**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, the facility staff failed to evidence clinical documentation was sent to the receiving facility at the time of resident discharge for three of 32 residents in the survey sample, Residents #23, #25, and #44. The findings include: 1. For Resident #23 (R23), the facility staff failed to evidence required information regarding the resident's clinical status, including a medication list and care plan goals, to the receiving facility when the resident was discharged to the hospital on 2/25/23. A review of R23's clinical record revealed the resident was discharged to the hospital on 2/25/23 and readmitted to the facility on [DATE]. Further review of the clinical record failed to reveal evidence that the facility provided the receiving hospital with a medication list or care plan goals at the time of the discharge. The resident's E-Interact form dated 2/25/23 did not evidence that the resident's medication list and care plan goals were sent to the hospital. On 4/11/23 at 3:55 p.m., LPN (licensed practical nurse) #2, the unit manager, was interviewed. She stated when a resident is discharged to the hospital, a document is generated (an E-Interact form) which includes a place to check off which information the nurse is sending to the hospital with the resident. She stated this includes a medication list and care plan goals. After reviewing R23's E-Interact form dated 2/25/23, LPN #2 stated she did not understand why the documents were not checked off as sent to the hospital with the resident. On 4/11/23 at 5:07 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were informed of these concerns. A review of the facility policy, Facility Initiated Transfers, revealed in part: The medical record .Will clearly identify the basis or reason for transfer or discharge .Identify Information provided to the receiving provider which at a minimum will include: .Special instructions and/or precautions for ongoing care, as appropriate, which must include, if applicable, but are not limited to treatments and devices (oxygen, implants, IVs, tubes/catheters) .The resident's comprehensive care plan goals; and .Medications (including when last received). No further information was provided prior to exit. 2. For Resident #25 (R25), the facility staff failed to evidence required information regarding the resident's clinical status, including a medication list and care plan goals, was sent to the receiving facility when the resident was discharged to the hospital on 1/26/23. A review of R25's clinical record revealed the resident was discharged to the hospital on 1/26/23 and readmitted to the facility on [DATE]. Further review of the clinical record failed to reveal evidence that the facility provided the receiving hospital with a medication list or care plan goals at the time of the discharge. The resident's E-Interact form dated 1/26/23 did not evidence that the resident's medication list and care plan goals were sent to the hospital. On 4/11/23 at 3:55 p.m., LPN (licensed practical nurse) #2, the unit manager, was interviewed. She stated when a resident is discharged to the hospital, a document is generated (an E-Interact form) which includes a place to check off which information the nurse is sending to the hospital with the resident. She stated this includes a medication list and care plan goals. After reviewing R25's E-Interact form dated 1/26/23, LPN #2 stated she did not understand why the documents were not checked off as sent to the hospital with the resident. On 4/11/23 at 5:07 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were informed of these concerns. No further information was provided prior to exit. 3. For Resident #44 (R44), the facility staff failed to evidence which documents were sent to the receiving facility for a transfer to the hospital on 1/8/2023. The E-INTERACT form, dated 1/8/2023 at 7:39 a.m. documented in part, Fall .Send to ED (emergency department) for eval (evaluation) and treat (treatment) after being found on the floor with head on metal bar, unwitnessed. Resident on Eliquis (used to prevent blood clots from forming) (1) 5 mg (milligrams). An interview was conducted with LPN (licensed practical nurse) #2, on 4/11/2023 at 3:14 p.m. When asked what documents are sent with the resident when they are transferred to the emergency room, LPN #2 stated, the E-INTERACT transfer form, DNR (do not resuscitate) form, if they have one, physician orders, vital signs, medication list, and bed hold notice. When asked if the care plan goals are sent with the resident, LPN #2 stated the E-INTERACT form has that on it. The above E-INTERACT form was reviewed with LPN #2. LPN #2 stated, They used the wrong form, that is not the transfer form, and there wasn't any documentation of what went with the resident. That was an agency nurse that did that. ASM #1, the administrator, ASM #2, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/11/2023 at 5:07 p.m. No further information was provided prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a613032.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, the facility staff failed to evidence written notification to the resident representative (RR), the resident and/or the Office of the State Long-Term Care Ombudsman of a resident's discharge for three of 32 residents in the survey sample, Residents #23, #25, and #44. The findings include: 1. For Resident #23 (R23), the facility staff failed to evidence written notification to the RR, resident and ombudsman when the resident was discharged to the hospital on 2/25/23. A review of R23's clinical record revealed the resident was discharged to the hospital on 2/25/23 and readmitted to the facility on [DATE]. Further review of the clinical record failed to reveal evidence that the facility notified the RR, resident and ombudsman in writing of the discharge. On 4/11/23 at 3:55 p.m., LPN (licensed practical nurse) #2, the unit manager, was interviewed. She stated when a resident is discharged to the hospital, the nurses are not responsible for notifying the ombudsman in writing or for providing written notification to the resident or RR. On 4/11/23 at 4:29 p.m., OSM (other staff member) #1, the social services director, was interviewed. She stated if a resident is admitted to the hospital, she types a letter to be sent to the RR. She stated she notifies the ombudsman quarterly of facility discharges to the hospital. She stated she could not provide evidence these notifications were made for R23. On 4/11/23 at 5:07 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were informed of these concerns. A review of the facility policy, Facility Initiated Transfers, revealed in part: Before a facility transfers or discharges a resident, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand Notice must be made as soon as practicable before transfer or discharge when .An immediate transfer or discharge is required by the resident's urgent medical needs .The facility will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman .Copies of notices for emergency transfers will be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis. No further information was provided prior to exit. 2. For Resident #25 (R25), the facility staff failed to evidence written notification to the RR, the resident and ombudsman when the resident was discharged to the hospital on 1/26/23. A review of R25's clinical record revealed the resident was discharged to the hospital on 1/26/23 and readmitted to the facility on [DATE]. Further review of the clinical record failed to reveal evidence that the facility notified the RR, resident and ombudsman in writing of the discharge. On 4/11/23 at 3:55 p.m., LPN (licensed practical nurse) #2, the unit manager, was interviewed. She stated when a resident is discharged to the hospital, the nurses are not responsible for notifying the ombudsman in writing or for providing written notification to the resident or RR. On 4/11/23 at 4:29 p.m., OSM (other staff member) #1, the social services director, was interviewed. She stated if a resident is admitted to the hospital, she types a letter to be sent to the RR. She stated she notifies the ombudsman quarterly of facility discharges to the hospital. She stated she could not provide evidence these notifications were made for R25. On 4/11/23 at 5:07 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were informed of these concerns. No further information was provided prior to exit. 3. For Resident #44 (R44), the facility staff failed to provide the resident and/or responsible party, a written notice of why the resident was being transferred to the hospital on 1/8/2023, and failed to notify the ombudsman of the transfer of 1/8/2023. The E-INTERACT form, dated 1/8/2023 at 7:39 a.m. documented in part, Fall .Send to ED (emergency department) for eval (evaluation) and treat (treatment) after being found on the floor with head on metal bar, unwitnessed. An interview was conducted with LPN (licensed practical nurse) #2, on 4/11/2023 at 3:14 p.m. When asked if she gives the resident and/or family anything in writing as to why the resident is being transferred to the hospital, LPN #2 stated she has called the emergency room but has not given them anything in writing regarding the transfer. When asked if she notifies the ombudsman, LPN #2 stated she did not. An interview was conducted with OSM (other staff member) #1, the social services director, on 4/11/2023 at 4:34 p.m. When asked if she send the notices of residents being transferred to the hospital to the ombudsman, OSM #1 stated, I send them if they go over night or are admitted . I don't send them if they go and come back. When asked if she sent one for R44, OSM #1 stated no, the resident didn't get admitted and was not out at midnight. ASM #1, the administrator, ASM #2, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/11/2023 at 5:07 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, the facility staff failed to evidence that a bed hold notice was provided to the resident and/or resident representative at the time of transfer to the hospital, for two of 32 residents in the survey sample, Residents #23 and #25. The findings include: 1. For Resident #23 (R23), the facility staff failed to evidence bed hold notification was provided to the resident when the resident was discharged to the hospital on 2/25/23. A review of R23's clinical record revealed the resident was discharged to the hospital on 2/25/23 and readmitted to the facility on [DATE]. Further review of the clinical record failed to reveal evidence that the facility provided the required bed hold notification to the resident at the time of discharge. The resident's E-Interact form dated 2/25/23 did not evidence that the bed hold notification was issued to the resident. On 4/11/23 at 3:55 p.m., LPN (licensed practical nurse) #2, the unit manager, was interviewed. She stated when a resident is discharged to the hospital, a document is generated (an E-Interact form) which includes a place to check off which information the nurse is sending to the hospital with the resident. She stated this includes a bed hold notification. After reviewing R23's E-Interact form dated 2/25/23, LPN #2 stated she did not understand why the bed hold notification was not checked off as having been given to the resident. On 4/11/23 at 5:07 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were informed of these concerns. A review of the facility policy, Facility Initiated Transfers, failed to reveal information related to bed hold notifications at the time of discharge. No further information was provided prior to exit. 2. For Resident #25 (R25), the facility staff failed to evidence bed hold notification was provided to the resident when the resident was discharged to the hospital on 1/26/23. A review of R25's clinical record revealed the resident was discharged to the hospital on 1/26/23 and readmitted to the facility on [DATE]. Further review of the clinical record failed to reveal evidence that the facility provided the required bed hold notification to the resident at the time of discharge. The resident's E-Interact form dated 1/26/23 did not evidence that the bed hold notification was issued to the resident. On 4/11/23 at 3:55 p.m., LPN (licensed practical nurse) #2, the unit manager, was interviewed. She stated when a resident is discharged to the hospital, a document is generated (an E-Interact form) which includes a place to check off which information the nurse is sending to the hospital with the resident. She stated this includes a bed hold notification. After reviewing R25's E-Interact form dated 1/26/23, LPN #2 stated she did not understand why the bed hold notification was not checked off as having been given to the resident. On 4/11/23 at 5:07 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were informed of these concerns. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to provide a resident or the resident representative with a summary of the baseline care plan for one of 32 residents in the survey sample, Resident #210. The findings include: For Resident #210 (R210), the facility staff failed to provide the resident or the representative a summary of the baseline care plan. R210 was admitted to the facility on [DATE]. A review of R210's clinical record, including the baseline care plan dated 4/1/23 and progress notes for April 2023, failed to reveal the facility staff provided R210 or the resident's representative, a summary of the baseline care plan. On 4/11/23 at 4:28 p.m., an interview was conducted with OSM (other staff member) #1, the social services director. OSM #1 stated a care conference is held with residents and/or their representatives within 72 hours of admission. OSM #1 stated at the care conference, she offers residents and their families a summary of the baseline care plan. OSM #1 stated that she doesn't specifically document that she offered a summary of the baseline care plan, but she documents that information was given or education was provided. On 4/11/23 at 5:18 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern.

Based on observation, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for two of 32 residents in the survey sample, Residents #34 and #44. The findings include: 1. For Resident #34 (R34), the facility staff failed to review and revise the resident's comprehensive care plan for bed rail use. A review of R34's clinical record revealed a side rail (bed rail) evaluation dated 11/17/22 that documented bilateral quarter side rails was recommended to assist with bed mobility. A review of R34's comprehensive care plan dated 12/7/22 failed to reveal documentation regarding bed rails. On 4/10/23 at 4:43 p.m., R34 was observed lying in bed with bilateral quarter bed rails in the upright position. On 4/11/23 at 3:12 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated the purpose of the care plan is, Where everybody can see them and go off with what's going on with the resident. LPN #2 stated residents' care plans should be reviewed and revised to include bed rails, So everybody can see what they are there for. On 4/11/23 at 5:18 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern. 2. For Resident #44 (R44) the facility staff failed to review and/or revise the comprehensive care plan after a fall on 1/8/2023. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/18/2023, the resident scored a five out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is severely cognitively impaired for making daily decisions. The nurse's note dated 1/8/2023 at 7:39 a.m. documented in part, Fall .Send to ED (emergency department) for eval (evaluation) and treat (treatment) after being found on the floor with head on metal bar, unwitnessed. Resident on Eliquis (used to prevent blood clots from forming) (1) 5 mg (milligrams). The comprehensive care plan dated 9/6/2022 documented in part, Focus: The resident is at risk for falls r/t (related to) deconditioning, gait/balance problems, unaware of safety needs. The Interventions were all dated 9/6/2022. On 4/11/2023 at 2:43 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated she could not find the risk management form (fall investigation) for the fall of 1/8/2023. She stated that was before her time. She further stated the risk management form would have documented the reviewing and revising of the care plan if new interventions would have been put into place. The above care plan was reviewed with ASM #2. ASM #2 stated she did not see any revising of the care plan after the fall on 1/8/2023 that sent the resident to the hospital. ASM #1, the administrator, ASM #2, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/11/2023 at 5:07 p.m. No further information was provided prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a613032.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide smoking supervision for one of 32 residents in the survey sample, Resident #33. The findings include: For Resident #33 (R33), on 4/10/23, the facility staff failed to provide a smoking apron per the resident's safe smoking assessment. R33 was admitted to the facility with diagnoses including Huntington Disease (1). On 4/10/23 at 2:18 p.m. and 3:53 p.m., R33 was sitting in a wheelchair outside on the smoking area patio. R33 had a lit cigarette in hand. R33 was not wearing a smoking apron at either observation. The resident was supervised per facility policy. A review of R33's safe smoking assessment dated [DATE] revealed, in part: 1. Is the resident a safe smoker? b. Safe to smoke with supervision. A review of R33's care plan dated 4/8/23 revealed, in part: .If resident is going to smoke cigarettes resident will need to utilize smoking apron. On 4/11/23 at 3:55 p.m., LPN (licensed practical nurse) #2, the unit manager, was interviewed. She stated that the resident had not smoked to her knowledge prior to 4/10/23. She stated on 4/8/23, the facility became aware of the resident's desire to smoke. She stated if R33 smokes, the resident needs to wear a smoking apron because of her diagnosis of Huntington disease. On 4/11/23 at 5:07 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were informed of these concerns. A review of the facility policy, Smoking Permitted, revealed, in part: Protective equipment to promote safe smoking will be offered as appropriate based on resident assessment, and the resident will be encouraged and assisted as necessary in using the protective devices. No further information was provided prior to exit. NOTES (1) Huntington disease is a progressive brain disorder that causes uncontrolled movements, emotional problems, and loss of thinking ability (cognition). This information is taken from the website https://medlineplus.gov/genetics/condition/huntington-disease/

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services for pain management in a timely manner for one of 32 residents in the survey sample; Resident #10. The findings include: For Resident #10, the facility staff failed to address the resident's complaint of pain on 4/10/23 at 4:10 PM. On the most recent MDS (Minimum Data Set), an admission / 5-Day MDS assessment, dated 3/15/23, Resident #10 was coded as being cognitively intact in ability to make daily life decisions. On 4/10/23 at 4:10 PM Resident #10 was observed and the resident requested something for pain from this surveyor. The resident's facial expression reflected pain and/or discomfort. At that time, RN #1 (Registered Nurse) was notified of the resident's complaint of pain and request for pain medication RN #1 stated that they did not know where the resident's assigned nurse was. On 4/10/23 at 4:25 PM a follow up interview was conducted with Resident #10. When asked if anyone had come to see them regarding their pain, the resident stated that no one had. At that time, LPN (Licensed Practical Nurse) #4 was observed at the nurse's station. Upon asking LPN #4 about Resident #10's pain, she stated that she just returned from break and had a written note on her computer about Resident #10's pain. RN #1 had not done anything to address Resident #10's complaint of pain. When asked if another nurse can administer pain medications to her resident when she is on break, she stated that she was not sure about facility rules on that. On 4/11/23 at 7:30 AM, a follow up interview was conducted with LPN #4. When asked if she notified RN #1 that she was going on break the previous afternoon, she stated that she had. When asked about another nurse providing care, treatment and/or medications to her residents when she is on break, she stated that The other nurse cannot give meds to my patients, that are under my care. The only one that can is the DON (Director of Nursing) in an emergency. On 4/11/23 at approximately 7:45 AM, ASM #2 (Administrative Staff Member) the Director of Nursing, was asked about nurses being able to provide medications to another nurse's residents when a nurse is on break. She stated that the nurses have access to all of the residents medication records and that another nurse absolutely can assess another nurse's resident and check for appropriate orders and administer medications, if appropriate. She stated that the nurse would have to just get the keys for the other nurse's medication cart from the other nurse or from her [the DON] who has a set of keys to all of the medication carts. ASM #2 was made aware of RN #1's failure to address the resident's complaint of pain while LPN #4 was on a break on 4/10/23. The facility policy, Pain Management, was reviewed. This policy documented, The organization will ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents ' goals and preferences . On 4/11/23 at the end-of-day meeting at 5:00 PM, ASM #1 (the Administrator) and ASM #2, were made aware of the findings. No further information was provided by the end of the survey.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed implement bed rail requirements for two of 32 residents in the survey sample, Residents #29 and #34. The findings include: 1. For Resident #29 (R29), the facility staff failed to review with the resident (and/or resident's representative) the risks and benefits of, and obtain consent for, the use of bed rails. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/13/23, R29 was coded as requiring the extensive assistance of staff for bed mobility and transfers. On 4/10/23 at 12:47 p.m. and 3:11 p.m., and on 4/11/23 at 9:18 a.m., R29 was sitting up in bed. At all three observations, bilateral bed rails (quarter rails) were up. A review of R29's physician orders revealed the following: 2/24/21 Patient is required (sic) bilateral 1/4 side rails to assist with repositioning. Further review of R29's clinical record failed to reveal an assessment for the use of bed rails, education regarding the risks and benefits of using bed rails, or a consent for the use of bed rails. On 4/11/23 at 3:55 p.m., LPN (licensed practical nurse) #2, the unit manager, was interviewed. She stated the nursing staff and therapy staff completes an evaluation for the use of bed rails. She stated, We have to get the consent. We have to find a diagnosis why they need a bed rail. On 4/11/23 at 5:07 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were informed of these concerns. In response to a request for the bed rail policy, the facility staff provided a copy of a blank education and consent for side rails. The document contained no information related to the facility's procedure for assessing for, education about, or obtaining consent for the use of side rails by a resident. No further information was provided prior to exit. 2. For Resident #34 (R34), the facility staff failed to review the risks and benefits of bed rails with the resident (and/or the resident's representative), and failed to obtain informed consent for the use of bed rails. A review of R34's clinical record revealed a side rail (bed rail) evaluation dated 11/17/22 that documented bilateral quarter side rails was recommended to assist with bed mobility. Further review of R34's clinical record failed to reveal documentation that the facility staff reviewed the risks and benefits of bed rails with R34 (and/or the resident's representative) and obtain informed consent. On 4/10/23 at 4:43 p.m., R34 was observed lying in bed with bilateral quarter bed rails in the upright position. On 4/11/23 at 3:12 p.m., an interview was conducted with LPN (licensed practical nurse) #2 in regard to residents' use of bed rails. LPN #2 stated, We are supposed to have an eval [evaluation] from therapy. We do an assessment, then we have to get the consent and find a diagnosis as to why they need the bed rails. On 4/11/23 at 5:18 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide sufficient staffing for one of 32 residents in the survey sample, Resident #34. The findings include: For Resident #34 (R34), the facility staff failed to administer the medication gabapentin (1) per the physician's order on 3/28/23 and 3/29/23 because there was only one nurse in the facility and two nurses were required to obtain the medication from the facility Omnicell (a machine of medications that are maintained in the facility in case a specific medication for a specific resident is not available). A review of R34's clinical record revealed a physician's order dated 3/2/23 for gabapentin 100mg (milligrams)- two capsules every eight hours for neuropathy. A review of R34's March 2023 MAR (medication administration record) failed to reveal evidence that R34 was administered gabapentin on 3/28/23 at 10:00 p.m. and 3/29/23 at 6:00 a.m. Nurses' notes dated 3/28/23 and 3/29/23 documented, Awaiting delivery from pharmacy. A review of the facility Omnicell list revealed gabapentin 100mg capsules were available in the facility. On 4/11/23 at 4:14 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing (and the nurse who documented the above progress notes). ASM #2 stated that on 3/28/23, the nurses ran out of R34's gabapentin so the nurse practitioner sent a new prescription to the pharmacy and the pharmacy staff stated the medication would be delivered on the next run. ASM #2 stated she could not obtain gabapentin from the Omnicell during the night of 3/28/23 or morning of 3/29/23 because two nurses called in and she was the only nurse working. ASM #2 stated two nurses are required to pull gabapentin from the Omnicell because it is a controlled substance. A review of the staffing sheet for the night of 3/28/23 into the morning of 3/29/23 revealed two nurses called in and ASM #2 was the only nurse in the building. On 4/11/23 at 4:43 p.m., an interview was conducted with OSM (other staff member) #2, the nurse staffing scheduler. OSM #2 stated nurses work 12-hour shifts and she schedules two nurses for each shift. OSM #2 stated there are a couple of nurses who are willing to pick up extra shifts if other nurses call in, and ASM #2 and the unit manager will work the floor if there is no other nurse able to work. OSM #2 stated the facility also contracts with agency staff. On 4/11/23 at 5:18 p.m., ASM #1, the administrator, and ASM #2 were made aware of the above concern. Reference: (1) Gabapentin is used to relieve pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a694007.html.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow the published menu for one of 32 residents in the survey sample, Resident #23. The findings include: For Resident #23 (R23), the facility staff failed to provide the resident with the items on the lunch menu on 4/10/23. On 4/10/23 at 12:31 p.m., R23 was sitting in a wheelchair, with a tray of food on the overbed table that was in front of the resident. The tray did not contain any chocolate pudding. A review of the meal ticket for R23 for this meal included that the resident should get chocolate pudding. On 4/10/23 at 12:34 p.m., OSM #7, a cook, evaluated the items on R23's tray. OSM #7 stated: No, this is not right. [R23] should have chocolate pudding. Somebody substituted applesauce instead, but there should be chocolate pudding on the tray. On 4/10/23 at 2:50 p.m., OSM #8, the dining services manager, was interviewed. OSM #8 stated the dietary aide who stands on the side of the tray line with the trays, condiments, silverware, and cold items, is responsible for calling out what should be on the resident's plate. The dietary aide is responsible for making sure items like pudding are placed on the resident's tray. She stated the menu should be followed unless the facility is out of a particular item. She stated: I was standing right there. I don't know what happened today with (R23)'s lunch tray. She stated (R23) likes chocolate pudding. She stated the dietary aide is usually the last person to touch the tray, and is responsible for making sure the correct items are being served to the resident. On 4/11/23 at 5:07 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were informed of these concerns. A review of the facility policy, Menus, revealed, in part: Menu items and available snacks reflect the religious, cultural, and ethnic preferences of the residents, whenever reasonable. Copies of menus are posted in resident areas, in positions and in print large enough for residents to read them. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to serve food at the physician-ordered consistency for one of 32 residents in the survey sample, Resident #23. The findings include: For Resident #23 (R23), the facility staff failed to serve pureed spinach at lunch on 4/10/23. On 4/10/23 at 12:31 p.m., R23 was sitting in a wheelchair, with a tray of food on the overbed table in front of the resident. The tray contained pureed meat and pasta. The tray also contained a serving of spinach, which was not pureed. Leaves and stems were visible in the serving cup. On 4/10/23 at 12:34 p.m., OSM #7, a cook, evaluated the items on R23's tray. OSM #7 stated: No, this is not right. That spinach is not pureed. A review of R23's physician orders revealed the following: 3/7/23 Regular diet. Puree texture. On 4/10/23 at 2:50 p.m., OSM #8, the dining services manager, was interviewed. OSM #8 stated the spinach had not been pureed enough at the lunch meal that day. She stated the spinach had been run through the food processor, but clearly needed more moisture to get it to the correct pureed texture. On 4/11/23 at 5:07 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were informed of these concerns. A review of the facility policy, Therapeutic Diets, revealed, in part: Therapeutic diets are prescribed by the physician/practitioner to support the resident's treatment and plan of care and in accordance with his or her goals and preferences .A 'therapeutic diet' is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to serve food according to a resident's preference for one of 32 residents in the survey sample, Resident #23. The findings include: For Resident #23 (R23), the facility staff served chicken, a documented dislike, to the resident at lunch on 4/10/23 On 4/10/23 at 12:31 p.m., R23 was sitting in a wheelchair, with a tray of food on the overbed table that was in front of the resident. The tray contained a serving of chicken and pasta. A review of the meal ticket for R23 stated in two places that R23 disliked chicken. R23's family member was sitting beside the resident. The family member stated: We keep telling them she does not like chicken. She never has. But they keep giving it to her. On 4/10/23 at 12:34 p.m., OSM #7, a cook, evaluated the items on R23's tray. OSM #7 stated: I am so sorry. This is not right. We should not have put chicken on the tray. I know (R23) doesn't like chicken. On 4/10/23 at 2:50 p.m., OSM #8, the dining services manager, was interviewed. She stated she served R23's tray from the steam table line at lunch. She stated: I'm sorry. I know (R23) does not like chicken. It's my fault. I shouldn't have served it. I don't know what happened. On 4/11/23 at 5:07 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were informed of these concerns. A review of the facility policy, Resident Food Preferences, revealed, in part: On admission and/or re-admission the dietary representative or nursing staff will identify a resident's food preferences .Resident dietary preferences will be reviewed periodically with the resident by the dietary team . When possible, staff will interview the resident and/or resident representative to determine current food preferences based on history and life patterns related to food and mealtimes. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to serve food in a sanitary manner in one of one facility kitchen. The findings include: On 4/10/23, a facility dietary staff member was standing at the end of the tray line during lunch service. At the time of the observation, the employee, who had a full beard, was not wearing a beard guard. On 4/10/23 at 12:25 p.m., OSM (other staff member) #6 was standing in the kitchen at the end of the steam table line as lunch trays were being served. OSM #6 had a full beard and mustache. OSM #6 was not wearing a beard guard. OSM #6 stated: But it's my day off. I just dropped something off for them. OSM #8, the dining services manager was serving lunch trays. OSM #8 stated: Yes, he is only here for a few minutes. It's his day off. When asked if anyone in the kitchen is supposed to wear a hair net and/or beard guard when in proximity to the tray line, OSM #8 stated: Yes. That is true. On 4/10/23 at 2:50 p.m., OSM #8 was interviewed. She stated OSM #6 had come to the facility at her request to drop off a needed item. She stated: He came past the line where he shouldn't have gone without a beard guard. It was partly my fault. He took one more step than he should have. She stated when OSM #6 works, he usually wears all the garb. On 4/11/23 at 5:07 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were informed of these concerns. A review of the facility policy, Prevention of Infection - Dietary Department, revealed, in part: Dietary staff will wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. No further information was provided prior to exit.

Based on staff interview and facility document review, the facility staff failed to provide abuse training for one of one CNA (certified nursing assistant) records reviewed. The findings include: The facility staff failed to evidence abuse training was provided to CNA #3, who was hired on 9/12/88. On 4/12/23 at 1:39 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern. On 4/13/23 at 12:22 p.m., OSM (other staff member) #4, the human resources manager, stated she could not provide evidence that CNA #3 was provided abuse training. OSM #4 stated the facility uses an online training program and the program changed when the facility was sold in December 2022. OSM #4 stated she sets up the training program then employees receive automatic notifications of certain trainings that are due. OSM #4 stated abuse training is one of the required trainings.

Based on staff interview and facility document review, the facility staff failed to provide infection control training for one of one CNA (certified nursing assistant) records reviewed. The findings include: The facility staff failed to evidence infection control training was provided to CNA #3, who was hired on 9/12/88. On 4/12/23 at 1:39 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern. On 4/13/23 at 12:22 p.m., OSM (other staff member) #4, the human resources manager, stated she could not provide evidence that CNA #3 was provided infection control training. OSM #4 stated the facility uses an online training program and the program changed when the facility was sold in December 2022. OSM #4 stated she sets up the training program then employees receive automatic notifications of certain trainings that are due. OSM #4 stated infection control training is one of the required trainings.

Based on staff interview and facility document review, the facility staff failed to provide 12 hours of annual training for one of one CNA (certified nursing assistant) records reviewed. The findings include: The facility staff failed to evidence 12 hours of annual training was provided to CNA #3, who was hired on 9/12/88. On 4/13/23 at 12:22 p.m., OSM (other staff member) #4, the human resources manager, stated she could not provide evidence that CNA #3 was provided 12 hours of annual training. OSM #4 stated the facility uses an online training program and the program changed when the facility was sold in December 2022. OSM #4 stated she sets up the training program then employees receive automatic notifications of certain trainings that are due. OSM #4 stated she did not know who was responsible for ensuring CNAs receive 12 hours of annual training. On 4/12/23 at 1:39 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #262 (R262), the facility staff failed to notify the physician of medications not administered as ordered on 12/28/2021. R262 was admitted to the facility on with diagnoses that included but were not limited to chronic obstructive pulmonary disease (1), hypertension and congestive heart failure (2). The eMAR (electronic medication administration record) for R262 dated 12/1/2021-12/31/2021 documented in part, - Metoclopramide HCL (3) Solution 5mg/ml (milligram per milliliter) Use 5mg intravenously three times a day for before meals. Start Date: 12/28/2021 0900 (9:00 a.m.). The eMAR documented a 9 in the administration area for 12/28/2021 at 9:00 a.m., 1:00 p.m. and 5:00 p.m. The eMAR chart codes documented in part, .9= Other/See Nurse Notes . - Diltiazem HCL (4) tablet 30mg Give 1 tablet by mouth three times a day for high blood pressure. Start Date: 12/28/2021 0900. The eMAR documented a 9 in the administration area for 12/28/2021 at 9:00 a.m., 1:00 p.m. and 5:00 p.m. - Tiotropium Bromide Monohydrate (5) Aerosol Solution 2.5 mcg/act (micrograms) 2 puff inhale orally in the morning for COPD. Start Date: 12/28/2021 0600 (6:00 a.m.). The eMAR documented a 9 in the administration area for 12/28/2021 at 6:00 a.m. - Symbicort (6) aerosol 160-4.5 mcg/act (Budesonide-Formoterol Fumarate) 2 puff inhale orally two times a day for COPD. Start Date: 12/28/2021 0900. The eMAR documented a 9 in the administration area for 12/28/2021 at 9:00 a.m. - acetazolamide (7) tablet 125mg Give 1 tablet by mouth one time a day for fluid retention. Start Date: 12/28/2021 0900. The eMAR documented a 9 in the administration area for 12/28/2021 at 9:00 a.m. - Lexapro (8) 10mg (Escitalopram Oxalate) Give 1 tablet by mouth in the afternoon for depression. Start Date: 12/28/2021 1300 (1:00 p.m.). The eMAR documented a 9 in the administration area for 12/28/2021 at 1:00 p.m. The nurses notes for R262 documented in part, - 12/28/2021 05:49 (5:49 a.m.) new resident waiting on meds from pharmacy. - 12/28/2021 15:32 (3:32 p.m.) med not avail (available)- waiting for delivery from pharm (pharmacy). - 12/28/2021 18:38 (6:38 p.m.) med not here yet. Should be coming in very shortly. - 12/28/2021 18:37 (6:38 p.m.) not given as med is not here and clarification of order needs to be done. The nurses notes failed to evidence notification of the physician for the medications not administered as ordered on 12/28/2021 at 6:00 a.m., 9:00 a.m., 1:00 p.m. or 5:00 p.m. as documented above. The physician orders for R262 documented orders for the medications listed above entered on 12/27/2021. The discharge summary for R262 dated 12/27/2021 from [Name of hospital] documented in part, .Severe COPD with acute exacerbation in the setting of chronic COPD. Improved. To have scheduled albuterol MDI (metered dose inhaler), prn (as needed) albuterol nebs (nebulizers), Spiriva, Singulair and Symbicort .Discharge Medications: Medication list: Start taking these medications: .acetazolamide 125mg tablet commonly known as: Diamox, Take 1 tablet (125 mg total) by mouth daily. Start taking on: December 28, 2021 .tiotropium 2.5mcg/act inhalation spray Commonly known as: Spiriva respimat inhale 2 puffs into the lungs every morning. Start taking on: December 28, 2021 .Change how you take these medications: .budesonide-formoterol 160-4.5 mcg/act inhaler Commonly known as: Symbicort Dose: 2 puff Instructions: Inhale 2 puffs into the lungs 2 (two) times daily .Diltiazem 30mg tablet Commonly known as: Cardizem 30mg Instructions: Take 1 tablet (30mg total) by mouth 3 (three) times daily . On 4/11/2023 at approximately 5:00 p.m., ASM (administrative staff member) #1, the administrator stated that there were no nurses currently employed at the facility who worked at the facility in December 2021. On 4/11/2023 at 3:25 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that medications were documented as given by signing them off on the eMAR. LPN #2 stated that any refusals or any time a medication was not given the physician was notified and it was documented in the nurses notes. On 4/12/2023 at 12:44 p.m., an interview was conducted with ASM #3, nurse practitioner. ASM #3 stated that they expected for a resident to start getting their medications as soon as possible after admission to the facility. ASM #3 stated that they would expect any pertinent medications such as blood pressure medications and inhalers to be started by the next day after admission. ASM #3 stated that they would expect the nursing staff to inform them of a resident not receiving their medications due to it not arriving from the pharmacy and at times they were able to use an alternate from the stock medications. On 4/12/2023 at 1:29 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the findings. No further information was obtained prior to exit. Reference: (1) chronic obstructive pulmonary disease (COPD) Disease that makes it difficult to breathe that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. (2) congestive heart failure A condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. This information was obtained from the website: https://medlineplus.gov/heartfailure.html (3) Metoclopramide injection is used to relieve symptoms caused by slow stomach emptying in people who have diabetes. These symptoms include nausea, vomiting, heartburn, loss of appetite, and feeling of fullness that lasts long after meals. Metoclopramide injection is also used to prevent nausea and vomiting caused by chemotherapy or that may occur after surgery. Metoclopramide injection is also sometimes used to empty the intestines during certain medical procedures. Metoclopramide injection is in a class of medications called prokinetic agents. It works by speeding the movement of food through the stomach and intestines. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601158.html (4) Diltiazem is used to treat high blood pressure and to control angina (chest pain). Diltiazem is in a class of medications called calcium-channel blockers. It works by relaxing the blood vessels so the heart does not have to pump as hard. It also increases the supply of blood and oxygen to the heart. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a684027.html (5) Tiotropium is used to prevent wheezing, shortness of breath, coughing, and chest tightness in patients with chronic obstructive pulmonary disease (COPD, a group of diseases that affect the lungs and airways) such as chronic bronchitis (swelling of the air passages that lead to the lungs) and emphysema (damage to air sacs in the lungs). Tiotropium is in a class of medications called bronchodilators. It works by relaxing and opening the air passages to the lungs to make breathing easier. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a604018.html (6) Formoterol oral inhalation is used to control wheezing, shortness of breath, and chest tightness caused by chronic obstructive pulmonary disease (COPD; a group of lung diseases that includes chronic bronchitis and emphysema). Formoterol is in a class of medications called long-acting beta agonists ([NAME]). It works by relaxing and opening air passages in the lungs, making it easier to breathe. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a602023.html (7) Acetazolamide is used to treat glaucoma, a condition in which increased pressure in the eye can lead to gradual loss of vision. Acetazolamide decreases the pressure in the eye. Acetazolamide is also used to reduce the severity and duration of symptoms (upset stomach, headache, shortness of breath, dizziness, drowsiness, and fatigue) of altitude (mountain) sickness. Acetazolamide is used with other medicines to reduce edema (excess fluid retention) and to help control seizures in certain types of epilepsy. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682756.html (8) Escitalopram is used to treat depression in adults and children and teenagers 12 years of ago or older. Escitalopram is also used to treat generalized anxiety disorder (GAD; excessive worry and tension that disrupts daily life and lasts for 6 months or longer) in adults. Escitalopram is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a603005.html Based on staff interview, and clinical record review, it was determined the facility staff failed to notify the responsible party and/or the physician when medications were not available for administration for three of 32 residents in the survey sample, Residents #37, #14 and #262. The findings include: 1. For Resident #37 (R37), the facility staff failed to notify the physician when medications when the medication, Lyrica, was not available for administration. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/16/2023, the resident scored a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired for making daily decisions. An interview was conducted with R37 on 4/10/2023 at approximately 2:00 p.m. R37 stated the facility runs out of their Lyrica (used to treat neuropathic pain) (1) at times. The physician order dated, 2/10/2023, documented, Lyrica 75 mg; Give 1 capsule by mouth two times a day for neuropathy. The February 2023 medication administration record (MAR) documented the above order. On 2/12/2023 and 2/13/2023 for the 9:00 a.m. and 9:00 p.m. doses a 9 was documented. On 2/14/2023 for the 9:00 a.m. dose a 9 was documented. A 9 indicated, Other/See nurse's notes. The nurse's notes for the dates and times with the 9 documented, read, On order. An interview was conducted with LPN (licensed practical nurse) #2, on 4/11/2023 at 3:14 p.m. When asked what the process is when a medication is not available at the time it is scheduled to be administered, LPN #2 stated, The (name of pharmacy machine with medications in the building) is the best thing. It has many of the medications we need. If it's a narcotic, then you need two nurses to get it out of the machine. When asked if the medication is not available in the (name of machine), what should the nurse do, LPN #2 stated, You have to call the pharmacy to get it and notify the nurse practitioner that it is not here. LPN #2 stated the Lyrica was not in the machine. When LPN #2 was shown when the Lyrica was not given and the nurses documented it was on order, LPN #2 stated she was not made aware of the unavailability of the Lyrica [for R37]. LPN #2 stated that sometimes it takes two days to get medications and even the stat (right away) medications can take up to 24 hours to get. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/11/2023 at 5:07 p.m. No further information was obtained prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a605045.html 2. For Resident #14 (R14), the facility staff failed to notify the physician when medication, Lyrica, as not available for administration. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/28/2022, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The physician order dated, 1/6/2023, documented, Lyrica Capsule 25 mg (milligram); Give 1 capsule by mouth at bedtime for neuropathic pain. The March 2023 MAR (medication administration record) documented the above order for Lyrica. A 9 was documented for the 9:00 p.m. dose on 3/9/2023 through 3/15/2023. A 9 indicated, Other/See nurse's notes. The nurse's notes for the above dates and 9:00 p.m. dose administration, read, On order. An interview was conducted with LPN (licensed practical nurse) #2, on 4/11/2023 at 3:14 p.m. When asked what the process is when a medication is not available at the time it is scheduled to be administered, LPN #2 stated, The (name of pharmacy machine with medications in the building) is the best thing. It has many of the medications we need. If it's a narcotic, then you need two nurses to get it out of the machine. When asked if the medication is not available in the (name of machine), what should the nurse do, LPN #2 stated, You have to call the pharmacy to get it and notify the nurse practitioner that it is not here. LPN #2 stated the Lyrica was not in the machine. When LPN #2 was shown when the Lyrica was not given and the nurses documented it was on order, LPN #2 stated she was not made aware of the unavailability of the Lyrica [for R14]. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/11/2023 at 5:07 p.m. No further information was obtained prior to exit.

