Based on interview, record review, review of the facility's agreement with the dialysis center, and review of the facility's policy, the facility failed to ensure that residents requiring dialysis received services consistent with professional standards of practice by failing to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 2 of 3 residents receiving dialysis, Resident (R) 64 and R123. The findings include: Review of the facility's policy titled, Continuum of Care with Dialysis Center, revised 10/2017, revealed the facility's intent was to maintain effective communication with the dialysis center to provide the best continuum of care and outcomes for all residents receiving hemodialysis. Additional review revealed nursing would provide the dialysis center with a current medication list. Further review revealed the dialysis center would send labs, diet, and weight sheets back to the facility following treatment for nursing to review and place in the resident's medical record. Review of the facility's agreement with the dialysis center Long Term Care Facility Outpatient Dialysis Service Coordination Agreement, signed by the facility on 06/10/2022 and signed by the dialysis center on 06/13/2022, revealed mutual obligations in collaboration of care by both parties by ensuring documented evidence of collaboration of care and communication between the two entities. 1. Review of R64's admission Record revealed the facility admitted the resident on 11/01/2021 with diagnoses to include stage 4 chronic kidney disease (CKD), dependence on renal dialysis, and anemia in CKD. Review of the R64's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/09/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 of 15, which indicated the resident was cognitively intact. Review of R64's Comprehensive Care Plan [CCP], not dated, revealed the facility assessed the resident as requiring hemodialysis due to renal failure. Interventions included dialysis every Tuesday, Thursday, and Saturday, evaluate access device for bruit, thrill as ordered, and observe for signs and symptoms of hypo/hypertension and infection. Record review of R64's dialysis folder revealed there was no completed Dialysis Communication Record to include dialysis center communication to the facility and the post-dialysis assessment to the facility. Further review indicated the communications regarding the continuum of care were either incomplete or entirely blank for dialysis sessions on 04/05/2025, 04/22/2025, 04/29/2025, 05/03/2025, 05/06/2025, 05/08/2025, and 05/16/2025. 2. Review of R123's admission Record revealed the facility admitted him on 05/12/2025 with diagnoses of Parkinson's disease, end stage renal disease, and dependence on renal dialysis. Review of R123's admission MDS, with an ARD of 05/18/2025, revealed the facility assessed the resident to have a BIMS score of 14 out of 15, indicative of intact mental cognition. Further review revealed dependence on hemodialysis therapy. Review of R123's Order Summary Report for May 2025 revealed a physican order for dialysis every Monday, Wednesday, and Friday, at the dialysis clinic specific location with chair time of 10:30 AM, and transport to pick up at 10:00 AM. Further review revealed an order to monitor dialysis port to right chest every shift. Review of R123's Electronic Medical Record (EMR) document titled Dialysis Communication Record, dated 05/19/2025, revealed sections post dialysis assessment and post dialysis vital signs were blank. Review of R123's dialysis folder revealed Dialysis Communication Record, dated 05/30/2025, with the section prior to dialysis/center nurse assessment data missing the assessment of the access site and had no nurse signature. Further review revealed the sections dialysis center communication to facility, post dialysis assessment, and post dialysis vital signs were blank. Review of R123's dialysis folder revealed Dialysis Communication Record, dated 06/04/2025, with the section prior to dialysis/center nurse assessment data missing the assessment of the access site and had no nurse signature. Further review revealed the sections dialysis center communication to facility, post dialysis assessment, and post dialysis vital signs were blank. In an interview with Registered Nurse (RN) 3 on 06/04/2025 at 9:35 AM, she stated that dialysis residents had a folder that went with them to treatment, which contained all pertinent information needed, including medication lists. She stated the dialysis center completed the post dialysis portion and sent the folder back with the resident. She stated the resident's nurse reviewed the information upon their return, and if any new diet orders or recommendations were made, the care nurse would notify the doctor and obtain new orders. In an interview with RN2 on 06/04/2025 at 9:37 AM, she stated she was the nurse for R123, and the dialysis folder was sent out with R123 to his treatment, she completed the communication form, and upon his return she would review the dialysis center information for his post dialysis vital signs, weight, how much fluid was removed, and any new recommendations. In a follow-up interview with RN2 on 06/04/2025 at 4:33 PM, following R123's return from the dialysis center, she stated she did not know why the Dialysis Communication Record was not completed, and she did not know why the folder only contained forms for 05/30/2025 and 06/04/2025. She stated she had not received any report from the dialysis center via phone, fax, or written documentation, and she had not attempted to call the dialysis center for report or information. In an interview with the Dialysis Clinic Manager on 06/05/2025 at 2:45 PM, she stated the expectation was for residents to arrive to the dialysis center with a folder that contained a face sheet, medication list, and any pertinent information that would be important for dialysis staff to know. The Dialysis Clinic Manager stated after the dialysis was completed, the staff completed their form Daily Transfer Sheet that included the pre- and post-dialysis weight and vital signs along with other pertinent information. She stated that form was placed in the folder which was sent back to the facility with the resident. She stated it would be her expectation for the facility to call and request a verbal report over the phone and request a fax of the form with the information if it had not been received upon the resident's return to the facility. In an interview with the Director of Nursing (DON) on 06/04/2025 at 2:29 PM, he stated the purpose for communication between the facility and the dialysis center was to ensure continuation of care for residents. The DON stated residents were sent to dialysis with a folder that had a transfer report that included a list of medications. The DON stated his expectation was for the RN or Charge Nurse on the unit to ensure the paperwork was completed prior to the resident leaving the facility and review it upon return for completed information. He stated he was unaware the forms were not being completed. In a follow-up interview with the DON on 06/04/2025 at 4:40 PM, he was asked by the State Survey Agency (SSA) Surveyor to review R123's dialysis folder after returning from treatment, and he stated the forms were not completed. The DON stated his expectation was that facility staff received a report from the dialysis center on every resident that had treatment, every time they had treatment. In an interview with the Administrator on 06/05/2025 at 10:46 AM, she stated it was her expectation that staff adhered to the facility's protocols, as they impacted the health quality of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of R130's closed admission Record revealed the facility admitted the resident on 03/19/2025 with diagnoses including orthopedic aftercare following surgical amputation, insomnia, depression, and anxiety disorder. Review of R130's MDS, with an ARD of 03/25/2025, revealed the facility assessed the resident with a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Further review revealed R130 denied depression symptoms such as feeling hopeless. Continued review revealed the facility assessed the resident as being free from delusions, hallucinations, and behaviors during the look back period. Review of R130's CCP, dated 03/20/2025, revealed the facility assessed the resident as at risk for side effects of psychotropic medications she was ordered due to a history of psychosis, hallucinations, and delusions. Further review revealed the facility included interventions such as observing the resident for worsening of her psychiatric condition and worsening confusion. Review of the staff interviews from the Facility Investigation, dated 04/02/2025, revealed on 04/02/2025, State Registered Nurse Aide (SRNA) 11 was giving report to SRNA12 and stated R130 had acted crazy that night. Further review revealed R130 overheard SRNA11 and called out, I'm not crazy! Continued review revealed the Social Services Director interviewed R130, who was upset, and stated she had not been sleeping and requested a room change. Review of R130's Discharge Summary, dated 04/10/2025, revealed the facility discharged R130 home on [DATE] according to her discharge plan. The State Survey Agency (SSA) Surveyor attempted an interview with R130 via phone; however, the number available for her had been disconnected. In an interview on 06/04/2025 at 8:03 PM, SRNA11 stated she did tell SRNA12 during report that R130 had acted crazy through the night. She stated, when she realized R130 had overheard her, she immediately told the nurses, who were also in report. SRNA11 stated she had been disciplined for her unprofessional comment and had learned to be more careful with what she said because a resident who overheard a careless comment could be offended. In an interview on 06/05/2025 at 10:45 AM, Licensed Practical Nurse (LPN) 5 stated she recalled hearing SRNA11 state R130 had overheard her say the resident was crazy during report. She further stated it was inappropriate for a staff member to say something like that because it could offend a resident and was also dismissive of medical symptoms the resident could be experiencing. In an interview on 06/05/2025 at 10:59 AM, Resident Care Manager (RCM) 1 stated her expectations for staff while giving report were for staff to speak quietly in the hallway. She further stated she expected staff to communicate clinical information in a professional manner, using clinical terms rather than slang. Per interview, RCM1 stated SRNA11 had a loud voice and made a poor choice of words that undermined R130's dignity while the resident was hallucinating. In continued interview, RCM1 stated R130 was briefly upset about SRNA11's comment, but was primarily upset about not being able to sleep. Per interview, R130 reported feeling better after a nap and continued participating in her normal activities. Additionally, RCM1 stated SRNA11 did not take care of or interact with R130 following the incident. RCM1 stated someone in upper management officially disciplined SRNA11 for her lack of professionalism, and RCM1 re-educated staff on the importance of speaking respectfully about residents. In an interview on 06/05/2025 at 2:18 PM, the Social Worker stated her role in investigating resident concerns about staff members was to interview any staff present at the time of the incident, as well as all interviewable residents to determine if any of them had a similar concern. In further interview, the Social Worker stated SRNA11 admitted she did call R130 crazy during report. Per interview, SRNA11 reported to the Social Worker she did not realize until after R130 called out, I'm not crazy! that the resident could hear her. The Social Worker stated R130's primary concern was not sleeping and requested a move to a private room to help her sleep better. Additionally, the Social Worker stated she followed up with R130 over the next few days and did not observe any psychosocial changes, and the resident reported feeling much better after sleeping. In an interview on 06/05/2025 at 11:17 AM, the Director of Nursing (DON) stated staff made him aware of SRNA11's inappropriate comment about R130 when he arrived at work that morning, shortly after the incident. He further stated he immediately suspended SRNA11 pending investigation. Per interview, the Social Worker conducted staff and resident interviews and determined SRNA11 did state that R130 was acting crazy, and R130 did overhear her. In continued interview, the DON stated the facility found no further concerns in the course of the investigation and brought SRNA11 back to work after official disciplinary action. Additionally, the DON stated he came in on night shift when SRNA11 was working to observe her and to personally talk to her about why it was important to protect the resident's dignity. In an interview on 06/05/2025 at 11:23 AM, the Director of Resident Care Services stated she conducted the meeting with SRNA11 and the night shift supervisor in which she gave SRNA11 the notice of official disciplinary action based on her unprofessional comment about R130's behavior. She further stated she instructed the night shift supervisor to observe SRNA11 more frequently to ensure she was meeting expectations to speak to and about residents respectfully. Based on observation, interview, record review, review of the facility's investigation report, and review of the facility's policy, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 4 of 26 sampled residents, Resident (R) 99, R110, R117, and R130. The findings include: Review of the facility's policy titled, Resident Rights, revised 10/2022, revealed the resident had the right to a dignified existence, self-determination, including privacy and the right to participate in decisions and care planning. 1. Review of R117's admission Record revealed the facility admitted her on 04/01/2025 with diagnoses of acute kidney failure, congestive heart failure, and hyponatremia. Review of R117's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/07/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, indicative of intact mental cognition. Further review revealed R117 was not admitted with any form of bladder appliance, was not on a urinary toileting program, and experienced frequent urinary incontinence. Review of R117's Physician Orders, dated 05/20/2025 revealed an order for an indwelling urinary catheter with catheter care every shift and as needed, intake and output every shift, and incontinence products as needed. Observation made on 06/02/2025 at 12:57 PM revealed R117 was lying in bed with the urinary catheter bag visible on entry to the resident's room. The drainage bag was placed on the bed frame, with no dignity bag covering in place. Observation made on 06/02/2025 at 4:03 PM revealed R117 was sitting in the wheelchair in the therapy gym participating in physical therapy with her urinary drainage bag visible and hooked on the wheelchair frame, with no dignity bag covering in place. Observation made on 06/03/2025 at 9:09 AM revealed R117 was lying in bed with her urinary drainage bag visible on entry to her room. It was placed on the bed frame, with no dignity bag covering in place. In an interview with R117 on 06/03/2025 at 9:09 AM, she stated she had a catheter placed at the hospital on an unknown date, and since its placement, she had never had any covering over the collection bag and was unaware what it was and that it was an option. R117 stated she had been going to therapy every day and had been concerned about the catheter bag being out where everyone could see it. In a follow up interview with R117 on 06/04/2025 at 9:30 AM, she stated she had asked staff if they could provide her with a covering for her catheter bag, and they immediately obtained one, placed it, and she was happy it was in place. In an interview with State Registered Nurse Aide (SRNA) 4 on 06/04/2025 at 9:26 AM, she stated dignity coverings for catheter bags were placed upon resident request, but not on a routine basis. In an interview with Registered Nurse (RN) 2 on 06/04/2025 at 9:37 AM, she stated to her knowledge it was not in the facility's catheter policy to place a dignity bag, but they were placed if the resident requested it as a preference. RN2 stated R117 had a dignity bag in place when she came on shift today and was unaware when or who had placed it. 2. Review of R99's admission Record revealed the facility admitted the resident on 10/10/2022 with diagnoses to include obstructive uropathy, benign prostatic hyperplasia, and congestive heart failure. Review of the R99's quarterly MDS, with an ARD of 05/21/2025, revealed the facility assessed the resident to have a BIMS score of 13 of 15, which indicated the resident was cognitively intact. Review of R99's Comprehensive Care Plan [CCP], not dated, revealed the facility assessed the resident as requiring a catheter for alterations in urinary elimination related to benign prostatic hyperplasia. The care plan for R99 did not include an intervention to provide a dignity bag cover. Observation of the 100 Hall on 06/03/2025 at 8:01 AM revealed R99's door was open. R99 was in the bed. The resident's catheter collection bag was visible from the hallway, contained urine, and had no dignity bag cover. Interviews with Resident R99 were attempted; however, none were successful. The resident was under Hospice care and was asleep during the interview attempts. 3. Review of R110's admission Record revealed the facility admitted the resident on 11/22/2024 with diagnoses to include obstructive uropathy, benign prostatic hyperplasia, and congestive heart failure. Review of the R110's quarterly MDS, with an ARD of 05/28/2025, revealed the facility assessed the resident to have a BIMS score of 10 of 15, which indicated the resident had moderate cognitive impairment. Review of R110's CCP, not dated, revealed the facility assessed the resident as requiring a catheter related to obstructive uropathy and required a suprapubic catheter. The care plan for R110 did not include an intervention to provide a dignity bag cover. Observation of the 100 Hall on 06/03/2025 at 9:02 AM revealed R110's door was open. The resident was in her room lying supine in bed. The resident's suprapubic catheter collection bag was visible from the hallway, contained urine, and had no dignity bag cover. During an interview with R110 on 06/03/2025 at 9:05 AM, the resident stated she would like the urine collection bag covered. During an interview with SRNA13 on 06/05/2025 at 10:20 AM, she stated dignity bag covers for catheter collection bags were not routinely used but were provided upon resident request. During an interview with Unit Manager (UM) 1 on 06/03/2025 at 11:27 AM, she stated to her knowledge, the facility's catheter policy did not require the use of dignity bags. She stated dignity covers were provided only if a resident requested them as a preference. During an interview with the Director of Nursing (DON) on 06/05/2025 at 2:43 PM, she stated it was her expectation that staff followed the facility's policy to maintain residents' privacy and dignity. She stated it was important to provide a dignity bag cover for the closed urine collection bag to maintain the resident's dignity. During a telephone interview with the Medical Director on 06/05/2025 at 3:41 PM, she stated staff should follow facility policies and procedures for the dignity, safety, and well-being of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections affecting 4 of 26 sampled residents, Residents (R) 57, R60, R87, and R132. Observations on 06/02/2025 and 06/04/2025 revealed opened packages of resident items, clothing, and equipment that were stored in unclean areas; staff providing direct care for residents in Enhanced Barrier Precautions (EBP) that did not wear appropriate personal protective equipment (PPE), dispose of PPE properly, and perform required hand hygiene; staff holding clean linen against their person; and staff, after performing fingersticks to measure blood glucose levels, did not clean and disinfect two glucometers according to the manufacturer's instructions and the required dwell times for the sanitizing wipes. The findings include: Review of the CDC Guidelines Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed hand hygiene should be performed immediately before providing resident care and after care was completed. It stated staff should ensure the proper selection and use of PPE based on the nature of the patient interaction and potential for exposure to blood, body fluids, and/or infectious materials. Review of the CDC Guidelines How to Safely Remove Personal Protective Equipment Example 1, no date, revealed to remove all PPE before exiting the room. The policy stated if the outside of the gloves were contaminated, they should be removed first in the sequence of PPE removal. Further review revealed to perform hand hygiene when hands became contaminated and immediately after removing all PPE. Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], revised May 2023, revealed the facility maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections per accepted national standards and guidelines. Review of the facility's policy titled, Standard Precautions, revised September 2024, revealed standard precautions would be applied to all residents, regardless of diagnosis or infection status. It stated hand hygiene must be performed using soap and water or alcohol-based hand rub (ABHR), especially when hands were visibly soiled or after contact with contaminated items. Per the policy, gloves should be removed before touching non-contaminated surfaces or other residents, and hands should be washed to prevent transferring microorganisms. Additionally, the policy stated shared equipment must be cleaned and disinfected before use on another resident. Review of the facility's policy titled, Infection Control Manual/Enhanced Barrier Precautions[EBP], dated 03/31/2025, revealed EBP reduced the transmission of multidrug-resistant organisms (MDRO) by staff wearing gloves and a gown during high-contact resident care. These high-contact activities included dressing, bathing, transferring patients, providing hygiene care, changing linens, changing briefs, and during device care or use. Review of the facility's policy titled, Care of Glucose Monitoring Equipment, revised February 2010, revealed the purpose of the policy was to prevent the direct transmission of an infectious agent through a contaminated device. Per the policy, it stated to clean the glucose monitoring equipment following the manufacturer's recommendations between every use. Review of the [Product Name] Blood Glucose Monitoring System Cleaning and Disinfecting Operations and Procedure Manual, revised 10/18/2023, revealed the blood glucose meters (glucometers) needed to be cleaned and disinfected after each use. The manual stated cleaning and disinfecting was accomplished according to the manufacturer's guidelines with an Environmental Protection Agency (EPA) registered disinfectant or germicide that was approved for a health care setting. Per the manual, the glucometer was to be stored in its original storage case. Additionally, Sani-Cloth Germicidal Wipes were approved for use with this brand of glucometer. Review of the Sani-Cloth Germicidal Wipe package instructions revealed to thoroughly clean and disinfect the glucometer surface, which must be thoroughly wet, and allow the treated surfaces to remain wet for three minutes, then air dry. Review of R132's admission Record revealed the facility admitted R132 on 06/04/2024 with diagnoses that included congestive heart failure, respiratory failure with hypoxia, and sepsis. Review of R132's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/04/2025, revealed a Brief Interview for Mental Status [BIMS] score of 13 out of 15, which indicated the resident was cognitively intact. Review of R87's admission Record revealed the facility admitted R87 on 02/16/2022 with diagnoses that included type 2 diabetes, anemia, and atrial fibrillation. Review of R87's admission MDS, with an ARD of 04/05/2025, revealed a BIMS score of four out of 15, which indicated the resident was severely cognitively impaired. Review of R87's Order summary Report, revealed the resident was place in EBP for a colostomy. 1. Observation of R60's room on 06/02/2025 at 11:42 AM revealed an open package of skin wipes and a tube of barrier cream were observed on the bathroom sink. On the floor, between the toilet and the wall, was an opened bag of incontinence pads and a bag of opened briefs. 2. Observation on 06/02/2025 at 11:47 AM, of R132's room, under EBP, revealed contaminated gloves and trash were on the floor in the bathroom, and the resident's clothing was left on the bathroom floor. Additionally, dirty clothes were placed on the bedside table. A used nebulizer's tubing and mouthpiece were discovered lying on top of the resident's mail in a plastic basket. State Registered Nurse Aide (SRNA) 1 was observed providing direct care to R132, but he failed to don (put on) the appropriate PPE. During an interview with R132 on 06/02/2025 at 11:42 AM, she stated staff might wear gloves while providing direct care, but she did not remember them gowning up. She stated she had a lot of belongings but would prefer that staff did their part to keep the room tidy. During an interview with Unit Manager (UM) 1 on 06/02/2025 at 11:47 AM, she stated the staff should maintain a clean and sanitary environment by ensuring that rooms were tidy and supplies were put away. She stated resident equipment, supplies, and personal belongings should not be stored on sinks or floors and respiratory equipment should be cleaned and stored in a plastic bag. Additionally, UM1 stated that nurses and nurse managers should conduct regular walk-throughs in the rooms to verify they were clean, organized, and equipment was stored in a sanitary manner. Furthermore, the UM stated that SRNA1 should wear the appropriate PPE when providing direct care to residents under EBPs. She stated all staff had participated in multiple in-service training sessions regarding PPE and EBPs. UM1 stated she did not know why the residents' supplies were not stored properly. She stated adhering to infection prevention and control practices (IPCP) was important to prevent the spread of infection and cross-contamination. 3. a. Observation on 06/02/2025 at 12:07 PM revealed Registered Nurse (RN) 7 used a shared glucometer to measure R57's blood sugar. Further observation revealed RN7 wiped the glucometer with a sanitizing wipe for less than 15 seconds. Continued observation revealed the glucometer stayed wet for less than 45 seconds. In an immediate interview, RN7 stated she did not know how long the glucometer needed to remain wet in order to kill bacteria and viruses that could be on the glucometer. She stated disinfection was important for infection control. b. Observation of RN1 on 06/04/2025 at 3:45 PM revealed she performed a blood glucose check on R87. RN1 completed a fingerstick; however, the glucose meter displayed an error message. RN1 disposed of the used test strip and placed the contaminated glucometer on top of the medication cart without any barrier. After removing her gloves, RN1 did not perform hand hygiene before putting on a new pair of gloves and picking up a different glucometer. She conducted another fingerstick, disposed of the test strip, and once again placed the contaminated glucometer on the medication cart without a barrier, neglecting to perform hand hygiene. RN1 then took a Sani-Cloth Germicidal Wipe and cleaned the surface of the first glucometer for 8.53 seconds before setting it on a clean barrier to dry. Subsequently, she wiped the surface of the second glucometer for 5.26 seconds and also placed it on a clean barrier to dry. After this, she removed her gloves, again without performing hand hygiene. During an immediate interview with RN1, she stated she was taught to wipe the glucometer clean and let it dry for three to five minutes. When asked by the State Survey Agency (SSA) Surveyor to explain what kill/dwell time meant, RN1 was unable to explain. Continued interview revealed RN1 reviewed the Sani-Cloth Germicidal Wipe instructions and stated that the object must remain wet for a full three minutes and then be left to air dry for complete disinfection to take place. 4. Observation of SRNA3 on 06/02/2025 at 1:02 PM, revealed she was holding clean linen against her person while walking in the hallway. During an interview with SRNA3 on 06/02/2025 at 1:02 PM, she stated she should not hold linen against her body during transport, as it might contaminate the clean linen. She stated she received training on infection control policies and procedures during orientation and multiple in-service trainings. SRNA3 further stated that following IPCP was important to prevent the spread of infection and cross-contamination. 5. Observation on 06/02/2025 at 2:00 PM revealed SRNA3 doffed (took off) her gown while still wearing contaminated gloves. After removing the gloves, she walked out of the room without performing hand hygiene while in a EBP room. During an interview with SRNA3 on 06/02/2025 at 2:02 PM, she stated she took off the gown the way she was trained. She stated she did not know to remove gloves first if wearing a reusable gown, and to her knowledge, there was no difference between taking off a disposable gown and a reusable gown. She stated she was going to perform hand hygiene after she disposed of her trash. 6. Observation of room [ROOM NUMBER] on 06/02/2025 at 2:15 PM revealed two cloth gowns were not hung up in a sanitary manner; one was placed on a chair, and the other was bundled up and placed on top of a dirty laundry basket. During an additional interview with UM1 on 06/02/2025 at 2:30 PM, she stated the staff should hang up reusable gowns on the provided hooks when doffed. She stated if the gown was soiled, it should be bagged and taken to the dirty utility room. Again, she stated that adhering to infection prevention and control practices (IPCP) was important to prevent the spread of infection and cross-contamination. During an interview with the Infection Preventionist/Staff Development Coordinator (IP/SDC) on 06/04/2025 at 10:23 AM, she stated the facility adhered to CDC's guidelines and followed the facility's infection prevention and control policies (IPCP). She stated all EBP rooms had signs on the doors leading into the room. The IP/SDC stated gowns and gloves must be worn whenever staff entered an EBP room if they were providing a high-level of care. She stated all staff needed to remove gloves and perform hand hygiene prior to performing care and before leaving a resident's room. According to the IP/SDC, all staff members received education related to IPCP. The IP further stated nursing staff should follow the facility policy and manufacturer's guidelines to clean and disinfect the glucometer. In continued interview with the IP/SDC on 06/04/2025 at 10:23 AM, the IP stated she was unsure why staff did not follow isolation precautions despite having been educated on the importance of observing the signs posted on doors. She stated all staff was trained upon hire in the use of PPE and isolation precautions, including EBP. The IP/SDC stated it was her expectation that all staff adhered to the facility's policies and procedures to help prevent the spread of infections. She stated it was important for the health and safety of the residents. During an interview with the Director of Nursing (DON) on 06/04/2025 at 2:43 PM, he stated the IP was responsible to oversee IPCP and ensure that staff was following facility policy based on CDC guidelines. The DON further stated following IPCP was important to prevent the spread of infection and cross-contamination. He stated he had received infection control training upon hire, and it was reviewed many times throughout the year. During an interview with the Administrator on 06/05/2025 at 10:46 AM, she stated the quality department and the infection prevention team were responsible for engaging upper leadership and nursing leadership to implement infection control practices. She stated everyone had a responsibility to follow the facility policies related to infection control, which was essential in preventing the spread of infections and cross-contamination. The Administrator stated further that all staff members had received infection control training upon hire, which was reviewed multiple times throughout the year. She stated it was her expectation that staff adhered to the infection prevention protocols in the facility, as this impacted the health quality of residents, staff, and their families. Additionally, she stated nursing leaders were expected to conduct audits for cleanliness, and adherence to CDC guidelines was essential. During a telephone interview with the Medical Director on 06/05/2025 at 3:41 PM, she stated following IPCP was important to prevent the spread of infection and cross-contamination. The Medical Director stated staff should follow facility policies and procedures for the safety and well-being of the residents.

Based on observation, interview, record review, review of the website www.drugs.com, and review of the facility's policy, the facility failed to ensure drugs and biologicals were stored according to professional standards for 1 of 3 medication room refrigerators and 3 of 4 medication carts. Proper temperature control for the medication room refrigerator on the Forest Heights Unit was not maintained, and staff failed to notify the Maintenance Director of the equipment failure. Staff failed to write the expiration date on three insulin pens (two in the medication cart on the Forest Heights Unit and one in the medication cart on the Garden View Unit) based on the date they were removed from refrigeration. Staff failed to discard two tramadol pills in the medication cart on the Shoreline Unit after the packaging was damaged . The findings include: Review of the facility's policy titled, Medication Storage in the Facility, not dated, revealed medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Review of the website www.drugs.com revealed, for both the unopened insulin glargine pen and the unopened insulin aspart pen, when stored at room temperature (below 86 degrees Fahrenheit (F)), they must be used within 28 days. 1. Observation on 06/26/2024 at 8:41 AM of the medication cart on the Shoreline Unit revealed two tramadol (an opioid pain relief medication) pills in a blister pack that had been damaged and taped over. In an immediate interview, Registered Nurse (RN) 4 stated she did not know how the packaging had been damaged, but whoever had placed the tape over the packaging should have instead wasted the pills with another nurse as witness. In an interview on 06/28/2024 at 8:40 AM, the Resident Care Manager (RCM) for the Shoreline Unit stated her expectation for a nurse who accidentally damaged a blister package for a controlled substance such as tramadol was for the nurse to waste the pills in the damaged container with another nurse. She further stated this was important because the pills could be contaminated and could create the risk of narcotics diversion. In an interview on 06/28/2024 at 2:05 PM, the Director of Nursing (DON) stated the tramadol pills observed in a damaged blister pack should have been wasted with another nurse. In an interview on 06/28/2024 at 2:34 PM, the Administrator stated staff should have notified the RCM when the packaging for a narcotic was damaged. She further stated her expectation was for two nurses to waste the medications in the damaged packaging and follow up with the pharmacy for any further instructions. 2. Observation on 06/26/2024 at 9:29 AM of the medication cart on the Garden View B Unit with Licensed Practical Nurse (LPN) 12 revealed an unopened glargine insulin pen (lowered blood sugar, given for diabetes) not dated. During interview with LPN 12 at the time of the observation she stated the insulin might not be effective and could cause the resident harm if out of date. She stated she would return the medication to the pharmacy and request a new medication. 3. Observation on 06/26/2024 at 10:10 AM revealed the medication room refrigerator temperature on the Forest Heights Unit was 33 degrees F. The refrigerator contained 23 unopened insulin pens, five vials of insulin, 113 suppositories, one container of skin barrier cream, two vials of lorazepam (an anti-anxiety agent) and 3 bags of intravenous ceftriaxone (an antibiotic). During interview with LPN4 RCM, at the time of the observation, she stated she did not know the correct temperature of the refrigerator. Review of the refrigerator's current Audit Sheet, dated 06/17/2024 to 06/26/2024 with LPN4 RCM, revealed the temperature was to be 36 to 45 degrees F. The sheet stated, If the temperature too high or too low, adjust thermostat and put in work order to maintenance department. The recorded temperature on 06/23/2024 was 30 degrees F; the recorded temperatures on 06/18/2024, 06/19/2024, 06/21/2024 and 06/25/2024 were 32 degrees F; and the recorded temperatures on 06/26/2024 and 06/27/2024 were 34 degrees F. The only documentation that maintenance was notified was on 06/27/2024. Review of past Audit Sheet, dated 06/01/2024 to 06/16/2024, revealed the temperature on 06/06/2024 was 28 degrees F; the temperatures on 06/03/2024, 06/05/2024, 06/08/2024, 06/09/2024, 06/13/2024, and 06/16/2024 were 30 degrees F; the temperatures on 06/02/2024, 06/04/2024, 06/07/2024, 06/11/2024, 06/12/2024, 06/14/2024, and 06/15/2024 were 32 degrees F; and the temperature on 06/01/2024 was 34 degrees F. During interview with the Maintenance Supervisor on 06/28/2024 at 8:22 AM, he stated he did not receive notifications that the refrigerator temperatures on the Forest Heights Unit were out of range from 06/01/2024 to 06/27/2024. During interview with Pharmacist 2 on 06/28/2024 at 10:43 AM, he stated the facility called him on 06/27/2024 and reviewed each medication that was in the refrigerator on the Forest Heights Unit. He stated none of the medications were harmed by the colder temperatures. 4. Observation on 06/27/2024 at 9:52 AM of the medication cart on the Forest Heights B Hall with LPN 16 revealed two unopened insulin pens, glargine and aspart, which were not dated. During interview with LPN 16 at the time of the observation, she stated the insulins would be returned to the pharmacy. She stated they might not be effective if they were out of date, and they could cause harm to the residents. During interview with the DON on 06/28/2024 at 8:50 AM, she stated she was not made aware of the temperature of the refrigerator being out of range. She stated she also was not notified that the insulin pens were not dated. She stated staff should have notified the Maintenance Director of the temperatures being out of range. She also stated staff should date insulin pens when they were taken out of the refrigerator. During interview with the Administrator on 06/28/2024 at 2:34 PM, the Administrator stated her expectation for the medication refrigerator temperatures was for staff to check the thermometers in the refrigerators daily and notify maintenance if the temperature was found to be out of range. She further stated she did not know what the practice was regarding labeling an insulin pen that was removed from the refrigerator for use, but the DON would be able to speak to that process.

