Based on observation and staff interviews the facility failed to talk with residents for whom they are providing assistance rather than conducting social conversations with other staff. A facility staff member also failed to speak with residents politely, respectfully, and communicate personal information in a way that maintains confidentiality for 2 of 3 meals observed. The facility reported a census of 41 residents. Findings include 1. During an observation on 3/14/22 at 11:58 AM, Staff D, Certified Nurses Aide (CNA), while assisting Resident #25 with their meal service, remarked that the food was not lasagna and laughed. Staff D then commented it's supposed to be a brownie or cookie or something and laughed again. During an observation at 3/14/22 at 12:01 PM Staff D while assisting Resident #25 got up and walked out of the dining room with no one to replace her. Staff D returned at 12:03 PM and stated in a loud voice that Resident #25 looks tired today like they were off in a daze and laughed. During an observation on 3/14/22 at 12:08 PM Staff D while assisting Resident #25 in a loud voice yelled over to another resident's table, do you even know what your talking about and laughed. She then returned to helping Resident #25 to eat, then in a loud voice stated, did you fall asleep mid conversation and laughed. During an observation on 3/14/22 at 12:17 PM Staff D in a loud, almost yelling, voice, vocalized, does it have no flavor without salt and laughed. Staff D then continued to repeat the same statement two (2) more times and continued to laugh. During observations on 3/14/22 during the noon meal service, other facility staff were present and no interventions were implemented for Staff D's behavior. 2. During an observation on 3/15/22 at 12:04 PM of Staff D while assisting Resident #4 with meal service, observed her ask Resident #4 if the food was good. When Resident #4 replied, no, Staff D laughed and failed to offer intervention or alternative to Resident #4. During an observation on 3/15/22 at 12:11 PM Staff D told another coworker present in the dining room about her days off coming up and a birthday party. During observations on 3/15/22 during the noon meal service, the other facility staff failed to implement interventions behaviors for Staff D while present during the observations of Staff D. During an interview on 3/17/22 at 12:35 PM the Administrator and Director of Nursing (DON) revealed they were aware of Staff D's inappropriate comments at times. They expressed that they would not expect inappropriate comments to be made to residents. They revealed that the dining service environment should be focused on the residents eating their meals.

Based on resident's record review and staff interviews the facility failed to keep 3 of 3 residents reviewed (Resident #6, #34, and #91) personal funds in an interest bearing account for funds that exceeded one hundred dollars ($100). The facility reported a census of 41 residents. Findings include: The record review of an untitled document dated 3/14/22 provided by the facility revealed that the facility managed 21 resident account funds. The form documented 8 of the 21 accounts received interest, however 3 of the accounts that exceeded the $100 amount were not receiving interest. During an interview on 3/16/22 at 2:08 PM Staff E explained that she was not aware that the three (3) accounts over $100 needed to receive interest. During an interview on 3/17/22 at 12:22 PM Staff E expressed that she was opening a savings account for the residents whose accounts exceeded $100 dollars. During an interview on 3/17/22 at 12:46 PM the Administrator said they were going to open savings accounts for any resident's account over $100 dollars. The undated Resident Trust Fund Evening and Weekend Fund Availability lacked policies or procedures on when a resident's personal funds account would receive interest. The undated Authorization Form for Personal Fund Allowed provided to residents by the facility lacked information related to interest bearing accounts for the resident trust.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #17's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The MDS documented Resident #17 independent with eating. Resident #17's diagnoses included Parkinson's Disease and Non-Alzheimer's Dementia. The Care Plan revised 12/14/21 documented Resident #17 had a diagnosis of dementia. As of 12/6/21 directed the staff to give medications as ordered. Monitor/document for side effects and effectiveness. The Care Plan also documented that the resident received anti-Parkinson therapy related to Parkinson's Disease and directed the nursing staff to administer anti-Parkinson's medications as ordered by the physician, revised 12/6/21. The Medication Review Report, signed by the attending physician on 2/28/22 documented the diagnosis of Parkinson's Disease with a physician's order for the following medication: a. Two orders for Carbidopa-Levodopa Tablet 25-100 Milligram (MG). Give 3 tablets by mouth once a day related to Parkinson's Disease. Start Date 12/13/21. b. Three orders for Carbidopa-Levadopa Tablet 25-100 MG. Give 4 tablets by mouth once a day related