or parts of the face], or to speak, paralysis weakness or if severe, death) (1), hemiplegia (paralysis affecting only one side of the body (2), Bipolar Disorder (a mental disorder characterized by episodes of mania and depression) (3), and chronic pain syndrome. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/5/2022, coded the resident as scoring a 13 on the BIMS (brief interview for mental status) score, indicating the resident is capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance for most of her activities of daily living such as bathing, eating, transfers and dressing. In Section J - Health Conditions, the resident was coded as having pain in the past five days. The resident was coded as having almost constant pain and the pain was coded as being severe in nature. The physician orders dated 11/20/2021 documented, Acetaminophen (Tylenol - used to treat mild to moderate pain) (4) Tablet 325 mg (milligrams); give 650 mg by mouth every 8 hours as needed for Pain scale 1-5. The physician order dated 11/20/2021 documented, Morphine Sulfate (used to treat moderate to severe pain) (5) solution 20MG/ML (milligrams per milliliter) Give 5 mg by mouth every 4 hours as needed for pain scale 5-10 = administration of Give 0.25 M: (5 mg). The December 2021 MAR (medication administration record) documented the above orders. On 12/30/2021 at 9:39 p.m., Resident #51 received Acetaminophen for a documented pain level of 5. The January 2022 MAR documented the above orders. On 1/9/2022 at 10:32 a.m. and 1/22/2022 at 11:48 p.m., Resident #51 received Morphine for a documented pain level of 5. The comprehensive care plan dated, 6/9/2017 and revised on 8/24/2021, documented in part, Focus: (Resident #51) has potential for pain related to S/P (status post) left hip fx (fracture), left hemi (hemiplegia) S/P CVA (stroke), depression, and other generalized discomforts such as neuropathic pain S/P CVA, c/o (complaint of) muscle spasms. The Interventions documented in part, Anticipate (Resident #51)'s need for pain relief and respond immediately to any complaint of pain. Monitor/document for probable cause for each pain episode. Remove/limit cases where possible. Monitor/record pain characteristics as patient complains of pain and PRN (as needed), Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset, Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors. Provide non-pharmacological interventions for pain relief prior to administering PRN medications such as change in position, cool compress or heat, diversional activities such as TV, snack, drink, others as desired. An interview was conducted with LPN (licensed practical nurse) #1, the unit manager, on 1/27/2022 at 9:41 a.m. The above orders for Acetaminophen and Morphine were reviewed with LPN #1. When asked what medication should the nurse give if the resident states their pain level is a 5, LPN #1 stated I don't know, that needs to be clarified. LPN #1 further stated it should be for one to five and then six to ten. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 1/27/2022 at 10:39 a.m. The above orders for Acetaminophen and Morphine were reviewed with ASM #2. When asked what medication should the nurse give if the resident states their pain level is a 5, ASM #2 stated that's not right. ASM #2 was asked what needed to be done; ASM #2 stated the orders needed to be clarified with the doctor. A policy on the clarification of orders was requested on 1/27/2022 at approximately 10:30 a.m. The following policy was presented, admission of Resident. The policy documented in part, Fax physician for clarification orders and transcribe telephone order to note clarification. Clarify ALL medications with MD (medical doctor) and note clarifications. On 1/27/2022 at 1:33 p.m. ASM #2, the director of nursing, stated their standard of practice the facility followed was Nursing by [NAME]. According to [NAME]'s Fundamentals of Nursing, 5th edition, page 553 documents the following statement, Always clarify with the prescriber any medication order that is unclear or seems inappropriate. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 1/27/2022 at 1:33 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 114. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 266. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 72. (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a681004.html. (5) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682133.html

Based on clinical record review and staff interview, it was determined that the facility staff failed to check the placement and function of the wander guard according to the physician's orders for 1 of 31 residents in the survey sample, Resident # 8. The findings include: Resident # 8 was admitted to the facility with diagnoses that included but were not limited to: high blood pressure, low iron and breast cancer. Resident # 8's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 11/01/2021, coded Resident # 8 as scoring a 0 (zero) on the brief interview for mental status (BIMS), indicating the resident is severely impaired of cognition for making daily decisions. Section P Restraints and Alarms coded Resident # 8 for a wander guard Used daily. The POS (physician's order sheet) for Resident # 8 documented in part, Wanderguard to wheelchair check function & (and) placement every shift. Date Order: 08/06/2021. Start Date: 08/06/2021. The comprehensive care plan for Resident # 8 dated 08/03/2021 documented. FOCUS: [Resident # 8] is an elopement risk/wanderer AEB (as evidenced by) impaired safety awareness. Date Initiated: 11/08/2021. Under Interventions it documented in part, WANDER ALERT: Wander guard to wheelchair. Check placement every shift. Date Initiated: 11/08/2021. The facility's Elopement Risk Assessment for Resident # 8 dated 11/22/2021 documented in part, 1. Is the resident cognitively impaired with poor decision-making skills? i.e. intermittent confusion, cognitive deficit or disoriented all the time?): Yes. 2. Is the resident able to ambulate or move around the facility independently or with limited assistance? (including w/c and assistive devices): Yes. Under section I it documented, Obtain wanderguard order if any of the following are met: 1. All questions are answered YES. 2. If #'s 1&2 are answered YES. The eTAR (electronic treatment record) for Resident # 8 dated January 2022 documented in part, Wanderguard to wheelchair check function & (and) placement every shift. Start Date: 08/06/2021. Further review of the eTAR revealed blanks on 01/17/2022 on the night shift and on 01/23/2022 on the evening shift. On 01/27/2022 at approximately 9:20 a.m., an interview was conducted with RN (registered nurse) # 1, unit manager. After reviewing Resident # 8's the comprehensive care plan dated 11/08/2021, the physician's order for Resident # 8's wander guard and the blanks on the eTAR dated January 2022 for the dates listed above, RN # 1 was asked what the blanks on the eTAR indicated. RN # 1 stated, It wasn't done. If it's blank I can't say it was done. The facility's policy Elopement Disoriented Residents Leaving Premises Without Notification of Staff, 831-023 documented in part, Wanderguards will be checked out from the nurse manager or charge nurse. The placement or removal of wanderguards from individual residents will be communicated to the administrative assistant, transport coordinator, or designee for updating information in the elopement risk binder. Every shift, nursing staff assigned to the resident will ensure proper placement of the wanderguard. Functionality of the wanderguard will be checked weekly by nursing staff or designee. On 01/27/2022 at approximately 1:30 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit.

Based on clinical record review and staff interview, it was determined that the facility staff failed to provide a therapeutic diet according to the physician's orders for 1 of 31 residents in the survey sample, Resident # 5. The facility staff failed to provide Resident # 5 with a NAS (No Added Salt) and NCS (no concentrated sugar) diet according to the physician ' s orders. The findings include: Resident # 5 was admitted to the facility with diagnoses that included but were not limited to: high blood pressure, heart failure and diabetes mellitus [1]. Resident # 5's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 10/27/2021, coded Resident # 5 as scoring a four on the brief interview for mental status (BIMS) of a score of 0 - 15, four - being severely impaired of cognition for making daily decisions. The POS (physician's order sheet) for Resident # 5 documented in part, Accu checks [2] at bed time related to TYPE 2 (two) DIABETES MELLITUS WITH DIABETIC NEUROPATHY [3]. Date Order: 02/18/2021. Start Date: 02/18/2021. Insulin [4] Glargine [5] Solution. Inject 20 unit subcutaneously [6] at bedtime for Diabetes. Date Order: 12/15/2019. Start Date: 12/15/2019. NAS No Added Salt) diet. Regular texture, Regular consistency, NCS/(no concentrated sugar)/NAS/Low sodium. Date Order: 03/21/2021. Start Date: 03/21/2021. The facility's Dietary/Nutritional Assessment for Resident # 5 dated 01/21/2022 documented in part, III. Diet. Type. NAS - No Added Salt. The facility's meal tickets for Resident # 5 documented in part, Jan (January) 27, 2022 (Thursday - Dinner). Diet: NAS, Jan (January) 27, 2022 (Friday - Lunch). Diet: NAS, Jan (January) 27, 2022 (Friday - Dinner). Diet: NAS. On 01/27/2022 at approximately 11:03 a.m., an interview was conducted with OSM (other staff member) # 8, clinical nutritional manager, and OSM # 2, food service director. When asked to describe the process for completing the dietary assessment for a resident OSM # 8 stated that they interview the resident, conduct a medical record review including review of the physician's orders, and input from the IDT (interdisciplinary team). When asked if a resident with who is diagnosed with diabetes should be on a low carbohydrate diet OSM #3 stated, They should be on a diabetic diet. After reviewing the physician's order for Resident # 5's diet for no added salt and no concentrated sugar and the dietary/nutritional assessment for Resident # 5 dated 01/21/2022, OSM # 8 and OSM # 3 were asked the dietary/nutritional assessment accurately reflected the physician's order as stated above OSM # 8 stated that the part of the order that documented, NCS/NAS/Low sodium was not part of the physician's order and was a food preference. On 01/27 2022 at 12:23 p.m. a telephone interview was conducted with ASM (administrative staff member) # 3, medical director. When asked about the diet order of no concentrated sugar and no added salt for Resident # 5, ASM # 3 stated that it was not their order and stated that they would check with the nurse practitioner. On 01/27/2022 at 12:27 p.m. an interview was conducted with ASM # 2, director of nursing. When asked to interpret the section on the physician's order that documented, NCS/NAS/Low sodium ASM # 2 stated that it was all part of the physician's order and that the resident should be on a no concentrated sugar, no added salt and a low sodium diet. After reviewing Resident # 5's dietary/nutritional assessment and meal ticket at stated above, ASM # 2 was asked if the meal ticket and assessment were accurate according to the physician's order ASM # 2 stated no. When asked if Resident # 5 was receiving the correct therapeutic diet ASM # 2 stated no. On 01/27/2022 at approximately 12:40 a telephone interview was conducted with ASM (administrative staff member) # 4, nurse practitioner. After being read Resident # 5's dietary/nutritional assessment and the physician's dietary order as stated above, ASM # 4 was asked to describe the type of diet Resident # 5 should have been receiving. ASM # 4 stated, Should continue with a no concentrated sugar, no added salt and low sodium diet. On 01/27/2022 at approximately 1:30 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit. References: [1] A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm. [2] A glucometer, also known as a glucose meter or blood glucose monitoring device, is a home measurement system you can use to test the amount of glucose (sugar) in your blood. This information was obtained from the website: https://www.dexcom.com/faq/what-glucometer. [3] Nerve damage. This information was obtained from the website: https://www.google.com/#q=neuropathy+nih. [4] Type 2 diabetes, the most common type, can start when the body doesn't use insulin as it should. If your body can't keep up with the need for insulin, you may need to take pills. Along with meal planning and physical activity, diabetes pills help people with type 2 diabetes or gestational diabetes keep their blood glucose levels on target. Several kinds of pills are available. Each works in a different way. Many people take two or three kinds of pills. Some people take combination pills. Combination pills contain two kinds of diabetes medicine in one tablet. Some people take pills and insulin. This information was obtained from the website: https://medlineplus.gov/diabetesmedicines.html. [5] A long-acting, manmade version of human insulin. Insulin glargine products work by replacing the insulin that is normally produced by the body and by helping move sugar from the blood into other body tissues where it is used for energy. It also stops the liver from producing more sugar. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a600027.html#:~:text=Insulin%20glargine%20is%20a%20long,liver%20from%20producing%20more%20sugar. [6] The term cutaneous refers to the skin. Subcutaneous means beneath, or under, all the layers of the skin. For example, a subcutaneous cyst is under the skin. This information was obtained from the website: https://medlineplus.gov/ency/article/002297.htm.

