How many inspection deficiencies does ANCHORAGE HEALTHCARE CENTER have?

ANCHORAGE HEALTHCARE CENTER has 83 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at ANCHORAGE HEALTHCARE CENTER?

ANCHORAGE HEALTHCARE CENTER has a three-star staffing rating from CMS with 0.52 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is ANCHORAGE HEALTHCARE CENTER located?

ANCHORAGE HEALTHCARE CENTER is located in SALISBURY, MD. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does ANCHORAGE HEALTHCARE CENTER have?

ANCHORAGE HEALTHCARE CENTER has 126 certified beds.

Who owns ANCHORAGE HEALTHCARE CENTER?

ANCHORAGE HEALTHCARE CENTER is a for profit - corporation facility and is part of the COMMUNICARE HEALTH chain.

How does ANCHORAGE HEALTHCARE CENTER compare to other nursing homes?

ANCHORAGE HEALTHCARE CENTER has a 2-star overall rating, which is below average compared to other nursing homes in MD. Families should carefully review inspection findings and consider alternatives.

ANCHORAGE HEALTHCARE CENTER

Name: ANCHORAGE HEALTHCARE CENTER
Address: 105 TIMES SQUARE, SALISBURY, MD, 21801, US
Telephone: (410) 749-2474
Rating: 2.0

105 TIMES SQUARE, SALISBURY, MD 21801 · (410) 749-2474

For profit - Corporation 126 Beds COMMUNICARE HEALTH Data: November 2025

Trust Grade

48/100

#134 of 219 in MD

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ANCHORAGE HEALTHCARE CENTER nursing home in SALISBURY, MD - Photo 1 of 3

ANCHORAGE HEALTHCARE CENTER nursing home in SALISBURY, MD - Photo 2 of 3

Photo by Anchorage Healthcare Center

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Last Inspection: March 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Anchorage Healthcare Center has received a Trust Grade of D, indicating below-average care with some concerns. It ranks #134 out of 219 facilities in Maryland, placing it in the bottom half of the state, and #3 out of 4 in Wicomico County, meaning only one local option ranks lower. The facility's trend is worsening, as the number of issues reported increased from 31 in 2019 to 45 in 2024. While staffing is somewhat of a strength with a 3/5 star rating and a turnover rate of 31% (better than the state average), the facility still has a concerning $10,033 in fines, which suggests some compliance issues. Specific incidents include residents lacking chairs for visitors, a failure to provide written notification for a resident's hospital transfer, and a resident experiencing significant weight loss without proper assessment, highlighting a mix of strengths and serious areas needing improvement.

Trust Score: D
In Maryland: #134/219
Safety Record: Low Risk
Inspections: Getting Worse
Staff Stability: 31% turnover. Near Maryland's 48% average. Typical for the industry.
Penalties: $10,033 in fines. Higher than 88% of Maryland facilities, suggesting repeated compliance issues.
Skilled Nurses: Each resident gets 31 minutes of Registered Nurse (RN) attention daily — about average for Maryland. RNs are the most trained staff who monitor for health changes.
Violations: 83 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★☆

4.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2019: 31 issues

2024: 45 issues

The Good

4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (31%)
17 points below Maryland average of 48%

Facility shows strength in quality measures, fire safety.

The Bad

2-Star Overall Rating

Below Maryland average (3.0)

Below average - review inspection findings carefully

Staff Turnover: 31%

15pts below Maryland avg (46%)

Typical for the industry

Federal Fines: $10,033

Below median ($33,413)

Minor penalties assessed

Chain: COMMUNICARE HEALTH

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 83 deficiencies on record

Mar 2024 32 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on interview and observation, it was determined that the facility failed to protect a resident's private space by not knocking prior to entering a resident's room. This was evident for 1 (Resident #17) out of 5 residents reviewed for dignity during the survey. The findings include: On 3/19/24 at 9:53 AM, Resident #17, a long-term resident of the facility was interviewed. During the interview, Resident #17 reported that at times, the facility staff come into the room, without knocking, when they have not been welcomed into the room. On 3/19/24 at 10:16 AM, an observation was made in the resident's room during an interview with Resident #17. The resident's door was closed. The observation revealed facility staff abruptly entered the room without knocking. The staff entered the room and addressed Resident #17 and the surveyor and said they would return later and then they left the room. On 3/19/24 at 3:05 PM, during an interview with the Director of Nursing (DON) and Administrator, they reported that the expectation is that all staff knock before entering a resident's room. The DON reported that Resident #17 reported the incident to her and that a grievance form was filled out and corrective education of the staff had already begun.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected 1 resident

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Based on record reviews and interviews, it was determined that the facility failed to document and address concerns raised by the resident council, as evidenced by the lack of documentation of those concerns and how they were addressed. This was evident in resident council meetings held between February 2023 and December 2023. The findings include: On 3/22/24 at 11:16 AM, a review of resident council meeting minutes for 2023, provided by the Activity Director (Staff #7), was completed. The review showed documentation of the minutes, and concerns voiced at a meeting held on 1/18/23. However, continued review failed to reveal records of the minutes and residents' concerns expressed at the February to December 2023 meetings. On 3/22/24 at 11:30 AM, during an interview with the nursing home administrator, she stated she was aware of the lack of documentation of residents' concerns or complaints voiced at the meetings from February to December 2023. The administrator also said, The resident council minutes book had changed hands in October 2023. A subsequent interview was done with Staff #7 on 3/25/24 at 10:30 AM. During the interview, she confirmed that she did not document residents' concerns or complaints voiced during the meetings when she took over the role from October to December 2023. During an interview on 3/25/24 at 11:50 AM, Staff #7 stated she had just received education earlier in the morning on how to conduct the resident council meetings and how to document the residents' concerns or complaints voiced during the sessions.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, it was determined that the facility failed to provide information to residents regarding their right to formulate an advanced directive, failed to document that the resident or resident representative was informed of their right to formulate an advanced directive by failing to document discussions regarding advanced directives and the outcome of the discussion in the resident's medical record. This was evident for 2 (Resident #292, and #43) of 17 residents reviewed for advanced directives. The finding include: Advanced Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law related to provision of health care when the individual is not able to make their own decisions. 1) Resident #292 was a newly admitted resident of the facility. On 3/19/24, the Director of Nursing (DON) indicated that advanced directive documentation should be found in the resident's hard charts. Later that day, the Social Services Director (SSD) indicated that advanced directives are discussed with newly admitted residents within 48 hours upon admission, or the following Monday if the resident was admitted on a weekend. On the same day at 11:04 AM, Resident #292's medical records were reviewed and revealed no evidence of an advanced directive. On 3/22/24 at 11:10 AM, the SSD was interviewed about her process when the facility gets a new admission. She indicated that she was aware that she should document when she offers information about formulating advanced directives and if the resident had declined them. On 3/26/24 at 1:28 PM, a review of Resident 292's medical records failed to reveal documentation from the SSD that she had provided information about formulating an advanced directive. The social history assessment indicated that it was overdue and was highlighted in red letters that revealed a due date of 3/23/24. Later on 3/26/24 at 3 PM, a review of the facility's policy regarding advanced directives indicated that the social services department is responsible for follow up with the resident or representative for education and communication and that it is discussed and completed at the initial social history assessment. On 3/28/24 at 12:44 PM, the concern was discussed with the Director of Nursing that, after multiple discussions with the SSD about advanced directives, there was still no evidence that she provided information about formulating an advanced directive to a newly admitted resident. 2) On 3/26/24 at 1:19 PM, a review of Resident #43's medical record revealed the resident was readmitted to the facility in mid-March 2024 following an acute hospitalization Review of a Social History Assessment ([NAME]) dated 12/18/23 revealed a section Advanced Directives, which documented Resident #43 was his/her own health care proxy/agent, and the resident had decision making-capacity. In the [NAME], the question Does resident request advance care planning information? was marked no, indicating the resident did not want the information. This was followed by a space labeled additional comments, which was blank. There was no further documentation in the [NAME] to indicate Resident #43 had formulated an advanced directive, and continued review of the medical record failed to reveal documentation to indicate Resident #43 had been informed of his/her right to formulate an advance directive or the resident's potential response. On 3/27/24 at 4:01 PM, during an interview, Staff #12, Social Service Director (SSD) indicated that residents would be asked whether they had formulated an advanced directive at their 1st care plan meeting. The SSD stated that, if the resident had an advanced directive, the SSD would ask for a copy which would be placed in the resident's hard chart and copy would be uploaded into the resident's electronic medical record (EMR). The SSD stated that if a resident who did not have an advanced directive wanted to formulate one, she would give the resident the information needed to formulate an advanced directive. The SSD stated that she was told that social services could not assist a resident to fill out the advance directive forms. The SSD stated if the resident could not fill out the form, the resident would be referred to the next of kin for assistance, and if the family was unable to assist or the resident did not have a representative, then the SSD would contact an eldercare attorney to help assist the resident fill out the form. When asked if the discussions with a resident about formulating an advanced directives and the outcome of the discussion was documented in the resident's medical record, the SSD indicated that prior to the current survey, the discussions were not documented in the resident's medical record. The SSD indicated that since speaking with another surveyor who inquired about advanced directives and documentation, the SSD was documenting any discussions about advanced directives in the resident's medical record. Following the interview, the SSD was made aware of the above concerns. The Director of Nurses (DON) was made aware of the above concerns on 3/28/24 at 12:43 PM, and the DON offered no comment at that time.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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Based on observation and interviews, it was determined that the facility failed to provide information on the facility's grievance procedures and how to file complaints or grievances available to residents. This was evident during a resident council meeting conducted during the annual survey. The findings include: On 3/22/24 at 9:33 AM, the surveyor attended a resident council meeting with five residents, including the president and vice presidents of the resident council. During the meeting, the residents stated that they did not know if the facility had a procedure, including a specific form, for filing grievances generated from the Resident Council meetings or by individual residents. The residents also stated they did not know who the facility's grievance officer was to assist them. Residents #49 and #30 were interviewed on 3/22/24 at 10:26 AM. During the interview, they stated they were unaware of the facility's formal grievance filing process. They also expressed concern that, residents who could not leave their rooms, could file a grievance. On 3/22/24 at 10:59 AM, the Social Services Director (Staff #12), was interviewed. During the interview, she stated that a new grievance form was recently initiated for documenting residents' grievances or complaints, which were turned in to the grievance coordinator. When asked if the residents were aware of the grievance process, Staff #12 responded that she could not answer that question but would be reviewing the grievance process with residents at the next resident council meeting. On 3/22/24 at 11:30 AM, during an interview with the nursing home administrator, she stated that she recently took over the role of grievance coordinator and would educate the residents on the process for filing grievances or complaints in their next resident council meeting. For those residents who could not attend, they would do room-to-room education. On 3/25/24 at 10:30 AM, during an interview with the activity director (Staff #7) she indicated she was unaware of the facility's grievance process until the surveyor's intervention.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0624 (Tag F0624)