Based on staff interview, facility document review and employee record review, it was determined the facility staff failed to implement their policies for screening potential employees for 13 of 25 employee record reviews. The findings include: For the following employees the criminal background check was not completed within 30 days of hire: 1. OSM (other staff member) #9, hired 12/2/2022. Criminal background check dated 4/11/2023, after it was requested by the survey team. 2. LPN (licensed practical nurse) #6, hired 12/1/2022, criminal background check was dated 9/26/2022. 3. LPN #7 hired on 2/14/2022. There was no evidence of a criminal background check. There was no employee record. 4. RN (registered nurse) #4, hired 6/1/2022. There was no evidence of a criminal background check. There was no employee record. 5. CNA (certified nursing assistant) #7, hired 7/1/2022. The criminal background check was dated 3/15/2023. 6. LPN #8, hired 7/13/2021. There was no evidence of a criminal background check. There was no employee record. 7. LPN #9, hired 2/14/2022. There was no evidence of a criminal background check. There was no employee record. 8. CNA (certified nursing assistant) #9, hired 3/11/2022. There was no evidence of a criminal background check. There was no employee record. 9. RN #5, hired 5/16/2022. There was no evidence of a criminal background check. There was no employee record. 10. OSM #12, Human Resources coordinator, hired 8/2/2021. There was no evidence of a criminal background check. There was no employee record. 11. LPN #11, hired 5/10/2022. There was no evidence of a criminal background check. There was no employee record. 12. OSM #14, activities coordinator, hired 8/2/2021. There was no evidence of a criminal background check. 13. OSM #15, social services assistant, hired 7/7/2022. Criminal background check was dated 3/20/2023. An interview was conducted with OSM #4, the business office/human resources (HR) staff member, on 4/12/2023 at 12:19 p.m. When asked the process for hiring a new staff member, OSM #4 stated they go through a recruiting site and select potential employees. Then the process is to bring them in for an initial interview, complete an application if not already done on the recruitment site, do the reference checks, they complete the rest of the package, which includes fair credit reporting, background check authorization, and sworn statement. If accepting the employee, then they pull the license, sex offenders registry, OIG (office of the inspector general) report, and criminal background check. Once is all done, they bring the staff member in for orientation. When asked how long employee records are retained, OSM #4 state she did not know that answer, but thinks it might be seven years. When asked why there are missing and/or not completed criminal background checks, OSM #4 stated that she just took on this position as HR in addition to her business office duties. OSM #4 further stated she did complete an audit a few months ago and ran some of the ones missing. She stated the other records were not available since the change of ownership of the building. The facility policy, Abuse documented in part, The organization will screen potential employees for a history of abuse, neglect or mistreating residents. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were made aware of the above on 4/12/2023 at 1:31 p.m. No further information was obtained prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. For Resident #61, the facility staff failed to implement the comprehensive care plan to administer oxygen as ordered. A review of the clinical record revealed a physician's order dated 2/23/22 oxygen at 3 liters, continuous. A review of the resident's care plan revealed one dated 2/28/22 for The resident has emphysema/COPD (chronic obstructive pulmonary disease). This care plan included the intervention dated 2/28/22 for O2 (oxygen) via nasal prongs at 3L (liters per minute) continuous humidified. A review of the Medication / Treatment Administration Records (MAR / TAR) for February and March 2022 failed to reveal any evidence of the oxygen being administered. A review of the nurse's notes revealed the following: On 3/1/22, 3/8/22, 3/14/22, 3/18/22, and 3/21/22 the oxygen was documented as not being used. On 2/24/22, 3/5/22, 3/6/22, 3/7/22, 3/12/22, 3/14/22 and 3/17/22 the oxygen was documented as being administered at 2 liters per minute instead of the ordered 3 liters per minute. On 2/26/22, 2/27/22, 2/28/22, 3/9/22, 3/10/22, 3/11/22, 3/13/22, 3/15/22, 3/16/22, 3/19/22, 3/22/22, and 3/22/22 there was no documentation that the oxygen was administered as ordered. On 4/12/23 at 10:40 AM an interview was conducted with LPN #5 (Licensed Practical Nurse). She stated that when a resident is on oxygen, it should be documented on the MAR or TAR. She stated that if a resident has oxygen on, it should be documented somewhere. On 4/12/23 at 11:16 AM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. She stated that if staff are documenting that physician ordered oxygen is not in use, then it should also be documented why. She stated that if it just says it was not in use and does not say the resident refused, then it is not being administered as ordered. On 4/12/23 at 1:11 PM an interview was conducted with LPN #3 (Licensed Practical Nurse). When asked what was the purpose of the care plan, she stated that it was a guide on how to care for the resident and that it should be followed. When asked if the care plan documented to administer oxygen as ordered, and the oxygen was not being administered as ordered, was the care plan being followed, she stated that it was not. A policy regarding care plans was requested however none was provided. On 4/12/23 at approximately 1:30 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2 were made aware of the findings. No further information was provided by the end of the survey. Based on observation, staff interview and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for five of 32 residents in the survey sample, Residents # 110, #14, #37, #3 and #61. The findings include: 1. For Resident #110 (R110) the facility staff failed to implement the care plan for colostomy care. On the most recent MDS (minimum data set) assessment, an admission assessment, the resident scored a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. In Section H - Bladder and Bowel, the resident was coded as having an ostomy. The comprehensive care plan dated, 6/16/2022, documented in part, Focus: Resident has a colostomy. The Interventions documented, Administer care as ordered. The physician order dated, 6/3/2022, documented, Ostomy: Colostomy Care every shift and as needed, every 12 hours for Ostomy. The TAR (treatment administration record) for June 2022 documented the above order. Of the 48 opportunities for completing the colostomy care, 11 were blank. The TAR for July and August did not have the order for colostomy care. The nurse's notes were reviewed. The nurses documented in their notes, Bowel has ostomy noted. There was no documentation from June through August of any care provided for the colostomy. An interview was conducted with LPN (licensed practical nurse) #2 on 4/11/2023 at 3:14 p.m. When asked the purpose of the care plan, LPN #2 stated it is so everyone can see them (the residents) and see what is going on with the resident's care, their refusals, behaviors. LPN #2 further stated the care plans come up generic and you have to go in and personalize them to each resident. Some nurses don't know how to do them. When asked if the care plan should be followed, LPN #2 stated, yes. ASM #1, the administrator, ASM #2, and ASM #4, the regional nurse consultant, were made aware of the above concerns on 4/12/2023 at 1:31 p.m. No further information was provided prior to exit. 2. For Resident #14 (R14), the facility staff failed to implement the care plan for administering treatments to a pressure injury. The comprehensive care plan dated, 2/23/2022, documented in part, Focus: The resident has pressure injury to sacral area or potential for pressure injury development. Resident has a pressure area to sacral area. The Interventions documented in part, Administer treatments as ordered and monitor for effectiveness. Resident has a wound vac. Change dressing to pressure area M-W-F and as necessary. Wound vac has pre-programmed settings. Check for functioning as needed. The physician order dated, 2/28/2022, documented, Wound Vac (vacuum) with black sponge to be changed M-W-F (Monday - Wednesday - Friday) every day shift every [NAME], Wed, Fri to wound. The May 2022 TAR (treatment administration record) documented the above order. On the following dates the wound vac dressing was not documented as being done, the boxes where the staff would initial that the treatment was performed were blank: 5/11/2022, 5/13/2022, 5/16/2022, 5/18/2022, 5/20/2022, 5/23/2022, 5/25/2022, 5/27/2022, and 5/30/2022. The June 2022 TAR documented the above order. There were blanks (unsigned areas) on the TAR for 6/10/2022. The July 2022 TAR documented the above order. There were blanks on the TAR for 7/1/2022, 7/9/2022, and 7/13/2022. The physician order dated, 8/19/2022, documented, Wound Care: Sacrum - Cleanse with normal saline, pat dry, apply skin prep to peri wound, place AquaCel AG on wound, secure with silicone super absorbent sacral dressing once daily and PRN (as needed) when soiled or dislodged every night shift for wound care. The September TAR documented the above order. On the following dates the treatment was not documented as being done, the boxes were blank: 9/5/2022, 9/8/2022, 9/9/2022, 9/16/2022, and 9/23/2022. The physician order dated, 9/23/2022, documented, Wound Care: Sacrum - Cleanse with normal saline, pat dry, apply skin prep to peri wound, place collagen particles on wound, secure with foam dressing once daily and PRN when soiled or dislodged, every night shift for wound care. The September TAR documented the above order. On the following dates the treatment was not documented as being done, the boxes were blank: 9/23/2022, 9/24/2022, 9/25/2022, 9/29/2022, and 9/30/2022. An interview was conducted with LPN (licensed practical nurse) #2 on 4/11/2023 at 3:14 p.m. When asked the purpose of the care plan, LPN #2 stated it is so everyone can see them (the residents) and see what is going on with the resident's care, their refusals, behaviors. LPN #2 further stated the care plans come up generic and you have to go in and personalize them to each resident. Some nurses don't know how to do them. When asked if the care plan should be followed, LPN #2 stated yes. ASM #1, the administrator, ASM #2, and ASM #4, the regional nurse consultant, were made aware of the above concerns on 4/12/2023 at 1:31 p.m. No further information was provided prior to exit. 3. For Resident #37, the facility staff failed to implement the care plan for hypotension (low blood pressure). The comprehensive care plan dated 9/8/2022, documented in part, Focus: The resident has hypotension. The Interventions documented, Encourage adequate fluid intake and a healthy diet. Encourage resident to get up slowly, sit on side of bed before standing. Give medications as ordered. Monitor for side effects and effectiveness. Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of hypotension, dizziness, fainting, syncope, blurred vision, lack of concentration, nausea, fatigue, cold clammy pale skin. The physician order dated, 10/7/2022, documented, Midodrine 10 mg (milligrams)(used to treat orthostatic hypotension. Midodrine works by causing blood vessels to tighten, which increases blood pressure) (1); 1 tablet by mouth every 8 hours for hypotension. Hold if above SBP (systolic blood pressure) 120. The March 2023 MAR (medication administration record) documented the above order. The MAR revealed the medication was administered on the following days and times with a systolic blood pressure greater or above 120: 3/1/2023 at 6:00 a.m. - 134/76 3/1/2023 at 10:00 p.m. - 130/76 3/2/2023 at 6:00 a.m. - 122/63 3/2/2023 at 10:00 p.m. - 122/60 3/4/2023 at 10:00 p.m. - 131/71 3/10/2023 at 2:00 p.m. - 134/62 3/14/2022 at 6:00 a.m. - 124/76 3/15/2023 at 6:00 a.m. - 130/74 3/15/2023 at 2:00 p.m. - 122/60 3/16/2023 at 2:00 p.m. - 161/69 3/18/2023 at 6:00 a.m. - 128/70 3/20/2023 at 2:00 p.m. - 122/68 3/21/2022 at 10:00 p.m. - 124/68 3/25/2023 at 2:00 p.m. - 124/68 3/25/2023 at 10:00 p.m. - 145/83 3/26/2023 at 2:00 p.m. - 124/76 3/29/2023 at 6:00 a.m. - 130/72 The April 2023 MAR documented the above order. The MAR revealed the medication was administered on the following days and times with a systolic blood pressure greater or above 120: 4/4/2023 at 2:00 p.m. there was documented a NA (not applicable) where the blood pressure should have been documented. The medication was documented as being administered. 4/5/2023 at 10:00 p.m. - 124/76 4/7/2023 at 6:00 a.m. - 128/70 4/8/2023 at 6:00 a.m. - 158/78 4/11/2023 at 6:00 a.m. - 132/78 An interview was conducted with LPN (licensed practical nurse) #2 on 4/11/2023 at 3:14 p.m. When asked the purpose of the care plan, LPN #2 stated it is so everyone can see them (the residents) and see what is going on with the resident's care, their refusals, behaviors. LPN #2 further stated the care plans come up generic and you have to go in and personalize them to each resident. Some nurses don't know how to do them. When asked if the care plan should be followed, LPN #2 stated yes. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/11/2023 at 5:07 p.m. No further information was obtained prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a616030.html. 4. For Resident #3 (R3), the facility staff failed to implement the care plan for oxygen administration. The comprehensive care plan dated, 8/14/2022, documented in part, Focus: The resident has oxygen therapy r/t (related to) Respiratory illness. The Interventions documented in part, OXYGEN SETTINGS: O2 (oxygen) via nasal prongs @ (at) 2L (liters) PRN to maintain SPO2 (oxygen saturation) if <(less than) 90%, humidified. On 4/11/2023 at 9:14 a.m. R3 was observed in bed with oxygen on via a nasal cannula. The oxygen concentrator was set at 1.5 LPM (liters per minute). A second observation was made on 4/12/2023 at 8:19 a.m., accompanied by LPN (licensed practical nurse) #2. The oxygen was in use via a nasal cannula. LPN #2 was asked to observe what rate the oxygen was set to. LPN #2 stated, it was somewhere around 1.5 (LPM). When asked if she knew what rate R3 was supposed to be on, LPN #2 stated, it should be 2 LPM. LPN #2 adjusted the rate to 2 LPM. The physician order dated, 1/16/2023 documented, Oxygen as needed PRN (as needed) via nasal cannula at 2 L.PRN to maintain SPO2 (oxygen saturation) if <(less than) 90%, humidified. An interview was conducted with LPN (licensed practical nurse) #2 on 4/11/2023 at 3:14 p.m. When asked the purpose of the care plan, LPN #2 stated it is so everyone can see them (the residents) and see what is going on with the resident's care, their refusals, behaviors. LPN #2 further stated the care plans come up generic and you have to go in and personalize them to each resident. Some nurses don't know how to do them. When asked if the care plan should be followed, LPN #2 stated yes. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were made aware of the above findings on 4/12/2023 at 1:31 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #34 (R34), the facility staff failed to administer the medication gabapentin (1) per the physician's order on 3/28/23 and 3/29/23. A review of R34's clinical record revealed a physician's order dated 3/2/23 for gabapentin 100mg (milligrams)- two capsules every eight hours for neuropathy. A review of R34's March 2023 MAR (medication administration record) failed to reveal evidence that R34 was administered gabapentin on 3/28/23 at 10:00 p.m. and 3/29/23 at 6:00 a.m. Nurses' notes dated 3/28/23 and 3/29/23 documented, Awaiting delivery from pharmacy. A review of the facility Omnicell list (a list of medications that are maintained in the facility in case a specific medication for a specific resident is not available) revealed gabapentin 100mg capsules were available in the facility. On 4/11/23 at 4:14 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing (and the nurse who documented the above progress notes). ASM #2 stated that on 3/28/23, the nurses ran out of R34's gabapentin so the nurse practitioner sent a new prescription to the pharmacy and the pharmacy staff stated the medication would be delivered on the next run. ASM #2 stated she could not obtain gabapentin from the Omnicell during the night of 3/28/23 or morning of 3/29/23 because two nurses called in and she was the only nurse working. ASM #2 stated two nurses are required to pull gabapentin from the Omnicell because it is a controlled substance. On 4/11/23 at 5:18 p.m., ASM #1, the administrator, and ASM #2 were made aware of the above concern. Reference: (1) Gabapentin is used to relieve pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a694007.html. Based on staff interview and clinical record review, it was determined that the facility staff failed to follow professional standards of nursing for medication and treatment administration for four of 32 residents in the survey sample; Residents #310, #37, #14 and #34. The findings include: 1. The facility staff failed to obtain an order regarding the frequency of colostomy bag changes for Resident #310. Resident #310's colostomy bag was not changed between 2/25/22 and 3/5/22, for a period of 9 days. A review of the clinical record revealed that Resident #310 was admitted to the facility on [DATE] status post a new colostomy resident. A review of the clinical record revealed that there were no orders on frequency to change the ostomy bag until 3/4/22. This order documented, change colostomy every 3 days. This order included a start date of 3/5/22. A review of the Treatment Administration Record (TAR) revealed the bag was changed on 3/5/22. The next scheduled change was for 3/8/22. A review of the nurse's notes dated 3/8/22 that documented, Resident wanted to wait till [they] had [their] shower to change [their] colostomy bag/appliance. Will pass on to the next shift to change colostomy. There was no evidence it was done by the following shift. A nurse's note dated 3/6/22 documented, Resident C/O (complained of) pain to stoma site. Area is red, irritated, with slight inflammation. No S/S (signs/symptoms) of infection noted but resident has required several bag changes in the past few days from picking at wafer. Education and reminders given to not pick at the wafer . A nurse's note dated 3/7/22 documented, .resident has required several bag changes in the past few days from picking at wafer. Education and reminders given to not pick at the wafer. On 4/12/23 at 1:00 PM, an interview was conducted with ASM #3 (Administrative Staff Member) the Nurse Practitioner. She stated that, Every 3 days is not the protocol for colostomy bag changes. Every 7 days or when it leaks. When asked about an order for when to change a colostomy bag, she stated, To be clear for the facility there should be an order on the frequency but the frequency is variable depending on doctor and patient. If they have a good seal, every 7 days. As long as they have a good seal and no breakdown. I say that but a lot of times it doesn't last that long. The seal breaks, etc., It is good if it makes it 3 to 4 days. I don't like to make it (the order) for 3 days because it can be worn longer. Depends on the resident activity level as well. The max time would be 7 days. When asked if there is not an order at the time of admission on the frequency, should the facility call the physician to clarify an order for frequency, she stated that she would expect nurses to clarify at the time of admission an order for frequency. On 4/12/23 at 1:11 PM an interview was conducted with LPN #3 (Licensed Practical Nurse). When asked how a nurse know how often to change a colostomy bag, she stated there should be an order. When asked if there is a new admission resident with a colostomy, should the resident be in the facility for a week or more before an order is obtained, she stated no. She stated that an order should be obtained on admission. When asked how often should a colostomy bag be changed, she stated she was not sure, hence the need for an order for when to change it. There was no evidence of bag changes before the above order and nurse's notes. From admission on [DATE] to the first bag change on 3/5/22 was a period of 9 days without an ostomy bag change. This exceeds the nurse practitioner's statement that it should be changed at least every 7 days. Policies regarding physician's orders and ostomy care and services were requested however none was provided. On 4/12/23 at approximately 1:30 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2 were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #37, the facility staff failed to follow the physician orders for the administration of Midodrine (used to treat orthostatic hypotension. Midodrine works by causing blood vessels to tighten, which increases blood pressure) (1). On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/16/2023, the resident scored a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired for making daily decisions. The physician order dated, 10/7/2022, documented, Midodrine 10 mg (milligrams); 1 tablet by mouth every 8 hours for hypotension. Hold if above SBP (systolic blood pressure) 120. The March 2023 MAR (medication administration record) documented the above order. The MAR documented the medication was administered on the following days and times with a systolic blood pressure greater or above 120: 3/1/2023 at 6:00 a.m. - 134/76 3/1/2023 at 10:00 p.m. - 130/76 3/2/2023 at 6:00 a.m. - 122/63 3/2/2023 at 10:00 p.m. - 122/60 3/4/2023 at 10:00 p.m. - 131/71 3/10/2023 at 2:00 p.m. - 134/62 3/14/2022 at 6:00 a.m. - 124/76 3/15/2023 at 6:00 a.m. - 130/74 3/15/2023 at 2:00 p.m. - 122/60 3/16/2023 at 2:00 p.m. - 161/69 3/18/2023 at 6:00 a.m. - 128/70 3/20/2023 at 2:00 p.m. - 122/68 3/21/2022 at 10:00 p.m. - 124/68 3/25/2023 at 2:00 p.m. - 124/68 3/25/2023 at 10:00 p.m. - 145/83 3/26/2023 at 2:00 p.m. - 124/76 3/29/2023 at 6:00 a.m. - 130/72 The April 2023 MAR documented the above order. The MAR documented the medication was administered on the following days and times with a systolic blood pressure greater or above 120: 4/4/2023 at 2:00 p.m. there was documented a NA (not applicable) where the blood pressure should have been documented. The medication was documented as being administered. 4/5/2023 at 10:00 p.m. - 124/76 4/7/2023 at 6:00 a.m. - 128/70 4/8/2023 at 6:00 a.m. - 158/78 4/11/2023 at 6:00 a.m. - 132/78 The comprehensive care plan dated 9/8/2022, documented in part, Focus: The resident has hypotension. The Interventions documented, Encourage adequate fluid intake and a healthy diet. Encourage resident to get up slowly, sit on side of bed before standing. Give medications as ordered. Monitor for side effects and effectiveness. Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of hypotension, dizziness, fainting, syncope, blurred vision, lack of concentration, nausea, fatigue, cold clammy pale skin. An interview was conducted on 4/11/2023 at 2:26 p.m. with LPN (licensed practical nurse) #2, one of the nurses that administered the Midodrine when the blood pressure was above 120. The above order for Midodrine and the March MAR were reviewed with LPN #2. The blood pressures for when she gave the Midodrine were reviewed. When asked if the medication should have been given, LPN #2 stated, no. When asked if that is following the physician order, LPN #2 stated, no. A request was made for the facilty policy on Medication Administration on 4/12/2023. No policy was provided. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/11/2023 at 5:07 p.m. No further information was obtained prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a616030.html 3. For Resident #14, the facility staff failed to follow the physician orders for the administration of Midodrine. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/28/2022, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The physician order dated, 1/6/2023, documented, Midodrine 5 mg; Give 5 mg by mouth two times a day for hypotension. Hold for SBP greater than SBP 100. The March 2023 MAR documented the above order. The MAR documented the medication was administered on the following days and times with a systolic blood pressure greater or above 100: 3/1/2023 at 5:00 p.m. - 120/63 3/2/2023 at 9:00 a.m. - 116/89 3/3/2023 at 9:00 a.m. - 134/70 3/3/2023 at 5:00 p.m. - 124/63 3/4/2023 at 9:00 a.m. - 108/63 3/4/2023 at 5:00 p.m. - 124/60 3/5/2023 at 9:00 a.m. - 123/81 3/5/2023 at 5:00 p.m. - 118/68 3/13/2023 at 9:00 a.m. - 116/60 3/14/2023 at 5:00 p.m. - 118/68 3/17/2023 at 9:00 a.m. - 106/71 3/17/2023 at 5:00 p.m. - 116/60 3/22/2023 at 9:00 a.m. - 117/60 3/22/2023 at 5:00 p.m. - 132/76 3/23/2023 at 9:00 a.m. - 116/79 3/23/2023 at 5:00 p.m. - 124/76 3/27/2023 at 9:00 a.m. - 124/76 3/27/2023 at 5:00 p.m. - 107/69 The April 2023 MAR documented the above order for Midodrine. The MAR documented the medication was administered on the following days and times with a systolic blood pressure greater or above 100: 4/1/2023 at 9:00 a.m. - 119/60 4/1/2023 at 5:00 p.m. - 105/65 4/2/2023 at 9:00 a.m. - 120/72 4/2/2023 at 5:00 p.m. - 115/72 4/5/2023 at 9:00 a.m. - 128/70 4/5/2023 at 5:00 p.m. - 127/77 4/6/2023 at 9:00 a.m. 130/72 4/6/2023 at 5:00 p.m. - 126/68 4/10/2023 at 9:00 a.m. - 136/70 4/10/2023 at 5:00 p.m. = 136/72 4/11/2023 at 9:00 a.m. - 130/77 4/11/2023 at 5:00 p.m. - 136/72 The comprehensive care plan dated, 11/9/2022, documented in part, Focus: The resident has hypertension r/t (related to) Heart Failure. Resident has orthostatic hypotension. The Interventions documented in part, Give anti-hypertensive medications as ordered. Monitor for side effects. Monitor/record use/side effects of medication. Report [NAME] MD/NP (medical doctor/nurse practitioner) as necessary. An interview was conducted on 4/11/2023 at 2:26 p.m. with LPN (licensed practical nurse) #2, one of the nurses that administered the Midodrine when the blood pressure was above 120. The above order for Midodrine and the March MAR were reviewed with LPN #2. The blood pressures for when she gave the Midodrine were reviewed. When asked if the medication should have been given, LPN #2 stated, no. When asked if that is following the physician order, LPN #2 stated, no. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/11/2023 at 5:07 p.m. No further information was obtained prior to exit.

2. For Resident #262 (R262), the facility staff failed to provide incontinence care. The comprehensive MDS (minimum data set) had not been completed for R262 due to the short time the resident was in the facility. The admission nursing assessment for R262 dated 12/27/2021 documented the resident as being alert and oriented to person, place and time. The assessment further documented R262 being moderately short of breath, requiring continuous oxygen, occasionally incontinent of bowel and frequently incontinent of urine. The assessment documented R262 using pads and/or briefs. The ADL (activities of daily living) Toilet use, B&B (bowel and bladder) Bowel and B&B Bladder documentation dated 12/1/2021-12/31/2021 for R262 documented incontinence care provided on 12/28/2021 on the 7:00 a.m. to 3:00 p.m. shift requiring extensive assistance of one staff member. The ADL Toilet use documentation failed to evidence incontinence care provided on 12/27/2021 evening (3:00 p.m. to 11:00 p.m.) shift and night (11:00 p.m. to 7:00 a.m.) shift. It further failed to evidence incontinence care was provided on 12/28/2021 on the evening and night shift. The documentation areas for 12/27/2021 and 12/28/2021 evening and night shifts were observed to be blank. On 4/11/2023 at 3:25 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that ADL's were documented in the computer. LPN #2 stated that blanks meant that they did not do anything. LPN #2 stated that they could not prove that anything was done. On 4/11/2023 at 4:04 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated that incontinence care was provided every two hours. CNA #1 stated that incontinence care was documented on the computer in the ADL's every shift to evidence that it was completed. On 4/12/2023 at 10:37 a.m., an interview was conducted with CNA #2. CNA #2 stated that incontinence care was provided every two hours. CNA #2 stated that they documented incontinence care in the electronic medical record under the ADL-Toilet use and B&B elimination areas. CNA #2 stated that they documented incontinence care every eight hours for each shift. CNA #2 reviewed the ADL-Toilet use and B&B elimination summary for R262 dated 12/1/2021-12/31/2021 and stated that the aide did not document that any care was provided. CNA #2 stated that there was no evidence that incontinence care was provided to R262 except for 12/28/2021 on the day shift. The facility policy Incontinence dated November 2017 documented in part, Based on the resident ' s comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services . On 4/12/2023 at approximately 1:29 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the concern. No further information was provided prior to exit. Based on staff interview, facility document review and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for two of 32 residents in the survey sample, Residents #263 and #262. The findings include: 1.a. For Resident #263 (R263), the facility staff failed to assist the resident with bathing/showers on multiple dates May 2022 through July 2022. R263's comprehensive care plan dated 10/28/21 documented, (R263) has an ADL self-care performance deficit r/t (related to) Activity Intolerance, Fatigue, Impaired balance, Limited Mobility, Musculoskeletal impairment and Chronic pain. Resident requires extensive to total care of 1-2 staff for the completion of ADL care . R263's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 5/30/22, coded the resident as being totally dependent on one staff with bathing. A review of R263's activities of daily living records for May 2022 through July 2022 revealed a section for staff to document bathing and showers. Further review of R263's clinical record, including ADL records and nurses' notes for May 2022 through July 2022, failed to reveal documentation that the resident was assisted with bathing and/or showers from 5/18/22 until 5/24/22 (five days), 5/31/22 until 6/7/22 (six days) and 6/11/22 until 7/11/22 (29 days). On 4/11/23 at 3:12 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated residents are provided showers two days each week and when requested. LPN #2 stated showers are evidenced by documentation in the computer (ADL records) and documentation on shower sheets, but the shower sheets were just implemented a month ago. On 4/11/23 at 4:04 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated residents are provided showers or a complete bed bath, per their preference, twice a week. CNA #1 stated that on the other five days, residents are provided partial bed baths. CNA #1 stated that CNAs should document any time that any type of bathing is provided. On 4/11/23 at 5:18 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern. The facility policy titled, Activities of Daily Living (ADLs) documented, 4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); i. Each resident shall receive tub or shower baths as often as needed, but not less than twice weekly or as required by state law. Residents preference and/or whose medical conditions prohibit tub or shower baths shall have a sponge bath daily. ii. Residents will be assisted with dressing and grooming as appropriate and resident choice will be respected. iii. Residents shall be assisted with oral care as needed. b. Mobility (transfer and ambulation, including walking); i. Residents will be assisted with transfer and mobility as ordered by the physician/practitioner and/or as instructed in the resident's care plan. c. Elimination (toileting); i. Residents shall be assisted with toileting as needed. ii. Residents who are incontinent of bladder or bowel, will be provided care in a timely manner. d. Dining (meals and snacks); and i. Residents who require assistance with eating or drinking will be provided assistance as instructed in the resident's care plan. 1.b. For Resident #263 (R263), the facility staff failed to assist the resident with transfers out of bed on multiple dates May 2022 through July 2022. R263's comprehensive care plan dated 10/28/21 documented, (R263) has an ADL self-care performance deficit r/t (related to) Activity Intolerance, Fatigue, Impaired balance, Limited Mobility, Musculoskeletal impairment and Chronic pain. Resident requires extensive to total care of 1-2 staff for the completion of ADL care . R263's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 5/30/22, coded the resident as requiring extensive assistance of two or more staff with transfers. A review of R263's activities of daily living records for May 2022 through July 2022 revealed a section for staff to document transfers. Further review of R263's clinical record (including ADL records and nurses' notes for May 2022 through July 2022) failed to reveal documentation that the resident was assisted with transfers on 5/1/22, 5/4/22, 5/5/22, 5/17/22, 6/13/22, 6/24/22, 6/28/22, 6/30/22, 7/1/22, 7/2/22, 7/3/22, 7/4/22, 7/8/22, 7/9/22 and 7/10/22. On 4/11/23 at 3:12 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated staff should offer residents assistance with getting out of bed every day. On 4/11/23 at 4:04 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated, I offer multiple (transfers) throughout the day, every day, to prevent bed sores and stuff. If we transfer at all, it should be documented. On 4/11/23 at 5:18 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern. 1.c. For Resident #263 (R263), the facility staff failed to provide eating assistance on multiple dates May 2022 through July 2022. R263's comprehensive care plan dated 10/28/21 documented, (R262) has an ADL self-care performance deficit r/t (related to) Activity Intolerance, Fatigue, Impaired balance, Limited Mobility, Musculoskeletal impairment and Chronic pain. Resident requires extensive to total care of 1-2 staff for the completion of ADL care . R263's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 5/30/22, coded the resident as requiring extensive assistance of one staff with eating. A review of R263's activities of daily living records for May 2022 through July 2022 revealed a section for staff to document eating assistance. Further review of R263's clinical record (including ADL records and nurses' notes for May 2022 through July 2022) failed to reveal documentation that the resident was assisted with eating on 5/4/22, 5/5/22, 5/13/22, 5/14/22, 5/17/22, 5/19/22, 5/20/22, 5/28/22, 5/29/22, 5/30/22, 6/1/22, 6/2/22, 6/3/22, 6/4/22, 6/5/22, 6/8/22, 6/10/22, 6/12/22, 6/13/22, 6/14/22, 6/15/22, 6/16/22, 6/17/22, 6/18/22, 6/21/22, 6/22/22, 6/23/22, 6/24/22, 6/25/22, 6/26/22, 6/30/22, 7/1/22, 7/2/22, 7/3/22, 7/4/22, 7/5/22, 7/7/22, 7/8/22, 7/9/22, 7/10/22, 7/14/22, and 7/16/22. On 4/11/23 at 3:12 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that most of the time, nurses recognize when a resident needs to be fed and tells the CNAs (certified nursing assistants) to feed the resident. LPN #2 stated feeding assistance has to be documented in the ADL records. On 4/11/23 at 4:04 p.m., an interview was conducted with CNA #1. CNA #1 stated that normally the speech therapist or a report from the hospital makes them aware of residents who need assistance with eating. CNA #1 stated that she makes the nurse aware and assists residents if she sees that they are having an issue with eating. CNA #1 stated she at least sits with residents and supervises them to see if they require assistance and she documents the assistance provided. On 4/11/23 at 5:18 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, it was determined the facility staff failed to administer treatments to a pressure injury for one of 32 residents in the survey sample, Resident #14. The findings include: A. For Resident #14 (R14), the facility staff failed to evidence the administration of a wound vacuum for a sacral pressure injury. A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. (1) On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 12/28/2022, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. On the MDS, closest to the time of the pressure injury, with an ARD of 5/31/2022, R14 was coded in Section M - Skin Conditions, as having a stage four pressure injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (1) The physician order dated, 2/28/2022, documented, Wound Vac (vacuum) with black sponge to be changed M-W-F (Monday - Wednesday - Friday) every day shift every [NAME], Wed, Fri to wound. The May 2022 TAR (treatment administration record) documented the above order. On the following dates the wound vac dressing was not documented as being done, the boxes were blank: 5/11/2022, 5/13/2022, 5/16/2022, 5/18/2022, 5/20/2022, 5/23/2022, 5/25/2022, 5/27/2022, and 5/30/2022. The June 2022 TAR documented the above order. There were blanks on the TAR for 6/10/2022. The July 2022 TAR documented the above order. There were blanks on the TAR for 7/1/2022, 7/9/2022, and 7/13/2022. The comprehensive care plan dated, 2/23/2022, documented in part, Focus: The resident has pressure injury to sacral area or potential for pressure injury development. Resident has a pressure area to sacral area. The Interventions documented in part, Administer treatments as ordered and monitor for effectiveness. Resident has a wound vac. Change dressing to pressure area M-W-F and as necessary. Wound vac has pre-programmed settings. Check for functioning as needed. An interview was conducted with LPN (licensed practical nurse) #2 on 4/11/2023 at 3:14 p.m. When asked what blanks on the TAR indicated, LPN #2 stated, It means they didn't do it. You can't prove you did it. The nurse might have forgotten to sign it off but you can't really prove that it was done. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/11/2023 at 5:07 p.m. No further information was obtained prior to exit. (1) This information was obtained from the following website: https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf B. For Resident #14, the facility staff failed to administer a physician ordered treatment to a sacral pressure injury. The physician order dated, 8/19/2022, documented, Wound Care: Sacrum - Cleanse with normal saline, pat dry, apply skin prep to peri wound, place AquaCel AG on wound, secure with silicone super absorbent sacral dressing once daily and PRN (as needed) when soiled or dislodged every night shift for wound care. The September TAR documented the above order. On the following dates the treatment was not documented as being done, the boxes were blank: 9/5/2022, 9/8/2022, 9/9/2022, 9/16/2022, and 9/23/2022. The physician order dated, 9/23/2022, documented, Wound Care: Sacrum - Cleanse with normal saline, pat dry, apply skin prep to peri wound, place collagen particles on wound, secure with foam dressing once daily and PRN when soiled or dislodged, every night shift for wound care. The September TAR documented the above order. On the following dates the treatment was not documented as being done, the boxes were blank: 9/23/2022, 9/24/2022, 9/25/2022, 9/29/2022, and 9/30/2022. An interview was conducted with LPN (licensed practical nurse) #2 on 4/11/2023 at 3:14 p.m. When asked what blanks on the TAR indicated, LPN #2 stated, It means they didn't do it. You can't prove you did it. The nurse might have forgotten to sign it off, but you can't really prove that it was done. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/11/2023 at 5:07 p.m. No further information was obtained prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #310's colostomy bag was not changed between 2/25/22 and 3/5/22, for a period of 9 days. A review of the clinical record revealed that there were no orders on frequency to change the ostomy bag until 3/4/22. The order documented, change colostomy every 3 days and included a start date of 3/5/22. A review of the Treatment Administration Record (TAR) revealed the bag was changed on 3/5/22. The next scheduled change was for 3/8/22. This was not done. A review of the nurse's notes revealed one dated 3/8/22 that documented, Resident wanted to wait till [they] had [their] shower to change [their] colostomy bag/appliance. Will pass on to the next shift to change colostomy. There was no evidence it was done. A nurse's note dated 3/6/22 documented, Resident C/O (complained of) pain to stoma site. Area is red, irritated, with slight inflammation. No S/S (signs/symptoms) of infection noted but resident has required several bag changes in the past few days from picking at wafer. Education and reminders given to not pick at the wafer . A nurse's note dated 3/7/22 documented, .resident has required several bag changes in the past few days from picking at wafer. Education and reminders given to not pick at the wafer. On 4/12/23 at 1:00 PM, an interview was conducted with ASM #3 (Administrative Staff Member) the Nurse Practitioner. She stated that, Every 3 days is not the protocol for colostomy bag changes. Every 7 days or when it leaks. When asked about an order for when to change a colostomy bag, she stated, To be clear for the facility there should be an order on the frequency but the frequency is variable depending on doctor and patient. If they have a good seal, every 7 days. As long as they have a good seal and no breakdown. I say that but a lot of times it doesn't last that long. The seal breaks, etc., It is good if it makes it 3 to 4 days. I don't like to make it (the order) for 3 days because it can be worn longer. Depends on the resident activity level as well. The max time would be 7 days. When asked if there is not an order at the time of admission on the frequency, should the facility call the physician to clarify an order for frequency, she stated that she would expect nurses to clarify at the time of admission an order for frequency. There was no evidence of bag changes before the above order and nurse's notes. From admission on [DATE] to the first bag change on 3/5/22 was a period of 9 days without an ostomy bag change. This exceeded the nurse practitioner's statement that it should be changed at least every 7 days. A policy regarding ostomy care and services was requested, however none was provided. On 4/12/23 at approximately 1:30 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2 were made aware of the findings. No further information was provided by the end of the survey. Reference: Colostomy (1) https://medlineplus.gov/ency/article/002942.htm Based on staff interview and clinical record review, it was determined the facility staff failed to provide colostomy care for two of 32 residents in the survey sample, Residents #110 and #310. The findings include: Colostomy is a surgical procedure that brings one end of the large intestine out through an opening (stoma) made in the abdominal wall. Stools moving through the intestine drain through the stoma into a bag attached to the skin of the abdomen. (1) 1. For Resident #110, the facility staff failed to evidence that colostomy care was completed. On the most recent MDS (minimum data set) assessment, an admission assessment, the resident scored a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. In Section H - Bladder and Bowel, the resident was coded as having an ostomy. The physician order dated, 6/3/2022, documented, Ostomy: Colostomy Care every shift and as needed, every 12 hours for Ostomy. The TAR (treatment administration record) for June 2022 documented the above order. Of the 48 opportunities for completing the colostomy care, 11 were blank. A blank on the TAR indicates the treatment was documented as performed. The TAR for July and August did not have the order for colostomy care. The nurse's notes were reviewed. The nurses documented in their notes, Bowel has ostomy noted. There was no documentation from June through August of any care provided for the colostomy. The comprehensive care plan dated, 6/16/2022, documented in part, Focus: Resident has a colostomy. The Interventions documented, Administer care as ordered. An interview was conducted with LPN (licensed practical nurse) #2 on 4/11/2023 at 3:14 p.m. When asked what blanks on the TAR indicated, LPN #2 stated, It means they didn't do it. You can't prove you did it. The nurse might have forgotten to sign it off but you can't really prove that it was done. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 4/12/2023 at 11:09 a.m. When asked what colostomy care consists of, ASM #2 stated, the wafer has to be removed, the area cleaned with soap and water, the skin should be inspected for breakdown and redness, then dry the area thoroughly, apply ostomy paste to make a seal, apply the wafer and make sure you have a good seal. When asked how often this is to be done, ASM #2 stated the ostomy should be checked every 24 hours. When asked where it is documented, ASM #2 stated on the TAR. A policy on colostomy care was requested, however none was provided. ASM #1, the administrator, ASM #2, and ASM #4, the regional nurse consultant, were made aware of the above concerns on 4/12/2023 at 1:31 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide respiratory care and services per plan of care and/or in a sanitary manner for four of 32 residents in the survey sample; Residents #61, #14, #3, and #7. The findings include: 1. For Resident #61, the facility staff failed to ensure that oxygen was administered as ordered on multiple dates in February and March 2022. Resident #61 was admitted to the facility on [DATE] and discharged on 3/24/22. A review of the clinical record revealed a physician order dated 2/23/22 for oxygen at 3 liters per minute, continuous. A review of the Medication / Treatment Administration Records (MAR / TAR) for February and March 2022 failed to reveal any documentation of the oxygen being administered. A review of the nurse's notes revealed the following: On 3/1/22, 3/8/22, 3/14/22, 3/18/22, and 3/21/22 the oxygen was documented as not being used. On 2/24/22, 3/5/22, 3/6/22, 3/7/22, 3/12/22, 3/14/22 and 3/17/22 the oxygen was documented as being administered at 2 liters per minute instead of the ordered 3 liters per minute. On 2/26/22, 2/27/22, 2/28/22, 3/9/22, 3/10/22, 3/11/22, 3/13/22, 3/15/22, 3/16/22, 3/19/22, and 3/22/22 there was no documentation at all that the oxygen was administered as ordered. On 4/12/23 at 10:40 AM an interview was conducted with LPN #5 (Licensed Practical Nurse). LPN #5 stated that when a resident is on oxygen, it should be documented on the MAR or TAR and that if a resident has oxygen on, it should be documented somewhere. On 4/12/23 at 11:16 AM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. ASM #2 stated that if staff are documenting that physician ordered oxygen is not in use, then it should also be documented why, and that if it just says it was not in use and does not say the resident refused, then it is not being administered as ordered. A review of the resident's care plan revealed one dated 2/28/22 for The resident has emphysema/COPD (chronic obstructive pulmonary disease). This care plan included the intervention dated 2/28/22 for O2 (oxygen) via nasal prongs at 3L (liters per minute) continuous humidified. The facility policy, Oxygen Administration, was reviewed. This policy documented, .Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .Documentation .1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment 6. All evaluation data obtained before, during, and after the procedure 8. If the resident refused the procedure, the reason(s) why and the intervention taken . On 4/12/23 at approximately 1:30 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2 were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #14 (R14), the facility staff failed to store oxygen tubing in a sanitary manner. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/28/2022, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. On 4/10/2023 at 12:25 p.m. R14 was observed sitting in their wheelchair with an oxygen concentrator behind the resident. The nasal cannula was draped over the concentrator and the nose prongs were touching the floor. The tubing was dated 4/9/2023. A second observation was made at 3:06 p.m. The oxygen tubing was still draped over the concentrator and the nasal prongs were touching the floor. The resident stated they only use the oxygen at night and occasionally during the day if they have an episode. Observation on 4/11/2023 at 8:30 a.m. revealed the oxygen tubing was draped over the oxygen concentrator again. The comprehensive care plan dated, 6/10/2022, documented in part, Focus: The resident has altered respiratory status/difficulty breathing r/t (related to) pneumonia, Exacerbation COPD (chronic obstructive pulmonary disease), Chronic Respiratory Failure with hypoxia. The Interventions documented in part, OXYGEN SETTING: O2 via nasal prongs @ (at) 2 LPM (liters per minute) PRN (as needed). An interview was conducted with LPN (licensed practical nurse) #2, on 4/12/2023 at 8:11 a.m. When asked how oxygen tubing is to be stored when not in use, LPN #2 stated there is supposed to be a bag with the resident's name on it attached to the oxygen concentrator. The facility policy, Oxygen Administration failed to evidence documentation related to storing the oxygen equipment when not in use. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were made aware of the above findings on 4/12/2023 at 1:31 p.m. No further information was provided prior to exit. 3. For Resident #3 (R3), the facility staff failed to administer oxygen at the physician prescribed rate. On 4/11/2023 at 9:14 a.m. R3 was observed in bed with oxygen on via a nasal cannula. The oxygen concentrator was set at 1.5 LPM (liters per minute). A second observation was made on 4/12/2023 at 8:19 a.m., accompanied by LPN (licensed practical nurse) #2. The oxygen was in use via a nasal cannula. LPN #2 was asked to observe what rate the oxygen was set to. LPN #2 stated, it was somewhere around 1.5 (LPM). When asked if she knew what rate R3 was supposed to be on, LPN #2 stated, it should be 2 LPM. LPN #2 adjusted the rate to 2 LPM. The physician order dated, 1/16/2023 documented, Oxygen as needed PRN (as needed) via nasal cannula at 2 L.PRN to maintain SPO2 (oxygen saturation) if <(less than) 90%, humidified. The comprehensive care plan dated, 8/14/2022, documented in part, Focus: The resident has oxygen therapy r/t (related to) Respiratory illness. The Interventions documented in part, OXYGEN SETTINGS: O2 (oxygen) via nasal prongs @ (at) 2L (liters) PRN to maintain SPO2 (oxygen saturation) if <(less than) 90%, humidified. The facility policy, Oxygen Administration documented in part, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .Turn on the oxygen at the number of liters/minute as ordered by the physician/practitioner. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were made aware of the above findings on 4/12/2023 at 1:31 p.m. No further information was provided prior to exit. 4. For Resident #7 (R7), the facility failed to store oxygen tubing in a sanitary manner. On 4/10/2023 at approximately 12:45 p.m. the oxygen tubing was observed wrapped around the handlebars of the resident's rollator (walker), and had an oxygen tank attached to it. The oxygen was not in use. The tubing was dated 4/9/2023. The physician order dated, 11/11/2022, documented, 2 L (liters) oxygen as needed, PRN. The comprehensive care plan dated, 10/28/2022, documented in part, Focus: The resident has oxygen therapy r/t respiratory illness. The Interventions documented in part, OXYGEN SETTINGS: O2 via nasal prongs @ 2L continuous. Humidified. An interview was conducted with LPN (licensed practical nurse) #2, on 4/12/2023 at 8:11 a.m. When asked how oxygen tubing is to be stored when not in use, LPN #2 stated there is supposed to be a bag with the resident's name on it attached to the oxygen concentrator. When asked if it was acceptable to have the tubing wrapped around the resident's rollator, LPN #2 stated, no. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were made aware of the above findings on 4/12/2023 at 1:31 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide complete dialysis care and services for one of 32 residents in the survey sample, Resident #32. The findings include: For Resident #32 (R32), the facility staff failed to ensure adequate communication and collaboration for care with the resident's hemodialysis center. A review of R32's clinical record revealed a physician's order dated 2/15/22 for hemodialysis every Monday, Wednesday and Friday. R32's comprehensive care plan revised on 2/26/22 failed to document information regarding communication with the dialysis center. A review of R32's dialysis communication book (a book that contained communication forms to be completed by facility staff, sent with the resident to dialysis, and returned with documented communication from the dialysis center) failed to reveal any documented communication for the following dialysis days: 3/10/23, 3/13/23, 3/17/23, 3/22/23, 3/27/23, 3/29/23, 3/31/23 and 4/5/23. On 4/11/23 at 3:12 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated there should be a communication form completed for each day R32 goes to dialysis. LPN #2 stated she reviewed R32's dialysis communication book and, It looks like there is stuff missing. On 4/11/23 at 5:18 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern. The facility policy titled, End Stage Renal Disease - Care of Resident documented, 3. Agreements between this facility and the contracted ESRD (end stage renal disease) facility will include all aspects of how the resident's care will be managed including but not limited to: a. the development of a comprehensive and integrated care plan b. the communication process between the nursing facility and the dialysis center that will reflect ongoing communication, coordination, and collaboration .