**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 the facility staff failed to maintain a complete pain management program for one of 31 residents in the survey sample, Resident #51. The facility staff failed to document the location of pain and failed to off non-pharmacological interventions prior to the administration of pain medication. The findings include: Resident #51 was admitted to the facility on [DATE] with diagnoses that included but not limited to: stroke (abnormal condition in which hemorrhage or blockage of the blood vessels of the brain leads to oxygen lack and resulting symptoms - sudden loss of ability to move a body part [as an arm or parts of the face], or to speak, paralysis weakness or if severe, death) (1), hemiplegia (paralysis affecting only one side of the body) (2), Bipolar Disorder (a mental disorder characterized by episodes of mania and depression) (3), and chronic pain syndrome. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/5/2022, coded the resident as scoring a 13 on the BIMS (brief interview for mental status) score, indicating the resident is capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance for most of her activities of daily living such as bathing, eating, transfers and dressing. In Section J - Health Conditions, the resident was coded as having pain in the past five days. The resident was coded as having almost constant pain and the pain was coded as being severe in nature. The physician orders dated 11/20/2021 documented, Acetaminophen (Tylenol - used to treat mild to moderate pain) (4) Tablet 325 mg (milligrams); give 650 mg by mouth every 8 hours as needed for Pain scale 1-5. Administration of Tylenol Document non - pharmacological interventions prior to administration of analgesic. For # - enter 1=reposition, 2=diversion/distraction activity, 3=reduce stimulation, 4=other = DOC (document) in nurse note. For LOC (location) enter location of pain. The physician order dated 11/20/2021 documented, Morphine Sulfate (used to treat moderate to severe pain) (5) solution 20MG/ML (milligrams per milliliter) Give 5 mg by mouth every 4 hours as needed for pain scale 5-10 = administration of Give 0.25 M: (5 mg). Document non-pharmacological interventions prior to administration of analgesic. For # - enter 1=reposition, 2=diversion/distraction activity, 3=reduce stimulation, 4=other = DOC (document) in nurse note. For LOC (location) enter location of pain. The November 2021 MAR (medication administration record) documented the above physician orders. On 11/21/2021 at 1:25 a.m., 11/23/2021 at 12:00 a.m. and 11/29/2021 at 10:00 p.m. the Morphine was administered. The location of the pain was documented as 3. There was no chart code for 3 for location. On 11/23/2021 at 2:07 p.m. the Morphine was administered, documented for non-pharmacological interventions was y. A y was documented also at that time for the location of pain. The December 2021 MAR documented the above physician orders. The Morphine was administered on 12/10/2021 at 3:08 a.m., 12/30/2021 at 1:51 a.m. and 12/31/2021 at 6:10 a.m., the location of the pain was documented as a 3. On 12/16/2021 at 11:40 p.m., the Morphine was administered. It was documented, a 0 in the box for the non-pharmacological interventions. The January 2022 MAR documented the above physician orders. The Acetaminophen was administered on 1/10/2022 at 6:25 a.m. In the box for the administration of non-pharmacological interventions and the location of the pain, documented, N/A. The Morphine was administered on 1/5/2021 at 2:33 p.m. A N/A was documented in the box for non-pharmacological interventions and for the location of the pain. On 1/8/2022 at 12:05 p.m., 1/9/2022 at 10:32 a.m., 1/10/2022 at 12:02 a.m. and 11:18 a.m., 1/16/2022 at 9:55 a.m., there was a y documented in the box for non-pharmacological interventions. On 1/17/2022 at 6:15 a.m. the box for non-pharmacological interventions was blank. Review of the nurse's notes from 11/1/2021 through 1/127/2022 failed to reveal further explanation of the MAR documentation. The comprehensive care plan dated, 6/9/2017 and revised on 8/24/2021, documented in part, Focus: (Resident #51) has potential for pain related to S/P (status post) left hip fx (fracture), left hemi (hemiplegia) S/P CVA (stroke), depression, and other generalized discomforts such as neuropathic pain S/P CVA, c/o (complaint of) muscle spasms. The Interventions documented in part, Anticipate (Resident #51)'s need for pain relief and respond immediately to any complaint of pain. Monitor/document for probable cause for each pain episode. Remove/limit cases where possible. Monitor/record pain characteristics as patient complains of pain and PRN (as needed), Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset, Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors. Provide non-pharmacological interventions for pain relief prior to administering PRN medications such as change in position, cool compress or heat, diversional activities such as TV, snack, drink, others as desired. An interview was conducted with LPN (licensed practical nurse) #1, the unit manager, on 1/27/2022 at 9:41 a.m. The above orders and MARs were reviewed with LPN #1. When asked what a 3 documented in the spot on the MAR for location of the pain, LPN #3 stated, We don't have a code for that part, they should write where the pain is. When asked what it indicates when it is documented a 0 in the box for non-pharmacological interventions, LPN #1 stated, To me it indicates they didn't offer any. LPN #1 was asked what a N/A indicated on the MAR for non-pharmacological interventions and location of the pain, LPN #1 stated, N/A doesn't apply as an answer for either one of those boxes. When asked what a y in the box for non-pharmacological interventions meant, LPN #1 stated, I guess it means they attempted them but they need to document what they attempted. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 1/27/2022 at 10:39 a.m. The above orders for Morphine and Acetaminophen were reviewed with ASM #2. The above MARs were reviewed with ASM #2. When asked what a 3 documented in the box on the MAR for location of the pain, ASM #2 stated the nurse is not paying attention to what she is documenting. When asked what a zero in the box for non-pharmacological interventions indicated, ASM #2 stated to her it meant nothing was offered. When asked was a N/A indicated on the MAR for non-pharmacological interventions and for the location of pain was, ASM #2 stated N/A is not acceptable for an answer in those boxes. When asked what a y in the box for non-pharmacological interventions indicated, ASM #2 stated she thought that they maybe did offer non-pharmacological interventions but they failed to document what they offered which is required. ASM #2 stated this process was changed to what appears on the MAR now. The facility policy, Pain Management documented in part, Purpose: To ensure that pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences Pain management is a multidisciplinary care process that included the following: assessing the potential for pain, effectively recognizing the presences of pain, identifying the characteristics of pain, addressing the underlying causes of pain, developing and implementing approaches to pain management and identifying and using specific strategies for different levels and sources of pain Pain management interventions shall reflect the sources, type and severity of pain. Various strategies and modalities may be utilized to assist the resident in achieving optimal comfort. Such as strategies and modalities may include, but are not limited to: Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Some non-pharmacological interventions include: Environment - adjusting the room temperature, smoothing the lines, provided a pressure-reducing mattress, repositioning, etc.; Physical - ice packs, cool or warm compresses, baths, transcutaneous electrical nerve stimulation (TENS), massage, acupuncture, etc.; Exercise - range of motion exercises to prevent muscle stiffness and contractures; and cognitive or behavioral - relaxation, music, diversions activities, etc. According to Fundamentals of Nursing, Fifth Edition, 2007, [NAME] & [NAME], page 1176 to 1207. Pain, one of the most complex human experiences, is an invisible phenomenon influenced by the interaction of affective (emotional), behavioral, cognitive, and physiologic-sensory factors. Because pain is a highly individual experience, the basis for pain management is simply the client's description of pain. Pain exists whenever the person says it does Typically people describe pain by its location, intensity, quality, and temporal pattern. Sensory components of the pain experience are subjective but can be measured using standardized tools Assessment: An accurate assessment focusing on pain's cause is essential for determining proper therapy. Ongoing assessment also is important for implementing an effective pain management plan Document pain assessment information in an accessible location. Even the best pain assessment conducted by the one nurse is of limited value unless he or she shares the information with other healthcare professionals responsible for the client's care. Subjective Data: In an attempt to assess the client's pain, obtain answers to the following questions: Where is the pain located? What is the magnitude or intensity (level) of the pain? What level of pain would the client like to have? What level of pain would the client be willing to tolerate? How does the pain feel to the client; how is it described (its quality)? How does the pain change with rest, activity, or time (its temporal pattern)? .Inadequate or poor pain assessment is a leading factor in poor pain control .Objective data Physiologic responses to pain are the result of the activation of the autonomic nervous system. With acute pain, the general responses observed include tachycardia, elevated blood pressure, increased respiratory rate, diaphoresis, and gastric distress. With persistent chronic pain, these responses may be modified or absent Related symptoms may give additional clues about pain. Nausea and vomiting, fatigue, anorexia, and withdrawal are common with pain Observe the client's facial expressions and body movements. Wincing, frowning, and grimacing can indicate pain .Body movements may represent protective actions to decrease the pain. Body movements such as rubbing, splinting, guarding, immobilizing, elevating the painful extremity, or changing positions frequently may increase with pain . ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 1/27/2022 at 1:33 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 114. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 266. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 72. (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a681004.html. (5) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682133.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of 31 residents in the survey sample was free of unnecessary pain medication, Resident #51. For Resident #51, the facility staff administered pain medication when the documented pain level was outside the parameters of the physician ordered pain medication. The findings include: Resident #51 was admitted to the facility on [DATE] with diagnoses that included but not limited to: stroke (abnormal condition in which hemorrhage or blockage of the blood vessels of the brain leads to oxygen lack and resulting symptoms - sudden loss of ability to move a body part [as an arm or parts of the face], or to speak, paralysis weakness or if severe, death) (1), hemiplegia (paralysis affecting only one side of the body) (2), Bipolar Disorder (a mental disorder characterized by episodes of mania and depression) (3), and chronic pain syndrome. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/5/2022, coded the resident as scoring a 13 on the BIMS (brief interview for mental status) score, indicating the resident is capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance for most of her activities of daily living such as bathing, eating, transfers and dressing. In Section J - Health Conditions, the resident was coded as having pain in the past five days. The resident was coded as having almost constant pain and the pain was coded as being severe in nature. The physician orders dated 11/20/2021 documented, Acetaminophen (Tylenol - used to treat mild to moderate pain) (4) Tablet 325 mg (milligrams); give 650 mg by mouth every 8 hours as needed for Pain scale 1-5. Administration of Tylenol Document non - pharmacological interventions prior to administration of analgesic. For # - enter 1=reposition, 2=diversion/distraction activity, 3=reduce stimulation, 4=other = DOC (document) in nurse note. For LOC (location) enter location of pain. The physician order dated 11/20/2021 documented, Morphine Sulfate (used to treat moderate to severe pain) (5) solution 20MG/ML (milligrams per milliliter) Give 5 mg by mouth every 4 hours as needed for pain scale 5-10 = administration of Give 0.25 M: (5 mg). Document non-pharmacological interventions prior to administration of analgesic. For # - enter 1=reposition, 2=diversion/distraction activity, 3=reduce stimulation, 4=other = DOC (document) in nurse note. For LOC (location) enter location of pain. The review of the November 2021 MAR (medication administration record) documented the above orders for Morphine. On 11/21/2021 at 1:25 a.m., Resident #51 received Morphine Sulfate for a documented pain level of 3. On 11/23/2021 at 12:00 a.m., Resident #51 received Morphine Sulfate for a documented pain level of 4. Both pain levels were outside of the physician ordered parameters for the administration of the Morphine. The review of the December 2021 MAR documented the above orders for Morphine. The Morphine was documented as given on the following dates with the following documented pain levels: 12/10/2021 at 3:08 a.m. - pain level documented, 3. 12/29/2021 at 4:15 a.m. - pain level documented, 4. 12/30/2021 at 1:51 a.m. - pain level documented, 4. 12/31/2021 at 6:10 a.m. - pain level documented, 4. The pain levels were outside of the physician ordered parameters for the administration of Morphine. The review of the January 2022 MAR documented the above orders for Acetaminophen and Morphine. The Acetaminophen was documented as given on 1/10//2022 for a documented pain level of 10. The pain levels were outside of the physician ordered parameters for the administration of Acetaminophen. The Morphine was documented as given on the following dates with the following documented pain levels: 1/5/2022 at 2:33 p.m. - pain level documented, 0. 1/15/2022 at 11:30 p.m. - pain level documented, 4. 1/16/2022 at 5:00 p.m. - pain level documented, 4. The pain levels were outside of the physician ordered parameters for the administration of Morphine. Review of the nurse's notes from November 2021 through January 27, 2022, failed to evidence documentation related to the reason the pain medications were given outside of the physician ordered parameters. The comprehensive care plan dated, 6/9/2017 and revised on 8/24/2021, documented in part, Focus: [Resident #51] has potential for pain related to S/P (status post) left hip fx (fracture), left hemi (hemiplegia) S/P CVA (stroke), depression, and other generalized discomforts such as neuropathic pain S/P CVA, c/o (complaint of) muscle spasms. The Interventions documented in part, Anticipate [Resident #51]'s need for pain relief and respond immediately to any complaint of pain. Monitor/document for probable cause for each pain episode. Remove/limit cases where possible. Monitor/record pain characteristics as patient complains of pain and PRN (as needed), Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset, Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors. Provide non-pharmacological interventions for pain relief prior to administering PRN medications such as change in position, cool compress or heat, diversional activities such as TV, snack, drink, others as desired. An interview was conducted with LPN (licensed practical nurse) #1, the unit manager, on 1/27/2022 at 9:41 a.m. The above orders for Acetaminophen and Morphine were reviewed with LPN #1. When asked if the Morphine should have been given when the pain level was zero or four, LPN #1 stated, no, the Acetaminophen should have been given for that pain level. When asked if the Acetaminophen should have been given for the pain level of ten, LPN #1 stated the order doesn't say that and the Morphine should have been given. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 1/27/2022 at 10:39 a.m. The above orders for Acetaminophen and Morphine were reviewed with ASM #2. When asked if the Acetaminophen should have been given for a pain level of 10, ASM #2 stated that unless the resident requested the Tylenol, then the Morphine should have been given. When asked if the Morphine should have been given for a pain level of 4, ASM #2 stated, no, that is not per the physician orders. The facility policy, Medication Management and Pharmaceutical Services, documented in part, The objectives of the pharmaceutical services are to: Assure that medications are administered as ordered . ensure the resident's drug regime is free of unnecessary medications. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 1/27/2022 at 1:33 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 114. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 266. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 72. (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a681004.html. (5) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682133.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to implement Resident # 8's comprehensive care plan for checking the placement of a wander guard. Resident # 8 was admitted to the facility with diagnoses that included but were not limited to: high blood pressure, low iron and breast cancer. Resident # 8's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 11/01/2021, coded Resident # 8 as scoring a 0 (zero) out of 15 on the brief interview for mental status (BIMS). A score of 0 indicates the resident severely impaired of cognition for making daily decisions. Section P Restraints and Alarms coded Resident # 8 for a wander guard Used daily. The POS (physician's order sheet) for Resident # 8 documented in part, Wanderguard to wheelchair check function & (and) placement every shift. Date Order: 08/06/2021. Start Date: 08/06/2021. The comprehensive care plan for Resident # 8 dated 08/03/2021 documented. FOCUS: [Resident # 8] is an elopement risk/wanderer AEB (as evidenced by) impaired safety awareness. Date Initiated: 11/08/2021. Under Interventions it documented in part, WANDER ALERT: Wander guard to wheelchair. Check placement every shift. Date Initiated: 11/08/2021. The eTAR (electronic treatment record) for Resident # 8 dated January 2022 documented in part, Wanderguard to wheelchair check function & (and) placement every shift. Start Date: 08/06/2021. Further review of the eTAR revealed blanks on 01/17/2022 on the night shift and on 01/23/2022 on the evening shift. On 01/27/2022 at approximately 9:20 a.m., an interview was conducted with RN (registered nurse) # 1, unit manager. After reviewing Resident # 8's the comprehensive care plan dated 08/03/2021, the physician's order for Resident # 8's wander guard and the blanks on the eTAR dated January 2022 for the dates listed above, RN # 1 was asked what the blanks on the eTAR indicated. RN # 1 stated, It wasn't done. If it's blank I can't say it was done. RN # 1 was asked if Resident # 8's comprehensive care plan was implemented. RN # 1 stated no. On 01/27/2022 at approximately 1:30 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit. 3. The facility staff failed to implement Resident # 5's comprehensive care plan for obtaining physician ordered daily weights. Resident # 5 was admitted to the facility with diagnoses that included but were not limited to: high blood pressure, heart failure and cancer of the liver. Resident # 5's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 10/27/2021, coded Resident # 5 as scoring a four out of 15 on the brief interview for mental status (BIMS), with four indicating the resident is severely impaired of cognition for making daily decisions. The POS (physician's order sheet) for Resident # 5 documented in part, Daily weight every day for Heart Failure. If weight greater than 3LBS (three pounds) in 1 (one) day and/or greater than 5LBS (five pounds) in 1 (one) week - reweigh immediately notify MD (medical doctor) loos/gain. Date Order: 03/26/2021. Start Date: 03/27/2021. The comprehensive care plan for Resident # 5 with a revision date of 05/07/2021 documented. FOCUS: [Resident # 5] is at increased nutritional risk r/t requiring a therapeutic diet, PMH (past medical history) of T2DM (type two diabetes mellitus), diabetic foot wound, HF (heart failure), Alzheimer's disease, dementia, chronic pain syndrome. She chooses to follow own eating plan that may contradict physician-ordered plan. Current BMI is 47.4 (obese classification). Revision on: 05/07/202. Under Interventions it documented in part, Monitor weight, notify MD/RP (medical doctor/responsible party) of weight change 5 % (five percent) x (times) 30 days, 7.5 (seven and a half) % x 90 days, 10% x 180 days, if indicated, anticipate variations and investigate causative factors upon occurrence. Date Initiated: 02/17/2021. The eTAR (electronic treatment record) for Resident # 5 dated November 2021 through January 2022 documented in part, Daily weight every day for Heart Failure. If weight greater than 3LBS (three pounds) in 1 (one) day and/or greater than 5LBS (five pounds) in 1 (one) week - reweigh immediately notify MD [medical doctor] loss/gain. Start Date: 03/27/2021. Further review of the eTARs revealed a blank on 11/24/2021, 12/17/2021, 12/23/2021, 12/25/2021, 12/29/2021, 12/30/2021, 01/08/2022 and on 01/14/2022. The facility's Weights and Vitals Summary sheet for Resident # 5 dated November 2021 through January 2022 failed to evidence weights for the same dates as listed above. The facility's progress notes for Resident # 5 dated November 2021 through January 2022 failed to evidence weights for the same dates as listed above. On 01/27/2022 at approximately 9:20 a.m., an interview was conducted with RN (registered nurse) # 1, unit manager. After reviewing Resident # 5's the comprehensive care plan dated 05/07/2021, the physician's order for Resident # 5's weigh and the blanks on the eTARs for the dates listed above, RN # 1 was asked what the blanks on the eTAR indicated. RN # 1 stated, It wasn't done. If it's blank I can't say it was done. RN # 1 was asked if Resident # 5's comprehensive care plan was implemented. RN # 1 stated no. On 01/27/2022 at approximately 1:30 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit. 4. The facility staff failed to implement Resident # 6's comprehensive care plan for behavior monitoring. Resident#16 was admitted to the facility with diagnoses that included but were not limited to Alzheimer's disease (1) and dementia with behavioral disturbances (2). Resident #6's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/29/2021, coded Resident # 6 as scoring an eleven on the staff assessment for mental status (BIMS) of a score of 0 - 15, with 11 indicating the resident is moderately impaired for making daily decisions. Section N documented Resident # 6 receiving antipsychotic and antidepressant medications. The POS (physician's order sheet) for Resident # 6 documented in part, Seroquel Tablet. Give 25MG (milligrams) by mouth at bedtime related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCES. Order Date: 12/30/2021. Start Date: 12/30/2021. The comprehensive care plan for Resident # 6 dated 03/01/2019 documented in part, Focus: [Resident # 6] uses antipsychotics r/t (related to) dementia with behavioral disturbances. Date Initiated: 03/01/2019. Under Interventions/Tasks it documented in part, Monitor/record occurrence of for target behavior symptoms Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Date Initiated: 03/01/2019. The eMARs (electronic medication administration records) for Resident # 6 dated 12/01/2021 through 01/26/2022 documented side effect monitoring for the use of psychotropic medications. The eMARs failed to evidence monitoring of behaviors. The progress notes for Resident # 6 dated 12/01/2021 through 01/26/2022 failed to evidence monitoring of behaviors. On 01/27/2022 at approximately 9:20 a.m., an interview was conducted with RN (registered nurse) # 1, unit manager. After reviewing Resident # 6's the comprehensive care plan dated 03/01/2019, the physician's order for Resident # 6's use of Seroquel the facility's progress notes dated 12/01/2021 through 01/26/2022 and the eMAR dated 12/01/2021 through 01/26/2022, RN # 1 was asked if Resident # 6's comprehensive care plan was implemented for behavior monitoring. RN # 1 stated no. On 01/27/2022 at approximately 1:30 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit. REFERENCES [1] A brain disorder that seriously affects a person's ability to carry out daily activities) This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/alzheimersdisease.html. [2] Psychological symptoms and behavioral abnormalities are common and prominent characteristics of dementia. They include symptoms such as depression, anxiety psychosis, agitation, aggression, disinhibition, and sleep disturbances. Approximately 30% to 90% of patients with dementia suffer from such behavioral disorders. There are complex interactions between cognitive deficits, psychological symptoms, and behavioral abnormalities. This information was obtained from the website: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181717/. Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for four of 31 residents in the survey sample, Residents #51, #8, #5, and #6. The findings include: 1. The facility staff failed to offer non-pharmacological interventions and document the location of pain prior to the administration of pain medications per the comprehensive care plan for Resident #51. Resident #51 was admitted to the facility on [DATE] with diagnoses that included but not limited to: stroke (abnormal condition in which hemorrhage or blockage of the blood vessels of the brain leads to oxygen lack and resulting symptoms - sudden loss of ability to move a body part [as an arm or parts of the face], or to speak, paralysis weakness or if severe, death) (1), hemiplegia (paralysis affecting only one side of the body (2), Bipolar Disorder (a mental disorder characterized by episodes of mania and depression) (3), and chronic pain syndrome. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/5/2022, coded the resident as scoring a 13 on the BIMS (brief interview for mental status) score, indicating the resident is capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance for most of her activities of daily living such as bathing, eating, transfers and dressing. In Section J - Health Conditions, the resident was coded as having pain in the past five days. The resident was coded as having almost constant pain and the pain was coded as being severe in nature. The comprehensive care plan dated, 6/9/2017 and revised on 8/24/2021, documented in part, Focus: (Resident #51) has potential for pain related to S/P (status post) left hip fx (fracture), left hemi (hemiplegia) S/P CVA (stroke), depression, and other generalized discomforts such as neuropathic pain S/P CVA, c/o (complaint of) muscle spasms. The Interventions documented in part, Anticipate (Resident #51)'s need for pain relief and respond immediately to any complaint of pain. Monitor/document for probable cause for each pain episode. Remove/limit cases where possible. Monitor/record pain characteristics as patient complains of pain and PRN (as needed), Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset, Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors. Provide non-pharmacological interventions for pain relief prior to administering PRN medications such as change in position, cool compress or heat, diversional activities such as tv, snack, drink, others as desired. The November 2021 MAR (medication administration record) documented the above physician orders. On 11/21/2021 at 1:25 a.m., 11/23/2021 at 12:00 a.m. and 11/29/2021 at 10:00 p.m. the Morphine was administered. The location of the pain was documented as 3. There was no chart code for 3 for location. On 11/23/2021 at 2:07 p.m. the Morphine was administered, documented for non-pharmacological interventions was y. A y was documented also at that time for the location of pain. The December 2021 MAR documented the above physician orders. The Morphine was administered on 12/10/2021 at 3:08 a.m., 12/30/2021 at 1:51 a.m. and 12/31/2021 at 6:10 a.m., the location of the pain was documented as a 3. On 12/16/2021 at 11:40 p.m., the Morphine was administered. It was documented, a 0 in the box for the non-pharmacological interventions. The January 2022 MAR documented the above physician orders. The Acetaminophen was administered on 1/10/2022 at 6:25 a.m. In the box for the administration of non-pharmacological interventions and the location of the pain, documented, N/A. The Morphine was administered on 1/5/2021 at 2:33 p.m. A N/A was documented in the box for non-pharmacological interventions and for the location of the pain. On 1/8/2022 at 12:05 p.m., 1/9/2022 at 10:32 a.m., 1/10/2022 at 12:02 a.m. and 11:18 a.m., 1/16/2022 at 9:55 a.m., there was a y documented in the box for non-pharmacological interventions. On 1/17/2022 at 6:15 a.m. the box for non-pharmacological interventions was blank. Review of the nurse's notes from 11/1/2021 through 1/127/2022 failed to reveal further explanation of the MAR documentation. An interview was conducted with RN (registered nurse) #1, the unit manager, on 1/27/2022 at 9:20 a.m. When asked the purpose of the care plan, RN #1 stated it was the plan of care for the resident, how to care for the resident. When asked should the care plan be implemented and followed, RN #1 stated, yes. An interview was conducted with LPN (licensed practical nurse) #1, the unit manager, on 1/27/2022 at 9:41 a.m. The above information was shared with LPN #1. When asked if that was following the comprehensive care plan, LPN #1 stated, no. The facility policy, Baseline Care Assessment and Comprehensive Care Plan documented in part, The care plan must describe the services that are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being in accordance with the comprehensive assessment .8. The care planning process must include the resident with information so that he/she can participate in goals and wishes regarding treatment. 9. When there appears to be a conflict between a resident's right and the residents health or safety, the facility must accommodate both the resident's rights and the residents health, including exploration of alternative care through the care planning process in which the resident participates. 10. The care plan must reflect current standards of professional practice. 11. The care plan includes treatment objectives that have measurable outcomes with time tables and specific approaches to meet the defined needs. A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care.(6) ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 1/27/2022 at 1:33 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 114. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 266. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 72. (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a681004.html. (5) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682133.html (6) Fundamentals of Nursing [NAME] & [NAME] 2007 [NAME] Company Philadelphia pages 65-77.