Could have caused harm · This affected 1 resident

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2) A medical record review completed for Resident #61 on 3/27/24 at 1:28 PM revealed that Resident #61 had severe cognitive impairment per a Minimum Data Set (MDS) assessment, dated 12/28/23. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. A continued review showed a nurse's note, dated 1/3/24, that documented a change in mental status and behaviors for Resident #61. The attending provider was notified and ordered to send the Resident to the emergency room for evaluation. However, the review failed to show that the facility staff documented in Resident #61's medical record if they prepared Resident #61 before the transfer and if the Resident understood where they were being transported to and why they were being transported. On 3/28/24 at 7:43 AM, during an interview with the Director of Nursing, she confirmed that there was no documentation regarding what the facility did to prepare Residents for transfer to the hospital. A subsequent interview was conducted with a Registered nurse (Staff #23), on 3/28/24 at 11:02 AM. During the interview, Staff #23 stated that she would only prepare the resident's paperwork to hand over to the emergency staff upon a resident's transfer to an acute facility. She also said that she would only make a resident whose cognitive status was intact aware of the transfer or discharge in preparation for the transfer. 2) On 3/28/24 at 12:21 PM, a medical record review was completed for Resident #43. The review showed an MDS assessment, dated 12/21/23, that recorded Resident #43 had intact cognitive status. Continued review revealed a Nursing facility to Hospital transfer form that recorded that Resident #43 was transferred to the hospital on 3/7/24 for altered mental status. However, the review failed to show what was done for Resident #43 in preparation for the transfer to the hospital and if Resident #43 understood why and where they were being transferred. On 3/28/24 at 11:10 AM, an interview conducted with Staff #23, a registered nurse, revealed that residents were only prepared for transfer to the hospital by making sure they were transferable to the stretcher and clean for transfer. Based on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was for 3 (Resident #7, #61 and #43) of 43 residents reviewed during the survey. The findings include: 1) Review of Resident #7's medical record on 3/26/24 at 9:19 AM revealed documentation that Resident #7 had been transferred to an acute care facility on 5/30/24 and 6/24/24 and failed to reveal evidence that the resident was oriented and prepared for the transfers in a manner s/he could understand and there was no documentation of the resident's understanding of the transfer. 1a) On 5/30/24 at 6:47 PM, in a SBAR (acronym for situation, background, assessment, recommendation), the nurse documented that Resident #7 complained of stabbing chest pain, the resident had a low pulse oxygen level, and bilateral rhonchi (low-pitched wheezes or coarse crackles in the lungs). The nurse further documented that the primary care provider (PCP) was notified and responded with an order to send the resident to the emergency room (ER) for evaluation. No documentation was found in the medical record to indicate Resident #7 had received an explanation of why he/she was going to the emergency room and the potential response of the resident's understanding. 1b) On 6/24/24 at 9:45 PM, in a SBAR note, the nurse documented that Resident #7 complained of swelling and right wrist pain following an unwitnessed fall in the facility, the physician was made aware, and ordered Resident #7 be sent to the ER for further evaluation. No documentation was found in the medical record to indicate Resident #7 had received an explanation of why he/she was going to the emergency room and the potential response of the resident's understanding. On 3/28/24 at 10:45 AM, during an interview, the Director of Nurses (DON) was made aware of the above findings and acknowledged the concerns at that time.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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2) A medical record review completed on 3/27/24 at 3:42 PM showed that Resident #61 was admitted to the facility in June 2022 and had severe cognitive impairment per a Minimum Data Set (MDS) assessment, dated 12/28/23. Further review revealed a nurse's note, dated 1/3/24, that documented that Resident #61 had a change in mental status and behaviors. The attending provider was notified and ordered to send Resident #61 to the emergency room for evaluation. Further review showed that Resident #61's representative was notified of the transfer via phone. However, the review failed to show that a copy of the bed hold policy was mailed to the Resident's representative. On 3/27/24 at 5:46 PM, Staff #6, a registered nurse (RN), was interviewed. During the interview, she revealed that she handed a packet of paperwork that included a copy of the bed hold policy to the Emergency medical team and not to the Resident during a transfer to the hospital. On 3/28/24 at 7:43 AM, during an interview with the director of nursing (DON), she confirmed that there was no evidence that the bed hold policy was mailed to Resident #61's representative. 2) On 3/28/24 at 11:48 AM, a medical record review completed for Resident #43 revealed a change in condition evaluation form, dated 3/7/24, that indicated Resident had a change in mental status. The provider was notified and ordered Resident #43 to be transferred to the emergency room for evaluation. A continued medical record review showed an acute transfer letter document, dated 3/7/24. The letter had three statements to be checked if completed. The checked statements were Told verbally due to emergency and Resident not cognitively able to sign and responsible party notified. However, further review failed to reveal evidence that a copy of the facility's bed hold policy was mailed to Resident #43's representative. On 3/28/24 at 12:43 PM, an interview with DON revealed that the Acute Transfer letter reviewed earlier was the bed hold policy. She stated that it was sent with the packet of paperwork given to the emergency staff upon a resident's transfer to the hospital. However, she confirmed that the facility did not send a copy to the Resident's representative in writing. Based on medical record review and staff interview, it was determined the facility failed to ensure residents were made aware of a facility's bed-hold and reserve bed payment policy when transferred to a hospital. This was evident for 3 (Resident #7,#61 and #43) of 43 residents reviewed during the annual survey. The findings include: 1) On 3/26/24 at 9:19 AM, a review of Resident #7's electronic medical record (EMR) revealed Resident #7 was transferred to an acute care facility on 6/24/23 with no documentation found to indicate the resident and/or the resident's representative was given written notice of the facility's bed hold policy at the time of the resident's transfer, or in cases of emergency transfer, within 24 hours. On 6/24/23 at 9:45 PM, in a SBAR note, the nurse documented that Resident #7 complained of swelling and right wrist pain following an unwitnessed fall in the facility, the physician was made aware, and ordered the resident be sent to the ER for further evaluation. On 6/24/23 at 9:45 PM, in a Transfer Form, the nurse documented Resident #7 was transferred to the hospital. The form included the statement Transfer Checklist: Print the following documents and include with this Transfer Form in the order listed. Send entire packet with the patient to the hospital. This was followed by a document checklist which included bed hold, that was not checked on the form, indicating the resident was not provided a written notice of the facility's bed hold policy upon transfer to the hospital. Continued review of Resident #7's EMR and paper medical record failed to reveal evidence the resident and/or the resident's representative was given written notice of the facility's bed hold policy at the time of the resident's transfer, or in cases of emergency transfer, within 24 hours. On 3/28/24 at 10:45 AM, during an interview, the Director of Nurses (DON) stated that upon a resident's transfer to the hospital, the resident would be provided with a copy of the facility's bed hold policy, however, the resident representative was not provided with written bed-hold notice at the time of the resident's transfer. At that time, the DON was made aware of the concerns that no documentation evidence was found in the medical record that the resident and/or the resident's representative was given written notice of the facility's bed hold policy at the time of the resident's transfer, or in cases of emergency transfer, within 24 hours.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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Based on record review and staff interviews, it was determined that the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days following a significant decline in a resident's condition. This was evident for 1 (#88) of 3 residents reviewed for closed records. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. The nursing home should complete a significant change in status MDS assessment within 14 days when there's a major decline or improvement in a resident's status. A medical record review completed on 3/20/24 at 1:57 PM for Resident #88 showed that they were admitted to the facility in February 2023, with diagnoses that included Dementia and Diabetes. Further review revealed that Resident #88 was seen by the attending provider on 12/4/23 for increased weakness, poor appetite, and limited responses. A continued review on 3/20/24 at 3:45 PM showed a dietary progress note, dated 12/4/23, that documented Resident #88's significant weight loss for one, three, and six months. The note also stated that Resident #88 had a significant decline in health and that poor health outlook was anticipated. The review also revealed a change in condition evaluation form dated 12/4/23, documenting that Resident #88 had a functional decline. On 3/20/24 at 4:07 PM, an interview was conducted with Staff #12, director of social services. During the interview, she stated that the interdisciplinary team had a care plan meeting with Resident #88's daughter in December 2023 to discuss the Resident's overall decline and general weakness. An interview was done with Staff #17, an MDS coordinator, on 3/21/24 at 10:42 AM. During the interview, she confirmed that a Significant Change in Status MDS assessment should have been completed for Resident #88.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview, it was determined that the facility failed to accommodate a resident's schedule to ensure the resident was able to participate in the interdisciplinary care plan meeting. This was found to be evident for 1 (Resident #76) out of 43 residents reviewed during the survey. The findings include: 1) Review of Resident #76's medical record revealed the resident had resided at the facility for more than a year. During an interview on 3/19/24 at 2:44 PM, the resident's representative expressed a concern that, due to a scheduling conflict, the resident was unable to actually participate in the care plan meeting held earlier that day. The meeting was scheduled for 11:45 AM and transportation for an outside appointment was scheduled for 12 noon. The representative reported that transportation showed up and was going to leave without the resident. The resident did sign in to the meeting, but did not participate because s/he had to leave. Each resident has the right to participate in choosing treatment options and must be given the opportunity to participate in the development, review and revision of his/her care plan. Facility staff have a responsibility to assist residents to engage in the care planning process, e.g., helping residents and resident representatives, if applicable, understand the assessment and care planning process; holding care planning meetings at the time of day when the resident is functioning best; planning enough time for information exchange and decision making. On 3/27/24, review of the medical record revealed a Minimum Data Set (MDS) assessment,with an Assessment Reference Date of 3/18/24 which revealed the resident had ]adequate hearing and speech for communication and a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident was cognitively intact. Further review of the medical record revealed a Care Conference Note, dated 3/19/24 at 11:40 AM that indicates the IDT [interdisciplinary team] met with the resident and the representative. Review of the corresponding sign in sheet revealed the IDT consisted of the Social Service Director (Staff #12) the Business Office Manager (Staff #27) and the unit nurse manager (Staff #10). No documentation was found to indicate the IDT included representatives from dietary, activities or a geriatric nursing assistant. Further review of the MDS with an ARD of 3/18/24 revealed that multiple sections of the assessment were not completed until after the care plan meeting was held on 3/19/24. The sections completed by the Registered Dietitian were not completed until 3/22/24, and some sections completed by the Social Service Director were not signed as completed until 3/25/24. During an interview on 3/28/24 at 9:00 AM, when asked about his/her recent care plan meeting, the resident reported s/he did not participate in the care plan meeting because s/he had to leave for an appointment. On 3/28/24 12:02 PM, surveyor reviewed the concern with the Director of Nursing (DON) that accommodations were not made to ensure the resident was able to participate in the care plan meeting. The DON indicated accommodations could have been made. At 12:25 PM on 3/28/24, the surveyor also reviewed the concern that the care plan meeting was scheduled prior to the completion of the MDS assessment.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on observations, interviews, and records review, it was determined that the facility failed to provide necessary services to maintain good personal hygiene to residents who are dependent on staff and/or who are requiring assistance from staff with activities of daily living (ADL). This was evident for 2 (Resident #15 and #75) of 2 residents reviewed for ADL's. The findings include: 1) Resident #15 had been residing in the facility since 2021. On 3/18/24 at 9:48 AM, the resident reported that s/he had a horrible time last night since s/he had to be given a suppository for not moving his/her bowels for a long time. The resident indicated that, after being cleaned, s/he was still going and stated, I laid here for like 3 hours with dirty stuff under me, poop and pee. On 3/21/24 at 3:18 PM, a review of Resident #15's medication administration record (MAR) confirmed the administration of an as needed suppository on 3/17/24 at 2:48 PM for bowel health. Further review of the MAR revealed that the resident was routinely taking Senna Plus oral tablet, twice a day and Colace oral capsule every evening. On 3/25/24 at 12:10 PM, Resident #15's care plan was reviewed and indicated that the resident was totally dependent on staff for toileting and personal hygiene where the helper is responsible to cleanse the resident after passing urine and stool. Soon after at 12:20 PM, Resident #15 was again interviewed and stated, last night after I was changed, I got wet again and I asked them to change me because I felt that my fitted sheet was soaking, and they said they couldn't change me yet because they just did it. I understand they need more help, but I'm just getting frustrated! A quick review of the resident's medical records revealed a task for Bladder continence and was documented as Resident Not Available on 3/25/24 at 6:15 AM. The unit nurse manager (UM Staff #32) was interviewed on 3/25/24 at 12:24 PM regarding the Task documentation for bladder continence. Staff #32 reported that the 3/25/24 documentation at 6:15 AM was the nursing aide's documentation for the entire night (11 PM - 7 AM) shift. She reported that staff should not be documenting under that tab (Resident Not Available) and stated, there really is no reason for them (Nursing Aides) to document that unless the resident was in the hospital. I did not even realize that they have been doing that. Staff #32 confirmed that Resident #15 was not transferred out. At that time, a review of the last 30 days of documentation under the bladder continence task with Staff #32, revealed that a total of 19 shifts were documented as Resident Not Available. The review also revealed 3 days of having 2 consecutive shifts on 2/25/24 (from evening to night shift), 3/3/24 (from day to evening shift), and 3/16/24 (from day to evening shift) documented the same way. Staff #32 was asked, does that mean Resident #32 did not void for 16 hours? Staff #32 shook her head and stated, I doubt that. She then indicated that she was printing the task documentation to provide the information for the nurse educator so that all nursing staff can be retrained. On 3/25/24 at 1:46 PM, the concern was discussed with the Director of Nursing (DON), that nursing aides have documented resident not available on 2/25/24 (evening and night shift), 2/28/24 (evening shift), 3/1/24 (day shift), 3/3/24 (day and evening shift), 3/4/24 (evening shift), 3/7/24 (evening shift), 3/8/24 (evening shift), 3/10/24 (evening shift), 3/16/24 (day and evening shift), 3/17/24 (day and night shift), 3/19/24 (night shift), 3/21/24 (evening shift), 3/22/24 (evening shift), and 3/24/24 (nigh shift). The DON reported that she had already started educating staff about it, and said that we try to educate staff right away when concerns are brought to my attention. She indicated that most of the training would be geared to the Nursing Aide (Staff #36) that had completed the erroneous documentation, but would be educating all nursing staff regarding the concern. The DON also confirmed that Resident #15 was in the facility for the dates documented as Resident Not Available. 2) Resident #75 was admitted to the facility in late 2022. A quick review of Resident #75's medical record indicated that the resident had severe cognitive impairment. On 3/17/24 at 2:40 PM, the resident was observed in his/her room. Resident #75 appeared unkempt, clothing was visibly soiled, and a strong odor of urine was observed. On 3/20/24 at 10:39 AM, the resident was in his/her room eating breakfast, a strong odor of urine was again observed. On 3/21/24 at 1:31 PM, Resident #75's most current minimum data set (MDS) assessment, with a reference date of 1/28/24, was reviewed and indicated that no moods or behaviors were exhibited by the resident and the MDS had documentation Need for assistance with personal care. Minimum Data Set- The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. The interview with Staff #32 on 3/25/24 at 12:24 PM indicated that nursing aides documented once per shift under the bowel and bladder continence task. Later that day at 1:23 PM, a review of Resident #75's medical records revealed the last 30 days of the bladder continence task where the nursing aides had documented Resident Not Available for 22 shifts, of which 3 days had 2 consecutive shifts and 1 day having all 3 shifts documented as such. Further review of the resident's medical records did not indicate that the resident was sent out or was out of the facility. On 3/25/24 at 1:46 PM, the concern was discussed with the Director of Nursing (DON), that nursing aides have documented resident not available on 2/25/24(evening and night shift), 2/29/24 (day shift), 3/1/24 (day shift), 3/3/24 (day and evening shift), 3/4/24 (evening shift), 3/5/24 (evening shift), 3/7/24 (evening shift), 3/8/24 (evening shift), 3/10/24 (evening shift), 3/13/24 (day and evening shift), 3/16/24 (evening shift), 3/17/24 (day, evening, and night shift), 3/19/24 (night shift), 3/21/24 (evening shift), and 3/24/24 (night shift). The DON reported that she had already started educating staff about it, and said that we try to educate staff right away when concerns were brought to their attention. She indicated that most of the training would be geared to the Nursing Aide (Staff #36) that had completed the erroneous documentation, but would be educating all nursing staff regarding the concernThe DON also confirmed that Resident #75 was in the facility for the dates documented as Resident Not Available.