Based on staff interview and facility document review, the facility staff failed to provide RN (registered nurse) coverage on three of 30 days reviewed. The findings include: A review of facility nursing schedules revealed there was no RN coverage on 3/11/23, 4/8/23 and 4/9/23. On 4/11/23 at 4:14 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated the facility is required to have eight hours of RN coverage each day, seven days a week, 365 days a year. ASM #2 stated there was only one other RN besides her, but she recently hired another RN. On 4/11/23 at 5:18 p.m., ASM #1, the administrator, and ASM #2 were made aware of the above concern. The facility policy titled, Department Duty Hours - Nursing Services documented, 7. Registered nurse hours will be eight consecutive hours per day; 7 days a week.

Based on resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure that medications were available for administration for three of 32 residents in the survey sample, Residents #262, #14, and #37. The findings include: 1. For R262, the facility staff failed to ensure medications were available for administration on 12/28/2021. R262 was admitted to the facility with diagnoses that included but were not limited to chronic obstructive pulmonary disease (1), hypertension and congestive heart failure (2). The eMAR (electronic medication administration record) for R262 dated 12/1/2021-12/31/2021 documented in part, - Metoclopramide HCL Solution 5mg/ml (milligram per milliliter) Use 5mg intravenously three times a day for before meals. Start Date: 12/28/2021 0900 (9:00 a.m.). The eMAR documented a 9 in the administration area for 12/28/2021 at 9:00 a.m., 1:00 p.m. and 5:00 p.m. The eMAR chart codes documented in part, .9= Other/See Nurse Notes . - Diltiazem HCL tablet 30mg Give 1 tablet by mouth three times a day for high blood pressure. Start Date: 12/28/2021 0900. The eMAR documented a 9 in the administration area for 12/28/2021 at 9:00 a.m., 1:00 p.m. and 5:00 p.m. - Tiotropium Bromide Monohydrate Aerosol Solution 2.5 mcg/act (micrograms) 2 puff inhale orally in the morning for COPD. Start Date: 12/28/2021 0600 (6:00 a.m.). The eMAR documented a 9 in the administration area for 12/28/2021 at 6:00 a.m. - Symbicort aerosol 160-4.5 mcg/act (Budesonide-Formoterol Fumarate) 2 puff inhale orally two times a day for COPD. Start Date: 12/28/2021 0900. The eMAR documented a 9 in the administration area for 12/28/2021 at 9:00 a.m. - acetazolamide tablet 125mg Give 1 tablet by mouth one time a day for fluid retention. Start Date: 12/28/2021 0900. The eMAR documented a 9 in the administration area for 12/28/2021 at 9:00 a.m. - Lexapro 10mg (Escitalopram Oxalate) Give 1 tablet by mouth in the afternoon for depression. Start Date: 12/28/2021 1300 (1:00 p.m.). The eMAR documented a 9 in the administration area for 12/28/2021 at 1:00 p.m. The nurses notes for R262 documented in part, - 12/28/2021 05:49 (5:49 a.m.) new resident waiting on meds from pharmacy. - 12/28/2021 15:32 (3:32 p.m.) med not avail (available)- waiting for delivery from pharm (pharmacy). - 12/28/2021 18:38 (6:38 p.m.) med not here yet. Should be coming in very shortly. - 12/28/2021 18:37 (6:38 p.m.) not given as med is not here and clarification of order needs to be done. The physician orders for R262 documented orders for the medications listed above entered on 12/27/2021 and scheduled to start on 12/28/2021. The discharge summary for R262 dated 12/27/2021 from [Name of hospital] documented in part, .Severe COPD with acute exacerbation in the setting of chronic COPD. Improved. To have scheduled albuterol MDI (metered dose inhaler), prn (as needed) albuterol nebs (nebulizers), Spiriva, Singulair and Symbicort .Discharge Medications: Medication list: Start taking these medications: .acetazolamide 125mg tablet commonly known as: Diamox, Take 1 tablet (125 mg total) by mouth daily. Start taking on: December 28, 2021 .tiotropium 2.5mcg/act inhalation spray Commonly known as: Spiriva respimat inhale 2 puffs into the lungs every morning. Start taking on: December 28, 2021 .Change how you take these medications: .budesonide-formoterol 160-4.5 mcg/act inhaler Commonly known as: Symbicort Dose: 2 puff Instructions: Inhale 2 puffs into the lungs 2 (two) times daily .Diltiazem 30mg tablet Commonly known as: Cardizem 30mg Instructions: Take 1 tablet (30mg total) by mouth 3 (three) times daily . On 4/11/2023 at approximately 5:00 p.m., ASM (administrative staff member) #1, the administrator stated that there were no nurses who worked at the facility in December 2021 that were currently employed at the facility, and the physician who cared for R262 no longer worked at the facility. On 4/12/2023 at 10:08 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that when a new resident was admitted to the facility they received the after visit summary from the admissions coordinator prior to the resident arriving. LPN #2 stated that the admissions coordinator worked with the hospital prior to the resident arriving to ensure that they had everything in place to care for the resident and they reviewed the discharge medications with the physician or nurse practitioner prior to the resident arriving and entered the orders into the computer for the pharmacy. LPN #2 stated that they had a flash meeting prior to the resident arriving with social services, admissions and therapy to prepare the room with any equipment the resident may need. LPN #2 stated that when transport arrived with the resident they provided the discharge summary which was compared to the after visit summary for any changes to the discharge medications. They notified the physician or nurse practitioner of any changes in the medications from the discharge summary and sent new orders to the pharmacy. LPN #2 stated that prior to January of 2023 they used another pharmacy which required the medications to be entered prior to 4:00 p.m. to get the medications the next morning. LPN #2 stated that when the medications were entered after 4:00 p.m. they were not received until the following day at midnight. LPN #2 stated that any medications that were needed urgently were called as stat to the pharmacy and they were delivered by a local pharmacy in about four hours. LPN #2 stated that the former pharmacy kept a stat box at the facility but it mostly contained antibiotics for them to use, and that the former pharmacy was slow getting inhalers to the facility and they would often have to get them sent from the local pharmacy or have the hospital send them with the resident at discharge. On 4/12/2023 at 12:44 p.m., an interview was conducted with ASM #3, nurse practitioner. ASM #3 stated that they expected for a resident to start getting their medications as soon as possible after admission to the facility. ASM #3 stated that they would expect any pertinent medications such as blood pressure medications and inhalers to be started by the next day after admission. ASM #3 stated that they would expect the nursing staff to inform them of a resident not receiving their medications due to it not arriving from the pharmacy and at times they were able to use an alternate from the stock medications. On 4/12/2023 at approximately 10:30 a.m., a request was made to ASM #1 for a listing of the medications available to staff in the stat box kept in the facility in December of 2021. On 4/12/2023 at approximately 1:00 p.m., ASM #1 stated that they were unable to get the list of medications that were available in the stat box in December of 2021 from the former pharmacy. The facility policy, Medication and Treatment Orders documented in part, .11. Drugs and biologicals that are required to be refilled will be reordered from the issuing pharmacy in a timely manner prior to the last dosage being administered to ensure that refills are readily available . The facility policy, General Guidelines for Medication Administration revised 8/2020 documented in part, .The facility has sufficient staff and a medication distribution system to ensure safe administration of medication without unnecessary interruptions .If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g., the resident is not in the facility at a scheduled time or a starter dose of an antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. If 3 consecutive doses, or in accordance with facility policy, of a vital medication are withheld, refused, or not available, the physician is notified. Nursing documents the notification and physician response. If an electronic MAR system is used, specific procedures required for resident identification, identification of medications due at specific times, and documentation of administration, refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the system's user manual . On 4/12/2023 at 1:29 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the findings. No further information was obtained prior to exit. Reference: (1) chronic obstructive pulmonary disease (COPD) Disease that makes it difficult to breathe that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. (2) congestive heart failure A condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. This information was obtained from the website: https://medlineplus.gov/heartfailure.html 2. For Resident #14 (R14), the facility staff failed to obtain and administer Lyrica, per the physician order. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/28/2022, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The physician order dated, 1/6/2023, documented, Lyrica Capsule (used to treat neuropathic pain) (1) 25 mg (milligram); Give 1 capsule by mouth at bedtime for neuropathic pain. The March 2023 MAR (medication administration record) documented the above order for Lyrica. A 9 was documented for the 9:00 p.m. dose on 3/9/2023 through 3/15/2023. A 9 indicated, Other/See nurse's notes. The nurse's notes for the above dates and 9:00 p.m. dose administration, documented, On order. Review of the (name of drug dispensing machine) contents was conducted however, the Lyrica was not listed as being in the machine. An interview was conducted with LPN (licensed practical nurse) #2, on 4/11/2023 at 3:14 p.m. When asked what the process was when a medication is not available at the time it is scheduled to be administered, LPN #2 stated the (name of pharmacy machine with medications in the building) is the best thing. It has many of the medications we need. If it's a narcotic, then you need two nurses to get it out of the machine. When asked if the medication is not available in the (name of machine), what should the nurse to do, LPN #2 stated you have to call the pharmacy to get it and notify the nurse practitioner that it is not here. When asked if Lyrica is in the machine, LPN #2 stated, no it is not. LPN #2 was shown where the Lyrica was not given on the above dates and the nurses documented, on order. LPN #2 stated she was not made aware of the unavailability of the Lyrica for R14. LPN #2 stated that sometimes it takes two days to get medications and even the stat (right away) medications can take up to 24 hours to get. A policy on Medication Administration and Medication Unavailability was requested. No policy was provided. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/11/2023 at 5:07 p.m. No further information was obtained prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a605045.html 3. For Resident #37 (R37), the facility staff failed to obtain and administer Lyrica, per the physician order. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/16/2023, the resident scored a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired for making daily decisions. An interview was conducted with R37 on 4/10/2023 at approximately 2:00 p.m. R37 stated the facility runs out of their Lyrica at times. The physician order dated, 2/10/2023, documented, Lyrica 75 mg; Give 1 capsule by mouth two times a day for neuropathy. The February 2023 MAR documented the above order. On 2/12/2023 and 2/13/2023 for the 9:00 a.m. and 9:00 p.m. doses a 9 was documented. On 2/14/2023 for the 9:00 a.m. dose a 9 was documented. A 9 indicates, Other/See nurse's notes. The nurse's notes for the dates and times with the 9 documented, documented On order. An interview was conducted with LPN (licensed practical nurse) #2, on 4/11/2023 at 3:14 p.m. When asked what the process was when a medication is not available at the time it is scheduled to be administered, LPN #2 stated the (name of pharmacy machine with medications in the building) is the best thing. It has many of the medications we need. If it's a narcotic, then you need two nurses to get it out of the machine. When asked if the medication is not available in the (name of machine), what should the nurse to do, LPN #2 stated you have to call the pharmacy to get it and notify the nurse practitioner that it is not here. When asked if Lyrica is in the machine, LPN #2 stated, no it is not. LPN #2 was shown where the Lyrica was not given on the above dates and the nurses documented, on order. LPN #2 stated she was not made aware of the unavailability of the Lyrica for R37. LPN #2 stated that sometimes it takes two days to get medications and even the stat (right away) medications can take up to 24 hours to get. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/11/2023 at 5:07 p.m. No further information was obtained prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to complete a monthly medication regimen review for three of 32 residents in the survey sample, Residents #25, #29, and #20. The findings include: 1. For Resident #25 (R25), the facility pharmacist did not complete a medication regimen review (MRR) in December 2022 or January 2023. A review of R25's clinical record failed to reveal evidence of an MRR in December 2022 and January 2023. On 4/11/23 at 5:07 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were informed of these concerns. ASM #1 stated: We just got a pharmacist. She stated the facility had undergone a change of ownership on 12/1/22, and lost their pharmacist. She stated the facility was without a pharmacist until February 2023. She stated she would check to make sure there were no MRRs for this resident in December 2022 and January 2023. On 4/12/23 at 9:24 a.m., ASM #1 stated: I couldn't find anything regarding a pharmacist until February [2023]. A review of the facility policy, Medication Regimen Review, revealed, in part: The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. No further information was received prior to exit. 2. For Resident #29 (R29), the facility pharmacist did not complete a medication regimen review (MRR) in December 2022 or January 2023. A review of R29's clinical record failed to reveal evidence of an MRR in December 2022 and January 2023. On 4/11/23 at 5:07 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were informed of these concerns. ASM #1 stated: We just got a pharmacist. She stated the facility had undergone a change of ownership on 12/1/22, and lost their pharmacist. She stated the facility was without a pharmacist until February 2023. She stated she would check to make sure there were no MRRs for this resident in December 2022 and January 2023. On 4/12/23 at 9:24 a.m., ASM #1 stated: I couldn't find anything regarding a pharmacist until February [2023]. No further information was received prior to exit. 3. For Resident #20 (R20), the facility pharmacist did not complete a medication regimen review (MRR) in January 2023. A review of R29's clinical record failed to reveal evidence of an MRR in January 2023. On 4/11/23 at 5:07 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were informed of these concerns. ASM #1 stated: We just got a pharmacist. She stated the facility had undergone a change of ownership on 12/1/22, and lost their pharmacist. She stated the facility was without a pharmacist until February 2023. She stated she would check to make sure there were no MRRs for this resident in and January 2023. On 4/12/23 at 9:24 a.m., ASM #1 stated: I couldn't find anything regarding a pharmacist until February [2023]. No further information was received prior to exit.

Based on staff interview and facility document review it was determined the facility staff failed to evidence infection tracking for 9 of 12 months reviewed. The findings include: The facility staff failed to evidence infection tracking for 4/1/2022 through 12/31/2022. On 4/11/2023 at approximately 11:30 a.m., a request was made to ASM (administrative staff member) #2, the director of nursing/infection preventionist, for the facility infection tracking logs for the past 12 months. On 4/12/2023 at approximately 8:40 a.m., LPN (licensed practical nurse) #2 provided a binder with infection tracking from 1/1/2023 through the present. LPN #2 stated that they were looking for the rest of the logs in the previous director of nursing's office files. On 4/12/2023 at 10:10 a.m., ASM #2 stated that they did not have any other tracking logs to provide. ASM #2 stated that the logs they had were the ones they had completed since they started working at the facility a few months back. ASM #2 stated that they were notified of new infections in their morning meetings, in chart reviews, and lab reviews. ASM #2 stated that they used the tracking sheets to locate residents and track any trends in infections. ASM #2 stated that they used the information to compile a monthly report which they reported in the QAPI (quality assurance performance improvement) meetings. The facility policy Infection Control Surveillance approved 6/15/2012 documented in part, .Surveillance refers to a system for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infections and detecting unusual pathogens with infection control implications. The ICP (infection control practitioner) coordinates the facilities infection surveillance using the [Name of facility] Infection Surveillance Log .The surveillance log should be completed monthly and managed through the QAPI process . On 4/12/2023 at 1:29 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the above concern. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview and facility document review it was determined that the facility staff failed to provide privacy for three of 35 residents in the survey sample, Resident #301, #33 and #47. Resident #301's urinary catheter bag was visible with urine in the bag from the hallway while the resident was in bed and was not covered with a privacy cover; Resident #33's protected health information was left open on the medication cart in the hallway and was visible to staff and or others passing by, during the medication administration observation; and facility staff failed to provide personal privacy for Resident #47 while she was receiving personal care on 9/7/21. The findings include: 1. On 9/7/2021 at approximately 12:47 p.m., an observation was made of Resident #301 in bed from the facility hallway. Resident #301 was observed lying in bed with a urinary catheter bag attached to the bedframe on the right side of the bed facing the hallway. Urine was observed in the catheter bag visible from the hallway. Additional observations on 9/7/2021 at 2:18 p.m., and 9/7/2021 at 4:33 p.m. revealed the urinary catheter bag hanging on the right side of the bed facing the hallway with urine visible in the bag from the hallway. On 9/8/2021 at 8:45 a.m., Resident #301 was observed in bed with a urinary catheter bag with a privacy cover hiding the contents of the bag from view. Resident #301 was admitted to the facility with diagnoses that included but were not limited to malignant neoplasm of the bladder (1) and paraplegia (2). Resident #301's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 9/2/2021, coded Resident #301 as scoring a 13 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 13- being cognitively intact for making daily decisions. Section H documented Resident #301 having an indwelling catheter. On 9/7/2021 at 4:33 p.m., an interview was conducted with Resident #301. Resident #301 stated that they were at the facility for therapy and short-term. Resident #301 stated that the nursing staff handled the urinary catheter bag and emptied it when needed. The physician's orders for Resident #301 documented in part, Flush suprapubic catheter (3) and Foley every 3 (three) hours with 50 ml (milliliter) of Normal Saline every 3 hours for mainance [sic]. Order Date: 08/28/2021. The orders further documented, Foley and Suprapubic catheter care every shift. Order Date: 08/28/2021. The progress notes for Resident #301 documented in part, 8/27/2021 21:33 (9:33 p.m.) [Resident #301] was admitted on [DATE] .Catheter is indwelling supra-pubic . The baseline care plan for Resident #301 dated 8/27/2021 documented in part, Altered elimination .Catheter care per policy . On 9/8/2021 at approximately 1:54 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated that they placed urinary catheter bags on the bed frame and made sure the bag had a privacy cover on it. CNA #1 stated that some residents were admitted from the hospital with urinary catheter bags that did not have privacy covers on them and the nurses changed them after they were admitted to the ones with privacy covers. CNA #1 stated that they did this so everyone could not see the contents in the bag and that the urinary catheter bag with urine inside should not be visible from the hallway. On 9/8/2021 at approximately 2:27 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that residents should have dignity bags for urinary catheters so that the contents could not be seen. LPN #1 stated that they should not be able to see the urine from the hallway. When asked about Resident #301's urinary catheter bag on 9/7/2021, LPN #1 stated that Resident #301 did not have a dignity bag but they had changed it to a dignity bag that morning so there would not be any further privacy concerns. On 9/9/2021 at approximately 10:30 a.m., a request was made to ASM #1 for the facility policy for care of urinary catheter bags and privacy. On 9/9/2021 at 3:48 p.m., ASM #1 provided via email, Catheter Care, Urinary dated 9/5/2017 which failed to evidence guidance on providing privacy for the urinary catheter bag contents. ASM #1 also provided the policy Notice of Privacy Practice dated 11/30/2014 which documented in part, .The facility is responsible to: Maintain the privacy of the resident health information . The facility policy Resident and Patient Rights dated 9/1/2017 documented in part, .It is the policy of The Company that all employees will conduct themselves in a professional manner at all times, respecting the rights of each resident or patient to privacy, personal care, self-respect and confidentiality . On 9/8/2021 at approximately 5:02 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional nurse were made aware of the findings. No further information was provided prior to exit. References: 1. Malignant neoplasm: refers to the presence of cancerous cells that have the ability to spread to other sites in the body (metastasize) or to invade nearby (locally) and destroy tissues. This information was obtained from the website: https://medlineplus.gov/ency/article/002253.htm. 2. Paraplegia: is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. Paralysis of the lower half of your body, including both legs, is called paraplegia. This information was obtained from the website: https://medlineplus.gov/paralysis.html 3. Suprapubic catheter: A suprapubic catheter (tube) drains urine from your bladder. It is inserted into your bladder through a small hole in your belly. This information is taken from the website https://medlineplus.gov/ency/patientinstructions/000145.htm. 2. On 9/7/2021 at approximately 4:55 p.m., an observation was made of LPN (licensed practical nurse) #3 administering medications at the facility. LPN #3 placed the medication cart in the hallway against the wall between the resident rooms. LPN #3 was observed preparing medications for administration to Resident #33. On 9/7/2021 at 5:07 p.m., LPN #3 entered Resident 33's room with the medications while leaving their laptop computer showing Resident #33's eMAR (electronic medication administration record) visible on the medication cart in the hallway. Another staff member was observed exiting Resident #33's room at that time, passing beside the medication cart. On 9/7/2021 at 5:11 p.m., LPN #3 exited Resident #33's room to obtain another medication and proceeded to enter the room with the eMAR still visible on the computer screen. On 9/7/2021 at 5:12 p.m., LPN #3 exited Resident #33's room and returned to the medication cart. Resident #33 was admitted to the facility with diagnoses that included but were not limited to chronic obstructive pulmonary disease (1) and dementia (2). Resident #33's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/6/2021, coded Resident #33 as scoring a 10 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 10- being moderately impaired for making daily decisions. On 9/7/2021 at approximately 5:14 p.m., an interview was conducted with LPN #3. LPN #3 stated that they normally locked the computer screen on their computer before they left the cart to go into the residents room. LPN #3 stated that they had forgotten to lock the computer screen and left the eMAR in view by mistake. On 9/8/2021 at approximately 5:02 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional nurse were made aware of the findings. No further information was provided prior to exit. References: 1. Chronic obstructive pulmonary disease (COPD) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 2. Dementia A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. 3. Resident #47 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including ESRD (end stage renal disease) (1), right and left above the knee amputations, and COPD (chronic obstructive pulmonary disease) (2). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/16/21, Resident #47 was coded as requiring the extensive assistance of one staff member for toileting. On 9/7/21 at 2:32 p.m., Resident #47 was observed lying in her bed. The privacy curtain between her bed and the door was pulled 3/4 of the way down the bed. The other two privacy curtains were open, allowing Resident #47 to be observed by her roommate and the surveyor. Resident #47 was receiving assistance to pull up her underwear after using the bedpan, from OSM (other staff member) #2, an occupational therapy assistant. Two subsequent attempts to interview Resident #47 were unsuccessful. On 9/8/21 at 1:35 p.m., OSM #2 was interviewed. When asked if she remembered her work with Resident #47 the day before, she stated she did. OSM #2 stated she had transferred Resident #47 back to bed because the resident wanted to use the bedpan. When asked if she remembered who was able to see Resident #47 as she was toileting and re-dressing, OSM #2 stated, You walked into the room as I was getting her pants back on. She stated when she first began working with Resident #47 yesterday, the roommate was not in the room. She stated she did not realize the roommate had entered the room. OSM #2 stated for the resident's personal privacy, she should have made sure all three privacy curtains were pulled, completely keeping Resident #47 out of anyone's view. On 9/8/21 at 5:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse, were informed of these concerns. No further information was provided prior to exit. REFERENCES: (1) End-stage kidney disease (ESKD) is the last stage of long-term (chronic) kidney disease. This is when your kidneys can no longer support your body's needs. End-stage kidney disease is also called end-stage renal disease (ESRD). This information is taken from the website https://medlineplus.gov/ency/article/000500.htm. (2) COPD, or chronic obstructive pulmonary disease, is a progressive disease that makes it hard to breathe. Progressive means the disease gets worse over time. COPD can cause coughing that produces large amounts of a slimy substance called mucus, wheezing, shortness of breath, chest tightness, and other symptoms. This information is taken from the website https://www.nhlbi.nih.gov/health-topics/copd.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide a clean and homelike environment for 2 of 35 residents in the survey sample; Residents #9 and #37. Resident #9's right and Resident #37's wheelchairs were not maintained in a condition of good repair. Resident #9's right wheelchair arm was observed with cracks in the vinyl material, and exposed foam in the cracks. The findings include: 1. Resident #9 was admitted to the facility on [DATE] and had the diagnoses of but not limited to Parkinson's disease, chronic kidney disease, dysphagia, lymphedema, high blood pressure, depression, dementia, heart failure, and osteoarthritis. The annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 6/22/21 coded Resident #9 as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing, hygiene and toileting; extensive assistance for dressing, transfers and bed mobility; as independent for eating; and as incontinent of bowel and bladder. On 09/07/21 5:22 PM during observations of Resident #9, the resident's right wheelchair arm was observed with cracks in the vinyl material, and exposed foam in the cracks. On 9/8/21 at 2:06 PM an interview was conducted with CNA #1 (Certified Nursing Assistant). She stated that when a resident's wheelchair is torn and requires maintenance, it should be written in the maintenance log at the nurse's station. A review of the maintenance log revealed that the last entry was dated 9/2/21 and there were no entries for Resident #9's torn wheelchair arm. On 9/8/21 at 4:18 PM an interview was conducted with OSM #4 (Other Staff Member) the Director of Maintenance. He stated that he was not aware of any issues with Resident #9's wheelchair arm rest and that it had not been documented in the log book. OSM #4 stated that the exposed foam absolutely cannot be cleaned and sanitized. A review of the facility policy Wheelchair Repairs - Non Electric Wheelchairs documented, Each resident requiring the use of a wheelchair will be provided the appropriate chair to maintain their highest level of functioning. All chairs will be maintained in safe operating condition. On 9/8/21 at approximately 5:00 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the interim Administrator, ASM #2 the interim Director of Nursing (DON) and ASM #3 the regional nurse, were made aware of the findings. No further information was provided by the end of the survey. 2. Resident #37 was admitted to the facility on [DATE] with the diagnoses of but not limited to stroke, dysphagia, diabetes, chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney disease, heart attack, depression, peripheral vascular disease, pacemaker, alcohol abuse, insomnia, and dementia. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/10/21 coded the resident as being cognitively impaired in ability to make daily life decisions. The resident was coded as requiring extensive assistance for bathing and dressing; limited assistance for transfers, bed mobility, toileting and hygiene; as independent for eating; and as continent of bowel and bladder. On 09/07/21 5:22 PM during observations of Resident #37, the resident's right wheelchair arm was observed with torn ripped vinyl, and exposed foam along the armrest. The top corners of the wheelchair backrest was also observed with torn vinyl and exposed foam. On 9/8/21 at 2:06 PM an interview was conducted with CNA #1 (Certified Nursing Assistant). She stated that when a resident's wheelchair is torn and requires maintenance, it should be written in the maintenance log at the nurse's station. A review of the maintenance log revealed that the last entry was dated 9/2/21 and there were no entries for Resident #9's torn wheelchair arm. On 9/8/21 at 4:18 PM an interview was conducted with OSM #4 (Other Staff Member) the Director of Maintenance. He stated that he was not aware of any current issues with Resident #37's wheelchair arm rest but that he has replaced it twice in the last 6 months, and most recently (approximately 3 weeks ago) repaired the breaks on Resident #37's wheelchair. OSM #4 stated that Resident #37 is hard on his wheelchair. He stated that the exposed foam absolutely cannot be cleaned and sanitized. On 9/8/21 at approximately 5:00 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the interim Administrator, ASM #2 the interim Director of Nursing (DON) and ASM #3 the regional nurse, were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview and clinical record review, it was determined that the facility staff failed to ensure written notification was provided to the ombudsman, the resident and the resident's representative (RP) for a facility/resident-initiated transfer for one of 35 residents in the survey sample, Residents #32. The facility staff failed to evidence that the ombudsman was notified and Resident # 14 and resident's representative were provided written notification of a resident-initiated transfer on 07/14/2021 for Resident # 32. The findings included: Resident # 32 was admitted to the facility with diagnoses included but were not limited to: fractured clavicle [bone that connects the shoulder to the breastplate], and low blood pressure. Resident # 32's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/04/2021, coded Resident # 32 as scoring a seven [7] on the brief interview for mental status (BIMS) of a score of 0 - 15, seven - being severely impaired of cognition for making daily decisions. The nurse's note for Resident # 32 dated 07/14/2021 at 4:34 p.m., documented, Nurse received X-ray results which showed displaced right clavicle fracture. Np [nurse practitioner] notified with orders to send to ER [emergency room] for further eval [evaluation]. RP [responsible party made aware. Review of the clinical record and the EHR (electronic health record) for Resident # 32 failed to evidence notification to the ombudsman and that a written notification was provided to the resident and resident's representative for Resident # 32's facility-initiated transfer on 07/14/2021. On 9/8/2021 at approximately 2:27 p.m., an interview was conducted with ASM [administrative staff member] # 1, the administrator. When asked about the documentation for the ombudsman notification and the written notification to Resident # 23 and Resident # 32's representative regarding the facility-initiated transfer on 07/14/2021, ASM # 1 stated that they were not completed because the staff knew the resident was being sent out and that they did not see a need for it. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide a bed hold policy to the resident or the resident's representative upon a transfer to the hospital for one of 35 residents in the survey sample, Residents # 32. The facility staff failed to provide Resident #32 and or the resident's representative with a copy of the bed hold policy prior to and or at the time of transfer to the hospital on [DATE]. The findings included: Resident # 32 was admitted to the facility with diagnoses included but were not limited to: fractured clavicle [bone that connects the shoulder to the breastplate], and low blood pressure. Resident # 32's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/04/2021, coded Resident # 32 as scoring a seven [7] on the brief interview for mental status (BIMS) of a score of 0 - 15, seven - being severely impaired of cognition for making daily decisions. The nurse's note for Resident # 32 dated 07/14/2021 at 4:34 p.m., documented, Nurse received X-ray results which showed displaced right clavicle fracture. Np [nurse practitioner] notified with orders to send to ER [emergency room] for further eval [evaluation]. RP [responsible party] made aware. Review of the clinical record and the EHR (electronic health record) for Resident # 32 failed to evidence documentation the a bed hold policy was provided to Resident # 32 or Resident # 32's responsible party in regard to the transfer to the hospital on [DATE]. On 9/8/2021 at approximately 2:27 p.m., an interview was conducted with ASM [administrative staff member] # 1, the administrator. When asked about documentation evidencing the bed hold policy was provided to Resident # 32 or Resident # 32's responsible party prior to and or at the time of transfer to the hospital on [DATE], ASM # 1 stated that it wasn't [provided] because the staff knew the resident was being sent out and that they did not see a need for it. The facility's policy Bed Hold documented in part, At the time of transfer to the hospital or therapeutic leave, the center will provide a copy of notification of bed hold. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident # 52 was admitted to the facility with diagnoses that included but were not limited to: high blood pressure, history of falling, and depression. Resident # 81's MDS (minimum data set) assessment, a discharge assessment with an ARD (assessment reference date) of 07/22/2021, coded Resident # 52 as 03 (three) - Acute hospital under section A2100 Discharge Status. The facility's Progress Notes dated 07/20/2021 documented in part, This SSD [social services department] spoke with resident about upcoming discharge. Resident states that she is ready to go home and feels that she and husband have developed a plan for safety when they discharge home. Resident will discharge home of 07/22/2021 with referral for home health to [Name of Home Health Agency]. On 09/08/2021 at 3:58 p.m., an interview was conducted with LPN #5 (Licensed Practical Nurse), the MDS nurse. She stated that it [A2100 Discharge Status on the MDS assessment] was coded in error. It should have been coded as a discharge to community. When asked if there was any policy or procedure she follows to complete the MDS assessments, LPN #5 stated that she was sure there was one somewhere. She did not identify the RAI manual. On 10/10/19 at approximately 4:10 p.m., ASM [administrative staff member] # 1, the administrator and ASM # 2, director of nursing and ASM # 3, regional nurse were made aware of the findings. No further information was provided prior to exit. Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure an accurate MDS (minimum data set) assessment for two of 35 residents in the survey sample; Residents #37 and #52. 1. The 8/10/21 quarterly MDS assessment for Resident #37 was not completed accurately regarding the coding of Section J1800 falls. The clinical record documented Resident #37 was found on the floor by staff on 6/8/21, and Section J1800 of the 8/10/21, quarterly MDS assessment coded the resident as having 0 falls, since admission/entry or reentry or the prior assessment. 2. The facility staff failed to accurately code Resident # 52's discharge status to community on the discharge MDS (minimum data set) assessment with an ARD (assessment reference date) of 07/22/2021. Instead, the resident's discharge was coded as Acute hospital. The findings include: 1. Resident #37 was admitted to the facility on [DATE] with the diagnoses of but not limited to stroke, dysphagia, diabetes, chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney disease, heart attack, depression, peripheral vascular disease, pacemaker, alcohol abuse, insomnia, and dementia. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/10/21 coded Resident #37 as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring extensive assistance for bathing and dressing; limited assistance for transfers, bed mobility, toileting and hygiene; independent for eating; and as continent of bowel and bladder. A review of the clinical record revealed a Change in Condition assessment dated [DATE] that documented, Found sitting on floor in room between w/c (wheelchair) and bed. States he was trying to get into w/c. Pants noted soaked with urine .No injuries noted. VSS (vital signs stable). A review of the clinical record revealed a nurse's note dated 6/10/21 that documented, S/p (status post) fall with no acute changes noted. Up to his wheelchair propel self up and down the hallways. Denied pain or discomfort. No concerns voiced this shift. Further review of the above quarterly MDS revealed that it was not accurately completed for Section J1800 Has the resident had any falls since admission/entry or reentry or the prior assessment . This question was coded as 0 (Code 0 for No and 1 for Yes). On 9/8/21 at 3:58 PM an interview was conducted with LPN #5 (Licensed Practical Nurse), the MDS nurse. She stated that it should be coded but was going to review it and see what happened with the coding. When asked if there was any policy or procedure she follows to complete the MDS, LPN #5 stated that she was sure there was one somewhere. She did not identify the RAI manual. A review of the facility policy MDS did not address the accuracy of an MDS. On 9/8/21 at approximately 5:00 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing (DON) and ASM #3 the regional nurse, were made aware of the findings. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to review and revise the comprehensive care plan for one of 35 residents in the survey sample; Resident #9. The facility staff failed to review and revise Resident #9's comprehensive care plan was to include and address the use of side rails. The findings include: Resident #9 was admitted to the facility on [DATE], with the diagnoses of but not limited to Parkinson's disease, chronic kidney disease, dysphagia, lymphedema, high blood pressure, depression, dementia, heart failure, and osteoarthritis. The annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 6/22/21 coded Resident #9 as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing, hygiene and toileting; extensive assistance for dressing, transfers and bed mobility; independent for eating; and as incontinent of bowel and bladder. On 09/07/21 5:22 PM during observations of Resident #9, the resident was observed in bed eating her dinner meal, and the half-length upper side rails on Resident #9's bed were up. A review of the clinical record revealed a Side Rail Evaluation dated 7/7/21. This assessment documented, Resident use the rails for assist. Risk and benefit explained and measurements completed. A review of Resident #9's comprehensive care plan failed to reveal any evidence that the resident was care planned for the use of side rails. On 9/8/21 at 3:58 PM an interview was conducted with LPN #5 (Licensed Practical Nurse), the MDS nurse. She stated that the purpose of the care plan was to direct resident care and set goals for resident care. LPN #5 stated that the use of side rails should be care planned. She stated that any nurse or the DON (Director of Nursing) can review and revise a care plan. When asked if there was any policy or procedure she follows regarding reviewing and revising care plans she stated that she was sure there was one somewhere. She did not identify the RAI manual. A review of the facility policy Plans of Care documented, Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA MDS assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental and psychosocial well-being. On 9/8/21 at approximately 5:00 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the interim Administrator, ASM #2 the interim Director of Nursing (DON) and ASM #3 the regional nurse, were made aware of the findings. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure professional standards for the administration of pain medications for one of 35 residents in the survey sample, Resident # 3. The facility staff failed to clarify physician orders for two prescribed as needed pain medications, Percocet and acetaminophen, to determine when and which medication should be administered. The findings include: Resident # 3 was admitted to the facility with diagnoses that include but not limited to: spinal stenosis [3] and osteoarthritis Resident # 3's most recent MDS (minimum data set), an admission assessment with an ARID (assessment reference date) of 06/10/2021, coded Resident # 3 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 3 as having frequent pain at a level of 4 [four] on a pain scale of zero to ten, with ten being the worse pain. The physician's order for Resident # 3 documented in part the following: • Percocet [Oxycodone-Acetaminophen] 5-325MG [milligram]. Give 1 [one] tablet by mouth every 12 hours as needed for pain. Oder Date: 7/12/2021. • Acetaminophen Tablet 325MG. Give 2 tablet by mouth every 4 [four] hours as needed for pain. Oder Date: 6/4/2021. Resident # 3's ear [electronic medication administration record] dated August 2021 documented the above physician's order for acetaminophen and Percocet. Further review of the eMAR documented the administration of acetaminophen on 08/14/2021 at 6:20 a.m. with pain level of six, Percocet on 08/14/2021 at 12:04 a.m. with pain level of seven and Percocet at 5:40 p.m. with pain level of six, acetaminophen on 08/16/2021 at 8:53 a.m. with pain level of two and Percocet at 1:30 p.m. for pain level of three, acetaminophen on 80/26/2021 at 10:36 a.m. with pain level of two and Percocet at 12:30 a.m. with pain level of seven, and Percocet at 9:16 p.m. with pain level of one. Resident # 3's eMAR [electronic medication administration record] dated September 2021 documented the above physician's orders for Percocet and acetaminophen. Further review of the eMAR documented the administration of acetaminophen on 09/03/2021 at11:25 p.m. with pain level of seven and Percocet at 2:41 p.m. with pain level of eight. On 09/09/2021 at 9:05 a.m., an interview was conducted with LPN [licensed practical nurse] # 4 regarding Resident # 3's prescribed as needed pain medication. LPN #4 reviewed the physician's orders for Resident # 3's as needed pain medications of acetaminophen and Percocet and the August and September eMARs. After completing the review, LPN # 4 was asked how staff determine which and when to administer each as needed pain medication to Resident # 3. LPN # 4 stated, [Resident # 3] requests which one she wants. When asked if this was the correct way to administer Resident # 3's as needed pain medications, LPN # 4 stated no. LPN # 4 stated, There are no parameters to tell me which pain medication to administer. When asked to describe the procedure that should be followed when they have two as needed pain medications without parameters LPN # 4 stated, Call the physician and get clarification. On 9/7/2021 at 5:47 p.m., ASM [administrative staff member] #1, administrator, stated that the facility used their policies and procedures and [NAME] as their standard of practice. According to Lippincott Manual of Nursing Practice, Eighth Edition: by [NAME] & [NAME], pg. 87 read: Nursing Alert: Unusual dosages or unfamiliar drugs should always be confirmed with the health care provider and pharmacist before administration. On pg. 15, the following is documented in part, Inappropriate Orders: 2. Although you cannot automatically follow an order you think is unsafe, you cannot just ignore a medical order, either. b. Call the attending physician, discuss your concerns with him, obtain appropriate .orders. c. Notify all involved medical and nursing personnel d. Document clearly. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit. References: [1] Oxycodone [percocet] is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html. [2] Used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of osteoarthritis (arthritis caused by the breakdown of the lining of the joints). This information was obtained from the website: https: https://medlineplus.gov/druginfo/meds/a681004.html. [3] A narrowing of the spinal column that causes pressure on the spinal cord, or narrowing of the openings (called neural foramina) where spinal nerves leave the spinal column. This information was obtained from the website: https://medlineplus.gov/ency/article/000441.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility document review, it was determined the facility staff failed to ensure physician ordered fluid restrictions were implemented and monitored per physicians orders for one of 35 residents in the survey sample, Resident # 44. The facility staff failed to ensure the amount of fluid Resident #44 received was monitored and within the physician prescribed fluid restriction amount of 1500 ml (milliliters). The findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: congestive heart failure ( CHF - abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys) (1), COPD (chronic obstructive pulmonary disease -general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (2) and dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation. (3). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/15/2021, coded the resident as scoring an 8 on the BIMS (brief interview for mental status) score, indicating Resident #44 was moderately impaired to moderately impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members for most of her activities of daily living except eating, which she was independent after set up assistance was provided. The physician order dated, 4/8/2021, documented in part, 1500 ml (milliliters) fluid restriction 260 ml per meal and 240 ml every shift for CHF. Review of the meal tickets for 9/8/2021, one full day for Resident #44 was conducted. The meal ticket documented the three meals. For breakfast, the resident received 8 ounces (equals 237 ml) of whole milk. The lunch meal documented, 4 oz. (ounces) of water and 4 oz. of iced tea (237 ml). The dinner meal documented 4 oz. (ounces) of water and 4 oz. of iced tea (237 ml). Review of the POC (point of care) documentation, recorded by the staff after meal intake, for August 2021 and September 2021, revealed no documentation of fluid intake for Resident #44. The medication administration record (MAR) for August 2021 was reviewed. The MAR documented the above physician order for 1500 ml (milliliters) fluid restriction. Of 93 possible entries for fluid consumption, there were only 82 documented entries. There was no total of liquids consumed for the day documented. On 8/15/2021 and 8/28/2021 for the day shift, a N/A (not applicable) was documented. On 8/18/2021 the total documented as consumed was 1640 ml. On 8/20/21 the total documented as consumed was 1700 ml. On 8/25/2021 the total documented as consumed was 2980 ml. The totals for the rest of the days in August 2021, documented 240 ml to 1240 ml. The MAR for September 2021 was reviewed. The MAR documented the above physician order for 1500 ml (milliliters) fluid restriction. There was no total of liquids consumed for the day documented. On 9/6/2021 for the night shift N/A was documented. The totals for the day documented 480 ml to 1240 ml. The nurse's note dated, 8/26/2021 at 1:06 p.m. documented in part, Resident with new order for chest x-ray for increased sob (shortness of breath) two views. Bumex (4), changed to two times a day. The comprehensive care plan dated, 7/18/2021, documented in part, Focus: (Resident #44) has congestive heart failure. The Interventions documented in part, Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of Congestive Heart Failure, dependent edema of legs and feet, periorbital edema, SOB (shortness of breath) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rate (tachycardia) lethargy and disorientation. The care plan further documented, dated, 2/3/2021, Focus: The resident has potential for fluid deficit r/t (related to) diuretic use. The Interventions documented in part, Monitor and document intake and output as per facility policy. An interview was conducted with LPN (licensed practical nurse) #1, on 9/8/2021 at 2:27 p.m. When asked how staff know how much fluid to give a resident on physician ordered fluid restrictions, LPN #1 stated the amount comes with the physician order. When asked where the total amount of fluids given for the day is documented, LPN #1 stated it's on the MAR or TAR (treatment administration record). When asked who monitors the fluid restriction, LPN #1 stated it (MAR or TAR) should have a place to put it in each shift. The CNA (certified nursing assistant) document fluids given. When a resident is on a fluid restriction, you normally know how much they had. The CNAs are with them more that we are. When asked why it is important to know the total amount of fluids given at the end of each day, LPN #1 stated it's to see if they went over their fluid restriction. When asked whose responsibility is it to monitor a fluid restriction, LPN #1 stated each nurse each shift should monitor it. They (the resident) has a specific number per shift they are allow, if they go over it they could go over it for the whole day. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 9/9/2021 at 8:48 a.m. When asked who is responsible for monitoring that a resident is maintaining their fluid restriction, ASM #2 stated it should be on the intake record. Would expect the nurse to record all the resident receives on their shift. It's up to the nurse to coordinate with the aide to document what intake the resident has had for their shift. Someone should be monitoring it. ASM #2 was informed of the above concern and shown the above documents. The facility policy, Fluid Restrictions documented in part, Policy: Residents receive adequate fluid intake within the limitations determined by the attending physician. Procedure: A written order will be obtained from the attending physician. The resident will have fluid restrictions calculated so that he/she can have intake on each shift based on resident preferences. In calculating intake per shift, keep in mind fluid required for resident to take medications and desired at mealtimes. Caregivers will be notified on limitations. Dietary will be notified that resident is on restricted fluids and fluids on the resident's tray will be calculated according to overall restrictions. The dietician will determine d the amount of fluid to be given with each meal. The amount of fluid per meal is translated into allowed beverages and entered on the tray cared for reach meal. The Care Planning Team will discuss the restrictions, and they will be included in the Care Plan. The dietician documents the allowed fluids in the medication record and provides a written breakdown of fluids to the nursing staff. Resident education will be provided on established limits and importance of adherence to the restrictions. The Attending physician will be notified of resident non-compliance. ASM #1, the administrator, ASM #2, and ASM #3, the regional nurse, were made aware of the above findings on 9/9/2021 at 11:14 a.m. No further information was obtained prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 138. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. (4) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=Bumex&_ga=2.204964112.1680204588.1631291755-1055126650.1631291755.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services consistent with professional standards of practice, to promote healing of a pressure injury for one of 35 residents in the survey sample, Resident #40. The facility staff failed to conduct a thorough initial assessment to include measurements of Resident #40's pressure injury upon discovery on 1/2/21, and failed to ensure ongoing assessments including measurements and staging until 2/1/2021. The findings include: Resident #40 was admitted to the facility on [DATE] with a recent readmission on [DATE], with diagnoses that included but were not limited to: dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.)(1), diabetes, COPD (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (2), schizophrenia (any of a group of mental disorders characterized by gross distortions of reality, withdrawal of thought, language, perception and emotional response) (3), and high blood pressure. The most recent MDS (minimum data set), a quarterly assessment, with an assessment reference date of 8/11/2021 coded the resident as scoring a 14 on the BIMS (brief interview for mental status) score, indicating she was capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members for all of her activities of daily living except eating in which she was independent after set up assistance was provided. In Section M - Skin Conditions, the resident was coded as having a Stage III pressure injury. (A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage III - Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.)(4). A physician order dated 12/15/2020 documented, Greers [NAME] three times a day to buttock. Review of the December 2020 TAR (treatment administration record) for Resident #40 documented the physician ordered Greers [NAME] was administered every day in December after the medication was ordered. The last Braden Scale (a scale to determine the likeness of developing a pressure injury) was dated 12/22/2020. The Braden Scale documented the resident was at low risk for developing a pressure injury. The Weekly Skin Integrity Review dated 12/24/2020 documented in part, Skin intact. A nurse's note dated, 1/2/2021 at 12:10 p.m. documented, New order for tx (treatment) to coccyx pressure injury noted possible stage 2. The Change in Condition form dated 1/2/2021 documented a check mark next to, Pressure ulcer/Pressure injury. Further review of the form failed to evidence documentation of the measurements of the area or any description of the area. A physician order dated 1/3/2021, documented, Desitin Paste; apply to wound on buttock twice a day, day and evening shift. Review of the January 2021, TAR for Resident #40 documented the physician ordered Desitin Paste was applied as ordered the entire month. Further review of the clinical record failed to evidence documentation of measurements of the wound on or around 1/2/2021. The first documentation of the wound was on 2/1/2021 on the Weekly Wound Report: Pressure Injury. The form documented the resident's name, visualized stage - 3, Measurements - 2x1x0.2 (2 centimeters [cm] in length, by 1 cm in width by 0.5 cm in depth), Location - sacrum. The nurse's notes dated 1/6/2021 at 9:36 p.m. documented in part, CNA (certified nursing assistant) reported to this nurse that she went in to resident's room to offer pericare since resident had not rung bell all shift to have brief changed (per resident's usual routine) and resident refused to allow CNA to check her brief or do pericare. Resident insisted she was dry and accused CNA of 'caller her a liar. The nurse's note dated 1/7/2021 at 12:09 p.m. documented, Pt (patient) is refusing to be changed at this time. The nurse's note dated 1/10/2021 at 2:48 p.m. documented, Pt refused CNAs to change her, pt states she is dry. The nurse's note dated 1/14/2021 at 12:59 p.m. documented, Patient refused shower and lunch, unable to redirect the pt. Educated pt. on importance of eating and taking a shower. Pt continues to refuse. The nurse's note dated 1/21/2021 at 11:33 a.m. documented, Pt refusing to have CNA change her at this time. Pt will not allow even be checked and stated to this write, 'I done (sic) even feel let I know if I'm wet. The comprehensive care plan dated 12/10/2018, documented in part, Focus: (Resident #40) has potential for impairment to skin integrity r/t (related to) fragile skin, incontinence, infection, diabetes, impaired mobility. The Interventions documented in part, Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration etc. to MD (medical doctor). The care plan, dated 2/3/2021, documented in part, (Resident #40) has a pressure injury on sacrum r/t hx (history of) ulcers, immobility, B&B (bowel and bladder) incontinence, refusal to be turned and repositioned, declining to get OOB (out of bed). The Interventions documented in part, Assess/record/ monitor wound healing per protocol. Resident refused to have air mattress placed on bed. On 9/7/2021 at 5:47 p.m., ASM [administrative staff member] #1, administrator, stated that the facility used their policies and procedures and [NAME] as their standard of practice. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 9/8/2021 at 1:37 p.m. The above documents were reviewed with ASM #2. When asked at what stage was the wound found at, ASM #2 stated it was found as a stage III on wound documents of 2/1/2021. When asked if a nurse finds something, such as a possible stage II pressure injury what is the process, ASM #2 stated the nurse should do a skin assessment, measure the wound, stage the wound or have someone look at it if they are not proficient in it, assess the wound is it a pressure injury or excoriation. They need to find out what it is and notify the doctor to get treatment orders. Observation was made of the wound on 9/8/2021 at 11:31 a.m. accompanied by LPN (licensed practical nurse) #4. The wound was cleansed with wound cleanser. LPN #4 measured the wound. The length was 3.5 cm (centimeters), the width was 2.0 cm, and the depth was 1.0 cm. LPN #4 stated the wound had 100% granulation tissue. An interview was conducted with LPN (licensed practical nurse) #6 on 9/8/2021 at 3:28 p.m. LPN #6 is the nurse who wrote the note of 1/2/2021. When asked if she was trained in wound care, LPN #6 stated she is trained in the basic dressing changes. When asked if she can stage a pressure injury, LPN #6 stated, Technically no, I need more training. LPN #6 was asked to explain what actions she took on 1/2/2021. LPN #6 stated when she found the area, she notified the doctor and management. She stated she had told the ADON (assistant director of nursing). [ADON no longer employed at facility]. LPN #6 stated she implemented the new orders from the physician. When asked if she measured the wound, LPN #6 stated she did not. When asked if she should have measured the wound, LPN #6 stated, she should have measured the wound. The facility policy, Pressure Injury Record documented, Policy: To document the presence of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter until the site is resolved. One site will be recorded per page. Procedure: 1. Residents will have a Pressure Injury Record completed for each skin impairment that is related to pressure. 2. [NAME] the pressure area on the body description identifying the site. 3. Enter the date. 4. Enter the stage of the pressure injury. 5. Enter the size of the pressure in jury - length x width x depth in centimeters. 6. Enter tissue type and color. 7. Enter the wound edges and drainage. 8. Enter the peri-wound information. 9. Licensed nurse to sigh the appropriate area. The Pressure Ulcer Treatment Quick Reference Guide by NPUAP states on page 8 concerning pressure ulcer assessment, Assess and accurately document physical characteristics such as location, Category/Stage, size, tissue type (s), wound bed and periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, necrotic tissue, odor, presence/absence of granulation tissue, and epithelialization. Page 10 of this reference states, Re-evaluate the pressure ulcer, the plan of care, and the individual if the pressure ulcer does not show progress toward healing within 2 weeks (or as expected given the individual's overall condition and ability to heal) . This information was obtained from: National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention and Treatment: Clinical Practice Guideline. [NAME], DC: National Pressure Ulcer Advisory Panel, Second edition published 2014. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse, were made aware of the above findings on 6/9/2021 at 11:14 a.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 522. (4) This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to provide appropriate services, and equipment, to maintain or improve mobility per the physicians order for one of 35 residents in the survey sample, Resident #15. The staff failed to apply Resident #15's physician ordered resting left hand splint on 9/7/21 and 9/8/21. The findings include: Resident #15 was admitted to the facility on [DATE], and most recently readmitted to the facility on [DATE], with diagnoses including cerebral palsy (1) and psychotic disorder (2). On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 7/6/21, Resident #15 was coded as being severely cognitively impaired for making daily decisions, having scored eight out of 15 on the BIMS (brief interview for mental status). She was coded as requiring extensive assistance of staff for all activities of daily living. She was coded as having functional limitations for range of motion on both left and right upper extremities. On the following dates and times, 9/7/21 at 12:36 p.m. and 1:59 p.m.; 9/8/21 at 8:46 a.m. and 10:42 a.m., Resident #15 was observed sitting in a wheelchair in her room. During all observations Resident #15 was not wearing a hand splint on her left hand. A review of Resident #15's clinical record revealed the following physician order dated 3/17/21: Pt (patient) to wear L (left) resting hand splint during the day, donned after breakfast and doffed before bed for pain management. Complete daily skin checks for s/s (signs/symptoms) skin breakdown. A review of Resident #15's comprehensive care plan, dated 11/12/18 and updated 5/5/21, revealed, in part: [Resident #15] has an ADL (activities of daily living) self-care performance deficit requiring extensive assist r/t Activity Intolerance, Cerebral Palsy, Fatigue, Limited Mobility .Hand splint as ordered. On 9/8/21 at 1:54 p.m., CNA (certified nursing assistant) #1 was interviewed. When asked how she knows what sorts of special devices a resident might need to wear, CNA #1 stated, It's usually on the chart. Or the nurse tells me. She stated she was not aware that Resident #15 needed a left hand splint. On 9/8/21 at 2:27 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the therapist usually informs the nursing staff of any devices needed to be worn by residents. She stated there is also usually an order. When asked if she was aware of any orders for Resident #15 for a left hand splint, she stated she was not. On 9/8/21 at 4:05 p.m., LPN #1 stated she had checked Resident #15's orders. She stated the computer software had not flagged the order as something that needed to be signed off by the nursing staff, so she was not aware of the order. She stated she would make a change in the electronic medical record to correct this error. On 9/8/21 at 5:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse, were informed of these concerns. A review of the facility policy, Contractures, Prevention revealed, in part: Some residents may have braces or splints to prevent or help release contractures - be sure to follow the physician's order regarding the schedule of when to put these on and when to remove them. No further information was provided prior to exit. REFERENCES: (1) Cerebral palsy is a group of disorders that affect a person's ability to move and to maintain balance and posture. This information is taken from the website https://medlineplus.gov/cerebralpalsy.html. (2) Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions. People with psychoses lose touch with reality. Two of the main symptoms are delusions and hallucinations. Delusions are false beliefs, such as thinking that someone is plotting against you or that the TV is sending you secret messages. Hallucinations are false perceptions, such as hearing, seeing, or feeling something that is not there. This information is taken from the website https://medlineplus.gov/psychoticdisorders.html.