to Parkinson's Disease. Start Date 12/13/21. A Consultation Note from the Department of Neurology, dated 3/1/22, documented Resident #17 had noticed being slower in the morning and more fatigued. Resident #17 reported that it took about 4-5 hours to start moving well. The Consultation Note documented a new plan to up-titrate (adjust dosage by adding medication slowly) his medication as follows: A. Increase the 6:00 a.m. dose to 3.5 tablets for 3 days, if tolerated increase to 4 tablets in the morning. B. After 3 days of this if he tolerates the dosage change, increase the 11:00 p.m. dose to 3.5 tablets. C. After 3 more days increase 11:00 p.m. dose to 4 tablets if tolerated. If he tolerates this titration his final dos would be: a. 6:00 a.m. 4 tablets b. 10:00 a.m. 4 tablets c. 2:00 p.m. 3 tablets d. 7:00 p.m. 4 tablets e. 11:00 p.m. 4 tablets. The Consultation Note, dated 3/1/22, did not the name of the medication, route or dose of the medication to be administered. The March 2022 Medication Administration Record (MAR) listed a physician order for Carbidopa-Levodopa Tablet 25-100 MG. Give 4 tablet by mouth one time a day related to Parkinson's Disease scheduled for 10:30 a.m The MAR documented on 3/14/22 at 10:30 a.m. the dose administered to the resident by Staff A, Registered Nurse. During an observation on 3/14/21 at 11:02 a.m. the resident sat in the recliner in his room with 4 circular yellow pills laid out on a napkin. He proceeded to place each pill into a small plastic cup of applesauce. Resident #17 then put the spoon in his mouth and took the pills. Resident #17 remained in his room without any facility licensed nurse present to observe the medication administration. Resident #7's Spouse stated that he took the medication for his Parkinson's Disease and he doesn't always remember well. During an interview on 3/14/22 at 4:00 p.m., Resident #17 stated he preferred to take his medication on his own. He asks the nurses to leave his medication so that he can take in applesauce himself. He administered his medications at home prior to coming to the facility and wanted to continue to be able to do this at the facility. He stated it upsets him that not all of the nurses will leave his medications at the bedside. He reported the nurses know he likes to have his medication left for him to take on his own. During an interview on 3/16/22 at 2:11 p.m. Staff A, Staff B, Certified Medication Aide, (CMA), and Staff C, CMA, all stated they were to supervise medications being taken by the residents. Staff A stated if a resident wants to take their own medications it would have to be assessed and care planned. She stated the DON would take care of the assessment and then it would be care planned and communicated to the nurses and CMA's. During an interview on 3/16/22 at 2:06 PM the Director of Nursing (DON) revealed that she expected the nurses to stay with a resident while they were swallowing their pills. The DON explained that the nurse must be present until the pills are gone. She reported that she wished Resident #17 would have told her because they have an option for self medication - the Occupational Therapist (OT) completes an evaluation and gets an physician's order and then OT completes the routine reviews if safe to continue as well. She reported none of the staff nurses had informed her they had been leaving the resident's medications for him to take without supervision. During a follow-up interview on 3/16/22 at 3:25 p.m. the DON reported that none of the nurses came to her to inform her Resident #17 wanted his medication left at the bedside to take on his own. She stated she would have expected the nurses to report it to her if the resident wanted medication left at the bedside of they couldn't follow the policy to supervise the taking of medications. On 3/17/21 at approximately 8:25 a.m. after the review of the Consultation Note dated 3/1/22, the DON stated technically the Consultation Note didn't contain a complete medication order and it should have been clarified. The undated, Medication Administration Policy provided by the facility documented the Purpose was that the facility accepted the following types of medication orders to meet quality and professional standards. The Procedure listed under titrating orders explained that the dose was adjusted in response to the resident's status. The required elements of a complete medication order include: the name of the medication, dose, route, and indication for use. If a written or faxed order is incomplete, illegible, or unclear, the nurse will contact the prescriber to clarify. Part D. Medication Administration, General Principles documented the following: A. At the facility, medications were administered independently by professional nurses including Registered Nurses and Licensed Practical Nurses. Certified Medication Aides may also administer medications under the supervision of a professional nurse via routes that they have proved proficient in. B. Before administration, the individual administering the medication would visually inspect the medication for particulates, discoloration, or other loss of integrity. C. Before administration, the individual