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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3) On 3/20/24 at 10:53 AM, review of records revealed that Resident # 17 was a long-term resident with a medical history that included diabetes. On 3/20/24 at 12:40 PM, review of records revealed a physician's order, with a start date of 11/11/23, to call the physician if Resident #17's blood sugar fell below 70 or went above 300. On 3/20/24 at 12:35 PM, the medication administration record (MAR) was reviewed. Review of the MAR revealed that Resident #17 had the following documented blood sugar values. On 3/11/24 during the day, Resident #17s blood sugar value was documented as 312 On 3/15/24 during the day, Resident #17s blood sugar value was documented as 335 On 3/20/24 during the day, Resident #17s blood sugar value was documented as 309 On 3/20/24, review of progress notes from 3/10/24 to 3/22/24 failed to reveal documentation that the physician was notified when the residents had blood sugars over 300. On 3/20/24 at 1:46 PM, during an interview, the Director of Nursing reported that she was unable to find documentation that the physician was notified between 3/10/24 and 3/20/24 regarding the blood sugar being out of the physician set parameters. Based on medical record review, interviews and observations, it was determined that the facility failed to ensure the administration of regularly scheduled medications; failed to ensure that recommendations made by the registered dietitian were communicated to the physician; and failed to ensure that staff followed a physician order to notify the physician when a lab value was outside of an ordered parameter. This was found to be evident for 3 (Resident #56, # 29, and #17) out of 43 residents reviewed during the survey. The findings include: 1) On 3/18/24, review of Resident #56's medical record revealed the resident had been receiving Hospice services since September 2023. Hospice is a program that gives special care to people who are near the end of life. The resident had current orders, in effect since 2/29/24, for Venlafaxine to be given three times a day for depression; for Risperdal to be administered two times a day for psychosis and Lorazepam (Ativan) to be given every 4 hours for terminal agitation. Lorazepam, which is frequently prescribed for residents on hospice, is a sedative that reduces anxiety and agitation. Review of the paper chart revealed a note written by the hospice nurse, dated 3/12/24 at 10:15 AM, that revealed the unit nurse manager (Staff #9) reported the resident ran out of risperdal yesterday and has been experiencing agitation, the hospice nurse observed the resident yelling out, crying and pushing back against aide when aide trying to turn pt and the resident was crying throughout the assessment conducted by the hospice nurse. On 3/18/24 at 11:30 AM, surveyor, who was in the hallway, could hear the resident actively calling out and yelling at someone. Observation revealed there was no one in the room with the resident at the time. The nurse (Staff #23) acknowledged the resident's behavior and stated: I do need to get [his/her] ativan [medication for agitation]. At 11:36 AM, the nurse reported she just gave the ativan. At 11:55 AM, surveyor observed the resident to be calmer but continued to verbalize to someone not present in the room. On 3/26/24 at 8:59 AM, surveyor observed the resident crying out and yelling but no one was in the room with the resident at the time. Nurse then arrived at the room with the medication cart. a) On 3/26/24, review of the Medication Administration Record revealed the Venlafaxine, which the resident has been receiving since September 2023, was not administered when due on March 10th or 11, 2023. Review of the corresponding progress notes for March 10th revealed documentation that the medication was on order but no documentation was found to indicate the physician was made aware on 3/10/24. Review of the nurse's note, dated 3/11/24 at 8:24 AM, revealed the primary care provider was notified and the pharmacy was contacted. On 3/26/24 at 9:21 AM, the unit nurse manager (Staff #9) was interviewed in regard to the process for re-ordering regularly scheduled medications. Staff #9 reported that, when a supply was down to about 5 pills, the med tech or the nurse can click on it (in the electronic health record) to order. She went on to reoprt that, if the medications were down to one pill, she would call the pharmacy for next delivery. She confirmed there was an Omnicell which contains an interim supply of some medications. Review of the Omnicell list failed to reveal the availablity of the Venlafaxine, but does include Risperidone (Risperdal) and Lorazepam. On 3/26/24 at 4:24 PM, the Director of Nursing (DON) provided an order audit report that indicated the Venlafaxine was ordered on 3/11/24. The DON confirmed the medication was ordered on 3/11/24. Surveyor then reviewed the concern that the resident did not receive the antidepressant medication on 3/10/24, but the provider was not notified and the medication was not re-ordered prior to 3/11/24. b) Further review of the MAR on 3/26/24 revealed that nursing staff documented that the Risperdal was not administered when due on the evenings of 3/23 and 3/24/24. Review of the corresponding progress note, written by Med Tech (Staff #31) and dated 3/23/24 at 7:39 PM, revealed out of stock. Review of the order audit report revealed the Risperdal was reordered on 3/20/24. Review of the Omnicell list of available medications revealed six 0.25 mg Risperidone tablets are usually kept in the supply. The resident's current order was for 0.5 mg two times a day, indicating two of the Risperidone tablets would need to be removed to provide one dose. On 3/26/24, review of the Omnicell transaction report for Resident #56 revealed staff began to obtain the Risperidone from the Omnicell starting with one tablet (half dose) for the evening dose on 3/20/24. Two tablets (full dose) was obtained for the morning dose on 3/21 but no documentation was found to indicate the medication was obtained for the 3/21 evening dose. Despite no documentation to indicate the medication was delivered, or obtained from the Omnicell, the staff documented that the evening dose was administered to the resident on 3/21. The Omnicell transaction report revealed the removal of two tablets for the morning dose on 3/22 and one tablet for the evening dose (this would account for the sixth tablet). There is a nursing progress note, dated 3/22/24 at 4:01 PM, which documented that 0.25mg was pulled from back up and a primary care provider was notified. No additional doses of medication were removed from the Omnicell for Resident #56 after 3/22/24. On 3/26/24 at 10:29 AM, observation of the resident's current supply of risperidone 0.5 mg tablets revealed that two of the 30 tablets had been removed and there was a hand written notation of 3/25/24 on the supply card. On 3/26/24 at 5:05 PM, the unit nurse manager (Staff #9) reported the risperidone 0.5 mg tablets were received and opened on 3/25/24. Surveyor reviewed the concern that the resident went several days without his/her antipsychotic medication. Further reveiw of the MAR revealed that staff had documented the administration of the risperidone when due on the mornings of 3/23 and 3/24/24. No documentation was provided to indicate the antipsychotic medication was available on these two dates. On 3/26/24 at 5:25 PM, the unit nurse manager (Staff #9) confirmed that they were out of the risperidone as of the evening dose on 3/22/24 when the half dose was pulled and the resident did not recieve the medication on 3/23 or 3/24. Staff #9 also reported having just refilled the Omnicell with 6 tablets. c) Further review of the March MAR revealed that staff documented the administration of the lorazepam every four hours as ordered. This documentation indicated the resident was receiving six doses of the lorazepam per day. Review of the Controlled Drug Administration Record for the resident's lorazepam failed to reveal the removal of six doses on multiple dates in March. On March 18, a fourth dose was removed at 1:00 PM and the current supply was noted to be 0. Review of the Omnicell transaction report for Resident #56 failed to reveal documentation to indicate that the interim supply of lorazepam was accessed during the month of March 2024. Review of the MAR revealed that staff documented the administration of the lorazepam on March 18th when due at 5:00 PM and 9:00 PM. No documentation was provided to indicate where these two doses were obtained. The next Controlled Drug Administration Record revealed that five doses were removed on March 19, the times of removal were not clearly legible. The MAR documented the administration of six doses on March 19. On March 20th, four doses were removed from the supply. No documentation was found to indicate that doses were removed when due at 1:00 AM or 5:00 AM. Review of the MAR revealed staff documented the adminstration of these doses. No documentation was provided to indicate where these two doses were obtained. On March 22, five doses were removed from the supply. No documentation was found to indicate that a dose was removed when due at 9:00 PM. Review of the MAR revealed that staff documented the adminstration of this dose. No documentation was provided to indicate where this dose was obtained. On March 23, four doses were removed from the supply. No documentation was found to indicate that doses were removed when due at 1:00 AM or 5:00 AM. Review of the MAR revealed that staff documented the adminstration of these doses. No documentation was provided to indicate where these two doses were obtained. On 3/26/24 at 10:36 AM, surveyor reviewed with the Director of Nursing (DON) the concern that staff were documenting the administration of the ativan 6 times a day, but there were multiple days of the month when the drug control sheet failed to reveal that 6 doses were removed. 2) Review of Resident #29's medical record revealed an admission in February 2024 for the completion of a course of intravenous antibiotics for an infection. Review of the Dietary - Nutritional Assessment, with an effective date of 2/24/24, revealed the Registered Dietitian (RD) recommended a probiotic regimen for 14 days. Probiotics given during antibiotic administration can help prevent antibiotic associated diarrhea. On 3/27/24, further review of the medical record failed to reveal documentation to indicate this recommendation was implemented or communicated to the attending physician. On 3/27/24 at 12:44 PM, the Director of Nursing (DON) reported that the RD will put in his own orders or will send them to the facility via email if he cannot put them in the system himself. The DON then provided a RD Consult Report and stated that, if the recommendation is not highlighted in yellow, then it is the unit managers responsibility to share with the physician. Review of the report revealed the recommendation for the probiotics for Resident #29 was included, but was not highlighted in yellow. On 3/27/24 at 1:40 PM, the DON confirmed that she could find no documentation to indicate the primary care providers were made aware of the recommendation for the probiotic.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview and observation, it was determined that the facility failed to identify and establish treatment orders for a newly acquired pressure ulcer and failed to ensure that treatment orders were updated as indicated by the wound care provider. This was found to be evident for one (Resident #24) out of two residents reviewed for pressure ulcers. The findings include: Review of Resident #24's medical record revealed the resident was admitted in 2023. The resident had functional limitations in range of motion for upper and lower extremities (arms and legs) on both sides and was dependent on staff for assistance with toileting, bathing, bed mobility and transfers from bed to a chair. A care plan addressing risk for alteration in skin integrity was established shortly after admission. On 7/31/23, a pressure ulcer was identified on the resident's left buttocks and treatment orders were initiated. The resident had several hospitalizations in the fall of 2023. Pressure ulcers are classified according to the level of skin damage and tissue loss. These include Stage 1 in which the skin is still intact with non-blanchable redness; Stage 2 involves partial thickness loss of skin and may present as a shallow open area or as an unopened blister; Stage 3 involves full thickness tissue loss in which subcutaneous fat may be visible; and Stage 4 involves full thickness loss with exposed bone, tendon or muscle. A wound is classified as Unstageable if there is full thickness loss but the base of the ulcer is not visible due to being covered with slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black). Review of the 12/12/23 wound nurse practitioner's (Staff #39) note revealed the resident had two stage 3 pressure ulcers, one on the left buttock and another on the left gluteal fold (area where the buttocks meets the leg). The resident was discharged to the hospital in December 2023 and was re-admitted on [DATE]. Review of the 12/20/23 nursing skin assessments (Skin Grid Pressure) revealed the presence of one stage 2 pressure ulcer on the left gluteal fold and three stage 3 pressure ulcers. Two of the stage 3 pressure ulcers were documented as being on the left gluteal fold (with different measurements) and one on the coccyx. The coccyx, or tailbone, is located at the base of the spine. Review of the Treatment Administration Record revealed there was one order, with a start date of 12/20/23, for wound care for four sites. This one order stated: Cleanse the coccyx, left gluteal fold x 2 and left buttock with Dakins solution apply nickel thick Santyl on calcium alginate and pack tunnels, cover with ABD pads daily every night shift for wound care. This order was in effect until it was discontinued on 1/3/24. Further review of the medical record revealed the wound NP assessed the resident on 12/26/23 and identified four wounds. Review of the notes from this assessment revealed: - An unstageable wound on the sacrum (sacrum is just above the coccyx) with a treatment of cleaning with Dakins and dressing with santyl soaked calcium alginate two times a day. - A stage 3 wound on the left buttocks with a treatment of cleaning with Dakins and dressing with Dakins moistened fluffed gauze two times a day. - A stage 3 wound on the left gluteal fold with a treatment of cleaning with Dakins and dressing with Dakins moistened fluffed gauze two times a day and as needed. -An unstageable wound on the right trochanter (hipbone) with a treatment of cleaning with Dakins and dressing with santyl soaked calcium alginate daily. The NP's documentation indicated all four of these wounds were present on admission and that the sacral and trochanter (hipbone) wounds had an acquired date of 12/20/23. Further review of the medical record failed to reveal documentation to indicate the wound on the right hipbone was identified prior to the 12/26/24 assessment. Review of the Treatment Administration Record (TAR) failed to reveal documentation that the nurses were completing a dressing change for the right hip wound until January 2024. The TAR also failed to reveal documentation to indicate any of the treatments documented in the 12/26/23 NP note were implemented in December. Surveyor discussed with the DON, on 3/25/24 at 4:41 PM, that no nursing assessment documentation was found to indicate the wound on the trochanter was present at the time of admission on [DATE]. A little while later, the DON reported she had reviewed the hospital record from the December hospitalization and was not able to find documentation regarding a wound to the right trochanter. Further review of the wound NP notes indicated the right trochanter wound was healed as of 2/28/24. On 3/21/24, review of the current orders revealed orders for the sacral wound to be changed daily on night shift and orders for two other wounds to be changed twice a day. On 3/26/24 at 2:11 PM, surveyor observed the unit nurse manager (Staff #9) complete the resident's dressing change. Nurse (Staff #6) was also present during the dressing change. Surveyor observed the removal of dressings, cleaning, packing and application of ABD pads for the left buttocks and left gluteal fold wounds. The unit manager also applied Greers [NAME] to the areas surrounding the wounds and the buttocks. After the dressing change observation, further review of the medical record revealed the wound NP had seen the resident on 3/20/24. Review of this note revealed the wound on the sacrum continued to be classified as unstageable with a length of 2 cm by 2 cm with a depth of 0.5 cm; the treatment was documented as cleanse with wound cleanser and dress with Dakins moistened fluffed gauze two times a day. Further review of NP notes revealed that, on 3/6/24, the treatment for the sacrum wound was documented as daily, and the 3/15/24 note documented the treatment frequency as two times a day. On 3/26/24 at 2:51 PM, the unit nurse manager (Staff #9) was interviewed in regard to the process for updating wound treatment orders. Staff #9 reported that the wound NP is required to tell them verbally of changes and that they actually update the orders while conducting rounds. She confirmed that the dressing changes observed were only for the left gluteal fold and the left buttocks, stating that the sacral wound was ordered for daily. Surveyor then reviewed the concern that the most recent wound NP note indicated that the sacral wound is to be changed two times a day. On 3/26/24 at 4:35 PM, surveyor reviewed the observations of the dressing change with the DON. The DON reported at that time that she had been made aware of the concern regarding the failure to update the order for the sacral wound. On 3/27/24 at 1:46 PM, the wound NP (Staff #39) was interviewed. In regard to changes in the wound orders, the NP reported that she informed the accompanying nurse while on rounds. She also reported that she completed her documentation while still in the facility and also sends a wound log report to the Director of Nursing and the unit nurse managers. A review of the spreadsheet that the NP indicated was sent to facility revealed a notation, dated 3/20/24, for BID [two times a day] for the sacral wound treatment. Surveyor reviewed the concern that the treatment change was not updated in the orders.