Based on observation, staff interview, clinical record review, it was determined that facility staff failed to the implement assistive device safety measures to ensure an environment free of accident hazards for one of 35 residents in the survey sample, Resident #32. The facility staff failed to implement Resident #32's fall mat on 9/07/21, 9/08/21, and the morning of 9/09/21, per the comprehensive plan of care. The findings include: Resident # 32 was admitted to the facility with diagnoses included but were not limited to: fractured clavicle [bone that connects the shoulder to the breastplate], low blood pressure, muscle weakness and low blood pressure. Resident # 32's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/04/2021, coded Resident # 32 as scoring a seven [7] on the brief interview for mental status (BIMS) of a score of 0 - 15, seven - being severely impaired of cognition for making daily decisions. On 09/07/2021 at 5:00 p.m., an observation of Resident # 32's room revealed Resident # 32 lying in bed. Further observation failed to evidence fall mats on the floor on the right or left side of the bed. On 09/08/2021 at 2:25 a.m., an observation of Resident # 32's room revealed Resident # 32 lying in bed. Further observation failed to evidence fall mats on the floor on the right or left side of the bed. On 09/08/2021 at 2:25 p.m., an observation of Resident # 32's room revealed Resident # 32 lying in bed. Further observation failed to evidence fall mats on the floor on the right or left side of the bed. On 09/09/2021 at 8:20 a.m., an observation of Resident # 32's room revealed Resident # 32 lying in bed. Further observation failed to evidence fall mats on the floor on the right or left side of the bed. The comprehensive care plan for Resident # 32 dated 05/28/2021 documented in part, Focus: [Resident # 32] has had an actual fall with major injury r/t [related to] poor communication/comprehension, unsteady gait, weakness and debility. Under Interventions was documented in part, Bilateral floor mats at bedside. Date Initiated: 05/28/2021. On 09/09/2021 at 8:05 a.m., an interview was conducted with LPN [licensed practical nurse] # 3. After observing Resident # 32's room and reviewing Resident # 32's comprehensive care plan LPN # 3 acknowledged that there were no fall mats alongside Resident # 32's bed. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit.

Based on observation, staff interview, resident interview and facility document review it was determined facility staff failed to obtain informed consent for the use of bed rails for one of 35 residents in the survey sample, Resident #301. The facility staff failed to obtain an informed consent prior to the use of bed rails for Resident #301. The findings include: On 9/7/2021 at approximately 12:47 p.m., an observation was made of Resident #301 in bed. Resident #301 was observed lying in bed with an upper side rail in place and up on the right side of the bed. Additional observations on 9/7/2021 at 2:18 p.m., and 9/7/2021 at 4:33 p.m. revealed Resident #301 in bed with the upper side rail in place and up on the right side of the bed. Resident #301 was admitted to the facility with diagnoses that included but were not limited to malignant neoplasm of the bladder (1) and paraplegia (2). Resident #301's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 9/2/2021, coded Resident #301 as scoring a 13 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 13- being cognitively intact for making daily decisions. Section G coded Resident #301 requiring extensive assistance of one staff member for bed mobility, dressing and personal hygiene. On 9/7/2021 at 4:33 p.m., an interview was conducted with Resident #301. Resident #301 stated that they were at the facility for therapy and short-term. Resident #301 stated that they used the bed rail at times to hold onto when staff were providing care. The baseline care plan for Resident #301 dated 8/27/2021 failed to evidence documentation of the use of bed rails. The Side Rail Evaluation dated 8/28/2021 for Resident #301 documented in part, .Side rails recommended; Per surgeon, resident is not allowed to transfer or use his abdominal muscles. Abd (abdominal) binder in place. Assist x 1 (one person) with rolling to either side per PT (physical therapy). PT also recommends side rails on both sides . On 9/8/2021 at approximately 9:00 a.m., a request was made to ASM (administrative staff member) #1, the administrator for the signed consent for use of bed rails for Resident #301. On 9/8/2021 at approximately 1:00 p.m., ASM #1 provided the document, Side Rail Evaluation which failed to evidence an informed consent for the use of bed rails for Resident #301. On 9/8/2021 at approximately 1:30 p.m., a second request was made to ASM #1 for the consent for use for bed rails for Resident #301. On 9/8/2021 at approximately 2:27 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that they performed a side rail assessment on each resident prior to the use of bed rails. LPN #1 stated that they spoke with the resident or the responsible party and explained the risks and benefits of using bed rails prior to using them. LPN #1 stated that a consent was obtained and documented in the medical record for the use of bed rails. LPN #1 stated that they could get a verbal consent from the responsible party but they documented it on the paper form and had two staff witness the document. On 9/9/2021 at approximately 10:30 a.m., a request was made to ASM #1 for the facility policy for bed rails. On 9/9/2021 at 3:48 p.m., ASM #1 provided via email, Side Rail/Bed Rail dated 4/19/2018 which documented in part, The Center will attempt alternative interventions, and document in the medical record, prior to the use of side rail/bed rail .3. Obtain consent from the resident and/or resident representative . On 9/8/2021 at approximately 5:02 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional nurse were made aware of the findings. No further information was provided prior to exit. References: 1. Malignant neoplasm: The term malignancy refers to the presence of cancerous cells that have the ability to spread to other sites in the body (metastasize) or to invade nearby (locally) and destroy tissues. This information was obtained from the website: https://medlineplus.gov/ency/article/002253.htm. 2. Paraplegia: Paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. Paralysis of the lower half of your body, including both legs, is called paraplegia. This information was obtained from the website: https://medlineplus.gov/paralysis.html 3. Suprapubic catheter: A suprapubic catheter (tube) drains urine from your bladder. It is inserted into your bladder through a small hole in your belly. This information is taken from the website https://medlineplus.gov/ency/patientinstructions/000145.htm.

Based on staff interview and facility document review, it was determined that the facility staff failed to ensure that two of 2 nurse aid records reviewed had received required annual competencies, (CNA [certified nursing assistant] #1 and CNA #2). CNA #1 was hired 9/12/1988 and CNA #2 hired 7/16/2019, and neither CNA had annual training and competency evaluations completed. The findings include: Upon entrance on 9/8/21 at approximately 11:45 AM, an Entrance Conference form was provided to the interim Administrator (ASM #1 - Administrative Staff Member). One document on this form was a request for a list of all current CNA (Certified Nursing Assistant) staff who had been employed at the facility for longer than one year. The list provided contained 2 CNA's that had been employed longer than a year and was still employed at the facility (CNA #1 was hired 9/12/1988 and CNA #2 hired 7/16/2019). A request was made for both CNA's #1 and #2 annual training and competency evaluations. On 9/09/21 at 9:51 AM, in an interview with ASM #1, he stated that there were no competencies because of COVID and that there was not an HR (Human Resources) person for 4 months. A review of the facility policy Employee Job Performance Evaluations documented, It is the policy of The Company to evaluate each employee's job performance on a continual and ongoing basis. Employees will receive an evaluation of their performance prior to the completion of their Introductory Period and annually thereafter. On 9/9/21 at approximately 11:10 AM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the interim Administrator, ASM #2 the interim Director of Nursing (DON) and ASM #3 the regional nurse, were made aware of the findings. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and in the course of a complaint investigation, it was determined facility staff failed to remove and discard of expired medications in one of one facility medications rooms and failed to provide pharmacy services for one of 35 residents in the survey sample, Resident # 101. 1. Expired Preservision eye vitamin mineral supplement soft gels with an expiration date of July 2021 were available for resident administration in the one facility medication room. 2. The facility staff failed to ensure Resident #101's physician ordered medication, Meropenem 500 mg (milligrams) every 8 hours for pneumonia for 10 days, was available and administered intravenously as prescribed on 1/11/2021 at 10:00 p.m. The findings include: 1. On 9/7/2021 at approximately 4:49 p.m., an inspection of the facility medication room was conducted with LPN (licensed practical nurse) #3. An unopened bottle of 120 preservision eye vitamin mineral supplements was observed on the bottom shelf stored with other house stock medications. The date 2021-07 was observed on the box. On 9/7/2021 at approximately 4:55 p.m., an interview was conducted with LPN #3. When asked what the date on the box of Preservision eye vitamin mineral supplements meant, LPN #3 stated that it meant they expired July of 2021 and should not have been on the shelf. LPN #3 stated that the medication was available for use and removed the box from the shelf. LPN #3 placed the medication in a pharmacy bag and stated that it would be returned to the pharmacy. LPN #3 stated that they checked the dates on the medications when they removed them from the medication room but the medication should have been found during routine checks by staff and pharmacy. On 9/9/2021 at approximately 10:30 a.m., a request was made to ASM (administrative staff member) #1, the administrator for the facility policy for disposal of expired medications. On 9/9/2021 at 3:48 p.m., ASM #1 provided via email, Disposal/Destruction of Expired or Discontinued Medication dated 12/01/07 which documented in part, .Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction . On 9/8/2021 at approximately 5:02 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional nurse was made aware of the findings. No further information was provided prior to exit. 2. Resident #101 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to: COVID, pneumonia (An infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia) (1), high blood pressure, history of breast cancer, anemia (condition in which the hemoglobin content of the blood is below normal limits) (2), depression and pancreatitis (inflammation of the pancreas) (3). The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/1/2021, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance of one staff member for all of her activities of daily living except eating in which she was coded ad being independent after set up assistance was provided. A physician order dated, 1/11/2021, documented, Meropenem Solution Reconstituted (used to treat skin and abdominal infections caused by bacteria and meningitis) (4) 500 mg (milligrams); use 500 mg intravenously every 8 hours for pneumonia for 10 days. The MAR (medication administration record) for January 2021, documented the above order. On 1/11/2021 at 10:00 p.m. a 9 was documented in the block for administration. The Code at the bottom of the MAR indicated a 9 is other/see nurse's notes. The nurse's note dated, 1/11/2021 at 10:00 p.m. documented, Hasn't arrived from pharmacy. An interview was conducted with LPN (licensed practical nurse) #1 on 9/8/2021 at 2:27 p.m. When asked how the medications arrive at the facility for a new admission, LPN #1 stated they go by the discharge summary, verify the orders with the physician and then fax them to the pharmacy. If we get the orders in by 2:00 p.m. the medications will come on the 8:00 - 9:00 p.m. run. Some medications can be pulled from the Stat box. Some medications don't come until the next day. Especially those that are once a day medications. The nurse's that signed the MAR that the resident did not receive her medications were no longer employed at the facility and unavailable for interview. The MARs were reviewed with ASM #2, the director of nursing, who was not at the facility at the time of this resident's admission, on 9/9/2021 at approximately 10:00 a.m. ASM #2 stated she could not tell why the medications were not given as there is no documentation but the medication were not given for whatever reason. ASM #2 stated the nurses are not filling out the notes in the computer related to not giving a medication. No other information was provided. Complaint Deficiency References: (1) This information was obtained from the following website: https://search.cdc.gov/search/index.html?query=COVID+-+19+definition&sitelimit=&utf8=%E2%9C%93&affiliate=cdc-main#content (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 33. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 432. (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a696038.html

Based on observation, staff interview and facility document review it was determined that the facility staff failed to secure medications properly on one of three facility medication carts, the medication cart on the Blue unit. The facility staff failed to lock the medication cart on the Blue unit when the cart was out of the line of sight of the nurse. The findings include: On 9/7/2021 at approximately 4:55 p.m., an observation was made of LPN (licensed practical nurse) #3 administering medications at the facility. LPN #3 placed the medication cart in the hallway against the wall between the resident rooms. LPN #3 was observed preparing medications, including two bottles containing eye drops to administer to a resident. On 9/7/2021 at 5:07 p.m., LPN #3 entered the residents room with the medications while leaving one bottle of eye drops on top of the medication cart. Another staff member was observed exiting the residents room at that time, passing beside the medication cart. On 9/7/2021 at 5:11 p.m., LPN #3 exited the residents room to obtain the bottle with the eye drops from the top of the medication cart and placed the other bottle of eye drops on the top of the medication cart. On 9/7/2021 at 5:12 p.m., LPN #3 exited Resident #33's room and returned to the medication cart. On 9/7/2021 at approximately 5:14 p.m., an interview was conducted with LPN #3. LPN #3 stated that they normally locked all medications in the cart when they left the cart unattended but did not have enough hands to hold everything and had left one bottle on top of the cart until they administered the first eye drop. LPN #3 stated that leaving the medication on top of the cart was not secured because anyone passing by could pick it up. On 9/9/2021 at approximately 10:30 a.m., a request was made to ASM (administrative staff member) #1, the administrator for the facility policy for securing medications. On 9/9/2021 at 3:48 p.m., ASM #1 provided via email, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles dated 12/1/07 which documented in part, .Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors . On 9/8/2021 at approximately 5:02 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional nurse were made aware of the findings. No further information was provided prior to exit. References: 1. Chronic obstructive pulmonary disease (COPD) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 2. Dementia A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm.

Based on observation, staff interview, facility document review and in the course of a complaint investigation, it was determined the facility staff failed to serve food at temperatures that were palatable for meal enjoyment during the evening meal. The findings include: Observation was made of the kitchen during the evening meal tray line on 9/7/2021 at 4:45 p.m. The following foods were at the documented temperatures that were obtained by facility staff using a facility thermometer: Potato wedges - 181.1 degrees Mixed Vegetables - 202.6 Corn flake chicken - 157.4 Ground chicken - 181.1 Puree chicken - 199 Mashed potatoes - 201.2 Puree vegetables - 194 Baked chicken for renal diets - 171.5 Chicken gravy - 188 Cheese Ravioli - 171.3 Mechanical renal chicken - 182.3 Coffee was taken from under the steam table and placed on individual trays. The coffee was not temped prior to being placed on the trays. A test tray was prepared at the end of the tray line. The fourth hall cart was observed. All trays were distributed. At 5:50 p.m., the test tray was taken to the dining room where the temperatures were taken and food tasted by OSM (other staff member) # 6, the dietary manager in training, and two surveyors. The food tasted good. The potato wedges were tasted and found to be cold. The temperature of the wedges was obtained by OSM #6, and was 119 at the time. OSM #6 stated it tasted like cold french fries. The coffee temperature was tested by OSM #6 and read 109 degrees. The coffee was tasted and was not warm. The facility policy, Food: Quality and Palatability documented in part ,Policy Statement: It is the center policy that, food is prepared by methods that conserve nutritive value, flavor and appearance. Food is palatable, attractive and served at the proper temperatures. The facility policy, Food Preparation documented in part, The Dining Services Director/Cook will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees and/or less that 135 degrees, or per state regulation .All foods will be held at appropriate temperatures, greater than 135 degrees F (Fahrenheit) for hot holding, and less that 41 degrees F for cold food holding. Temperature for TCS (temperature control safety) foods will be recorded at time of service, and monitored periodically during meal service periods. ASM (administrative staff member) #1, the administrator, ASM #2 the director of nursing and ASM #3, the regional nurse, were made aware of the above concerns on 9/8/2021 at 5:10 p.m. No further information was obtained prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, and during the course of a complaint investigation, it was determined the facility staff failed to maintain a complete and accurate clinical record for one of 35 residents in the survey sample, Resident # 101. Resident #101's January MAR (medication administration record) documented see nurses note on 1/27/21 and 1/28/21, beside the physician ordered medication Flovent. Review of the January 2021, nurses notes for Resident #101 failed to evidence any documentation related to the use of the Flovent. The findings include: Resident #101 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to: COVID, pneumonia (An infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia) (1), high blood pressure, history of breast cancer, anemia (condition in which the hemoglobin content of the blood is below normal limits) (2), depression and pancreatitis (inflammation of the pancreas) (3). The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/1/2021, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance of one staff member for all of her activities of daily living except eating in which she was independent after set up assistance was provided. The physician order dated 1/26/2021 documented, Flovent HFA Aerosol (used to prevent difficulty breathing, chest tightness, wheezing, and coughing caused by asthma in adults and children.) (4) 220 MG/ACT - 2 puffs inhale orally two times a day related to acute respiratory distress syndrome. The January 2021 MAR (medication administration record) documented the above order for Flovent. The MAR documented for 1/27/2021 and 1/28/2021 - see nurse's note. Review of the nurse's notes failed to evidence any documentation related to the use of the Flovent. The nurse's that signed off the above medications were no longer employed at the facility and were unavailable for interview. An interview was conducted with LPN (licensed practical nurse) #1 on 9/8/2021 at 2:27 p.m. When asked how the medications arrive at the facility for a new admission, LPN #1 stated they go by the discharge summary, verify the orders with the physician and then fax them to the pharmacy. If we get the orders in by 2:00 p.m. the medications will come on the 8:00 - 9:00 p.m. run. Some medications can be pulled from the Stat box. Some medications don't come until the next day. Especially those that are once a day medications. The MARs were reviewed with ASM #2, the director of nursing, who was not at the facility at the time of this resident's admission, on 9/9/2021 at approximately 10:00 a.m. ASM #2 stated she could not tell why the medications were not given as there is no documentation but the medication were not given for whatever reason. ASM #2 stated the nurses are not filling out the notes in the computer related to not giving a medication. Complaint Deficiency References: (1) This information was obtained from the following website: https://search.cdc.gov/search/index.html?query=COVID+-+19+definition&sitelimit=&utf8=%E2%9C%93&affiliate=cdc-main#content (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 33. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 432. (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a601056.html

