**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Resident interview, staff interview, and facility document review, the facility staff failed to provide the appropriate size adult brief for one Resident (Resident #1) in a survey sample of 3 Residents. The findings include: For Resident #1, the facility staff applied an adult incontinence brief that was too small for the Resident causing discomfort and spilling of waste onto the Resident's bed Resident #1, was admitted to the facility on [DATE]. Diagnoses included; diabetes, cancer, hypertension, and morbid obesity. Resident #1's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-05-24 was coded as a quarterly assessment. Resident #1 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #1 was also coded as requiring extensive to total dependence on one to two staff members to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident was coded as frequently incontinent of bowel and bladder. On 4-9-24 at 12:00 noon, Resident #1 was observed in bed, with the head of the bed elevated, during initial tour of the facility. A Resident interview was conducted, and the Resident complained that this lunch today is again not what it is supposed to be. She explained that she got lunch and that the menu said one thing and her tray had another. She went on to state that she was diabetic and almost everything on the tray was carbohydrates which she was not supposed to have & not her choice. She went on to say that she could not sit up comfortably because her brief was too small and she kept pulling at it to rearrange every time she moved in the bed to reposition herself. She stated look at this, and pulled her bed linens back to expose herself and the brief for the surveyor to view, and it was noted that the brief side closures were cutting into the skin across her abdomen and were too tight on her leg openings, and there was a yellow urine wet spot next to the Resident's right leg opening. That just makes no sense, she stated they have bigger ones that do fit. On a wheel chair near the Resident's bed was noted a clean stack of about 10 of the same briefs that the Resident was wearing. On 4-9-24 at approximately 12:30 p.m., the supply room on Resident #1's unit was toured and no largest bariatric briefs were in the supplies in the room, however, many other sizes were there in stock. A nurse from the unit was with the surveyor and when asked stated yes we have more supplies in the big store room and if we run out we can get them from (name) employee C, the person who orders supplies and does the schedule. On 4-9-24 at 1:30 p.m., Employee C was interviewed and stated We do have those largest briefs in the store room, and if staff will let us know when they are out we will restock them. She showed the surveyor briefs of all sizes from inventory on hand and identified the brief in the Resident's room as the next to the largest available, and had the largest to compare it to for the surveyor. On 4-9-24 at 3:00 p.m., Employee C delivered supply requisition documents for several months illustrating that the largest briefs were used by 2 Residents in the facility and were ordered weekly and always on hand. The information revealed that the largest briefs were available and nursing unit staff simply did not ask for stock when it ran low. They used whatever they had on the unit for their convenience rather that restocking the appropriate size for Resident #1. On 4-9-24 at end of day debrief the DON (director of nursing), and Administrator were notified of the above findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to administer medications on 1/26/24 as ordered by the physician for Resident #3. Resident #3 was admitted to the facility in May of 2017 with diagnoses including but not limited to essential hypertension, and other psychoactive substance abuse. nontraumatic intracerebral hemorrhage. viral hepatitis c, dysphasia, cataract, altered mental status, convulsions, anxiety, asymptomatic human immunodeficiency virus (HIV) disease, and need for assistance with personal care. The most recent MDS (minimum data set) was a quarterly assessment with an (ARD) assessment reference date of 3/14/24 was reviewed and revealed a (BIMS) Brief Interview for Mental Status score of 14 out of a possible score of 15 which indicated no cognitive impairment. A review of the clinical record was conducted on 4/09/24-4/10/24. A review of the January 2024 Medication Administration Record (MAR) revealed a check mark that indicated all medications were administered to Resident #3. On 4/10/24, Resident #3's clinical record was reviewed and revealed physician orders and medication administration documentation as follows: -Keppra Tablet 500 MG (levetiracetam) give 1 tablet by mouth two times a day related to unspecified convulsions. -Restasis (cyclosporine) Emulsion 0.05 %, instill 1 drop in both eyes two times a day, for chronic dry eyes. On 4/10/2024, an interview was conducted with the Corporate Nurse Consultant (CNC) who stated that she would be able to access an audit report that reflected medications that were missed or administered late on 1/26/2024 on Unit 2. The CNC provided a copy of the Medication Audit Report for Unit 2. Reviewing the Medication Administration Audit Report revealed that two (2) medications scheduled for administration on 1/26/24 at 8:00 p.m. were not administered until 12:00 a.m. on 1/27/24. The two medications were Keppra and Restasis. On 4/10/24 at 11:45 AM an interview was conducted with the Director of Nursing (DON) who stated that the expectation was that medications would be administered as ordered by the physician. Review of the facility policy entitled, Administering Medications, Medications are administered in a safe and timely manner, and as prescribed and subheading Policy Interpretation and Implementation, item 4 read, Medications are administered per prescribed orders, including any required time frame. According to [NAME]'s Nursing Procedures, Seventh Edition, 2016, section entitled, Oral Drug Administration, steps in the implementation of medication administration included but were not limited to: Verify the medication is being administered at the proper time .to reduce the risk of medication errors. On 4/10/24 during the end-of-day debriefing, the Administrator and DON were informed of the above findings. The DON stated that the expectation was that medications should be administered timely, as ordered by the physician. No further information was provided Based on staff interview, Resident interview, facility documentation review, and clinical record review, the facility staff failed to maintain the professional standards of medication administration in nursing practice for two Residents(Residents #1 and # 3) in a survey sample of 3 Residents. The findings included: 1. For Resident #1, the facility staff failed to check finger stick blood sugar (FSBS), and failed to administer insulin for an insulin dependent Resident with Diabetes. Resident #1, was admitted to the facility on [DATE]. Diagnoses included; diabetes, cancer, hypertension, and morbid obesity. Resident #1's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-05-24 was coded as a quarterly assessment. Resident #1 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #1 was also coded as requiring extensive to total dependence on one to two staff members to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident was coded as frequently incontinent of bowel and bladder. On 4-9-24 at 12:00 noon, Resident #1 was observed in bed, with the head of the bed elevated, during initial tour of the facility. A Resident interview was conducted, and the Resident complained that this lunch today is again not what it is supposed to be. She explained that she got lunch and that the menu said one thing and her tray had another. She went on to state that she was diabetic and almost everything on the tray was carbohydrates which she was not supposed to have & not her choice. The Resident's physician orders were reviewed and reveal orders for FSBS, and insulin administration for diabetes treatment. Those orders were for the following; 1. Ordered 3-9-24 Tresiba insulin Deglu[DATE] unit/milliliter give 60 units one time per day subcutaneously hold if blood sugar less than 100. Administer at 7:30 a.m. 2. Ordered 9-28-23 Humalog insulin Lispro 100 unit/milliliter inject subcutaneously as per sliding scale before meals and at bedtime for Diabetes. Administer 4 times per day at 6:30 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m. The sliding scale was as follows; 0-150 = give 0 units 151-200 = give 2 units 201-250 = give 4 units 251-300 = give 6 units 301-350 = give 8 units 351-400 = give 10 units, and call MD (doctor) if greater than 400 The Medication and Treatment Administration Record (MAR/TAR) was reviewed for April 2024, and revealed the absence of nursing signatures indicating the Insulin and FSBS blood sugar checks were not completed on 6 occasions. Those follow; Tresiba 4-2-24 at 7:30 a.m. Humalog 4-2-24 at 4:00 p.m., 4-4-24 at 11:00 a.m., and 4:00 p.m., 4-5-24 at 9:00 p.m., and 4-6-24 at 6:30 a.m. Nursing medication administration notes do not indicate why the FSBS were not completed, and why insulin was omitted. Nurses on the nursing unit were asked if insulin was administered on the dates in question and the responses were if it's not documented, it's not done. Guidance for the administration of Insulin is given by The National Institutes of Health (NIH), and is as follows; National Institutes of Health & Medline.gov Insulin must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses and check blood sugar as ordered to decide proper dosing needed. Do not discontinue this medication without seeking a doctor's help. Stopping Insulin will increase the risk of hyperglycemic attack which can be life threatening. The nursing facility stated [NAME] as their nursing standard. [NAME] stated all medications must be administered by the physician's order. Resident #1's care plan was reviewed and revealed a care plan for diabetes that instructed to administer medications as ordered by the physician. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the medication had been omitted, nor that the doctor was made aware of the omissions. On 4-10-24 at 11:00 a.m., the DON (director of nursing) and Administrator were interviewed in the conference room and stated that they had been unaware that medications had not been given, nor that the doctor and family were not notified of medications being omitted by staff. The DON was a new staff member and had recently been hired. On 4-10-24 at approximately 2:00 p.m., at the end of day debrief, the Administrator and DON were again made aware of the failure of staff to administer finger stick blood sugar checks, and insulin as ordered. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, Resident interview, facility documentation review, and clinical record review, the facility staff failed to prevent significant medication errors for one Resident (Residents #1) in a survey sample of 3 Residents. The findings included: For Resident #1, the facility staff failed to check finger stick blood sugar (FSBS), and failed to administer insulin for an insulin dependent Resident with Diabetes Resident #1, was admitted to the facility on [DATE]. Diagnoses included; diabetes, cancer, hypertension, and morbid obesity. Resident #1's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-05-24 was coded as a quarterly assessment. Resident #1 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #1 was also coded as requiring extensive to total dependence on one to two staff members to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident was coded as frequently incontinent of bowel and bladder. On 4-9-24 at 12:00 noon, Resident #1 was observed in bed, with the head of the bed elevated, during initial tour of the facility. A Resident interview was conducted, and the Resident complained that this lunch today is again not what it is supposed to be. She explained that she got lunch and that the menu said one thing and her tray had another. She went on to state that she was diabetic and almost everything on the tray was carbohydrates which she was not supposed to have & not her choice. The Resident's physician orders were reviewed and reveal orders for FSBS, and insulin administration for diabetes treatment. Those orders were for the following; 1. Ordered 3-9-24 Tresiba insulin Deglu[DATE] unit/milliliter give 60 units one time per day subcutaneously hold if blood sugar less than 100. Administer at 7:30 a.m. 2. Ordered 9-28-23 Humalog insulin Lispro 100 unit/milliliter inject subcutaneously as per sliding scale before meals and at bedtime for Diabetes. Administer 4 times per day at 6:30 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m. The sliding scale was as follows; 0-150 = give 0 units 151-200 = give 2 units 201-250 = give 4 units 251-300 = give 6 units 301-350 = give 8 units 351-400 = give 10 units, and call MD (doctor) if greater than 400 The Medication and Treatment Administration Record (MAR/TAR) was reviewed for April 2024, and revealed the absence of nursing signatures indicating the Insulin and FSBS blood sugar checks were not completed on 6 occasions. Those follow; Tresiba 4-2-24 at 7:30 a.m. Humalog 4-2-24 at 4:00 p.m., 4-4-24 at 11:00 a.m., and 4:00 p.m., 4-5-24 at 9:00 p.m., and 4-6-24 at 6:30 a.m. Nursing medication administration notes do not indicate why the FSBS were not completed, and why insulin was omitted. Nurses on the nursing unit were asked if insulin was administered on the dates in question and the responses were if it's not documented, it's not done. Guidance for the administration of Insulin is given by The National Institutes of Health (NIH), and is as follows; National Institutes of Health & Medline.gov Insulin must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses and check blood sugar as ordered to decide proper dosing needed. Do not discontinue this medication without seeking a doctor's help. Stopping Insulin will increase the risk of hyperglycemic attack which can be life threatening. The nursing facility stated [NAME] as their nursing standard. [NAME] stated all medications must be administered by the physician's order. Resident #1's care plan was reviewed and revealed a care plan for diabetes that instructed to administer medications as ordered by the physician. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the medication had been omitted, nor that the doctor was made aware of the omissions. On 4-10-24 at 11:00 a.m., the DON (director of nursing) and Administrator were interviewed in the conference room and stated that they had been unaware that medications had not been given, nor that the doctor and family were not notified of medications being omitted by staff. The DON was a new staff member and had recently been hired. On 4-10-24 at approximately 2:00 p.m., at the end of day debrief, the Administrator and DON were again made aware of the failure of staff to prevent significant medication errors in omissions of finger stick blood sugar checks, and insulin as ordered. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, facility document review, clinical record review, staff interview, and Resident interview the facility staff failed to follow the menu and preferences of two Residents (Resident #1, and #2) in the survey sample of 3 residents. The findings included: 1. For Resident #1, the tray ticket, and menu, were not followed for the lunch meal on 4-9-24. Resident #1, was admitted to the facility on [DATE]. Diagnoses included; diabetes, cancer, hypertension, and morbid obesity. Resident #1's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-05-24 was coded as a quarterly assessment. Resident #1 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #1 was also coded as requiring extensive to total dependence on one to two staff members to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident was coded as frequently incontinent of bowel and bladder. On 4-9-24 at 12:00 noon, Resident #1 was observed in bed, with the head of the bed elevated, during initial tour of the facility. A Resident interview was conducted, and the Resident complained that this lunch today is again not what it is supposed to be. She explained that she got lunch and that the menu said one thing and her tray had another. She went on to state that she was diabetic and almost everything on the tray was carbohydrates which she was not supposed to have & not her choice. She stated I can't eat that hard pork, and I don't like it, they know that. The pork cutlet was found on the tray untouched. The tray ticket revealing the menu was on the tray and reviewed at that time by the surveyor. The tray ticket indicated that the meal should consist of A Controlled Carbohydrate Diet (CCD), meaning that the carbohydrates in a meal must be consistently planned to avoid blood sugar spikes for those with diabetes. The tray ticket described the meal as consisting of; smothered chicken thigh, whipped sweet potatoes, lima beans, corn bread, sliced pears, and 8 ounces of iced tea. This would indicate a meal of almost all carbohydrates. The meal tray actually consisted of a pork cutlet in gravy, brussels sprouts, white potatoes with cheese on them, a hamburger bun (for a dinner roll), 8 ounces of iced tea, and no fruit. The Resident's room mate's tray ticket was reviewed as well and was identical to Resident #1's tray ticket and identical to the meal that was served for Resident #1. The meal served was not what the menu planned, nor what the Resident preferred, and there was only one 8 ounce drink on the tray. On 4-9-24 at end of day debrief the DON (director of nursing), and Administrator were notified of the above findings. the Administrator stated there should be at least 2 drinks on every tray, and the menu should be followed. No further information was provided. 2. For Resident #2, the tray ticket, and menu, were not followed for the lunch meal on 4-9-24. Resident #2 was admitted to the facility on [DATE] with diagnoses including; Stroke, vascular dementia, hypertension, diabetes, chronic kidney disease, and urinary tract infection. Resident #2's most recent MDS (minimum data set) with an ARD (assessment reference date) of 3-28-24 was coded as a new payment assessment. Resident #2 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #2 was also coded as requiring only supervision of one staff member to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident was coded as continent of bowel and bladder. On 4-9-24 at 12:00 noon, Resident #2 was observed sitting in a wheel chair at her bedside, during initial tour of the facility. A Resident interview was conducted, and the Resident complained that this lunch today is again not what it is supposed to be. She explained that she got lunch and that the menu said one thing and her tray had another. She went on to state that she was diabetic and almost everything on the tray was carbohydrates which she was not supposed to have & not her choice. The Resident and her room mate (Resident #1) agreed on this. The tray ticket revealing the menu was on the tray and reviewed at that time by the surveyor. The tray ticket indicated that the meal should consist of A Controlled Carbohydrate Diet (CCD) (NAS) no added salt, meaning that the carbohydrates in a meal must be consistently planned to avoid blood sugar spikes for those with diabetes, and because of high blood pressure no added salt was included. The tray ticket described the meal as consisting of; smothered chicken thigh, whipped sweet potatoes, lima beans, corn bread, sliced pears, and 8 ounces of iced tea. This would indicate a meal of almost all carbohydrates. The meal tray actually consisted of a pork cutlet in gravy, brussels sprouts, white potatoes with cheese on them, a hamburger bun (for a dinner roll), 8 ounces of iced tea, and no fruit. The Resident's room mate's tray ticket was reviewed as well and was identical to Resident #2's tray ticket and identical to the meal that was served for Resident #2. The meal served was not what the menu planned, nor what the Resident preferred, and there was only one 8 ounce drink on the tray. On 4-9-24 at end of day debrief the DON (director of nursing), and Administrator were notified of the above findings. the Administrator stated there should be at least 2 drinks on every tray, and the menu should be followed. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards for medication administration for 1 resident, Resident #1, in a survey sample of 3 residents. The findings included: For Resident #1, facility staff failed to administer, and/or document medications as administered, as ordered by the physician on 7/16/23 and 7/26/23. On 11/13/23, Resident #1's clinical record was reviewed and revealed physician orders and medication administration documentation as follows: -Depakote Extended Release, 250mg, ordered to be given once a day at 12:00 PM--missed dose on 7/16/23 and 7/26/23. -Diltiazem HCl Extended Release, 300mg, ordered to be given once a day at 9:00 AM--missed dose on 7/16/23 and 7/26/23. -Lisinopril, 5mg, ordered to be given once a day at 8:00 AM--missed dose on 7/16/23. -Plavix, 75mg, ordered to be given once a day at 8:00 AM--missed dose on 7/16/23. -Hydralazine HCl, 10mg, ordered to be given two times a day--missed the 8:00 AM dose on 7/16/23 -Meformin HCl, 1000mg, ordered to be given two times a day--missed the 8:00 AM dose on 7/16/23. -Namenda, 10mg, ordered to be given two times a day--missed the 8:00 AM dose on 7/16/23. On 11/13/23 at approximately 2:45 PM, an interview was conducted with the Facility Administrator who confirmed the findings and stated that medications are expected to be given as ordered by the physician. The Facility Administrator stated that the facility's professional nursing standards reference was [NAME]. A facility policy on medication administration was requested and received. At approximately 3:00 PM, an interview was conducted with licensed practical nurse (LPN C) who was assigned to Resident #1 on 7/16/23 and responsible for administering the medications. LPN C stated, I can't explain why I didn't chart his [Resident #1's] morning meds, it's not like me to miss this but I feel like I did give them to him, he did not have any problems that were out of the ordinary on that day, I just can't explain how I missed charting his meds, I click them off as I prepare them, I must have forgot to click the last button that records the med pass before closing out of his record, I am so sorry about all of this. Review of the facility policy entitled, Administering Medications, revised April 2019, heading Policy read, Medications are administered in a safe and timely manner, and as prescribed and subheading Policy Interpretation and Implementation, item 4 read, Medications are administered in accordance with prescriber orders, including any required time frame. According to [NAME] Nursing Procedures, Seventh Edition, 2016, section entitled, Oral Drug Administration, steps in the implementation of medication administration included but were not limited to: Verify the medication is being administered at the proper time .to reduce the risk of medication errors. On 11/13/23 at the end of day meeting, the Facility Administrator was updated on the findings. No further information was provided.

Based on document review and interview, the facility failed to ensure there was a Registered Nurse (RN) on duty for eight continuous hours per day. This failure had the potential to affect residents who needed the skills of an RN on those days. Findings include: Review of the facility provided Daily Staffing sheets for the weekends in the Centers for Medicare and Medicaid (CMS), quarter one (Q1) (October, November, and December 2022), triggered on the Payroll Based Journal [PBJ] facility reporting for no RN coverage for eight continuous hours on weekends in Q1 showed the following dates without RN coverage: 10/08/22 Saturday -- no RN coverage. 10/15/22 Saturday -- no RN coverage. 10/22/22 Saturday -- no RN coverage. 10/23/22 Sunday -- no RN coverage. During an interview on 05/10/23 at 9:45 AM the Administrator confirmed there were no RN's working on the listed dates. At end of day debriefing on 05/11/23, the Administrator and Director of Nursing were made aware of deficient practice and stated there was no further information to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility's policy, the facility failed to ensure a resident's environment promoted their dignity for two of 18 sampled residents (Resident (R) 8 and R71). Observations revealed urinary catheter bags for two residents were fully visible to other residents and staff during the survey, resulting in the potential for residents to have an undignified living situation. Findings include: 1. Review of R8's undated admission Record, located in the resident's electronic medical record (EMR) under the profile tab, revealed the resident was admitted to the facility on [DATE], with a subsequent readmission on [DATE]and diagnoses which included Alzheimer's dementia, urinary retention and stage 4 coccyx pressure ulcer. Review of R8's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/20, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated the resident was moderately cognitively impaired. During an observation of R8, in his room laying in bed, on 03/08/21 at 1:00 PM, the catheter bag was not in a dignity bag, and was visible from the hallway and anyone passing by in the hall. Clear yellow urine was noted. It was hooked to the bed in the middle, not placed below the level of the bladder. During an observation of R8, in his room laying on his bed, on 03/09/21 at 10:00 AM, the catheter bag was not in a dignity bag, and was visible from the hallway and anyone passing by in the hall. Clear yellow urine was noted. It was hooked to the bed in the middle, not placed below bladder level. During an observation of R8, in his room laying on his bed, on 03/11/21 at 9:30 AM, the catheter bag was observed not in a dignity bag, was visible from the hallway and was placed at the level of the bladder. Clear yellow urine was noted in the tubing. 