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to ensure that occupational therapy recommendations for a restorative nursing plan were discussed with the interdisciplanary team or incorporated into the resident's care plan. This was found to be evident for one (Resident #24) out of three residents reviewed for positioning and mobility. The findings include: Review of Resident #24's medical record revealed that the resident was admitted in 2023. The resident had functional limitations in range of motion for upper and lower extremities (arms and legs) on both sides and was dependent on staff for assistance with toileting, bathing, bed mobility and transfers from bed to chair. Review of the 2/16/24 Minimum Data Set assessment revealed that the resident had not recently received therapy and currently was not receiving restorative nursing program services. On 3/22/24, review of the Occupational Therapy Discharge summary, dated [DATE], revealed the discharge recommendations included a RNP [restorative nursing program] for BUE [bilateral upper extremity] exercises. On 3/22/24 at 1:30 PM, the Rehab Director (Staff #41) was interviewed in regard to the process of implementing restorative nursing after discharge from therapy. Staff #41 reported they write up a restorative nursing form and take it to the restorative meeting. When asked about Resident #24, the Rehab Director reported that he remembered the resident being on restorative and provided a copy of Therapy Referral to Restorative form for the resident. Review of the Therapy Referral to Restorative form revealed a program for range of motion with a goal of maintaining bilateral upper extremity strength and indicated verbal cueing was needed. The plan included a set of 4 exercises to be performed for 3 sets of 10 reps each one time a day for 6 days a week. There is a notation that all the exercises were to be performed with a 5 lb wrist weight. The section of the form for the Restorative Aides to sign off and provide date of instruction was noted to be blank. Surveyor confirmed with the Rehab Director that this plan would require staff to verbally cue the resident to perform these exercises. On 3/22/24 at 1:42 PM, the restorative coordinator nurse (Staff #17) reported she has been in this role for about one year. She reported that a restorative meeting is held once a week and indicated they keep 22 residents in the restorative program. Staff #17 went on to report that Resident #24 was not on the current restorative roster and had not been on the roster. Staff #17 was not aware of the recommendation from therapy, surveyor informed her it would of been in June 2023. Staff #17 proceeded to check a notebook and reported the resident was not discussed, nor was mentioned at meetings in June or July 2023. Review of the resident's care plans failed to reveal documentation to indicate that verbal cueing for these active range of motion exercises were implemented. On 3/28/24 at 5:10 PM, surveyor reviewed the concern with the DON and the NHA regarding the failure to ensure that OT recommendation for restorative were addressed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation and interview with facility staff, it was determined that the facility failed to ensure that residents were free from accident hazards when smoking, by failing to follow a resident's care plan to implement adaptive equipment when the resident smoked. This was evident for 1 (Resident #7) of 8 residents reviewed for accidents. The findings include: On 3/26/24 at 8:59 AM, a review of Resident #7's medical record revealed a Smoking Assessment, with an effective date of 1/18/24 at 9:27 AM, that documented Resident #7 smoked cigarettes and assessed their ability to smoke safely. The assessment documented that Resident #7 had a visual deficit, a dexterity problem, the resident could not light his/her own cigarette and s/he could not dispose of a cigarette appropriately. The safety assessment identified that, when smoking, Resident #7 needed supervision, and needed to wear a smoking apron (protects clothing and skin from burns and hot ashes). Review of Resident #7's care plans revealed a care plan, [Resident #7] utilizes nicotine products r/t (related to) lifestyle; supervision and smoking apron, due to visual defect, initiated on 2/12/2024, that had the goal, [Resident #7] will be able to articulate the risks of continued cigarette use through the next review, with the interventions, 1) complete smoking evaluation, 2) educate resident / resident representative to designated smoking areas, and long-term side effects of extended nicotine, 3) educate resident / resident representative to facility smoking policy, obtain resident signature, and 4) Resident needs smoking adaptive equipment of: apron, holder, supervision On 3/26/24 at 1:45 PM, during a facility scheduled smoke break, with facility staff in attendance, Resident #7 was observed to be smoking a lit cigarette that s/he was holding in his/her right hand, and Resident #7 was not wearing a smoking apron while s/he smoked. The facility failed to ensure that Resident #7 was adequately supervised when smoking by failing to ensure the resident wore a smoking apron that was identified as needed for safety in the resident's smoking assessment. In addition, the facility staff failed to follow the care plan by failing to implement the care plan intervention which identified that the resident needed the smoking adaptive equipment of an apron. On 3/26/24 at 5:22 PM, the Director of Nurses (DON) was made aware of the surveyor's observation and the above findings and acknowledged the concern. At that time, the DON indicated the smoking assessment was accurate, and stated that Resident #7 should wear a protective apron when s/he smoked.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview, it was determined the facility failed to provide the necessary care and services for a resident with suprapubic catheter by failing to ensure a follow-up urology consult was scheduled as recommended after a hospitalization. This was evident for 1 (Resident #80) of 3 residents reviewed for urinary catheter. The finding includes: An indwelling urinary catheter is a tube inserted into the bladder and left in the bladder to drain urine. Often known as a Foley catheter, the catheter is held in the bladder by a water-filled balloon, which prevents it from falling out and allows urine to flow through it and into a drainage bag. These catheters are most commonly indwelling urethral catheters (IUC) inserted into the bladder through the urethra (the canal that carries the urine out of the bladder). A suprapubic (SP) is an indwelling catheter that was inserted into the bladder through a small surgical incision in the abdomen. 1) On 3/26/24 at 11:29 AM, a review of the medical record revealed that when Resident #80 was initially admitted to the facility in June 2023, following an acute hospital stay, they had an indwelling urethral catheter. Resident #80 returned to the facility in November 2023, following an acute hospital stay which included the insertion of a suprapubic catheter, On 10/31/23 at 6:54 PM, in a nurses note, the nurse documented Resident #80 complained of severe lower abdominal pain, that the resident had blood in his/her urine and foley catheter tubing, and 911 was called. On 10/31/23 at 8:16 PM, in a nurse's note, the nurse documented that Resident #80 was being admitted to the hospital for urinary retention, UTI (urinary tract infection), hematuria (blood in urine) and failure to thrive as an adult. On 11/8/23, in a hospital discharge summary, the physician documented that Resident #80 was admitted to the hospital due to hematuria and the resident's Foley was not draining properly. The physician wrote that Resident #80 had a recent neurological disease diagnosis and a neurogenic bladder (bladder dysfunction caused by nervous system conditions) requiring a chronic Foley catheter for urine retention issues. The physician documented that the urology team was consulted and due to the urological findings, and that Resident #80 had a suprapubic catheter procedure performed in the ER, Resident #80 was to follow-up with a [physician's name] and [urology practice] urology team for the first suprapubic catheter exchange within 4 weeks from date of insertion, and to continue with routine Foley care at the nursing home. The physician further documented that Resident #80 had been admitted to the intensive care unit for septic shock (widespread infection), the resident was now clinically stable to return back to the facility and recommended Resident #80 follow-up with the [urology practice] urology team within 1 month for the first suprapubic catheter exchange. The hospital discharge instructions included the statement, Resident #80 has a newly placed suprapubic catheter and will need follow-up with the [urology practice] urology team for its first exchange within 4 weeks from date of insertion. Review of Resident #80's medical record revealed on 11/10/23, in an encounter note, Staff #25 documented Resident #80 had a diagnosis of neurogenic bladder (loss of bladder control caused by nervous system condition) with a new SP catheter placement on 10/31/23, and the resident needed to follow-up with urology in 3 to 4 weeks for the initial catheter change. Staff #25 also documented plan for the resident included follow-up with [name of urology practice] within 1 month for initial suprapubic exchange. Continued review of Resident #80's medical record failed to reveal evidence that a follow-up Urology appointment had been scheduled within 4 weeks of Resident #80's suprapubic catheter insertion for the catheter's first exchange as recommended in Resident #80's discharge summary. On 2/28/24, in an encounter note, Staff #26, CRNP (certified registered nurse practitioner) documented that Resident #80 had a suprapubic catheter placement on 10/31/23, and for Resident #80 to follow-up with urology for the catheter. On 2/28/24 at 4:07 PM, in a nurse's note, Staff #5, RN documented that Resident #80's Foley was occluded (blocked), the Foley was changed, the UM (unit manager) was aware and the UM was following up with urology. Also, on 2/28/24, at 4:08 PM, in a SBAR (acronym situation, background, assessment, response) (communication tool), Staff #10, RN, 1st floor UM documented that Resident #80 had two Foley changes in the last week, that the resident's SP catheter continued to occlude, and the patient was referred to urology. Continued review of the medical record failed to reveal documentation to indicate that Resident #80 had seen a urologist, and there was no documentation in the medical record to indicate the resident was scheduled to see a urologist for follow-up of the resident's suprapubic catheter. On 3/28/24 at 3:03 PM, during an interview, the appointment scheduler, Staff #16 indicated that she recently became aware of the need to schedule Resident #80 for a urology appointment. Staff #16 stated that the UM needed to fill out a packet sent from the urologist's office with Resident #80's information and once it was completed, Staff #16 would schedule the urology appointment. On 3/28/24 at 3:11 PM, during an interview, when asked to speak to the unit manager, Staff #5, RN, stated the UM was not working that day. Staff #5 stated that s/he was familiar with Resident #80, and that s/he thought the resident had already saw a urologist. Staff #5 stated s/he was not aware of a packet that needed to be completed prior scheduling the resident's urology appointment. The above concerns were discussed with the Director of Nurses (DON) and the Nursing Home Administrator (NHA) on 3/28/24 at 5:35 PM, and the DON and NHA responded that they understood the concerns. The DON stated that, when the facility contacted the urology practice to schedule an appointment for Resident #80, the urology office sent the resident a new urology patient packet that needed to be filled out and sent back to their office prior to scheduling the appointment and the facility had just received the packet. At that time, the DON offered no explanation as to why the facility failed to schedule Resident #80 for follow-up urology appointment for the resident's initial SP catheter change within 4 weeks of his/her suprapubic placement as recommended in the resident's hospital discharge summary.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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Based on records review and interviews, it was determined that the facility to ensure pain management was provided to a resident requiring this service. This was evident for 1 (Resident #15) of 7 residents reviewed for pain management. The findings include: Resident #15 had been residing in the facility since 2021. On 3/18/24 at 10:35 AM, the resident was interviewed and indicated that s/he was in constant pain at a level of 9 to 10 where 10 being the highest. The resident also reported that pain medications help, but must be taken routinely. The resident stated, I have to ask for them because sometimes they are late. On 3/21/24 at 3:05 PM, Resident #15's medical records were reviewed and revealed orders for pain management with different classes of medication to treat the resident's pain. Later at 3:18 PM, the resident's medication administration record (MAR) was reviewed for the month of March and revealed the order for Diclofenac Sodium Gel to be applied to the resident's knees, ankles, and both feet, every 6 hours, was not marked as administered on the 14th, 15th, and 20th for the 6 PM dose. Diclofenac sodium topical gel is a medication used to treat pain and other symptoms of arthritis of the joints (eg, osteoarthritis), such as inflammation, swelling, stiffness, and joint pain. However, this medicine does not cure osteoarthritis and will help you only as long as you continue to use it. On 3/22/24 at 10:27 AM, Resident #15 was interviewed about the administration of the Diclofenac Sodium Gel. The resident stated, some of the nurses don't ever give it to me, or it's like way late. On the same day at 10:37 AM, the concern was discussed with the Unit Manager (UM Staff #32) that the gel used to treat pain, inflammation, swelling, and stiffness was not being administered to the resident as ordered by the physician. This concern was raised after the MAR was reviewed and the resident interviewed. Staff #32 confirmed that Resident #15 was in the facility for the dates identified. She also reported that the administration time for the medication was recently changed to make sure that the residents get it, and that it was evened out over a 24-hour schedule. Staff #32 further stated that, They (nurses) are supposed to document if the medication was not administered and not leave it blank. And explained that if there was an issue with administration times, she could facilitate changing it to accommodate the resident. Staff #32 indicated that she would follow up to make sure the nurses are aware of the concern. On 3/28/24 at approximately 2 PM, the concern was discussed with the Director of Nursing and the Nursing Home Administrator that the nursing staff failed to ensure that pain management was provided to the resident as evidenced by the absence of documentation in the residents MAR. Both acknowledged the concern.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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Based on medical record review and interviews, it was determined that the facility failed to ensure transportation for regularly scheduled dialysis treatment, failed to follow up with the dialysis center to obtain a report after a dialysis treatment, and failed to notify the primary care provider when a dialysis session was missed. This was found to be evident for one (Resident #29) out of one resident reviewed for dialysis. The findings include: Review of Resident #29's medical record revealed an admission in February 2024 after a hospitalization for an infection. The resident's diagnosis included, but was not limited to, end stage renal disease with dependence on renal dialysis. The resident was scheduled to attend dialysis on Tuesday/Thursday and Saturdays at 11:00 AM at a dialysis center not located within the facility. Dialysis is a treatment that filters and purifies the blood using a machine in people whose kidneys can no longer perform these functions naturally. End-Stage Renal Disease (ESRD) is the stage of kidney impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life. On 3/18/24 at 11:41 AM, the resident reported that s/he did not attend dialysis on Saturday 3/16/24, but that s/he waited in the lobby for almost two hours. On 3/27/24 at 2:39 PM, nurse (Staff #5) reported that, for dialysis residents, there is a pre and post UDA [user defined assessment] form that is completed in the electronic health record but not printed out. The residents are sent to dialysis with a dialysis book which would include a face sheet, copy of orders and the Dialysis Communication Form. Upon return from dialysis, the nurse would assess the resident, complete the post dialysis UDA and check the communication sheet. If the communciation sheet was not filled out, the nurse reported s/he would call the dialysis center. Review of the resident's paper chart revealed Dialysis Communication Forms that included areas to document the resident's name, the date, pre and post dialysis weights,vital signs and lines for any additional documentation including any labs, and an area for the nurse to sign. Review of the Dialysis Communication Form for 2/24/24 revealed it only included the resident's name and the date. No documentation from dialysis staff was found. Review of the electronic health record revealed that a Pre Dialysis Evaluation (UDA) and Post Dialysis Evaluation were completed with an effective date of 2/24/24. In the section for Additional Information/Comments, the nurse documented: Dialysis did not provide weights or vitals. No documentation was found on this form, or elsewhere in the medical record, to indicate nursing staff had contacted the dialysis center for a report. On 3/27/24 at 11:20 PM, the DON and the surveyor spoke with the dialysis center charge nurse (Staff #37) who confirmed that the resident had attended dialysis on 2/24/24. Further review of the 2/24/24 Pre and Post Dialysis Evaluation forms revealed they were completed and signed by the unit nurse manager (Staff #9) on 2/26/24. On 3/28/24 at 2:00 PM the staffing coordinator (Staff #18) reported that the unit nurse manager (Staff #9) did not work on 2/24/24. Review of the Dialysis Communication Form for 3/2/24 revealed it only included the resident's name, the date and vital signs dated 8:30. (Resident was scheduled for dialysis at 11 AM). Review of the progress notes revealed a note written by nurse (Staff #22) on 3/2/24 at 1:13 PM that the [dialysis] book was provided but the appointment was cancelled and the primary care provider was made aware. No Dialysis Communication Form was found for Saturday 3/16/24. On 3/27/24 at 11:20 PM the DON and the surveyor spoke with the dialysis center charge nurse (Staff #37) who confirmed that the resident had not attended dialysis on 3/2 or 3/16. Review of the electronic health record revealed a Pre Dialysis Evaluation (UDA) and Post Dialysis Evaluation were completed with effective date of 3/16/24. In the section of the notes for the Name of Nurse completing this assessment revealed Staff #9's initials. Staff #9 had signed these forms on 3/19/24. On 3/28/24 at 2:00 PM the staffing coordinator (Staff #18) reported that the unit nurse manager (Staff #9) did not work on 3/16/24. An interview with the electronic health record coordinater (Staff #16) on 3/27/24 at 11:48 AM revealed Staff #16 was also responsible for scheduling resident appointments and arranging transportation as needed. Staff #16 reported that due to staffing at the transportation company no one was allotted for pick up on Saturdays. Staff #16 was aware of the missed dialysis appointment on 3/2 because she saw the resident sitting outside around 10:30 AM and she called the transportation company who reported there was no staff to pick the resident up. Their only option was to send the resident by taxi which the facility would have to pay for themselves. One Saturday they paid for a taxi but then the taxi did not pick the resident up from dialysis and Staff #16 had to use the facility van to pick the resident up, this was on 3/9. She went on to report the issue was only on Saturdays and that no arrangements for transportation were made for Saturday 3/16/24. Further review of the medical record revealed two notes written by nurse (Staff #22) on 3/16/24. The one at 10:05 AM included: Resident wheeled to lobby for dialysis pickup and at 1:39 PM the nurse (Staff #22) documented: resident not picked up for dialysis. No documentation was found in the medical record to indicate the primary care provider was informed the resident did not attend dialysis on Saturday 3/16/24. In a follow up interview on 3/27/24 at 12:12 PM, Staff #16 confirmed that no transportation arrangements were made for 3/16. She reported she had informed the nurse (named Staff #22) and that this was discussed in clinical meetings. Staff #16 went on to report that she was unable to document in the electronic health record progress notes. On 3/27/24 at approximately 11:25 AM, surveyor reviewed the concern with the DON that no documentation was found to indicate the physician was made aware that the resident did not attend dialysis on 3/16/24. On 3/28/24 at 5:10 PM, surveyor reviewed concerns with the DON and Nursing Home Administrator regarding the failure to ensure transportation to dialysis, failure of staff to contact dialysis center when no report was provided, and failure to ensure pre/post dialysis UDAs were completed by a nurse on duty when the assessments were scheduled to occur.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