Based on staff interview and facility document review, it was determined that the facility staff failed to maintain an effective Quality Assurance program. The findings include: On 09/09/2021 at approximately 11:00 a.m., a review of the facility's QAPI [quality assurance performance improving] Meeting sign-in sheets dated January 2021 through March 2021 failed to evidence the signature of the facility's medical director. On 09/09/2021 at approximately 11:28 a.m., an interview was conducted with ASM [administrative staff member] # 1, administrator, regarding the missing signature of the medical director for the date listed above. When asked about the missing signature of the facility's medical director ASM # 1 stated that they did not have any evidence that they had attended. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review it was determined that the facility staff failed ensure the required documentation and information was provided to the receiving provider, upon facility-initiated transfers for five of 35 residents in the survey sample. Residents #39, #18, #26, #13 and #32. The facility staff failed to evidence what if any required documentation was provided to the receiving facility for a facility-initiated transfers of Resident #39 on 8/2/2021, and Resident #18 on 6/18/2021. The staff failed to evidence the comprehensive care plan goals were provided to the receiving facility for a facility-initiated transfers of Resident #26 on 7/22/21, Resident #13 on 5/10/2021 and 5/26/2021, and Resident #32 on 7/14/21. The findings include: 1. Resident #39 was admitted to the facility with diagnoses that included but were not limited to pneumonia (1) and end stage renal disease (2). Resident #39's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 8/11/2021, coded Resident #39 as scoring a 10 on the brief interview for mental status (BIMS) of a score of 0 - 15, 10 - being moderately impaired for making daily decisions. The progress notes for Resident #39 documented in part, 8/2/2021 09:12 (9:12 a.m.) Nursing progress note. NP (nurse practitioner) requests to send patient to [Name of hospital] ER (emergency room) for AMS (altered mental status), dusky color, facial swelling, and cough. Chest xray obtained yesterday showed CHF (congestive heart failure). Patient stated he was feeling too bad to go to dialysis today. BS (blood sugar) checked 152. Pt (patient) refused to eat breakfast. VS (vital signs) 119/79 (blood pressure), 97.8 (temperature), 92 (pulse), 93% RA (oxygen saturation on room air), 24 (respirations). Patient currently on Augmentin (antibiotic) for cough. Family notified. The clinical record failed to evidence documentation of information provided to the hospital on 8/2/2021. On 9/8/2021 at approximately 2:27 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that when a resident was sent to the hospital they completed a transfer form, a SBAR (situation, background, assessment, response), contact the family, set up transport or called 911. LPN #1 stated that they sent the residents orders, a face sheet, the transfer form and the care plan if it coordinated with why they were going to the hospital. LPN #1 stated that they did not always send the care plan with the resident unless it applied to the reason they were being sent. LPN #1 stated that they documented this information in a progress note to evidence what was sent. LPN #1 stated that if there was no progress note or transfer form they could not evidence what information was provided to the receiving facility. LPN #1 stated that they had sent Resident #39 out to the emergency room on 8/2/2021 and thought they had completed a transfer form, SBAR and documented what was sent to the hospital but did not see it in the medical record. On 9/9/2021 at approximately 10:30 a.m., a request was made to ASM #1 for the facility policy for transfers and discharges. On 9/9/2021 at 3:48 p.m., ASM #1 provided via email, Transfer/Discharge Notification & Right to Appeal dated 3/26/2018, which documented in part, .Information provided to the receiving provider must include but is not limited to: Contact information of the practitioner responsible for care of the resident; Resident representative information including contact information; Advance Directives; Special care instructions or precautions for ongoing care as indicated; Comprehensive care plan goals; All other necessary information, including copies of the resident's discharge summary and other documentation, as applicable to ensure safe and effective transition of care . On 9/8/2021 at approximately 5:02 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional nurse was made aware of the findings. No further information was provided prior to exit. References: 1. Pneumonia: An infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia. You can also get pneumonia by inhaling a liquid or chemical. This information was obtained from the website: <https://medlineplus.gov/pneumonia.html> 2. End-stage kidney disease: The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/000500.htm. 2. Resident #18 was admitted to the facility with diagnoses that included but were not limited to chronic obstructive pulmonary disease (1) and dysphagia (2). Resident #18's most recent MDS (minimum data set) assessment, a significant change assessment with an ARD (assessment reference date) of 7/9/2021, coded Resident #18 as scoring a 13 on the brief interview for mental status (BIMS) of a score of 0 - 15, 13 - being cognitively intact for making daily decisions. The progress notes for Resident #18 documented in part, 6/18/2021 12:47 (12:47 p.m.) Nursing progress note. [Name of nurse practitioner] in to see resident with new orders to draw Amylase and Lipase (laboratory test) on next day lab [laboratory] r/t (related to) jaundice (3). RP (responsible party) aware. The Change in Condition (SBAR) (situation, background, assessment, response) for Resident #18 dated 6/18/2021 documented in part, .critical total bilirubin of 13.1; Primary Care Clinician Notified: [Name of nurse practitioner], Date/Time notified: 06/18/2021 18:00 (6:00 p.m.); Recommendations of Primary Clinician: Send to ER (emergency room) . The physician orders for Resident #18 documented in part, 6/18/2021 17:59 (5:59 p.m.) send to ER for critical bilirubin/possible obstruction . The clinical record for Resident #18, failed to evidence documentation of what if any information that was provided to the hospital on 6/18/2021. On 9/8/2021 at approximately 2:27 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that when a resident was sent to the hospital they completed a transfer form, a SBAR (situation, background, assessment, response), contacted the family, set up transport or called 911. LPN #1 stated that they sent the residents orders, a face sheet, the transfer form and the care plan if it coordinated with why they were going to the hospital. LPN #1 stated that they did not always send the care plan with the resident unless it applied to the reason they were being sent. LPN #1 stated that they documented this information in a progress note to evidence what was sent. LPN #1 stated that if there was no progress note or transfer form they could not evidence what information was provided to the receiving facility. On 9/8/2021 at approximately 5:02 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional nurse was made aware of the findings. No further information was provided prior to exit. References: 1. Chronic obstructive pulmonary disease (COPD): Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 2. Dysphagia: A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. 3. Jaundice: causes your skin and the whites of your eyes to turn yellow. Too much bilirubin causes jaundice. Bilirubin is a yellow chemical in hemoglobin, the substance that carries oxygen in your red blood cells. As red blood cells break down, your body builds new cells to replace them. The old ones are processed by the liver. If the liver cannot handle the blood cells as they break down, bilirubin builds up in the body and your skin may look yellow. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=jaundice&_ga=2.78999444.126298920.1631308167-1838772440.1562936034 5. Resident # 32 was admitted to the facility with diagnoses included but were not limited to: fractured clavicle [bone that connects the shoulder to the breastplate], and low blood pressure. Resident # 32's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/04/2021, coded Resident # 32 as scoring a seven [7] on the brief interview for mental status (BIMS) of a score of 0 - 15, seven - being severely impaired of cognition for making daily decisions. The nurse's note for Resident # 32 dated 07/14/2021 at 4:34 p.m., documented, Nurse received X-ray results which showed displaced right clavicle fracture. Np [nurse practitioner] notified with orders to send to ER [emergency room] for further eval [evaluation]. RP [responsible party] made aware. Review of the EHR [electronic health record] and the paper clinical record for Resident # 32 failed to evidence that the comprehensive care plan goals were sent to the receiving facility at the time of Resident # 32's resident-initiated transfer on 07/14/2021. On 9/8/2021 at approximately 2:27 p.m., an interview was conducted with LPN (licensed practical nurse) # 1. LPN # 1 stated that residents transferred to the hospital were sent with the physician orders, a face sheet, a transfer form and the care plan if it applied to the transfer. LPN # 1 stated that they did not always send the care plan with the resident unless it applied to the reason they were being sent. LPN # 1 stated that they documented this information in a progress note to evidence what was sent. LPN # 1 stated that if there was no progress note or transfer form they could not evidence what information was provided to the receiving facility. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit. 3. Resident #26 was admitted to the facility on [DATE] with a recent readmission of 12/14/2020 with diagnoses that included but were not limited to: stroke (1), dysphagia (2), and sepsis (your body's overactive and extreme response to an infection) (3). The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 8/4/2021, coded Resident #26 as scoring a 6 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions In Section O - Special Treatments, Procedures and Programs, the resident was coded as receiving hospice care while a resident at the facility. The nurse's note dated 7/22/2021 at 2:52 p.m. documented in part, Upon starting my shift, it was reported to this nurse that resident was unresponsive and had been since about noon. It was reported also that resident had been running a fever of over 101 and that on call DR (doctor) and family had been notified. Dr . orders for 1 L (liter) of fluid to be run via IV (intravenously) and STAT (immediately) labs (laboratory tests) were drawn by day nurse .Lab results later arrived and . was notified. WBC (white blood cell) count very high and NP suggested calling the family to see if they wanted comfort care or for resident to be sent to the ER (emergency room). Family notified and requested resident to be sent to the ER for treatment. 911 called and took resident to the ER around 2230 (10:30 p.m.). Review of the clinical record failed to evidence a transfer form or documentation that the comprehensive care plan goals were sent with the resident and provided to the receiving hospital on 7/22/21. On 9/8/2021 at approximately 2:27 p.m., an interview was conducted with LPN (licensed practical nurse) # 1. LPN #1 stated that residents transferred to the hospital were sent with the physician orders, a face sheet, a transfer form and the care plan if it applied to the transfer. LPN #1 stated that they did not always send the care plan with the resident unless it applied to the reason they were being sent. LPN #1 stated that they documented this information in a progress note to evidence what was sent. LPN # 1 stated that if there was no progress note or transfer form they could not evidence what information was provided to the receiving facility. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse, were made aware of the above finding on 9/9/2021 at 11:14 a.m. No further information was provided prior to exit. References: (1) Stroke: abnormal condition in which hemorrhage or blockage of the blood vessels of the brain leads to oxygen lack and resulting symptoms - sudden loss of ability to move a body part [as an arm or parts of the face], or to speak, paralysis weakness or if severe, death. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 114. (2) Dysphagia: a condition in which swallowing is difficult or painful due to obstruction of the esophagus or muscular abnormalities of the esophagus or pharynx. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 178. (3) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=Sepsis&_ga=2.155403059.908502701.1629920181-1530802455.1629920181 4. Resident #13 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to: dementia (1), high blood pressure, and kidney stones. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/30/2021 coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident is capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members for most of her activities of daily living. Review of the clinical record revealed the following: A Transfer Form dated 5/10/2021, which documented, reason for transfer, Unable to move from the neck down and stating she cannot see. A Transfer Form dated 5/26/2021, which documented, reason for transfer, Severe RLQ (right lower quadrant) pain. Further review of the clinical record failed to evidence any nurse's notes addressing the transfers of Resident #13 5/10/2021 and 5/26/2021, as documented above. Further review of the clinical record failed to evidence documentation that the comprehensive care plan goals were sent to the hospital with the resident upon transfer on 5/10/2021 and 5/26/2021. On 9/8/2021 at approximately 2:27 p.m., an interview was conducted with LPN (licensed practical nurse) # 1. LPN #1 stated that residents transferred to the hospital were sent with the physician orders, a face sheet, a transfer form and the care plan if it applied to the transfer. LPN #1 stated that they did not always send the care plan with the resident unless it applied to the reason they were being sent. LPN #1 stated that they documented this information in a progress note to evidence what was sent. LPN # 1 stated that if there was no progress note or transfer form they could not evidence what information was provided to the receiving facility. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse, were made aware of the above finding on 9/9/2021 at 11:14 a.m. No further information was provided prior to exit. (1) Dementia: a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10. The facility staff failed to develop a comprehensive care plan for Resident #25, who was admitted to the facility on [DATE]. Resident #25 was admitted to the facility with diagnoses that included but were not limited to cerebral infarction (1), diabetes (2) and heart failure (3). Resident #25's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/4/2021, coded Resident #25 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Section G coded Resident #25 requiring extensive assistance of two or more staff for bed mobility and transfers and total assistance of two or more persons for toileting. Section H coded Resident #25 having an indwelling catheter and always incontinent of bowel. Section J coded Resident #25 having pain occasionally. Section M coded Resident #25 being at risk of developing pressure ulcers/injuries. Section N coded Resident #25 receiving antianxiety, antidepressant and diuretic medications during the observation period. Section O coded Resident #25 receiving dialysis. Section V documented care area assessment triggers in the area of visual function, ADL (activities of daily living) Functional/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Falls, Nutritional Status, Dehydration/Fluid maintenance, Pressure ulcer and Psychotropic drug use. Section V of the assessment was signed by the facility staff on 8/6/2021. On 9/7/2021 at approximately 12:52 p.m., an interview was conducted of Resident #25 in their room. Resident #25 was observed in a wheelchair beside their bed. Resident #25 stated that they went to dialysis three days a week and had an access in their chest for dialysis. Resident #25 stated that they had recently had their right leg amputated (removed) and was there for therapy. Resident #25 stated that they had a history of eye problems and needed to see the eye doctor because they were not in the building when the optometrist had visited recently. Resident #25 also stated that they were working with therapy to get assessed for a prosthetic leg. Resident #25 stated that they had talked with the physical therapist but had not participated in a care plan meeting. The comprehensive care plan for Resident #25 dated 9/7/2021 documented a care plan for activities by the community life director, a care plan for code status by the social worker and a care plan for dialysis three times a week by nursing. The comprehensive care plan failed to evidence documentation for the additional care areas triggered from the comprehensive assessment including visual function, ADL Functional/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Falls, Nutritional Status, Dehydration/Fluid maintenance, Pressure ulcer and Psychotropic drug use. On 9/8/2021 at 3:58 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #5, the MDS nurse. LPN #5 stated that the purpose of the care plan was to direct resident care and set goals for resident care. LPN #5 stated that a resident admitted on [DATE] should have had a comprehensive care plan developed by now. LPN #5 stated that it could be an issue if someone who did not know the resident was assigned to care for them and there was no care plan to direct the resident's care. LPN #5 stated that they were the only MDS nurse and was trying to do all of the MDS work by themselves and was behind on getting things done. When asked if there was any policy or procedure they followed regarding developing care plans she stated that she was sure there was one somewhere. LPN #5 did not identify the RAI (resident assessment instrument) manual. On 9/9/2021 at 8:10 a.m., an interview was conducted with RN (registered nurse) #1, unit manager. RN #1 stated that the baseline care plan was developed by the admitting nurse or the unit manager and placed in a book kept at the nurse's station. RN #1 stated that there were not sure who developed the comprehensive care plan, that they only did the baseline care plan on admission. On 9/9/2021 at 8:48 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that the purpose of the care plan was to direct the care the staff provide to residents. On 9/9/2021 at approximately 10:30 a.m., a request was made to ASM #1 for the facility policy for developing the comprehensive care plan. On 9/9/2021 at approximately 8:45 a.m., ASM #1, the administrator was made aware of the findings. No further information was provided prior to exit. References: 1. Cerebrovascular disease, infarction or accident: A stroke. When blood flow to a part of the brain stops. A stroke is sometimes called a brain attack. If blood flow is cut off for longer than a few seconds, the brain cannot get nutrients and oxygen. Brain cells can die, causing lasting damage. This information was obtained from the website: https://medlineplus.gov/ency/article/000726.htm . 2. Diabetes mellitus: A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm. 3. Congestive heart failure: A condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. This information was obtained from the website: https://medlineplus.gov/heartfailure.html 9. The staff failed to implement Resident #15's comprehensive care plan to apply Resident #15's physician ordered resting left hand splint on 9/7/21 and 9/8/21. Resident #15 was admitted to the facility on [DATE], and most recently readmitted to the facility on [DATE], with diagnoses including cerebral palsy (1) and psychotic disorder (2). On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 7/6/21, Resident #15 was coded as severely cognitively impaired for making daily decisions, having scored eight out of 15 on the BIMS (brief interview for mental status). She was coded as requiring extensive assistance of staff for all activities of daily living. She was coded as having functional limitations for range of motion on both left and right upper extremities. On the following dates and times, Resident #15 was observed sitting in a wheelchair in her room. During all observations she was not wearing a hand splint on her left hand: 9/7/21 at 12:36 p.m. and 1:59 p.m.; 9/8/21 at 8:46 a.m. and 10:42 a.m. A review of Resident #15's comprehensive care plan, dated 11/12/18, updated on 5/5/21, revealed, in part: [Resident #15] has an ADL (activities of daily living) self-care performance deficit requiring extensive assist r/t Activity Intolerance, Cerebral Palsy, Fatigue, Limited Mobility .Hand splint as ordered. A review of Resident #15's clinical record revealed the following physician order dated 3/17/21: Pt (patient) to wear L (left) resting hand splint during the day, donned after breakfast and doffed before bed for pain management. Complete daily skin checks for s/s (signs/symptoms) skin breakdown. On 9/8/21 at 1:54 p.m., CNA (certified nursing assistant) #1 was interviewed. When asked how she knows what sorts of special devices a resident might need to wear, CAN #1 stated, It's usually on the chart. Or the nurse tells me. She stated she was not aware that Resident #15 needed a left hand splint. When asked if she can see a resident's care plan, CNA #1 stated she can only see what comes up on the tablet for her to chart. On 9/8/21 at 2:27 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the therapist usually informs the nursing staff of any devices needed to be worn by residents. She stated there is also usually an order. When asked if she was aware of any orders for Resident #15 for a left hand splint, LPN #1 stated she was not. When asked the purpose of a care plan, she stated the care plan is special for each resident. LPN #1 stated the care plan lets the staff know how to provide the right care for each person. When asked how she makes sure the care plan for each resident is being followed, LPN #1 stated, I know the residents well. I know how they like things. On 9/8/21 at 5:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse, were informed of these concerns. No further information was provided prior to exit. REFERENCES: (1) Cerebral palsy is a group of disorders that affect a person's ability to move and to maintain balance and posture. This information is taken from the website https://medlineplus.gov/cerebralpalsy.html. (2) Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions. People with psychoses lose touch with reality. Two of the main symptoms are delusions and hallucinations. Delusions are false beliefs, such as thinking that someone is plotting against you or that the TV is sending you secret messages. Hallucinations are false perceptions, such as hearing, seeing, or feeling something that is not there. This information is taken from the website https://medlineplus.gov/psychoticdisorders.html. Based on observations, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for 10 of 35 residents in the survey sample, Resident's # 3, # 16, # 32, # 36, #26, # 44, #40, # 30, # 15 and # 25. The findings include: 1. The facility staff failed to develop a comprehensive care plan to address Resident # 3's pain. Resident # 3 was admitted to the facility with diagnoses that include but not limited to: spinal stenosis [3] and osteoarthritis. Resident # 3's most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 06/10/2021, coded Resident # 3 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 3 as having frequent pain at a level of 4 [four] on a pain scale of zero to ten, with ten being the worse pain. The physician's order for Resident # 3 documented in part, Percocet [1] [Oxycodone-Acetaminophen] 5-325MG [milligram]. Give 1 [one] tablet by mouth every 12 hours as needed for pain. Order Date: 7/12/2021. Acetaminophen [2] Tablet 325MG. Give 2 tablet by mouth every 4 [four] hours as needed for pain. Order Date: 6/4/2021. Review of the comprehensive care plan dated 06/09/2021 for Resident # 3 failed to evidence a care plan to address pain. On 09/08/2021 at 3:58 p.m., an interview was conducted with LPN #5 (Licensed Practical Nurse), the MDS nurse. LPN #5 stated that the purpose of the care plan was to direct resident care and set goals for resident care. When asked about a care plan to address Resident # 3's assessed pain, and prescribed pain medications, LPN #5 stated that the resident should have had a care plan developed by now. She stated that it [comprehensive care plan] could be an issue if someone who did not know the resident was assigned to care for the resident and there was no care plan to direct the resident's care. She stated that she was the only MDS nurse and was trying to do all the MDS work by herself and was behind on getting things done. When asked if there was any policy or procedure she follows regarding developing care plans she stated that she was sure there was one somewhere. She did not identify the RAI manual. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit. References: [1] Oxycodone [Percocet] is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html. [2] Used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of osteoarthritis (arthritis caused by the breakdown of the lining of the joints). This information was obtained from the website: https: https://medlineplus.gov/druginfo/meds/a681004.html. 2. The facility staff failed to implement the comprehensive care plan for the use of non-pharmacological interventions prior to the administration of as needed [prn] pain medication to Resident #16. Resident # 16 was admitted to the facility with diagnoses that included but were not limited to: spinal stenosis [1], back and left hip pain. Resident # 16's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/30/2021, coded Resident # 16 as scoring a 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 16 as having frequent moderate pain. The physician's order for Resident # 16 documented in part, Percocet [2] [Oxycodone-Acetaminophen] 5-325MG [milligram]. Give 5 [five] mg by mouth every 8 [eight] hours as needed for pain. Order Date: 2/12/2020. Resident # 16's eMAR [electronic medication administration record] dated August 2021 documented the above physician's order. The eMAR failed to evidence documentation of non-pharmacological interventions attempted prior to the administration of Percocet to Resident #16 on: 08/02/2021 at 8:29 a.m., with pain level of six, on 08/11/2021 at 10:30 a.m. with pain level of ten, on 08/14/2021 at 7:45 p.m. with pain level of seven, on 08/16/2021 at 9:03 a.m. with pain level of five, and on 08/31/2021 at 12:07 a.m. with pain level of seven. Further review of the August 20212 eMAR failed to evidence the location of Resident # 16's pain on: 08/02/2021 at 8:29 a.m., with pain level of six, 08/14/2021 at 7:45 p.m. with pain level of seven, 08/18/2021 with pain level of seven, and on 08/31/2021 at 12:07 a.m. with pain level of seven. Resident # 16's eMAR [electronic medication administration record] dated September 2021 documented the above physician's order for Percocet. The eMAR failed to evidence documentation of non-pharmacological interventions attempted prior to the administration of Percocet on: 09/01/2021 at 8:54 a.m. with pain level of five and on 09/02/2021 at 8:48 p.m. with pain level of nine. The comprehensive care plan for Resident # 16 with a revision date of 01/18/2021 documented in part, Focus: [Resident # 16] has potential for pain r/t Chronic Physical Disability, GERD, Osteoarthritis, Neuropathy, Gout. Revision on 01/18/2021. Under Interventions it documented in part, Use non pharmacological interventions per protocol. Date Initiated: 03/05/2020. On 09/07/2021 at approximately 3:25 p.m., an interview was conducted with Resident # 16. When asked if the nurse's attempt non-pharmacological interventions before administering the as needed pain medications, Resident # 16 stated, Sometimes. On 09/09/2021 at approximately 9:05 a.m., an interview was conducted with LPN [licensed practical nurse] # 4. After reviewing the eMARs for the dates and times listed above and Resident # 16's comprehensive care plan, LPN # 4 was asked if the care plan was being implemented for the use of non-pharmacological interventions before administering the prn pain medications. LPN # 4 stated no. When asked to describe the purpose of the care plan, LPN # 4 stated, So we know how to care for their individual needs. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit. References: [1] A narrowing of the spinal column that causes pressure on the spinal cord, or narrowing of the openings (called neural foramina) where spinal nerves leave the spinal column. This information was obtained from the website: https://medlineplus.gov/ency/article/000441.htm. [2] Oxycodone [Percocet] is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html. 3. The facility staff failed to implement the comprehensive care plan for the use of fall mats for Resident #32. Resident # 32 was admitted to the facility with diagnoses included but were not limited to: fractured clavicle [bone that connects the shoulder to the breastplate], muscle weakness and low blood pressure. Resident # 32's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/04/2021, coded Resident # 32 as scoring a seven [7] on the brief interview for mental status (BIMS) of a score of 0 - 15, seven - being severely impaired of cognition for making daily decisions. On 09/07/2021 at 5:00 p.m., an observation of Resident # 32's room revealed Resident # 32 lying in bed. Further observation failed to evidence fall mats on the floor on the right or left side of the bed. On 09/08/2021 at 2:25 a.m., an observation of Resident # 32's room revealed Resident # 32 lying in bed. Further observation failed to evidence fall mats on the floor on the right or left side of the bed. On 09/08/2021 at 2:25 p.m., an observation of Resident # 32's room revealed Resident # 32 lying in bed. Further observation failed to evidence fall mats on the floor on the right or left side of the bed. On 09/09/2021 at 8:20 a.m., an observation of Resident # 32's room revealed Resident # 32 lying in bed. Further observation failed to evidence fall mats on the floor on the right or left side of the bed. The comprehensive care plan for Resident # 32 dated 05/28/2021 documented in part, Focus: [Resident # 32] has had an actual fall with major injury r/t [related to] poor communication/comprehension, unsteady gait, weakness and debility. Under Interventions it documented in part, Bilateral floor mats at bedside. Date Initiated: 05/28/2021. On 09/09/2021 at 8:05 a.m., an interview and observation of Resident #32 was conducted with LPN [licensed practical nurse] # 3. LPN #3 observed Resident # 32 in bed without fall mats on the left or right side of the bed. After reviewing Resident # 32's comprehensive care plan, LPN # 3 stated that there were no fall mats alongside Resident # 32's bed. When asked if the care plan was being implemented, LPN # 3 stated no. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit. 4. The facility staff failed to develop a comprehensive care plan to address Resident # 36's use of oxygen. Resident # 36 was admitted to the facility with diagnoses that include but not limited to: respiratory failure and chronic obstructive pulmonary disease [1]. Resident # 36's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 08/17/2021, coded Resident # 36 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 36 as receiving oxygen therapy. On 09/07/2021 at 2:44 p.m., an observation of Resident # 36 revealed they were receiving oxygen by nasal cannula connected to an oxygen concentrator. Observation of the oxygen concentrator flow meter revealed the oxygen flow rate at two liters per minute. On 09/08/2021 at 9:15 a.m., an observation of Resident # 36 revealed they were receiving oxygen by nasal cannula connected to an oxygen concentrator. Observation of the oxygen concentrator flow meter revealed the oxygen flow rate at two liters per minute. The physician's order for Resident # 36 dated 08/24/2021 documented, Respiratory: Oxygen - Continuous 2L NC [two liters per minute nasal cannula]. Order Date: 08/24/2021. Review of the comprehensive care plan for Resident # 36 dated 09/07/2021 failed to evidence a care plan to address Resident # 36's use of oxygen. On 09/08/2021 at 3:58 p.m., an interview was conducted with LPN #5 (Licensed Practical Nurse), the MDS nurse. She stated that the purpose of the care plan was to direct resident care and set goals for resident care. When asked about Resident # 36's care plan for oxygen, LPN #5 stated that the resident should have had a care plan developed by now. She stated that it could be an issue if someone who did not know the resident was assigned to care for the resident and there was no care plan to direct the resident's care. She stated that she was the only MDS nurse and was trying to do all the MDS work by herself and was behind on getting things done. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit. References: [1] Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html.8. The facility staff failed to develop a comprehensive care plan for Resident #30. Resident #30 was admitted to the facility on [DATE] and had the diagnoses of but not limited to cervical cancer, morbid obesity, diabetes, congestive heart failure, chronic kidney disease, lymphedema, high blood pressure, stroke, heart attack, peripheral vascular disease. The admission MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 8/5/21 coded the resident as cognitively intact in ability to make daily life decisions. Resident #30 was coded as requiring extensive care for bathing; limited assistance for transfers, toileting and hygiene; supervision for bed mobility; independent for eating; and as continent of bowel and bladder. This MDS assessment was coded in Section VO200C2 Signature of Person Completing Care Plan Decision and Date Signed of Section V - Care Area Assessment (CAA) Summary, was dated 8/12/21. A review of the RAI manual (Resident Assessment Instrument) dated October 2019 documented on page 2-16 the following in the table: Care Plan Completion Date (Item V0200C2) No Later Than, CAA(s) Completion Date + [plus] 7 calendar days. This indicates that the comprehensive care plan should have been completed by 8/19/21. A review of the care plan revealed that a comprehensive care plan was never completed as of 9/8/21. The only care plan areas that were developed for the resident were Activities (dated 8/6/21), Urinary tract infection (dated 8/5/21), and Mood (dated 8/16/21). Section V of the MDS documented the following areas as triggered to be care planned: Visual Function, ADL (activities of daily living) Functional/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Psychosocial Well-Being, Activities, Falls, Nutritional Status, Dehydration/Fluid Maintenance, Dental Care, Pressure Ulcer, Pain. None of the above areas other than Activities had been care planned. On 9/8/21 at 3:58 PM an interview was conducted with LPN #5 (Licensed Practical Nurse), the MDS nurse. She stated that the purpose of the care plan was to direct resident care and set goals for resident care. She stated that Resident #30 should have had a comprehensive care plan developed by now. She stated that it could be an issue if someone who did not know the resident was assigned to care for the resident and there was no care plan to direct the resident's care. LPN #5 stated that she was the only MDS nurse and was trying to do all the MDS work by herself and was behind on getting things done. When asked if there was any policy or procedure she follows regarding developing care plans, LPN #5 stated that she was sure there was one somewhere. She did not identify the RAI manual. A review of the facility policy Plans of Care documented, An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements Develop and implement an Individualized Person-Centered comprehensive plan of care by the Interdisciplinary Team that includes but is not limited to - the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident, and, to the extent practicable, the participation of the resident and the resident's representative(s) within seven (7) days after completion of the comprehensive assessment (MDS). On 9/8/21 at approximately 5:00 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing (DON) and ASM #3 the regional nurse, were made aware of the findings. ASM #1 stated that there had been a lot of staffing changes and the MDS nurse had been pulled to work on the unit for a period of time. No further information was provided by the end of the survey. No further information was provided by the end of the survey. 5. The facility staff failed to develop a care plan to address the needs of a resident receiving hospice care for Resident #26. Resident #26 was admitted to the facility on [DATE] with a recent readmission of 12/14/2020 with diagnoses that included but were not limited to: stroke (abnormal condition in which hemorrhage or blockage of the blood vessels of the brain leads to oxygen lack and resulting symptoms - sudden loss of ability to move a body part [as an arm or parts of the face], or to speak, paralysis weakness or if severe, death) (1), dysphagia (a condition in which swallowing is difficult or painful due to obstruction of the esophagus or muscular abnormalities of the esophagus or pharynx) (2), and sepsis (your body's overactive and extreme response to an infection) (3). The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 8/4/2021, coded the resident as scoring a 6 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions. The resident was coded as being dependent upon one or more staff members for most of her activities of daily living. In Section O - Special Treatments, Procedures and Programs, the resident was coded as receiving hospice care while a resident at the facility. The physician order dated 7/26/2021, documented, Resident to be under the care of (Name of Hospice Company). The comprehensive care plan, dated 4/30/2020, failed to evidence a care plan to address hospice care for Resident #26. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 9/9/2021 at 8:48 a.m. When asked the purpose of the care plan, ASM #2 stated it's to direct the staff to provide the care for each resident. When asked if a resident receiving hospice care, should have a care plan to address the hospice services and care, ASM #2 stated, yes, it should be care planned. ASM (administrative staff member) #1, the administrator; ASM #2 the director of nursing and ASM #3, the regional nurse, were made aware of the above concerns on 9/8/2021 at 5:10 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 114. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 178. (3) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=Sepsis&_ga=2.155403059.908502701.1629920181-1530802455.1629920181 6. The facility staff failed to develop a care plan to address Resident #44's physician ordered fluid restriction. Resident #44 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: congestive heart failure ( CHF - abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys) (1), COPD (chronic obstructive pulmonary disease -general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (2) and dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation. (3). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/15/2021, coded the resident as scoring an 8 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members for most of her activities of daily living except eating which she was coded as independent after set up assistance was provided. The physician order dated, 4/8/2021, documented in part, 1500 ml (milliliters) fluid restriction 260 ml per meal and 240 ml every shift for CHF. The comprehensive care plan dated, 7/18/2021, documented in part, Focus: (Resident #44) has congestive heart failure. The Interventions documented in part, Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of Congestive Heart Failure, dependent edema of legs and feet, periorbital edema, SOB (shortness of breath) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rate (tachycardia) lethargy and disorientation. The care plan further documented, dated, 2/3/2021, Focus: The resident has potential for fluid deficit r/t (related to) diuretic use. The Interventions documented in part, Monitor and document intake and output as per facility policy. The care plan did not address the need for Resident #44 to be on a fluid restriction. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 9/9/2021 at 8:48 a.m. When asked if a physician prescribes a fluid restriction for a resident should that be addressed on the care plan, ASM #2 stated, Absolutely. The facility policy, Fluid Restrictions documented in part, The Care Planning Team will discuss the restriction, and they will be included in the Care Plan. ASM #1, the administrator, ASM #2 and ASM #3, the regional nurse, were made aware of the above concern on 9/8/2021 at 5:10 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for three of 35 residents in the survey sample, Residents # 201, # 3, and # 16. The facility staff failed to assess and document the location of pain and failed to attempt and or provide non-pharmacological interventions prior to the administration of a prn [as needed] pain medications to Resident #201, #3 and Resident #16, on multiple occasions during August and September 2021. The findings include: 1. Resident # 201 was admitted to the facility with diagnoses that included but were not limited to: osteoarthritis [1], and chronic pain. Resident # 201's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 08/30/2021, coded Resident # 201 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 201 as having pain at a level of [seven] on a pain scale of zero to ten, with ten being the worse pain. The physician's order for Resident # 201 documented in part, Norco Tablet 7.5-325 MG [milligram] (Hydrocodone-Acetaminophen) *Controlled Drug* Give 2 tablet by mouth every 4 [four] hours as needed for Pain. Resident # 201's eMAR [electronic medication administration record] dated August 2021 documented the physician's order as stated above. The eMAR failed to evidence documentation of non-pharmacological interventions attempted and or provided prior to the administration of Norco on: 08/25/2021 at 1:50 a.m., with pain level of 10, at 6:24 a.m. with pain level of eight, at 10:21 a.m. with pain level of nine, at 2:59 p.m. with pain level of eight and at 8:25 p.m. with pain level of six, on 08/26/2021 at 12:35 a.m. with pain level of ten, at 9:23 a.m. with pain level of nine, on 08/27/2021 at 3:55 a.m. with pain level of ten, 08/28/2021 at 12:30 a.m. with pain level of nine, at 7:44 a.m. with pain level of ten, at 4:00 p.m. with pain level of eight, 08/29/2021 at 2:05 a.m. with pain level of six, at 2:36 p.m. with pain level of seven, on 08/30/2021 at 7:05 with pain level of eight, at 9:05 p.m. with pain level of six and on 08/31/2021 at 7:21 a.m. with pain level of seven and at 2:39 p.m. with pain level of seven. Further review of the August 2021 eMAR failed to evidence the location of Resident # 201's pain on 08/25/2021 at 8:25 p.m. with pain level of six, on 08/26/2021 at 12:35 a.m. with pain level of ten, on 08/28/2021 at 12:30 a.m., at 4:00 p.m. with pain level of eight, 08/29/2021 at 2:05 a.m. with pain level of six, on 08/30/2021 at 7:05 with pain level of eight, at 9:05 p.m. with pain level of six and on 08/31/2021 at 7:21 a.m. with pain level of seven and at 2:39 p.m. with pain level of seven. Resident # 201's eMAR [electronic medication administration record] dated September 2021 documented the physician's order as stated above. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of Norco on: 09/01/2021 at 10:07 a.m. with pain level of seven, at 6:48 p.m. with pain level of seven, at 11:50 p.m. with pain level of eight, on 09/02/2021 at 1:08 a.m. with pain level of seven, at 11:26 a.m. with pain level of seven, at 3:32 p.m. with pain level of six and at 8:08 p.m. with pain level of seven, on 09/03/2021 at 1:08 a.m. with pain level of nine, at 8:13 a.m. with pain level of eight, at 7:49 p.m. with pain level of seven, on 09/04/2021 at 12:37 a.m. with pain level of seven, at 7:10 a.m. with pain level of eight, at 11:22 a.m. with pain level of seven, on 09/05/2021 at 7:07 a.m. with pain level of six, at 12:23 with pain level of seven, at 5:35 p.m. with pain level of six, at 11:53 p.m. with pain level of seven, on 09/06/2021 at 6:57 p.m. with pain level of seven, and on 09/07/2021 at 8:06 a.m. Further review of the September 2021 eMAR failed to evidence the location of Resident # 201's pain on: 09/01/2021 at 10:07 a.m. with pain level of seven, at 6:48 p.m. with pain level of seven at 11:50 p.m. with pain level of eight, on 09/02/2021 at 11:26 a.m. with pain level of seven, at 3:32 p.m. with pain level of six and at 8:08 p.m. with pain level of seven, on 09/04/2021 at 12:37 a.m. with pain level of seven, on 09/05/2021 at 7:07 a.m. with pain level of six, at 12:23 with pain level of seven, at 5:35 p.m. with pain level of six, at 11:53 p.m. with pain level of seven, on 09/06/2021 at 6:57 p.m. with pain level of seven, 09/07/2021 at 8:06 a.m. with pain level of seven and on 09/08/2021 at 2:10 a.m. with pain level of eight and at 7:16 a.m. with pain level of eight. Review of the facility's Progress Notes for Resident # 201 dated 08/24/2021 through 09/08/2021 failed to evidence documentation of non-pharmacological interventions prior to the administration of Norco and failed to document the location Of Resident # 201's pain as stated above. The comprehensive care plan for Resident # 201 dated 09/01/2021 documented in part, Focus [Resident # 201] has acute/chronic pain r/t Diabetic neuropathy, osteomyelitis, surgical wound, severe PAD, Date Initiated: 09/01/2021. Under Interventions: it documented, Monitor/document for side effects of pain medication. Date Initiated: 09/01/2021; Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Date Initiated: 09/01/2021. On 09/07/2021 at approximately 3:00 p.m., an interview was conducted with Resident # 201. When asked if the nurse's attempt non-pharmacological interventions before administering the as needed pain medications Resident # 201 stated, No. On 9/7/2021 at 5:47 p.m., ASM [administrative staff member] #1, administrator, stated that the facility used their policies and procedures and [NAME] as their standard of practice. On 09/09/2021 at approximately 9:05 a.m., an interview was conducted with LPN [licensed practical nurse] # 4, regarding the procedure nursing staff follows when administering a prn pain medication. LPN #4 stated, the resident should be assessed for pain by determining a pain level on a scale of zero to 10, with ten being the worst pain, if the resident is able to communicate, determine the location of the resident's pain, try non-pharmacological strategies such as repositioning or relaxation to alleviate their pain. If it doesn't help check the physician's orders for what medication is prescribed, and administer the medication. When asked if the pain assessment including the location of the resident's pain and attempted non-pharmacological strategies are documented and where staff document this information, LPN # 4 stated that they are documented in the nurse's notes. LPN # 4 was then asked to review the eMAR and nurse's notes for the dates listed above for the administration of Resident # 201's prn Norco. LPN # 4 stated that there was no documented evidence of the location of Resident # 201's pain or the attempts of non-pharmacological strategies on the dates listed above. The facility's policy Pain Management Guideline documented in part, Treatment: Develop patient centered interventions (pharmacologic and non- pharmacologic) to manage pain. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit. References: [1] Norco [Hydrocodone] is an opioid pain medication. An opioid is sometimes called a narcotic. Acetaminophen is a less potent pain reliever that increases the effects of hydrocodone. The combination of acetaminophen and hydrocodone is used to relieve moderate to severe pain. This information was obtained from the website: https://www.rxlist.com/norco-5-325-drug/patient-images-side-effects.htm. [2] The most common form of arthritis. It causes pain, swelling, and reduced motion in your joints. It can occur in any joint, but usually it affects your hands, knees, hips or spine. This information was obtained from the website: https://medlineplus.gov/osteoarthritis.html. 2. Resident # 3 was admitted to the facility with diagnoses that include but not limited to: spinal stenosis [3] and osteoarthritis. Resident # 3's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 06/10/2021, coded Resident # 3 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 3 as having frequent pain at a level of 4 [four] on a pain scale of zero to ten, with ten being the worse pain. The physician's order for Resident # 3 documented in part, - Percocet [Oxycodone-Acetaminophen] 5-325MG [milligram]. Give 1 [one] tablet by mouth every 12 hours as needed for pain. Order Date: 7/12/2021. - Acetaminophen Tablet 325MG. Give 2 tablet by mouth every 4 [four] hours as needed for pain. Order Date: 6/4/2021. Resident # 3's eMAR [electronic medication administration record] dated August 2021 documented the physician's order for Percocet as stated above. The eMAR failed to evidence documentation of non-pharmacological interventions attempted or provided prior to the administration of Percocet on: 08/01/2021 at 10:46 p.m. with pain level of eight, 08/04/2021 at 2:43 a.m. with pain level of eight and at 3:44 p.m. with pain level of five, 08 05/2021 at 8:20 a.m. with pain level of eight, 08/11/2021 at 11:03 a.m. with pain level of ten and at 11:59 p.m. with pain level of eight, 08/14/2021 at 12:04 a.m. with pain level of seven and at 5:40 p.m. with pain level of six, 08/16/2021 at 1:31 p.m. with pain level of three, 08/18/2021 at 12:22 a.m. with pain level of five, 08/23/2021 at 8:31 a.m. with pain level of four, 08/24/2021 at 8:54 a.m. with pain level of four and at 9:26 p.m. with pain level of two, 08/26/2021 at 12:30 a.m. with pain level of seven and at 2:16 with pain level of one, 08/28/2021 at 10:11 a.m. with pain level of eight, 08/30/2021 at 1:21 p.m. with pain level of one, 08/31/2021 at 2:26 a.m. with pain level of six and at 2:26 p.m. with pain level of ten. Further review of the August 2021 eMAR for the administration of Percocet, failed to evidence the location of Resident # 3's pain on: 08 05/2021 at 8:20 a.m. with pain level of eight, 08/11/2021 at 11:03 a.m. with pain level of ten and at 11:59 p.m. with pain level of eight, 08/14/2021 at 12:04 a.m. with pain level of seven and at 5:40 p.m. with pain level of six, 08/16/2021 at 1:31 p.m. with pain level of three, 826/2021 at 2:16 with pain level of one, 08/30/2021 at 1:21 p.m. with pain level of one, 08/31/2021 at 2:26 p.m. with pain level of ten. Resident # 3's eMAR [electronic medication administration record] dated August 2021 documented the physician's order for Acetaminophen as stated above. The eMAR failed to evidence documentation of non-pharmacological interventions attempted or provided prior to the administration of Acetaminophen on: 08/14/2021 at 6:20 a.m. with pain level of six, 08/16/2021 at 8:53 a.m. with pain level of two and on 08/26/2021 at 10:36 a.m. with pain level of two. Further review of the August 2021 eMAR for the administration of Acetaminophen, failed to evidence the location of Resident # 3's pain on: 08/14/2021 at 6:20 a.m. with pain level of six, 08/16/2021 at 8:53 a.m. with pain level of two. Resident # 3's eMAR [electronic medication administration record] dated September 2021 documented the physician's order for Percocet as stated above. The eMAR failed to evidence documentation of non-pharmacological interventions attempted or provided prior to the administration of Percocet on: 09/01/2021 at 9:17 p.m. with pain level of seven, 09/02/2021 at 5:26 with pain level of seven, 09/03/2021 at 2:41 p.m. with pain level of eight, 09/04/2021 at 3:46 a.m. with pain level of seven and at 5:19 p.m. with pain level of six, 09/05/2021 at 4:46 p.m. with pain level of seven, 09/07/2021 at 12:51 a.m. with pain level of six and at 12:22 p.m. with pain level of eight and on 09/08/2021 at 12:56 a.m. with pain level of eight. Further review of the August 2021 eMAR for the administration of Percocet, failed to evidence the location of Resident # 3's pain on: 09/02/2021 at 5:26 with pain level of seven, 09/04/2021 at 3:46 a.m. with pain level of seven and at 5:19 p.m. with pain level of six, 09/05/2021 at 4:46 p.m. with pain level of seven, 09/07/2021 at 12:51 a.m. with pain level of six and at 12:22 p.m. with pain level of eight. Resident # 3's eMAR [electronic medication administration record] dated September 2021 documented the physician's order for Acetaminophen as stated above. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of Acetaminophen and the location of Resident # 3's pain on: 09/03/2021 at:25 p.m. with pain level of seven. Review of the facility's Progress Notes for Resident # 3 dated 08/01/2021 through 09/08/2021 failed to evidence documentation of non-pharmacological interventions attempted and or provided prior to the administration of Percocet and acetaminophen and failed to document the location of Resident # 3's pain as stated above. On 09/07/2021 at approximately 2:26 p.m., an interview was conducted with Resident # 3. When asked if the nurse's attempt non-pharmacological interventions before administering the prn pain medications Resident # 3 stated, No. On 09/09/2021 at approximately 9:05 a.m., an interview was conducted with LPN [licensed practical nurse] # 4, regarding the procedure nursing staff follows when administering a prn pain medication. LPN #4 stated, the resident should be assessed for pain by determining a pain level on a scale of zero to 10, with ten being the worst pain, if the resident is able to communicate, determine the location of the resident's pain, try non-pharmacological strategies such as repositioning or relaxation to alleviate their pain. If it doesn't help check the physician's orders for what medication is prescribed, and administer the medication. When asked if the pain assessment including the location of the resident's pain and attempted non-pharmacological strategies and where staff document this information, LPN # 4 stated that they are documented in the nurse's notes. LPN #4 was then asked to review the eMAR and nurse's notes for the dates listed above for the administration of Resident # 3's prn Percocet and acetaminophen. LPN # 4 stated that there was no documented evidence of the location of Resident # 3's pain or the attempts of non-pharmacological strategies on the dates listed above. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit. References: [1] Oxycodone [Percocet] is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html. [2] Used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of osteoarthritis (arthritis caused by the breakdown of the lining of the joints). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681004.html. [3] A narrowing of the spinal column that causes pressure on the spinal cord, or narrowing of the openings (called neural foramina) where spinal nerves leave the spinal column. This information was obtained from the website: https://medlineplus.gov/ency/article/000441.htm. 3. Resident # 16 was admitted to the facility with diagnoses that included but were not limited to: spinal stenosis [2], back and left hip pain. Resident # 16's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/30/2021, coded Resident # 16 as scoring a 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 16 as having frequent moderate pain. The physician's order for Resident # 16 documented in part, Percocet [Oxycodone-Acetaminophen] 5-325MG [milligram]. Give 5 [five] mg by mouth every 8 [eight] hours as needed for pain. Order Date: 2/12/2020. Resident # 16's eMAR [electronic medication administration record] dated August 2021 documented the physician's order as stated above. The eMAR failed to evidence documentation of non-pharmacological interventions attempted and or offered prior to the administration of Percocet on: 08/02/2021 at 8:29 a.m., with pain level of six, on 08/11/2021 at 10:30 a.m. with pain level of ten, on 08/14/2021 at 7:45 p.m. with pain level of seven, on 08/16/2021 at 9:03 a.m. with pain level of five, on 08/31/2021 at 12:07 a.m. with pain level of seven. Further review of the August 20212 eMAR failed to evidence the location of Resident # 16's pain on: 08/02/2021 at 8:29 a.m., with pain level of six, 08/14/2021 at 7:45 p.m. with pain level of seven, 08/18/2021 with pain level of seven, and on 08/31/2021 at 12:07 a.m. with pain level of seven. Resident # 16's eMAR [electronic medication administration record] dated September 2021 documented the physician's order as stated above. The eMAR failed to evidence documentation of non-pharmacological interventions attempted and or offered prior to the administration of Percocet on: 09/01/2021 at 8:54 a.m. with pain level of five and on 09/02/2021 at 8:48 p.m. with pain level of nine. The comprehensive care plan for Resident # 16 with a revision date of 01/18/2021 documented in part, Focus: [Resident # 16] has potential for pain r/t Chronic Physical Disability, GERD, Osteoarthritis, Neuropathy, Gout. Revision on 01/18/2021. Under Interventions it documented in part, Use non pharmacological interventions per protocol. Date Initiated: 03/05/2020 On 09/07/2021 at approximately 3:25 p.m., an interview was conducted with Resident # 16. When asked if the nurse's attempt non-pharmacological interventions before administering the prn pain medications Resident # 16 stated, Sometimes. On 9/7/2021 at 5:47 p.m., ASM [administrative staff member] #1, administrator, stated that the facility used their policies and procedures and [NAME] as their standard of practice. On 09/09/2021 at approximately 9:05 a.m., an interview was conducted with LPN [licensed practical nurse] # 4, regarding the procedure nursing staff follows when administering a prn pain medications. LPN #4 stated, the resident should be assessed for pain by determining a pain level on a scale of zero to 10, with ten being the worst pain, if the resident is able to communicate, determine the location of the resident's pain, try non-pharmacological strategies such as repositioning or relaxation to alleviate their pain. If it doesn't help check the physician's orders for what medication is prescribed, and administer the medication. When asked if the pain assessment including the location of the resident's pain and attempted non-pharmacological strategies are documented and where staff document this information, LPN # 4 stated that they are documented in the nurse's notes. LPN #4 was then asked to review the eMAR and nurse's notes for the date's list above for the administration of Resident # 16's prn Percocet. LPN # 4 stated that there was no documented evidence of the location of Resident # 61's pain or the attempts of non-pharmacological strategies on the dates listed above. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit. References: [1] Oxycodone [Percocet] is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html. [2] A narrowing of the spinal column that causes pressure on the spinal cord, or narrowing of the openings (called neural foramina) where spinal nerves leave the spinal column. This information was obtained from the website: https://medlineplus.gov/ency/article/000441.htm.