administering the medication verifies that the medication matches the order, the label, that it wasn't expired, or was contraindicated. D. Before administration, the individual administering the medication verifies that the medication was administered at the proper time, in the prescribed dose, and by the correct route. E. Before administration if any irregularities were noted, these were discussed with the physician and/or professional nurses involved with the resident's care for resolution. F. Before administration of a new medication, the resident and/or family was informed of any potential clinically significant adverse side effects or other concerns regarding the medication. The Medication Administration Policy regarding Self-Administration of Medication recored that the facility would allow residents to self-administer medications when requested by the resident and then ordered by the attending physician. The Procedure documented the following: 1. When a resident receives an order to self-administer medications, the Occupational Therapist, (OT), would be notified. The OT will then screen the resident. Mental status will be evaluated and documented as part of this screen. 2. If the OT believes that self-administration of medication was appropriate, the physician will be contacted for an order for therapy evaluation treatment. 3. When the order is received by the therapist, an individualized self-administration plan will be formulated as a component of the therapy treatment. 4. The therapist will assure that medication education was provided to the residents and involve family regarding the medication name, type, and reasons for use. They also instruct on the process of how to administer the medications, time, frequency, route, and dose. Instructions also cover anticipated actions and potential side effects as well as monitoring the effects of the medication. The therapist will also observe and monitor the resident to assure that medication administration is correctly completed and documented by the resident. 5. The therapist will also assure that medications are safely stored to prevent tampering by other residents. 6. At the end of therapy, the therapist will submit the individualized plan to the interdisciplinary team for inclusion in the resident's plan of care. 7. Compliance with the plan will be evaluated by the team. The Medication Administration Policy Checklist for dispensing medication documented the med pass was complicated and had the potential to produce most medication errors. A widely published checklist of ten rights focused on the important steps to administer medications to residents under effective and safe circumstances. When followed in a medication pass, the guidelines could minimize errors and assure the medications were able to provide the desired results. Those guidelines were: 1. Right Medication - The nurse should be sure the medication to be administered is that ordered by the physician and appropriate to the resident's medical condition. 2. Right Dosage - The nurse should assure that the dosage ordered was appropriate to the resident, their physical, and their medical condition. 3. Right Patient - New patients, patients with similar names, and new employees could lead to the wrong person getting the medications of another patient. To prevent this, a photo, armband, and/or self identification by the resident were necessary each time medication was dispensed. 4. Right Manner and Route - Crushing pills to be hidden in food should not be done with delayed absorption medication and someone vomiting may need oral medication administered in another approved form and/or route. 5. Right Time - Keeping medication at the same level in the body may require adhering to a right schedule of dispensation. 6. Right Documentation - An accurate record of the medication taken by the resident was important so the dispensing nurse could complete the necessary record keeping before moving on to the next resident. 7. Right Assessment - An immediate condition, such as blood pressure, may be determined if a medication decreased blood pressure was to be given without harm to the resident. 8. Right Education - The patient should know why they were getting the medication and effects they should expect, the food, or the beverages they should avoid or encourage, and how to report any undesirable effects. 9. Right Evaluation - The resident should be observed to assess the outcome of the medication. Is the drug having the positive effect expected? 