Based on clinical record review and staff interview, it was determined that the facility staff failed to obtain daily weights according to the physician's orders for 1 of 31 residents in the survey sample, Resident # 5. The findings include: Resident # 5 was admitted to the facility with diagnoses that included but were not limited to: high blood pressure, heart failure and cancer of the liver. Resident # 5's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 10/27/2021, coded Resident # 5 as scoring a four on the brief interview for mental status (BIMS), indication the resident is severely impaired of cognition for making daily decisions. The POS [physician's order sheet] for Resident # 5 documented in part, Daily weight every day for Heart Failure. If weight greater than 3LBS (three pounds) in 1 day and/or greater than 5LBS (five pounds) in 1 week - reweigh immediately notify MD (medical doctor) loss/gain. Date Order: 03/26/2021. Start Date: 03/27/2021. The comprehensive care plan for Resident # 5 with a revision date of 05/07/2021 documented. FOCUS: [Resident # 5] is at increased nutritional risk r/t requiring a therapeutic diet, PMH (past medical history) of T2DM (type two diabetes mellitus), diabetic foot wound, HF (heart failure), Alzheimer's disease, dementia, chronic pain syndrome. She chooses to follow own eating plan that may contradict physician-ordered plan. Current BMI is 47.4 (obese classification). Revision on: 05/07/202. Under Interventions it documented in part, Monitor weight, notify MD/RP (medical doctor/responsible party) of weight change 5 % (five percent) x (times) 30 days, 7.5 (seven and a half) % x 90 days, 10% x 180 days, if indicated, anticipate variations and investigate causative factors upon occurrence. Date Initiated: 02/17/2021. The eTAR (electronic treatment record) for Resident # 5 dated November 2021 through January 2022 documented in part, Daily weight every day for Heart Failure. If weight greater than 3LBS (three pounds) in 1 day and/or greater than 5LBS (five pounds) in 1 week - reweigh immediately notify MD (medical doctor) loss/gain. Start Date: 03/27/2021. Further review of the eTARs revealed a blank on 11/24/2021, 12/17/2021, 12/23/2021, 12/25/2021, 12/29/2021, 12/30/2021, 01/08/2022 and on 01/14/2022. The facility's Weights and Vitals Summary sheet for Resident # 5 dated November 2021 through January 2022 failed to evidence weights for the same dates as listed above. The facility's progress notes for Resident # 5 dated November 2021 through January 2022 failed to evidence weights for the same dates as listed above. On 01/27/2022 at approximately 9:20 a.m., an interview was conducted with RN (registered nurse) # 1, unit manager. When asked why Resident # 5's weight was being monitored RN # 3 stated, For congestive heart failure to ensure there is no fluid build-up around their heart. After reviewing Resident # 5's the comprehensive care plan dated 05/07/2021, the physician's order for Resident # 5's weigh and the blanks on the eTARs for the dates listed above, RN # 3 was asked what the blanks on the eTAR indicated. RN # 3 stated, It wasn't done. If it's blank I can't say it was done. On 01/27/2022 at approximately 1:30 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility failed to specify and monitor target Resident # 6's behaviors for the use of Seroquel [1]. Resident#16 was admitted to the facility with diagnoses that included but were not limited to Alzheimer's disease [1] and dementia with behavioral disturbances [2]. Resident #6's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/29/2021, coded Resident # 6 as scoring an eleven on the staff assessment for mental status (BIMS) of a score of 0 - 15, eleven- being moderately impaired for making daily decisions. Section N documented Resident # 6 receiving antipsychotic and antidepressant medications. The POS (physician's order sheet) for Resident # 6 documented in part, Seroquel Tablet. Give 25MG (milligrams) by mouth at bedtime related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCES. Order Date: 12/30/2021. Start Date: 12/30/2021. The comprehensive care plan for Resident # 6 dated 03/01/2019 documented in part, Focus: [Resident # 6] uses antipsychotics r/t (related to) dementia with behavioral disturbances. Date Initiated: 03/01/2019. Under Interventions/Tasks it documented in part, Monitor/record occurrence of for target behavior symptoms Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Date Initiated: 03/01/2019. The eMARs [electronic medication administration records for Resident # 6 dated 12/01/2021 through 01/26/2022 documented side effect monitoring for the use of psychotropic medications. The eMARs failed to evidence monitoring of behaviors. The progress notes for Resident # 6 dated 12/01/2021 through 01/26/2022 failed to evidence monitoring of behaviors. On 01/27/2022 at approximately 9:20 a.m., an interview was conducted with RN [registered nurse] #1, unit manager. After reviewing the Resident # 6's physician's orders as stated above, the facility's progress notes dated 12/01/2021 through 01/26/2022 and the eMAR dated 12/01/2021 through 01/26/2022, RN # 1 was asked to identify what specific behaviors were being monitored and to provide documentation evidencing behavior monitoring. RN # 1 stated that they did not specify specific behaviors on the eMAR nor could they provide documentation of behavior monitoring. On 01/27/2022 at 10:30 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. After reviewing the Resident # 6's physician's orders as stated above, the facility's progress notes dated 12/01/2021 through 01/26/2022 and the eMAR dated 12/01/2021 through 01/26/2022, ASM # 2 was asked to identify what specific behaviors were being monitored and to provide documentation evidencing behavior monitoring. ASM # 2 stated that they did not specify specific behaviors on the eMAR nor could they provide documentation of behavior monitoring. On 01/27/2022 at approximately 1:30 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit. References: [1] Quetiapine is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a698019.html. [2] A brain disorder that seriously affects a person's ability to carry out daily activities) This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/alzheimersdisease.html. [3] Psychological symptoms and behavioral abnormalities are common and prominent characteristics of dementia. They include symptoms such as depression, anxiety psychosis, agitation, aggression, disinhibition, and sleep disturbances. Approximately 30% to 90% of patients with dementia suffer from such behavioral disorders. There are complex interactions between cognitive deficits, psychological symptoms, and behavioral abnormalities. This information was obtained from the website: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181717/. Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to identify and monitor targeted behaviors for the use of psychotropic medications for two of 31 residents in the survey sample, Residents #40 and #6. The findings include: 1. The facility staff failed to identify and monitor targeted behaviors for the use of Seroquel (used to treat schizophrenia, bipolar disorder, and in combination with other medications to treat depression) (1) for Resident #40. Resident #40 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: anxiety disorder (state of mild to severe apprehension, often without specific cause, resulting in body changes such as quickened heartbeat and sweat.) (2), mood disorder (a mood disorder, feeling sad or irritable, affects a person's everyday emotional state.) (3), depression (a dejected state of mind with feelings of sadness, discouragement, and hopelessness, often accompanied by reduced activity and ability to function, apathy and sleep disturbance) (4), and dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.) (5). The most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 12/28/2021, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. The resident was coded as being independent or requiring supervision of one staff member for all of his activities of daily living. In Section N - Medications, the resident was coded as receiving an anti-psychotic medication for all seven days of the look back period. The physician order dated, 1/23/2022, documented, Seroquel Tablet 25 MG (milligrams); Give 1 tablet by mouth at bedtime for BPSD (behavioral and psychological symptoms of dementia) (6) r/t (related to) Dementia. A physician order dated, 10/14/2020, documented, Seroquel Tablet 25 MG; Give 25 mg by mouth in the morning for BPSD r/t dementia. The physician orders dated, 8/3/2019, documented, Observe for absence of behaviors to indicate effectiveness of psychotropic medication. Document Y if none observed. Document N, if behaviors observed and record in nurses' notes, every shift. The MARs (medication administration records) for November, December of 2021 and January 2022, were reviewed. The above orders were documented on the MARs. The MARs documented the behavior monitoring. For all three months, a check mark was documented in each block for each shift, not a Y or N. The comprehensive care plan dated, 5/8/2021 and revised on 8/22/2019, documented in part, Focus: (Resident #40) is at risk for ineffective coping related to insomnia, depression, mood disorder, anxiety and utilizes psychotropic medications. The Interventions documented in part, Monitor for behaviors every shift and record accordingly in EMR (electronic medical record). Contact family members if (Resident #40) becomes agitated (recently tapered off of other antipsychotic medications [this intervention was dated 11/26/2018]. Provide 1:1 assistance during episodes of ineffective coping. Allow (Resident #40) to vent feelings and offer support. Review of the progress notes to include physician notes and nurse's notes was conducted. The attending physician note dated, 11/29/2021, documented in part, Insomnia: controlled with Seroquel and temazepam (sleeping pill). Has failed other options. Failed tapers. Unable to get THC (The main, active ingredient in marijuana is THC [short for delta-9-tetrahydrocannabinol]) (7). Depression controlled with current rx (medications). No more psychosis. The social services note dated, 1/5/2022 documented in part, Resident does not do well with change and the smallest change, such as Bingo time changing and can cause major distress for the resident. The Care Plan Meeting notes dated 1/12/2022, documented in part, Resident was also upset because the resident's shower was late yesterday. Resident becomes upset if anything changes. The psychiatric nurse practitioner notes dated 11/23/2021 documented in part, Mental Status Exam: Attitude: Cooperative, Pleasant, Friendly. Appearance: Appropriate, Alert. Behavior: No agitation, good eye contact, no psychomotor retardation. Mood: good. Affect: Mood congruent. Thought Content: no hallucinations, no delusions, no illusions. The psychiatric nurse practitioner note dated, 12/30/2021, documented in part, Mental Status Exam: Attitude: Cooperative, pleasant, friendly. Appearance: appropriate, alert. Behavior: no agitation, good eye contact, no psychomotor retardation. Speech: Coherent, fluent, spontaneous. Mood: good. Affect: mood congruent. Thought content: no hallucinations, no delusions, no illusions. The psychiatric nurse practitioner note dated, 1/21/2022, documented in part, Mental Status Exam: Attitude: Cooperative, pleasant, friendly. Appearance: appropriate, alert. Behavior: no agitation, good eye contact, no psychomotor retardation. Speech: Coherent, fluent, spontaneous. Mood: good. Affect: mood congruent. Thought content: no hallucinations, no delusions, no illusions. An interview was conducted with LPN (licensed practical nurse) #5 on 1/26/2022 at 3:25 p.m. When asked what Resident #40's behaviors are, LPN #5 stated he has commanding behaviors. He wants things very specific if it's not done for him, he becomes demanding. He will scream at staff if he doesn't want something. Once you give him what he wants he calms down. An interview was conducted with RN (registered nurse) #1, the unit manager, on 1/26/2022 at 3:32 p.m. When asked what is the targeted behavior for Resident #40 for the use of Seroquel, RN #1 stated she would have to look and get back with the surveyor. At 3:52 p.m. RN #1 stated (Resident #40) is on it for behavioral disturbances such as aggressiveness, agitation. He's been on it long term and when they tried to decrease it he became verbally abusive. An interview was conducted with RN #1 on 1/27/2022 at 9:20 a.m. The MARs were reviewed with RN #1. When asked what the check marks indicate, RN #1 stated a check mark would equal a yes. When asked how nurses know what the resident's behavior is that they are monitoring, RN #1 stated all nurses are oriented to all units. There is nothing in place that would give the nurse the information. When asked is there anywhere the nurse can review what the behaviors are for each resident, RN #1 stated, It is our responsibility to read the psych (psychiatric) notes and you are given information in report at the change of shift. The care plan above was reviewed with RN #1. When asked what ineffective coping was, RN #1 stated she was not sure. When asked what the targeted behavior for Resident #40 is, RN #1 stated, I've never seen them but I've heard he can be verbally abusive. When asked if it would be helpful for the nurse to have that information on the MAR that they are signing off on, RN #1 stated, Yes. An interview was conducted with LPN #3, the MDS coordinator, on 1/27/2022 at 10:19 a.m. When asked what ineffective coping was, LPN #3 stated, It may be he is having difficult time dealing with his disease process. The care plan above was reviewed with LPN #3. When asked if she saw the targeted behaviors in Resident #40's care plan, LPN #3 stated, No, you didn't miss them, they aren't there. When asked if the targeted behaviors for the use of an antipsychotic medication be on the care plan, LPN #3 stated, yes. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 1/27/2022 at 10:29 a.m. The MARs were reviewed with ASM #2. When asked what the check marks indicated on the MAR, ASM #2 stated, The way you have to answer this in the system, the check marks would be equivalent of a yes. If they check no, it should force them to satisfy it and document the behavior noted. This system was in place before I came. When asked how the nurse can tell what the targeted behavior is for each resident, ASM #2 stated, For each resident you would want it to be specific to them. The behaviors aren't documented. When asked how then are the nurses monitoring for targeted behaviors for the use of the psychotropic medication, ASM #2 stated, It needs to be more specific. The facility policy, Psychoactive Medication Management and Behavior Monitoring documented in part, Policy: To optimize the therapeutic psychoactive medications by observation of behaviors and to minimize adverse effects Targeted behaviors to be observed are specific to the psychoactive medication being administered and individualized to the patient. Monitoring of behaviors should occur at least daily, and targeted behavior is identified in the care plan. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 1/27/2022 at 1:33 p.m. No further information was provided prior to exit. References: (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a698019.htm. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 43. (3) This information was obtained from the following website: https://medlineplus.gov/mooddisorders.html (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 160. (5) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. (6) This information was obtained from the following website: www.ncbi.[NAME].nih.gov (7) This information was obtained from the following website: https://medlineplus.gov/ency/patientinstructions/000796.htm