Based on staff interview and facility document review, it was determined that the facility staff failed to have a complete infection control program as evidenced by missing infection control surveillance for April, May and June 2021. The findings include: On 09/09/2021 at approximately 10:00 a.m., a review of the facility's infection control surveillance for the past six months was conducted. Review of the surveillance records failed to evidence infection control surveillance for April, May and June 2021. On 09/09/2021 at approximately 10:33 a.m., an interview was conducted with ASM [administrative staff member] # 1, administrator. When asked about the missing surveillance ASM # 1 stated, We don't have a full six months of surveillance, we're unable to locate them. When asked who was responsible for infection control ASM # 1 stated that it was [ASM # 2], director of nursing who started at the facility on 09/02/2021. On 09/09/2021 at 12:58 p.m. an interview was conducted with ASM # 3, regional nurse. When asked to describe the procedure for maintaining the infection control surveillance ASM # 3 stated, They are all kept together for the year in a binder. When asked why it was important to maintain the surveillance records ASM # 3 stated, To track and trend infections and tract the use of antibiotics for overuse.' The facility's policy Surveillance for Infections documented in part, Policy Interpretation and Implementation. 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections. Under Gathering Surveillance Data it documented in part, 1. The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. The Infection Control Committee and/or QAPI [quality insurance performance improvement] Committee may be involved in interpretation of the data. Under Data Collection and Recording it documented in part, 4. For targeted surveillance using facility-created tools, follow these guidelines: a. DAILY (as indicated): Record detailed information about the resident and infection on an individual infection report form. b. MONTHLY: Collect information from individual resident infection reports and enter line listing of infections by resident for the entire month. c. MONTHLY: Summarize monthly data for each nursing unit by site and pathogen. d. MONTHLY/QUARTERLY: Identify predominant pathogens or sites of infection among residents in the facility or in particular units by recording month to month and observing trends. e. MONTHLY/QUARTERLY: Compare incidents of current infections to previous data to identify trends and patterns. Use average infection rate over a previous time period as a baseline. Compare subsequent rates to the average rate to identify possible increases in infection rates. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that facility staff failed to maintain a resident's dignity for one of 32 residents in the survey sample, Resident # 6. The facility staff failed to provide privacy for Resident # 6's catheter, collection bag and urine inside the collection bag was visible from the hallway. The findings include: Resident # 6 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: heart failure, stage 4 kidney disease and high cholesterol. Resident # 6's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/22/19, coded Resident # 6 as scoring a 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. Resident # 6 was coded as requiring limited assistance of one staff member for activities of daily living. Section H Bladder and Bowel coded Resident # 6 as occasional incontinence of bladder and continent of bowel. On 01/07/20 at 1:17 p.m., observation revealed Resident # 6 lying in bed. Observation of the room from the hallway revealed a catheter collection bag hanging on the right lower portion of the bed. Observation of the catheter collection bag failed to evidence a privacy bag over the collection bag and urine inside the collection bag was visible from the hallway. On 01/07/20 at 2:46 p.m., observation revealed Resident # 6 lying in bed. Observation of the room from the hallway revealed a catheter collection bag hanging on the right lower portion of the bed. Observation of the catheter collection bag failed to evidence a privacy bag over the collection bag and urine inside the collection bag was visible from the hallway. On 01/07/20 at approximately 4:10 p.m., during an interview with Resident # 6, the resident was informed of the observation of the catheter collection bag being visible from the hallway. When asked how it made them feel, Resident # 6 stated, I wouldn't like everyone to be watching it. The POS [physician's order sheet] dated and signed by the physician on 12/27/19 for Resident # 6 documented, Foley catheter for comfort measures. The comprehensive care plan for Resident # 6 dated of 01/06/2020 failed to evidence care and services for an indwelling catheter. On 01/08/2020 at 1:00 p.m., an interview was conducted with LPN [licensed practical nurse] # 4. When asked about the care of a catheter collection bag for Resident #6, LPN # 4 stated, It should be positioned off the floor, below the resident's bladder and placed in a privacy bag. When informed of the above observations LPN # 4 stated that the catheter collection bag should have been placed in a privacy bag. When asked if it was dignified for a resident's catheter collection bag to be visible from the hallway LPN # 4 stated no. On 01/09/2020 at 11:14 a.m., an interview was conducted with ASM [administrative staff member] # 2, director of nursing, regarding Resident # 6's catheter collection bag not being covered. When informed of the above observations ASM # 2 agreed it was a dignity issue for Resident #6 and stated, It should have been covered. On 01/08/2020 at approximately 5:50 p.m., ASM # 1, the executive director and ASM # 2, director of nursing, ASM # 3, regional director of clinical services and LPN # 5 traveling MDS coordinator, were made aware of the findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide the resident representative and Ombudsman with the required written notification of a hospital transfer for one of 36 residents in the survey sample; Resident #65. The facility staff failed to evidence that a written notification of a hospital transfer for Resident #65 on 12/10/19, was provided to the resident representative and Ombudsman. The findings include: Resident #65 was admitted to the facility on [DATE]. Diagnoses included, but are not limited to, brain cancer, aphasia, convulsions, epilepsy, obesity, alcohol abuse, and adult failure to thrive. Due to the short amount of time, the resident was in the facility prior to the hospital transfer the MDS (Minimum Data Set) assessment had not been completed. The admission nursing assessment and admission nursing note dated 12/9/19, documented the resident was alert and oriented to person, place and time. A review of the clinical record revealed that the resident went to the hospital on [DATE] and did not return to the facility. The record revealed a doctor's note about 12/11/19 that documented, past and current medical history of GBM (glioblastoma multiforme of brain (2)), seizure disorder, recurrent UTI (urinary tract infection) and history of craniotomy for GBM resection admitted with diagnosis of syncope, altered mental status with significant cognitive decline and possibly UTI. She underwent IV (intravenous) antibiotics, continue steroid, Vimpat (1) and follow up with oncology group for immunotherapy. She got transferred to SNF (skilled nursing facility) for PT/OT (physical therapy and occupational therapy) and 24 hour nursing care. She later had erratic behavior with combative nature and not safe for her and other residents, she was sent to ER (emergency room) for psych (psychiatric) admission. On 1/8/20 at 2:25 PM in an interview with OSM #1 (Other Staff Member - the Director of Social Services), she stated that she usually sends a notice to the family and the same notice is sent to the Ombudsman. OSM #1 stated that for Resident #65 she did not have the family and ombudsman notice for this hospital transfer. She stated she missed doing it. A review of a Notice of Transfer and Bed Hold Policy For residents transferring to ED or hospital form that OSM #1 stated she sends out but did not in this case, documented: The purpose of this letter is to inform you that after careful consideration, (resident name) was sent to an acute care medical center on (date). The transfer was necessary for (his/her) welfare and (his/her) medical needs could not be met in this facility. (Resident name) was transferred to (name of hospital and address.) Notice of Bed Hold Policy: You are being sent to the hospital today. If you are a Medicaid/Medicare resident and you are admitted to the hospital, Virginia Medicaid and Medicare does not pay to hold your bed. Whatever your payment source, unless the nursing home is paid to reserve the bed while you are in the hospital, the nursing home may move someone else into your room. However, even if the nursing home is not paid to hold your bed, you may have the right to return as soon as a bed is available in a semi-private room in this nursing home as long as you still need the services provided by this nursing home (and, if you are on Medicaid, you are eligible for Medicaid nursing home services.) If the nursing home does not readmit you to the first available bed in a semi-private room when you are ready to leave the hospital - You have the right to appeal . You may also file a complaint . For help in filing an appeal or a complaint . Bed Hold: If you wish to hold your bed at (facility) during your hospitalization, you will be responsible to pay privately for the room at the facilities per diem rate. Once you hold the bed, the only reason that you would not be able to be admitted to (facility) is if: 1. The level of care required is not provided at (facility) 2. The patient is judged by the physician to be of danger to themselves or others. 3. The resident at the time of readmission has an outstanding payment to the nursing home for which they are responsible. On 1/08/20 03:59 PM, in an interview with LPN #2 (Licensed Practical Nurse), when asked about the paper work provided to the hospital for a resident transfer, LPN #2 stated, Facesheet, med [medication] list, bed hold, care plan, transfer form, SBAR (Situation, Background, Assessment, Recommendation) form, and DNR (Do Not Resuscitate). When asked where staff document this information provided to the hospital, LPN #2 stated, Usually documented on the transfer form or make a note of what was sent. Review of the clinical record revealed the Nursing Home to Hospital Transfer Form dated 12/10/19. This form did not document that written notification was provided to the resident representative and Ombudsman. A review of the clinical record failed to reveal any nursing or social worker notes that documented that written notification was provided to the resident representative and Ombudsman. A review of the facility policy, Transfer/Discharge Notification & Rights to Appeal documented, .Notice Before Transfer: Before a center transfers or discharges a resident the center must: *Notify the resident and resident representative(s) of the transfer or discharge and the reasons for the move in writing (in a language and manner they understand); *The Center must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman; *Record the reasons for the transfer or discharge in the resident's medical record. Timing of the Notice: Notice of transfer or discharge must be made 30 days prior to resident is transferred or discharged except when: An immediate transfer or discharge is required by the resident's urgent medical needs Notices must be made as soon as practicable before transfer or discharge. *Note: Notices to the ombudsman in these situations can be sent when practicable, such as a list of residents on a monthly basis . On 1/8/20 at 5:50 PM, ASM #1 (Administrative Staff Member - the Executive Director) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. References: 1. Vimpat - is used to treat seizures. Information obtained from https://medlineplus.gov/druginfo/meds/a609028.html 2. Glioblastoma is a malignant (cancerous) brain tumor that develops from a specific type of brain cell called an astrocyte. This information was obtained from the website: https://rarediseases.info.nih.gov/diseases/2491/glioblastoma

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide a written bed hold notice upon a hospital transfer for 1 of 36 residents in the survey sample; Resident #65. The facility staff failed to evidence that a bed hold notice was provided upon Resident #65's hospital transfer on 12/10/19. The findings include: Resident #65 was admitted to the facility on [DATE]. Diagnoses included, but are not limited to, brain cancer, aphasia, convulsions, epilepsy, obesity, alcohol abuse, and adult failure to thrive. Due to the short amount of time, the resident was in the facility prior to the hospital transfer the MDS (Minimum Data Set) assessment had not been completed. The admission nursing assessment and admission nursing note dated 12/9/19, documented the resident was alert and oriented to person, place and time. A review of the clinical record revealed that the resident went to the hospital on [DATE] and did not return to the facility. The record revealed a doctor's note about 12/11/19 that documented, past and current medical history of GBM (glioblastoma multiforme of brain (2)), seizure disorder, recurrent UTI (urinary tract infection) and history of craniotomy for GBM resection admitted with diagnosis of syncope, altered mental status with significant cognitive decline and possibly UTI. She underwent IV (intravenous) antibiotics, continue steroid, Vimpat (1) and follow up with oncology group for immunotherapy. She got transferred to SNF (skilled nursing facility) for PT/OT (physical therapy and occupational therapy) and 24 hour nursing care. She later had erratic behavior with combative nature and not safe for her and other residents, she was sent to ER (emergency room) for psych (psychiatric) admission. On 1/08/20 03:59 PM, in an interview with LPN #2 (Licensed Practical Nurse), regarding residents transfers to the hospital and the paper work sent to the hospital, LPN #2 stated, Facesheet, med [medication] list, bed hold, care plan, transfer form, SBAR (Situation, Background, Assessment, Recommendation) form, and DNR (Do Not Resuscitate). When asked where staff document the paper work provided to the hospital, LPN #2 stated, Usually documented on the transfer form or make a note of what was sent. Review of the clinical record revealed the Nursing Home to Hospital Transfer Form dated 12/10/19. This form did not document that bed hold notice was provided to the resident and or resident representative. A review of the clinical record failed to reveal any nursing or social worker notes that documented that the bed hold notice was provided to the resident and or resident representative on transfer to the hospital on [DATE]. On 1/8/20 at 2:25 PM in an interview with OSM #1 (Other Staff Member - the Director of Social Services), she stated that she usually sends a notice to the family and the same notice is sent to the Ombudsman. This form also contained information about bed holds. OSM #1 stated that for Resident #65 she did not have the family and ombudsman notice for this hospital transfer. She stated she missed doing it. A review of a Notice of Transfer and Bed Hold Policy For residents transferring to ED [emergency department] or hospital form that OSM #1 stated she sends out but did not in this case, documented: The purpose of this letter is to inform you that after careful consideration, (resident name) was sent to an acute care medical center on (date). The transfer was necessary for (his/her) welfare and (his/her) medical needs could not be met in this facility. (Resident name) was transferred to (name of hospital and address.) Notice of Bed Hold Policy: You are being sent to the hospital today. If you are a Medicaid/Medicare resident and you are admitted to the hospital, Virginia Medicaid and Medicare does not pay to hold your bed. Whatever your payment source, unless the nursing home is paid to reserve the bed while you are in the hospital, the nursing home may move someone else into your room. However, even if the nursing home is not paid to hold your bed, you may have the right to return as soon as a bed is available in a semi-private room in this nursing home as long as you still need the services provided by this nursing home (and, if you are on Medicaid, you are eligible for Medicaid nursing home services.) If the nursing home does not readmit you to the first available bed in a semi-private room when you are ready to leave the hospital - You have the right to appeal . You may also file a complaint . For help in filing an appeal or a complaint . Bed Hold: If you wish to hold your bed at (facility) during your hospitalization, you will be responsible to pay privately for the room at the facilities per diem rate. Once you hold the bed, the only reason that you would not be able to be admitted to (facility) is if: 1. The level of care required is not provided at (facility) 2. The patient is judged by the physician to be of danger to themselves or others. 3. The resident at the time of readmission has an outstanding payment to the nursinghome for which they are responsible. A review of the facility policy, Transfer/Discharge Notification & Right to Appeal did not include any criteria for the provision of a written Bed Hold notice. On 1/8/20 at 5:50 PM, ASM #1 (Administrative Staff Member - the Executive Director) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. References: 1. Vimpat - is used to treat seizures. Information obtained from https://medlineplus.gov/druginfo/meds/a609028.html 2. Glioblastoma is a malignant (cancerous) brain tumor that develops from a specific type of brain cell called an astrocyte. This information was obtained from the website: https://rarediseases.info.nih.gov/diseases/2491/glioblastoma