10. Right to Refuse Medication - The right to refuse medication should be respected with the nurse determining why the refusal and inform the physician and care planning team of the refusal for medication adjustments that would address the medical concern. The Long Term Care Center's Pharmacy Services and Procedure Manual, revised 1/19, provided by the facility documented a new order should include: 1. Date of order 2. Resident name 3. Identification number 4. date of birth 5. Medication name, strength, dosage, time or frequency, and route of administration; 6. Physician's/prescriber's name; and 7. Pertinent ancillary instructions 8. Reason for use 9. Stop order date, as appropriate 10. Administration parameters Based on observation, staff interviews and policy review the facility failed to ensure nursing staff followed professional standards of practice during medication administration for 2 of 6 residents reviewed (Resident #30 and #17). A facility nurse failed to verify if giving the correct pain medication for Resident #30 when observations and interviews revealed she was not present during the dispensing of the medication to ensure she gave the right drug. A facility nurse also failed to follow standards of practice for supervising medication administration when the nurse left a resident unattended to take his medications. The facility reported a census of 41 residents. Findings include: 1. During an observation on 3/16/22 at 11:32 AM of Resident #30's medication administration revealed the following: A. Staff C, Certified Medication Aide (CMA), observed Staff F, Licensed Practical Nurse (LPN), dispense and verify the following order: Norco Tablet 5-325 MG (HYDROcodone-Acetaminophen) 1 tablet, give by mouth, three times a day while Staff C observed. B. Staff F then preceded to sign it off on Resident #30 Individual Narcotic Record. C. Staff C then left stating she will give the pain medication to give to Resident #30 and did not sign #30 Individual Narcotic Record. During an interview on 3/16/22 at 11:33 AM Staff F declared that the staff come and get narcotic medication for Resident #30 when they need it. Staff F added that the staff who administer the medication to Resident #30 do not cosign the narcotic record book to show it was in their possession. Staff F then revealed that she didn't verify or observe if the narcotic medication is given to Resident #30. During an observation on 3/16/22 at 11:33 AM of Resident #30's Individual Narcotic Record revealed only Staff F's initials. Resident #30's Medication Administration Record (MAR) for 3/16/22, documented the noon dose of their Norco Tablet 5-325 MG (HYDROcodone-Acetaminophen) 1 tablet, give by mouth, three times a day order, revealed Staff A, Registered Nurse (RN), signed the medication off as given. However, Staff A was not present during the observation of the medication set up and did not sign off on the narcotic record that she was in possession of the narcotic. During an interview on 3/16/22 at 2:08 PM Staff A, Registered Nurse (RN), reported being busy with another resident that day, so they had Staff C go up front to get Resident #30's noon narcotic medication. She stated she and Staff C stood together as she gave the medication to the Resident #30. She then signed on the MAR that she had administered the medication. She commented that she couldn't verify if the medication was correct as she didn't see the MAR or the pill card before giving the medication. During an interview on 3/16/22 at 2:03 PM Staff C, reported that she asked the nurse to get the resident's narcotic medication out of lock up. Staff C looked at the MAR and the medication card to confirm that the nurse was giving her the correct medication. Staff C then took the medication down to the unit, opened the MAR to review the order to administer the medication herself or gives it to the nurse to administer. During an interview on 3/16/22 at 2:40 PM the Director of Nursing (DON) revealed she has not instructed staff to cosign the narcotic record book when taking the narcotic medication out to administer to Resident #30. The DON explained that as of the time of the interview, they implemented that after being made aware. The DON commented that she would expected Staff C to administer Resident #30's narcotic pain medication since she was present when the medication was dispensed and able to verify it is the correct medication instead of Staff A who was not present.

Based on resident record reviews, staff interviews, and policy review, the facility failed to ensure all resident's personal fund accounts, including savings accounts, that the facility manages had a surety bond in place to cover the total amount. The facility reported a census of 41 residents. Findings include: The untitled document dated 3/14/22 provided by the facility documented that the facility managed 21 residents' personal fund's accounts. The 21 accounts combined equaled $9,327.09, of the 21 accounts 8 of the accounts also had money in their own individual savings account and total money in the savings accounts equaled $8,052.00 of the $9,327.09. The record review of a billing notice renewal period of 5/16/21 to 5/16/22 revealed a resident fund bond covering $3,000, which is less than 9,327.09. During an interview on 3/17/22 at 12:25 PM Staff E revealed that she was not aware the money in the savings account needed to be covered by the surety bond. She explained the surety bond does cover everything, but not in the savings account. During an interview on 3/17/22 at 12:40 PM the Administrator revealed that she was not aware that the money in the savings account needed to be covered by the surety bond and had discussed this with Staff E. The record review of the undated facilities polices for resident fund accounts lacked policies or procedures regarding the surety bond for resident funds.