Based on observation, interview and review of the facility's Policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (1) of twenty-five (25) total sampled residents (Resident #29). Observation of staff member with residents in the Parlor Dining Room located on The Forest Heights Unit, on 03/27/19, revealed State Registered Nursing Assistant (SRNA) #1 obtaining vital signs for one (1) of twenty-five (25) total sampled residents, Resident #29. The findings include: Review of the facility's Policy titled, Social Services Resident Rights, revised 11/2017 revealed the facility recognized each resident's right to a dignified existence and self-determination. Further review revealed it was the policy of the facility to ensure resident's rights were promoted and protected. Continued policy review revealed the facility would provide Resident Rights education to staff annually. Review of Resident #29's clinical record revealed the facility admitted the resident on 07/14/18 with diagnoses to include Dementia without Behavioral Disturbance, Anemia, Lack of Coordination, History of Repeated Falls, Major Depressive Disorder, Atrophy of Thyroid and Dysphagia. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/09/19, revealed the facility assessed Resident #29 to have a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15) indicating the resident was moderately cognitively intact. Further review of the MDS revealed the facility assessed Resident #29 to require limited physical assistance of one (1) for bed mobility and locomotion on the unit, required extensive physical assistance of one (1) for transfers, walking in the room and corridor, locomotion off unit, dressing, toilet use and personal hygiene. Continued review of the Quarterly MDS revealed the facility assessed Resident #29 to require supervision with set up help only with eating/dining. Observation, on 03/27/19 at 8:32 AM, revealed State Registered Nursing Assistant (SRNA) #1 in Parlor Dining Room, located on The Forest Heights Unit, obtaining Resident #29's blood pressure and pulse with facility's digital monitoring equipment. Further observation revealed Resident #29 sitting in his/her wheelchair at dining room table with three (3) other female residents present. Continued observations revealed two (2) additional female residents and one male resident in the Parlor Dining Room as SRNA #1 obtained the resident's vital signs. Additional observation revealed SRNA #1 engaged in conversation with Social Worker Manager (SWM), not Resident #29, and continued obtaining resident's vital signs. Interview with SRNA #1, on 03/27/19 at 8:40 AM, revealed she was the staff member assigned to duty on Forest Heights Unit A-Hall and would provide direct care for Resident #29 on 03/27/19 from 6:30 AM until 3:00 PM as per her usual day-shift routine. Further interview with the SRNA revealed she obtained the resident's vital signs as directed by Licensed Practical Nurse (LPN) #2, who was also assigned to Forest Heights A-Hall. SRNA #1 reported she knew she should not obtain vital signs or provide any direct resident care in the dining room or other public area because this was a resident rights violation and dignity issue. SRNA #1 added she realized she had violated the resident's rights as soon as she placed the blood pressure cuff on his/her arm but did not want to stop in the middle of the procedure, therefore, she continued to obtain the rest of Resident #29's vital signs until she had completed them to provide to LPN #2. Continued interview revealed obtaining vital signs in the Dining Room could cause embarrassment to the resident as he/she may not want others to see him/her as requiring medical treatment or may not want other staff or residents/visitors to know he/she required vital signs be monitored and this could be a dignity concern. SRNA #1 reported her normal routine would be to obtain the resident's vital signs and other direct care in the resident's room or bathroom with the curtain and/or door closed to provide privacy. Interview with SRNA #2, on 03/27/19 at 9:06 AM, revealed she was the staff responsible for assisting SRNA #1 on A-Hall this day and was therefore familiar with Resident #29's care. In addition, A-Hall was SRNA #2's usual assignment from 6:30 AM until 3:00 PM on most days. Further interview with SRNA #2 revealed, Absolutely no resident care was to be provided in the Parlor Dining Room or any other public area. We are to provide resident care in the resident's room or other private area. SRNA #2 continued, We all know that is a dignity/confidentiality/privacy concern. Continued interview revealed resident care was to be provided in a private setting and only by authorized personnel qualified to do so. SRNA #2 advised if direct care was performed in a dining room or other public setting other residents, family members and unauthorized staff could potentially acquire resident clinical or personal information and this would be a violation of the resident's right to privacy and confidentiality. Interview with the facility's Social Worker Manager (SWM), on 03/27/19 at 9:16 AM, revealed she serviced the needs of the residents residing on The Forest Heights Unit, which included Rooms #201-224. Further interview revealed it was inappropriate to perform any direct resident care in a public area because it violated the resident's rights to dignity and privacy/confidentiality. Further interview revealed SRNA #1 should have obtained Resident #29's blood pressure, pulse and other vital signs in the resident's room or other discreet location to protect the resident's right to privacy, dignity and confidentiality. Continued interview with SWM revealed direct care should always be delivered in a private, discreet location to ensure unauthorized staff, visitors, and other residents are not able to receive or access the resident's medical information or compromise the resident's care. The SWM added that would be a violation of the resident's rights and could become a dignity concern. Additional interview with the SWM revealed she had failed to request SRNA #1 refrain from obtaining Resident #29's vital signs in the Parlor Dining Room because she was not paying attention to the SRNA's actions at the time. SWM added, if she had realized SRNA #1 had been obtaining the resident's vital signs, she would have told her to stop because she would not want Resident #29 to be in an uncomfortable situation. Interview with Licensed Practical Nurse (LPN) #2, on 03/27/19 at 9:32 AM , who was assigned to administer medications and treatments to residents on The Forest Heights Unit, A-Hall from 6:30 AM until 7:00 PM, revealed resident care was to be delivered in private setting and only by authorized personnel to respect resident's dignity and privacy. Further LPN interview revealed direct care delivered in the dining room or other public location would be considered a violation of the resident's rights and a dignity/privacy issue. Continued interview with LPN #2 revealed resident medical information and clinical treatment was to remain private with direct care expected to be delivered in private setting to maintain the resident's dignity. Interview with Quality Control/Transitional Care Registered Nurse (QC/TC), on 03/28/19 at 5:44 PM, revealed staff are to obtain vital signs and perform other direct resident care in the resident's room or other discreet location with the door closed and the curtains pulled. Further interview revealed staff are provided intense two (2) day training upon hire and annually relating to the importance of Resident Rights and respecting the resident's rights related to dignity and confidentiality most specifically. Continued interview with the QC/TC revealed it may be embarrassing for a resident to have staff obtain his/her vital signs in the dining room or other public area as he/she may (in the resident's mind), she explained, may appear sickly or needy in the eyes of his/her peers who are also residing in the facility. This, QC/TC added, is definitely a dignity issue and a violation of the resident's rights and will require re-education and re-training. Interview with The Forest Heights Unit Resident Care Manager (RCM) #1, on 03/27/19 at 9:42 AM revealed staff are to perform all resident care in the resident's room with the door closed and the privacy curtain pulled to maintain resident dignity, confidentiality and privacy. Further interview with RCM #1 revealed it would never be appropriate or acceptable to obtain a resident's vital signs (blood pressure, pulse, etc.) or to provide any other direct resident care in the Parlor Dining Room due to privacy/confidentiality/dignity concerns. Interview with the Director of Nursing (DON), on 03/28/19 at 5:56 PM, revealed she expected staff to perform all direct care in resident's room or other private/discreet location as this was a dignity, privacy and confidentiality issue. Further interview with the DON revealed she expected staff to maintain resident dignity at all times by adhering to the facility's Resident Rights Policy. Continued DON interview revealed she expected all staff to treat each resident with respect and dignity. Interview with Licensed Nursing Home Administrator (LNHA), on 03/28/19 at 6:23 PM, revealed his expectations were for staff to perform all direct resident care in private to maintain privacy and confidentiality. The LNHA explained a private location could be a resident's room, a bath/shower room, or other discreet location where only authorized staff were present and involved in the delivery of care to the resident. Further interview revealed the LNHA expected staff to adhere to the facility's Resident Rights Policy and to respect all resident's right to dignity, privacy and confidentiality and never perform any resident care in a public area for other residents or unauthorized staff to have access to resident clinical information as this would be a violation of the resident's privacy and confidentiality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) User Manual Version 3.0, it was determined the facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflected the resident's status for one (1) of twenty-five (25) sampled residents (Resident #64). Although Resident #64 sustained a fall on 01/26/19, this fall was not reflected on the Quarterly MDS assessment dated [DATE]. The findings include: Review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) User Manual Version 3.0, revised May 2011, revealed under Chapter 3, Section J1800, if this is not the first assessment, review period from the day after the Assessment Reference Date (ARD) of the last MDS Assessment to the ARD of the current Assessment. Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Review nursing home incident reports, fall logs and the medical record (physician, nursing, therapy, and nursing assistant notes). Ask the resident and family about falls during the look back period. 1. Review of Resident #64's medical record revealed the facility admitted the resident on 10/30/18 with diagnoses to include Cerebral Infarction due to Unspecified Occlusion or Stenosis of Unspecified Cerebral Artery; Unspecified Lack of Coordination; Hemiplegia and Hemiparesis following Other Cerebrovascular; and Disease Affecting Right Dominant Side. Review of the admission Assessment, dated 11/16/18, revealed the facility assessed Resident #64 as having no falls. Review of the facility Fall Incident Report Form, revealed Resident #64 had a fall on 01/26/19 at 11:00 AM in the solarium near the resident's room. Per the Report, the resident fell from his/her wheel chair when reaching for his/her catheter bag and he/she toppled forward striking his/her head on the floor and sustaining a skin tear to the right side top of the eyebrow. Review of the Root Cause Analysis Section, revealed the facility investigated to determine the root cause of the fall and corrective action was to give the resident a Reacher/Grabber and Keep the resident in populated areas. Review of the Quarterly MDS Assessment, dated 02/13/19, revealed the facility assessed Resident #64 as scoring a twelve (12) out of fifteen (15) on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident as not ambulating in the room and as having no falls since admission or the prior Assessment. Interview with Resident #64, on 03/27/19 at 9:11 AM, revealed he/she had a fall at the facility, but he/she could not recall the date of the fall. Continued interview revealed when he/she fell, it was from the wheelchair, and he/she did not sustain injury from the fall. Interview on 03/28/19 at 3:39 PM, with MDS Nurse #2, revealed the facility utilized the RAI Manual for guidance in completing MDS assessments. She stated when she was completing MDS Assessments she reviewed the medical record, assessed the resident and interviewed the resident. She further stated she had completed the MDS assessment dated [DATE] for Resident #64, and coded the resident as having no falls. After reviewing the medical record documentation related to Resident #64's fall on 01/26/19, she stated she had coded the MDS assessment dated [DATE], incorrectly related to falls and she would need to complete a correction to the MDS assessment. Interview on 03/28/19 at 4:31 PM, with the Director of Nursing (DON), revealed Resident #64 did sustain a fall on 01/26/19 and the MDS Assessment, dated 02/13/19, should have been coded to reflect the fall. Continued interview revealed the facility had falls meetings weekly and MDS staff attended the meetings and should have been aware of the fall that occurred on 01/26/19 for Resident #64 Further interview with the DON, revealed it was her expectation MDS staff follow the RAI Manual for guidance in completing the MDS Assessments. Interview with the Administrator, on 03/28/19 at 5:05 PM, revealed it was his expectation the MDS Assessments were coded correctly as the Comprehensive Care Plan was derived from the MDS Assessment.

Based on interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to implement Comprehensive Care Plans for each resident, to meet a resident's medical, nursing, and mental and psychosocial needs to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being related to ongoing psychotropic medication monitoring for one (1) of twenty-five (25) sampled residents (Resident #56). Resident #56's Comprehensive Care Plan, dated 08/14/18, revealed interventions to observe for effectiveness of medications; and observe for side effects of medication. However, there was no documented evidence during January, February or Mach of 2019, of ongoing monitoring for efficacy and adverse consequences of Haloperidol Lactate Concentrate which was prescribed for a diagnosis of Unspecified Dementia without Behavioral Disturbance, on 06/29/18. (Refer to F-758) The findings include: Review of facility's Policy, titled Comprehensive Plan of Care, revised November 2002, revealed the comprehensive care plan must describe services to be furnished to attain or maintain the resident's highest physical, mental, and psychosocial well-being. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of the facility's Medication Monitoring and Management Policy, undated, revealed the facility staff would perform ongoing monitoring for appropriate, effective, and safe medication use. Additionally, the information gathered during the ongoing monitoring would be incorporated into a Comprehensive Care Plan (CCP) that reflects parameters for monitoring the resident's condition, ongoing need for the medication, what was monitored, and who was responsible for monitoring. Review of Resident #56's medical record revealed the facility admitted the resident on 11/01/17 with diagnoses to include Unspecified Psychosis, Major Depressive Disorder, Hallucinations, Unspecified Dementia without Behavioral Disturbance, and Anxiety. Review of Resident #56's Comprehensive Care Plan, dated 08/14/18, revealed the resident was at risk for side effects and adverse reactions due to psychotropic medication. The goal revealed the resident would be free of harm/injury related to medication daily. There were several interventions including: observe for effectiveness of medications; observe for side effects of medication including drowsiness; and report any signs and symptoms to the Physician. Review of Resident #56's Physician's Orders, dated January 2019, revealed orders with a start date of 06/28/18 for Haloperidol (Haldol) tablet; give one (1) milligram (mg) orally, one (1) time at bedtime; and orders with a start date of 06/29/18, for Haloperidol tablet, give 0.5 mg orally, one (1) time a day related to Unspecified Dementia without Behavioral Disturbance. (Haldol is an antipsychotic drug-psychotropic drug) Review of Resident #56's Medication Administration Record (MAR), dated January 2019, revealed Haloperidol tablet, 0.5 mg orally, one (1) time a day and Haloperidol, one (1) mg orally, at bedtime, was administered daily. Review of Resident #56's Weekly Nursing Assessments, dated 01/12/19, 01/19/19, 01/25/19, and 01/26/19 revealed there was no documented evidence of hallucinations or delusions in the neurological section. Review of Resident #56's Monthly Behavior Monitoring, dated January 2019, revealed worksheets for Remeron related to Depression; Aricept related to Dementia; and Namenda related to Alzheimer's. All these forms were blank, indicating no behaviors. However, there was no documented evidence of a Monthly Behavior Monitoring worksheet for Haldol. Review of Resident #56's Nursing Notes, Social Services Notes, and Physician's Progress Notes, for January 2019, revealed no documented evidence of ongoing monitoring related to psychotropic drugs. Review of Resident #56's Abnormal Involuntary Movement Scale (AIMS) (exam used for assessing side effect of antipsychotic drugs), dated 01/30/19, revealed the resident scored zero (0), indicating the resident was at low risk for movement disorders. Review of Resident #56's Quarterly Minimum Data Set (MDS) Assessment, dated 01/30/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15), indicating severe cognitive impairment; and a Mood Interview score of zero (0), which indicated no depression; and no presence of behaviors. Further review revealed the facility assessed the resident as receiving seven (7) days of psychotropic medication. Review of Resident #56's February Weekly Nursing Assessments, dated 02/02/19, 02/09/19, 02/16/19, and 02/23/19, revealed there was no documented evidence of hallucinations or delusions in the neurological section. Review of the Physician's Order Sheet and Progress Notes, dated 02/06/19, revealed the resident was very sleepy, stated he/she was okay; and was sitting in the Geri chair at bedside falling asleep. Further review revealed palliative care needed to be discussed with the family related to chronic Respiratory failure, Diabetes, and progressive Dementia. However, the Note did not discuss the use of or efficacy and adverse consequences for Haldol. Review of Resident #56's Pharmacy Consultation Report, dated 02/10/19, revealed the Consultant Pharmacist evaluated the current dose of Haldol 0.5 milligrams (mg) every day (QD) and one (1) mg at bed time (HS) and recommended attempting a Gradual Dose Reduction (GDR); however, there was no response from the Provider related to this Report in February 2019. Review of the Social Services Progress Note, dated 02/22/19, revealed the resident was alert, but disoriented. Additionally, Resident #56 would not answer direct questions, but would recite his/her ABC's or talk about family. However, the Note did not discuss the use of or efficacy and adverse consequences for Haldol. Review of Resident #56's Physician's Orders, dated February 2019, revealed an order for Haloperidol tablet, give 0.5 mg orally, one (1) time a day with a start date of 02/23/19. Continued review revealed an order, with a start date of 