2. Review of R71's undated admission Record, located in the resident's EMR under the profile tab, revealed the resident was admitted to the facility on [DATE], with a subsequent readmission on [DATE]and diagnoses which included Alzheimer's dementia, urinary retention and stage 4 coccyx pressure ulcer. Review of R71's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/21, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of zero out of 15, which indicated the resident was severely cognitively impaired. During an observation of R71, in her room laying in bed, on 03/08/21 at 1:30 PM, the catheter bag was not in a dignity bag, was visible from the hallway and anyone passing by in the hall. Clear yellow urine was noted. It was hooked to the bed in the middle, not placed below the bladder level. During an observation of R71, in her room laying in bed, on 03/09/21 at 10:28 AM, the catheter bag was not in a dignity bag, was visible from the hallway and anyone passing by in the hall. Clear yellow urine was noted. It was hooked to the bed in the middle, not placed below bladder level. During an observation of R71, in her room laying in bed, on 03/10/21 at 9:54 AM, the catheter bag was observed not in a dignity bag, was visible from the hallway and was placed above the level of the bladder. Clear yellow urine was noted in the tubing. During an observation of R71, in her room laying in bed, on 03/10/21 at 02:41 PM, the catheter bag was observed not in a dignity bag, was visible from the hallway and was placed at the level of the bladder. Clear yellow urine was noted in the tubing. During an observation of R71, in her room laying in bed, on 03/11/21 at 9:00 AM, the catheter bag was observed not in a dignity bag, was visible from the hallway and was placed at the level of the bladder. Clear yellow urine was noted in the tubing. During an interview with Unit Manager (UM)1 on 03/11/21 at 9:15 AM, she stated the catheter should always be covered in a dignity bag and she was not sure why one was not in place. UM1 also stated the catheter bag should always be placed below the level of bladder. During an interview with the Director of Nursing (DON) on 03/11/21 at 10:00 AM, the DON stated catheter bags should .always be in a dignity bag and hooked to the bed at the level of the bladder or below. During an additional interview with the DON on 03/11/21 at 11:00 AM she stated she makes rounds each morning when she is here to check if catheters are covered and if not, reminds the staff to cover them. She further stated ,.I think nightshift is removing them and not replacing them, but I don't know why. According to the facility's policy provided titled, Catheter Care, Urinary, revised September 2014, it stated, .the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility's policy and procedures Advance Directives, the facility failed to ensure the medical record had documentation of discussion with three of three residents reviewed for Advance Directives. Resident (R) 25, R28, R67. Findings include: On 03/09/21 at approximately 2:00 PM during an interview with the Unit Manager (UM) 2 she reported if a resident is a Full Code status, there is no Advance Directive Form completed and placed in the resident's charts. 1. Review of the Electronic Medical Record (EMR), face sheet and physician orders for R25 documented the resident was admitted to the facility 07/19/2018. Further review of the updated face sheet and physician order, dated 11/04/19, documented Full Code status under resident status. Review of the EMR did not reveal a documentation of an Advance Directive discussed with R25. Review of the Significant Change Minimum Data Set (MDS), Assessment Reference Date (ARD) of 07/15/20 for R25. The resident's Brief Interview for Mental Status (BIMS) score 15, cognitively aware. 2. Record review for R28 EMR documented he was admitted to the facility on [DATE]. Review of the physician orders and face sheet, dated January 2021, documented Full Code status under resident status. The EMR did not document evidence that an Advance Directive had been discussed with R28. Review of the admission MDS with an ARD of 01/13/21. The resident's BIMS score of 12, cognitively intact. 3. Review of R 67 face sheet and physician orders, found in the EMR, documented the resident was readmitted to the facility 02/12/21, initial admission date 08/30/19. The face sheet and physician orders, dated February 2021, document Full Code status for R67.The resident was admitted to Hospice on 02/13/21. The EMR did not document evidence that an Advance Directive had been discussed with R67 and/or his representative. Review of the Significant Change MDS with an ARD of 02/12/21 revealed R67 had a BIMS score of 03, cognitively impaired. During an interview on 03/11/21 at 11:33 AM with Director of Nursing (DON), and the Social Worker Director (SWD) regarding residents' rights in the participation of Advance Directives being documented in the medical records. They stated, New admits are automatically listed as a Full Code until a signature is obtain by the doctor. If the resident is admitted from the hospital with a Full Code, they inform the doctor and get an order. When asked are families given the opportunity to decide for residents who may not be capable or their own responsible person. They stated, the Social Worker is responsible for following through with completing Advance Directives. On 03/11/21 at approximately 11:45 AM, the SWD and the DON confirmed that the discussion of the Advance Directives were not in the EMR and or paper book on the Unit for the three residents R25, R28, R67. Review of the facility's policy and procedures Advance Directives, revised December 2016 indicated, Policy Interpretation and Implementation.7.Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 8/ If the resident indicated that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives.b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the accuracy of the Minimum Data Assessment (MDS) for one of 18 sampled Residents (R), R42 was incorrectly assessed as needing assistance with eating meals. Findings include: On 03/10/21 at 12:00 PM, R42 was observed independently eating lunch. R42 was observed sitting in a wheelchair in his/her room with a bedside table placed in front of the wheelchair. Certified Nursing Assistant (CNA)1 was observed serving R42 a lunch tray. CNA1 placed the tray on the bedside table in front of the resident and informed R42 what foods were on the tray During the continued observation, R42 was observed eating the food without any assistance. On 03/10/21 at 12:25 PM, an interview was conducted with CNA1. CNA1 stated R42 was a picky eater and only ate approximately 50% of the food on the lunch tray. CNA1 further stated R42 always eats meals independently and does not need any assistance with feeding. Review of R42's admission Record located under the Profile tab of the Electronic Health Record (EHR) documented R42 was admitted to the facility on [DATE]. The Diagnosis tab of her EHR documented the resident's admitting diagnosis as dementia, and failure to thrive. Review of R42's Annual MDS, with an Assessment Reference Date (ARD) of 01/28/21, the facility assessed R42 with the ability to eat meals independently. However, the assessment further indicated R42 needed one person to assist him/her with eating meals. On 03/10/21 at 12:48 PM, an interview was conducted with the facility's MDS Coordinator/Registered Nurse (RN). RN stated the CMS Long-term Care Facility RAI 3.0 User's Manual was the guidance the facility used for assessing residents. After reviewing R42's Annual MDS with the ARD of 01/28/21 with the RN, the RN stated the assessment did not accurately reflect the ability of the resident to eat meal on his/her own and R42 only needed facility staff to set up the resident's tray. On 03/11/21 at 12:49 PM, an interview was conducted with the Administrator. The Administrator stated he expected residents to be accurately assessed according to the facility's practices. Review of CMS Long-term Care Facility RAI 3.0 User's Manual related to the accuracy of MDS assessments revealed on page 1 - 7, .The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that.(1) the assessment accurately reflects the resident's status. In addition, on page 1 - 8 of the RAI 3.0 Manual, .An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, or significant other as appropriate or acceptable.

Based on observation, interview, and document review, the facility failed to post the nurse staffing timely and daily, resulting in the potential for inaccurate information to be presented to residents and visitors. Findings include: During an observation on 03/08/21 at 9:30 AM, the daily nursing staff report posted in the main lobby was dated 03/05/21. During an interview on 03/11/21 at 9:55 AM with the staffing scheduler, she stated she was the responsible person for posting the nurse staffing hours Monday through Friday. She also stated she did not work on the weekends and the staffing hours were not posted on the weekends. The staffing scheduler stated, .I was not aware the hours were to be posted on the weekends. and did not have any completed nursing staff hour postings for the weekend of 03/05/21 - 03/06/21. During an interview on 03/11/21 at 10:05 AM with the Administrator, he stated the facility expectation was that nurse staffing hours are to be posted 7 days a week. He was unable to state why the scheduler had not been informed, or trained, to post them on the weekends. According to the facility's policy provided Posting Direct Care Daily Staffing Numbers, revised July 2016, it stated .Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview and clinical record review, the facility staff failed to ensure that one resident (Resident # 41) in a survey sample of 25 residents was free from neglect. For Resident # 41, the facility staff failed to ensure enough oxygen was available for her trip to the Pulmonologist on 5/7/2018. The findings include: Resident # 41, a [AGE] year old female, was admitted to the facility 1/17/2018. Her diagnoses included but were not limited to Sarcoidosis of Lung, Pulmonary Fibrosis, Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease, Stage 3, Edema, Long term use of Steroids, Hypertension and repeated falls. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 5/1/2018. The MDS coded Resident # 41 as having a Brief Interview of Mental Status score of 14, indicating no cognitive impairment. Resident # 41 was coded as ranging from independent to requiring supervision and set up assistance only for Activities of Daily Living except required extensive assistance of one staff person for bathing. Resident # 41 was coded as always continent of bowel and bladder. On 6/6/2018 at 1:30 PM, a Group Interview was conducted with 12 residents. During the first two minutes of the group interview, Resident # 41 stated she wanted to know what was going to be done about the transportation to doctor's appointments. Resident # 41 stated she had been left at the doctor's office about a month ago and ran out of oxygen while waiting for the transportation to bring her back to the facility. Resident # 41 stated she was very upset because she needed oxygen all the time and was so lucky that the staff at the doctor's office stayed with her until the transportation finally came for her hours later. On 6/6/2018 at 2:30 PM after the Group Interview was over, Resident # 41 stated she told the facility staff that she ran out of oxygen at her Pulmonary Doctor's appointment a month ago. Review of the clinical record was conducted on 6/7/2018 at 8:45 AM. Review of the Physicians Orders revealed an order was written on 4/27/2018 for a follow up appointment with the Pulmonologist on 5/7/2018. Further review of the orders revealed an order written on 2/27/2018 for Oxygen Therapy-Oxygen at 2 Liters per minute via nasal cannula every shift. Review of the Nursing Progress Notes from March - June 2018, revealed no documentation of a Pulmonology doctor's office visit during the month of May 2018. Review of the care plan revealed documentation of: Focus: The resident has altered respiratory status/difficulty breathing related to Sarcoidosis-Steroid and Respiratory Failure-Oxygen dependent. Created on 1/18/2018. Goals: The resident will have no signs or symptoms of poor oxygen absorption through the review date. Created on 1/18/2018, Revision on 5/9/2018, Target Date: 8/8/2018 The resident Will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date. Created on 1/18/2018, Revision on 5/9/2018, Target Date: 8/8/2018 The resident will have no complications related to SOB (Shortness of Breath) through the review date Created on 1/18/2018, Revision on 5/9/2018, Target Date: 8/8/2018 Interventions: Administer medications/puffers as ordered. Monitor effectiveness and side effects. Created on 1/18/2018 Assist resident/family/caregiver in learning signs of respiratory compromise. Created on 1/18/2018 Monitor/document changes in orientation, increased restlessness, anxiety, and air hunger. Created on 1/18/2018 Monitor for signs and symptoms of respiratory distress and report to MD (Medical Doctor) as needed. Created on 1/18/2018 Monitor/document/report abnormal breathing patterns to MD Created on 1/18/2018 Oxygen as ordered. Created on 1/18/2108 Pace and schedule activities providing adequate rest periods. Created on 1/18/2018. On 6/7/218 at 10:50 am, an interview was conducted with the Unit Manager, Licensed Practical Nurse (LPN) A who stated Resident # 41 told her that she ran out of oxygen during her appointment one day. LPN A stated Resident # 41 was alert and oriented and credible. LPN A stated she did not document anything in the clinical record. LPN A stated she did not see any documentation in the Nurses Progress Notes about Resident # 41 running out of oxygen during an appointment to a physician's office. LPN A stated the facility policy was to send a full tank of oxygen with residents who were being transported to outside