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2) Resident #82 was admitted to the facility in late 2023. During an interview on 3/18/24 at 11:40 AM, the resident was observed with a bed rail on the left side. The resident indicated that s/he wanted them on both sides as it helped with positioning and had previously informed the nurses. On 3/27/25 at 11:40 AM, Resident #82's medical records were reviewed and revealed the Nursing Referral to Therapy documentation created by the unit nurse manager (UM Staff #32). This document was created on 3/21/24 at 5:23 PM and indicated that the resident required an evaluation for bedrails. The resident's progress notes were then reviewed and revealed a late entry note from therapy, with an effective date of 3/22/24, as a follow up to the referral created by Staff #32, which stated, Evaluation is not indicated due to patient already with bed rails on bed. Later at 1:37 PM, further review of Resident #82's medical record failed to reveal evidence of a care plan for bed rails, and indicated the order for grab bars for bed mobility and repositioning was started on 3/21/24. The residents' medical record also failed to reveal an informed consent for the use of bed rails. On 3/27/24 at 2:32 PM, Staff #32 was interviewed, and she confirmed the findings that Resident #82 was not assessed for safety and informed consent was not obtained prior to the installation and utilization of the bed rail. 3) Resident #15 had been residing in the facility since 2017 with weakness on the left side of the body. On 3/18/24 at 10:43 AM, the resident was observed in bed with upper side rails in the ON position in both sides. The resident indicated that the side rails were very useful for positioning. On 3/27/25 at 11:40 AM, Resident #15's medical records were reviewed and revealed the Nursing Referral to Therapy documentation created by the unit nurse manager (UM Staff #32). This document was created on 3/21/24 at 5:24 PM and indicated that the resident required an evaluation for bedrails. The resident's progress notes were then reviewed and revealed a late entry note from therapy, with an effective date of 3/22/24, as a follow up to the referral created by Staff #32, which stated, Evaluation is not indicated due to patient already with bed rails on bed. On 3/27/24 at 1:54 PM, further review of Resident #15's medical record failed to reveal documentation to indicate that informed consent was obtained prior to the initiation of bed rails. In an interview with the unit nurse manager (UM Staff #32) on 3/27/24 at 2:32 PM, she indicated that the facility recently did an in-house audit of bed rails. In this audit, the facility identified several residents without consent and/or safety assessments not completed prior to the installation, but did not want to remove bed rails or grab bars from resident beds as it would upset them. Staff #32 also reported that a new policy for bed rails was created and that they were in the process of correcting the concern. On 3/28/24 at approximately 2 PM, the concern was discussed with the Director of Nursing and the Nursing Home Administrator that assessment for safety and/or informed consents were not done prior to the installation of bed rails. Both acknowledged the concern and confirmed that the facility was in the process of correcting the issue. Based on observations, interviews, and records review, it was determined that the facility failed to assess residents for safety or obtain informed consent prior to the installation of bed rails, and failed to obtain orders or establish a care plan to address the use of side rails. This was evident for 3 (Resident #56, #82, and #15) of 8 residents reviewed for accidents. The findings include: 1) Review of Resident #56's medical record revealed that the resident was originally admitted to the facility in September 2023. The resident had severe cognitive impairment and was dependent on staff for activities of daily living such as eating, bathing and dressing. The resident did not have any functional limitations to range of motion in either the arms or the legs. On 3/17/24 at 1:58 PM, Resident #56 was observed in bed with padded quarter side rails in the up position on both sides of the bed. On 3/19/24 at 09:05 AM, the resident was observed in bed with padded quarter side rails in the up position on both sides of the bed. Review of the medical record on 3/21/24, revealed a Bed Safety Review assessment, with an effective date of 9/1/23, which revealed that grab bars (side rails) were in use to assist with turning and repositioning. This assessment form also indicated that a care plan was to be established for the use of this device. The section of this form to document Informed Consent was noted to be blank. On 3/21/24 at 8:28 AM, review of the medical record failed to reveal an order for side rails, review of the current care plan also failed to reveal documentation regarding the use of side rails for the resident. A review of the Bed Safety Review assessment, with an effective date of 12/1/23, revealed documentation that No device was currently in use for bed mobility or support for the resident; and in response to Section F Question 10. Bed assist rails present? Staff documented No. On 3/21/24 at 8:50 AM, the resident was observed in bed with padded quarter side rails in the up position on both sides of the bed. On 3/21/24 at 9:03 AM, the unit nurse manager (Staff #9) was interviewed in regard to side rails. Staff #9 reported that therapy would conduct an evaluation to determine if the side rail would be an enabler or a hindrance. If therapy indicated that side rails were appropriate, then they would obtain a physician order and initiate a care plan. She went on to report that this was a new process that she was just made aware of and that an audit was completed on the 19th. Review of the audit sheet provided revealed a notation for Resident #56's siderails: come off. Staff #9 reported she had already put in a TELS (computerized system for reporting maintenance issues) for removal of Resident #56's side rails. On 3/21/24 at 9:38 AM, surveyor reviewed with the unit nurse manager (Staff #9) that the December Bed Safety Review indicated no side rails were being used. Staff #9 reported that the side rails were already on the bed when the resident was transferred to this unit from another floor in the facility. On 3/21/24 at 10:02 AM, Staff #9 reported the side rails were removed. On 3/21/24 at 11:10 AM, both the Director of Nursing (DON) and the unit nurse manager (Staff #9) indicated the resident no longer needed the side rails. On 3/21/24 at 11:35 AM, the DON provided the TELS report that was created 3/21 at 9:41 AM for the removal of the side rails. At 11:41 AM, Staff #9 showed surveyor a text that was sent from her personal phone to maintenance on 3/19 regarding the removal of the side rails. On 3/28/24 at 12:02 PM, surveyor reviewed with the DON the concerns regarding the failure to obtain a consent for the use of the side rails, failure to obtain an order or establish a care plan for the side rail usage and failure to remove the side rails after the 12/1/23 evaluation which indicated no side rails. At 12:25 PM, the DON confirmed there was no documentation for informed consent for the use of the side rails.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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2) On 3/25/24 at 3:36 PM, a review of Resident #191's March 2024 Medication Administration Record revealed a 2/29/24 order for Hydralazine (blood pressure medication) 25 MG (milligrams) by mouth 3 times a day for hypertension, which was documented as given 3 times a day, every day from 3/1/24 to 3/20/24; and a 3/11/24 order for Hydralazine 10 MG by mouth 3 times a day for hypertension, give with 25 MG [Hydralazine] and hold if systolic BP (top number of a BP reading) is less than 130, which was documented as given at 5:00 PM on 3/11/24, and 3 times a day from 3/12/24 to 3/20/24. Further review of the MAR failed to reveal documentation to indicate that Resident #191's blood pressure was monitored prior to the administration of the Hydralazine since the initiation of the order on 3/11/24. The facility staff failed to follow the physician's order to monitor the resident's BP prior to the administration of the antihypertensive medication. The Director of Nurses (DON) was made aware of the above concerns on 3/26/24 at 5:22 PM and the DON offered no comment at that time. Based on medical record review and interview, it was determined that the facility failed to ensure residents were free from unnecessary medication. This was found to be evident for two (Resident #24 and #191) out of seven resident's whose medication regimens were reviewed during the survey. The findings include: 1) On 3/22/24, a review of Resident #24's medical record revealed a current order, with a start date of 12/20/23, for Midodrine to be given three times a day for hypotension, and to hold for a SBP [systolic blood pressure] greater than 110. Hypotension is low blood pressure. The systolic blood pressure is the top number of a blood pressure reading. Low blood pressure can lead to dizziness and fainting. Review of the Medication Administration Record for March 2024 revealed multiple occasions when the resident's SBP was greater than 110 and the medication was administered. These dates include: 3/21 afternoon dose 3/20 morning dose 3/18 afternoon dose 3/14 evening dose 3/5 morning dose On 3/22/24 at 12:36 PM, the unit nurse manager (Staff #9) confirmed that the current Midodrine order included BP parameters. When surveyor reviewed the concern that there were several occasions when the SBP was above the ordered parameters, Staff #9 responded: sounds like an error to me. On 3/22/24 at 2:11 PM, surveyor reviewed the concern with the Director of Nursing (DON) that, on multiple occasions, the midodrine was given when the BP was above the stated parameters. DON acknowledged the concern and indicated the medication should have been held.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to ensure that a prn (as needed) order for an antipsychotic medication was limited to 14 days. This was found to be evident for one (Resident #24) out of five residents selected for unnecessary medication review. The findings include: Review of Resident #24's medical record revealed the resident was admitted in 2023. The resident had several hospitalizations in the fall of 2023. On 3/20/24, review of the medical record revealed that the Consultant Pharmacist Recommendation to Physician on 11/2/23 included the following: Resident has the following order: Promethazine 12.5 mg Give 25 mg by mouth every 8 hours as needed for nausea or vomiting. Promethazine can technically be classified as a phenothiazine psychotropic medication -- please consider adding a duration of therapy/stop date for the above order. The form indicated that the prescriber agreed with the recommendation on 11/6/23. Review of the physician orders revealed an order to discontinue the medication on 11/6/23. Phenothiazines are a type of antipsychotic medication. On 3/22/24 at 12:36 PM, the unit nurse manager (Staff #9) reported that she or the Director of Nursing (DON) will hand the pharmacy recommendations to the physician or the nurse practitioner, and that she (Staff #9) will make all the changes in the computer. Further review of the medical record revealed that the resident was re-admitted on [DATE] after a hospitalization. On 3/22/24, review of the orders revealed a current order, with a start date of 12/20/23, for Promethazine 12.5 mg give 2 tablets every 8 hours as needed for nausea/vomiting. On 3/22/24 at 2:11 PM, surveyor reviewed with the DON the concern that the prn (as needed) promethazine order had been in effect since December 2023. On 3/29/24, further review of the medical record revealed that the Promethazine was discontinued by the nurse practitioner (Staff #25) and confirmed by nurse (Staff #10) on 3/22/24 with a notation: Reviewed admin audit for past two months and patient has not needed; will DC at this time. Continued review of the medical record revealed a new order for the Promethazine 12.5 mg give one tablet every 8 hours as needed for nausea and vomiting that was ordered by a different nurse practitioner (Staff #26) and confirmed by unit nurse manager (Staff #9) on 3/27/24. No documentation was found in the 3/27/24 order to indicate that a stop date was included.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observations and staff interviews, it was determined that the facility failed to ensure that 1) expired medications were disposed of promptly and 2) medications were stored correctly per the manufacturer's specifications. This was evident for 3 of 4 medication carts observed and 1 of 2 medication rooms observed. The findings include: 1a) On 3/25/24 at 12:54 PM, the 3rd-floor nurses' medication cart was observed in the presence of Staff #33, a registered nurse (RN). The observation revealed five vials of ipratropium bromide and albuterol sulfate inhalation solution and a second pack with two vials, all available for use, with the expiration dates of 12/2023, for Resident #78. Staff #33 confirmed they were expired and should have been discarded. 1b) An observation of the 3rd-floor medication storage room refrigerator in the presence of Staff #33 on 3/25/24 at 1:30 PM revealed a COVID-19 vaccine, with an expiration date of 12/22/23, for Resident #40 and another COVID-19 vaccine with an expiration date of 12/25/23 for Resident #14. Staff #33 stated they were expired and should have been discarded. 1c) On 3/25/24 at 2:00 PM, the 3rd-floor unit medicine cart was observed in the presence of Staff #21, a certified medicine aide (CMA). The observation revealed a Latanoprost eye drop for Resident #14, which was opened on 1/13/24 and was available for use. The instructions on the package stated, Discard after six weeks. Staff #21 said it should have been discarded six weeks after 1/13/24. 1d) A continued observation of the 3rd-floor unit medicine cart on 3/25/24 at 2:30 PM showed a medication card with the top portion ripped off and missing the medication name and the resident name. The medication card had nine reddish-brown pills available for use. Staff #21 stated that the medication looked like Risperdal, but since the name had been removed, she was unsure of that. and it should have been discarded. 1e) On 3/25/24 at 2:37 PM, the 2nd-floor unit CMA medication cart was observed in the presence of Staff #35, a CMA. The observation showed a latanoprost eye drop for Resident #36, which was opened on 12/10/23 and available for use, noted with an instruction on the package: Discard after six weeks. Staff #35 confirmed that the eye drop had expired. 2) On 3/25/24 at 2:45 PM, the 2nd-floor unit CMA medication cart was observed in the presence of Staff #35, a CMA. The observation revealed an unopened latanoprost eyedrop with an unbroken seal for Resident #36. The package had an instruction: Refrigerate unopened and store opened at room temperature. Staff #35 stated that it should have been kept in the refrigerator, not the medication cart. On 3/26/24 at 10:00 AM, during an interview with registered nurse Staff #33, she stated that to avoid administering expired medications to residents, she removed any expired medications from the medication cart and discarded them appropriately. On 3/26/24 at 10:15 AM, during an interview with the director of nursing (DON), she stated that her expectation of the nurses was to get rid of expired medications. She also said that she expected the nurses to write the expiration dates on the medication packages so that they would know when to discard them once they were received from the pharmacy.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