02/23/19 for Haloperidol tablet; give one (1) mg orally, one (1) time at HS related to Unspecified Dementia without Behavioral Disturbance. Review of Resident #56's Medication Administration Record (MAR), dated February 2019, revealed Haloperidol tablet, 0.5 mg orally, one (1) time a day and Haloperidol, one (1) mg orally, at HS, was administered each day. Review of Resident #56's Monthly Behavior Monitoring, for February 2019, revealed worksheets for Remeron related to Depression; Aricept related to Dementia; and Namenda related to Alzheimer's. All the forms were blank, indicating no behaviors. However, there was no documented evidence of a Monthly Behavior Monitoring sheet for Haldol. Review of Resident #56's Nursing Progress Notes, dated February 2019, revealed there was no documented evidence of ongoing monitoring related to psychotropic drugs for efficacy and adverse consequences. Additional review of the Pharmacy Consultation Report, dated 02/10/19, revealed the Advanced Registered Nurse Practitioner (ARNP) signed the Pharmacy Consultation Report, which was dated 02/10/19, on 03/05/19. The ARNP agreed with the Consultant Pharmacist to attempt a Gradual Dose Reduction (GDR) to discontinue Haldol 0.5 mg daily, and continue Haldol one (1) mg at bedtime. Additional review revealed the APRN would re-evaluate in ten to fourteen (10-14) days. Review of Resident #56's Physician's Orders, dated March 2019, revealed orders dated 03/05/19 to discontinue Haloperidol tablet, 0.5 mg orally, one (1) time a day. Further review revealed orders, with a start date of 03/05/19, for Haloperidol tablet; give one (1) mg orally, one (1) time at bedtime related to Unspecified Dementia without Behavioral Disturbance. Review of Resident #56's Medication Administration Record (MAR), dated March 2019, revealed Haloperidol tablet, 0.5 mg orally, one (1) time a day, was signed as administered 03/01/19 through 03/05/19; and Haloperidol, one (1) mg orally, at bedtime, was signed as administered daily. Review of Resident #56's March Weekly Nursing Assessments, dated 03/09/19, 03/16/19, and 03/23/19, revealed there was no documented evidence of hallucinations or delusions in the neurological section. Review of Resident #56's Monthly Behavior Monitoring, for March 2019, revealed worksheets for Remeron related to Depression; Aricept related to Dementia; and Namenda related to Alzheimer's Disease. All these forms were blank, indicating no behaviors. However, there was no documented evidence of a Monthly Behavior Monitoring sheet for Haldol. Review of Resident #56's Nursing, and Social Services Progress Notes, dated March 2019, revealed there was no documented evidence of ongoing monitoring related to psychotropic drugs for efficacy and adverse consequences. Review of the ARNP Progress Note, dated 03/18/19 at 3:20 PM, revealed she would re-evaluate psychotropic medication adjustment in two to three (2-3) weeks; if no increase in hallucinations, then consider decreasing the Haldol dose at night. Further review revealed Subjective (S) Resident stated, please I'm not so good; I get upset when the little kids find things. Objective (O) patient in normal confused state. Talking more about little kids, but not yelling out and seemed to be sleeping per usual. No change in his/her mental status. No Acute distress, lungs clear to auscultation bilaterally, Abdomen soft, non-tender, bowel sounds present, vital signs stable, and weight 236.8 pounds. Hallucinations at baseline, despite the decrease in Haldol. Will continue Haldol one (1) mg at HS (night) for a few more weeks, then consider decreasing HS Haldol. However, there was no further documented evidence Resident #56's psychotropic drugs use had ongoing monitoring for efficacy or adverse consequences, to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being related to Haldol. Observation of Resident #56, on 03/26/19 at 11:30 AM, revealed the resident was in the parlor sitting upright in a broda chair, with his/her legs dangling down. Further observation revealed the resident's eyes were closed, mouth was open, head was tilted to the right, and he/she was receiving oxygen per nasal cannula. Continued observation of Resident #56, on 03/26/19 at 1:04 PM, revealed the resident was sitting reclined in a broda chair, at bedside. Additional observation revealed the resident's eyes were closed, mouth was open, and he/she was receiving oxygen per nasal cannula. Observation of Resident #56, on 03/27/19 at 8:00 AM, revealed the resident was sitting reclined in his/her broda chair, leaning towards the right, at the dining room table with the meal tray in front of him/her on the table, covered. Further observation revealed the resident was receiving oxygen per nasal cannula, and the resident's eyes were closed. Interview with Licensed Practical Nurse (LPN) #15, on 03/28/19 at 9:41 AM revealed he was assigned to Resident #56 on the day shift. Per interview, the CCP should be followed to provide necessary care to residents. He stated this was important to ensure quality care was provided and resident's needs were met. Further, he stated there should have been Monthly Behavior Monitoring worksheets for daily use of Haldol for Resident #56. Continued interview with LPN #15, revealed Resident #56's Haldol dose had recently been reduced and it was important to closely monitor the resident related to the drug reduction to ensure efficacy of the drug. Interview with the Resident Care Manager (RCM) for Shoreline Hallway where Resident #56 resided, on 03/28/19 at 3:01 PM, revealed she expected the facility policy related to implementing the CCP to be maintained. Additionally, she stated Resident #56's CCP related to monitoring psychotropic medication, should have been implemented by the nursing staff related to Haldol. Further interview revealed implementing the CCP would ensure quality care and standards of practice were provided to the resident. Interview with Social Services, on 03/28/19 at 3:17 PM, revealed Resident #56's CCP should have been implemented related to providing ongoing monitoring of psychotropic medication to ensure high-risk medication was necessary and at a therapeutic dose related to Haldol medication. Further, it was important to implement the CCP to ensure resident care needs were met. Interview with ARNP, on 03/28/19 at 2:45 PM, revealed she expected nursing staff to implement the CCP related to ongoing monitoring of psychotropic medications. Per interview, this monitoring was important to ensure providers could attempt reductions, and keep the medication regime therapeutic. Further, it was important to ensure ongoing monitoring of psychotropic medications was maintained to ensure health care providers could quickly assess the residents' needs and adjust medications as necessary so residents were not in distress or fearful. Per interview, this was especially important in Resident #56's case, to ensure the resident was not fearful. Further, she stated ongoing monitoring and assessment by direct care nursing staff, related to Resident #56's Haldol medication to ensure the medication was not negatively effecting him/her was imperative. Interview with the Director of Nursing (DON) on 03/28/19 at 3:33 PM revealed she expected the facility policy and regulation related to implementing the CCP to be followed related to monitoring psychotropic medications. Additional interview revealed Resident #56 should have had ongoing monitoring of efficacy and adverse consequences related to Haldol use. Further, it was important to implement the CCP for each resident receiving psychotropic medications to ensure adverse consequence did not interfere with resident care, daily routine and mental status. Interview with the Administrator on 03/28/19 at 5:45 PM revealed he expected facility policy and regulation to be maintained related to implementation of the CCP. Additionally, Resident #56 should have had ongoing monitoring in place related to psychotropic drug use related to Haldol, as per facility policy. Further, it was important for CCP to be followed by all staff to ensure residents receive appropriate care and their needs were met.

Based on interview and record review, it was determined the facility failed to ensure the Comprehensive Care Plan was revised for one (1) of twenty-five (25) sampled residents (Resident #64). Resident #64, sustained a fall on 01/26/19, and the facility conducted aRoot Cause Analysis with corrective action including interventions for a Reacher/Grabber and to Keep the resident in populated areas; however, the Comprehensive Care Plan was not revised with the new interventions. The findings include: Review of facility's Policy, titled Comprehensive Plan of Care, revised November 2002, revealed the comprehensive care plan must describe services to be furnished to attain or maintain the resident's highest physical, mental, and psychosocial well-being. Further review revealed the care plan will be updated quarterly, whenever significant changes occur, or annually. 1. Review of Resident #64's medical record revealed the facility admitted the resident on 10/30/18 with diagnoses which included Cerebral Infarction due to Unspecified Occlusion or Stenosis of Unspecified Cerebral Artery; Unspecified Lack of Coordination; Hemiplegia and Hemiparesis Following Other Cerebrovascular; Weakness; and Disease Affecting Right Dominant Side. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 02/13/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Further review revealed the facility assessed Resident #64 as not walking in the room; and as having no falls since admission or the prior Assessment. (Refer to F-641) Review of Resident #64's Comprehensive Care Plan, initiated 11/16/18 and revised 02/14/19, revealed the resident was at high risk for falls due to Cerebrovascular Accident with Hemiparesis and due to receiving antidepressant medication. The goal initiated 11/16/18, and revised 02/14/19, with a target date of 05/15/19, revealed the resident would be free of falls and fall related injuries every day. The interventions initiated 11/18/19 included: assist with transfers, monitor per falling star program, and sensor pad to bed and chair AAT (at all times). Review of Resident #64's March 2019 Monthly Physician's Orders, revealed orders initiated 11/09/18 for nonskid footwear; orders initiated 01/28/19 for sensor pad to bed every shift for Fall Prevention Check Placement and check function every shift; orders initiated 01/28/19 for Sensor Pad to chair every shift for Fall Prevention, Check Placement and function every shift; and orders initiated 01/30/19 for a reacher/grabber every shift. Observation of Resident #64 on 03/27/19 at 9:11 AM, revealed he/she was in bed with the head of the bed elevated. The resident had a bolster/concave mattress on the bed, and there was an Alarm box on the wall behind the bed. Resident #64 stated he/she had a fall recently, but he/she could not recall the date of the fall. Continued interview revealed he/she fell from the wheelchair, but he/she was not hurt. Review of the facility Fall Incident Report Form, revealed Resident #64 had a fall on 01/26/19 at 11:00 AM, in the solarium near his/her room. Resident #64 fell from his/her wheel chair when reaching for his/her catheter bag that fell from the wheel chair and he/she toppled forward striking his/her head on the floor and sustaining a skin tear to the right side top of the eyebrow. Review of the Root Cause Analysis, revealed the date of the event was 01/26/19, and the facility investigated to determine the root cause of the fall. Corrective action documented was for the resident to have a Reacher/Grabber and to Keep the resident in populated areas. However, further review of Resident #64's Comprehensive Care Plan, initiated 11/16/18 and revised 02/14/19, revealed there was no documented evidence Resident #64's Plan of Care was reviewed or revised to include the corrective action interventions for Reacher/Grabber and to Keep the resident in populated areas. Interview on 03/28/19 at 3:39 PM, with MDS Nurse #2, revealed care plans were revised according to Physician's orders, and new interventions were added to the Care Plan only if there were Physician's Orders for the interventions. She stated the Fall Incident Report Form for Resident #64 related to the fall sustained on 01/26/19, revealed the corrective interventions for the fall included the reacher/grabber and to Keep the resident in populated areas. Continued interview revealed Resident #64's Physician's Orders included an order for the reacher/grabber, and the Care Plan should have been revised with this intervention. However, further interview revealed there was no Physician's Order to Keep in populated areas, and therefore the Care Plan was not revised with this intervention. Interview with MDS Nurse #3, on 03/28/19 at 3:51 PM, revealed Resident #64 had Physician's Orders for the reacher/grabber, and the Care Plan should have been revised with this intervention. Further interview revealed there was not a Physician's Order to Keep in populated area, and therefore the Care Plan would not need to be revised with this intervention. Interview on 03/28/19 at 4:31 PM, with the Director of Nursing (DON), revealed the facility normally ensured Physician's Orders were written for new fall interventions, and a copy of the orders was sent to the MDS staff in order to revise the care plans from the orders. Further interview revealed Resident #64's Care Plan should have been revised with interventions for Reacher/grabber and to keep the resident in populated areas. Continued interview revealed the facility had falls meetings weekly and MDS staff attended; therefore, the Care Plan should have been revised with these interventions. Further interview with the DON, revealed it was her expectation for MDS staff to follow the RAI Manual. Interview with the Administrator, on 03/28/19 at 5:05 PM, revealed after a fall occurred an initial fall report was completed, immediate interventions were placed, and the fall was reviewed in the fall meeting to ensure interventions were appropriate. Continued interview revealed the facility ensured Physician's Orders were obtained for selected interventions after a fall and the Care Plan was to be revised with these interventions. The Administrator further stated if you don't know what care to provide you can't provide the appropriate care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility Policy, it was determined the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of twenty-five (25) sampled residents (Resident #35). Resident #35 exhibited hoarding behaviors including hoarding of papers which were stacked against the walls of the resident's room and were all over the resident's bed. In addition, there was hoarding of left over food and perishable foods. Although there was a Physician's Order received on 08/23/17, which stated may have psychiatric evaluation as needed, there was no documented evidence the facility attempted to provide psychiatric services as ordered. In addition, there was no documented evidence the facility addressed Resident #35's hoarding behavior through behavioral management to ensure necessary person-centered care and services were implemented related to the resident's hoarding behaviors. The findings include: Review of facility Behavior Management Policy, revised November 2017, revealed it is the policy of the facility that staff be aware of each residents' current health status and regular activity, and be able to promptly identify changes that may indicate a change in condition. Further review revealed the procedure included the following: 1. The facility will document resident's behavior changes. 2. If a resident's behavior becomes harmful to self or others the nursing staff must notify the resident's physician and resident's designated responsible party. The Social work Services Director will also be notified. 3. Resident behavior changes and care will clearly and objectively be documented in the resident's medical record. 4. Resident behavior changes will be dealt with through the behavioral management program and interdisciplinary care planning. Specific goals and approaches will be developed for that particular resident so that his/her care is delivered in a consistent and coordinated manner. 5. If the facility is unable to care for the resident's changing needs, nursing will assist social services in finding appropriate alternate placement. Continued review of the Policy, revealed when a normally alert and competent resident verbally or physically exhibits behavioral problems, possible causes should be investigated to determine if it is an isolated incident or the start of a behavioral pattern. The resident's Physician and designated family contact should be called. Review of the facility Comprehensive Care plans Policy, revised November, 2002, revealed the facility will provide an individualized Plan of Care for each resident, by means of a written document which includes input from all disciplines involved in the provision of care. Further review revealed the Comprehensive Care Plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs that are identified in the Comprehensive Assessment; and any services that are not provided due to the resident's exercise of their rights, including the right to refuse treatment. Review of the Refrigerated Storage, Policy, revised May 2006, revealed the facility will store, prepare and serve foods in accordance with federal, state and local sanitary codes. Further review revealed it is essential that refrigerator temperatures be low enough to safely keep most perishable foods and refrigerator temperatures that are consistently thirty eight (38) degrees Fahrenheit or below will provide this safety margin. Review of Resident #35's medical record revealed the facility re-admitted the resident on 01/27/17. Per record review, the resident had diagnoses including Left Artificial Hip Joint; Unspecified Atrial Fibrillation; Presence of Cardiac Pacemaker; and Gastro-esophageal Reflux Disease without Esophagitis. Further record review revealed there were no mental health diagnoses on the Face Sheet. Review of the Social Services Progress Note, dated 02/02/18, revealed the Social Service Worker met with the resident that date in his/her room, with the Maintenance Director, Life Safety Director, Social Workers, and RCM (Resident Care Manager), regarding some concern over the mess {he/she}has in there. Continued review revealed staff discussed safety concerns for the resident and staff taking care of the resident and staff offered for someone to come in and help him/her get organized and make the room safe. Per the Note, the resident was kind of in agreement, but also said he/she did not want to throw anything away. Further review of the Note, revealed staff were going to come up with some interventions for the resident and hopefully the resident would compromise some for his/her safety. Review of the Social Services Progress Notes, dated 04/25/18, revealed the Resident was AxOx3 (alert and oriented times three) and was able to make wants and needs known. After assessment, Resident's PHQ-9 (Resident Mood Interview over the last two weeks) score was 0 (zero) and BIMS (Brief Interview for Mental Status) was 15 (fifteen). (A BIMS score of fifteen (15) indictes no cognitive impairment). No behavioral issues at this time. Further review revealed it was noted for the MDS assessment dated [DATE], the resident did have some hoarding issues that social services and housekeeping had talked to him/her about. Review of the Social Services Progress Notes, dated 07/24/18, revealed Resident is AxOx3 (alert and oriented times three) and was able to make wants and needs known. After assessment, Resident's PHQ-9 (Resident Mood Interview over the last two weeks) score was 0 (zero) and BIMS (Brief Interview for Mental Status) was 15 (fifteen). No behavioral issues at this time. Continued review revealed it was noted for the MDS Assessment, dated 07/15/18, the resident did have some hoarding issues that social services and housekeeping had talked to him/her about. Review of the Social Services Progress Note, dated 10/24/18, revealed Resident is AxOx3 (alert and oriented times three) and able to make wants and needs known. After assessment, Resident's PHQ-9 (Resident Mood Interview over the last two weeks) score was 0 (zero) and BIMS (Brief Interview for Mental Status) was 15 (fifteen). No behavioral issues at this time. Additional review revealed it was noted for the MDS Assessment, dated 10/24/18, the resident did have some hoarding issues that social services and housekeeping had talked to him/her her about. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 10/24/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of fifteen (15) out of fifteen (15 indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as having no mood indicators, no behaviors, and no rejection of care during the assessment period. Further review of the MDS Assessment revealed the facility assessed the resident as requiring supervision or set up help only for most ADLs (Activities of Daily Living). However, per the MDS Assessment, the resident required limited assistance of one (1) staff for locomotion off unit; supervision with one (1) person physical assist for walking in corridor; and limited assistance of one (1) person for transfers. Review of the Nurse's Progress Note, dated 11/12/18, revealed Resident #35 refused to take medications in front of the nurse; and told the nurse to just leave the medications on the table. Per the Note, the nurse explained the importance of the nurse making sure the resident received all medications prescribed and the resident stated he/she would be fine. Further review of the Note, revealed flies were noted in the resident's room and the nurse had a hard time moving around in the resident's room as the resident demanded the nurse not step on anything. The nurse documented there was an immense amount of clutter in the room. Review of the Significant Change in Status Minimum Data Set (MDS) Assessment, dated 01/16/19, revealed the facility assessed Resident #35 as having a Brief interview for Mental Status score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Further review of the MDS Assessment revealed the facility assessed the resident as having no mood indicators or behaviors, and no rejection of care during the assessment period. Further review of the MDS Assessment, revealed the facility assessed the resident as supervision or set up help only for ADL's (Activities of Daily Living) with the exception of locomotion off unit which the resident required limited assistance of one (1) staff. Review of the Social Services Progress Note, dated 01/17/19, revealed the Social Services Worker met with patient to update his/her annual assessments. Both the PHQ-9, score of 0 (zero) and BIMS, score of 0 (zero) remained the same. Review of the Physician's Order Sheet and Progress Notes dated 01/31/19 revealed a progress note which documented patient does hoard. Review of Resident #35's Comprehensive Care Plan, initiated 02/18/19, revealed the resident had episodes of behaviors as evidenced by: Hoarding. The goal stated the resident would have no episodes of behavior through next review with a target date of 05/31/19. Interventions included: approach in calm non threatening manner; attempt to guide away from source of distress before agitation escalates; attempt to identify cause for resistance and reduce/eliminate if possible; attempt to identify factual basis for concerns/behaviors and resolve if possible; avoid commands using do's and don't's; give resident as many choices as possible about care and activities and identify trigger stimuli and educate staff to avoid as much as possible. Review of Resident #35's Monthly March 2019 Physician's Orders, revealed no mental health diagnoses documented on the orders. Further review revealed a current order initiated 08/23/17, which stated, May have psychiatric eval as needed. Review of the Physician's Progress Note, dated 03/28/19, revealed patient does not always take medications; hoarding; and continues to keep food/letters in room. However, further review of the medical record revealed there was no documented evidence evidence a psychiatric evaluation was discussed with or offered to Resident #35, as per the Physician's Orders initiated 08/23/17. In addition, there was no documented evidence the facility addressed Resident #35's hoarding behavior through behavioral management and interdisciplinary care planning to ensure necessary person-centered care and services were implemented related to the resident's hoarding behaviors. Observation of Resident #35, on 03/26/19 at 4:10 PM, revealed the resident was observed sitting in a chair beside the bed and window, and his/her legs were propped up on another chair. The resident's room had large amounts of mail, paper, and other items in the room; and the bed was covered in paper items, mail, and framed photos. Continued observation revealed there were pieces of paper woven through the slats of the window blinds, and paper items stacked along the walls of the room, allowing only a narrow path in the center of the room to walk. Further observation revealed there were two (2) meal trays with perishable food under the lids, on the floor beside the bed; and several unopened cups of puddings. There was also six (6) cups of a pink colored drink on the bedside table which were not covered, labeled or dated. Interview with Resident #35 on 03/26/19 at 4:10 PM, during the observation, revealed two (2) cups of the pink drink were from today (03/26/19) and two cups of pink liquid were from yesterday (03/25/19). The resident did not elaborate on the final two (2) cups of pink drink. Resident #35 stated he/she did not waste. Continued interview revealed the mail in the room was left over from when the resident and spouse were both critically ill and couldn't open and read the mail. Per interview, the resident's spouse did live in the facility, but passed away in December, 2017. Further interview revealed a friend brought the resident six (6) hot dogs once, and the resident stated he/she ate them from a Friday to a Wednesday, and they didn't ruin. Per interview, he/she did not have a refrigerator, but he/she would know if food had spoiled. Further interview revealed he/she would tell staff to leave his/her her meal tray in the wheel chair and he/she would eat in his/her room. Resident #35 stated he/she could ambulate and tried to take care of himself/herself. Additional interview revealed he/she did not sleep in the bed, but slept in the chair. Per interview, the bed was used as his/her desk. On 03/27/19 at 2:04 PM, the Resident Care Manager (RCM) unlocked the door to Resident #35's room and entered the room with the State Agency Representative. The RCM stated the resident was at an appointment and requested the room be locked when he/she left the facility, but staff had the key to the room. Continued interview revealed Resident #35 would know if anything had been touched. Observation of Resident #35's room revealed more than fifty (50) assorted containers of yogurt, which were not refrigerated, stacked in the room. There was two (2) meal trays observed on the floor beside the bed in the same place as observed the prior day, 03/26/19, with perishable food under the lids. Interview with the RCM at the time of the observation verified the meal trays were delivered on 03/26/19 meal. There were two (2) additional meal trays noted with perishable foods observed, which the RCM stated was delivered today, 03/27/19 for breakfast and lunch. Continued observation revealed the six (6) uncovered, unlabeled or undated cups of a pink colored drink that were observed on 03/26/19 were still the bedside table. There were three (3) additional cups observed on the bedside table, which were covered, but undated, for a total of nine (9) cups of fluids in the room. Observation on 03/28/19 at 8:57 AM, revealed Resident #35 was in the wheel chair propelling towards the resident's room while male staff were bringing boxes with yogurt, butter packages, and other items out of the room. Resident #35 stated he/she had saved the meal trays for when he/she returned from the doctor and when he/she entered the room, the trays were gone. Resident #35 then told facility staff they needed to give him/her $20.00 for the four (4) food trays which were removed from his/her room and and stated this was really upsetting. Resident #35 further stated the door was locked when he/she left for his/her appointment, but someone entered his/her room and drank the lemonade and stole the boxes which were in his/her room. Interview on 03/28/19 at 2:32 PM, with State Registered Nurse Aide (SRNA) #6, revealed Resident #35 required supervision, but could basically do everything for himself/herself including feeding self. SRNA #6 stated Resident #35 was kind of a hoarder and did not let people in his/her room often. SRNA #6 further stated she had been in the resident's room and it was full of clutter. Per interview, Resident #35 told her the papers were his/her spouses fan mail. Continued interview revealed Resident #35 had refused to allow her to remove meal trays when she was assigned to the resident and would scold her and tell her, no. SRNA #6 stated when she asked the resident the reason he/she didn't want the tray removed, the resident told her he/she was saving it, and the food would be good. Further interview revealed someone brought the resident six (6) hot dogs and the resident told him/her they lasted six (6) days. Per interview, Resident #35 told her he/she received the hot dogs on a Saturday and when she saw the resident on a Monday, the resident had one (1) hot dog left. SRNA #6 was unable to provide specific dates the resident had the hot dogs, but stated she just started working at the facility in February, 2019, so it had not been that long ago. Per interview, Resident #35 did not have a refrigerator and the yogurt and perishable food trays being left in the resident's room could spoil which could definitely be a health issue for the resident. SRNA #6 stated Resident #35 could get food poisoning and could get really sick with vomiting and diarrhea if the resident ate spoiled food. Interview on 03/28/19 at 2:48 PM, with Licensed Practical Nurse (LPN) #7, revealed she had worked as an LPN since June 2018, but worked as a SRNA at the facility since 2016. She stated she worked with Resident #35 as an aide and a nurse. Continued interview revealed Resident #35 moved back to this unit after the resident's spouse passed away. LPN #7 stated the resident used to have a care taker who helped manage him/her, and the care taker could help keep him/her calm while staff removed leftover food from the room. However, at present the resident would not allow staff to remove the food tray from the room. Per interview, yogurt should be refrigerated and leftover food trays should be picked up within two (2) hours of delivery; but Resident #35 would not allow this. LPN #7 stated Resident #35 did not have a refrigerator in his/her room and residents weren't allowed to have refrigerators. Continued interview revealed she honestly did not think the resident ate the left over food but there was no way to know. Further interview revealed there could be possible negative outcomes for Resident #35, if he/she were to eat expired food, such as food poisoning, upset stomach, and diarrhea. Additional interview revealed she did not know if Resident #35 had ever been seen by a psychiatrist. Interview on 03/28/19 at 3:13 PM, with LPN #6, revealed yogurt should be refrigerated. Further interview revealed Resident #35 hoarded meal trays and then tried to give some of the food to staff. Per interview, if Resident #35 ate spoiled food, he/she could have gastrointestinal upset, and could get sick with diarrhea or vomiting. Interview with the Dietary Manager, on 03/28/19 at 2:52 PM, revealed room temperature food which was not refrigerated could grow bacteria and could cause food poisoning. Interview with the Facility Operations Manager, on 03/28/19 at 2:45 PM, revealed the facility needed to work with Resident #35 in finding a solution to storing food in the facility refrigerator that could be accessed by the RCM. Continued interview revealed this could be a goal to provide better quality of life for the resident. Interview on 03/28/19 at 3:18 PM, with the RCM, revealed food trays and left over food were removed from the resident's room on 03/27/19, prior to the resident returning from his/her appointment. Further interview revealed the resident was upset when he/she learned of this and the facility reimbursed the resident for the food trays as per the resident's request. Further interview revealed all other food items that facility staff removed from the resident's room were returned. When questioned if the foods left in the resident's room such as yogurt could be spoiled, the RCM stated it could be. Further interview with the RCM, revealed it was a pattern for this resident to leave perishable foods in his/her room. She stated the resident could get sick from eating these foods, but she felt the resident's body was accustomed to eating the left over foods. The RCM stated Resident #35 did not have a refrigerator. Further interview revealed they had tried to have Resident #35 seen by psychiatric services and the resident refused; however, there was no documented evidence of this. Further interview with the RCM, revealed Resident #35 had a recent endoscope and dilation and referral to GI (gastrointestinal) for complaints of bright red blood in stool. Interview on 03/28/19 at 3:56 PM, with the Social Services Manager, revealed she had talked to Resident #35 several times related to hoarding behaviors and leaving old food in the room; however, the resident denied having hoarding behaviors. Per interview, Resident #35 was offered grief counseling after the resident's spouse died and the resident refused. Per interview, she thought the resident's hoarding behaviors got worse after the resident's spouse passed. When the Social Services Manager was questioned if Resident #35's hoarding behavior would warrant psychiatric evaluation, the Social Services Manager stated she thought she had offered the resident a psychiatric appointment in the past, but probably didn't document this, and did not recall when this occurred. Further interview revealed she would refrigerate the resident's yogurt, but the resident would refuse this. Per interview, the resident had told the Social Services Manager, he/she did not drink the cups of liquids in the room, but would rinse them out and recycle them. Continued interview revealed the resident also told her, he/she did not eat the leftover food, but stated he/she was going to give it to kids, or staff. Per interview, when the resident gave staff food, staff would dispose of the food. Additional interview with the Social Services Manager, revealed if the resident consumed improperly stored food, it could it make the resident sick. Interview on 03/28/19 at 3:58 PM, and 03/28/19 at 4:31 PM, with the Director of Nursing (DON), revealed she was familiar with Resident #35's hoarding behaviors, and staff had tried to educate the resident on the risks of leaving leftover food in the room. However; per interview, the resident liked to feel like he/she was helping staff by offering them food, which they would accept and then discard. Further interview revealed all perishable food should be stored properly to keep from spoiling and that was not occurring for this resident. When questioned if the facility Behavior Management Policy was followed, or if there was any behavior modification program for this resident, the DON revealed there was no documented evidence the resident's behaviors were discussed related to behavior management as per facility policy. When questioned if Physician's Orders were followed for this resident related to obtaining a psychiatric evaluation, the DON stated the resident's behaviors could warrant a psychiatric evaluation if the resident would agree to this. Per interview, to her knowledge there was no documented evidence the resident had been offered a psychiatrist consult, and if it had been offered and refused, the facility should try again. Further interview with the DON, revealed she expected staff to follow Physician's orders and the Policies and Procedures of the facility. Interview with the Administrator, on 03/28/19 at 4:14 PM, 03/28/19 at 5:05 PM, revealed Resident #35 had a right to make choices even when the resident did not make good choices. The Administrator stated Resident #35 had a right to keep food in his/her room, but perishable foods must be stored properly in a refrigerator, and and he was unaware of the resident keeping hot dogs in the room. Further interview revealed he was unaware of the resident eating any of the stored perishable food he/she kept in the room, but was aware he/she would offer it to staff and they would discard the food. When questioned if Resident #35 had been seen for a psychiatric evaluation as per the Physician Orders, the Administrator stated the order was written as, May have psychiatric eval as needed. When questioned if the resident's behaviors related to hoarding behaviors would warrant a psychiatric evaluation, the Administrator stated the resident would have to be willing, and he was not sure if this service had been offered to the resident. He stated he would not say verbatim he had offered the resident a psych consult. Continued interview revealed the facility had offered the resident vast resources, such as providing staff needed to help the resident declutter and get things out of the facility to the resident's home; however, he was aware there was no documented evidence of a lot of the things the facility had done for the resident, related to the resident's behaviors of hoarding. Further interview revealed it was his expectation the facility would follow Policies and Procedures of the facility, including policies related to Behavior Management.