appointments. LPN A stated there was no documentation that Resident # 41 left the facility with a full tank of oxygen. LPN B stated there was oxygen on the transportation vehicles as well that was available for any resident's use during transport. Review of the email dated 6/7/2018 at 11:18 AM from the Oxygen supplier to the Corporate Nurse Consultant regarding how long the E-cylinders should last revealed documentation that the cylinders should last approximately 5.875 hours of constant usage at 2 liters per minute. Review of a Release of Responsibility for Leave of Absence Form showed documentation Resident # 41 being signed out of the facility on 5/7/2018 at 1:30 PM. There was no signature denoting when Resident # 41 returned to the facility. There were no Nurses Notes documented on 5/7/2018. On 6/7/2018 at 3 PM, an interview was conducted with the facility Administrator, Corporate Consultant and Director of Nursing who all stated they had no knowledge of Resident # 41 being left at an office appointment for over 2 hours and running out of oxygen. The current Administrator was a new employee of less than one week, the Director of Nursing began employment on 5/9/2018 (2 days after the incident.) The Administrator, Director of Nursing and Corporate Consultant stated they looked in the facility's files and did not find any documentation of an incident or issue involving Resident # 41. On 6/7/2018 at 4 PM, an interview was conducted with the office manager (Other B) of the Pulmonology Specialist for Resident # 41. Other B stated that on 5/7/2018 Resident # 41 had an appointment at 2:30 PM. Other B stated residents are expected to arrive 15 minutes prior to the appointments. Other B stated Resident # 41 arrived one hour late at 3:15 PM. Other B stated three staff members (she and two other office staff members) waited with Resident # 41 after the office was closed because the transportation service arrived two and a half hours late to pick her up to return to the nursing facility. Other B stated Resident # 41 did run out of oxygen at her appointment because the transportation service was so late picking Resident # 41 up. Other B stated Resident # 41 was very upset and crying because she had not been picked up and ran out of oxygen. Other B stated their Pulmonology office provided oxygen for Resident # 41 while she waited after hours. Other B stated she and the office staff were very upset because they attempted to call the transportation service numerous times to determine when Resident # 41 was going to be picked up. Other B stated she called the nursing facility and was told that the transportation service was supposed to be on the way. Other B stated all three of the office staff tried calling the transportation service to see why they were late and to determine an estimated time of arrival but were not able to contact them. Other B stated she decided to call from her personal cellular phone (which had a long distance number) and the transportation service picked up immediately. Other B stated she was so upset that Resident # 41 had to endure this incident. Other B stated transportation had been a problem during other appointments. Other B stated that on 5/9/2018, she contacted the facility administrator to inform him of the incident of Resident # 41 being left at the office by the transportation service for several hours and of her running out of oxygen. Other B stated the administrator told her he would follow up on the call. Other B stated she never received any follow up call or contact from the facility. Other B stated she suggested to Resident # 41 to have her daughter talk with the facility about the serious problem with the transportation service and her running out of oxygen. On 6/7/2018 at 4:30 PM, an interview was conducted with Resident # 41 who stated she was still very upset about being left at my appointment and I ran out of oxygen. Resident # 41 stated she had breathing problems and always needed her oxygen. Resident # 41 stated she was very afraid to go to any future doctor's appointments because of the problems with transportation and that she ran out of oxygen. She stated it's always a problem with the transportation. Resident # 41 stated she told the facility staff about the problems and that nobody did anything. Resident # 41 stated she felt like the facility staff don't care. Resident # 41 stated she kept missing appointments or was late going to and from appointments. Resident # 41 stated the problem at the Pulmonology office on 5/7/18 really scared her and upset her. Resident # 41 stated she did not know what would have happened if the Pulmonology office staff had not waited with her and had not given her some oxygen when she ran out. Resident # 41 stated the staff at the facility did not seem to care about what happened to her and were trying to sweep it under the rug. Resident # 41 stated they act like they don't know how scary it was to be left at the doctor's office and to run out of oxygen. And they haven't told me anything about why it happened. They know about it though. The transportation is terrible. I don't trust them. On 6/7/2018 at 3:09 PM, LPN B presented a copy of the Facility's Transportation Policy, entitled Transportation and Appointments, Policy # 1537, effective 2/1/15 on page 97 which stated : Policy: A licensed nurse will ensure transportation to medically related appointments and will be responsible for coordinating those accommodations for transport as appropriate. Review of the facility's contract on transportation revealed statements under 4.10 Transportation Services, page 86: The Contractor shall cover emergency, urgent and non-emergency transportation services to ensure that Members have necessary access to and from providers of covered medical, behavioral health,dental and LTSS services . Under 4.10.5 Transportation Provider Network, page 88 The Contractor shall recruit, credential, maintain, and negotiate reimbursement to ensure an adequate network of qualified NEMT providers to furnish high-quality transportation services that are safe, reliable and on-time. Under 4.10.10 On-Time Arrival, page 92 On-time means from fifteen (15) minutes before the scheduled pick-up time until fifteen (15) minutes after the scheduled pick-up time of an A leg. If the vehicle arrive with in this thirty-minute span of time, the vehicle is on-time for the pick-up. Under 4.10.13 Back-Up Services, page 93 The Contractor, [NAME], or internal transportation services shall ensure the NEMT providers inform the contractor, [NAME], or internal transportation services immediately of a breakdown, accident, incident or any other problems that might cause a trip delay beyond the scheduled and contracted window of time for pick up and/or arrival. Immediately after the Contractor, [NAME] or internal transportation services is notified of a delay, the Contractor, [NAME], or internal transportation services must notify the member or their representatives and the facilities or families at the destination points and document the notification. Other transportation should be arranged to ensure the transport is recovered. Ultimately, it is the responsibility of the Contractor, [NAME] or internal transportation services to make sure trips are provided and to have a continuity of operations plan in place for recovery of trips to ensure member safety and timely recovery of trips. During the end of day debriefing on 6/7/2018, the facility Administrator, Director of Nursing and Corporate Consultant were informed of the findings. No further information was provided.

Based on staff interview and facility documentation review the facility failed to include correct reporting times in all the facility's abuse policies. The abuse policy provided by the facility from their Nursing Policies and Procedures did not include the correct abuse reporting time frames. The findings included: The abuse policy was requested during the entrance conference on 6/5/18 as part of the survey process. The policy was reviewed on 6/7/18. The policy referenced abuse reporting requirements for a different state. At this time, the policy specific to Virginia was requested. The correct policy was provided by Licensed Practical Nurse B (LPN B). The policy titled Abuse/ Investigative Reporting was dated 11/4/16. The section titled Policy read A licensed nurse will immediately respond to and all allegations and/ or reasonable suspicions of staff to patient, patient to patient, and/or visitor to patient, abuse, neglect, mistreatment, exploitation or any misappropriations of patient property or crime against a patient. The Procedure section read 8. The Administrator and/or his/her designee will immediately notify (within 24 hours of knowledge of the allegation) the Virginia Department of Health Office of Licensure and Certification by filing the Virginia Department of Health Facility Reported Incident Form. The policy also read 9. The Administrator or hi/her designee must initiate an investigation within 2 or 24 hours of their knowledge of the alleged event. On 6/7/18 at the end of day meeting, the Administrator stated that she was the abuse coordinator for the facility. When asked if she knew the abuse reporting time frames, she stated that she had 2 hours to report if the allegation involved abuse or serious bodily injury and 24 hours for other reportable events. At this time, it was reviewed with the Administrator and the Corporate Nurse that the abuse policy provided did not include the correct reporting time frame. The Corporate Nurse was handed the policy to review. The Corporate Nurse thought that the wrong version of the policy was provided. On 6/7/18 at 6:30 p.m., this surveyor and the Corporate Nurse talked with LPN B to identify where LPN B had accessed the abuse policy. LPN B stated that she got the policy from the Nursing policy manual. It was identified at this time that the facility had two policy manuals, an Administrative manual and a Nursing manual. LPN B was asked if she ever had to look up policies in the Nursing policy manual. She stated that she referenced the policies often. The Corporate Nurse provided a copy of the abuse policy from the Administrative policy manual. The Administrative abuse policy included correct reporting time frames. It was reviewed with the Corporate Nurse that the policy to be used by the nursing staff was incorrect. She referenced the following in the Nursing abuse policy 3. A licensed nurse will notify the Administrator and/or Director of Nursing immediately and stated that once the nurse notified the Administration of the allegation, the reporting nurse would not need the reporting time frames because it was the Administration's role to report abuse to the state agency. It was reviewed that the facility had an active abuse policy available for use by staff that included incorrect abuse reporting time frames. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review and clinical record review, the facility staff failed to report an allegation of neglect for one resident (Resident # 41) in a survey sample of 25 residents. For Resident # 41, the facility staff failed to report an allegation of neglect to the State Agency. The facility failed to provide enough oxygen to last to and from a Pulmonologist appointment on 5/7/2018 Findings included: Resident # 41, a [AGE] year old female, was admitted to the facility 1/17/2018. Her diagnoses included but were not limited to Sarcoidosis of Lung, Pulmonary Fibrosis, Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease, Stage 3, Edema, Long term use of Steroids, Hypertension and repeated falls. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 5/1/2018. The MDS coded Resident # 41 as having a Brief Interview of Mental Status score of 14, indicating no cognitive impairment. Resident # 41 was coded as ranging from independent to requiring supervision and set up assistance only for Activities of Daily Living except required extensive assistance of one staff person for bathing. Resident # 41 was coded as always continent of bowel and bladder. On 6/6/2018 at 1:30 PM, a Group Interview was conducted with 12 residents. During the first two minutes of the group interview, Resident # 41 stated she wanted to know what was going to be done about the transportation to doctor's appointments. Resident # 41 stated she had been left at the doctor's office about a month ago and ran out of oxygen while waiting for the transportation to bring her back to the facility. Resident # 41 stated she was very upset because she needed oxygen all the time and was so lucky that the staff at the doctor's office stayed with her until the transportation finally came for her hours later. On 6/6/2018 at 2:30 PM after the Group Interview was over, Resident # 41 stated she told the facility staff that she ran out of oxygen at her Pulmonary Doctor's appointment a month ago. Review of the clinical record was conducted on 6/7/2018 at 8:45 AM. Review of the Physicians Orders revealed an order was written on 4/27/2018 for a follow up appointment with the Pulmonologist on 5/7/2018. Further review of the orders revealed an order written on 2/27/2018 for Oxygen Therapy-Oxygen at 2 Liters per minute via nasal cannula every shift. Review of the Nursing Progress Notes from March - June 2018, revealed no documentation of a Pulmonology doctor's office visit during the month of May 2018. The only documentation of any doctor's office was a note on written on 3/2/2018 reporting that Resident # 41 returned from a Nephrologist's appointment. On 6/7/218 at 10:50 am, an interview was conducted with the Unit Manager, Licensed Practical Nurse (LPN) A who stated Resident # 41 told her that she ran out of oxygen during her appointment one day. LPN A stated Resident # 41 was alert and oriented and credible. LPN A stated she did not document anything in the clinical record. LPN A stated she did not see any documentation in the Nurses Progress Notes about Resident # 41 running out of oxygen during an appointment to a physician's office. LPN A stated the facility policy was to send a full tank of oxygen with residents who were being transported to outside appointments. LPN A stated there was no documentation that Resident # 41 left the facility with a full tank of oxygen. LPN B stated there was oxygen on the transportation vehicles as well that was available for any resident's use during transport. Review of the email dated 6/7/2018 at 11:18 AM from the Oxygen supplier to the Corporate Nurse Consultant regarding how long the E-cylinders should last revealed documentation that the cylinders should last approximately 5.875 hours of constant usage at 2 liters per minute. Review of a Release of Responsibility for Leave of Absence Form showed documentation Resident # 41 being signed out of the facility on 5/7/2018 at 1:30 PM. There was no signature denoting when Resident # 41 returned to the facility. There were no Nurses Notes documented on 5/7/2018. On 6/7/2018 at 3 PM, an interview was conducted with the facility Administrator, Corporate Consultant and Director of Nursing who all stated they had no knowledge of Resident # 41 being left at an office appointment for over 2 hours and running out of oxygen. The current Administrator was a new employee of less than one week, the Director of Nursing began employment on 5/9/2018 (2 days after the incident.) The Administrator, Director of Nursing and Corporate Consultant stated they looked in the facility's files and did not find any documentation of an incident or issue involving Resident # 41. On 6/7/2018 at 4 PM, an interview was conducted with the office manager (Other B) of the Pulmonology Specialist for Resident # 41. Other B stated that on 5/7/2018 Resident # 41 had an appointment at 2:30 PM. Other B stated residents are expected to arrive 15 minutes prior to the appointments. Other B stated Resident # 41 arrived one hour late at 3:15 PM. Other B stated three staff members (she and two other office staff members) waited with Resident # 41 after the office was closed because the transportation service arrived two and a half hours late to pick her up to return to the nursing facility. Other B stated Resident # 41 did run out of oxygen at her appointment because the transportation service was so late picking Resident # 41 up. Other B stated Resident # 41 was very upset and crying because she had not been picked up and ran out of oxygen. Other B stated their Pulmonology office provided oxygen for Resident # 41 while she waited after hours. Other B stated she and the office staff were very upset because they attempted to call the transportation service numerous times to determine when Resident # 41 was going to be picked up. Other B stated she called the nursing facility and was told that the transportation service was supposed to be on the way. Other B stated all three of the office staff tried calling the transportation service to see why they were late and to determine an estimated time of arrival but were not able to contact them. Other B stated she decided to call from her personal cellular phone (which had a long distance number) and the transportation service picked up immediately. Other B stated she was so upset that Resident # 41 had to endure this incident. Other B stated transportation had been a problem during other appointments. Other B stated that on 5/9/2018, she contacted the facility administrator to inform him of the incident of Resident # 41 being left at the office by the transportation service for several hours and of her running out of oxygen. Other B stated the administrator told her he would follow up on the call. Other B stated she never received any follow up call or contact from the facility. Other B stated she suggested to Resident # 41 to have her daughter talk with the facility about the serious problem with the transportation service and her running out of oxygen. On 6/7/2018 at 4:30 PM, an interview was conducted with Resident # 41 who stated she was still very upset about being left at my appointment and I ran out of oxygen. Resident # 41 stated she had breathing problems and always needed her oxygen. Resident # 41 stated she was very afraid to go to any future doctor's appointments because of the problems with transportation and that she ran out of oxygen. She stated it's always a problem with the transportation. Resident # 41 stated she told the facility staff about the problems and that nobody did anything. Resident # 41 stated she felt like the facility staff don't care. Resident # 41 stated she kept missing appointments or was late going to and from appointments. Resident # 41 stated the problem at the Pulmonology office on 5/7/18 really scared her and upset her. Resident # 41 stated she did not know what would have happened if the Pulmonology office staff had not waited with her and had not given her some oxygen when she ran out. Resident # 41 stated the staff at the facility did not seem to care about what happened to her and were trying to sweep it under the rug. Resident # 41 stated they act like they don't know how scary it was to be left at the doctor's office and to run out of oxygen. And they haven't told me anything about why it happened. They know about it though. The transportation is terrible. I don't trust them. On 6/7/2018 at 3:09 PM, LPN B presented a copy of the Facility's Transportation Policy, entitled Transportation and Appointments, Policy # 1537, effective 2/1/15 on page 97 which stated : Policy: A licensed nurse will ensure transportation to medically related appointments and will be responsible for coordinating those accommodations for transport as appropriate. Review of the facility's contract on transportation revealed statements under 4.10 Transportation Services, page 86: The Contractor shall cover emergency, urgent and non-emergency transportation services to ensure that Members have necessary access to and from providers of covered medical, behavioral health,dental and LTSS services . Under 4.10.5 Transportation Provider Network, page 88 The Contractor shall recruit, credential, maintain, and negotiate reimbursement to ensure an adequate network of qualified NEMT providers to furnish high-quality transportation services that are safe, reliable and on-time. Under 4.10.10 On-Time Arrival, page 92 On-time means from fifteen (15) minutes before the scheduled pick-up time until fifteen (15) minutes after the scheduled pick-up time of an A leg. If the vehicle arrive with in this thirty-minute span of time, the vehicle is on-time for the pick-up. Under 4.10.13 Back-Up Services, page 93 The Contractor, [NAME], or internal transportation services shall ensure the NEMT providers inform the contractor, [NAME], or internal transportation services immediately of a breakdown, accident, incident or any other problems that might cause a trip delay beyond the scheduled and contracted window of time for pick up and/or arrival. Immediately after the Contractor, [NAME] or internal transportation services is notified of a delay, the Contractor, [NAME], or internal transportation services must notify the member or their representatives and the facilities or families at the destination points and document the notification. Other transportation should be arranged to ensure the transport is recovered. Ultimately, it is the responsibility of the Contractor, [NAME] or internal transportation services to make sure trips re provided and to have a continuity of operations plan in place for recovery of trips to ensure member safety and timely recovery of trips. On 6/7/2018 at 4:25 PM, LPN B stated she just spoke with the previous Administrator who stated he only remembered that the Pulmonologist's office called to say the facility needed to send someone to the appointments with Resident # 41. On 6/7/2018 at 4:35 PM, an interview was conducted with Licensed Practical Nurse (LPN) D who stated This is the first I've heard of this. LPN D stated she was not aware of Resident # 41 being left at an appointment or her running out of oxygen. LPN D stated that according to the schedule, she was working on 5/7/2018 on the 3-11 when Resident # 41 went to the Pulmonologist's office but she could not remember anything like that happening. LPN D stated she thought she must not have worked that day because she would have remembered that incident. During the end of day debriefing on 6/7/2018, the facility Administrator, Director of Nursing and Corporate Consultant were informed of the findings that facility staff members were aware of the incident but it had not been reported to the State Agency. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review and clinical record review, the facility staff failed to report an allegation of neglect for one resident (Resident # 41) in a survey sample of 25 residents. For Resident # 41, the facility staff failed to investigate an allegation of neglect to the State Agency. The facility failed to provide enough oxygen to last to and from a Pulmonologist appointment on 5/7/2018. Findings included: Resident # 41, a [AGE] year old female, was admitted to the facility 1/17/2018. Her diagnoses included but were not limited to Sarcoidosis of Lung, Pulmonary Fibrosis, Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease, Stage 3, Edema, Long term use of Steroids, Hypertension and repeated falls. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 5/1/2018. The MDS coded Resident # 41 as having a Brief Interview of Mental Status score of 14, indicating no cognitive impairment. Resident # 41 was coded as ranging from independent to requiring supervision and set up assistance only for Activities of Daily Living except required extensive assistance of one staff person for bathing. Resident # 41 was coded as always continent of bowel and bladder. On 6/6/2018 at 1:30 PM, a Group Interview was conducted with 12 residents. During the first two minutes of the group interview, Resident # 41 stated she wanted to know what was going to be done about the transportation to doctor's appointments. Resident # 41 stated she had been left at the doctor's office about a month ago and ran out of oxygen while waiting for the transportation to bring her back to the facility. Resident # 41 stated she was very upset because she needed oxygen all the time and was so lucky that the staff at the doctor's office stayed with her until the transportation finally came for her hours later. On 6/6/2018 at 2:30 PM after the Group Interview was over, Resident # 41 stated she told the facility staff that she ran out of oxygen at her Pulmonary Doctor's appointment a month ago. Review of the clinical record was conducted on 6/7/2018 at 8:45 AM. Review of the Physicians Orders revealed an order was written on 4/27/2018 for a follow up appointment with the Pulmonolgist on 5/7/2018. Further review of the orders revealed an order written on 2/27/2018 for Oxygen Therapy-Oxygen at 2 Liters per minute via nasal cannula every shift. Review of the Nursing Progress Notes from March - June 2018, revealed no documentation of a Pulmonology doctor's office visit during the month of May 2018. On 6/7/218 at 10:50 am, an interview was conducted with the Unit Manager, Licensed Practical Nurse (LPN) A who stated Resident # 41 told her that she ran out of oxygen during her appointment one day. LPN A stated Resident # 41 was alert and oriented and credible. LPN A stated she did not document anything in the clinical record. LPN A stated she did not see any documentation in the Nurses Progress Notes about Resident # 41 running out of oxygen during an appointment to a physician's office. LPN A stated the facility policy was to send a full tank of oxygen with residents who were being transported to outside appointments. LPN A stated there was no documentation that Resident # 41 left the facility with a full tank of oxygen. LPN B stated there was oxygen on the transportation vehicles as well that was available for any resident's use during transport. Review of the email dated 6/7/2018 at 11:18 AM from the Oxygen supplier to the Corporate Nurse Consultant regarding how long the E-cylinders should last revealed documentation that the cylinders should last approximately 5.875 hours of constant usage at 2 liters per minute. Review of a Release of Responsibility for Leave of Absence Form showed documentation Resident # 41 being signed out of the facility on 5/7/2018 at 1:30 PM. There was no signature denoting when Resident # 41 returned to the facility. There were no Nurses Notes documented on 5/7/2018. On 6/7/2018 at 3 PM, an interview was conducted with the facility Administrator, Corporate Consultant and Director of Nursing who all stated they had no knowledge of Resident # 41 being left at an office appointment for over 2 hours and running out of oxygen. The current Administrator was a new employee of less than one week, the Director