**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 facility staff failed to serve food and provide catheter care in a manner to promote resident dignity for one of 40 residents in the survey sample, Residents # 175. On 10/17/19, a nursing student was observed standing while feeding Resident #175 her breakfast in bed. The findings include: Resident # 175 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: swallowing difficulties, low iron and high blood pressure. The most recent MDS (minimum data set) assessment for Resident # 175's was not due at the time of the survey. The facility's nursing admission assessment dated [DATE], coded Resident # 175 as Oriented to place times one. Resident # 57 was coded as requiring the assistance of one staff member for eating. The facility's baseline care plan for Resident # 175 dated 10/11/2019 documented, Cognitive status: Cognitively impaired. Under Communication it documented, 1. Can the resident communicate easily with staff? No. Does the resident understand the staff? No. Under Functional Abilities and Goals - Self Care it documented, 1. Eating support provided: One person physical assist [assistance]. On 10/17/19 at approximately 8:45 a.m., an observation of Resident #175 from the hallway revealed she was in her bed, head of bed raised and eating breakfast with the assistance from a nursing student (NS [nursing student] #1). Further observation revealed the nursing student from [Name of Nursing School] standing next to the bed on Resident # 175's right side feeding her. On 10/17/19 at approximately 8:50 a.m., LPN [licensed practical nurse] # 4 was asked to observe the situation describe above from the hallway. LPN # 4 immediately went into Resident # 175's room, informed the nursing student that she should be seated when feeding a resident and drew the privacy curtain so the resident, could no longer be seen from the hallway. On 10/17/19 at 11:33 a.m., an interview was conducted with LPN # 4. When asked who was immediately responsible for the actions of nursing students on the floor providing care and services to residents', LPN # 4 stated, I would say me because I'm responsible for the residents. When asked about Resident # 175's functional status, LPN # 4 stated, She is nonverbal able to follow simple one-step directives with guidance and a lot of cueing. When asked about Resident's ability to feed herself, LPN # 4 stated, She is unable to feed herself. When asked to describe the procedure that should be followed when assisting and feeding a resident with their meal, LPN # 4 stated, Set up the resident's food, open containers, position the resident to 90 degrees, pull the curtain for privacy and sit next to the resident. You should be seated next to or in-front of resident when feeding them. When asked why someone should be in the position she described, LPN # 4 stated, To not make them feel rushed because if someone was standing over the top of me, feeding me, I would feel rushed. When asked if it was dignified to stand and feed Resident # 175, LPN # 4 stated, No. The student should have been sitting next to the bed and should have the curtain pulled for privacy. The [Name of Facility Resident Rights] documented in part, A resident at [Name of Facility] .10. Is treated with consideration, respect, and in full recognition of his/her dignity and individuality, including privacy in treatment and in care for his/her personal needs. The facility's policy Conduct of Employees to Promote Patient/Resident Rights documented in part, Objective: It is the policy of this facility that all personnel conduct themselves in a manner that promotes dignity and respect to residents. Under Procedure it documented, 8. Treat all residents with kindness, respect and dignity. On 10/17/19 at 5:25 p.m., ASM [administrative staff member] # 1, administrator and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide the necessary paperwork to the receiving facility for a facility initiated transfer for one of 40 residents, Resident #325. The facility staff failed to provide evidence that all required information was provided to the hospital staff when Resident #325 was transferred to the hospital on 9/5/19. The findings include: Resident #325 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: congestive heart failure [circulatory congestion, retention of fluid in the lungs and edema of extremities. (1)], pleural effusion [accumulation of fluid in the space between the chest wall and the lungs. (2)] and atrial fibrillation [rapid and random contraction of the atria of the heart (3)]. The most recent MDS (minimum data set) assessment, a 14 day Medicare assessment, with an ARD (assessment reference date) of 9/24/19, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating he has moderately impaired cognition. Review of Resident #325's clinical record revealed the resident was transferred to the hospital on 9/5/19 for hypoxia and shortness of breath. The resident transfer form and discharge summary documented resident diagnosis, vital signs, code status and discharge diagnosis. The facility's Interact transfer form included a checklist including documents to be sent with resident upon transfer, this section was blank. Review of the clinical record failed to reveal a progress note documenting the information provided to the receiving hospital for Resident #325's hospital transfer on 9/5/19. On 10/17/19 at 5:30 PM, ASM (administrative staff member) #1, the administrator and #2, the director of nursing was informed of inability to find documentation of paperwork sent with Resident #325 upon transfer to the hospital on 9/5/19. On 10/18/19 at 8:00 AM, ASM #2, the director of nursing, provided a checklist for Resident #325's transfer to ER (emergency room) dated 9/5/19 and stated I had the nurse write a late entry note and complete the list of documentation that she sent. Review of the Checklist provided for Resident #325's transfer to ER revealed that the Checklist had been completed to reflect that all the required documentation was sent to the hospital and that the form was dated 9/5/19. ASM #2, the director of nursing, was asked when the Checklist was completed. ASM #2 stated, Last evening. The late entry progress note dated 9/5/19 4:00 PM was created 10/17/19 at 6:41 PM by LPN (licensed practical nurse) #3. A phone interview to verify documentation was sent on 9/5/19, was attempted on 10/18/19 at 9:38 AM and message was left for LPN #3. The facility document titled, Facility Initiated Transfer and Discharge documented, The medical record will identify information provided to the receiving provider which at a minimum will include: contact information of the practitioner, resident representative information, comprehensive care plan, advance directive information, special risks (falls and pressure ulcers) and all information necessary to meet the resident's needs. No further information was provided prior to exit. References: 1. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 133. 2. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 459. 3. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 54.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed implement the comprehensive care plan for two of 40 residents in the survey sample, Residents # 63 and # 31. The facility staff failed to implement the comprehensive care plan for Resident # 63 and Resident #31 for the use of non-pharmacological interventions prior to the administration of as needed pain medications. The findings include: 1. The facility staff failed to implement Resident # 63 comprehensive care plan for the use of non-pharmacological interventions prior to the administration of as needed Tylenol [1]. Resident # 63 was admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included but were not limited to: chronic pain osteoarthritis [2] and high blood pressure. Resident # 63's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/26/19, coded Resident # 63 as scoring a 12 on the brief interview for mental status (BIMS) of a score of 0 - 15, 12 - being moderately impaired of cognition for making daily decisions. Section J Health Conditions coded Resident # 63 as having frequent pain at a level of six on a pain scale of zero to ten, with ten being the worse pain. The comprehensive care plan for Resident # 63's pain documented, [Name of Resident # 63] has chronic pain r/t [related to] Arthritis especially Right knee, back and hands. Date Initiated: 09/28/2018. Under Interventions/Tasks it documented, Monitor/document for probable cause of ache pain episode. Remove/limit causes where possible. Date Initiated: 09/28/2018. The POS [physician order sheet] for Resident # 63 dated OCT [October] 2019 documented, Tylenol Tablet (Acetaminophen). Give 650 milligrams by mouth every 12 hours as needed for pain. Start Date: 05/21/20019. The eMAR [electronic medication administration record] for Resident # 63 dated AUG [August] 2019 documented the physician order documented above on the October 2019 POS. Further review of the eMAR revealed Tylenol 650 milligrams was administered on the dates and times as follows: - 08/02/19 at 3:33 a.m. for pain level of eight, 08/06/19 at 2:54 a.m. with pain level of two, - 08/12/19 at 3:00 a.m. with pain level of eight, - 08/16/19 at 2:02 a.m. with pain level of six, - 08/23/19 at 3:48 a.m. with pain level of four and on 08/29/19 at 3:09 p.m. with pain level of eight. The eMAR for Resident # 63 dated SEPT [September] 2019 documented the same physician order as documented above on the October 2019 POS [physician order sheet]. Further review of the eMAR revealed Tylenol 650 milligrams was administered on dates and times as follows: -09/01/19 at 3:06 p.m. with pain level of four, -09/02/19 at 5:42 p.m. with pain level of seven, - 09/06/19 at 4:21 p.m. with pain level of five and on 09/23/19 at 2:50 a.m. with pain level of seven. The eMAR for Resident # 63 dated OCT [October] 2019 documented the same physician order for Tylenol as documented above on the October 2019, POS. Further review of the eMAR revealed Tylenol 650 milligrams was administered on 10/06/19 at 7:54 a.m. with pain level of five. Review of the facility's nursing Progress Notes' for the dates Tylenol was administered to Resident # 63 as stated above in August, September and October 2019, failed to evidence documentation non-pharmacological interventions were attempted prior to the administration of Tylenol. On 10/16/19 at 4:10 p.m., an interview was conducted with Resident # 63. When asked about her pain medication, Resident # 63 stated, I get scheduled and prn pain medication. They ask me the level of pain and where it is. When asked if the nursing staff attempt to alleviate her pain before giving her the as needed pain medication, Resident # 63 stated, No. They just give me the medication. On 10/18/19 at 10:37 a.m., LPN [licensed practical nurse] # 4 was interviewed. LPN #4 was asked to describe the process of administering prn [as needed] pain medication. LPN # 4 stated, Determine where the pain is, get a pain level zero to ten, ten being the worse pain, will try a non-pharmacological interventions, if not effective then give the prescribed medication and recheck 30 minutes later to see if it was effective. When asked where non-pharmacological interventions are documented, LPN # 4 stated, It's documented in the nurse's notes. When asked to describe the purpose of a resident's care plan, LPN # 4 stated, To ensure we are providing the proper care. When asked if an intervention or approach should be implemented if it is documented on the resident's care plan, LPN # 4 stated, Yes but if is not documented can't say it is being done. LPN #4 was asked to review Resident # 63's care plan statement Monitor/document for probable cause of ache pain episode. Remove/limit causes where possible. When asked about this intervention, LPN # 4 stated, I would interpret it as implementing non-pharmacological intervention. After reviewing the nurse's progress notes for the dates Tylenol was administered to Resident # 31 and eMARs dated August, September and October 2019, and the comprehensive care plan, LPN # 4 was asked if the care plan intervention for the use non-pharmacological interventions was being implemented. LPN # 4 stated, no. On 10/17/19 at 5:25 p.m., ASM [administrative staff member] # 1, administrator and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] Acetaminophen is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of osteoarthritis (arthritis caused by the breakdown of the lining of the joints). Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). It works by changing the way the body senses pain and by cooling the body. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681004.html. [2] The most common form of arthritis. It causes pain, swelling, and reduced motion in your joints. It can occur in any joint, but usually it affects your hands, knees, hips or spine. This information was obtained from the website: https://medlineplus.gov/osteoarthritis.html. 2. The facility staff failed to implement Resident # 31's comprehensive care plan for the use of non-pharmacological interventions prior to the administration of as needed Percocet [1] and Tylenol [2] for Resident # 31. Resident # 31 was admitted to the facility on [DATE] and a re-admission on [DATE] with diagnoses that included but were not limited to: high blood pressure and chronic pain. Resident # 31's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/23/19, coded Resident # 31 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section J Health Conditions coded Resident # 31 as having pain level of ten on a scale of zero to ten Almost constantly. The comprehensive care plan for Resident # 31's pain documented, [Name of Resident # 30] has alteration in comfort r/t [related to] pain from h/o [history of] cellulitis of bilateral lower limbs, stage III pressure ulcer on coccyx, chronic right hip pain and gout, diabetic neuropathy. Date Initiated: 06/08/2017. Under Interventions/Tasks it documented, Eliminate additional stressor or sources of discomfort when possible. Date Initiated: 06/08/2017. The POS [physician order sheet] for Resident # 31 dated OCT [October] 2019 documented, Percocet Tablet 5-325MG [milligrams] (Oxycodone-Acetaminophen). Give 1 [one] tablet by mouth every 6 [six] hours as needed for pain. Order Date: 01/18/2019 and documented, Tylenol Tablet (Acetaminophen). Give 1000 milligrams by mouth every 8 [eight] hours as needed for pain. Start Date: 03/01/20019. The eMAR [electronic medication administration record] for Resident # 31 dated AUG [August] 2019 documented the above physicians orders. Review of the eMAR revealed Percocet 5-325 mg was administered on the dates and times as follows: -08/04/19 at 9:37 p.m. with pain level of eight, -08/06/19 at 10:41 p.m. with pain level of nine, -08/07/19 at 5:05 p.m. with pain level of five, -08/08/19 at 4:56 p.m. with pain level of nine, -08/15/19 at 8:54 a.m. with pain level of nine and at 8:20 p.m. with pain level of ten, -08/18/19 at 4:40 p.m. with pain level of five, 08/22/19 at 2:01 a.m. with pain level of four, and on 08/31/19 at 12:11 p.m. with pain level of seven. Further review of the [DATE] eMAR revealed Tylenol 1000 milligrams was administered on dates and times as follows: -08/02/19 at 12:35 a.m. for pain level of nine, -08/03/19 at 2:22 a.m. with pain level of two and at 11:19 with pain level of five, 08/04/19 at 12:41 a.m. with pain level of three and at 4:38 p.m. with pain level of four, -08/06/19 at 1:03 a.m. with pain level of two, -08/10/19 at 1:24 p.m. with pain level of six, - 08/11/19 at 10:42 a.m. with pain level of four, -08/14/19 at 3:36 p.m. with pain level of ten, -08/15/19 at 7:48 p.m. with pain level of ten, -08/18/19 at 11:51 a.m. with pain level of five and at 11:53 p.m. with pain level of five and on 08/22/19 at 12:05 a.m. with pain level of two The eMAR for Resident # 31 dated SEPT [September] 2019 documented the above physicians orders for Percocet and Tylenol. Review of the eMAR revealed Percocet 5-325 mg was administered on dates and times as follows: - 09/01/19 at 4:17 p.m. with pain level of seven, - 09/07/19 at 11:30 a.m. with pain level of nine, - 09/10/19 at 6:15 a.m. with pain level of three, - 09/12/19 at 6:39 a.m. with pain level of two, - 09/14/19 at 5:11 p.m. with pain level of four, - 09/15/19 at 3:15 p.m. with pain level of six, - 09/16/19 at 11:37 a.m. with pain level of nine, - 09/17/19 at 11:44 a.m. with pain level of nine, - 09/18/19 at 12:27 p.m. with pain level of eight, - 09/19 at 11:24 a.m. with pain level of nine, - 09/22/19 at 11:26 a.m. with pain level of seven, - 09 /23/19 at 12:56 p.m. with pain level of nine, - 09/24/19 at 5:58 a.m. with pain level of nine, - 09/26/19 at 3:47 a.m. with pain level of two and at 12:01 p.m. with pain level of nine, - 09/27/19 