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure residents who use psychotropic drugs receive adequate monitoring for efficacy and adverse consequences, to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for one (1) of two (2) residents reviewed for psychotropic medications out of (25) sampled residents (Resident #56). Resident #56 was prescribed scheduled Haloperidol Lactate Concentrate (antipsychotic psychotropic drug) related to Unspecified Dementia without Behavioral Disturbance, on 06/29/18; however, there was no documented evidence during January, February or Mach of 2019, of ongoing monitoring for efficacy and adverse consequences for the psychotropic drug. The findings include: Review of the facility's Psychotropic Medication Management Program Policy, revised October 2017, revealed the facility would monitor behaviors and adverse consequences of psychotropic medication for residents receiving psychotropic medications. Further, all residents on psychotropic medications would be monitored for episodes of behaviors and behaviors would be documented on behavior sheets. Continued review revealed the facility staff would perform ongoing monitoring for appropriate, effective, and safe medication use. Additionally, the information gathered during the ongoing monitoring would be incorporated into a Comprehensive Care Plan (CCP) that reflects parameters for monitoring the resident's condition, ongoing need for the medication, what was being monitored, and who was responsible for monitoring. Review of Resident #56's medical record revealed the facility admitted the resident on 11/01/17 with diagnoses to include Unspecified Psychosis, Major Depressive Disorder, Hallucinations, Unspecified Dementia without Behavioral Disturbance, and Anxiety. Review of Resident #56's Comprehensive Care Plan, dated 08/14/18, revealed the resident was at risk for side effects and adverse reaction due to psychotropic medication. The goal stated the Resident would be free of harm/injury related to medication daily. Interventions included: observe for effectiveness of medications; observe for side effects of medication including drowsiness; and report any signs and symptoms to the Medical Director. Review of Resident #56's Physician's Orders, dated January 2019, revealed an order, with a start date of 06/28/18 for Haloperdidol (Haldol) tablet; give one (1) milligram (mg) orally, one (1) time at bedtime; and an order with a start date of 06/29/18, for Haloperdidol tablet, give 0.5 mg orally, one (1) time a day related to Unspecified Dementia without Behavioral Disturbance. Review of Resident #56's Medication Administration Record (MAR), dated January 2019, revealed Haloperdidol tablet, 0.5 milligrams (mg) orally, one (1) time a day and Haloperdidol, one (1) mg orally, at bedtime, was administered daily. Review of Resident #56's Weekly Nursing Assessments, dated 01/12/19, 01/19/19, 01/25/19, and 01/26/19 revealed no documented evidence of hallucinations or delusions in the neurological section. Review of Resident #56's Monthly Behavior Monitoring, for January 2019, revealed worksheets for Remeron related to Depression; Aricept related to Dementia; and Namenda related to Alzheimer's. All forms were blank, indicating no behaviors. However, there was no Monthly Behavior Monitoring sheet for Haldol. Review of Resident #56's Nursing Notes, Social Services Notes, and Physician's Progress Notes, dated January 2019, revealed no documented evidence of ongoing monitoring related to psychotropic drugs. Review of the Abnormal Involuntary Movement Scale (AIMS) (exam used for assessing side effect of antipsychotic drugs), dated 01/30/19, revealed the resident scored zero (0), indicating the resident was at low risk for movement disorders. Review of Resident #56's Quarterly Minimum Data Set (MDS) Assessment, dated 01/30/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15), indicating severe cognitive impairment; and a Mood Interview score of zero (0), indicating no depression; and no presence of behaviors. Additional review revealed the facility assessed the resident as receiving seven (7) days of psychotropic medication. Review of Resident #56's February Weekly Nursing Assessments, dated 02/02/19, 02/09/19, 02/16/19, and 02/23/19, revealed no documented evidence of hallucinations or delusions in the neurological section. Review of Physician's Order Sheet and Progress Notes, dated 02/06/19, revealed the Resident was very sleepy, stated he/she was okay; and was sitting in the Geri chair at bedside falling asleep. Further, palliative care needed to be discussed with the family related to chronic Respiratory failure, Diabetes, and progressive Dementia. However, there was no documented evidence of the use of or efficacy and adverse consequences for the psychotropic drug. Review of Resident #56's Pharmacy Consultation Report, dated 02/10/19, revealed the Consultant Pharmacist evaluated the current dose of Haldol 0.5 milligrams (mg) every day (QD) and one (1) mg at bed time (HS) and recommended attempting a Gradual Dose Reduction (GDR). However, there was no response from the Provider related to this Report in February 2019. Review of Resident #56's Social Services Progress Note, dated 02/22/19, revealed the resident was alert, but disoriented. Additionally, the resident would not answer direct questions, but would recite his/her ABC's or talk about family. However, there was no documented evidence of the use of or efficacy and adverse consequences for the psychotropic drug. Review of Resident #56's Physician's Orders, dated February 2019, revealed an order for Haloperidol tablet, give 0.5 mg orally, one (1) time a day related to Unspecified Dementia without Behavioral Disturbance, with a start date of 02/23/19. Further review revealed an order, with a start date of 02/23/19 for Haloperidol tablet; give one (1) mg orally, one (1) time at HS related to Unspecified Dementia without Behavioral Disturbance. Review of Resident #56's Medication Administration Record (MAR), dated February 2019, revealed Haloperidol tablet, 0.5 mg orally, one (1) time a day and Haloperidol, one (1) mg orally, at HS, was administered daily. Review of Resident #56's Monthly Behavior Monitoring, for February 2019, revealed worksheets for Remeron related to Depression; Aricept related to Dementia; and Namenda related to Alzheimer's. All forms were blank, indicating no behaviors. However, there was no Monthly Behavior Monitoring sheet for Haldol. Review of Resident #56's Nursing Progress Notes, dated February 2019, revealed no documented evidence of ongoing monitoring related to psychotropic drugs for efficacy and adverse consequences. Additional review of the Pharmacy Consultation Report, dated 02/10/19, revealed the Advanced Registered Nurse Practitioner (ARNP) signed the Pharmacy Consultation Report, dated 02/10/19, on 03/05/19. The ARNP agreed with the Consultant Pharmacist to attempt a Gradual Dose Reduction (GDR) to discontinue Haldol 0.5 mg daily, and to continue Haldol one (1) mg at bedtime. Further review revealed the APRN would re-evaluate in ten to fourteen (10-14) days. Review of Resident #56's Physician's Orders, dated March 2019, revealed an order dated 03/05/19 to discontinue Haloperidol tablet, 0.5 mg orally, one (1) time a day. Further review revealed an order, with a start date of 03/05/19, for Haloperidol tablet; give one (1) mg orally, one (1) time at bedtime related to Unspecified Dementia without Behavioral Disturbance. Review of Resident #56's Medication Administration Record (MAR), dated March 2019, revealed Haloperidol tablet, 0.5 mg orally, one (1) time a day, was administered 03/01/19 through 03/05/19; and Haloperidol, one (1) mg orally, at bedtime, was administered daily. Review of Resident #56's March Weekly Nursing Assessments, dated 03/09/19, 03/16/19, and 03/23/19, revealed no documented evidence of hallucinations or delusions in the neurological section. Review of Resident #56's Monthly Behavior Monitoring, for March 2019, revealed worksheets for Remeron related to Depression; Aricept related to Dementia; and Namenda related to Alzheimer's. All forms were blank, indicating no behaviors. However, there was no Monthly Behavior Monitoring sheet for Haldol. Review of Resident #56's Nursing, and Social Services Progress Notes, dated March 2019, revealed no documented evidence of ongoing monitoring related to psychotropic drugs for efficacy and adverse consequences. Review of the Progress Note, dated 03/18/19 at 3:20 PM, revealed the ARNP was to re-evaluate psychotropic medication adjustment in two to three (2-3) weeks; if no increase in hallucinations, then consider decreasing the Haldol dose at night. Additional review revealed Subjective (S) Resident stated, please I'm not so good; I get upset when the little kids find things. Objective (O) patient in his/her normal confused state. Talking more about little kids but not yelling out and seems to be sleeping per usual. No change in mental status. No Acute distress, lungs clear to auscultation bilaterally, Abdomen soft, non-tender, bowel sounds present, vital signs stable, weight 236.8 pounds. Hallucinations at baseline despite the decrease in Haldol. Will continue Haldol one (1) mg at HS (night) for a few more weeks, then consider decrease HS Haldol. However, there was no further documented evidence Resident #56's psychotropic drugs use had ongoing monitoring for efficacy or adverse consequences, to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. Observation of Resident #56, on 03/26/19 at 11:30 AM, revealed the resident was in the parlor sitting upright in a broda chair, with his/her legs not reclined, but dangling down. Continued observation revealed the resident's eyes were closed, mouth was open, head was tilted to the right, and he/she was receiving oxygen per nasal cannula. Further observation of Resident #56, on 03/26/19 at 1:04 PM, revealed the resident was sitting reclined in a broda chair, at bedside. Continued observation revealed the resident's eyes were closed, mouth was open, and he/she was receiving oxygen per nasal cannula. Observation of Resident #56, on 03/27/19 at 8:00 AM, revealed he/she was sitting reclined in his/her broda chair, leaning towards the right, at the dining room table with the meal tray in front of him/her on the table, covered. Continued observation revealed the resident was receiving oxygen per nasal cannula. Further, the Resident's eyes were closed. Interview with Licensed Practical Nurse (LPN) #15, on 03/28/19 at 9:41 AM, revealed he was assigned to Resident #56 on the day shift. Per interview, residents who receive psychotropic medication received ongoing monitoring for efficacy and adverse consequences. Additional interview revealed monitoring was documented in the Nursing Notes and on a Monthly Behavior Monitoring worksheet, which was the responsibility of the direct care Nurses. LPN #15 further stated all staff were to report to the nurse if the residents were exhibiting any signs or symptoms of adverse reactions and/or behaviors. Continued interview revealed the night shift nurses removed the Monthly Behavior Monitoring worksheets from the binder at the nurse's station, at the end of the month and gave them to the Resident Care Manager (RCM) to review and to discuss with the Director of Nursing (DON). Per interview, the night shift nurses were responsible to make new Monthly Behavior Monitoring sheets for each resident that received psychotropic medications and place it in the binder at the nursing station during monthly change over. Additional interview with LPN #15, revealed it was his role to ensure residents receiving psychotropic medications were monitored ongoing for efficacy and adverse consequences including behaviors and to ensure there was continued communication with staff, resident, families and face to face observations of residents. Further interview revealed it was important to maintain ongoing monitoring of residents receiving psychotropic medication to ensure the residents were receiving the most therapeutic medication and dose because if the wrong medication or dose was administered it could be detrimental to a resident's health or even be considered a chemical restraint. Continued interview with LPN #15, revealed Resident #56 did receive Haldol, and the dose had recently been reduced. Per interview, Resident #56 did have hallucinations; however, it had been awhile since he had observed the resident talk about seeing children. Further, the Resident should have a Monthly Behavior Monitoring worksheet for daily use of Haldol. Interview with the Resident Care Manager (RCM) for Shoreline Hallway, on 03/28/19 at 3:01 PM, revealed she expected the facility policy related to monitoring residents on psychotropic medication and behavior monitoring to be maintained by direct care staff. Continued interview revealed SRNAs should report to the nurse any adverse consequences and behaviors residents were exhibiting; and the nurse should document reported behaviors or observed actions on the Monthly Behavior Monitoring worksheet daily. Per the RCM, all residents who receive a psychotropic medication should have a Monthly Behavior Monitoring sheet for each medication, and Resident #56 should have had a Monthly Behavior Monitoring worksheet for Haldol. Additional interview revealed Monthly Behavior Monitoring documentation was by exception; and if the resident had no reported or observed behaviors, the worksheet would be blank. Per the RCM, Social Services reviewed the Monthly Behavior Monitoring worksheets daily, talked with the nurses and ensured follow up as necessary, and discussed behaviors with the RCM. Further, it was the responsibility of the night shift nurse, during monthly change over, to make new Monthly Behavior Monitoring worksheets for each resident that received psychotropic medications; and each psychotropic medication should have a separate sheet. Per the RCM, Resident #56's Monthly Behavior Monitoring worksheets for the last three (3) months were missed due to human error because there was not a specific process in place to ensure residents receiving a psychotropic medication had a new Monthly Behavior Monitoring sheet initiated during switch over each month. Continued interview with the RCM for Shoreline Hallway, revealed she ensured ongoing monitoring of residents who received psychotropic medication by communicating with social services daily related to concerns with resident behaviors documented on the Monthly Behavior Monitoring worksheet. Additionally, behaviors were reviewed during weekly Focus meetings which included the RCMs, social services, Minimum Data Set (MDS) nurse, dietary, DON, and occasionally the provider. However, the RCM stated the facility process for monitoring and review of psychotropic medication did not include ensuring a Monthly Behavior Monitoring worksheet was in place for each resident receiving a psychotropic medication. Further, it was important to monitor high-risk drugs such as Haldol to ensure the resident was not receiving unnecessary medication, and was receiving the most therapeutic dose. Per interview, ongoing monitoring assisted with ensuring necessary medication changes were made. Interview with Social Services, on 03/28/19 at 3:17 PM, revealed she reviewed the Monthly Behavior Monitoring worksheets each morning for documented behaviors. Continued interview revealed she spoke with the nurses and the RCMs to see if any behaviors had been reported to them as well. Per interview, if there was a behavior documented or reported she would look into it further and find out if the behavior was still present. She stated if it was a continued behavior, she would ensure there was an intervention in place related to the behavior. Additional interview revealed she attended the weekly Focus meeting where the Interdisciplinary team (IDT) talked about behaviors and made ongoing revisions to the care plan as needed. Further interview revealed residents receiving psychotropic medications should have a Monthly Behavior Monitoring worksheet for each psychotropic medication and it was the responsibility of the night shift nurse to ensure a worksheet was initiated and placed in the binder at the nurse's station. However, she stated there was not a process in place to ensure each resident had a sheet for each psychotropic medication. Per interview, it was important to provide ongoing monitoring of residents who receive a psychotropic medication to ensure high-risk medications are necessary and at a therapeutic dose. Further, she revealed Resident #56 should have had a Monthly Behavior Monitoring worksheet related to Haldol. Interview with the ARNP, on 03/28/19 at 2:45 PM, revealed she expected nursing staff to document a daily assessment for one to two (1-2) weeks for patients who receive psychotropic medication with recent changes in the medication. Additionally, she stated she expected documented ongoing monitoring of adverse consequences such as behaviors and changes in mental status for all residents who receive psychotropic medications. Continued interview revealed she spoke with staff and patients, and reviewed documentation in the Progress Notes, and Monthly Behavior Monitoring worksheets, when gathering information related to psychotropic drug use. Further, ongoing monitoring of psychotropic medications was important to ensure providers could attempt reductions, keep the medication regime therapeutic, and document unsuccessful attempts. Additional interview with the ARNP, revealed she was unaware Resident #56 did not have a Monthly Behavior Monitoring sheet for Haldol for the last three (3) months. She stated Resident #56 had been receiving Haldol for two (2) years now related to fearful hallucination. Per interview, a Gradual Dose Reduction (GDR) during the end of last year failed because the Resident had hallucinations of little kids, and became fearful, and cried. She stated the most recent GDR attempt on 03/05/19 had been successful, and the resident was not exhibiting negative behaviors such as being fearful, and crying; however, did report seeing little kids. Further, it was important that ongoing monitoring was maintained to ensure health care providers could quickly assess the residents needs and adjust medications as necessary so residents were not distressed and not fearful. Per interview, this was true especially in Resident #56's case, because it was important he/she was not fearful. Further interview revealed ongoing monitoring and assessment by direct care nursing staff, of Resident #56's Haldol was imperative to ensure the medication was not negatively effecting him/her. Interview with the DON, on 03/28/19 at 3:33 PM, revealed she expected the facility policy and regulation related to psychotropic medication use and behavior monitoring to be followed. Additional interview revealed residents who receive a psychotropic medication should have ongoing monitoring of efficacy and adverse consequences. Continued interview revealed ongoing monitoring should be documented on a Monthly Behavior Monitoring worksheet and Progress Note. Per interview, there should have been Monthly Behavior Monitoring worksheets for Resident #56 related to Haldol. Further interview revealed night shift nursing staff were responsible to ensure Monthly Behavior Monitoring worksheets were in place for each psychotropic medication for each resident, and Social Services and the RCM were responsible to review the worksheets routinely and follow up with the provider with any concerns. Per interview, behaviors and psychotropic drug use were reviewed weekly in Focus meeting and daily in clinical meetings on each unit. Further, it was important to maintain ongoing monitoring of residents receiving psychotropic medications to ensure adverse consequences did not interfere with resident care, daily routine and mental status. Interview with the Pharmacy Consultant, on 03/28/19 at 4:10 PM, revealed she was at the facility at least once a month. Per interview, she expected nursing staff to provide ongoing monitoring of efficacy and adverse consequences for residents who received psychotropic medications. Continued interview revealed it was important to have ongoing documentation to assist with providing the resident with the most therapeutic medication; at the lowest possible dose. Additional interview revealed ongoing monitoring provided supportive evidence if a medication was therapeutic when recommending possible reduction. Further, she was familiar with Resident #56 and the resident should have had a Monthly Behavior Monitoring worksheet and/or Progress Notes related to Haldol use. Per interview, Resident #56 had a recent dose reduction and ongoing monitoring should have been implemented to ensure the Resident did not have adverse consequence(s) related to the medication change. Interview with the Administrator, on 03/28/19 at 5:45 PM, revealed he expected facility policy and regulation to be maintained for psychotropic medication use and behavior monitoring. Per interview, each resident receiving psychotropic medications should have ongoing monitoring for adverse reactions and effectiveness of the medication. Additional interview revealed Resident #56 should have had ongoing monitoring in place for Haldol medication as per facility policy. Further, it was important for ongoing monitoring to be maintained to ensure residents remained at their highest practicable functional ability and did not receive unnecessary medications.

Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to ensure that its medication error rates were not five percent (5%) or greater. Observation of medication pass, on 03/28/19 at 9:01 AM, for Resident #277, revealed the nurse crushed one (1) Potassium Chloride Extended Release (ER) twenty (20) Milliequivalents (MEQ) Tablet, crushed three (3) Metoprolol Succinate ER twenty-five (25) Milligram (MG) tablets, crushed one (1) Amiodarone Hydrochloride (HCL) 100 Milligram (MG) Tablet, and crushed one (1) Methocarbamol 500 mg Tablet. Then, the nurse opened one (1) Omeprazole 20 mg Delayed-Release (DR) Capsule and opened one (1) Duloxetine 30 mg DR Capsule and placed the contents of each crushed tablet and each opened capsule into a medication cup. The nurse further mixed the contents with vanilla pudding, and administered the preparation as a bolus. However, there was no documented evidence of a Physicians' Order to crush the medications or to administer the medications in a bolus for this resident. This observation revealed six (6) medication errors out of a total of thirty-three (33) medication opportunities, resulting in an eighteen percent (18%) medication error rate. The findings include: Review of the facility's Policy titled, Medication Administration-General Guidelines, effective 04/2002, revealed it was the policy of the facility to provide medications as ordered. Further policy review revealed the facility would administer medications according to the Five (5) Rights of medication administration that included the following: 1. Right Resident 2. Right Route 3. Right Dose 4. Right Time 5. Right Medication. Review of the facility's Policy titled, Administration of Crushed Oral Medications, effective 11/2017, revealed it was the policy of the facility to ensure medications were administered as prescribed and in accordance with current standard nursing principles and practices. Further policy review, revealed the facility would ensure crushed oral medications would be administered individually and would not be combined and given together as a bolus administration. If the physician/prescriber and the interdisciplinary team had evaluated the resident and determined administration of crushed oral medications as a single oral bolus outweighed the risk of administering crushed medications individually, the physician/prescriber would do the following: A) Write a Physician's Order for medications to be administered crushed and administered together as bolus. B) Include the rationale for crushing and administering oral medications at once in resident's clinical record. C) Ensure the oral bolus administration of crushed medications was addressed in resident's plan of care. D) Ensure resident and/or representative was informed of rationale of crushing and administering oral medications. E) Monitor resident for any adverse effects of bolus administration of crushed medications. Additional policy review revealed the facility staff would periodically re-evaluate the resident's need for medications to be administered together as a bolus. Observation of medication pass, on Forest Heights Unit, A-Hall, on 03/28/19 at 9:01 AM, for Resident #277, revealed Licensed Practical Nurse (LPN) #8 crushed one (1) Potassium Chloride Extended Release (ER) twenty (20) Milliequivalents (MEQ) (ER is a formulation of the tablet used to slow the release of potassium into the gastro-intestinal tract) Tablet; crushed three (3) Metoprolol Succinate ER twenty-five (25) Milligram (MG) tablets; crushed one (1) Amiodarone Hydrochloride (HCL) 100 Milligram (MG) Tablet; and crushed one (1) Methocarbamol 500 mg Tablet. The nurse then opened one (1) Omeprazole 20 mg Delayed-Release (DR) Capsule and opened one (1) Duloxetine 30 mg DR Capsule and placed contents of each crushed tablet and each opened capsule into a medication cup. The nurse mixed the contents with vanilla pudding, and administered the preparation as a bolus. However, there was no documented evidence of Physicians' Orders to crush the medications or to administer the medications in a bolus for this resident. This observation accounted for six (6) medication errors, out of a total of thirty-three (33) medication opportunities observed during medication pass, to result in an eighteen percent (18%) medication error rate. Interview with LPN #8, on 03/28/19 at 9:20 AM, revealed she was aware she should have had a Physician's Order to crush medications prior to administration of the medicines; however, she was unaware of the need for a specific Physician's Order allowing staff to combine crushed medications. Further interview revealed she was unaware she did not have a Physician's Order to crush the medication for Resident #277, stating, I am a new nurse and I was trained on this medicine cart to crush this resident's medications. That's the only reason I did it that way. Continued interview revealed LPN #8 had received facility provided training and orientation on the use of the Electronic Health Record (EHR) system. However, when asked to pull up Resident #277's Physician's Orders on the EHR, LPN #8 was unable to explain or demonstrate the process of locating a Physician's Order in the EHR. Interview with LPN #9, who was assigned to administer medications to residents on Forest Heights Unit B-Hall, on 03/29/19 at 9:50 AM, revealed staff was to ensure there was a Physician's Order to crush a medication prior to doing so. In addition, LPN #9 advised there would need to be a specific Physician's Order to crush and combine medications to be administered together as a bolus. Further interview revealed the interdisciplinary team and the Physician would first have to evaluate/assess the resident to ensure crushing the medications or administering the crushed medications in a bolus would not be contraindicated and the benefits outweighed the risks, prior to an order being obtained. Interview with Forest Heights Unit Resident Care Manager (RCM) #1, on 03/28/19 at 9:45 AM and at 3:22 PM, revealed a Physician's Order was required to crush a resident's medications prior to administration. Further interview revealed LPN #8 should not have crushed Potassium Chloride ER twenty (20) MEQ Tablet and should not have crushed Metoprolol Succinate ER twenty-five (25) MG three (3) Tablets as the medications were documented on the Oral Dosage Forms That Should Not Be Crushed List and also there was not a Physician's Order to crush the medications. Continued interview revealed there also had to be a Physician's Order to combine medications, even if there was a Physician's Order to crush medications. Further, per facility policy, the Interdisciplinary Team (IDT) and the Physician/Prescriber needed to evaluate/assess the need for crushing and/or combining medications and administering the medicines together as a bolus, prior to an order being written. Additional interview revealed there must also be an assessment documented in the medical record if medications were to be crushed and/or combined crushed medications administered as bolus and this must be care planned, which was not the situation for Resident #277. Interview with the Consultant Pharmacist, on 03/29/19 at 4:19 PM, revealed a Physician's Order was required for crushing medications. Further interview revealed LPN #8 should never have crushed Potassium Chloride ER Tablets because it is one of the drugs on our DO NOT CRUSH LIST. The Pharmacist explained, Potassium Chloride ER was an extended release tablet that could cause gastro-intestinal upset, a potential spike in potassium, and several other negative or adverse effects if crushed; depending on the resident's condition and history of pre-existing conditions. Per interview, if a resident already had increased potassium levels in the body at the time the crushed dose was given, the resident could potentially have negative cardiac side effects. Further interview revealed staff should never crush Metoprolol Succinate ER Tablets for the exact same reason. Continued Pharmacist interview revealed Metoprolol was on the Pharmacy's DO NOT CRUSH LIST or Oral Dosage Forms That Should Never Be Crushed List, and if crushed could cause gastric irritation and/or potentially negative cardiac side effects such as hypotension (low blood pressure), vertigo (dizziness) and fainting. Additional interview with the Pharmacist, revealed a Physician's Order was required to change dosage form of any medication prior to administration and alternative forms of Metoprolol Succinate ER and Potassium Chloride ER were available for use. Per interview, staff had been in-serviced and were aware of the need for Physician's Orders for crushing medications or combining medications to administer as a bolus. Interview with the Director of Nursing (DON), on 03/29/19 at 5:56 PM, revealed LPN #8 should have obtained a Physician's Order prior to crushing Resident #277's medications. Further interview revealed LPN #8 should have ensured a Physician's Order was present prior to combining the resident's crushed medications together in pudding and administering the medications together as a bolus. Continued interview revealed LPN #8 failed to follow standards of practice by crushing medications which were on the DO NOT CRUSH list. Further, the nurse failed to follow facility policy by mixing Resident #277's medications into a vanilla pudding and administering the bolus preparation to the resident without a Physician's Order. Additional interview revealed LPN #8 would need to be re-educated prior to receiving another medication administration assignment. The DON further stated LPN #8 was familiar with obtaining/receiving and locating the Physician's Orders and should have been able to demonstrate or verbalize the process. Interview with the Administrator, on 03/29/19 at 6:23 PM, revealed he expected nursing staff to follow the facility's policies and procedures regarding medication administration. Further interview revealed LPN #8 should have obtained a Physician's Order prior to crushing a resident's medication or combining crushed medications for administration. Continued interview revealed the Administrator expected staff to have the ability to reference the resource material provided to them such as the DO NOT CRUSH list provided by the Pharmacy and should have knowledge of medications that could not be crushed. Additional interview revealed staff should absolutely know how and where to locate a Physician's Order when requested.

Based on observation, interview, record review and review of the facility's Policies, it was determined the facility failed to ensure residents were free of significant medication errors for one (1) of twenty-five (25) sampled residents (Resident #277). Observation of medication administration, on 03/29/19 at 9:01 AM, on Forest Heights Unit, A-Hall, revealed Licensed Practical Nurse (LPN) #8 crushed Potassium Chloride Extended-Release (ER) and Metoprolol Succinate Extended Release (ER) and administered the medication to Resident #277. Potassium Chloride Extended-Release (ER) and Metoprolol Succinate Extended Release (ER) were two (2) medications that were listed on the facility's Oral Dosage Forms That Should Not Be Crushed List. The findings include: Review of the facility's Policy titled, Medication Administration-General Guidelines, effective 04/2002, revealed it was the policy of the facility to provide resident medications as ordered. Further policy review revealed the facility would administer medications according to the Five (5) Rights of medication administration that included the following: 1. Right Resident 2. Right Route 3. Right Dose 4. Right Time 5. Right Medication. Review of the facility's documentation of Oral Dosage Forms That Should Not Be Crushed, copyright 2016, revealed the following medications should not be crushed: Drug Name: Potassium Chloride Extended-Release (ER) | Drug Class: Electrolyte | Form: Tablet, Extended Release (ER). Further review of facility's documented list of medications that should not be crushed revealed the following: Drug Name: Metoprolol Succinate Extended Release (ER) | Drug Class: Beta-Blocker | Slow-Release (SR) |Form: Tablet, Extended Release (ER). Continued review revealed all medications listed on the provided documentation/list as Slow-Release were documented as such to designate any special-release medication form such as extended-release, delayed-release, sustained release and/or controlled release. Additional review revealed alternate forms of Potassium Chloride and Metoprolol Succinate were available. Review of Resident #277's clinical record revealed the facility re-admitted the resident on 03/06/19 with diagnoses to include Paroxysmal Atrial Fibrillation, Orthostatic Hypotension, Essential Primary Hypertension, Cognitive Communication Deficit, Unspecified Lack of Coordination, Gastro-Esophageal Reflux, Dysphagia and Arthropathy (arthritis or other joint disease). Review of Resident #277's March 2019 Physician's Order Summary, dated 03/28/19, revealed an order to administer Klor-Con M20 Tablet Extended Release (ER) 20 MEQ (Potassium Chloride Crystals), one (1) tablet by mouth twice daily for potassium deficit. Continued review revealed an order to administer Metoprolol Succinate ER Tablet (Extended Release 24-hour) 75 milligram (mg) by mouth daily for Hypertension. Further review revealed there was no documented evidence of a Physician's Order to crush Resident #277's medications. Observation of medication pass, on 03/28/19 at 9:01 AM, for Resident #277, revealed the nurse crushed one (1) Potassium Chloride Extended Release (ER) twenty (20) Milliequivalents (MEQ) Tablet, crushed three (3) Metoprolol Succinate ER twenty-five (25) Milligram (MG) tablets, crushed one (1) Amiodarone Hydrochloride (HCL) 100 Milligram (MG) Tablet, and crushed one (1) Methocarbamol 500 mg Tablet. Then, the nurse opened one (1) Omeprazole 20 mg Delayed-Release (DR) Capsule and opened one (1) Duloxetine 30 mg DR Capsule and placed the contents of each crushed tablet and each opened capsule into a medication cup. The nurse further mixed the contents with vanilla pudding, and administered the preparation as a bolus. Interview with Resident #277, on 03/28/19 at 9:10 AM, revealed he/she was given medications crushed by staff all the time and he/she hated the way the pills tasted when they were crushed up. Resident #277 stated, although it was the quickest way to take the pills, he/she would prefer to take the medicine whole, just like he/she used to do before coming to stay at the facility. Resident #277 stated he/she could not recall there being any staff discussion with him/her related to his/her desire to have pills taken whole or crushed. Interview with LPN #8, on 03/28/19 at 9:20 AM, revealed the nurse was aware of the need for a Physician's Order to crush medications. However, she was unaware there was not an order to crush Resident #277's medications. Further interview revealed, I am a new nurse and I was trained on this medicine cart to crush this resident's medications. That's the only reason I did it that way. Continued interview revealed LPN #8 had received facility provided training and orientation on the use of the Electronic Health Record (EHR) system; however, was unable to explain or demonstrate the process of locating Resident #277's Physician's Orders in the EHR. Further interview with LPN #8, revealed she was unaware of the list of Oral Dosage Forms That Should Not Be Crushed provided to the facility by the facility's pharmacy. She further stated she was never taught Potassium, Metoprolol and other Extended-Release, Slow-Release, and/or Controlled-Release medications should not be crushed. Interview with LPN #9, on 03/29/19 at 9:50 AM, revealed she was assigned to administer medications on Forest Heights Unit B-Hall. Per interview, there had to be a Physician's Order to crush medications. Continued interview revealed multiple copies of the list of Oral Dosage Forms That Should Not Be Crushed were kept in binders located at each of the nursing stations on every unit and remained accessible to all staff, at all times. Per interview, the medications on this list should not be crushed due to the possible side effects. Interview with Forest Heights Unit Resident Care Manager (RCM) #1, on 03/28/19 at 9:45 AM and at 03:22 PM, revealed LPN #8 should not have crushed any of Resident #277's medications prior to administration, as there was no Physician's Orders to crush this resident's medications. Further interview revealed LPN #8 should not have crushed Potassium Chloride ER twenty (20) MEQ Tablet and should not have crushed Metoprolol Succinate ER twenty-five (25) MG three (3) Tablets as the medications were documented on the Oral Dosage Forms That Should Not Be Crushed List. Interview with the Consultant Pharmacist, on 03/29/19 at 4:19 PM, revealed a Physician's Order was required before crushing medications. Further interview revealed LPN #8, Should never have crushed Potassium Chloride ER Tablets because it is one of the drugs on our DO NOT CRUSH LIST. The Pharmacist stated, Potassium Chloride ER was an extended release tablet that could cause gastro-intestinal upset, a potential spike in potassium, and several other negative or adverse effects if crushed; depending on the resident's condition and history of pre-existing conditions. Per interview, if a resident already had increased potassium levels in the body at the time the crushed dose was administered, the resident could potentially have negative cardiac side effects. Continued interview revealed staff should never crush Metoprolol Succinate ER Tablets for the exact same reason. The Pharmacist stated Metoprolol was on the Pharmacy's DO NOT CRUSH LIST or Oral Dosage Forms That Should Never Be Crushed List, and if crushed could cause gastric irritation and/or potentially negative cardiac side effects such as hypotension (low blood pressure), vertigo (dizziness) and fainting. Additional interview revealed a Physician's Order was required to change dosage form of any medication prior to administration and alternative forms of Metoprolol Succinate ER and Potassium Chloride ER were available for use. Further, staff had been in-serviced and were aware of the need for Physician's Orders for crushing medications or combining medications to administer as a bolus. Interview with the Director of Nursing (DON), on 03/29/19 at 5:56 PM, revealed LPN #8 should have ensured there was a Physician's Order to crush medications and to administer medications as a bolus prior to crushing or combining any of Resident #277's medications. Continued interview revealed LPN #8 failed to follow standards of practice by crushing medications which were on the DO NOT CRUSH list; which could have led to a negative outcome for this resident. Additional interview revealed LPN #8 would need to be re-educated related to medication administration as well as locating the Physician's Orders on the EHR. Interview with the Administrator, on 03/29/19 at 6:23 PM, revealed he expected nursing staff to follow the facility's policies and procedures regarding medication administration. Further interview revealed LPN #8 should have obtained a Physician's Order prior to crushing any of Resident #277's medication. Continued interview revealed the Administrator expected staff to have the ability to reference the resource material provided to them such as the DO NOT CRUSH list provided by the Pharmacy and to be knowledgeable of medications that could not be crushed. Additional interview revealed staff should absolutely be knowledgeable of how to locate a Physician's Order.