of Nursing began employment on 5/9/2018 (2 days after the incident.) The Administrator, Director of Nursing and Corporate Consultant stated they looked in the facility's files and did not find any documentation of an incident or issue involving Resident # 41. On 6/7/2018 at 4 PM, an interview was conducted with the office manager (Other B) of the Pulmonology Specialist for Resident # 41. Other B stated that on 5/7/2018 Resident # 41 had an appointment at 2:30 PM. Other B stated residents are expected to arrive 15 minutes prior to the appointments. Other B stated Resident # 41 arrived one hour late at 3:15 PM. Other B stated three staff members (she and two other office staff members) waited with Resident # 41 after the office was closed because the transportation service arrived two and a half hours late to pick her up to return to the nursing facility. Other B stated Resident # 41 did run out of oxygen at her appointment because the transportation service was so late picking Resident # 41 up. Other B stated Resident # 41 was very upset and crying because she had not been picked up and ran out of oxygen. Other B stated their Pulmonology office provided oxygen for Resident # 41 while she waited after hours. Other B stated she and the office staff were very upset because they attempted to call the transportation service numerous times to determine when Resident # 41 was going to be picked up. Other B stated she called the nursing facility and was told that the transportation service was supposed to be on the way. Other B stated all three of the office staff tried calling the transportation service to see why they were late and to determine an estimated time of arrival but were not able to contact them. Other B stated she decided to call from her personal cellular phone (which had a long distance number) and the transportation service picked up immediately. Other B stated she was so upset that Resident # 41 had to endure this incident. Other B stated transportation had been a problem during other appointments. Other B stated that on 5/9/2018, she contacted the facility administrator to inform him of the incident of Resident # 41 being left at the office by the transportation service for several hours and of her running out of oxygen. Other B stated the administrator told her he would follow up on the call. Other B stated she never received any follow up call or contact from the facility. Other B stated she suggested to Resident # 41 to have her daughter talk with the facility about the serious problem with the transportation service and her running out of oxygen. On 6/7/2018 at 4:30 PM, an interview was conducted with Resident # 41 who stated she was still very upset about being left at my appointment and I ran out of oxygen. Resident # 41 stated she had breathing problems and always needed her oxygen. Resident # 41 stated she was very afraid to go to any future doctor's appointments because of the problems with transportation and that she ran out of oxygen. She stated it's always a problem with the transportation. Resident # 41 stated she told the facility staff about the problems and that nobody did anything. Resident # 41 stated she felt like the facility staff don't care. Resident # 41 stated she kept missing appointments or was late going to and from appointments. Resident # 41 stated the problem at the Pulmonology office on 5/7/18 really scared her and upset her. Resident # 41 stated she did not know what would have happened if the Pulmonology office staff had not waited with her and had not given her some oxygen when she ran out. Resident # 41 stated the staff at the facility did not seem to care about what happened to her and were trying to sweep it under the rug. Resident # 41 stated they act like they don't know how scary it was to be left at the doctor's office and to run out of oxygen. And they haven't told me anything about why it happened. They know about it though. The transportation is terrible. I don't trust them. On 6/7/2018 at 4:25 PM, LPN B stated she just spoke with the previous Administrator who stated he only remembered that the Pulmonologist's office called to say the facility needed to send someone to the appointments with Resident # 41. On 6/7/2018 at 4:35 PM, an interview was conducted with Licensed Practical Nurse (LPN) D who stated This is the first I've heard of this. LPN D stated she was not aware of Resident # 41 being left at an appointment or her running out of oxygen. LPN D stated that according to the schedule, she was working on 5/7/2018 on the 3-11 when Resident # 41 went to the Pulmonologist's office but she could not remember anything like that happening. LPN D stated she thought she must not have worked that day because she would have remembered that incident. During the end of day debriefing on 6/7/2018, the facility Administrator, Director of Nursing and Corporate Consultant were informed of the findings that facility staff members were aware of the incident but no investigation had been conducted. There was no noted documentation of the incident. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure the highest practicable well being for one resident (Resident # 41) in a survey sample of 25 residents. For Resident # 41, the facility staff failed to ensure transportation to and from doctor's appointments were timely. Findings included: Resident # 41, a [AGE] year old female, was admitted to the facility 1/17/2018. Her diagnoses included but were not limited to Sarcoidosis of Lung, Pulmonary Fibrosis, Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease, Stage 3, Edema, Long term use of Steroids, Hypertension and repeated falls. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 5/1/2018. The MDS coded Resident # 41 as having a Brief Interview of Mental Status score of 14, indicating no cognitive impairment. Resident # 41 was coded as ranging from independent to requiring supervision and set up assistance only for Activities of Daily Living except required extensive assistance of one staff person for bathing. Resident # 41 was coded as always continent of bowel and bladder. On 6/6/2018 at 1:30 PM, a Group Interview was conducted with 12 residents. During the first two minutes of the group interview, Resident # 41 stated she wanted to know what was going to be done about the transportation to doctor's appointments. Resident # 41 stated she had been left at the doctor's office about a month ago and ran out of oxygen while waiting for the transportation to bring her back to the facility. Resident # 41 stated she was very upset because she needed oxygen all the time and was so lucky that the staff at the doctor's office stayed with her until the transportation finally came for her hours later. Review of the clinical record was conducted on 6/7/2018 at 8:45 AM. Review of the Physicians Orders revealed orders written on 2/8/2018 for a follow up appointment with the Nephrologist. Another order written on 3/6/2018 for a follow up with the Nephrologist in 4 months. An order was written on 4/27/2018 for a follow up appointment with the Pulmonologist on 5/7/2018. Review of the Nursing Progress Notes from March - June 2018, revealed no documentation of a Pulmonology doctor's office visit during the month of May 2018. The only documentation of any doctor's office was a note on written on 3/2/2018 reporting that Resident # 41 returned from a Nephrologist's appointment. Review of a Release of Responsibility for Leave of Absence Form showed documentation Resident # 41 being signed out of the facility on 5/7/2018 at 1:30 PM. There was no signature denoting when Resident # 41 returned to the facility. There were no Nurses Notes documented on 5/7/2018. On 6/7/2018 at 2:25 PM, an interview was conducted with the office staff (Other A) at Resident # 41's Nephrologist's office. Other A stated she remembered the day Resident # 41 visited on 3/2/2018. Other A stated Resident # 41 arrived late to the appointment and the oxygen tank was low. Other A stated I did mention it to her that the oxygen was low. Other A stated the transportation service was a little late picking her up from her appointment. Other A stated she had to call the transportation service to make sure they were coming to pick Resident # 41 up. Other A stated the office was closed when the transportation service arrived at about 4:45 PM, which was 15 minutes past the office's 4:30 PM closing time. Other A stated problems with transportation was a continual problem for Resident # 41. Other A stated Resident # 41 had three appointments that were canceled at the last minute. The facility called the day of those appointments to say Resident # 41 was not coming due to transportation. Other A stated Resident # 41 really needed to keep that appointment on 3/2/18 and the office agreed to see her even though she arrived late. Other A stated she was concerned that the oxygen tank was low and was happy the transportation service arrived before the tank was completely empty. On 6/7/2018 at 4 PM, an interview was conducted with the office manager (Other B) of the Pulmonology Specialist for Resident # 41. Other B stated that on 5/7/2017 Resident # 41 had an appointment at 2:30 PM. Other B stated residents are expected to arrive 15 minutes prior to the appointments. Other B stated Resident # 41 arrived one hour late at 3:15 PM. Other B stated three staff members (she and two other office staff members) waited with Resident # 41 after the office was closed because the transportation service arrived two and a half hours late to pick her up to return to the nursing facility. Other B stated Resident # 41 did run out of oxygen at her appointment because the transportation service was so late picking Resident # 41 up. Other B stated Resident # 41 was very upset and crying because she had not been picked up and ran out of oxygen. Other B stated their Pulmonology office provided oxygen for Resident # 41 while she waited after hours. Other B stated she and the office staff were very upset because they attempted to call the transportation service numerous times to determine when Resident # 41 was going to be picked up. Other B stated she called the nursing facility and was told that the transportation service was supposed to be on the way. Other B stated all three of the office staff tried calling the transportation service to see why they were late and to determine an estimated time of arrival but were not able to contact them. Other B stated she decided to call from her personal cellular phone (which had a long distance number) and the transportation service picked up immediately. Other B stated there were several problems noted during Resident # 41's visit on 5/7/18. Other B stated Resident # 41 did not have an attendant escorting her to the appointment and the office staff had to assist Resident # 41 to the bathroom during the visit. Other B stated Resident # 41 came to the office without the proper paperwork which should have described the list of medications and diagnoses. Other B stated she was so upset that Resident # 41 had to endure this incident. Other B stated transportation had been a problem during other appointments. Other B stated that on 5/9/2018, she contacted the facility administrator to inform him of the incident of Resident # 41 being left at the office by the transportation service for several hours and of her running out of oxygen. Other B stated she also told the Administrator that the facility sent Resident # 41 to the Pulmonology office without an attendant and the office staff had to assist her to the bathroom during and after the appointment while waiting for the transportation service. Other B stated the administrator told her he would follow up on the call. Other B stated she never received any follow up call or contact from the facility. Other B stated she suggested to Resident # 41 to have her daughter talk with the facility about the serious problem with the transportation service and her running out of oxygen. The Facility's Transportation Policy, entitled Transportation and Appointments, Policy # 1537, effective 2/1/15 on page 97 which stated : Policy: A licensed nurse will ensure transportation to medically related appointments and will be responsible for coordinating those accommodations for transport as appropriate. Review of the facility's contract on transportation revealed statements under 4.10 Transportation Services, page 86: The Contractor shall cover emergency, urgent and non-emergency transportation services to ensure that Members have necessary access to and from providers of covered medical, behavioral health,dental and LTSS services . Under 4.10.5 Transportation Provider Network, page 88 The Contractor shall recruit, credential, maintain, and negotiate reimbursement to ensure an adequate network of qualified NEMT providers to furnish high-quality transportation services that are safe, reliable and on-time. Under 4.10.10 On-Time Arrival, page 92 On-time means from fifteen (15) minutes before the scheduled pick-up time until fifteen (15) minutes after the scheduled pick-up time of an A leg. If the vehicle arrive with in this thirty-minute span of time, the vehicle is on-time for the pick-up. Under 4.10.13 Back-Up Services, page 93 The Contractor, [NAME], or internal transportation services shall ensure the NEMT providers inform the contractor, [NAME], or internal transportation services immediately of a breakdown, accident, incident