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Based on observations, records review, and interviews, it was determined that the facility failed to ensure that food and drink was provided to the resident. This was evident for 1 (Resident #292) of 3 residents reviewed for food. The findings include: Resident #292 was a newly admitted resident of the facility that arrived on a weekend. On 3/17/24 at 3:07 PM, the resident was observed in bed and stated, I want to go back to the hospital because they're not treating me well, like I have to remind them to give me my meals. The resident indicated that this was every mealtime. Later at 6:06 PM, the resident reported that s/he was upset because s/he had not received his/her dinner tray. Resident #292 indicated that his/her roommate received a dinner tray like usual but not him/her. The resident's roommate was observed with a dinner tray that was about 50% consumed at that time. Two staff were observed about 4 rooms down the hall passing dinner trays. When the staff saw the surveyor walk in Resident #292's room, 1 staff peeked in the resident's room and told the other staff, His/Her tray was not in the cart again. Approximately 3 minutes later, the other staff, who was a Geriatric Nursing Assistant (GNA Staff #42), came in the room with a dinner tray and placed it on the resident's bedside table and stepped out. At this time, the surveyor asked the resident if staff had asked which meal s/he wanted or preferred, the resident answered, No, I'm lucky to get one! On observation of the dinner tray given to Resident #292, it did not have a meal ticket. Staff #42 came back into the resident's room and was asked where she got the dinner tray from. Staff #42 reported that the dinner tray came from another resident that refused/declined the meal. On 3/18/24 at 9:36 AM, Resident #292 reported that a breakfast tray was served at the same time as the roommate. The meal ticket from the breakfast tray was obtained and observed to have the residents name and room number. Also, at 2:28 PM, the resident reported receiving a lunch tray at the same time as his/her roommate. In a interview with the Food Service Director (FSD) on 3/21/24 at 11:56 AM, she indicated that if a meal ticket was not printed, the kitchen staff would not have made a tray for a resident. Later at 3:30 PM, the FSD was interviewed again, and she reported her process when the facility has a new admission. The FSD indicated that she works Monday to Friday and that she had an assistant FSD who was also a part time cook (Staff #11) who works Sunday to Thursday, and on Saturdays, the cook assumes the responsibility. The FSD reported that if her assistant or the cook had known that there was a new admission, they would have printed the meal ticket of Resident #292 so that the kitchen staff could have prepared the resident's meal tray. She further reported that Saturday should have been a blank meal ticket filled out by the cook, and on Sunday Staff #11 would have printed the meal ticket. On 3/21/24 at 3:59 PM, Staff #11 was interviewed and was accompanied by the FSD, and he explained that Nursing would normally call him if there was an admission on a Sunday. Staff #11 confirmed in this interview that he was only made aware of Resident #292 being a new admission on Sunday dinner time. When he learned of this, he printed the meal ticket for the resident for the next day's breakfast. The FSD reported that they are currently thinking of a new process for the Nursing Department to inform them of weekend admissions, to make sure meal tickets are printed timely so kitchen staff would know to prepare a meal tray for a newly admitted resident. On 3/28/24 at approximately 2 PM, the concern was discussed with the Director of Nursing and the Nursing Home Administrator that a resident did not receive their meal tray as evidenced by the resident report and observed by the surveyor. Both acknowledged the concern.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected 1 resident