Based on observation, interview, and review of the facility's Policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of five (5) residents reviewed for infections out of a total of twenty-five (25) sampled residents (Resident #277). Observation of medication administration on 03/28/19 revealed staff failed to perform proper hand hygiene prior to preparation of medications, before entering resident's room and during administration of eye medication for one (1) of twenty-five (25) sampled residents, Resident #277. The findings include: Review of the facility's Policy titled, Handwashing, dated 12/2001 and revised 02/2003, revealed the facility recognized handwashing as the most basic yet most effective means of preventing and controlling the spread of infection. Further review of the facility's Handwashing Policy revealed, Every staff member had a responsibility to recognize the importance of and carry out good hand washing techniques not only to protect the residents they serve, but also themselves. Continued review revealed staff would reduce their chances of spreading an infection to residents or acquiring an infection themselves by practicing effective hand hygiene. Additional Policy review revealed the facility would ensure ongoing staff monitoring of staff utilization of appropriate timing and technique of handwashing during compliance rounds, infection control rounds, and other infection control monitoring programs. Review of the facility's Policy titled, Infection Prevention and Control Program, dated 04/01/13 and revised on 12/2017, revealed the purpose of the facility's policy was to provide a safe, sanitary and comfortable environment for all residents, staff and visitors. Further Policy review revealed the facility's program would include surveillance, reporting and tracking as well as prevention and control of infections to improve clinical outcomes. Continued review revealed the Infection Prevention and Control Program would prevent the development and transmission of communicable diseases and infections. Additional Policy review revealed the facility would identify and monitor all Infection Control issues, problems, and concerns through the monthly Quality Assurance and Performance Improvement meeting. Review of Resident #277's clinical record revealed, the facility re-admitted the resident on 03/06/19 with diagnoses to include Paroxysmal Atrial Fibrillation (heart arrhythmia), Orthostatic Hypotension, Cognitive Communication Deficit, Dysphagia, Unspecified Lack of Coordination, Gastro-Esophageal Reflux Disease, and Arthropathy (disease of a joint). Review of the admission Minimum Data Set (MDS) Assessment, dated 03/13/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) Score of five (5) out of fifteen (15), which indicated the resident was severely cognitively impaired. Further review of the admission MDS revealed the facility assessed the resident to require extensive physical assistance of one for bed mobility, transfer, dressing and personal hygiene. Continued review revealed Resident #277 required limited physical assistance of one with eating. Observation of a medication administration performed by Licensed Practical Nurse (LPN) #8, on 03/28/19 at 9:09 AM, revealed LPN #8 preparing Resident #277's morning medications without washing or sanitizing hands. Further observation revealed LPN #8 entered Resident #277's room and administered oral medications without washing or sanitizing her hands after entering the resident's private bathroom to don clean gloves. Continued observation of the medication administration revealed LPN #8 using the same-gloved index finger of her right hand to administer eye medication to Resident #277's right eye following the administration of medication to the resident's left eye without washing/sanitizing hands or changing gloves. LPN #8 failed to utilize proper hand hygiene prior to and during administration of Resident #277's medications. Interview with LPN #8, on 03/28/19 at 9:20 AM, revealed she was the nurse assigned to administer medications and treatments to Resident #277 on 03/28/19. Further interview revealed she should have washed her hands prior to preparing Resident #277's medications; however, she was a new nurse and had failed to wash her hands because she was nervous about the survey process. Continued interview with LPN #8 revealed she should have washed and/or sanitized her hands prior to entering the resident's room to prevent the potential spread of germs, illness, disease or infection to or from the resident to her and vice versa as this was an infection control concern. Additional interview with LPN #8 revealed she was not aware of the need to remove gloves, wash/sanitize hands, and don clean gloves following the administration of resident's medication into left eye and prior to administration of medication in to right eye. LPN #8 stated she was taught to administer the resident's eye drops without washing/sanitizing hands and changing gloves between administration of medication into the left and right eye. Further, LPN #8 revealed she was not aware this was an infection control issue although she had received facility provided training on Infection Control and Prevention upon hire two (2) months ago. Interview with Resident Care Manager (RCM) #1, on 03/28/19 at 9:45 AM, revealed she was in charge of the unit on which Resident #277 resided. RCM #1 revealed she expected staff to wash/sanitize hands prior to preparing and administering each resident's medications, prior to entering a resident's room and before donning clean gloves to provide any resident care. Further interview with RCM #1 revealed she expected staff to remove soiled gloves after the administration of eye medication, wash/sanitize hands, don clean gloves and administer medication to resident's other eye as ordered to prevent the potential spread of bacteria, germs or infection from one eye to the other when same gloved finger is being used. RCM #1 explained this was an infection control topic that staff had received facility provided training on upon hire, quarterly and as needed. Continued interview with RCM #1 revealed she expected staff to utilize proper hand hygiene and standard precautions for all residents for infection control, as residents were vulnerable population and could become very ill, very quickly. RCM #1 added she was disappointed this was found on her unit and with her LPN. Interview with Registered Nurse Quality Manager (QM) #1, on 03/28/19 at 5:44 PM, revealed she expected staff to follow the facility's policy and practices for Infection Control when administering medications and providing any direct resident care. Further interview revealed she expected staff to wash/sanitize their hands and apply clean gloves before preparing and administering any resident medication, including eye drops. QM #1 stated once staff have washed and or sanitized their hands and applied clean gloves, then administered the resident's medications to the first eye, they should then remove their soiled gloves, wash/sanitize their hands again, re-apply clean gloves and administer medication in resident's other eye. She stated that proper hand hygiene and gloving technique will help to prevent the potential spread of bacteria, germs or infection in to the resident's other eye. QM #1 added this was an Infection Control and Prevention issue explaining the facility had provided educational material and training to all staff upon hire, quarterly, and as needed when issues or concerns are identified during Infection Control rounds or monthly Quality Assurance and Performance Improvement conferences. Interview with Director of Nursing (DON), on 03/28/19 at 5:56 PM, revealed she expected staff to practice proper hand hygiene and gloving technique when providing direct resident care. DON explained she expected staff to follow the facility's policies and procedures when caring for residents. Further interview with the DON revealed she expected staff to wash/sanitize hands prior to preparation and administration of resident's medications, including medications administered into the eye. Continued DON interview revealed she would expect LPN #8 to know to wash/sanitize their hands following administration of medication into resident's eye, before administration of medication into the resident's other eye to prevent potential cross contamination of bacteria or germs from that eye to the other eye or from staff to the resident or vice versa. Continued interview with the DON revealed she expected LPN #8 to wash/sanitize hands prior to entering a resident's room to decrease the potential transfer of illness, diseases or germs to resident, visitors or other staff members. Additional interview with the DON revealed she expected staff to wash and or sanitize hands before applying clean gloves. The DON continued to explain she and other administrative staff members work hard in an attempt to identify, monitor and track infection control and prevention concerns and will continue to provide educational and training material to staff as those issues arise. Interview with Facility Administrator, on 03/28/19 at 6:23 PM, revealed he expected staff to wash/sanitize hands prior to providing any direct resident care. Further interview with the Administrator revealed he expected LPN #8 to wash her hands prior to preparing and administering Resident #277's medications, including eye medicines. Continued Administrator interview revealed he expected LPN #8 to wash/sanitize her hands prior to entering the resident's room to administer medications. The Administrator added it was his expectation LPN #8 changed her soiled gloves following administration of medication in the resident's left eye, washed her hands, and donned clean gloves prior to administration of medication in to the resident's right eye. Further, the Administrator revealed he expected staff to follow the Facility's Infection Prevention and Control Policy and Practices to prevent the potential spread of bacteria, germs, viruses, diseases and illnesses to residents, staff, visitors/family members, vendors and others in the facility.

Based on observation, interview and review of facility Policy, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation during initial tour on 03/26/19 of the kitchen, revealed there was an accumulation of dust on the dish room ceiling, above the kitchen production area and on the ceiling in the refrigerator walk-in. In addition, the temperature logs for the walk-in refrigerator, freezer and dry storage were incomplete. Additionally, Resident #35 was observed to have multiple perishable food items in his/her room. The findings include: Review of the kitchen document titled Weekly Cleaning Schedule undated, revealed it did not include a schedule for cleaning dust on the ceiling. Review of the facility Policy titled Refrigerated Storage dated 05/2006, revealed a variety of foods are stored under refrigeration and the temperatures are low enough to safely keep perishable foods. Per Policy, each refrigerator contains a thermometer and temperature charts are to be documented daily. Review of the Refrigerated Storage, Policy, revised May 2006, revealed the facility will store, prepare and serve foods in accordance with federal, state and local sanitary codes. Further review revealed it is essential that refrigerator temperatures be low enough to safely keep most perishable foods and refrigerator temperatures that are consistently thirty eight (38) degrees Fahrenheit or below will provide this safety margin. 1. Observation on 03/26/19 at 11:26 AM, during initial kitchen tour, revealed there was dust accumulation on the ceiling of the walk-in cooler near the fans. Observation on 03/27/19 8:38 AM, revealed the ceiling vents over the production area and the ceiling vents in the dish room had an accumulation of dust. Interview on 03/28/19 at 2:00 PM, with Dietary Aide #1, revealed staff cleaned their assigned area and their area of production. Per interview, the Supervisor assigned the daily cleaning and checked the areas assigned. Further interview revealed the Maintenance staff dusted the ceiling once a week to prevent cross contamination of dust from the ceiling to the food. Interview on 03/28/19 at 2:19 PM, with the Dietary Manager, revealed the Supervisor assigned the daily cleaning, and made rounds to ensure areas were cleaned as assigned. Further interview revealed Maintenance staff was responsible to clean the kitchen ceiling; however, it may need to be cleaned more frequently as there was a dust build up which could fall into the food and cause cross contamination. Interview on 03/28/19 at 2:29 PM, with the Dietary Supervisor, revealed staff assigned cleaning tasks daily and staff were to clean their work area of the kitchen. Per interview, Maintenance was responsible for cleaning the kitchen ceiling. Per interview, the ceiling needed to be cleaned regularly to prevent dust from falling into the food. Per interview, dietary staff could inform Maintenance of the need to have the ceiling dusted and cleaned verbally or through work orders. Interview on 03/28/19 at 2:38 PM, with the Maintenance Director, revealed the kitchen ceiling was cleaned bi-annually. Further interview revealed if the ceiling needed cleaned more often due to an accumulation of dust, kitchen staff could fill out a work order and Maintenance would ensure the ceiling was cleaned. 2. Observation on 03/26/19 at 11:15 AM, during initial kitchen tour revealed Temperature logs for the walk-in refrigerator, walk-in freezer and Dry storage were had incomplete documentation. Review of the kitchen temperature logs, titled Temperature Chart-Storage Areas, dated 03/2019, revealed the freezer temperature log had no documented temperatures for the 16th, 17th and 25th; the refrigerator temperature log had no documentation of temperatures for the 16th, 17th and 25th and the dry storage temperature log had incomplete documentation of temperatures for the 16th, 17th and 25th. Interview on 03/28/19 at 2:00 PM, with Dietary Aide #1, revealed kitchen staff were responsible to record temperatures on the temperature chart morning and evening and report to the supervisor if temperatures were not in proper range. Per interview, this was important to ensure food which was stored in the refrigerator, freezer and dry storage did not spoil. Interview on 03/28/19 at 2:19 PM, with the Dietary Manager, revealed the walk-in refrigerator and freezer temperatures, as well as dry storage needed to be monitored daily to ensure food was stored at proper temperatures to prevent food from spoiling. Interview on 03/28/19 at 2:29 PM, with the Dietary Supervisor, revealed the temperature logs of the kitchen equipment and dry storage were to be recorded in the morning and evening. Per interview, this was important temperature to ensure equipment was working correctly for proper food storage. Interview on 03/28/19 at 3:43 PM, with the Director of Nursing (DON), revealed dust accumulated in areas of the kitchen could fall into the food and cause physical cross contamination. Further interview revealed temperature logs for the equipment and dry storage in the kitchen needed to be monitored and documented daily to ensure equipment was running properly and to prevent the spoilage of foods. Interview on 03/28/19 at 4:35 PM, with the Administrator, revealed dust was not to accumulate in the kitchen as this was to be a clean and sanitary environment. Further interview revealed temperature logs for the equipment and dry storage in the kitchen needed to be completed on a daily basis to ensure the equipment was functioning properly to prevent food from spoiling. 3. Review of Resident #35's clinical record revealed the facility re-admitted the resident on 01/27/17. Per record review, the resident's diagnoses included Left Artificial Hip Joint; Unspecified Atrial Fibrillation; Presence of Cardiac Pacemaker; and Gastro-esophageal Reflux Disease without Esophagitis. Review of the Nurse's Progress Note, dated 11/12/18, revealed flies were noted in the resident's room and the nurse had a hard time moving around in the resident's room as the resident demanded the nurse not step on anything. Further review of the Note, revealed there was an immense amount of clutter in the room. Review of the Significant Change in Status Minimum Data Set (MDS) Assessment, dated 01/16/19, revealed the facility assessed Resident #35 as having a Brief interview for Mental Status score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Continued review of the MDS Assessment revealed the facility assessed the resident as having no mood indicators or behaviors, and no rejection of care during the assessment period. Additional review of the MDS Assessment, revealed the facility assessed the resident as supervision or set up help only for ADL's (Activities of Daily Living) with the exception of locomotion off unit which the resident required limited assistance of one (1) staff. Review of the Physician's Order Sheet and Progress Notes dated 01/31/19 revealed a progress note which stated, patient does hoard. Review of Resident the Comprehensive Care Plan, initiated 02/18/19, revealed the resident had episodes of behaviors as evidenced by: Hoarding. The goal revealed the resident would have no episodes of behavior through next review with a target date of 05/31/19. The interventions included: approach in calm non threatening manner; attempt to guide away from source of distress before agitation escalates; attempt to identify cause for resistance and reduce/eliminate if possible; attempt to identify factual basis for concerns/behaviors and resolve if possible; avoid commands using do's and don't's; give resident as many choices as possible about care and activities and identify trigger stimuli and educate staff to avoid as much as possible. Review of Resident #35's Monthly March 2019 Physician's Orders, revealed a current order initiated 08/23/17, which stated, May have psychiatric eval as needed. Review of the Physician's Progress Note, dated 03/28/19, revealed the patient does not always take medications; hoarding; and continues to keep food/letters in room. Observation of Resident #35, on 03/26/19 at 4:10 PM, revealed the resident was observed sitting in a chair beside the bed and window, and there was large amounts of mail, paper, and other items in the room. Further observation revealed there were two (2) meal trays with perishable food under the lids, on the floor beside the bed; and also several unopened cups of puddings. In addition, there was six (6) cups of a pink colored drink on the bedside table which were not covered, labeled or dated. Interview with Resident #35, on 03/26/19 at 4:10 PM, during the observation, revealed the two (2) cups of the pink drink were from today (03/26/19) and the other two (2) cups of pink liquid were from yesterday (03/25/19). The resident did not mention the final two (2) cups of pink drink. Continued interview revealed a friend brought the resident six (6) hot dogs once, and he/she ate them from a Friday to a Wednesday, and they didn't ruin. Resident #35 stated he/she did not have a refrigerator, but he/she would know if food had spoiled. On 03/27/19 at 2:04 PM, the Resident Care Manager (RCM) unlocked Resident #35's door and entered the room with the State Agency Representative. The RCM stated the resident was at an appointment and requested the room be locked when he/she left the facility, but staff kept a key to the room. Observation of Resident #35's room revealed there was more than fifty (50) assorted containers of yogurt, which were not refrigerated, stacked in the room. There was also two (2) meal trays observed on the floor beside the bed in the same place as observed the prior day, 03/26/19, with perishable food under the lids. Interview with the RCM at the time of the observation, confirmed the meal trays were delivered on 03/26/19 meal. There were two (2) additional meal trays noted with perishable foods observed, which the RCM stated was delivered today, 03/27/19 at breakfast and lunch. Additional observation revealed the six (6) uncovered, unlabeled or undated cups of a pink colored drink that were observed on 03/26/19 were still the bedside table. There were three (3) additional cups observed on the bedside table, which were covered, but undated, revealing a total of nine (9) cups of fluids in the room. Interview on 03/28/19 at 2:32 PM, with State Registered Nurse Aide (SRNA) #6, revealed Resident #35 could feeding himself/herself, and was kind of a hoarder. Further interview revealed Resident #35 had refused to allow her to remove meal trays when she was assigned to the resident and would scold her and tell her, no. SRNA #6 further stated when she asked the resident the reason he/she didn't want the tray removed, the resident told her he/she was saving it, and the food would be good. Additional interview revealed someone brought the resident six (6) hot dogs and the resident told him/her they lasted six (6) days. Per interview, Resident #35 informed her he/she received the hot dogs on a Saturday and when she saw the resident on a Monday, the resident still had one (1) hot dog left. SRNA #6 could not recall the date of this incident. SRNA #6 stated Resident #35 did not have a refrigerator and the yogurt and perishable food trays being left in the resident's room could spoil which could definitely be a health issue for the resident. SRNA #6 further stated Resident #35 could get food poisoning and could get really sick with vomiting and diarrhea if the resident ate spoiled food. Interview on 03/28/19 at 2:48 PM, with Licensed Practical Nurse (LPN) #7, revealed Resident #35 used to have a care taker who helped manage him/her, and the care taker could help keep him/her calm while staff removed leftover food from the room. However, at present the resident would not allow staff to remove the food trays from his/her room. Per interview, yogurt should be refrigerated and leftover food trays should be picked up within two (2) hours of delivery; however, Resident #35 would not allow this. LPN #7 revealed Resident #35 did not have a refrigerator in his/her room as residents weren't allowed to have refrigerators. Continued interview revealed she honestly did not think the resident ate the left over food, but there was no way to know for sure. Additional interview revealed there could be possible negative outcomes for Resident #35, if he/she were to eat expired food, such as food poisoning, upset stomach, and diarrhea. Interview with the Dietary Manager, on 03/28/19 at 2:52 PM, revealed perishable food which was not refrigerated and was left at room temperature, could grow bacteria and could cause food poisoning if ingested. Interview with the Facility Operations Manager, on 03/28/19 at 2:45 PM, revealed the facility needed to work with Resident #35 in finding a solution to storing food in the facility refrigerator that could be accessed by the RCM upon the resident's request. Further interview revealed this could be a goal to provide better quality of life for the resident. Interview on 03/28/19 at 3:18 PM, with the RCM, revealed it was a pattern for Resident #35 to leave perishable foods in his/her room. She stated the resident could get sick from eating these foods; however, she felt the resident's body was accustomed to eating the left over foods. The RCM stated Resident #35 did not have a refrigerator. Interview on 03/28/19 at 3:56 PM, with the Social Services Manager, revealed she had talked to Resident #35 several times related to hoarding behaviors and leaving old food in the room. Continued interview revealed she would refrigerate the resident's yogurt, but the resident would refuse this. Per interview, the resident had told the Social Services Manager, he/she did not drink the cups of liquids in the room, but would rinse the cups out and recycle them. Further interview revealed the resident also told her, he/she did not eat the leftover food, but stated he/she was going to give it to kids, or staff. Per interview, when the resident gave staff food, staff would discard of the food. Additional interview revealed if the resident consumed improperly stored food, it could it make the resident sick. Interview on 03/28/19 at 3:58 PM, and 03/28/19 at 4:31 PM, with the Director of Nursing (DON), revealed she was familiar with Resident #35's hoarding behaviors, and staff had tried to educate the resident on the risks of leaving leftover food in his/her room. Per interview, all perishable food should be stored properly to keep from spoiling and that was not occurring for this resident. Interview with the Administrator, on 03/28/19 at 4:14 PM, 03/28/19 at 5:05 PM, revealed Resident #35 had a right to keep food in his/her room, but perishable foods must be stored properly in a refrigerator, and he was unaware of the resident keeping hot dogs in the room. Per interview, he was unaware of the resident eating any of the stored perishable food he/she kept in the room, but was aware he/she would offer it to staff and they would discard the food. Further interview, revealed if the resident ate spoiled food this could have a negative outcome for the resident. Additional interview revealed it was important for the facility to follow the policies related to food storage.