or any other problems that might cause a trip delay beyond the scheduled and contracted window of time for pick up and/or arrival. Immediately after the Contractor, [NAME] or internal transportation services is notified of a delay, the Contractor, [NAME], or internal transportation services must notify the member or their representatives and the facilities or families at the destination points and document the notification. Other transportation should be arranged to ensure the transport is recovered. Ultimately, it is the responsibility of the Contractor, [NAME] or internal transportation services to make sure trips re provided and to have a continuity of operations plan in place for recovery of trips to ensure member safety and timely recovery of trips. On 6/7/2018 at 4:30 PM, an interview was conducted with Resident # 41 who stated she was still very upset about being left at my appointment and I ran out of oxygen. Resident # 41 stated she had breathing problems and always needed her oxygen. Resident # 41 stated she was very afraid to go to any future doctor's appointments because of the problems with transportation and that she ran out of oxygen. She stated it's always a problem with the transportation. Resident # 41 stated she told the facility staff about the problems and that nobody did anything. Resident # 41 stated she felt like the facility staff don't care. Resident # 41 stated she kept missing appointments or was late going to and from appointments. Resident # 41 stated the problem at the Pulmonology office on 5/7/18 really scared her and upset her. Resident # 41 stated she did not know what would have happened if the Pulmonology office staff had not waited with her and had not given her some oxygen when she ran out. Resident # 41 stated the staff at the facility did not seem to care about what happened to her and were trying to sweep it under the rug. Resident # 41 stated they act like they don't know how scary it was to be left at the doctor's office and to run out of oxygen. And they haven't told me anything about why it happened. They know about it though. The transportation is terrible. I don't trust them. During the end of day debriefing on 6/7/2018, the facility Administrator, Director of Nursing and Corporate Consultant were informed of findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review the facility staff failed to ensure pressure ulcer prevention interventions were in place for 1 resident (Resident #16) of 25 residents in the survey sample. Resident #16 was observed with the heels up cushion (used to prevent pressure ulcers on the heels) was placed under the calves with both heels flat on the mattress. The findings included: Resident #16, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included hyperlipidemia, hypothyroidism, hypertension, congestive heart failure and dementia. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 4/12/18. Resident #16 was coded with a Brief Interview of Mental Status score of 9 indicating severe cognitive impairment and required extensive assistance with activities of daily living. On 6/5/18 at 11:40 a.m., Resident #16 was observed lying in bed. She was verbal but confused. A heels up cushion was placed under the calves with both heels flat on the mattress. Resident #16's clinical record was reviewed. She did not have any current wounds to the heels. On 6/7/18 at 1:37 p.m., Licensed Practical Nurse F (LPN F) was asked if Resident #16 had any current wounds. LPN F stated no. LPN F was asked to explain the purpose of the heels up cushion. She stated the cushion was used for preventative purposes to keep the heels off the bed when Resident #16 was in bed. The care plan was reviewed. Included was the focus revised on 9/14/17 Potential for skin impairment, incontinence. The heels up cushion was not listed as an intervention. At the end of day meeting on 6/6/18, the Administrator and Director of Nursing were notified that Resident #16 was observed with the heels up cushion improperly placed and heels flat on the mattress. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility documentation review and clinical record review, the facility staff failed to ensure one resident (Resident # 41) received oxygen as ordered by the physician. For Resident # 41, the facility staff failed to ensure enough oxygen was available to last to and from a doctor's appointment 5/7/2018 (Pulmonologist). Findings included: Resident # 41, a [AGE] year old female, was admitted to the facility 1/17/2018. Her diagnoses included but were not limited to Sarcoidosis of Lung, Pulmonary Fibrosis, Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease, Stage 3, Edema, Long term use of Steroids, Hypertension and repeated falls. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 5/1/2018. The MDS coded Resident # 41 as having a Brief Interview of Mental Status score of 14, indicating no cognitive impairment. Resident # 41 was coded as ranging from independent to requiring supervision and set up assistance only for Activities of Daily Living except required extensive assistance of one staff person for bathing. Resident # 41 was coded as always continent of bowel and bladder. On 6/6/2018 at 1:30 PM, a Group Interview was conducted with 12 residents. During the first two minutes of the group interview, Resident # 41 stated she wanted to know what was going to be done about the transportation to doctor's appointments. Resident # 41 stated she had been left at the doctor's office about a month ago and ran out of oxygen while waiting for the transportation to bring her back to the facility. Resident # 41 stated she was very upset because she needed oxygen all the time and was so lucky that the staff at the doctor's office stayed with her until the transportation finally came for her hours later. On 6/6/2018 at 2:30 PM after the Group Interview was over, Resident # 41 stated she told the facility staff that she ran out of oxygen at her Pulmonary Doctor's appointment a month ago. Review of the clinical record was conducted on 6/7/2018 at 8:45 AM. Review of the Physicians Orders revealed orders written on 2/8/2018 for a follow up appointment with the Nephrologist. Another order written on 3/6/2018 for a follow up with the Nephrologist in 4 months. An order was written on 4/27/2018 for a follow up appointment with the Pulmonologist on 5/7/2018. Further review of the orders revealed an order written on 2/27/2018 for Oxygen Therapy-Oxygen at 2 Liters per minute via nasal cannula every shift. Review of the Nursing Progress Notes from March - June 2018, revealed no documentation of a Pulmonology doctor's office visit during the month of May 2018. The only documentation of any doctor's office was a note on written on 3/2/2018 reporting that Resident # 41 returned from a Nephrologist's appointment. On 6/7/218 at 10:50 am, an interview was conducted with the Unit Manager, Licensed Practical Nurse (LPN) A who stated Resident # 41 told her that she ran out of oxygen during her appointment one day. LPN A stated Resident # 41 was alert and oriented and credible. LPN A stated she did not document anything in the clinical record. LPN A stated she did not see any documentation in the Nurses Progress Notes about Resident # 41 running out of oxygen during an appointment to a physician's office. LPN A stated the facility policy was to send a full tank of oxygen with residents who were being transported to outside appointments. LPN A stated there was no documentation that Resident # 41 left the facility with a full tank of oxygen. LPN B stated there was oxygen on the transportation vehicles as well that was available for any resident's use during transport. Review of the email dated 6/7/2018 at 11:18 AM from the Oxygen supplier to the Corporate Nurse Consultant regarding how long the E-cylinders should last revealed documentation that the cylinders should last approximately 5.875 hours of constant usage at 2 liters per minute. Review of a Release of Responsibility for Leave of Absence Form showed documentation Resident # 41 being signed out of the facility on 5/7/2018 at 1:30 PM. There was no signature denoting when Resident # 41 returned to the facility. There were no Nurses Notes documented on 5/7/2018. On 6/7/2018 at 3:30 PM, another interview was conducted with LPN A to determine if the facility kept any type of tracking of appointments. LPN A presented a copies of the Appointment Request Forms for 3/2/2018 at 2:30 PM appointment with the Kidney Specialists and one for 5/7/2018 at 2:30 PM with the Pulmonology Specialist. Review of the form dated 3/2/2018 revealed no Special Needs were circled, level of care was listed as wheelchair. Pick-up was scheduled at 1:35 PM. Review of the Appointment request form for 5/7/18 revealed documentation of scheduled pick-up at 1:30 PM for the 2:30 PM appointment. The form had Oxygen listed as a Special Need and level of service was listed as Wheelchair. There was no documentation in the Nursing Progress Notes of Resident # 41 going to the appointment or of her complaint about being left at the appointment and running out of oxygen. On 6/7/2018 at 4 PM, an interview was conducted with the office manager (Other B) of the Pulmonology Specialist for Resident # 41. Other B stated that on 5/7/2018 Resident # 41 had an appointment at 2:30 PM. Other B stated residents are expected to arrive 15 minutes prior to the appointments. Other B stated Resident # 41 arrived one hour late at 3:15 PM. Other B stated three staff members (she and two other office staff members) waited with Resident # 41 after the office was closed because the transportation service arrived two and a half hours late to pick her up to return to the nursing facility. Other B stated Resident # 41 did run out of oxygen at her appointment because the transportation service was so late picking Resident # 41 up. Other B stated Resident # 41 was very upset and crying because she had not been picked up and ran out of oxygen. Other B stated their Pulmonology office provided oxygen for Resident # 41 while she waited after hours. Other B stated she and the office staff were very upset because they attempted to call the transportation service numerous times to determine when Resident # 41 was going to be picked up. Other B stated she called the nursing facility and was told that the transportation service was supposed to be on the way. Other B stated all three of the office staff tried calling the transportation service to see why they were late and to determine an estimated time of arrival but were not able to contact them. Other B stated she decided to call from her personal cellular phone (which had a long distance number) and the transportation service picked up immediately. Other B stated she was so upset that Resident # 41 had to endure this incident. Other B stated transportation had been a problem during other appointments. Other B stated that on 5/9/2018, she contacted the facility administrator to inform him of the incident of Resident # 41 being left at the office by the transportation service for several hours and of her running out of oxygen. Other B stated the administrator told her he would follow up on the call. Other B stated she never received any follow up call or contact from the facility. Other B stated she suggested to Resident # 41 to have her daughter talk with the facility about the serious problem with the transportation service and her running out of oxygen. On 6/7/2018 at 4:30 PM, an interview was conducted with Resident # 41 who stated she was still very upset about being left at my appointment and I ran out of oxygen. Resident # 41 stated she had breathing problems and always needed her oxygen. Resident # 41 stated she was very afraid to go to any future doctor's appointments because of the problems with transportation and that she ran out of oxygen. She stated it's always a problem with the transportation. Resident # 41 stated she told the facility staff about the problems and that nobody did anything. Resident # 41 stated she felt like the facility staff don't care. Resident # 41 stated she kept missing appointments or was late going to and from appointments. Resident # 41 stated the problem at the Pulmonology office on 5/7/18 really scared her and upset her. Resident # 41 stated she did not know what would have happened if the Pulmonology office staff had not waited with her and had not given her some oxygen when she ran out. Resident # 41 stated the staff at the facility did not seem to care about what happened to her and were trying to sweep it under the rug. Resident # 41 stated they act like they don't know how scary it was to be left at the doctor's office and to run out of oxygen. And they haven't told me anything about why it happened. They know about it though. The transportation is terrible. I don't trust them. During the end of day debriefing on 6/7/2018, the facility Administrator, Director of Nursing and Corporate Consultant were informed of findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate record for one resident (Resident # 41) in a survey sample of 25 residents. For Resident # 41, the facility staff failed to document in the clinical record about the resident returning late to the facility and running out of oxygen during an office visit to the Pulmonologist on 5/7/2018. Findings included: Resident # 41, a [AGE] year old female, was admitted to the facility 1/17/2018. Her diagnoses included but were not limited to Sarcoidosis of Lung, Pulmonary Fibrosis, Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease, Stage 3, Edema, Long term use of Steroids, Hypertension and repeated falls. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 5/1/2018. The MDS coded Resident # 41 as having a Brief Interview of Mental Status score of 14, indicating no cognitive impairment. Resident # 41 was coded as ranging from independent to requiring supervision and set up assistance only for Activities of Daily Living except required extensive assistance of one staff person for bathing. Resident # 41 was coded as always continent of bowel and bladder. On 6/6/2018 at 1:30 PM, a Group Interview was conducted with 12 residents. During the first two minutes of the group interview, Resident # 41 stated she wanted to know what was going to be done about the transportation to doctor's appointments. Resident # 41 stated she had been left at the doctor's office about a month ago and ran out of oxygen while waiting for the transportation to bring her back to the facility. Resident # 41 stated she was very upset because she needed oxygen all the time and was so lucky that the staff at the doctor's office stayed with her until the transportation finally came for her hours later. On 6/6/2018 at 2:30 PM after the Group Interview was over, Resident # 41 stated she told the facility staff that she ran out of oxygen at her Pulmonary Doctor's appointment a month ago. Review of the clinical record was conducted on 6/7/2018 at 8:45 AM. Review of the Physicians Orders revealed orders an order was written on 4/27/2018 for a follow up appointment with the Pulmonologist on 5/7/2018. Further review of the orders revealed an order written on 2/27/2018 for Oxygen Therapy-Oxygen at 2 Liters per minute via nasal cannula every shift. Review of the Nursing Progress Notes from March - June 2018, revealed no documentation of a Pulmonology doctor's office visit during the month of May 2018. On 6/7/218 at 10:50 am, an interview was conducted with the Unit Manager, Licensed Practical Nurse (LPN) A who stated Resident # 41 told her that she ran out of oxygen during her appointment one day. LPN A stated Resident # 41 was alert and oriented and credible. LPN A stated she did not document anything in the clinical record. LPN A stated she did not see any documentation in the Nurses Progress Notes about Resident # 41 running out of oxygen during an appointment to a physician's office. LPN A stated the facility policy was to send a full tank of oxygen with residents who were being transported to outside appointments. LPN A stated there was no documentation that Resident # 41 left the facility with a full tank of oxygen. Review of the email dated 6/7/2018 at 11:18 AM from the Oxygen supplier to the Corporate Nurse Consultant regarding how long the E-cylinders should last revealed documentation that the cylinders should last approximately 5.875 hours of constant usage at 2 liters per minute. Review of a Release of Responsibility for Leave of Absence Form showed documentation Resident # 41 being signed out of the facility on 5/7/2018 at 1:30 PM. There was no signature denoting when Resident # 41 returned to the facility. There were no Nurses Notes documented on 5/7/2018. On 6/7/2018 at 3 PM, an interview was conducted with the facility Administrator, Corporate Consultant and Director of Nursing who all stated they had no knowledge of Resident # 41 being left at an office appointment for over 2 hours and running out of oxygen. The current Administrator was a new employee of less than one week, the Director of Nursing began employment on 5/9/2018 (2 days after the incident.) The Administrator, Director of Nursing and Corporate Consultant stated they looked in the facility's files and did not find any documentation of an incident or issue involving Resident # 41. On 6/7/2018 at 4:25 PM, LPN B stated she just spoke with the previous Administrator who stated he only remembered that the Pulmonologist's office called to say the facility needed to send someone to the appointments with Resident # 41. On 6/7/2018 at 4:35 PM, an interview was conducted with Licensed Practical Nurse (LPN) D who stated This is the first I've heard of this. LPN D stated she was not aware of Resident # 41 being left at an appointment or her running out of oxygen. LPN D stated that according to the schedule, she was working on 5/7/2018 on the 3-11 when Resident # 41 went to the Pulmonologist's office but she could not remember anything like that happening. LPN D stated she thought she must not have worked that day because she would have remembered that incident. During the end of day debriefing on 6/7/2018, the facility Administrator, Director of Nursing and Corporate Consultant were informed of the findings that facility staff members were aware of the incident but no investigation had been conducted. There was no noted documentation of the incident. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review the facility staff failed to ensure an effective infection control program was in place for 1 resident (Resident #138) of 25 residents in the survey sample. Resident #138 was on contact precautions. Staff was observed to enter the room with a gown but no gloves. The findings included: Resident #138, an [AGE] year old, was re-admitted to the facility on [DATE]. Diagnoses included reflux, hypertension, hyponatremia, ileostomy, depression, sepsis and abdominal wound. As Resident #138 was new to the facility, a Minimum Data Set assessment had not been completed. She was able to hold a conversation and did not appear to have a cognitive impairment during an interview. On 6/5/18 at 11:25 a.m., the door to Resident #138's room was closed. Outside of the door was a plastic set of drawers that contained masks, gowns and gloves. On 6/5/18 at 11:45 a.m., Licensed Practical Nurse E (LPN E) was asked if Resident #138 was on contact precautions. LPN E stated yes. On 6/5/18 at 12:10 p.m., Certified Nursing Assistant A (CNA A) was observed passing lunch trays on Resident #138's hall. CNA A was observed to put on a gown from the plastic supply box outside of Resident #138's room. The gloves available in the box of supplies were blue. CNA A did not put on gloves. CNA A took the lunch tray from the meal cart and entered Resident #138's room. On 6/7/18 at 11:45 a.m., Resident #138 was observed in her room receiving therapy. The therapist was wearing gown and gloves. Resident #138 stated that she felt awful from the antibiotics. On 6/07/18 1:28 p.m., Registered Nurse A (RN A), Infection Control Nurse was interviewed. She stated that Resident #138 was on contact precautions due to the excessive amount of drainage from the abdominal wound. Resident #138 was receiving antibiotics for both a urinary tract infection and the abdominal wound infection. At this time, RN A was notified that CNA A entered Resident #138's room without gloves. RN A stated that she expected all staff and visitors to use gown and gloves when entering a contact precaution room. The facility policy Transmission Based Precautions- General Practice was reviewed. The policy read 19. If protective attire is determined necessary, when donning the protective attire follow these steps: e. Put on gloves. The issue was reviewed with the Administrator, Director of Nursing and Corporate Nurse at the end of day meeting on 6/7/18. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview, and Clinical record review the facility failed to develop and implement a comprehensive person centered care plan for 5 Residents ( Residents #19, #44, #72, #86, and #187) in a survey sample of 25 Residents. 1. For Resident #19 the facility failed to incorporate the focus area of discharge planning in the care plan. 2. For Resident #44 the facility failed to incorporate the focus area of discharge planning in the care plan. 3. For Resident #72 the facility failed to incorporate the focus area of discharge planning in the care plan. 4. For Resident #86 the facility failed to incorporate the focus area of discharge planning in the care plan. 5. For Resident #187 the facility failed to incorporate the focus area of discharge planning in the care plan. The findings included: 1. For Resident #19 the facility failed to incorporate the focus area of discharge planning in the care plan Resident #19, a [AGE] year female, was admitted to the facility on [DATE] with diagnoses that include but are not limited to Hypertension (high blood pressure) Orthostatic Hypotension ( sudden blood pressure drop upon change in position), dementia, schizophrenia, and stage II renal failure (kidney failure). On 6/6/18 at 9:50 AM a clinical record review was conducted and it was found that Resident # 19 had a care plan that did not address the area of discharge planning. On 6/7/18 at 3:45 PM an interview with the facility Social Worker was conducted and when asked if the care plans should address discharge planning she stated yes they should. When asked when this should be implemented or addressed she stated that it should be part of the baseline care plan and addressed at each care plan meeting. On 6/7/18 at approximately 6:30 PM the Administrator and the DON (Director of Nursing) were told of these findings during the end of day conference and given the opportunity to provide additional documentation. No further information was provided. 2. For Resident #44 the facility failed to incorporate the focus area of discharge planning in the care plan. Resident # 44 a [AGE] year female was admitted on [DATE] with diagnoses that include but not limited to dementia, depression, anxiety, diabetes, and hypertension. On 6/6/18 at 10:50 AM a clinical record review was done and found that Resident #44 had a care plan that did not contain a focus area for discharge planning. On 6/7/18 at 3:45 PM an interview with the facility Social Worker was conducted and when asked if the care plans should address discharge planning she stated yes they should. When asked when this should be implemented or addressed she stated that it should be part of the baseline care plan and addressed at each care plan meeting. On 6/7/18 at approximately 6:30 PM the Administrator and the DON were told of these findings during the end of day conference and given the opportunity to provide additional documentation. No further information was provided 3. For Resident #72 the facility failed to incorporate the focus area of discharge planning in the care plan. Resident #72 a [AGE] year female was admitted to the facility on [DATE] with diagnoses that include but are not limited to Dementia with behavioral disturbance, Schizophrenia, depression and history of pacemaker. On 6/6/18 at 11:55 AM a clinical record review was conducted and it was found that Resident # 72 had a care plan that did not address discharge planning. On 6/7/18 at 3:45 PM an interview with the facility Social Worker was conducted and when asked if the care plans should address discharge planning she stated yes they should. When asked when this should be implemented or addressed she stated that it should be part of the baseline care plan and addressed at each care plan meeting. On 6/7/18 at approximately 6:30 PM the Administrator and the DON were told of these findings during the end of day conference and given the opportunity to provide additional documentation. No further information was provided. 4. For Resident #86 the facility failed to incorporate the focus area of discharge planning in the care plan. Resident # 86 an [AGE] year female was admitted to the facility on [DATE] with diagnoses of but not limited to dementia with behavioral disturbance, Schizophrenia, Hypertension and chronic kidney disease. On 6/6/18 at 12:35 AM a clinical record review was conducted and it was found that Resident # 86 had a care plan that did not address discharge planning. On 6/7/18 at 3:45 PM an interview with the facility Social Worker was conducted and when asked if the care plans should address discharge planning she stated yes they should. When asked when this should be implemented or addressed she stated that it should be part of the baseline care plan and addressed at each care plan meeting. On 6/7/18 at approximately 6:30 PM the Administrator and the DON were told of these findings during the end of day conference and given the opportunity to provide additional documentation. No further information was provided 5. For Resident #187 the facility failed to incorporate the focus area of discharge planning in the care plan. Resident # 187 a [AGE] year female was admitted to the facility on [DATE] with diagnoses of but not limited to CVA (stroke) Schizophrenia, Hypertension and major depressive disorder. On 6/7/18 at 11:55 AM a clinical record review was conducted and it was found that Resident # 187 had a care plan that did not address discharge planning. On 6/7/18 at 3:45 PM an interview with the facility Social Worker was conducted and when asked if the care plans should address discharge planning she stated yes they should. When asked when this should be implemented or addressed she stated that it should be part of the baseline care plan and addressed at each care plan meeting. On 6/7/18 at approximately 6:30 PM the Administrator and the DON were told of these findings during the end of day conference and given the opportunity to provide additional documentation. No further information was provided.