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Based on observation, record review and interview, it was determined that the facility failed to ensure that residents requiring pureed diets received adequately pureed foods. This was found to be evident for two out of two residents (Resident #34 and #19) observed to have incorrect diet consistency served during a random observation. The findings include: On 3/21/24 at 12:39 PM, while touring the kitchen with the Food Service Director (FSD Staff #8) a test tray was pulled at random from the cart as it was preparing to leave the kitchen, the meal ticket was given back to staff to make another tray. The tray had multiple thickening packets, which were given back to kitchen staff prior to removing the tray from the kitchen. Surveyor and FSD observed three items on the plate: one scoop of white/cream colored item, one rounded scoop of chopped up ravioli, and a finely chopped up, but not smooth pudding like puree, of a green bean item. The FSD confirmed the ravioli and green bean items would be considered ground, not pureed. The FSD and surveyor reviewed the diet list for the residents on the floor the cart was headed to and the FSD identified two residents who eat in their room who also receive thickening packets, Resident #34 and Resident #19. Both of these resident's diets were listed as pureed. On 3/21/24 at approximately 1:00 PM, surveyor and FSD observed Resident #19 in his/her room, the food on the resident's tray was similar to the test tray. FSD had the tray removed. The tray for Resident #34 was then pulled from the cart and was observed to also be similar to the test tray. FSD indicated she would have these trays re-done and would go address other trays for residents with orders for puree diets. Review of Resident #19's medical record revealed a diagnosis of dementia and a history of dysphasia (difficulty swallowing). The resident had an order for a pureed diet since March 2022, with thickened liquids. Review of Resident #34's medical record revealed a diagnosis of dementia and dysphasia. The resident had an order for a pureed diet since December 2023, with thickened liquids. On 3/21/24 at 1:47 PM, the FSD reported the purees were re-made and that she had identified two resident's on another floor whose trays she had also stopped from being served. On 3/22/24 at 12:23 PM, the FSD reported the issue the day before was that the puree items were not pureed enough, and that she educated her entire staff. Observation of the current tray line puree items revealed that several items appeared too thin and the FSD indicated they would be thickening them prior to serving. A taste test of the pureed fish at this time revealed it to be a smooth pudding like consistency.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

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Based on observation and interview, it was determined that the facility failed to ensure that refuse was properly disposed. This was found to be evident on 2 out of 2 observations of the dumpster area. The findings include: On 3/21/24 at 3:00 PM, observation of the dumpster area revealed various debris noted on the ground including multiple cans and cups from a convience store. An old mattress was observed on the ground behind one of the dumpsters. On 3/21/24 at 3:37 PM, when asked who was responsible for the dumpster area, the Food Service Director reported it was not dietary staff, but environmental services or maintenance. On 3/29/24 at 9:09 AM, observation of the dumpster area again revealed various debris, although somewhat different than debris observed on 3/21, the mattress remained behind the one dumpster. At 9:15 AM, the area was observed with the Nursing Home Administrator who confirmed it was a facility mattress. Surveyor reviewed the concern that it had originally been observed on 3/21/24.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

QAPI Program (Tag F0867)