at12:17 p.m. with pain level of nine and on 09/29/19 12:34 p.m. with pain level of eight. Further review of the [DATE], eMAR revealed Tylenol 1000 milligrams was administered on the dates and times as follows: - 09/02/19 at 11:02 p.m. with pain level of nine, - 09/10/19 at 9:33 p.m. with pain level of seven, - 09/14/19 at 10:23 a11:44 a.m. with pain level of four, - 09/15/19 at10:22 a.m. with pain level of four, - 09/16 at 11:37 a.m. with pain level of nine, - 09/17/19 at 2:52 a.m. with pain level of nine, - 09/18/19 at 10:23 a.m. with pain level of nine, - 09/19/19 at 11:23 a.m. with pain level of nine, - 09/21/19 at 2:09 p.m. with pain level of three, - 09/22/19 at 11:27 a.m. with pain level of seven, - 09/24/19 at 12:44 p.m. with pain level of nine, - 09/25/19 at 2:00 a.m. with pain level of two, - 09/26 at 1:00 a.m. with pain level of two and at 12:01 p.m. with pain level of nine and on 09/28/19 at 3:56 a.m. with pain level of two. The eMAR for Resident # 31 dated OCT [October] 2019 documented the same physicians orders for Percocet and Tylenol as documented on the [DATE] POS. Review of the eMAR revealed Percocet 5-325 mg was administered on the dates and times as follows: - 10/01/19 at 11:55 a.m. with pain level of four, - 10/02/19 at 10:30 a.m. with pain level of eight, - 10/03/19 at 1:15 p.m. with pain level of nine, - 10/05/19 at 7:42 a.m. with pain level of five, - 10/07/19 at 1:13 p.m. with pain level of nine, - 10/08/19 at 11:48 a.m. with pain level of nine, - 10/09/19 at 1:00 p.m. with pain level of nine, - 10/10/19 at 1:00 p.m. with pain level of nine, - 10/11/19 at 3:52 p.m. with pain level of eight, - 10/14/19 at 4: 44 p.m. with pain level of eight and on 10/15/19 at 1:17 p.m. with pain level of nine. Further review of the [DATE] eMAR revealed Tylenol 1000 milligrams was administered on dates and times as follows: - 10/02/19 at 12:19 a.m. with pain level of four, - 10/03/19 at 7:38 a.m. with pain level of ten, - 10/05/19 at12:07 p.m. with pain level of three, - 10/06/19 at 12:52 p.m. with pain level of seven, - 10/07/19 at 11:40 p.m. with pain level of two, - 10/08/19 at 8:03 a.m. with pain level of nine, - 10/12/19 at 12:32 p.m. with pain level of five and on 10/15/19 at 8:33 p.m. with pain level of three. Review of the facility's nursing Progress Notes' for the dates Percocet and Tylenol were administered to Resident # 30 as stated above in August, September and October 2019, failed to evidence documentation that non-pharmacological interventions were attempted prior to the administration of the pain medication. On 10/16/19 at 11:07 a.m., an interview was conducted with Resident# 31 regarding his pain. Resident # 31 stated that he has chronic pain at a pain level of eight to nine out of ten. Resident # 31 stated, When I'm in pain I tell the aide and they get the nurse and the nurse brings me my pain medication. When asked if the nurse tries to do anything to relieve the pain before giving the pain medication, Resident # 31 stated, No. On 10/18/19 at 10:37 a.m., LPN [licensed practical nurse] # 4 was interviewed. LPN #4 was asked to describe the process of administering prn [as needed] pain medication. LPN # 4 stated, Determine where the pain is, get a pain level zero to ten, ten being the worse pain, will try a non-pharmacological interventions, if not effective then give the prescribed medication and recheck 30 minutes later to see if it was effective. When asked where non-pharmacological interventions are documented, LPN # 4 stated, It's documented in the nurse's notes. When asked to describe the purpose of a resident's care plan, LPN # 4 stated, To ensure we are providing the proper care. When asked if an intervention or approach should be implemented if it is documented on the resident's care plan, LPN # 4 stated, Yes but if is not documented can't say it is being done. LPN #4 was asked to review Resident # 31's care plan statement Eliminate additional stressor or sources of discomfort when possible. After reviewing the statement, LPN #4 was asked about the intervention. LPN # 4 stated, I would interpret it as implementing non-pharmacological intervention. After reviewing the nurse's progress notes for the dates Tylenol was administered to Resident # 31 and eMARs dated August, September and October 2019, and the comprehensive care plan, LPN # 4 was asked if the care plan was being implemented for the use non-pharmacological interventions. LPN # 4 stated, No. On 10/17/19 at 5:25 p.m., ASM [administrative staff member] # 1, administrator and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] Percocet- Oxycodone is used to relieve moderate to severe pain. Oxycodone extended-release tablets and extended-release capsules are used to relieve severe pain in people who are expected to need pain medication around the clock for a long time and who cannot be treated with other medications. Oxycodone is also available in combination with acetaminophen (Oxycet, Percocet, Roxicet, Xartemis XR, others); aspirin (Percodan); and ibuprofen. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html [2] Acetaminophen is used to relieve mild to moderate pain.This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681004.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined that facility staff failed to review or revise the comprehensive care plan for two of 40 residents in the survey sample, Resident # 41 and # 50. The facility staff failed to revise Resident # 41's comprehensive care plan to reflect the correct use of a seat cushion and not a back brace cushion for the resident, and failed to revise Resident # 50's comprehensive care plan to reflect the use of an indwelling catheter. The findings include: 1. Resident # 41 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: lower back pain, heart failure and chest pain. Resident # 41's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/04/2019, coded Resident # 41 as scoring an eight on the staff assessment for mental status (BIMS) of a score of 0 - 15, eight - being moderately impaired of cognition for making daily decisions. Resident # 41 was coded as requiring extensive assistance of one staff member for activities of daily living. The comprehensive care plan for Resident # 41 date 08/08/2019 documented, Focus: [Name of Resident # 41] has an ADL [activities of daily living] Self Care Performance Deficit r/t [related to] activity intolerance and impaired mobility. Date Initiated: 08/08/2019. Under Interventions it documented, Provide back brace cushion to wheelchair. Date Initiated: 09/09/2019. On 10/16/19 at 1:52 p.m., an observation of Resident # 41 revealed she was dressed sitting up in her wheelchair in her room. Observation of the wheelchair failed to evidence a back brace cushion. On 10/17/19 at 11:17 a.m., an observation of Resident # 41 seated in her wheel chair failed to evidence a back brace cushion in the wheelchair. On 10/18/19 8:20 a.m., an observation of Resident # 41 revealed she was sitting up in her wheelchair in her room. Observation of the wheelchair failed to evidence a back brace cushion. The POS [physician's order sheet] for Resident # 41 dated OCT [October] 2019 for Resident # 41 failed to evidence the use of a back brace cushion. On 10/18/19 at 8:25 a.m., an interview was conducted with LPN # 4 regarding Resident # 41's back brace cushion. After reviewing, the comprehensive care plan LPN # 4 was asked to examine Resident # 41's room and wheelchair for the cushion. LPN # 4 stated, This was an intervention requested by the family. When asked about Resident # 41's comprehensive care plan, LPN # 4 stated, I would say it needs to be revised to indicate it is provided by the family. I assume the family has it. On 10/18/19 at 9:05 a.m., an interview was conducted with RN [registered nurse] #1, the MDS coordinator. RN # 1 was asked to review the comprehensive care plan for Resident # 41 dated 08/08/2019 regarding the back brace cushion. RN # 1 stated, It is documented on the care plan incorrectly. It should have a chair cushion not the back brace. When asked to describe the process to revise/update the care plan for a resident, RN # 1 stated, I check the order recap report every day, its summary of all physician orders over past 24 hours and from Friday to Monday morning. I check for any changes that affect the resident, go through, and update the care plan. We also conduct quarterly reviews and it could have been pick up then. The facility's policy Baseline Care Assessment and Comprehensive Care Plan documented in part, 12. The care plan is evaluated and changed in reference to the resident's response to treatment and whenever there is a change in the resident. All disciplines participate in maintaining the care plan so that it reflects the current status of the resident. On 10/18/19 at approximately 11:25 a.m., ASM [administrative staff member] # 1, administrator, was made aware of the above findings. No further information was provided prior to exit. 2. The facility staff failed to revise Resident # 50's comprehensive care plan to reflect the use of an indwelling catheter. Resident # 50 was admitted to the facility on [DATE], with a readmission to the facility on [DATE], with diagnoses that included but were not limited to: stroke, other disorders of the autonomic nervous system [1] and low blood pressure. Resident # 50's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/13/19, coded Resident # 50 as scoring a 12 on the brief interview for mental status (BIMS) of a score of 0 - 15, 12 - being moderately impaired of cognition intact for making daily decisions. Resident # 50 was coded as requiring extensive assistance of one staff member for all activities of daily living. Section H Bladder and Bowel coded Resident # 50 as having an indwelling catheter [2]. On 10/16/19 at 2:15 p.m., an observation of Resident # 50 revealed he was lying in bed with a catheter bag connected to the side of the bed. When interviewed about this observation the resident confirmed he had an indwelling catheter in place. On 10/17/19 at approximately 10:15 p.m., an observation of Resident # 50 revealed he was lying in bed and had an indwelling catheter. On 10/18/19 at approximately 8:30 a.m., an observation of and interview with Resident # 50 revealed he was lying in bed and had an indwelling catheter. The comprehensive care plan for Resident # 41 date 06/18/2019 documented, Focus: [Name of Resident # 50] has an indwelling catheter. Date Initiated: 06/18/2019. Under Interventions it documented, Change external catheter per facility protocol or MD [medical doctor] order. Date Initiated: 06/18/2019. On 10/17/19 at 2:30 p.m., an interview was conducted with LPN # 4 regarding Resident # 50's care plan for an external catheter. After reviewing the comprehensive care plan LPN # 4 was asked to describe an external catheter. LPN # 4 stated, An external catheter for male patients sometimes called a 'Texas' catheter that fits over the penis. An indwelling catheter goes inside the urethra. When asked about Resident # 50's catheter LPN # 4 stated, He has an indwelling catheter. After reviewing Resident # 50's catheter care plan, LPN # 4 stated that the care plan was not correct. On 10/18/19 at 10:17 a.m., an interview was conducted with ASM [administrative staff member] # 2, director of nursing. ASM # 2 was asked to review Resident # 50's comprehensive care plan. When asked about Resident # 50's catheter, ASM # 2 stated, He has an indwelling catheter. After reviewing Resident # 50's catheter, care plan ASM # 2 stated that the care plan was not correct. On 10/18/19 at 9:05 a.m., an interview was conducted with RN [registered nurse] #1 MDS coordinator. RN # 1 was asked to review the comprehensive care plan for Resident # 50 dated 06/18/2019 regarding the catheter. RN # 1 stated, It is documented on the care plan incorrectly. It should be indwelling catheter. On 10/18/19 at approximately 11:25 a.m., ASM [administrative staff member] # 1, administrator, was made aware of the above findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, it was determined that facility staff failed to provide respiratory care consistent with professional standards of practice, the comprehensive person-centered care plan for two of 40 residents in the survey sample, Residents # 27 and 31. The facility staff failed to store Resident # 27's C-PAP [Continuous Positive Airway Pressure] [1] mask in a sanitary manner and failed to administer Resident # 31's oxygen according to the physician's orders. The findings include: 1. Resident # 27 was admitted to the facility on [DATE] and a re-admission on [DATE] with diagnoses that included but were not limited to: obstructive sleep apnea [1], anxiety [2], and muscle weakness. Resident # 27's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/21/19, coded Resident # 27 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Review of the annual MDS with an ARD of 02/26/19 coded Resident # 27 under Section O Special Treatments, Procedures and Programs as having a C-PAP. The POS [physician order sheet] for Resident # 27 dated CT [October] 2019 documented, C-PAP Machine at bedtime for sleep apnea. Order Date: 04/30/2016. The comprehensive care plan for Resident # 27 dated 03/28/2016 documented, [Name of Resident # 27] has Obstructive Sleep Apnea. Date Initiated: 07/14/2016. Under Interventions it documented, C-PAP nightly per order. Date Initiated: 07/14/2016. On 10/16/19 at 11:30 a.m., at 1:51 p.m., and at 4:50 p.m., observations of Resident # 27 room revealed the C-PAP mask lying on top of the over-the- bed table next to the bed uncovered. On 10/17/19 at 8:40 a.m., an observation of Resident # 27 room revealed the C-PAP mask lying on top of the over-the- bed table next to the bed uncovered. On 10/17/19 at 11:39 a.m., an interview was conducted with Resident # 27. When asked about the C-PAP mask Resident # 27 stated she wears the mask every night. When asked if staff ever told her to store the mask in a bag Resident # 27 stated no. On 10/18/19 at 10:37 a.m., an interview was conducted with LPN [licensed practical nurse] # 4. When asked if a C-PAP was considered a piece of respiratory equipment, LPN # 4 stated yes. When asked how a C-PAP mask should be stored when not in use, LPN # 4 stated, It should be stored in a bag. Someone should have identified it and bagged it. When informed of the above observations of Resident # 27's C-PAP mask uncovered and not stored in a bag, LPN # 4 stated, It should be bagged. On 10/18/19 at approximately 11:25 a.m., ASM [administrative staff member] # 1, administrator, was made aware of the above findings and the policy for storing respiratory equipment was requested. 