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop a baseline care plan for the use of an incentive spirometer [1] for one of 32 residents in the survey sample, Resident # 163. The findings include: Resident # 163 was admitted to the facility on [DATE] with diagnoses that included but were not limited to high blood pressure and chronic obstructive pulmonary disease [2]. The most recent MDS (minimum data set), Resident # 163 was not due at the time of the survey. The facility's admission Data Collection sheet dated 01/03/2020 for Resident # 163 documented in part, Cognition: Alert, Oriented to Person. Under Communication it documented, Usually Understood and Understands. Under Respiratory, it documented, Special Treatments and Procedures: None per history and/or observation. On 01/07/20 at 1:49 p.m., at 2:43 p.m., and at 4:05 p.m., observations of Resident # 163's over-the-bed table revealed an incentive spirometer. On 01/08/20 at 8:25 a.m., an observation of Resident # 163's over-the-bed table revealed an incentive spirometer. The POS [physician's order sheet] dated 01/01/2020 through 01/31/2020, signed by the physician on 01/04/2020 for Resident # 163 failed to evidence documentation for the use of an incentive spirometer. The facility's baseline care plan for Resident 163 dated 01/03/2020 failed to evidence documentation for the use of an incentive spirometer. On 01/08/20 at 8:30 a.m., during an interview conducted with Resident # 163, when asked if they used the incentive spirometer, Resident # 163 stated sometimes. On 01/08/2020 at 1:00 p.m., during an interview conducted with LPN [licensed practical nurse] # 4, when asked about a baseline care plan for the use of the incentive spirometer, LPN # 4 reviewed the baseline care plan for Resident # 163 and stated that they could not locate one. On 01/08/20 at 1:43 p.m., an interview was conducted with LPN # 5, traveling MDS coordinator. LPN # 5 stated there was no physician order for Resident # 163's incentive spirometer. LPN # 5 further stated that they had spoken to Resident # 163's nurse practitioner and that Resident # 163 would benefit from the use of the incentive spirometer. LPN # 5 stated they would obtain a physician's order for prn [as needed] use of an incentive spirometer and update the plan of care. On 01/08/2020 at approximately 2:00 p.m., LPN # 5 provided this surveyor with a copy of Resident # 163's revised baseline care plan. The baseline care plan documented, Altered Cardiac/Resp [Respiratory] Functioning. Encourage use of incentive spirometer PRN (as needed) 1/8/20. The facility policy Plans of Care documented in part the following: Procedure: Develop and implement an Individualized-Person-Centered baseline care plan within 48 hours of admission that includes, but not limited to, initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, PASARR [Preadmission Screening and Resident Review] recommendations, if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed. On 01/08/2020 at approximately 5:50 p.m., ASM (administrative staff member) # 1, the executive director and ASM # 2, director of nursing, ASM # 3, regional director of clinical services and LPN # 5 traveling MDS coordinator, were made aware of the findings. No further information was provided prior to exit. References: [1] A device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm. [2] Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for six of 32 residents in the survey sample, Residents #47, 41, 61, 37, 3, and 25. The comprehensive care plan for Resident #47, failed to evidence documentation for as needed use of oxygen. The facility staff failed to include the use of an incentive spirometer when they developed Resident #41's comprehensive care plan for altered respiratory status, dated 1/7/20, and failed to develop the comprehensive care plan for care and services of the resident's disease process of diabetes. The facility staff failed to include an intervention of a scoop mattress on Resident #61's comprehensive care plan that the facility determined was a required intervention, after a fall on 12/29/19; and failed to follow the care plan for the use of fall mats after a fall on 12/29/19. The facility staff failed to implement the comprehensive care plan for the administration of blood pressure medications to Resident #37. The facility staff failed to implement resident # 3's and Resident #25's comprehensive care plan for the administration of oxygen. The findings include: 1. Resident #47 was admitted to the facility 12/13/2019 with diagnoses, that included but were not limited to congestive heart failure (1), pneumonia (2) and chronic obstructive pulmonary disease (3). Resident #47's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/19/19, coded Resident #47 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Section O of the MDS documented Resident #47 as receiving oxygen therapy while a resident of the facility. On 1/7/19 at approximately 2:30 p.m., an interview was conducted with Resident #47. Observation of Resident #47's room revealed an oxygen concentrator located on the right side of the bed with a nasal cannula (oxygen delivery device) in a plastic bag and a prefilled humidifier bottle of sterile water dated 12/23/19. When asked about the oxygen, Resident #47 stated that she did not use it currently. Resident #47 stated that she used her oxygen when she first came into the facility in the middle of December but had not used it recently but it was there in case she felt that she needed it. The order summary report dated 01/01/20 through 01/31/20 documented, 12/14/19 Oxygen @ (at) 2 (two) LPM (liters per minute) via (by way of) N/C (nasal cannula) to maintain sats (oxygen saturations) > (greater than) 92%. The MAR (medication administration record) dated December 2019, and January 2020 for Resident #47 failed to evidence documentation of oxygen for Resident #47. The TAR (treatment administration record) dated 01/01/20-01/31/20 failed to evidence documentation of oxygen for Resident #47. The baseline care plan dated 12/15/19 for Resident #47 documented Altered Cardiac/Resp. (respiratory) functioning). Under Interventions: it documented in part, O2 (oxygen) therapy as ordered, Monitor O2 saturation as ordered. The baseline care plan further documented, Below are signatures and dates signifying the final review of the baseline care plan with transition to the Comprehensive Care Plan, signed by [Name of registered nurse] and [Name of Resident #47], dated 12/30/19. The baseline care plan further documented in part, This baseline care plan will be effective until the development of the Comprehensive Care Plan, which will supersede the baseline care plan. This document will remain a part of the resident's permanent record. The comprehensive care plan for Resident #47 failed to evidence documentation for as needed use of oxygen. On 1/08/20 at 04:00 p.m., an interview was conducted with LPN (licensed practical nurse) #2. When asked the purpose of the care plan, LPN #2 stated that it lets you know how to take care of the patient. When asked when care plans are completed, LPN #2 stated that new admissions have baseline care plans completed in 24 hours and then the MDS (minimum data set) staff update them. LPN #2 stated that when new orders are received or changes occur that new interventions are added to the care plan. When asked if oxygen should be on the comprehensive care plan, LPN #2 stated that it should. On 1/8/20 at 5:25 p.m., an interview was conducted with LPN #6, MDS (minimum data set) coordinator. When asked the purpose of the comprehensive care plan, LPN #6 stated that it is used to drive the plan of care of the resident. When asked if oxygen should be on the comprehensive care plan for a resident, LPN #6 stated that it should be. When asked if the oxygen is ordered and available for use in the resident's room should it still be on the care plan LPN #6 stated, Yes. When asked about the care plan for Resident #47 for oxygen administration as needed, LPN #6 stated that she did not see one in the record for Resident #47. On 1/9/20 at 9:45 a.m., an interview was conducted with LPN #5, traveling MDS coordinator. When asked how long the baseline care plan is effective for residents, LPN #5 stated that they are good for 21 days or until the comprehensive care plan is completed. LPN #5 stated that when the comprehensive care plan is completed it supersedes the baseline care plan and it is kept on the record as a reference afterwards. On 01/09/20 at approximately 12:30 p.m., a request was made by written list to ASM (administrative staff member) #1, the executive director for the facility policy on developing and implementing the care plan. On 01/20/20 at approximately 1:30 p.m., ASM (administrative staff member) #2, the director of nursing stated that the facility uses their policies, [NAME], and [NAME] & [NAME] as their standard of practice. The facility policy Plans of Care, Effective Date: 11/30/2014; Revision Date: 09/25/2017 documented in part, Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. According to [NAME], [NAME] A., & [NAME], [NAME]. (2005). Fundamentals of Nursing, sixth Edition, St. Louis, MO: Mosby, Inc. Page 327, A nursing care plan is a guide for clinical care. It also serves as a document that communicates a client's nursing care to all members of the health care team. It is made available to the team as a ready reference for nursing care interventions. On 01/08/20 at approximately 5:50 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and LPN (licensed practical nurse) #5, the travelling MDS coordinator were made aware of the findings. On 1/9/20 at approximately 8:00 a.m., ASM (administrative staff member) #3, the regional director of clinical services provided a copy of Physician's Interim/Telephone Orders for Resident #47, which documented, DC (discontinue) O2 (oxygen), Duonebs (nebulizer medication) & (and) IS (incentive spirometer) dated 1/8/20, 1610 (4:10 p.m.). ASM #3 also provided a copy of the baseline care plan for Resident #47 as documented above. No further information was provided prior to exit. Reference: 1. Congestive heart failure is a condition in which the heart can't pump enough blood to meet the body's needs. This information was obtained from the website: https://medlineplus.gov/heartfailure.html 2. Pneumonia - An infection in one or both of the lungs. This information was obtained from the website: https://medlineplus.gov/pneumonia.html. 3. Chronic obstructive pulmonary disease (COPD) is a disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 5. The facility staff failed to implement resident # 3's comprehensive care plan for the administration of oxygen. Resident # 3 was admitted to the facility on [DATE] with a readmission of 07/22/2019 with diagnoses that included but were not limited to respiratory failure, shortness of breath and chronic obstructive pulmonary disease [1]. Resident # 3's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/26/19, coded Resident # 3 as scoring a 12 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 12- being moderately impaired of cognition for making daily decisions. Resident # 3 was coded as requiring extensive assistance of one staff member for activities of daily living. Section O Special Treatments, Procedures and Programs coded Resident # 3 for the use of oxygen. On 01/07/2020 at approximately 3:15 P.m., an observation of Resident # 3 revealed they were lying in bed receiving oxygen by nasal cannula connected to an oxygen concentrator that was running. Observation of the oxygen flow meter on the oxygen concentrator revealed a flow rate of one-and-a-half liters per minute. On 01/08/2020 at 10:39 a.m., an observation of Resident # 3 revealed they were lying in bed receiving oxygen by nasal cannula connected to an oxygen concentrator that was running. Observation of the oxygen flow meter on the oxygen concentrator revealed a flow rate of one-and-a-half liters per minute. The POS [physician's order sheet] dated 01/01/2020 through 01/31/2020 and signed by the physician on 1/7/2020 for Resident # 3 documented, 09/04/19 Oxygen at 2L [two liters per minute] via [by] nasal cannula every shift. The comprehensive care plan for Resident # 3 with a revision date of 12/31/2018 documented, Focus: [Resident # 3] has shortness of breath SOB r/t [related to] Decreased lung expansion. Date Initiated 12/31/2018. Revision on 12/31/2018. Under Interventions it documented in part, Oxygen setting: O2 [oxygen] 2L via NC [nasal cannula]. Date Initiated 12/31/2018. Revision on 04/16/2019. On 01/08/2020 at 1:00 p.m., an interview was conducted with LPN [licensed practical nurse] # 4. When asked to describe the procedure for reading the oxygen, flow rate meter on an oxygen concentrator, LPN # 4 stated, You should be at eye level with the meter and the liter line should pass through the middle of the ball. LPN # 4 was asked to read the flow meter on Resident # 3's oxygen concentrator. After looking at the flow meter, LPN # 4 stated the oxygen flow rate was at one-and-a-half liters per minute. When asked what the flow rate should be, LPN # 4 stated two-liter's per-minute. LPN # 4 then readjusted the flow rate on the oxygen concentrator. After reviewing Resident # 3's comprehensive care plan for oxygen, LPN # 4 was asked if the care plan was being implemented. LPN # 4 stated no. On 01/08/2020 at approximately 5:50 p.m., ASM (administrative staff member) # 1, the executive director and ASM # 2, director of nursing, ASM # 3, regional director of clinical services and LPN # 5 traveling MDS coordinator, were made aware of the findings. No further information was provided prior to exit. References: [1] Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 6. The facility staff failed to implement resident # 25's comprehensive care plan for the administration of oxygen. Resident # 25 was admitted to the facility on [DATE] with diagnoses that included but were not limited to respiratory failure, shortness of breath and chronic obstructive pulmonary disease [1]. Resident # 25's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/29/19, coded Resident # 25 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making daily decisions. Resident # 25 was coded as requiring extensive assistance of one staff member for activities of daily living. Section O Special Treatments, Procedures and Programs coded Resident # 25 for the use of oxygen. On 01/07/20 at 1:25 p.m., an observation of Resident #25 revealed the resident in bed receiving oxygen by nasal cannula connected to an oxygen concentrator that was running. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate set at three-and-a-half liters per minute. On 01/07/20 at 2:45 p.m., an observation of Resident #25 revealed they were in bed receiving oxygen by nasal cannula connected to an oxygen concentrator that was running. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate set at three-and-a-half liters per minute. On 01/07/20 at 4:05 p.m., an observation of Resident #25 revealed the resident in bed receiving oxygen by nasal cannula connected to an oxygen concentrator that was running. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate set at three-and-a-half liters per minute. On 01/08/20 at 8:30 a.m., an observation of Resident #25 revealed the resident in bed receiving oxygen by nasal cannula connected to an oxygen concentrator that was running. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate set at three-and-a-half liters per minute. The POS [physician's order sheet] dated 01/01/2020 through 01/31/2020 and signed by the physician on 1/7/2020 for Resident # 3 documented, 12/17/19 Oxygen @ [at] 4L [four liters per minute] via [by] nasal cannula continuous every shift to maintain SPO2 [oxygen saturation] [2] greater than 90%. The comprehensive care plan for Resident # 25 with a revision date of 12/03/2019 documented, Focus: [Resident # 25] has Congestive Heart Failure. Revision Date: 12/03/2019. Under Interventions it documented in part, Oxygen setting: O2 [oxygen] via NC [nasal cannula] at 4L. Revision on 12/03/2019. On 01/08/2020 at approximately 1:00 p.m., an interview was conducted with LPN [licensed practical nurse] # 4. When asked to describe the procedure for reading the oxygen, flow rate meter on an oxygen concentrator, LPN # 4 stated, You should be at eye level with the meter and the liter line should pass through the middle of the ball. LPN # 4 was asked to read the flow meter on Resident # 25's oxygen concentrator. After looking at the flow meter, LPN # 4 stated the oxygen flow rate was at three-and-a-half liters per minute. When asked what the flow rate should be, LPN # 4 stated four-liter's per-minute. LPN # 4 then readjusted the flow rate on the oxygen concentrator. After reviewing Resident # 25's comprehensive care plan for oxygen, LPN # 4 was asked if the care plan was being implemented. LPN # 4 stated no. On 01/08/2020 at approximately 5:50 p.m., ASM (administrative staff member) # 1, the executive director and ASM # 2, director of nursing, ASM # 3, regional director of clinical services and LPN # 5 traveling MDS coordinator, were made aware of the findings. No further information was provided prior to exit. References: [1] Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 2a. The facility staff failed to include the use of an Incentive Spirometer when they developed Resident #41's comprehensive care plan for altered respiratory status, dated 1/7/20. Resident #41 was admitted to the facility on [DATE]; diagnoses include, but are not limited to, hydrocephalus, psychotic disorder, right kidney cancer with removal of kidney, cardiac defibrillator, high blood pressure, atrial fibrillation, diabetes, bipolar disorder, spinal stenosis with fusion, and cerebral palsy. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/21/19 coded the resident as being cognitively intact in ability to make daily life decisions. The resident was coded as requiring extensive care for bathing, toileting, dressing, and transfers; supervision for eating and hygiene; and was incontinent of bowel and bladder. A review of the facility policy, Plans of Care documented, Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment The individualized Person Centered plan of care may include but is not limited to the following: Resident's strengths and needs; Services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being A review of the comprehensive care plan revealed one dated 1/7/20 for (Resident #41) has altered respiratory status/difficulty breathing r/t (related to) Wheezing. This care plan failed to reveal the use of the Incentive Spirometer. On 1/07/20 at 12:10 PM, an observation was made of Resident #41's room. Resident #41 was not in the room. An Incentive Spirometer was observed on the over bed table. On 1/08/20 at 8:52 AM, the resident was observed inn bed. The Incentive Spirometer remained as previously observed. On 1/08/20 at 1:00 PM, the Resident #41 was observed, and an interview was conducted. The over bed table was across the resident. The incentive spirometer was on the table. Resident #41 stated that he has used it on occasion. On 1/8/20 at 1:07 PM in an interview with RN #1 (Registered Nurse), she stated that there should be an order for the use of the Incentive Spirometer. RN #1 stated that the residents come in with them from the hospital. On 1/8/19 at 4:04 PM, during in an interview with LPN #2 (Licensed Practical Nurse), when asked about the purpose of a comprehensive care plan, LPN #2 stated, so that we know how to take care of the patient. When asked if a resident's conditions, treatments, medications, etc., should be care planned, LPN #2 stated, Yes. On 1/8/19 at 3:13 PM, in an interview with RN #1, she stated that it (Incentive Spirometer) should have been care planned when he came back from the hospital with it on 12/28/19. RN #1 stated that he would benefit from using it since he has been treated for respiratory issues since 1/6/20. On 1/8/20 at 5:50 PM, ASM #1 (Administrative Staff Member - the Executive Director) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. 2b. The facility staff failed to develop the comprehensive care plan for care and services of the Resident #41's disease process of diabetes. On 1/08/20 at 8:52 AM, RN #1 (Registered Nurse) was observed preparing and administering the following medications to Resident #41: • Clonidine (1) 0.1 mg (milligrams), 1 tablet • Metoprolol (2) 100 mg, 1 tablet • Metformin (3) 500 mg, 1 tablet • Depakote (4) ER (extended release) 500 mg, 1 tablet • Accupril (5) 20 mg, 1 tablet • Folic Acid (6) 1 mg, 1 tablet • Azithromycin (7) 250 mg, 1 tablet • Prednisone (8) 20 mg, 1 tablet • Mucinex (9) 600 mg, 1 tablet (as needed) Upon record review, the following medications were also noted as being ordered but were not prepared and administered to Resident #41: • Multivitamin (10), 1 tablet daily. • Vitamin D (11) 25 mcg (micrograms) (1000 units), daily. • Glimepiride (12) 4 mg tablet daily. The comprehensive care plan was reviewed in relation to the resident's diagnosis of diabetes and the administration of his diabetic medications (Metformin and Glimepiride, specifically the Glimepiride; that was not administered as ordered). There was no documented comprehensive care plan developed for the provision of care and services related to the resident's diabetes. On 1/8/20 at 4:04 PM, in an interview with LPN #2 (Licensed Practical Nurse), when asked about the purpose of a comprehensive care plan, LPN #2 stated, so that we know how to take care of the patient. When asked if a resident's conditions, treatments, medications, etc., should be care planned, LPN #2 stated, Yes. On 1/9/20 at 1:07 PM, ASM #1 (Administrative Staff Member - the Executive Director) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. References: 1. Clonidine - is used to treat high blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a682243.html 2. Metoprolol - is used to treat high blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a682864.html 3. Metformin - is used to treat diabetes Information obtained from https://medlineplus.gov/druginfo/meds/a696005.html 4. Depakote ER - is used to treat bipolar disorder Information obtained from https://medlineplus.gov/druginfo/meds/a682412.html 5. Accupril - is used to treat high blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a692026.html 6. Folic Acid - helps the body make healthy new cells. Information obtained from https://medlineplus.gov/folicacid.html 7. Azithromycin - is an antibiotic. Information obtained from https://medlineplus.gov/druginfo/meds/a697037.html 8. Prednisone - reduces swelling and redness by changing the way the immune system works. Information obtained from https://medlineplus.gov/druginfo/meds/a601102.html 9. Mucinex - is used to relieve chest congestion. Information obtained from https://medlineplus.gov/druginfo/meds/a682494.html 10. Multivitamin - used to treat or prevent vitamin deficiency due to poor diet, certain illnesses, or during pregnancy. Vitamins are important building blocks of the body and help keep you in good health. Information obtained from https://www.webmd.com/drugs/2/drug-18820-9038/multivitamin-oral/multivitamins-includes-prenatal-vitamins-oral/details 11. Vitamin D - Vitamins are substances that your body needs to grow and develop normally. Vitamin D helps your body absorb calcium. Calcium is one of the main building blocks of bone. A lack of vitamin D can lead to bone diseases such as osteoporosis or rickets. Vitamin D also has a role in your nerve, muscle, and immune systems. Information obtained from https://medlineplus.gov/vitamind.html 12. Glimepiride - is used to treat diabetes. Information obtained from https://medlineplus.gov/druginfo/meds/a696016.html 3. The facility staff failed to include an intervention of a scoop mattress on Resident #61's comprehensive care plan that the facility determined was a required intervention, after a fall on 12/29/19; and failed to follow the care plan for the use of fall mats after a fall on 12/29/19. Resident #61 was admitted to the facility on [DATE]; diagnoses include but are not limited to, dementia with behaviors, panic disorder, thyroid disorder, restless leg, anxiety disorder, high blood pressure and delirium. The admission / 5-day MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 12/29/19 coded the resident as being severely impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing, hygiene, toileting, and eating; extensive assistance for ambulation and transfers; and was coded as incontinent of bowel and bladder. A review of the clinical record revealed a nurse's note dated 12/29/19 at 6:30 AM that documented, Resident yelling out help me! Found on floor in sitting position. MAEW (moves all extremities well), vital signs obtained, neuro (neurological) checks initiated. NP (nurse practitioner), son, and RP (responsible party) notified. A review of a fall investigation dated 12/29/19 documented that the resident stated she had to go to the bathroom but did not ask for help. An Interdisciplinary Team (IDT) meeting note dated 12/30/19 documented, IDT met to discuss/review resident's fall on 12/29/19. Found sitting on (R) (right) side of bed in floor in sitting position. No injuries. B+B (bowel and bladder), med [medication] review. No further recommendations at this time. An Interdisciplinary Team meeting note dated 1/3/20 documented, IDT met to discuss/review 60 day look back on falling last 30 days. B+B, med review. No further recommendations at this time. An Interdisciplinary Team meeting note dated 1/6/20 documented, IDT met to discuss/review fall on 1/3/20 (note: there was no fall noted on 1/3/20. Note refers to the IDT note dated 1/3/20). Found laying (Sic.) on floor beside bed. No injuries. Fall mats, scoop mattress. No further recommendations. On 1/08/20 at 9:57 AM, Resident #61 was observed in bed asleep. There were no fall mats next to the resident's bed and no scoop mattress observed on the bed. A review of the comprehensive care plan dated 12/30/19 for (Resident #61) has had an actual fall with no injury r/t (related to) poor balance, poor communication/comprehension. This care plan included the intervention, dated 12/30/19 for Fall mats on both sides of bed. The care plan did not include any intervention for the scoop mattress. On 1/09/20 at 10:46 AM, LPN #3 (Licensed Practical Nurse) was asked about the fall mats and scoop mattress for Resident #61. She stated that she was not aware the resident was to have fall mats and a scoop mattress. At this time, she checked on Resident #61 and verified that there were no fall mats or scoop mattress in place. When asked about implementing these interventions, LPN #3 stated, They should have been implemented as soon as it was decided she needed them. When asked about updating and following the care plan for these interventions, LPN #3 stated, They should have been care-planned and the care plan followed for them. On 1/9/20 at 1:07 PM, ASM #1 (Administrative Staff Member - the Executive Director) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. 4. The facility staff failed to implement the comprehensive care plan for the administration of blood pressure medications to Resident #37. Resident #37 was admitted to the facility on [DATE]; diagnoses include but are not limited to, encephalopathy, heart disease, dysphagia, diabetes, atrial flutter, abdominal aortic aneurysm, high blood pressure, cardiac pacemaker, and pneumonia. The admission / 5-day MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 12/17/19 coded the resident as significantly cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing and toileting; extensive assistance for transfers, dressing, and hygiene; was independent for eating; and incontinent of bowel and bladder. A review of the comprehensive care plan for Resident #37 revealed one dated 1/8/20 for (Resident #37) has altered cardiovascular status r/t (related to) CVA (cerebral vascular disease), CAD (coronary artery disease), HTN (hypertension - high blood pressure), HLP (hyperlipidemia). This care plan included the intervention, dated 1/8/20, for Administer cardiac meds [medications] and monitor for side effects. On 1/08/20 at 9:08 AM, RN #1 (Registered Nurse) was observed to prepare and administer the following medications for Resident #37: Allopurinol (1) 100 mg (milligrams), 1 tablet Atenolol (2) 25 mg, 3 tablets for 75 mg (RN #1 only prepared 1 tablet). Eliquis (3) 2.5 mg, 1 tablet Multivitamin (4), 1 tablet Vitamin D3 (5), 1000 units, 2 tablets for 2000 units. On 1/8/19 at 3:27 PM, during an interview with RN#1, when asked about the five rights of medication administration, RN #1 stated, Right person, right dose, right med, right time, right route. Review of the clinical record and medications, the physician's orders documented that the resident was to receive three tablets (75 mg) of the Atenolol. RN #1 only administered one tablet during the observation. On 1/09/20 at 9:54 AM, in a follow up interview with RN #1, when asked about the dose of the Atenolol, RN #1 stated, I don't know. I don't know him that well. When asked if the comprehensive care plan was implemented for the administration of his blood pressure medication, RN #1 stated it was not. On 1/9/20 at 1:07 PM, ASM #1 (Administrative Staff Member - the Executive Director) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. References: 1. Allopurinol is used to treat gout. Information obtained from https://medlineplus.gov/druginfo/meds/a682673.html 2. Atenolol is used to treat high blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a684031.html 3. Eliquis is used to prevent strokes and blood clots in people with atrial fibrillation. Information obtained from https://medlineplus.gov/druginfo/meds/a613032.html 4. Multivitamin - used to treat or prevent vitamin deficiency due to poor diet, certain illnesses, or during pregnancy. Vitamins are important building blocks of the body and help keep you in good health. Information obtained from https://www.webmd.com/drugs/2/drug-18820-9038/multivitamin-oral/multivitamins-includes-prenatal-vitamins-oral/details 5. Vitamin D - Vitamins are substances that your body needs to grow and develop normally. Vitamin D helps your body absorb calcium. Calcium is one of the main building blocks of bone. A lack of vitamin D can lead to bone diseases such as osteoporosis or rickets. Vitamin D also has a role in your nerve, muscle, and immune systems. Information obtained from https://medlineplus.gov/vitamind.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan, for two of 32 residents in the survey sample, Resident #6 and Resident #25. The facility staff failed to review and revise Resident #6's comprehensive care plan to include hospice care and services and care of an indwelling catheter. The facility staff failed to review and revise the comprehensive care plan for Resident #25 to include the use of an incentive spirometer [1]. The findings include: 1. Resident # 6 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: heart failure, stage 4-kidney disease and high cholesterol. Resident # 6's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/22/19, coded Resident # 6 as scoring a 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. The POS [physician's order sheet] dated and signed by the physician on 12/27/19, for Resident # 6 documented, Hospice services to eval [evaluate]. [Name of Hospice and Telephone Number]. Hospice nurse to be @ [at] facility 12/28/2019. Dated: 12/27/2019. Foley catheter for comfort measures. Dated: 12/27/2019. Review of Resident # 6's clinical record revealed a document entitled, [Name of Hospice] form. The form documented in part, Patient Name: [Name of Resident # 6]. This is a patient of [Name of Hospice], INC. as of 12/28/19. The comprehensive care plan for Resident # 6 dated of 01/06/2020 failed to evidence care and services for an indwelling catheter, and failed to evidence documentation for hospice care and services. On 01/08/2020 at 3:20 p.m., an interview was conducted with LPN [licensed practical nurse] # 5, traveling MDS coordinator. When asked to describe the purpose of the resident's comprehensive care plan, LPN # 5 stated, It is specific to the resident and tells what should be done for the resident. When asked to describe the process for updating the comprehensive care plan, LPN # 5 stated, When there is a change in the resident's status, condition or treatment the care plan should be updated. LPN # 5 was asked to review the comprehensive care plan for Resident # 6. When asked if the comprehensive care plan for Resident # 6 included hospice care, LPN # 5 stated she was unable to locate it on the care plan. When asked if the care plan should have been updated to include hospice care being provided, LPN # 5 stated, Yes. When asked if the comprehensive care plan for Resident # 6 included care and services for an indwelling catheter, LPN # 5 stated, No, there isn't a care plan for it. On 01/09/2020 at approximately 8:10 a.m., ASM [administrative staff member] # 2, director of nursing, provided this surveyor with an updated copy of Resident # 6's comprehensive care plan. The care plan documented, Focus: [Resident # 6] has a terminal prognosis r/t [related to] end of life hospice care. Date Initiated: 01/08/2020 and Focus: [Resident # 6] has indwelling catheter r/t terminal condition. Date Initiated: 01/08/2020. The facility's policy Plans of Care documented in part, Review, update and/or revise the comprehensive care plan based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA [ Omnibus Budget Reconciliation Act] MDS [minimum data set] assessment (except discharge assessment) and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental and psychosocial well-being. On 01/08/2020 at approximately 5:50 p.m., ASM # 1, the executive director and ASM # 2, director of nursing, ASM # 3, regional director of clinical services and LPN # 5 traveling MDS coordinator, were made aware of the findings. No further information was provided prior to exit. 2. Resident # 25 was admitted to the facility on [DATE] with diagnoses that included but were not limited to respiratory failure, shortness of breath and chronic obstructive pulmonary disease [2]. Resident # 25's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/29/19, coded Resident # 25 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making daily decisions. Resident # 25 was coded as requiring extensive assistance of one staff member for activities of daily living. Section O Special Treatments, Procedures and Programs coded Resident # 25 for the use of oxygen. On 01/07/20 at 1:25 p.m., an observation of Resident # 25's bedside table revealed an incentive spirometer uncovered. When asked if they use the incentive spirometer [1] Resident # 25 stated yes. On 01/07/20 at 2:45 p.m., and at 4:05 p.m., observations of Resident # 25's bedside table revealed an incentive spirometer uncovered. On 01/08/20 at 8:30 a.m., an observation of Resident # 25's bedside table revealed an incentive spirometer uncovered. Review of Resident # 25's clinical record failed to evidence a physician's order for the use of an incentive spirometer. On 01/08/2020 at 1:00 p.m., an interview was conducted with LPN [licensed practical nurse] # 4. When asked about a physician's order for the use of the incentive spirometer for Resident # 25, LPN # 4 reviewed the physician's orders and stated that they could not locate one. The comprehensive care plan for Resident # 25 with a revision date of 12/03/2019 failed to evidence documentation for the use of an incentive spirometer. On 01/08/20 at 3:20 p.m., an interview was conducted with LPN # 5, traveling MDS coordinator. After reviewing Resident # 25's comprehensive care plan, LPN # 5 was asked if the care plan had been updated to include the incentive spirometer. LPN # 5 stated, No, there isn't a care plan for it. On 01/08/2020 at approximately 4:00 p.m., LPN # 5 stated they had spoken to the nurse practitioner and stated, The nurse practitioner feels she [Resident # 25] doesn't need it [incentive spirometer] so I will remove it. It was something she had in her belonging when she came here. On 01/08/2020 at approximately 5:50 p.m., ASM # 1, the executive director and ASM # 2, director of nursing, ASM # 3, regional director of clinical services and LPN # 5 traveling MDS coordinator, were made aware of the findings. No further information was provided prior to exit. References: [1] A device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm. [2] Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and review of facility documentation it was determined the facility staff failed to provide treatment and care in accordance with professional standards of practice for one of 32 residents in the survey sample, Resident #3. The facility staff failed to administer sliding scale insulin per the physician orders to Resident # 3. On 01/07/2020 at 7:30 a.m., 11:30 a.m. and 4:30 p.m., and 01/08/2020 at 7:30 a.m., 11:30 a.m. there was no documentation of the amount of insulin administered or the location of the injections. The findings include: Resident # 3 was admitted to the facility on [DATE] with a readmission of 07/22/2019 with diagnoses that included but were not limited to type 2 diabetes mellitus with complications [1]. Resident # 3's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/26/19, coded Resident # 3 as scoring a 12 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 12- being moderately impaired of cognition for making daily decisions. Resident # 3 was coded as requiring extensive assistance of one staff member for activities of daily living. Section N Medications coded Resident # 3 as receiving insulin injections during the past seven days. The POS [physician's order sheet] dated 01/01/2020 through 01/31/2020 for Resident # 3 documented, Novolog [2] Flexpen 100/ML [milliliter] Unit. Inject subcutaneously three times daily before meals per sliding scale: 150-199: 3 units, 200-249: 6 units, 250-299: 9 units, 300-349: 12 units, > [greater than] 350 or < [[NAME] than] 60 call provider for diabetes mellitus. Date 09/03/2019. The MAR [medication administration record] for Resident # 3, dated January 2020 documented the physician's order as above. Review of the MAR revealed Resident # 3's blood sugar on 01/07/20 was 198 at 7:30 a.m., 206 at 11:30 a.m., and 149 at 4:30 p.m. On 01/08/20, Resident # 3's blood sugars were 172 at 7:30 a.m. and 189 at 11:30 a.m. Further review of the MAR failed to evidence the amount of insulin administered and the location of the injection on the dates and times above. The facility's nurse's notes dated 01/07/2020 through 01/08/2020 failed to evidence the amount of insulin administered and the location of the injection on the dates and times above. On 01/08/2020 at 3:00 p.m., an interview was conducted with LPN [licensed practical nurse] # 4 regarding the documentation of Resident # 3's insulin. After reviewing the MAR [medication administration record] dated January 2020 and nurse's notes dated 01/07/2020 through 01/08/2020. When asked about the lack of documentation showing how much insulin was administered and location of the injection site, LPN # 4 stated, It doesn't say if she got it [insulin] or where. When asked if they could evidence the sliding scale, insulin was administered as ordered, LPN # stated, Absolutely not. On 01/09/20 at 11:14 a.m., an interview was conducted with ASM [administrative staff member] # 2, director of nursing. When asked to describe the documentation procedure for insulin administration, ASM # 2 stated, Write down what the insulin is, give according to the sliding scale, document how much was given and I'll ask the resident where they want the injection. When asked if they follow a procedure to rotate the injection site ASM # 2 stated, Not all the time. When asked about a negative outcome of not rotating the site ASM # 2 stated, There wouldn't be because were not injecting in the exact same spot. ASM # 2 agreed that it could not be determined how if any insulin was administered per the physician order due to the lack of documentation. The facility's policy Insulin Administration documented in part, Rotate and document injection sites; Document medical record. Insulin Injection Know How. Select a part of your body that you can see, reach, and access easily. But be sure to use a number of different spots within that body part. This is called rotating injection sites. Injecting into the same spot too often can cause skin problems and can impair insulin absorption. This information was obtained from the website: https://www.diabeteseducator.org/docs/default-source/legacy-docs/_resources/pdf/general/Insulin_Injection_Pro_Tips_AADE.pdf On 01/08/2020 at approximately 5:50 p.m., ASM (administrative staff member) # 1, the executive director and ASM # 2, director of nursing, ASM # 3, regional director of clinical services and LPN # 5 traveling MDS coordinator, were made aware of the findings. No further information was provided prior to exit. References: [1] A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure environment free of accident hazards and assistance devices to prevent accidents for one of 32 residents in the survey sample; Resident #61. The facility staff failed to implement fall interventions for Resident #61 after a fall on 12/29/19, fall mats and a scoop mattress were determined by the facility to be required interventions. Neither intervention had been implemented as of the survey date of 1/9/20. The findings include: Resident #61 was admitted to the facility on [DATE]; diagnoses include but are not limited to dementia with behaviors, panic disorder, thyroid disorder, restless leg, anxiety disorder, high blood pressure and delirium. The admission / 5-day MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 12/29/19 coded the resident as being severely impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing, hygiene, toileting, and eating; extensive assistance for ambulation and transfers; and was coded as incontinent of bowel and bladder. On 1/08/20 at 9:57 AM, Resident #61 was observed in bed asleep. No fall mats were observed next to the resident's bed and no scoop mattress observed on the bed. On 1/09/20 at 10:46 AM, LPN #3 (Licensed Practical Nurse) was asked about the fall mats and scoop mattress for Resident #61. She stated that she was not aware the resident was to have fall mats and a scoop mattress. At this time, she checked on Resident #61 and verified that there were no fall mats or scoop mattress in place. When asked about implementing these interventions, LPN #3 stated, They should have been implemented as soon as it was decided she needed them. A review of the admission nursing assessment dated [DATE] documented under Fall Risk: History of Falls: ___No history of falls; ___Fell in past 30 days; ___Fell in past 31-180 days. The box for Fell in past 30 days was marked. In addition, a Fall Risk Evaluation form was completed which coded the resident as an 18. This form documented, A resident who scores a 10 or higher is at risk. A review of the clinical record revealed a nurse's note dated 12/29/19 at 6:30 AM that documented, Resident yelling out help me! Found on floor in sitting position. MAEW (moves all extremities well), vital signs obtained, neuro [neurological] checks initiated. NP (nurse practitioner), son, and RP (responsible party) notified. A review of a fall investigation dated 12/29/19 documented that the resident stated she had to go to the bathroom but did not ask for help. An Interdisciplinary Team (IDT) meeting note dated 12/30/19 documented, IDT met to discuss/review resident's fall on 12/29/19. Found sitting on (R) (right) side of bed in floor in sitting position. No injuries. B+B (bowel and bladder), med [medication] review. No further recommendations at this time. An Interdisciplinary Team meeting note dated 1/3/20 documented, IDT met to discuss/review 60 day look back on falling last 30 days. B+B, med review. No further recommendations at this time. An Interdisciplinary Team meeting note dated 1/6/20 documented, IDT met to discuss/review fall on 1/3/20 (note: there was no fall noted on 1/3/20. Note refers to the IDT note dated 1/3/20). Found laying (Sic.) on floor beside bed. No injuries. Fall mats, scoop mattress. No further recommendations. A review of the comprehensive care plan dated 12/30/19, documented, (Resident #61) has had an actual fall with no injury r/t (related to) poor balance, poor communication/comprehension. This care plan included the intervention, dated 12/30/19 for Fall mats on both sides of bed. The care plan did not include any intervention for the scoop mattress. A review of the facility policy, Fall Management documented, B. Fall Mitigation Strategies: 1. Develop resident centered interventions based on resident risk factors. 2. Update the resident's care plan and the Nurse Aide [NAME] with interventions .C. Post Fall Strategies: .4. Re-evaluate fall risk utilizing the Post Fall Evaluation; 4. Update Care plan and Nurse Aide [NAME] with intervention(s) .8. Update plan of care with new interventions as appropriate On 1/9/20 at 1:07 PM, ASM #1 (Administrative Staff Member - the Executive Director and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility staff failed to ensure that two of four residents in the Medication Administration task (Residents #41 and #37) were free of medication errors of less than 5%. Out of 32 opportunities, five errors were observed, resulting in a medication error rate of 15.63%. The facility staff failed to ensure that Resident #41 was free of medication errors. Resident #41 was administered a medication that was not ordered for him and staff failed to administer ordered medications. The facility staff failed to ensure that Resident #37 was free of medication errors. Resident #37 was administered a partial dose of the blood pressure medication, Atenolol, and not the full dose that was ordered. The findings include: 1. Resident #41 was admitted to the facility on [DATE]; diagnoses included but are not limited to hydrocephalus, psychotic disorder, right kidney cancer with removal of kidney, cardiac defibrillator, high blood pressure, atrial fibrillation, diabetes, bipolar disorder, spinal stenosis with fusion, and cerebral palsy. The quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 12/21/19 coded the resident as being cognitively intact in ability to make daily life decisions. The resident was coded as requiring extensive care for bathing, toileting, dressing, and transfers; supervision for eating and hygiene; and was incontinent of bowel and bladder. On 1/08/20 at 8:52 AM, RN #1 (Registered Nurse) was observed preparing and administering the following medications to Resident #41: • Clonidine (1) 0.1 mg (milligrams), 1 tablet • Metoprolol (2) 100 mg, 1 tablet • Metformin (3) 500 mg, 1 tablet • Depakote (4) ER (extended release) 500 mg, 1 tablet • Accupril (5) 20 mg, 1 tablet • Folic Acid (6) 1 mg, 1 tablet, observation revealed another resident's name was documented on the pharmacy label of the medication card. • Azithromycin (7) 250 mg, 1 tablet • Prednisone (8) 20 mg, 1 tablet • Mucinex (9) 600 mg, 1 tablet (as needed) Upon record review of the physician's orders, it was verified that Resident #41 was not ordered to receive the Folic Acid that was observed being administered to the resident as documented above from another resident's medication card. In addition, upon record review, the following medications were noted as being ordered but were not prepared and administered: • Multivitamin (10) 1 tablet every morning (listed on orders but was not given.) • Vitamin D (11) 25 mcg (micrograms) (1000 units) every morning (listed on orders but was not given.) • Glimepiride (12) 4 mg tablet daily (listed on orders but was not observed administered.) These medications were not administered and were all listed on the same page of the MAR (Medication Administration Record), evidencing an entire page of medications was missed during the Medication Administration observation. The multivitamin, Vitamin D, Glimepiride, and Folic Acid were all medication errors for Resident #41. On 1/08/20 at 1:07 PM, in an interview with RN #1, when asked how Resident #41 was administered a medication he was not ordered, the Folic Acid medication that was not listed on Resident #41's MAR, that had another resident's name documented on it, if she was comparing the MAR (Medication Administration Record) to the medication card. RN#1 stated she did not know how that happened. On 1/8/19 at 3:27 PM, in a follow up interview with RN#1, when asked about the five rights of medication administration, RN #1 stated, Right person, right dose, right med, right time, right route. On 1/09/20 at 9:54 AM, in a second follow up interview with RN #1 after the medication orders were reviewed, when asked about the three missed medications, RN #1 stated that she may have missed the page (of the MAR) that these medications were listed on. A review of the facility policy, Medication - Oral Administration of documented, Review the MAR or EMAR (Medication Administration Record or Electronic Medication Administration Record) with the Physician's Order Sheet (POS) and seek clarification as indicated Compare the medication unit/dose label against the MAR or EMAR prior to returning the medication container or card to the medication cart or disposing of the empty container; and prior to supporting the resident to accept and ingesting the medication On 1/8/20 at 5:50 PM, ASM #1 (Administrative Staff Member - the Executive Director) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. References: 1. Clonidine - is used to treat high blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a682243.html 2. Metoprolol - is used to treat high blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a682864.html 3. Metformin - is used to treat diabetes Information obtained from https://medlineplus.gov/druginfo/meds/a696005.html 4. Depakote ER - is used to treat bipolar disorder Information obtained from https://medlineplus.gov/druginfo/meds/a682412.html 5. Accupril - is used to treat high blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a692026.html 6. Folic Acid - helps the body make healthy new cells. Information obtained from https://medlineplus.gov/folicacid.html 7. Azithromycin - is an antibiotic. Information obtained from https://medlineplus.gov/druginfo/meds/a697037.html 8. Prednisone - reduces swelling and redness by changing the way the immune system works. Information obtained from https://medlineplus.gov/druginfo/meds/a601102.html 9. Mucinex - is used to relieve chest congestion. Information obtained from https://medlineplus.gov/druginfo/meds/a682494.html 10. Multivitamin - used to treat or prevent vitamin deficiency due to poor diet, certain illnesses, or during pregnancy. Vitamins are important building blocks of the body and help keep you in good health. Information obtained from https://www.webmd.com/drugs/2/drug-18820-9038/multivitamin-oral/multivitamins-includes-prenatal-vitamins-oral/details 11. Vitamin D - Vitamins are substances that your body needs to grow and develop normally. Vitamin D helps your body absorb calcium. Calcium is one of the main building blocks of bone. A lack of vitamin D can lead to bone diseases such as osteoporosis or rickets. Vitamin D also has a role in your nerve, muscle, and immune systems. Information obtained from https://medlineplus.gov/vitamind.html 12. Glimiperide - is used to treat diabetes. Information obtained from https://medlineplus.gov/druginfo/meds/a696016.html 2. The facility staff failed to ensure that Resident #37 was free of medication errors. Resident #37 was administered a partial dose of a medication, and not the full dose that was ordered. Resident #37 was admitted to the facility on [DATE]; diagnoses included but are not limited to encephalopathy, heart disease, dysphagia, diabetes, atrial flutter, abdominal aortic aneurysm, high blood pressure, cardiac pacemaker, and pneumonia. The admission / 5-day MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 12/17/19 coded the resident as significantly cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing and toileting; extensive assistance for transfers, dressing, and hygiene; was independent for eating; and was coded as incontinent of bowel and bladder. On 1/08/20 at 9:08 AM, RN #1 (Registered Nurse) was observed preparing and administering the following medications for Resident #37: • Allopurinol (1) 100 mg (milligrams), 1 tablet • Atenolol (2) 25 mg, 3 tablets for 75 mg (RN #1 only prepared 1 25 mg tablet). • Eliquis (3) 2.5 mg, 1 tablet • Multivitamin (4), 1 tablet • Vitamin D3 (5), 1000 units, 2 tablets for 2000 units. On 1/8/19 at 3:27 PM, in an interview conducted with RN#1, when asked about the five rights of medication administration, RN #1 stated, Right person, right dose, right med, right time, right route. Review of the clinical record revealed, the physician's orders documented that the resident was to get three (3) 25 mg tablets (75 mg) of the Atenolol. RN #1 only administered one 25 mg tablet during the observation. This resulted in a medication error for Resident #37. On 1/09/20 at 9:54 AM, in a follow up interview with RN #1 after the medication orders were reviewed, when asked about the dose of the Atenolol, RN #1 stated, I don't know. I don't know him that well. When asked if one has to know the resident really well in order to carefully check the MAR (Medication Administration Record) against the pharmacy label on the medication card, and to ensure that the correct amount of medication is prepared per orders, she stated, Well, yes, one does. A review of the facility policy, Medication - Oral Administration of documented, Review the MAR or EMAR (Medication Administration Record or Electronic Medication Administration Record) with the Physician's Order Sheet (POS) and seek clarification as indicated Compare the medication unit/dose label against the MAR or EMAR prior to returning the medication container or card to the medication cart or disposing of the empty container; and prior to supporting the resident to accept and ingesting the medication On 1/8/20 at 5:50 PM, ASM #1 (Administrative Staff Member - the Executive Director) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. References: 1. Allopurinol is used to treat gout. Information obtained from https://medlineplus.gov/druginfo/meds/a682673.html 2. Atenolol is used to treat high blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a684031.html 3. Eliquis is used to prevent strokes and blood clots in people with atrial fibrillation. Information obtained from https://medlineplus.gov/druginfo/meds/a613032.html 4. Multivitamin - used to treat or prevent vitamin deficiency due to poor diet, certain illnesses, or during pregnancy. Vitamins are important building blocks of the body and help keep you in good health. Information obtained from https://www.webmd.com/drugs/2/drug-18820-9038/multivitamin-oral/multivitamins-includes-prenatal-vitamins-oral/details 5. Vitamin D - Vitamins are substances that your body needs to grow and develop normally. Vitamin D helps your body absorb calcium. Calcium is one of the main building blocks of bone. A lack of vitamin D can lead to bone diseases such as osteoporosis or rickets. Vitamin D also has a role in your nerve, muscle, and immune systems. Information obtained from https://medlineplus.gov/vitamind.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure that one of 32 residents in the survey sample, Resident #37 was free significant medication errors. Resident #37 was not administered the correct dose of the blood pressure medication Atenolol (2). The findings include: Resident #37 was admitted to the facility on [DATE]; diagnoses included but are not limited to encephalopathy, heart disease, dysphagia, diabetes, atrial flutter, abdominal aortic aneurysm, high blood pressure, cardiac pacemaker, and pneumonia. The admission / 5-day MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 12/17/19 coded the resident as significantly cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing and toileting; extensive assistance for transfers, dressing, and hygiene; was independent for eating; and was coded as incontinent of bowel and bladder. A review of the clinical record for Resident #37 revealed that on 1/8/20, during the 11pm on 1/7/20 to 7a.m., on 1/8/20 shift a blood pressure of 126/76 was obtained. On 1/8/20 during the 3pm to 11pm shift, a blood pressure of 136/72 was obtained. On 1/08/20 at 9:08 AM, RN #1 (Registered Nurse) was observed preparing and administering the following medications for Resident #37: • Allopurinol (1) 100 mg (milligrams), 1 tablet • Atenolol (2) 25 mg, 3 tablets for 75 mg (Note: RN #1 only prepared 1 tablet). • Eliquis (3) 2.5 mg, 1 tablet • Multivitamin (4), 1 tablet • Vitamin D3 (5), 1000 units, 2 tablets for 2000 units. On 1/8/19 at 3:27 PM in an interview conducted with RN#1, when asked about the five rights of medication administration, RN #1 stated, Right person, right dose, right med, right time, right route. Review of the clinical record revealed the physician's orders documented that the resident was to receive three (3) 25 mg tablets (75 mg) of the Atenolol. RN #1 only administered one 25 mg tablet during the observation. On 1/09/20 at 9:54 AM, in a follow up interview with RN #1, when asked about the dose of the Atenolol, RN #1 stated, I don't know. I don't know him that well. When asked if one has to know the resident really well in order to carefully check the MAR (Medication Administration Record) against the pharmacy label on the medication card, and to ensure that the correct amount of medication is prepared per orders, she stated, Well, yes, one does. A review of the facility policy, Medication - Oral Administration of documented, Review the MAR or EMAR (Medication Administration Record or Electronic Medication Administration Record) with the Physician's Order Sheet (POS) and seek clarification as indicated Compare the medication unit/dose label against the MAR or EMAR prior to returning the medication container or card to the medication cart or disposing of the empty container; and prior to supporting the resident to accept and ingesting the medication On 1/8/20 at 5:50 PM, ASM #1 (Administrative Staff Member - the Administrator) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. References: 1. Allopurinol is used to treat gout. Information obtained from https://medlineplus.gov/druginfo/meds/a682673.html 2. Atenolol is used to treat high blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a684031.html 3. Eliquis is used to prevent strokes and blood clots in people with atrial fibrillation. Information obtained from https://medlineplus.gov/druginfo/meds/a613032.html 4. Multivitamin - used to treat or prevent vitamin deficiency due to poor diet, certain illnesses, or during pregnancy. Vitamins are important building blocks of the body and help keep you in good health. Information obtained from https://www.webmd.com/drugs/2/drug-18820-9038/multivitamin-oral/multivitamins-includes-prenatal-vitamins-oral/details 5. Vitamin D - Vitamins are substances that your body needs to grow and develop normally. Vitamin D helps your body absorb calcium. Calcium is one of the main building blocks of bone. A lack of vitamin D can lead to bone diseases such as osteoporosis or rickets. Vitamin D also has a role in your nerve, muscle, and immune systems. Information obtained from https://medlineplus.gov/vitamind.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to maintain a complete and accurate medical record for one of 32 residents in the survey sample, Resident #43. The facility staff failed to maintain an accurate record documenting treatments performed for applying Nystatin (medication used to treat infection) powder topically twice daily and changing the wound vac (The vacuum assisted closure (VAC) therapy (also known as negative pressure wound therapy to assist with wound healing) dressing three times a week. The findings include: Resident #43 was admitted to the facility on [DATE] with diagnoses that included but were not limited to osteomyelitis (1) and diabetes (2). Resident #43's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/17/2019, coded Resident #43 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. On 1/7/20 at approximately 4:30 p.m., an interview was conducted with Resident #43. Resident #43 was observed lying on top of her bed watching television. When asked about the dressing on her foot Resident #43 stated that she was staying at the facility short term to receive antibiotics for an infection in her foot. Resident #43 stated that she had just returned from the doctor's office having a check up on the foot. When asked if the staff at the facility provide treatment to the foot, Resident #43 stated that the staff change the dressing on it and keep the wound vac on it when she is at the facility. Resident #43 stated that the staff provide her with the antibiotics in her IV (intravenous) in her arm to treat the infection. Resident #43 stated that the physician had changed the dressing on her foot at the office that morning and rewrapped it with a compression bandage. When asked if staff provide the ordered Nystatin powder twice daily, Resident #43 stated that they did. The physicians order summary for Resident #43 dated 01/01/20 through 01/31/20 documented 12/11/19: Nystop (generic name for Nystatin) 100000 Unit/1G (gram) powder for Nystatin- Apply to affected areas topically twice daily and 12/11/19 Tx (treatment)- Wound vac at pre-programmed setting every shift- change dressing on Monday-Wednesday-Friday & (and) as needed. The TAR (treatment administration record) dated 01/01/20-01/31/20 for Resident #43 documented the treatment orders listed above. Review of the TAR revealed that it failed to evidence documentation of treatments being performed for the following treatments on the following dates and times: 1. Nystatin Apply to affected areas topically twice daily. -1/1/20 on 3-11 (3:00 p.m. to 11:00 p.m.) shift. -1/2/20 on 7-3 (7:00 a.m. to 3:00 p.m.) shift and 3-11 shift. -1/3/20 on 7-3 shift and 3-11 shift. -1/5/20 on 3-11 shift. -1/6/20 on 3-11 shift. -1/7/20 on 7-3 shift and 3-11 shift. -1/8/20 on 7-3 shift. 2. Wound vac at pre-programmed setting every shift- change dressing on Monday-Wednesday-Friday & as needed. -1/3/20. On 1/8/20 at approximately 5:10 p.m., an interview was conducted with RN (registered nurse) #2. When asked how treatments are documented, RN #2 stated that they are documented on the TAR (treatment administration record) when they are performed. When asked what blank boxes on the TAR mean RN #2 stated that she was not sure. RN #2 observed the blank boxes on Resident #43's TAR dated 01/01/20-01/31/20 for the Nystatin topically twice daily and changing the wound vac dressing on the dates listed above. RN #2 stated that the blanks mean that the nurse did not sign the TAR to document the treatment was done. RN #2 stated that the treatment book might have been in a different area when the nurse was charting, the nurse may have forgotten to sign the TAR, or that the treatment may have not been done. When asked if it could be determined if the treatment was administered according to the documentation on the TAR, RN #2 stated that it could not be determined. RN #2 stated that the treatment should have been signed off on the record to document it as being completed. On 01/09/20 at approximately 12:30 p.m., a request was made by written list to ASM (administrative staff member) #1, the executive director for the facility policy on maintaining an accurate and complete medical record. On 01/09/20 at approximately 1:00 p.m., ASM #3, the regional director of clinical services stated that the facility did not have a policy for maintaining an accurate medical record. On 01/20/20 at approximately 1:30 p.m., ASM (administrative staff member) #2, the director of nursing confirmed that the facility uses their policies, [NAME], and [NAME] & [NAME] as their standard of practice. According to Fundamentals of Nursing Made Incredibly Easy [NAME] and [NAME], Philadelphia PA page 23: Nursing documentation is a highly significant issue since documentation is a fundamental feature of nursing care. Patient records are legally valid, and need to be accurate and comprehensive so that care can be communicated effectively to the health care team. Unless the content of documentation provides an accurate depiction of patient and family care, quality of care may not be possible. Many nurses do not realize that what they document or fail to record can produce an enormous effect on the care that is provided by other members of the health care team. The following quotation is found in [NAME] and [NAME]'s Fundamentals of Nursing 6th edition (2005, p. 477): Documentation is anything written or printed that is relied on as record or proof for authorized persons. Documentation within a client medical record is a vital aspect of nursing practice. Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice. Information in the client record provides a detailed account of the level of quality of care delivered to the clients. On 01/09/20 at approximately 1:00 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and LPN (licensed practical nurse) #5 were made aware of the findings. No further information was provided prior to exit. References: 1. Osteomyelitis Osteomyelitis is the medical term for inflammation in a bone. It's usually caused by a bacterial infection. It often affects the long bones of the arms and legs, but can happen in any bone. This information was obtained from the website: https://kidshealth.org/en/parents/osteomyelitis.html 2. Diabetes A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident # 3 was admitted to the facility on [DATE] with a readmission of 07/22/2019 with diagnoses that included but were not limited to respiratory failure, shortness of breath and chronic obstructive pulmonary disease [1]. Resident # 3's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/26/19, coded Resident # 3 as scoring a 12 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 12- being moderately impaired of cognition for making daily decisions. Resident # 3 was coded as requiring extensive assistance of one staff member for activities of daily living. Section O Special Treatments, Procedures and Programs coded Resident # 3 for the use of oxygen. On 01/07/2020 at approximately 3:15 p.m., Resident # 3 was observed lying in bed receiving oxygen by nasal cannula connected to an oxygen concentrator that was running. Observation of the oxygen flow meter on the oxygen concentrator revealed a flow rate of one-and-a-half liters per minute. On 01/08/2020 at 10:39 a.m., an observation of Resident # 3 revealed they were lying in bed receiving oxygen by nasal cannula connected to an oxygen concentrator that was running. Observation of the oxygen flow meter on the oxygen concentrator revealed a flow rate of one-and-a-half liters per minute. The POS [physician's order sheet] dated 01/01/2020 through 01/31/2020 and signed by the physician on 1/7/2020 for Resident # 3 documented, 09/04/19 Oxygen at 2L [two liters per minute] via [by] nasal cannula every shift. The comprehensive care plan for Resident # 3 with a revision date of 12/31/2018 documented, Focus: {Resident # 3] has shortness of breath (SOB) r/t [related to] Decreased lung expansion. Date Initiated 12/31/2018. Revision on 12/31/2018. Under Interventions it documented in part, Oxygen setting: O2 [oxygen] 2L via NC [nasal cannula]. Date Initiated 12/31/2018. Revision on 04/16/2019. On 01/08/2020 at 1:00 p.m., an interview was conducted with LPN [licensed practical nurse] # 4. When asked to describe the procedure for reading the oxygen, flowrate meter on an oxygen concentrator, LPN # 4 stated, You should be at eye level with the meter and the liter line should pass through the middle of the ball. LPN # 4 was asked to read the flow meter on Resident # 3's oxygen concentrator. After looking at the flow meter, LPN # 4 stated the oxygen flow rate was at one-and-a-half liters per minute. When asked what the flow rate should be, LPN # 4 stated two-liter's per-minute. LPN # 4 then readjusted the flow rate to 2LPM (liters per minute) on the oxygen concentrator. On 01/08/2020 at approximately 5:50 p.m., ASM (administrative staff member) # 1, the executive director and ASM # 2, director of nursing, ASM # 3, regional director of clinical services and LPN # 5 traveling MDS coordinator, were made aware of the findings. No further information was provided prior to exit. References: [1] Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 3. Resident # 163 was admitted to the facility on [DATE] with diagnoses that included but were not limited to high blood pressure and chronic obstructive pulmonary disease [2]. The most recent MDS (minimum data set), for Resident # 163 was not due at the time of the survey. The facility's admission Data Collection sheet dated 01/03/2020 for Resident # 163 documented in part, Cognition: Alert, Oriented to Person. Under Communication it documented, Usually Understood and Understands. Under Respiratory, it documented, Special Treatments and Procedures: None per history and/or observation. On 01/07/20 at 1:49 p.m., at 2:43 p.m., and at 4:05 p.m., observations of Resident # 163's over-the-bed table revealed an incentive spirometer. Observation of the incentive spirometer [1] failed to evidence that it was placed in a bag or covered. On 01/08/20 at 8:25 a.m., an observation of Resident # 163's over-the-bed table revealed an incentive spirometer. Observation of the incentive spirometer failed to evidence that it was placed in a bag or covered. The POS [physician's order sheet] dated 01/01/2020 through 01/31/2020 and signed by the physician on 01/04/2020 for Resident # 163 failed to evidence documentation for the use of an incentive spirometer. The facility's baseline care plan for Resident 163 dated 01/03/2020 failed to evidence documentation for the use of an incentive spirometer. On 01/08/20 at 8:30 a.m., an interview was conducted with Resident # 163. When asked if they used the incentive spirometer, Resident # 163 stated sometimes. On 01/08/2020 at 1:00 p.m., an interview was conducted with LPN [licensed practical nurse] # 4. When asked if an incentive spirometer was a piece of respiratory equipment, LPN # 4 stated yes. When how the incentive spirometer should be stored when not in use, LPN # 4 stated it should be covered or placed in a bag. LPN # 4 was shown Resident # 163's incentive spirometer on the over-the-bed table. LPN # 4 stated it should be covered. When asked why the incentive spirometer should be covered, LPN # 4 stated, It could collect germs and could cause an infection when used by the resident. When asked about a physician's order for Resident #163's use of the incentive spirometer, LPN # 4 reviewed the physician's orders and stated that they could not locate one. On 01/08/20 at 1:43 p.m., an interview was conducted with LPN # 5, traveling MDS coordinator. LPN # 5 stated there was no physician order for Resident # 163's incentive spirometer. LPN # 5 further stated that they had spoken to Resident # 163's nurse practitioner and that Resident # 163 would benefit from the use of the incentive spirometer. LPN # 5 stated they would obtain a physician's order for prn [as needed] use of an incentive spirometer. On 01/08/2020 at approximately 2:00 p.m., LPN # 5 provided this surveyor with a copy of a physician's telephone order dated 01/08/2020 for Resident # 163. The order documented, Encourage use of incentive spirometer PRN. On 01/08/2020 at approximately 5:50 p.m., ASM # 1, the executive director and ASM # 2, director of nursing, ASM # 3, regional director of clinical services and LPN # 5 traveling MDS coordinator, were made aware of the findings. No further information was provided prior to exit. References: [1] A device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm. [2] Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 4a. Resident # 25 was admitted to the facility on [DATE] with diagnoses that included but were not limited to respiratory failure, shortness of breath and chronic obstructive pulmonary disease [1]. Resident # 25's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/29/19, coded Resident # 25 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making daily decisions. Resident # 25 was coded as requiring extensive assistance of one staff member for activities of daily living. Section O Special Treatments, Procedures and Programs coded Resident # 25 for the use of oxygen. The POS [physician's order sheet] dated 01/01/2020 through 01/31/2020 and signed by the physician on 1/7/2020 for Resident # 3 documented, 12/17/19 Oxygen @ [at] 4L [four liters per minute] via [by] nasal cannula continuous every shift to maintain SPO2 [oxygen saturation] [2] greater than 90%. The comprehensive care plan for Resident # 25 with a revision date of 12/03/2019 documented, Focus: [Resident # 25] has Congestive Heart Failure. Revision Date: 12/03/2019. Under Interventions it documented in part, Oxygen setting: O2 [oxygen] via NC [nasal cannula] at 4L (liter). Revision on 12/03/2019. On 01/07/20 at 1:25 p.m., 2:45 p.m., and at 4:05 p.m., observations revealed Resident #25 in bed receiving oxygen by nasal cannula connected to an oxygen concentrator that was running. Observations of the flow meter on the oxygen concentrator revealed an oxygen flow rate set at three-and-a-half liters per minute. On 01/08/20 at 8:30 a.m., an observation revealed Resident #25 in bed receiving oxygen by nasal cannula connected to an oxygen concentrator that was running. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate set at three-and-a-half liters per minute. On 01/08/2020 at approximately 1:00 p.m., an interview was conducted with LPN [licensed practical nurse] # 4. When asked to describe the procedure for reading the oxygen, flowrate meter on an oxygen concentrator LPN # 4 stated, You should be at eye level with the meter and the liter line should pass through the middle of the ball. LPN # 4 was asked to read the flow meter on Resident # 25's oxygen concentrator. After looking at the flow meter LPN # 4 stated the oxygen flow rate was at three-and-a-half liters per minute. When asked what the flow rate should be per the physician order, LPN # 4 stated four-liter's per-minute. LPN # 4 then readjusted the flow rate on the oxygen concentrator to 4 LPM (liters per minute). On 01/08/2020 at approximately 5:50 p.m., ASM (administrative staff member) # 1, the executive director and ASM # 2, director of nursing, ASM # 3, regional director of clinical services and LPN # 5 traveling MDS coordinator, were made aware of the findings. No further information was provided prior to exit. References: [1] Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 4b. On 01/07/20 at 1:25 p.m., at 2:45 p.m., and at 4:05 p.m., observations of Resident # 25's bedside table revealed a nebulizer and a nebulizer mask sitting on top of the table. Observations of the nebulizer mask revealed it was uncovered. When asked if they receive nebulizer treatments Resident # 25 stated yes. Further observation of the bedside table revealed an incentive spirometer uncovered. When asked if they use the incentive spirometer Resident # 25 stated yes. On 01/08/20 at 8:30 a.m., an observation of Resident # 25's bedside table revealed a nebulizer and a nebulizer mask sitting on top of the table. Observation of the nebulizer mask revealed it was uncovered. Further observation of the bedside table revealed an incentive spirometer uncovered. The Physician's Telephone Order dated 12/27/2019 documented, Duo nebs Q [every] 4 [four] hours for SOB [shortness of breath]. Further review of the clinical record failed to evidence a physician's order for the use of an incentive spirometer. The comprehensive care plan for Resident # 25 with a revision date of 12/03/2019 documented, Focus: [Resident # 25] has COPD [chronic obstructive pulmonary disease]. Date Initiated: 12/03/2019. Under Interventions it documented, Give nebulizer treatments and oxygen therapy as ordered. Date Initiated: 12/03/2019. On 01/08/2020 at 1:00 p.m., an interview was conducted with LPN [licensed practical nurse] # 4. When asked if an incentive spirometer was a piece of respiratory equipment, LPN # 4 stated yes. When how the incentive spirometer should be stored when not in use, LPN # 4 stated it should be covered or placed in a bag. When asked how a nebulizer mask should be stored when not in use, LPN # 4 stated it should be placed in a bag. When shown Resident # 25's nebulizer mask and incentive spirometer on the bedside table LPN # 4 stated the incentive spirometer and nebulizer mask should be covered. When asked why the incentive spirometer and nebulizer mask should be covered, LPN # 4 stated, It could collect germs and could cause an infection when used by the resident. On 01/08/2020 at approximately 5:50 p.m., ASM # 1, the executive director and ASM # 2, director of nursing, ASM # 3, regional director of clinical services and LPN # 5 traveling MDS coordinator, were made aware of the findings. No further information was provided prior to exit. References: [1] A device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm. 4c. On 01/07/20 at 1:25 p.m., an observation of Resident # 25's bedside table revealed an incentive spirometer uncovered. When asked if they use the incentive spirometer Resident # 25 stated yes. On 01/07/20, at 1:25 p.m., at 2:45 p.m., and at 4:05 p.m., observations of Resident # 25's bedside table revealed an incentive spirometer. On 01/08/20 at 8:30 a.m., an observation of Resident # 25's bedside table revealed an incentive spirometer uncovered. Review of Resident # 25's clinical record failed to evidence a physician's order for the use of an incentive spirometer. On 01/08/2020 at 1:00 p.m., an interview was conducted with LPN [licensed practical nurse] # 4. When asked about a physician's order for the use of the incentive spirometer for Resident # 25, LPN # 4 reviewed the physician's orders and stated that they could not locate one. On 01/08/20 at 1:43 p.m., an interview was conducted with LPN # 5, traveling MDS coordinator. LPN # 5 stated they had spoken to the nurse practitioner (NP) and the NP stated, The nurse practitioner feels she [Resident # 25] doesn't need it [incentive spirometer] so I will remove it. It was something she had in her belonging when she came here. LPN # 5 verbally confirmed there was no physician's order for the use of an incentive spirometer. On 01/08/2020 at approximately 5:50 p.m., ASM # 1, the executive director and ASM # 2, director of nursing, ASM # 3, regional director of clinical services and LPN # 5 traveling MDS coordinator, were made aware of the findings. No further information was provided prior to exit. Based on observations, staff interview, resident interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice, the comprehensive person-centered care plan for four of 32 residents in the survey sample; Residents #41, #3, #163, and #25. The facility staff failed to ensure a physician's order was in place for Resident #41's use of an incentive spirometer and failed to ensure Resident #4's nebulizer mask and incentive spirometer were stored in a sanitary manner when not in use. The facility staff failed to administer Resident # 3's oxygen at the flow rate ordered by the physician. The facility staff failed to store Resident #163's incentive spirometer [1] in a sanitary manner and failed to obtain physician orders for the use of the incentive spirometer. The facility staff failed to administer Resident # 25's oxygen according to the physician's orders and failed to store Resident # 25's nebulizer mask and incentive spirometer in a sanitary manner. The facility staff failed to obtain a physician's order for Resident # 25's use of an incentive spirometer. The findings include: 1a. Resident #41 was admitted to the facility on [DATE]; diagnoses include but are not limited to, hydrocephalus, psychotic disorder, right kidney cancer with removal of kidney, cardiac defibrillator, high blood pressure, atrial fibrillation, diabetes, bipolar disorder, spinal stenosis with fusion, and cerebral palsy. The quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 12/21/19 coded the resident as being cognitively intact in ability to make daily life decisions. The resident was coded as requiring extensive care for bathing, toileting, dressing, and transfers; supervision for eating and hygiene; and was coded as incontinent of bowel and bladder. On 1/07/20 at 12:10 PM, an observation was made of Resident #41's room. Resident #41 was not in the room. An Incentive Spirometer was observed on the over bed table. On 1/08/20 at 8:52 AM, Resident #41 was observed in bed. The Incentive Spirometer remained on the over bed table as previously observed. On 1/08/20 at 1:00 PM, Resident #41 was observed and an interview conducted. The over bed table was across the resident. The incentive spirometer was on the table. Resident #41 stated that he has used it on occasion. A review of the clinical record failed to reveal any evidence of a physician's order for the use of an Incentive Spirometer. A review of the comprehensive care plan failed to reveal the use of the Incentive Spirometer as being care planned. On 1/8/20 at 1:07 PM in an interview with RN #1 (Registered Nurse), she stated that there should be an order for the use of the Incentive Spirometer. RN #1 stated that the residents come in with them from the hospital. A review of the facility policy, Incentive Spirometer did not document any criteria for obtaining a physician's order prior to use. On 1/8/20 at 5:50 PM, ASM #1 (Administrative Staff Member - the Executive Director) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. 1b. The facility staff failed to ensure Resident #41's nebulizer mask and Incentive Spirometer were stored in a sanitary manner when not in use. On 1/07/20 at 12:10 PM, an observation was made of Resident #41's room. Resident #41 was not in the room. An Incentive Spirometer was observed on the over bed table. It was not covered. A nebulizer machine and mask was observed on nightstand next to the bed. The nebulizer mask was not covered. On 1/08/20 at 8:52 AM, Resident #41 was observed in bed. The Incentive Spirometer and nebulizer mask remained uncovered as previously observed. On 1/08/20 at 1:00 PM, Resident #41 was observed and an interview conducted. The over bed table was across the resident. The incentive spirometer was on the table, uncovered. No bag was observed to store the Incentive Spirometer. The nebulizer mask was now, observed covered in a new bag and dated. The resident stated that he has used both items on occasion and that to his recollection neither item, had been covered. On 1/8/20 at 1:07 PM in an interview with RN #1 (Registered Nurse), she stated that the nebulizer mask should be covered. RN #1 stated the Incentive Spirometer should be wiped clean. RN #1 stated, I guess it should be stored in a bag but I was never told that. A review of the facility policy, Nebulizer documented, Place entire unit in a bag to be maintained in the resident's room. A review of the facility policy, Incentive Spirometer did not document any criteria for maintaining the device in a sanitary manner between uses. On 1/8/20 at 5:50 PM, ASM #1 (Administrative Staff Member - Executive Director) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure the drug regimen must be free from unnecessary drugs for two of 32 residents in the survey sample, Resident # 3 and # 25. The facility staff failed to attempt non-pharmacological interventions prior to the administration of prn (as needed) pain medications [Oxycodone (1) and Acetaminophen] (2)] to Resident #3 on multiple dates in November and December 2019. The facility staff failed to attempt non-pharmacological interventions prior to the administration of a prn (as needed) pain medication [Hydrocodone- Acetaminophen (2)] to Resident #25 on multiple dates during November, December 2019 and January 2020. The findings include: 1. Resident # 3 was admitted to the facility on [DATE] with a readmission of 07/22/2019 with diagnoses that included but were not limited to lower back pain. Resident # 3's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/26/19, coded Resident # 3 as scoring a 12 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 12- being moderately impaired of cognition for making daily decisions. Resident # 3 was coded as requiring extensive assistance of one staff member for activities of daily living. Section J Health Conditions coded Resident # 3 as having occasional pain with a pain level of seven on a scale of zero to ten with ten being the worse pain. The comprehensive care plan with a revision date of 12/31/2018 for Resident # 3 documented, Focus: [Resident # 3] has chronic pain r/t [related to] arthritis, diabetic neuropathy, peripheral vascular disease. Date Initiated: 12/31/2018. Under Interventions it documented, Administer analgesia as per order. Give ½ [one half] hour before treatments or care Date Initiated: 12/31/2018. The physician's telephone order dated 11/06/2019 for Resident # 3 documented, Oxycodone 5MG [five milligrams]. 1 [one] tab [tablet] by mouth Q 8 [eight hours] prn for pain. The MAR [medication administration record] for Resident # 3, dated November 2019 documented the physician orders as above. Review of the MAR revealed Resident # 3 received Oxycodone on the dates and times that follow: 11/12/19 at 2:00 a.m., and at 1:07 p.m., 11/13/19, at 1:45 p.m., and at 9:00 p.m., 11/14/19 at 8:30 p.m., 11/15/19 at 1:10 p.m., 11/17/19 at 4:15 a.m. and at 11:45 a.m., 11/19/19 at 5:00 p.m., 11/20/19 at 1:00 a.m., 11/30/19 at 10:00 a.m. and at 9:00 p.m. Further review of the MAR failed evidence documentation of non-pharmacological interventions attempted prior to the administration of the pain medication and failed to evidence documentation of Resident # 3's pain level for the above dates and times. The POS [physician's order sheet] dated 12/01/19 through 12/31/2019 for Resident # 3 documented, Acetaminophen 325MG Tablet. Take 1 tab by mouth every 4 [four] hours as needed for pain. 09/03/2019. The MAR [medication administration record] for Resident # 3, dated December 2019 documented the same physician order as above. Review of the MAR revealed Resident # 3 received Acetaminophen on the dates and times as follows: 12/01/19 at 2:00 p.m., 12/02/19 at 9:30 a.m., 12/03/19 at 12:15 p.m., 12/04/19 at 12:47 p.m., 12/07/19 at 12:27 p.m., 12/10/19 at 11:00 a.m., 12/11/19 at 12:15 p.m., 12/13/19 at 1:05 p.m., 12/15/19 at 8:30 p.m., 12/16/19 at 8:15 p.m., 12/18/19 at 12:45 p.m., 12/21/19 at 12:05 p.m., and on 12/25/19 at 4:22 p.m. Further review of the MAR failed evidence documentation of non-pharmacological interventions attempted prior to the administration of the as needed pain medication and failed to evidence documentation of Resident # 3's pain level for the above dates and times. The facility's nurse's notes dated 11/08/2019 through 12/28/2019 failed to evidence documentation of Resident # 3's pain level and failed to document non-pharmacological interventions prior to the administration of Oxycodone and Acetaminophen to for the above dates and times. Review of Resident # 3's pain flow sheets dated November and December 2019 failed to evidence pain levels and non-pharmacological interventions for the above dates and times. On 01/07/2020 at approximately 4:00 p.m., an interview was conducted with Resident # 3. When asked if the staff attempt to alleviate the pain before administering pain medication Resident # 3 stated no. On 01/08/2020 at 4:02 p.m., an interview was conducted with LPN [licensed practical nurse] # 4, regarding the procedure for administering prn [as needed] pain medication. LPN # 4 stated, Start with non-pharmacological interventions, return in about a half-hour to an hour and reassess, if it is not effective check what is ordered, get the resident's pain level, based on zero to ten, ten being the worse, and minister meds [medication] and recheck in about an hour. When asked about the procedure staff follows for documenting that non-pharmacological interventions were attempted and the pain levels, LPN # 4 stated, It's documented on the back of the MAR [medication administration record] or the nurse's notes. After reviewing the MAR and nurse's notes for Resident # 3, LPN # 4 stated there was no documentation of non-pharmacological interventions being attempted or the pain levels. When asked about the lack of documentation of non-pharmacological interventions and the pain levels, LPN # 4 stated, It's not documented can't say it's done. On 01/09/20 at 11:14 a.m., an interview was conducted with ASM [administrative staff member] # 2, director of nursing. When asked to describe the procedure for prn [as needed] pain medication, ASM # 2 stated, Rate the pain zero to ten, medicate them, and recheck in about an hour to see if was effective. When asked about attempting non-pharmacological interventions prior to administering as needed pain medication, ASM # 2 stated, It depends on what the pain is, chronic pain such as cancer pain we don't attempt them. Sometimes the patient will just ask for it and we won't argue with them. When asked if they expected to attempt non-pharmacological interventions if the resident was not experiencing chronic pain, ASM # 2 stated it should document on the pain flow sheet or nurse's notes. ASM # 2 further stated that the location and level of pain should be documented on the pain assessment sheet with the MAR. On 01/08/2020 at approximately 5:50 p.m., ASM # 1, the executive director and ASM # 2, director of nursing, ASM # 3, regional director of clinical services and LPN # 5 traveling MDS coordinator, were made aware of the findings. No further information was provided prior to exit. References: [1] Oxycodone is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html. [2] Used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). It works by changing the way the body senses pain and by cooling the body. This information was obtained from the website: https: https://medlineplus.gov/druginfo/meds/a681004.html. 2. Resident # 25 was admitted to the facility on [DATE] with diagnoses that included but were not limited to chest pain. Resident # 25's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/29/19, coded Resident # 25 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making daily decisions. Resident # 25 was coded as requiring extensive assistance of one staff member for activities of daily living. Section O Special Treatments, Procedures and Programs coded Resident # 25 for the use of oxygen. The POS [physician's order sheet] dated 01/01/20 through 01/31/2020 for Resident # 25 documented, Hydrocodone-Acetaminophen 10MG-325MG [milligrams] Tablet. Take 1 tab [tablet] by mouth every 8 [eight] hours as needed for moderate to severe pain. 11/26/2019. The MAR [medication administration record] for Resident # 25 dated November 2019 documented the physician order as above. Review of the MAR revealed Resident # 25 received Hydrocodone-Acetaminophen on 11/25/19 at 6:00 p.m., 11/26/19 at 5:30 p.m., and on 11/27/19 at 9:30 a.m., and at 6:00 p.m. Further review of the MAR failed evidence documentation evidencing that non-pharmacological interventions for the above dates and times were attempted prior to the administration of as needed pain medication. The MAR [medication administration record] for Resident # 25, dated December 2019 documented the physician order as above. Review of the MAR revealed Resident # 25 received Hydrocodone-Acetaminophen on the dates and times as follows: 12/01/19 at 11:00 a.m., 12/02/19 at 9:05 a.m., 12/03/19 at 9:09 a.m., 12/04/19 at 4:50 a.m., and at 9:00 p.m., 12/06/19 at 8:00 p.m., 12/07/19 at 6:30 a.m. and at 7:55 p.m., 12/13/19 at 5:05 p.m., 12/16/19 at 6:50 a.m., 12/17/19 at 7:18 p.m., 12/18/19 at 12:20 p.m. and at 8:00 p.m., 12/21/19 at 5:56 p.m., 12/22/19 at 9:00 p.m., 12/23/19 at 8:00 p.m., and on 12/30/19 at 9:00 p.m. Further review of the MAR failed evidence documentation non-pharmacological interventions were attempted, prior to administration of as needed pain medication. The MAR failed to evidence documentation of Resident # 25's pain level for the above dates and times. The MAR [medication administration record] for Resident # 25, dated January 2020 documented the physician order as above. Review of the MAR revealed Resident # 25 received Hydrocodone-Acetaminophen on 01/01/20 at 1:55 p.m., 01/02/20 at 6:00 p.m., 01/03/20 at 9:00 a.m., 01/04/20 at9:19 a.m., 01/05/20 at 4;40 p.m., 01/06/20 at 4:45 p.m., and on 01/07 20 at 9:30 a.m. Further review of the MAR failed evidence documentation of attempted non-pharmacological interventions for the above dates and times. On 01/07/20 at 1:33 p.m., during an interview with Resident # 25, when asked if they received prn [as needed] pain medication. Resident # 25 stated yes and that they have pain in their legs. When asked if the staff attempt to alleviate the pain before administering pain medication, Resident #25 stated no. The facility's nurse's notes dated 11/2019 through 01/07/2020 failed to evidence documentation of Resident # 25's pain level and failed to evidence non-pharmacological interventions were attempted prior to the administration of Hydrocodone-Acetaminophen to Resident # 25 for the above dates and times. Review of Resident # 3's pain flow sheets dated November and December 2019 and January 2020 failed to evidence non-pharmacological interventions for the above dates and times. The comprehensive care plan for Resident # 25 dated 12/03/2019 documented, Focus: [Resident # 25] has chronic pain r/t [related to] Neurology. Date Initiated: 12/03/2019. Under Interventions, it documented in part, Administer analgesia as per orders. Date Initiated: 12/03/2019. On 01/08/2020 at 4:02 p.m., an interview was conducted with LPN [licensed practical nurse] # 4, regarding the procedure for administering prn [as needed] pain medication. LPN # 4 stated, Start with non-pharmacological interventions, return in about a half-hour to an hour and reassess, if it is not effective check what is ordered, get the resident's pain level, based on zero to ten, ten being the worse, and minister meds [medication] and recheck in about an hour. When asked about the procedure staff follows for documenting that non-pharmacological interventions were attempted and the pain levels, LPN # 4 stated, It's documented on the back of the MAR [medication administration record] or the nurse's notes. After reviewing the MAR and nurse's notes for Resident # 25, LPN # 4 stated there was no documentation of non-pharmacological interventions being attempted or the pain levels. When asked about the lack of documentation of non-pharmacological interventions and the pain level, LPN # 4 stated, It's not documented can't say it's done. On 01/09/20 at 11:14 a.m., an interview was conducted with ASM [administrative staff member] # 2, director of nursing. When asked to describe the procedure for prn [as needed] pain medication, ASM # 2 stated, Rate the pain zero to ten, medicate them, and recheck in about an hour to see if was effective. When asked about attempting non-pharmacological interventions prior to administering as needed pain medication, ASM # 2 stated, It depends on what the pain is, chronic pain such as cancer pain we don't attempt them. Sometimes the patient will just ask for it and we won't argue with them. When asked if they expected to attempt non-pharmacological interventions if the resident was not experiencing chronic pain, ASM # 2 stated it should document on the pain flow sheet or nurse's notes. ASM # 2 further stated that the location and level of pain should be documented on the pain assessment sheet with the MAR. On 01/08/2020 at approximately 5:50 p.m., ASM # 1, the executive director and ASM # 2, director of nursing, ASM # 3, regional director of clinical services and LPN # 5 traveling MDS coordinator, were made aware of the findings. No further information was provided prior to exit. References: [1] Hydrocodone is available in combination with other ingredients, and different combination products are prescribed for different uses. Some hydrocodone combination products are used to relieve moderate-to-severe pain. Hydrocodone relieves pain by changing the way the brain and nervous system respond to pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601006.html.