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. No further information was provided prior to exit. References: [1] Positive airway pressure (PAP) treatment uses a machine to pump air under pressure into the airway of the lungs. This helps keep the windpipe open during sleep. The forced air delivered by CPAP (continuous positive airway pressure) prevents episodes of airway collapse that block the breathing in people with obstructive sleep apnea and other breathing problems. This information was obtained from the website: https://medlineplus.gov/ency/article/001916.htm. 2. The facility staff failed to administer Resident # 31's oxygen according to the physician's orders. Resident #31 was observed receiving oxygen at a flow rate of between two and a half liters and three liters per minute when the physician order was for three liters of oxygen a minute. Resident # 31 was admitted to the facility on [DATE] and a re-admission on [DATE] with diagnoses that included but were not limited to: hypertension [1], gastroesophageal reflux disease [2], hypotension [3] and chronic pain. Resident # 31's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/23/19, coded Resident # 31 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Under Section O Special Treatments, Procedures and Programs Resident # 31 was coded as receiving oxygen while a resident. On 10/16/19 at 11:07 a.m., an observation of Resident # 31 revealed he was lying in bed receiving oxygen [O2] by nasal cannula connected to an oxygen concentrator. Observation of the O2 flow meter on the oxygen concentrator revealed the O2 flow rate was between two and a half liters and three liters per minute. Resident # 31 stated, I get oxygen when I need it. It should be at three [three liters per minute. On 10/17/19 at 8:48 a.m., an observation of Resident # 31 revealed he was lying in bed watching television receiving oxygen [O2] by nasal cannula connected to an oxygen concentrator. Observation of the O2 flow meter on the oxygen concentrator revealed the O2 flow rate was set between two and a half liters and three liters per minute. On 10/17/19 at 8:51 a.m., an observation of Resident # 31's oxygen flow rate was conducted. Observation of the O2 flow meter on the oxygen concentrator revealed the O2 flow rate was between two and a half liters and three liters per minute. The POS [physician order sheet] for Resident # 31 dated OCT [October] 2019 documented, Oxygen at 3L/Min [three liters per minute] via [by] nasal cannula every shift. Order Date: 01/18/2019. The comprehensive care plan for Resident # 31 dated 12/03/2018 documented, [Name of Resident # 27] has oxygen therapy r/t [related to] acute respiratory failure. Date Initiated: 12/03/2018. Under Interventions it documented, Oxygen as ordered. Date Initiated: 12/03/2018. On 10/18/19 at 10:37 a.m., an interview was conducted with LPN [licensed practical nurse] # 4. When asked how often a resident's oxygen flow rate is checked, LPN # 4 stated, At the beginning of every shift. When asked to describe how to read the oxygen flow rate on the flow meter of the oxygen concentrator, LPN # 4 stated, The liter line should go through the middle of the ball. When informed of the observations of Resident # 31's oxygen flow rate, LPN # 4 stated it was not set correctly. According to Fundamentals of Nursing, 6th edition, [NAME] and [NAME], 2005, page 1122, Oxygen should be treated as a drug. It has dangerous side effects, such as atelectasis or oxygen toxicity ([NAME], 2002). As with any drug, the dosage or concentration of oxygen should be continuously monitored. The nurse should routinely check the physician's orders to verify that the client is receiving the prescribed oxygen concentration. The six rights of medication administration also pertain to oxygen administration. On 10/18/19 at approximately 11:25 a.m., ASM [administrative staff member] # 1, administrator, was made aware of the above findings. No further information was provided prior to exit. References: [1] High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. [2] Stomach contents to leak back, or reflux, into the esophagus and irritate it. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/gerd.html. [3] Low blood pressure. This information was taken from the website: https://medlineplus.gov/lowbloodpressure.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to ensure physician prescribed medication was obtained and provided for administration as ordered for one of 40 residents in the survey sample, Resident #8. The facility staff failed to ensure Resident #8's newly prescribed antibiotic medication was provided for administration on 1/2/19 at 9:00 PM as ordered by the physician. The antibiotic was not obtained and administered until 1/3/19 at 9:00 AM. The findings include: Resident #8 was admitted to the facility on [DATE] with the diagnoses of but not limited to Parkinson's disease, dementia, high blood pressure, psychosis, glaucoma, and left arm fracture. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/24/19 coded the resident as being severely impaired in ability to make daily life decisions. A review of the clinical record revealed a social worker note dated 1/2/19 regarding an interdisciplinary meeting that documented, Wound culture results will be looked at more thoroughly by NP (Nurse Practitioner) before making any recommendations Further, review revealed results of a wound culture, collected 12/31/19 and results of the culture dated 1/2/19, that documented a positive result for Escherichia Coli (1) in a wound. A physician, staff member on 1/2/19, initialed the culture results. An order entered into the electronic medical record system on 1/2/19 at 3:43 PM by the Physician's Assistant, documented, Cefprozil (2) tablet, 500 mg (milligrams), Give 1 tablet every 12 hours for infection, skin, until 1/12/19. A review of the January 2019 MAR (Medication Administration Record) revealed that this order was to begin at 9:00 PM on 1/2/19. The first dose was not administered until 9:00 AM on 1/3/19. Further review of the above order revealed the nurse confirmed it electronically, on 1/3/19 at 4:02 AM. On 10/18/19 at 9:50 AM, when providing this surveyor a copy of the order details, ASM #2 (Administrative Staff Member) the Director of Nursing, stated that the order was not confirmed until the night shift. ASM #2 stated she was not employed at the facility at the time. She states she could not speak to why the antibiotic order was not confirmed until the night shift. On 10/18/19 at approximately 10:20 AM in an interview was conducted with LPN #1 (Licensed Practical Nurse). LPN #1 stated that nurses should check the electronic system every hour for any new orders that need to be confirmed. LPN #1 stated that the orders are not complete and sent electronically to the pharmacy for filling until the nurse confirms an order. She stated the confirmation process involves the nurse clicking on confirm. LPN #1 stated not confirming an order entered at 3:43 PM until 4:02 AM caused a delay in treatment for Resident #8. On 10/18/19 at 11:37 AM, in an interview with LPN #6, she stated that she was not sure how the electronic system worked regarding when the orders are sent to the pharmacy but that nurses should check at least twice a shift. On 10/18/19 at 12:05 PM, in a follow up interview with ASM #2, she stated that nurses should check at the beginning and midway through their shifts for any new orders that need to be confirmed. ASM #2 stated that the order is not sent electronically to the pharmacy to be filled until the nurse clicks on confirm. She stated this only applies to orders entered by physician staff. ASM #2 stated that when a nurse enters an order, it is confirmed immediately. When a physician staff member enters an order, they enter the medication, dose, route, and frequency, but the nurses enter the scheduled times for the medication, which is why the nurse has to confirm the order, so that the order to be completed and then sent to the pharmacy. ASM #2 stated the orders are not sent electronically until the order is complete, which happens in the confirmation step. ASM #2 stated in this case, even if the nurse had checked at the beginning of the shift and if the order was not in yet at that time, that the nurse should have caught it on a mid-shift check around 7:00 PM so the medication could have been sent, or obtained from the back up pharmacy. ASM #2 stated the medication was not one that is available in the on-site medication supply. A review of the facility policy, Telephone Orders did not address the above concern. On 10/18/19 at 12:18 AM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. (1) Escherichia Coli - E. coli is the name of a type of bacteria that lives in your intestines. Most types of E. coli are harmless. However, some types can make you sick and cause diarrhea You can get E. coli infections by eating foods containing the bacteria. Information obtained from https://medlineplus.gov/ecoliinfections.html (2) Cefprozil - an antibiotic used to treat certain infections caused by bacteria, such as bronchitis; and infections of the skin, ears, sinuses, throat, and tonsils. Information obtained from https://medlineplus.gov/druginfo/meds/a698022.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, it was determined that the facility staff failed to dispose of biologicals upon expiration date in one of two nourishment rooms. The facility staff failed to dispose of biologicals upon expiration date. Three bottles of expired tube feeding formula were observed available for resident use in the Dogwood/Willow nourishment room. The findings include: On [DATE] at 8:00 AM an inspection of nourishment rooms was conducted. Three bottles of expired tube feeding formula were found in one nourishment room, 1000 milliliter bottle of Osmolite expired [DATE], 1000 milliliter bottle of Jevity expired [DATE] and 500 milliliter bottle of Vital expired [DATE]. An interview was conducted with LPN (licensed practical nurse) #2, on [DATE] at 8:00 AM. LPN #2 stated, I was checking the tube feedings this morning and found they were expired, but I couldn't reach them to throw them out. All three bottles of expired tube feedings were located on the third shelf. When asked about the process for checking expiration dates of tube feeding, LPN #2 stated, The supply manager stocks the tube feeding and checks expiration dates. An interview was conducted on [DATE] at 11:30 AM with ASM (administrative staff member) #1, the administrator. When asked about the process for stocking tube feedings and removing expired biological's, ASM #1 stated, The supply manager stocks tube feedings and rotates stock so older stock is out front. When asked who takes the tube feedings to the nourishment room, ASM #1 stated, I believe the nursing staff, maybe the nursing assistants, take it from central supply to nourishment room. An interview was conducted on [DATE] at 4:00 PM with CNA (certified nursing assistant) #2. When asked who stocks the nourishment room, CNA #2 stated, The supply manager stocks it. When asked about the process staff follows for checking for expired tube feedings, CNA #2 stated, I don't know her process. ASM #1, the administrator and ASM #2, the director of nursing were informed of the expired tube feedings on [DATE] at 5:30 PM. ASM #2 stated, The CNA's don't stock the tube feeding in the nourishment room. The nurse's usually take it to the nourishment room. ASM #2 was informed the LPN's and CNA's stated the supply manager stocked the nourishment room. ASM #1 and ASM #2 were asked to provide a copy of the facility policy regarding checking for expired biologicals including tube feedings. On [DATE] 8:00 AM, ASM #1 stated they did not have a policy on expired biologicals or tube feedings. On [DATE] at 11:20 AM during exit with ASM #2, she stated, I can't find any policy on expired biologicals or tube feedings, but I will keep on looking. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, it was determined that facility staff failed to implement infection control practices to prevent the development and transmission of infections for one of 40 residents in the survey sample, Residents # 27. The facility staff failed to implement infection control practices for the storage of Resident # 27's C-PAP mask [Continuous Positive Airway Pressure] [1] when it was not in use. The findings include: Resident # 27 was admitted to the facility on [DATE] and a re-admission on [DATE] with diagnoses that included but were not limited to: obstructive sleep apnea [1], anxiety [2], and muscle weakness. Resident # 27's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/21/19, coded Resident # 27 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Review of the annual MDS with an ARD of 02/26/19 coded Resident # 27 under Section O Special Treatments, Procedures and Programs as having a C-PAP. On 10/16/19 at 11:30 a.m., at1:51 p.m., and at 4:50 p.m., an observations of Resident # 27 room revealed the C-PAP mask lying on top of the over-the- bed table next to the bed uncovered. On 10/17/19 at 8:40 a.m., an observation of Resident # 27 room revealed the C-PAP mask lying on top of the over-the- bed table next to the bed uncovered. The POS [physician order sheet] for Resident # 27 dated CT [October] 2019 documented, C-PAP Machine at bedtime for sleep apnea. Order Date: 04/30/2016. The comprehensive care plan for Resident # 27 dated 03/28/2016 documented, [Name of Resident # 27] has Obstructive Sleep Apnea. Date Initiated: 07/14/2016. Under Interventions it documented, C-PAP nightly per order. Date Initiated: 07/14/2016. On 10/17/19 at 11:39 a.m., an interview was conducted with Resident # 27. When asked about the C-PAP mask Resident # 27 stated she wears the mask every night. When asked if staff ever told her to store the mask in a bag Resident # 27 stated no. On 10/18/19 at 10:37 a.m., an interview was conducted with LPN [licensed practical nurse] # 4. When asked if a C-PAP was considered a piece of respiratory equipment, LPN # 4 stated yes. When asked how a C-PAP mask should be stored when not in use, LPN # 4 stated, It should be stored in a bag. When asked why the C-PAP mask should be stored in a bag, LPN # 4 stated, For infection control. When informed of the above observations of Resident # 27's C-PAP mask, LPN # 4 stated, It should be bagged. On 10/18/19 at approximately 11:25 a.m., ASM [administrative staff member] # 1, administrator, was made aware of the above findings. 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. No further information was provided prior to exit. References: [1] Positive airway pressure (PAP) treatment uses a machine to pump air under pressure into the airway of the lungs. This helps keep the windpipe open during sleep. The forced air delivered by CPAP (continuous positive airway pressure) prevents episodes of airway collapse that block the breathing in people with obstructive sleep apnea and other breathing problems. This information was obtained from the website: https://medlineplus.gov/ency/article/001916.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed ensure the drug regimen for three of 40 residents in the survey sample, Residents # 63, # 30 and # 31, were free from unnecessary pain medications. The facility staff failed to implement non-pharmacological interventions prior to the administration of as needed pain medication, for Resident # 63 and #31 on multiple occasions in August, September and October 2019, and for Resident # 30 on multiple occasions in September 2019. The findings include: 1. The facility staff failed to implement non-pharmacological interventions prior to the administration of as needed pain medication, Tylenol [1] for Resident # 63 on multiple occasions in August, September and October 2019. Resident # 63 was admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included but were not limited to: chronic pain osteoarthritis [2] and high blood pressure. Resident # 63's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/26/19, coded Resident # 63 as scoring a 12 on the brief interview for mental status (BIMS) of a score of 0 - 15, 12 - being moderately impaired of cognition for making daily decisions. Section J Health Conditions coded Resident # 63 as having frequent pain at a level of six on a pain scale of zero to ten, with ten being the worse pain. The POS [physician order sheet] for Resident # 63 dated OCT [October] 2019 documented, Tylenol Tablet (Acetaminophen). Give 650 milligrams by mouth every 12 hours as needed for pain. Start Date: 05/21/20019. The eMAR [electronic medication administration record] for Resident # 63 dated AUG [August] 2019 documented the physician order documented above on the October 2019 POS. Further review of the eMAR revealed Tylenol 650 milligrams was administered on the dates and times as follows: - 08/02/19 at 3:33 a.m. for pain level of eight, 08/06/19 at 2:54 a.m. with pain level of two, - 08/12/19 at 3:00 a.m. with pain level of eight, - 08/16/19 at 2:02 a.m. with pain level of six, - 08/23/19 at 3:48 a.m. with pain level of four and on 08/29/19 at 3:09 p.m. with pain level of eight. The eMAR for Resident # 63 dated SEPT [September] 2019 documented the same physician order as documented above on the October 2019 POS [physician order sheet]. Further review of the eMAR revealed Tylenol 650 milligrams was administered on dates and times as follows: -09/01/19 at 3:06 p.m. with pain level of four, -09/02/19 at 5:42 p.m. with pain level of seven, - 09/06/19 at 4:21 p.m. with pain level of five and on 09/23/19 at 2:50 a.m. with pain level of seven. The eMAR for Resident # 63 dated OCT [October] 2019 documented the same physician order for Tylenol as documented above on the October 2019, POS. Further review of the eMAR revealed Tylenol 650 milligrams was administered on 10/06/19 at 7:54 a.m. with pain level of five. Review of the facility's nursing Progress Notes' for the dates Tylenol was administered to Resident # 63 as stated above in August, September and October 2019, failed to evidence documentation non-pharmacological interventions were attempted prior to the administration of Tylenol. The comprehensive care plan for Resident # 63's pain documented, [Name of Resident # 63] has chronic pain r/t [related to] Arthritis especially Right knee, back and hands. Date Initiated: 09/28/2018. Under Interventions/Tasks it documented, Monitor/document for probable cause of ach pain episode. Remove/limit causes where possible. Date Initiated: 09/28/2018. On 10/16/19 at 4:10 p.m., an interview was conducted with Resident # 63. When asked about her pain medication, Resident # 63 stated, I get scheduled and prn pain medication. They ask me the level of pain and where it is. When asked if the nursing staff attempt to alleviate her pain before giving her the as needed pain medication, Resident # 63 stated, No. They just give me the medication. On 10/18/19 at 10:37 a.m., an interview was conducted with LPN [licensed practical nurse] # 4. When asked to describe the process of administering prn [as needed] pain medication, LPN # 4 stated, Determine where the pain is, get a pain level zero to ten, ten being the worse pain, try non-pharmacological interventions, if not effective then give the prescribed medication and recheck 30 minutes later to see if it was effective. When asked where staff document non-pharmacological interventions attempted, LPN # 4 stated, It's documented in the nurse's notes. When asked to describe the purpose of using non-pharmacological interventions LPN # 4 stated, To see if we can do without pain medication to relieve the pain. After reviewing the nurse's progress notes for the dates Tylenol was administered to Resident # 63 and eMARs dated August, September and October 2019, LPN # 4 was asked if non-pharmacological interventions were documented. LPN # 4 stated, no. If it wasn't documented it wasn't done. The facility's policy Pain Management documented in part, 3B. Alternative treatments such as positioning, heat, and cold applications, music, aroma therapy, message, acupuncture, etc . Non-pharmacological interventions should be attempted before or in addition to medication. On 10/17/19 at 5:25 p.m., ASM [administrative staff member] # 1, administrator and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] Acetaminophen is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of osteoarthritis (arthritis caused by the breakdown of the lining of the joints). Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). It works by changing the way the body senses pain and by cooling the body. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681004.html. [2] The most common form of arthritis. It causes pain, swelling, and reduced motion in your joints. It can occur in any joint, but usually it affects your hands, knees, hips or spine. This information was obtained from the website: https://medlineplus.gov/osteoarthritis.html. 2. The facility staff failed to implement non-pharmacological interventions prior to administering as needed pain medications, Butalbital-APAP-Caffeine Tablet [1], and Tylenol extra strength [2] to Resident # 30 on multiple occasions in September 2019. Resident # 30 was admitted to the facility on [DATE], with a readmission on [DATE] with diagnoses that included but were not limited to: muscle spasms, lumbago [4] with sciatica [5] and high blood pressure. Resident # 30's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 08/19/19, coded Resident # 30 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section J Health Conditions coded Resident # 30 as having severe pain Almost constantly. The POS [physician order sheet] for Resident # 30 dated OCT [October] 2019 documented, - Butalbital-APAP-Caffeine Tablet 50-325-40 MG [milligrams]. Give 1 [one] tablet by mouth every 4 [four] hours as needed for Pain. Order Date: 04/01/2019. - Tylenol Extra Strength Tablet 500 MG. (Acetaminophen). Give 2 [two] tablet by mouth every 8 [eight] hours as needed for Moderate Pain. Order Date: 08/30/2019. The eMAR [electronic medication administration record] for Resident # 30 dated SEPT [September] 2019 documented the above physicians orders documented on the October 2019 POS. Review of the eMAR revealed Butalbital-APAP-Caffeine Tablet 50-325-40 milligrams was administered on the dates and times as follows: 09/15/19 at 2:00 a.m. with pain level of two and on 09/18/19 at 8:20 p.m. with pain level of eight. Further review of the September 2019 eMAR revealed Tylenol Extra Strength Tablet 500 milligrams was administered on the dates and times as follows: -09/03/19 at 12:42 a.m. with pain level of four, - 09/06/19 at 9:24 a.m. with pain level of six, - 09/14/19 at 10:19 a.m. with pain level of six, - 09/15/19 at 9:46 a.m. with pain level of four, - 09/17/19 at 5:30 p.m. with pain level of eight and on 09/29/19 at 9:38 a.m. with pain level of six and at 10:54 p.m. with pain level of five. Review of the facility's nursing Progress Notes' for Resident # 30 for the dates Butalbital-APAP-Caffeine Tablet and Tylenol Extra Strength was administered to Resident # 30 as stated above in September 2019, failed to evidence documentation non-pharmacological interventions were attempted prior to the administration of the pain medications. The comprehensive care plan for Resident # 30's pain dated 12/27/2017 documented, [Name of Resident # 30] has alteration in comfort related to depression, Hx [history] of breast CA [cancer], and low back pain secondary to stenosis 08/10/2018; new c/o [complaint of] rib pain when coughing and L [left] shoulder pain. Revision on: 11/14/2018. On 10/17/19 at 9:01 a.m., an interview was conducted with Resident # 30. When asked about her pain medication, Resident # 30 stated, I get scheduled and prn pain medication. They ask me the level of pain and where it is. When asked if the nursing staff attempts to alleviate her pain before giving her the as needed pain medication, Resident # 30 stated, No. They just give me the medication. On 10/18/19 at 10:37 a.m., an interview was conducted with LPN [licensed practical nurse] # 4. When asked to describe the process of administering prn [as needed] pain medication, LPN # 4 stated, Determine where the pain is, get a pain level zero to ten, ten being the worse pain, try non-pharmacological interventions, if not effective then give the prescribed medication and recheck 30 minutes later to see if it was effective. When asked where staff document non-pharmacological interventions attempted, LPN # 4 stated, It's documented in the nurse's notes. When asked to describe the purpose of using non-pharmacological interventions, LPN # 4 stated, To see if we can do without pain medication to relieve the pain. After reviewing the nurse's progress notes for the dates Butalbital-APAP-Caffeine and Tylenol Extra Strength was administered to Resident # 30 and eMARs dated September 2019, LPN # 4 was asked if non-pharmacological interventions were documented. LPN # 4 stated, no. If it wasn't documented it wasn't done. On 10/17/19 at 5:25 p.m., ASM [administrative staff member] # 1, administrator and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] This combination of drugs is used to relieve tension headaches. The combination of aspirin, butalbital, and caffeine comes as a capsule and tablet to take by mouth. It usually is taken every 4 hours as needed. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601023.html. [2] Acetaminophen is used to relieve mild to moderate pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681004.html. [4] Back pain. This information was obtained from the website: https://medlineplus.gov/backpain.html. [5] Refers to pain, weakness, numbness, or tingling in the leg. It is caused by injury to or pressure on the sciatic nerve. Sciatica is a symptom of a medical problem. It is not a medical condition on its own. This information was obtained from the website: https://medlineplus.gov/ency/article/000686.htm. 3. The facility staff failed to implement non-pharmacological interventions prior to administering as needed pain medications Percocet [1] and Tylenol [2] to Resident # 31 on multiple occasions in August, September, and October 2019. Resident # 31 was admitted to the facility on [DATE] and a re-admission on [DATE] with diagnoses that included but were not limited to: high blood pressure and chronic pain. Resident # 31's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/23/19, coded Resident # 31 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section J Health Conditions coded Resident # 31 as having pain level of ten on a scale of zero to ten Almost constantly. The POS [physician order sheet] for Resident # 31 dated OCT [October] 2019 documented, Percocet Tablet 5-325MG [milligrams] (Oxycodone-Acetaminophen). Give 1 [one] tablet by mouth every 6 [six] hours as needed for pain. Order Date: 01/18/2019 and documented, Tylenol Tablet (Acetaminophen). Give 1000 milligrams by mouth every 8 [eight] hours as needed for pain. Start Date: 03/01/20019. The eMAR [electronic medication administration record] for Resident # 31 dated AUG [August] 2019 documented the above physicians orders. Review of the eMAR revealed Percocet 5-325 mg was administered on the dates and times as follows: -08/04/19 at 9:37 p.m. with pain level of eight, -08/06/19 at 10:41 p.m. with pain level of nine, -08/07/19 at 5:05 p.m. with pain level of five, -08/08/19 at 4:56 p.m. with pain level of nine, -08/15/19 at 8:54 a.m. with pain level of nine and at 8:20 p.m. with pain level of ten, -08/18/19 at 4:40 p.m. with pain level of five, 08/22/19 at 2:01 a.m. with pain level of four, and on 08/31/19 at 12:11 p.m. with pain level of seven. Further review of the [DATE] eMAR revealed Tylenol 1000 milligrams was administered on dates and times as follows: -08/02/19 at 12:35 a.m. for pain level of nine, -08/03/19 at 2:22 a.m. with pain level of two and at 11:19 with pain level of five, 08/04/19 at 12:41 a.m. with pain level of three and at 4:38 p.m. with pain level of four, -08/06/19 at 1:03 a.m. with pain level of two, -08/10/19 at 1:24 p.m. with pain level of six, - 08/11/19 at 10:42 a.m. with pain level of four, -08/14/19 at 3:36 p.m. with pain level of ten, -08/15/19 at 7:48 p.m. with pain level of ten, -08/18/19 at 11:51 a.m. with pain level of five and at 11:53 p.m. with pain level of five and on 08/22/19 at 12:05 a.m. with pain level of two The eMAR for Resident # 31 dated SEPT [September] 2019 documented the above physicians orders for Percocet and Tylenol. Review of the eMAR revealed Percocet 5-325 mg was administered on dates and times as follows: - 09/01/19 at 4:17 p.m. with pain level of seven, - 09/07/19 at 11:30 a.m. with pain level of nine, - 09/10/19 at 6:15 a.m. with pain level of three, - 09/12/19 at 6:39 a.m. with pain level of two, - 09/14/19 at 5:11 p.m. with pain level of four, - 09/15/19 at 3:15 p.m. with pain level of six, - 09/16/19 at 11:37 a.m. with pain level of nine, - 09/17/19 at 11:44 a.m. with pain level of nine, - 09/18/19 at 12:27 p.m. with pain level of eight, - 09/19 at 11:24 a.m. with pain level of nine, - 09/22/19 at 11:26 a.m. with pain level of seven, - 09 /23/19 at 12:56 p.m. with pain level of nine, - 09/24/19 at 5:58 a.m. with pain level of nine, - 09/26/19 at 3:47 a.m. with pain level of two and at 12:01 p.m. with pain level of nine, - 09/27/19 at12:17 p.m. with pain level of nine and on 09/29/19 12:34 p.m. with pain level of eight. Further review of the [DATE], eMAR revealed Tylenol 1000 milligrams was administered on the dates and times as follows: - 09/02/19 at 11:02 p.m. with pain level of nine, - 09/10/19 at 9:33 p.m. with pain level of seven, - 09/14/19 at 10:23 a11:44 a.m. with pain level of four, - 09/15/19 at10:22 a.m. with pain level of four, - 09/16 at 11:37 a.m. with pain level of nine, - 09/17/19 at 2:52 a.m. with pain level of nine, - 09/18/19 at 10:23 a.m. with pain level of nine, - 09/19/19 at 11:23 a.m. with pain level of nine, - 09/21/19 at 2:09 p.m. with pain level of three, - 09/22/19 at 11:27 a.m. with pain level of seven, - 09/24/19 at 12:44 p.m. with pain level of nine, - 09/25/19 at 2:00 a.m. with pain level of two, - 09/26 at 1:00 a.m. with pain level of two and at 12:01 p.m. with pain level of nine and on 09/28/19 at 3:56 a.m. with pain level of two. The eMAR for Resident # 31 dated OCT [October] 2019 documented the same physicians orders for Percocet and Tylenol as documented on the [DATE] POS. Review of the eMAR revealed Percocet 5-325 mg was administered on the dates and times as follows: - 10/01/19 at 11:55 a.m. with pain level of four, - 10/02/19 at 10:30 a.m. with pain level of eight, - 10/03/19 at 1:15 p.m. with pain level of nine, - 10/05/19 at 7:42 a.m. with pain level of five, - 10/07/19 at 1:13 p.m. with pain level of nine, - 10/08/19 at 11:48 a.m. with pain level of nine, - 10/09/19 at 1:00 p.m. with pain level of nine, - 10/10/19 at 1:00 p.m. with pain level of nine, - 10/11/19 at 3:52 p.m. with pain level of eight, - 10/14/19 at 4: 44 p.m. with pain level of eight and on 10/15/19 at 1:17 p.m. with pain level of nine. Further review of the [DATE] eMAR revealed Tylenol 1000 milligrams was administered on dates and times as follows: - 10/02/19 at 12:19 a.m. with pain level of four, - 10/03/19 at 7:38 a.m. with pain level of ten, - 10/05/19 at12:07 p.m. with pain level of three, - 10/06/19 at 12:52 p.m. with pain level of seven, - 10/07/19 at 11:40 p.m. with pain level of two, - 10/08/19 at 8:03 a.m. with pain level of nine, - 10/12/19 at 12:32 p.m. with pain level of five and on 10/15/19 at 8:33 p.m. with pain level of three. Review of the facility's nursing Progress Notes' for the dates Percocet and Tylenol were administered to Resident # 30 as stated above in August, September and October 2019, failed to evidence documentation that non-pharmacological interventions were attempted prior to the administration of the pain medication. The comprehensive care plan for Resident # 31's pain documented, [Name of Resident # 30] has alteration in comfort r/t [related to] pain from h/o [history of] cellulitis of bilateral lower limbs, stage III pressure ulcer on coccyx, chronic right hip pain and gout, diabetic neuropathy. Date Initiated: 06/08/2017. Under Interventions/Tasks it documented, Eliminate additional stressor or sources of discomfort when possible. Date Initiated: 06/08/2017. On 10/16/19 at 11:07 a.m., an interview was conducted with Resident# 31 regarding his pain. Resident # 31 stated that he has chronic pain at a pain level of eight to nine out of ten. Resident # 31 stated, When I'm in pain I tell the aide and they get the nurse and the nurse brings me my pain medication. When asked if the nurse tries to do anything to relieve the pain before giving the pain medication, Resident # 31 stated, No. On 10/18/19 at 10:37 a.m., an interview was conducted with LPN [licensed practical nurse] # 4. When asked to describe the process of administering prn [as needed] pain medication LPN # 4 stated, Determine where the pain is, get a pain level zero to ten, ten being the worse pain, try non-pharmacological interventions, if not effective then give the prescribed medication and recheck 30 minutes later to see if it was effective. When asked where non-pharmacological interventions are documented, LPN # 4 stated, It's documented in the nurse's notes. When asked to describe the purpose of using non-pharmacological interventions, LPN # 4 stated, To see if we can do without pain medication to relieve the pain. After reviewing the nurse's progress notes for the dates Tylenol was administered to Resident # 31 and eMARs dated August, September and October 2019, LPN # 4 was asked if non-pharmacological interventions were documented. LPN # 4 stated, No. If it wasn't documented it wasn't done. On 10/17/19 at 5:25 p.m., ASM [administrative staff member] # 1, administrator and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] Percocet- Oxycodone is used to relieve moderate to severe pain. Oxycodone extended-release tablets and extended-release capsules are used to relieve severe pain in people who are expected to need pain medication around the clock for a long time and who cannot be treated with other medications. Oxycodone is also available in combination with acetaminophen (Oxycet, Percocet, Roxicet, Xartemis XR, others); aspirin (Percodan); and ibuprofen. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html [2] Acetaminophen is used to relieve mild to moderate pain.This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681004.html.