Based on observation staff interview and review of facility documents it was determined the facility staff failed to store and prepare food in accordance with professional standards for food service safety. The findings include: On 01/072020 at 12:25 p.m., an observation of the facility's kitchen was conducted with OSM [other staff member] # 2, dietary manager. Observation of the reach-in refrigerator in the facility's kitchen revealed the following: One 46-ounce carton of thickened lemon water with approximately half of the contents remaining. One 46-ounce carton of thickened orange juice with approximately three-quarters of the contents remaining. Further One 46-ounce carton of thickened cranberry juice with approximately three-quarters of the contents remaining. Further observation failed to evidence an open date or a use-by-date. One quart of honey thickened milk with most of the contents remaining. One quart of honey thickened milk with most of the contents remaining. Further observation of all items above failed to evidence any open dates or a use-by-dates. OSM # 2 immediately removed the above items from the refrigerator. OSM # 2 stated that the items should be dated when they are opened, with a labeled use-by-date. Observation of the drying rack in the facility's kitchen revealed three quarter pans, four inches deep, wet nesting on the middle shelf of the drying rack. Further observation revealed two half pans, six inches deep wet nesting on the middle shelf of the drying rack. OSM # 2 immediately removed the above item from the drying rack and sent them to the dishwasher. OSM # 2 stated the pans should not be stacked wet. The facility policy Receiving documented in part, All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. The facility's policy Manual Warewashing documented in part, 3. All serviceware and cookware will be air dried prior to storage. On 01/08/2020 at approximately 5:50 p.m., ASM (administrative staff member) #1, the executive director and ASM # 2, director of nursing, ASM # 3, regional director of clinical services and LPN (licensed practical nurse) # 5 traveling MDS coordinator, were made aware of the findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to maintain infection control practices in the storage of a nebulizer (1) for Resident #47. Resident #47 was admitted to the facility 12/13/2019 with diagnoses, that included but were not limited to congestive heart failure (2), pneumonia (3) and chronic obstructive pulmonary disease (4). Resident #47's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/19/19, coded Resident #47 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. On 1/7/19 at approximately 2:30 p.m., an interview was conducted with Resident #47. Observation of Resident #47's room revealed a nebulizer delivery device on the top of a nightstand, which was located to the right side of the bed. The nebulizer device was observed uncovered with the mouthpiece touching the wood of the nightstand top. When asked about the nebulizer Resident #47 stated that she used it as needed. Resident #47 stated that she had been admitted with pneumonia and had required it frequently on admission and had not used it lately since she had been feeling better. When asked if the nebulizer was ever placed in a bag or covered between uses, Resident #47 stated that she did not remember it being covered. Further observation of Resident #47's room revealed an oxygen concentrator located on the right side of the bed with a nasal cannula (oxygen delivery device) in a plastic bag and a prefilled humidifier bottle of sterile water dated 12/23/19. When asked about the oxygen Resident #47 stated that she had not used it recently. Resident #47 stated that she used her oxygen when she first came into the facility in the middle of December but had not used it recently but it was there in case she felt that she needed it. The order summary report dated 01/01/20 through 01/31/20 documented, 12/22/19 Duoneb Albuterol (5) inhale 1 (one) unit dose via (by way of) nebulizer every 6 (six) hours as needed, and 12/14/19 Oxygen @ (at) 2 (two) LPM (liters per minute) via (by way of) N/C (nasal cannula) to maintain sats (oxygen saturations) > (greater than) 92%. The Physician's Interim/Telephone Orders dated 12/15/19 documented, Duonebs tx (treatment) via inhalation q6 (every six hours) x3 (for three) days prn (as needed). The MAR (medication administration record) dated December 2019 for Resident #47 documented the physician orders above. The MAR documented Resident #47 receiving the Duoneb nebulizer treatment on 12/16/19 and 12/17/19, no time of administration was documented for either date. The MAR further documented Resident #47 receiving the Duoneb nebulizer treatment on 12/18/19 at 6:00 a.m., and 12:00 p.m., on 12/19/19 at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m., and on 12/20/19 at 6:00 a.m., 12:00 p.m., and 12:00 a.m. The MAR (medication administration record) dated December 2019, and January 2020 for Resident #47 failed to evidence documentation of oxygen for Resident #47. The TAR (treatment administration record) dated 01/01/20-01/31/20 failed to evidence documentation of oxygen for Resident #47. The comprehensive care plan for Resident #47 failed to evidence documentation for nebulizer treatments or oxygen administration. On 1/08/20 at 1:00 p.m., an interview was conducted with LPN (licensed practical nurse) #4, regarding the process staff follows for handling nebulizer delivery devices. LPN #4 stated that they are cleaned after each use, and then stored in a bag. LPN #4 stated that the bags are changed weekly on Sundays. When asked why staff clean and store the nebulizers in this manner, LPN #4 stated that if they, (nebulizer) are left uncovered they could be exposed to germs, which can cause infection when used by the resident. When asked how often sterile water humidifier bottles on the oxygen concentrators are changed, LPN #4 stated that they are changed weekly on Sundays or before if needed. When asked why they are changed weekly, LPN #4 stated that it is an infection control practice. When asked if the oxygen is used as needed would it make a difference in how often the water bottle is changed, LPN #4 stated that it should still be changed weekly. An observation was conducted with LPN #4 of the uncovered nebulizer device with the mouthpiece touching the wood of the nightstand top. LPN #4 stated that it (nebulizer) should be in a bag. An observation was made with LPN #4 of the sterile water humidifier bottle dated 12/23/19 located in Resident #47's room. LPN #4 stated that it (sterile water humidifier bottle) was dated 12/23/19 and that should have been changed 12/30/19. LPN #4 agreed that the oxygen and the nebulizer were available for use for Resident #47. On 01/09/20 at approximately 12:30 p.m., a request was made by written list to ASM (administrative staff member) #1, the executive director for the facility policy on nebulizers and oxygen. On 01/20/20 at approximately 1:30 p.m., ASM (administrative staff member) #2, the director of nursing stated that the facility uses their policies, [NAME], and [NAME] & [NAME] as their standard of practice. The facility policy Nebulizer (small volume nebulizer), Effective Date: 11/30/2014; Revision Date: 03/20/2018 documented in part, .Disassemble device and rinse the mouthpiece and nebulizer cup with water and air dry. Place the entire unit in a bag to be maintained in the resident's room. The facility policy Oxygen Therapy, Effective Date: 11/30/2014; Revision Date: 08/28/2017 documented in part, Follow infection control procedures, as appropriate .Label tubing and humidifier with date and time. In Fundamentals of Nursing 7th edition, 2009: [NAME] A. [NAME] and [NAME]: Mosby, Inc; Page 648. Box 34-2 Sites for and Causes of Health Care-Associated Infections under Respiratory Tract -- Contaminated respiratory therapy equipment. The humidification system may be a source of bacteria. Pseudomonas aeruginosa is frequently the organism involved. Oxygen delivery equipment such as cannulas and masks can also harbor organisms. (Ignatavicius, D. & [NAME], L. (2002) Medical Surgical Nursing, Critical Thinking for Collaborative Care, 4th edition. (p.492) Philadelphia, Pennsylvania: W. B. [NAME] Company.) On 01/08/20 at approximately 5:50 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, ASM #3, the regional director of clinical services and LPN (licensed practical nurse) #5 were made aware of the findings. On 1/9/20 at approximately 8:00 a.m., ASM (administrative staff member) #3, the regional director of clinical services provided a copy of Physician's Interim/Telephone Orders for Resident #47 which documented, DC (discontinue) O2 (oxygen), Duonebs (nebulizer medication) & (and) IS (incentive spirometer) dated 1/8/20, 1610 (4:10 p.m.). No further information was provided prior to exit. Reference: 1. Nebulizer - a device used to aerosolize medications for delivery to patients. Taken from Encyclopedia & Dictionary of Medicine, Nursing & Allied Health -Seventh Edition, [NAME]-[NAME], page 1182. 2. Congestive heart failure A condition in which the heart can't pump enough blood to meet the body's needs. This information was obtained from the website: https://medlineplus.gov/heartfailure.html 3. Pneumonia is an infection in one or both of the lungs. This information was obtained from the website: https://medlineplus.gov/pneumonia.html. 4. Chronic obstructive pulmonary disease (COPD) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 5. Duoneb Albuterol The combination of albuterol and ipratropium is used to prevent wheezing, difficulty breathing, chest tightness, and coughing in people with chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways) such as chronic bronchitis (swelling of the air passages that lead to the lungs) and emphysema (damage to the air sacs in the lungs). Albuterol and ipratropium combination is used by people whose symptoms have not been controlled by a single inhaled medication. Albuterol and ipratropium are in a class of medications called bronchodilators. Albuterol and ipratropium combination works by relaxing and opening the air passages to the lungs to make breathing easier. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601063.html 4. Resident # 163 was admitted to the facility on [DATE] with diagnoses that included but were not limited to high blood pressure and chronic obstructive pulmonary disease [2]. Resident # 163's most recent MDS (minimum data set), was not due at the time of the survey. The facility's admission Data Collection sheet dated 01/03/2020 for Resident # 163 documented in part, Cognition: Alert, Oriented to Person. Under Communication it documented, Usually Understood and Understands. Under Respiratory, it documented, Special Treatments and Procedures: None per history and/or observation. On 01/07/20 at 1:49 p.m., an observation of Resident # 163's over-the-bed table revealed an incentive spirometer. Observation of the incentive spirometer failed to evidence that it was placed in a bag or covered. On 01/07/20 at 2:43 p.m., an observation of Resident # 163's over-the-bed table revealed an incentive spirometer. Observation of the incentive spirometer failed to evidence that it was placed in a bag or covered. On 01/07/20 at 4:05 p.m., an observation of Resident # 163's over-the-bed table revealed an incentive spirometer. Observation of the incentive spirometer failed to evidence that it was placed in a bag or covered. On 01/08/20 at 8:25 a.m., an observation of Resident # 163's over-the-bed table revealed an incentive spirometer. Observation of the incentive spirometer failed to evidence that it was placed in a bag or covered. The POS [physician's order sheet] dated 01/01/2020 through 01/31/2020 and signed by the physician on 01/04/2020 for Resident # 163 failed to evidence documentation for the use of an incentive spirometer. The facility's baseline care plan for Resident 163 dated 01/03/2020 failed to evidence documentation for the use of an incentive spirometer. On 01/08/20 at 8:30 a.m., an interview was conducted with Resident # 163. When asked if they used the incentive spirometer, Resident # 163 stated sometimes. On 01/08/2020 at 1:00 p.m., an interview was conducted with LPN [licensed practical nurse] # 4. When asked if an incentive spirometer was a piece of respiratory equipment, LPN # 4 stated yes. When how the incentive spirometer should be stored when not in use, LPN # 4 stated it should be covered or placed in a bag. LPN # 4 was shown Resident # 163's incentive spirometer on the over-the-bed table. LPN # 4 stated it should be covered. When asked why the incentive spirometer should be covered, LPN # 4 stated, It could collect germs and could cause an infection when used by the resident. On 01/08/2020 at approximately 5:50 p.m., ASM # 1, the executive director and ASM # 2, director of nursing, ASM # 3, regional director of clinical services and LPN # 5 traveling MDS coordinator, were made aware of the findings. No further information was provided prior to exit. References: [1] A device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. Using the incentive spirometer teaches you how to take slow deep breaths. Deep breathing keeps your lungs well inflated and healthy while you heal and helps prevent lung problems, like pneumonia. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm. [2] Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 5. The facility staff failed to store nebulizer mask and an incentive spirometer [1] in a sanitary manner. Resident # 25 was admitted to the facility on [DATE] with diagnoses that included but were not limited to respiratory failure, shortness of breath and chronic obstructive pulmonary disease [1]. Resident # 25's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/29/19, coded Resident # 25 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making daily decisions. Resident # 25 was coded as requiring extensive assistance of one staff member for activities of daily living. Section O Special Treatments, Procedures and Programs coded Resident # 25 for the use of oxygen. On 01/07/20 at 1:25 p.m., an observation of Resident # 25's bedside table revealed a nebulizer and a nebulizer mask sitting on top of the table. Observation of the nebulizer mask revealed it was uncovered. When asked if they receive nebulizer treatments, Resident # 25 stated yes. Further observation of the bedside table revealed an incentive spirometer uncovered. When asked if they use the incentive spirometer, Resident # 25 stated yes. On 01/07/20 at 2:45 p.m., an observation of Resident # 25's bedside table revealed a nebulizer and a nebulizer mask sitting on top of the table. Observation of the nebulizer mask revealed it was uncovered. Further observation of the bedside table revealed an incentive spirometer uncovered. On 01/07/20 at 4:05 p.m., an observation of Resident # 25's bedside table revealed a nebulizer and a nebulizer mask sitting on top of the table. Observation of the nebulizer mask revealed it was uncovered. Further observation of the bedside table revealed an incentive spirometer uncovered. On 01/08/20 at 8:30 a.m., an observation of Resident # 25's bedside table revealed a nebulizer and a nebulizer mask sitting on top of the table. Observation of the nebulizer mask revealed it was uncovered. Further observation of the bedside table revealed an incentive spirometer uncovered. The Physician's Telephone Order dated 12/27/2019 documented, Duo nebs Q [every] 4 [four] hours for SOB [shortness of breath]. Further review of the clinical record failed to evidence a physician's order for the use of an incentive spirometer. The comprehensive care plan for Resident # 25 with a revision date of 12/03/2019 documented, Focus: [Resident # 25] has COPD [chronic obstructive pulmonary disease]. Date Initiated: 12/03/2019. Under Interventions it documented, Give nebulizer treatments and oxygen therapy as ordered. Date Initiated: 12/03/2019. On 01/08/2020 at 1:00 p.m., an interview was conducted with LPN [licensed practical nurse] # 4. When asked if an incentive spirometer was a piece of respiratory equipment, LPN # 4 stated yes. When how the incentive spirometer should be stored when not in use, LPN # 4 stated it should be covered or placed in a bag. When asked how a nebulizer mask should be stored when not in use, LPN # 4 stated it should be placed in a bag. When shown Resident # 25's nebulizer mask and incentive spirometer on the bedside table LPN # 4 stated the incentive spirometer and nebulizer mask should be covered. On 01/08/2020 at approximately 5:50 p.m., ASM # 1, the executive director and ASM # 2, director of nursing, ASM # 3, regional director of clinical services and LPN # 5 traveling MDS coordinator, were made aware of the findings. No further information was provided prior to exit. References: [1] A device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. Using the incentive spirometer teaches you how to take slow deep breaths. Deep breathing keeps your lungs well-inflated and healthy while you heal and helps prevent lung problems, like pneumonia. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm. Based on observation, staff interview, resident interview, clinical record review, and facility document review, it was determined that the facility staff failed to follow infection control practices for four of 32 residents in the survey sample; Residents #41, #37, #47, #163, and #25. The facility staff failed to store Resident #41's nebulizer and Incentive spirometer in a manner to prevent infections. Resident #41's nebulizer mask and Incentive spirometer were observed uncovered on the residents over the bed table. The facility staff failed to prepare and administer medications to Resident #37, in a manner to prevent the spread of infection. RN (registered nurse) #1 was observed touching medications in a plastic medication cup with her ungloved finger. The facility staff failed to maintain infection control practices in the storage of a nebulizer for Resident #47, the storage of Resident #163's incentive spirometer and Resident #25's nebulizer and incentive spirometer to prevent infection. The findings include: 1. Resident #41 was admitted to the facility on [DATE]; diagnoses included but are not limited to hydrocephalus, psychotic disorder, right kidney cancer with removal of kidney, cardiac defibrillator, high blood pressure, atrial fibrillation, diabetes, bipolar disorder, spinal stenosis with fusion, and cerebral palsy. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/21/19 coded the resident as being cognitively intact in ability to make daily life decisions. The resident was coded as requiring extensive care for bathing, toileting, dressing, and transfers; supervision for eating and hygiene; and was incontinent of bowel and bladder. A review of the facility policy, Nebulizer documented, Place entire unit in a bag to be maintained in the resident's room. A review of the facility policy, Incentive Spirometer did not document any criteria for maintaining the device in a sanitary manner between uses. On 1/07/20 at 12:10 PM, an observation was made of Resident #41's room. Resident #41 was not in the room. An Incentive Spirometer was observed on the over bed table. It was not covered. A nebulizer machine and mask was observed on nightstand next to the bed. The mask was not covered. On 1/08/20 at 8:52 AM, the resident was observed in bed. The Incentive Spirometer and nebulizer mask remained uncovered as previously observed. On 1/08/20 at 1:00 PM, the resident was observed and an interview conducted. The over bed table was across the resident. The incentive spirometer was on the table, uncovered. There was no bag present to cover and store the incentive spirometer. Observation of the nebulizer mask revealed it was now covered, in a new bag and dated. Resident #41 stated that he has used both items on occasion and that to his recollection neither item had been covered. On 1/8/20 at 1:07 PM, in an interview with RN #1 (Registered Nurse), she stated that the nebulizer mask should be covered. She stated the incentive spirometer should be wiped clean. RN #1 stated, I guess it should be stored in a bag but I was never told that. On 1/8/20 at 5:50 PM, ASM #1 (Administrative Staff Member - the Excutive Director) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. 2. The facility staff failed to prepare and administer medications to Resident #37, in a manner to prevent the spread of infection. RN (registered nurse) #1 was observed touching medications in a plastic medication cup with her ungloved finger. Resident #37 was admitted to the facility on [DATE]; diagnoses include but not limited to, encephalopathy, heart disease, dysphagia, diabetes, atrial flutter, abdominal aortic aneurysm, high blood pressure, cardiac pacemaker, and pneumonia. The admission / 5-day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/17/19 coded the resident as significantly cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing and toileting; extensive assistance for transfers, dressing, and hygiene; was independent for eating; and incontinent of bowel and bladder. On 1/08/20 at 9:08 AM, RN #1 (Registered Nurse) was observed to preparing and administering the following medications to Resident #37: Allopurinol (1) 100 mg (milligrams), 1 tablet Atenolol (2) 25 mg, 3 tablets for 75 mg Eliquis (3) 2.5 mg, 1 tablet Multivitamin (4), 1 tablet Vitamin D3 (5), 1000 units, 2 tablets for 2000 units. The Eliquis was missing from the medication cart. RN #1 closed up the cart and carried the medication cup that contained the other medications to the medication room to obtain the missing Eliquis from the stat box. RN #1was observed with her finger down in the medication cup that contained the medications, touching the pills while she was carrying it. RN #1 returned to the cart with the medications, and then crushed the medications and administered them to Resident #37. On 1/08/20 at 3:16 PM, in an interview conducted with RN #1, she stated that you shouldn't touch the medication with your fingers. RN #1 stated, I didn't realize I was doing that. I know better than to do that. I know that you are not supposed to touch the pills. A review of the facility policy, Medication - Oral Administration of documented, Refrain from touching powders, capsules, or pills with hands. On 1/8/20 at 5:50 PM, ASM #1 (Administrative Staff Member - the Executive Director) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. References: 1. Allopurinol is used to treat gout. Information obtained from https://medlineplus.gov/druginfo/meds/a682673.html 2. Atenolol is used to treat high blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a684031.html 3. Eliquis is used to prevent strokes and blood clots in people with atrial fibrillation. Information obtained from https://medlineplus.gov/druginfo/meds/a613032.html 4. Multivitamin - used to treat or prevent vitamin deficiency due to poor diet, certain illnesses, or during pregnancy. Vitamins are important building blocks of the body and help keep you in good health. Information obtained from https://www.webmd.com/drugs/2/drug-18820-9038/multivitamin-oral/multivitamins-includes-prenatal-vitamins-oral/details 5. Vitamin D - Vitamins are substances that your body needs to grow and develop normally. Vitamin D helps your body absorb calcium. Calcium is one of the main building blocks of bone. A lack of vitamin D can lead to bone diseases such as osteoporosis or rickets. Vitamin D also has a role in your nerve, muscle, and immune systems. Information obtained from https://medlineplus.gov/vitamind.html