Could have caused harm · This affected 1 resident

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Based on review of medical records and other pertinent information and interview, it was determined that the facility failed to develop and implement appropriate plans of action to correct identified deficiencies. This deficient practice has the potential to affect all residents. The findings include: On 3/29/24, review of the last two recertification surveys revealed several deficiencies that were identified again during this survey which had similarly identified findings. These included deficiencies in regard to MDS inaccuracies (F 641), comprehensive care plans (F 656) and restorative nursing (F 688). Additionally, a complaint survey conducted in January 2024 also identified deficiencies related to MDS inaccuracies and comprehensive care plans. Review of the plans of corrections for the MDS and care plan related deficiencies revealed they primarily addressed the specific examples that evidenced the deficient practice rather than the processes involved in the deficiency. On 3/29/24 at 11:05 AM, the Nursing Home Administrator (NHA) reported that nurse (Staff #10) had been the QA nurse, but they are in the process of transitioning that role back to the Director of Nursing. On 3/29/24 at 11:31 AM, surveyor reviewed with NHA the concern regarding the repeat deficiencies and that the POCs were only addressing the specific examples.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) An interview with Staff #19, the infection preventionist (IP) nurse, on 3/26/24 at 12:56 PM revealed that the maintenance director was responsible for the facility's water management. On 3/26/24 at 2:02 PM, Staff #3, the maintenance director, was interviewed. During the interview, he stated he was unaware of any measures the facility had in place to prevent legionella growth in the water system. On 3/26/24 at 2:35 PM, during an interview with the nursing home administrator (NHA), she was asked if there was a system to identify risk areas in the facility's water system for legionella. She responded that she would check if there were one and then stated that corporate was responsible for it. On 3/26/24 at 3:43 PM, a review of the facility's water management plan was completed. The review noted that the NHA, IP nurse, and maintenance director were the members of the water management team. Yet, during earlier interviews, they all indicated they were not responsible for the facility's water management. A continued review of the plan showed that water testing will be performed annually, and the test results will be recorded in the facilities' water management/legionella plan. However, no testing evidence was provided to the surveyor by the end of the survey. On 3/29/24 at 7:36 AM, during an interview with the NHA, she was asked about the part of the water management plan that stated, Water testing will be performed on an annual basis and the results of the test recorded in the facilities water management/legionella plan. She responded that she had just ordered a water testing kit, which had not yet been delivered to the facility. Further questioning showed that water testing was not implemented as indicated in the policy. 3) On 3/20/24, review of records revealed that Resident #80 was a long-term resident of the facility. Resident # 80 was readmitted to the facility following a hospital stay, where s/he was treated for sepsis (a serious infection) and returned with a suprapubic catheter in place. A suprapubic catheter is a urinary catheter that is inserted into the bladder from a small cut in your abdomen, just above your pubic bone. You will not need to pass urine yourself from your urethra. The catheter will drain urine from the bladder into a catheter bag. On 3/20/24 at 9:34 AM, an observation was made of Resident # 80. Resident #80 was observed on the ground floor of the facility propelling her/himself in a wheelchair towards the elevator. The surveyor heard an audible rubbing and dragging sound as the resident entered the elevator. Further observation revealed Resident # 80's catheter bag, with a privacy cover, was dragging on the floor. Continued observation revealed that the resident exited the elevator onto the first floor. Continued observation revealed the Unit Nurse Manager (Staff # 10) assisted resident off the evaluator in his/her wheelchair, for a short distance down the hall. Resident # 80 then began propelling her/himself down the hall with an audible rubbing, dragging sound and the catheter was observed dragging on the floor. On 3/22/24 at 8:29 AM, an observation of Resident # 80, propelling his/her wheelchair on the ground floor, traveling in the direction of the activity room/dining hall, was made. Further observation revealed the catheter bag was dragging on the ground as the resident propelled her/himself into the activity/dining room. On 3/22/24 at 9:00 AM, continued observation revealed Resident #80 moving his/her wheelchair in activity/dining area as the catheter bag continued to drag on the floor. A dragging sound could be heard when Resident # 80 propelled him/herself in the wheelchair. On 3/22/24 at 9:20 AM, an observation was made of Resident # 80 getting onto the elevator. Continued observation revealed the resident exited the elevator onto the first floor. The unit nurse manager ( Staff # 10) was observed as she attended the resident. Staff #10 removed the clip attaching the catheter bag to the lowest bar on the wheelchair and reclipped it to a higher bar underneath the wheelchair. Further observation revealed that the resident's catheter bag was no longer touching the floor. On 3/25/24 at 9:58 AM, review of section GG0130, Self care of the MDS, dated [DATE], revealed the following concerning Resident #80, as dependent on the staff for help to complete the following activities: dress and undress above the waist; including fasteners, if applicable dress and undress below the waist, including fasteners. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners. On 3/25/24 at 11:31 AM, Occupational Therapist (Staff # 38) was interviewed. During the interview Staff #38 reported she had provided care of Resident #80 and had been familiar with his/her abilities. She reported it was her professional opinion that Resident #80 did not have the physical ability to move or alter the position of her/his catheter bag when it is hung under her/his wheelchair. On 3/26/24 at 8:30 AM, the surveyor discussed the above concerns with Director of Nursing and the Administrator. No additional information was provided. 4) According to the Centers for Disease Control's (CDC) Fact Sheet on Tuberculosis Skin Testing (TST) dated 9/2020, the skin test reaction should be read between 48 and 72 hours after administration by a health care worker trained to read TST results. If a person's TST reaction was not read within 72 hours, the person would need to be scheduled for another skin test. On 3/25/24 at 1:48 PM, a review of Resident #191's February 2024 medication administration record (MAR) revealed an order for a Tuberculin PPD (purified protein derivative) solution, inject transdermally (through the skin), one time a day to rule out tuberculosis (TB) that was administered on 2/29/24 at 6:54 PM. The TST location where the tuberculin PPD was administered, to ensure reading of the TST was accurate, was not documented on the MAR. Review of Resident #191's March 2024 MAR revealed a 3/4/24 order to read TB skin test (PPD) 1 of 2 and document results in immunization record, which was documented as 0 mm (millimeters) on 3/4/24, which was approximately 15 hours after the 72-hour mark. The Director of Nurses was made aware of the above concerns on 3/26/24 at 5:22 PM, and acknowledged the concerns at that time. Based on observation, record review and interview, it was determined that the facility failed to 1) ensure that staff kept the door between the clean and dirty areas of the laundry closed to prevent cross contamination; 2) to have measures in place to monitor for and prevent the growth of legionella and other opportunistic water-borne pathogens in its water systems; 3) to maintain a residents catheter bag in proper a sanitary condition; and 4) to ensure that PPD skin test are read within the 48-72-hour timeframe. This was found to be evident for 1 (Resident # 80) out of 3 residents reviewed for urinary catheter use and 1 (Resident #191) of 6 residents reviewed for tuberculosis skin testing. The findings include: 1) On 3/17/24 at 3:34 PM, the door to the laundry was open and accessible from a secured hall. The door between the clean area, where the dryers and clean folded laundry are kept, and the dirty area where the washers are located, was noted to be open. A washer was running at this time and no staff were present. On 3/17/24 at 3:45 PM, surveyor again observed the door between the dirty and clean sections of the laundry to be open. Folded clean laundry was noted on clean side, including a cart with clean folded sheets, blankets and gowns. Staff #24 was observed by a washing machine at this time. Staff #24 reported the door between the two areas is usually closed and that she had just opened it to get a cart. Staff #24 then proceeded to load dirty laundry into a washing machine, while the door to the clean section remained open. On 3/29/24 at 9:19 AM, surveyor reviewed the concern with the Nursing Home Administrator (NHA) of the observation of the laundry room and staff report that door should be shut but then proceeded to load dirty clothes into the washer with the door remaining open. NHA confirmed that the door should be shut.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and pertinent document review, it was determined that the facility failed to have a monitoring process in place to ensure that the resident call system remained functioning. This was evident for 4 out of 12 rooms, during a random observation. The findings include: On 3/18/24 at 9:40 AM, during an interview with Resident # 7, a long-term resident of the facility, s/he reported that his/her call light had not worked for some time. Resident # 7 reported that, when s/he pressed the call system device, there was an audible sound but the light outside her room above the door frame did not light up. S/he reported that s/he had told staff that it was not working. On 3/18/24 at 9:43 AM, an observation was made of Resident #7 when s/he pressed his/her call system device at the bed side. Observation outside of the Resident #7's room failed to reveal an illuminated light outside of the resident's room. Further observation failed to reveal a bell or substitute call system in Resident # 7's room. On 3/18/24 at 9:55 AM, a second test of the call system in Resident #7 room was made. The call system by the resident's bed was pressed (activated) and a beeping sound was heard. Further observation failed to reveal an illuminated light outside of the resident room. On 3/18/24 at 9:56 AM, during an interview with certified medication aide (CMA Staff #4) she reported that she heard the sound but could not see any light in the hall. She advised the surveyor she could tell what room had requested help by the lights at the nurse's station. Staff #4 went to the nurse's station and came back and reported that the request for help came from room [ROOM NUMBER]. Staff #22 then entered room [ROOM NUMBER] (not Resident #7's room). She quickly exited room [ROOM NUMBER] and then went to Resident #7's room. Staff # 4 then reported that sometimes it is hard to tell exactly what room the call light board was indicating. Staff # 20 reported that the call system for Resident #7's room had not been working for a couple of days. On 3/18/24 at 10:44 AM, Resident #191 who had been admitted to the facility for rehabilitation, demonstrated the use of her/his call system. On 3/18/24 at 10:45 AM, an observation of the call light system in Resident #191 room revealed the beeping sound from the call system, but failed to reveal an illuminated light over the door frame. On 3/18/24 at 10:55 AM, an observation was made of the call light system for Resident #7's room with the Maintenance Director, Staff #3. Observation failed to reveal that the light portion of the call light system was working. Staff #3 removed the light cover and replaced the light bulb above Residents#7's door. On 3/18/24 at 11:38 AM, observations of the first-floor call system was made with the Director of Nursing (DON). Observations revealed that rooms [ROOM NUMBERS] had the light covers off and were recently fixed by Staff #3. Also, that the light bulb in Resident #7's call system was replaced and was operational. On 3/18/24 at 11:25 AM, CMA staff # 4 reported that the light part of the call system was not working earlier today for room [ROOM NUMBER] and 107. Staff #4 reported that they had been worked on by maintenance and were just fixed. On 3/19/24 review of Work Orders for Anchorage Healthcare Center since 3/10/24, failed to reveal any work orders submitted to fix the call system lighting for the above identified rooms prior to the arrival of the survey team.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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5) On 3/18/24, observations made between 10:00AM and 4:30 PM revealed that multiple rooms did not have a comfortable chair available to the resident or resident visitors in their rooms. These rooms included 302-B, 308-A, 304-A, 307-A, 317-A, 317-B, 320-B, 323-B, and 324-B. On 3/18/24 at 10:13 AM, Resident #15, reported that when his/her family member comes to visit, the family member would need to get a chair from somewhere in the facility to use during the visit; at 11:10 AM, Resident #82, reported when my company comes, we have to borrow my roommate's chair; at 1:39 PM, Resident #10 indicated that when a visitor comes, they would have to get a chair from the lobby; at 3:35 PM, Resident #2's resident representative indicated that when she comes by, there hasn't been a chair in the resident's room. On 3/28/24 at 11:24 AM, the concern was discussed with the Director of Nursing (DON) that several rooms were inspected and observed to not have chairs available to the resident or their visitors, making the environment of their rooms not homelike. The DON acknowledged the concern. On the same day at 12:40 PM, a tour of the rooms was conducted with the Maintenance Director, and he confirmed that there were no available chairs in the rooms identified for the resident and/or visitors to use. 4) On 3/17/24 at 4:12 PM, Resident # 21, a resident admitted to the facility for rehabilitation was interviewed. During the interview, Resident #21 reported that there were issues with the sink faucet in his/her bathroom. Resident #21 reported that s/he had told the maintenance manager about the faucet. Resident #21 reported that faucet was not secure and was loose since her/his admission to the facility. On 3/17/24 at 4:16 PM, an observation revealed that Resident # 21's bathroom was a shared bathroom utilized by the Residents # 21 and the resident next door, Resident #17. On 3/17/24 at 4:12 PM, an observation of Resident #21's bathroom was made. The observation revealed a silver sink facet that was not secure and moved laterally. Further observation revealed 1 dark pink bottle, that laid on the floor, by the toilet. The observation failed to reveal that the bottle was labeled with a resident's name. On 3/19/24 at 10:12 AM, Resident #17, a long-term resident of the facility was interviewed. During interview, Resident #17 reported there were issues with her/his bathroom toilet and sink faucet. Further observation revealed the bathroom is a shared bathroom with Resident # 21. On 3/19/24 at 10:13 AM, observation of the bathroom shared by Resident #21 and #17 again reveaeled the sink facet that was not secure and easilly shifted from side to side. Further observation revealed the dark pink bottle that laid on the floor by the toilet was still present. On 3/20/24, the Environmental Services Manager Staff #34, was interviewed. During the interview she reported the resident's bathrooms are cleaned every day. She describes the cleaning as a 5-step process which includes wiping the sink down, cleaning the toilet, and cleaning the floor, which included picking up any items or trash from the floor. On 3/20/24 review of the Room Readiness Forms for Resident #21's room on 3/6/24, and Resident #17's on 3/11/24 revealed that the rooms had been inspected, but failed to reveal any issues with the bathroom sink were identified. On 3/21/24 at 10:15 AM, a third observation of the shared bathroom revealed the dark pink bottle was still on the floor in the corner to the left of the toilet. Further observation revealed a new sink faucet was secured in place. On 3/21/24 at 12:45 PM, The Administrator confirm that the loose sink faucet was not noted in the Room Readiness Form that was completed on 3/6/24. In addition, she confirmed that the dark pink bottle remaining on the floor in the bathroom from 3/17/24 to 3/21/24 was present. She reported she would speak to housekeeping concerning the issue. 6) On 3/26/24 at 1:05 PM, an observation of Resident #19 was completed. The resident was lying in bed and a GNA (geriatric nursing assistant), who appeared to be feeding the resident, was sitting on Resident #19's bed. At that time, when asked why s/he was sitting on the resident's bed, Staff #13, GNA stated that s/he was sitting on the bed to feed the resident because s/he could not find a chair in the resident's room. At that time, further observation of the resident's room failed to reveal a comfortable chair in the resident's room The above findings, along with the concerns with the resident not having a comfortable chair in his/her room were discussed with the Director of Nurses (DON), on 3/28/24 at 11:25 AM and the DON acknowledged the concerns at that time. Based on observation and interview it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment. This was found to be evident throughout the facility and for seven (Resident #17, #21, #82, #10, #2, #15 and #19) out of 43 residents reviewed during the survey. The findings include: 1) On 3/17/24 at 1:35 PM, an initial tour of the dry storage area of the kitchen revealed a puddle of standing water on the floor underneath and in front of one of the dry storage racks. There was also damaged floor tiles and at least two damaged baseboard tiles. The back wall of the the dry storage area was observed to be discolored and the corner of the room had black stains from the floor to ceiling. On 3/21/24 at 12:04 PM, surveyor reviewed observations made on 3/17 with the Food Service Director (FSD Staff #8). The FSD reported the damaged floor tiles had been reported to maintenance since they started at the facility, which was more than one year ago. The surveyor and FSD proceeded to tour the kitchen together and made the following observations: - Directly across from FSD office there was a hole in the wall below the breaker box that measured approximately 8 inches x 9 inches. At the corner of this wall, the drywall was noted to have damage for at least 12 inches. Directly to the left of the entrance to the FSD office, one of the baseboard tiles was noted to be missing with damage to the wall where the tile had been. In the dry storage area, the floor was noted to have some wet areas near where the puddle was observed on 3/17. Observation under the dry storage racks revealed drainage pipes from the walk in freezer and walk in refrigerator going into a pipe built into the floor. The FSD confirmed the existence of the water on the floor and reported the area was recently mopped. She also reported that some days the floor is dry. The FSD went on to report that she has put in a report to maintenance on multiple occasions regarding this concern, and confirmed the first was at least 6 months ago. Damage was noted to the bottom corner of the walk-in refrigerator door which resulted in approximately 1 inch x 1 inch area missing and exposed jagged metal. The flashing between the walk-in fridge and the walk-in freezer was noted to have corrosive damage where the flashing met the floor. Broken floor tiles were observed in various sections of the kitchen including: 3 in the dry storage area, 2 near the entrance of the walk-in fridge, and more than 9 in the dishwashing area. 2) On 3/17/24 at approximately 3:50 PM, surveyor observed significant damage to the door frame of an outside exit door located in the stairwell used by staff. The damage was noted on the bottom 7 inches of the door frame and was allowing light and cold air in from the outside. On 3/28/24 at approximately 8:30 AM, the Nursing Home Administrator (NHA) indicated she was aware of surveyor's concern regarding the exit door and that she had already notified corporate. 3) On 3/28/24 and again on 3/29/24 at 8:20 AM, surveyor observed in the first floor day room a call light indicator panel that was mounted on the wall. The panel was smaller than a light switch cover, however, the area around the panel was not sealed, with an open area of drywall noted. This observation was reported to the Nursing Home Administrator (NHA) on 3/29/24 at 8:30 AM at which time she indicated she would have staff address this issue.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 3/27/24 at 1:28 PM, a medical record review was completed for Resident #61. The review showed that Resident #61 was admitted to the facility in June 2022 with diagnoses that included Dementia and Bipolar. A continued review of the record on 3/27/24 at 3:42 PM revealed a nurse's note dated 1/3/24 that documented that Resident #61 had a change in mental status and behaviors. The attending provider was notified and ordered to send the Resident to the emergency room for evaluation. Further review of the medical record showed that Resident #61's representative was notified via phone. However, the review failed to show that the Resident and/or the Resident representative was notified in writing of the transfer/discharge of the Resident and the reason for the transfer. During an interview with a licensed practical nurse (Staff #32), on 3/27/24 at 5:35 PM, she reported that she only notified the Resident's representative of a hospital transfer via phone and not in writing. On 3/28/24 at 7:43 AM, during an interview with the Director of Nursing (DON), she confirmed that the nurses only notified the residents' representatives via phone and not in writing. 3) A medical record review completed for Resident #43 on 3/28/24 at 11:48 AM showed that Resident was admitted to the facility in December 2023 with diagnoses including pulmonary disease (Lung disease). Further review revealed an MDS assessment dated [DATE] that recorded that Resident #43 had intact cognitive status. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. Continued review revealed an attending provider's encounter note dated 3/7/24 that recorded that Resident #43 was assessed by the provider for altered mental status and ordered for the Resident to be sent to an acute care facility for evaluation on 3/7/24. Further review completed on 3/28/24 at 12:21 PM revealed a nurse's note dated 3/7/24 that stated, attempted to contact son without success. However, the review failed to show that the Resident or the representative was notified in writing of the transfer and the reason for the transfer. On 3/28/24 at 11:02 AM, an interview conducted with a registered nurse (Staff #23) showed that she only notified residents verbally if they were their own decision-makers and would only notify the representative via phone if they were not. 2) On 3/26/24 at 9:19 AM, a review of Resident #7's electronic medical record (EMR) revealed Resident #7 was transferred to an acute care facility on 6/24/23. In a SBAR (acronym for situation, background, assessment, recommendation) note, on 6/24/23 at 9:45 PM, the nurse documented that, following an unwitnessed fall, Resident #7 complained of right wrist pain and swelling, that the physician was notified, and ordered the resident be sent to the emergency room (ER) for further evaluation. On 6/24/23 at 9:45 PM, in a Transfer Form, the nurse documented Resident #7 was transferred to the hospital. The form included the statement Transfer Checklist: Print the following documents and include with this Transfer Form in the order listed. Send entire packet with the patient to the hospital. This was followed by a document checklist which included, Notice of Transfer, which was not checked, indicating a notice of transfer was not provided to the resident upon his/her transfer to the hospital. Continued review of the medical record failed to reveal documentation to indicate Resident #7 and the resident's representative(s) received written notification of the transfer, which included the reason for the transfer, the location of the transfer and the resident's appeal rights. On 3/28/24 at 10:45 AM, the above concerns were discussed with the Director of Nurses (DON). At that time, the DON confirmed that when a resident was transferred to the hospital the resident and the resident's representative were not provided with written transfer notification. Based on observation and interview, it was determined that the facility failed to have an effective system in place to ensure that the required information is provided to residents or their representatives in writing when a resident is discharged to the hospital. This was found to be evident for 3 (Resident #24, #7, #61, and #43) out of 43 residents reviewed during the survey. The findings include: 1) Review of Resident #24's medical record on 3/21/24 revealed the resident had resided at the facility since April 2023. The resident was discharged to the hospital in December 2023 due to a fever. Review of the resident's paper chart revealed an Acute Transfer Letter, dated 12/12/2023. The letter included, but was not limited to, the following statement: The resident and /or the resident's representative have the right to request an impartial hearing, to be held at the facility, regarding the discharge and transfer. Details of your appeal rights will be provided by a facility representative as soon as practical following this acute transfer. Further review of this letter failed to reveal documentation of the location to which the resident was being transferred, contact information if an appeal was desired, or the ombudsman contact information. The nurse documented that this information was told verbally due to emergency. On 3/26/24 at 1:44 PM, the unit nurse manager (Staff #9), when asked who the facility representative was that would be contacting the resident as referenced in the Acute Transfer Letter, reported that the admission director or the facility hospital liaison. Stating that they coordinate with speaking with the patient. On 3/26/24 at 3:57 PM the Admissions Director (Staff #20) reported the only time she would contact the resident would be to confirm if they are coming back to the facility. She denied reviewing any resident rights or providing any additional paperwork. Further review of the medical record failed to reveal documentation to indicate a facility representative had contacted either the resident or the resident's representative regarding the appeal rights information after the resident left the facility, or that the required information was provided to the resident or the representative in writing.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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4) Resident #61 has been residing in the facility since 2022. On 3/19/24 at 9:02 AM, the resident's medical record was reviewed and revealed the most recent weight taken on 3/11/24 was 143.9 lbs. and about 6 months prior on 9/15/23 was 162 lbs. The Long-term Care Survey Process (LTCSP) calculator indicated these weights as an 11.17% weight loss. On 3/21/24 at 9:35 AM, a review of Resident #61's medical record revealed an MDS assessment with an assessment reference date (ARD) of 2/13/24 section K (Swallowing/Nutritional status), was coded as No or unknown when assessed for Loss of 5% or more in the last month or loss of 10% or more in last 6 months. This section was signed by the MDS registered nurse (RN Staff #28) on 2/16/24 at 10:47 AM. Further review of the resident's medical record revealed the weight on 2/5/24 was 140.4 lbs. and 169 lbs. on 8/24/23. The LTCSP calculator marked this as a 16.92% weight loss. On 3/22/24 at 12:23 PM, a review of the progress note created on 2/11/24 by the Registered Dietician (RD) for Resident #61 documented that the resident had a significant weight loss of 16.9% in 6 months and to continue with the current care plan and monitoring of the resident. Later, at 12:33 PM, a phone interview was conducted with the RD, and he reported that 99% of the time, he completed Section K of the MDS assessments for residents. The MDS assessment with an ARD of 2/13/24 for Resident #61 was reviewed with the RD. He confirmed that he did not do the assessment for section K and was not familiar with Staff #28. The RD continued to report that, if he had done this assessment, he would have coded the resident as having a significant weight loss. On 3/28/24 at approximately 2 PM, the concern was discussed with the Director of Nursing and the Nursing Home Administrator that MDS assessments were not coded accurately; both acknowledged the concern. 3) On 3/26/24 at 8:43 AM, a medical record review for Resident #17 revealed an MDS assessment, dated 2/15/24, that documented antibiotic use in section N. A continued review of Resident #17's medical record showed a medication administration record for February 2024 with no documentation of antibiotic use for the observation period of the MDS assessment. Further review of the record failed to show an attending provider's order for antibiotic use in February 2024. On 3/26/24 at 4:20 PM, during an interview with staff #17, the MDS Coordinator, she stated that she referred to attending providers' orders and Medication administration records within the observation period to code section N of the MDS. However, Staff #17 could not provide supporting documentation showing that Resident #17 received antibiotics during the MDS observation period. During a continued interview, Staff #17 confirmed that antibiotic use recorded on Resident #17's MDS assessment, dated 2/15/24, was documented in error. Based on medical record review, interview and observations, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the residents status. This was found to be evident for 4 (Resident #24, #56, #17 and #61) out of 43 residents whose medical records were reviewed during the survey. The findings include: Minimum Data Set- The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. 1) On 3/21/24, review of Resident #24's medical record revealed that the resident had resided at the facility for almost one year. Review of the MDS, with an Assessment Reference Date (ARD) of 2/16/24, revealed documentation that the resident had received 1 injection of insulin during the assessment reference period. Further review of the medical record failed to reveal documentation to indicate the resident received insulin during the assessment period, or had an order for insulin during that time period. On 3/22/24 at 9:34 AM, the surveyor reviewed the concern with the MDS nurse (Staff #17) that the MDS indicated that the resident received insulin but surveyor was unable to find documentation to support that assessment. Staff #17 reported that she did not complete that assessment, it was a different nurse who was working on an as needed basis. On 3/28/24 at 5:10 PM surveyor reviewed with the Director of Nursing the concern regarding the MDS inaccuracy for insulin administration. As of time of survey exit on 3/29/24 at 2:00 PM, no documentation was provided to indicate that the resident had received insulin during the assessment period. 2) On 3/18/24, review of Resident #56's medical record revealed the resident had been receiving Hospice services continuously since September 2023. No documentation was found to indicate the resident was not receiving Hospice services for any period of time since September. Review of the MDS with an ARD of 2/29/24 failed to reveal documentation in Section O Special Treatments, Procedures, and Programs K1Hospice Care to indicate the resident was receiving hospice care while a resident, as evidenced by marking None of the Above for all of Section O. On 3/22/24 at 9:32 AM, surveyor reviewed with the MDS nurse (Staff #17) that the most recent MDS had NO marked for hospice. Staff #17 acknowledged this error, stating a modification needed to be done.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Review of Resident #82's medical records revealed that the resident was admitted to the facility in late 2023 and was cognitively intact. The resident was interviewed and observed on multiple occasions throughout the survey process, and the only activity the resident was observed in was watching TV. On 3/20/24 at 2:05 PM, the Activities Director (AD) was interviewed, and she explained her process when the facility admits a new resident. The AD also reported that she does the activities section of the minimum data set assessment, activity preference interview, and provides feedback and information to the interdisciplinary team when they conduct care plan meetings, and stated, I don't attend the actual care plan meeting, am I supposed to attend? I don't know. The AD indicated that they were trying to come up with a plan to do more activities with residents on the 3rd floor (Resident #82 resides on the 3rd floor). She further reported that, if a resident from the 3rd floor wanted to attend a scheduled activity, they would try to bring them down to the ground floor where they usually hold their group activities stating, I'm not gonna lie, it's hard right now because it's just the 2 of us (referring to the Activity leader, Staff #30). On 3/21/24 at 8:22 AM, Resident #82's medical records were reviewed and failed to reveal a care plan that focused on the resident's activities. Later, at 10:22 AM, the AD was interviewed again, and she confirmed that Resident #82 had no care plan for activities. In this interview, she also confirmed that she does not update resident care plans for activities. On 3/28/24 at approximately 2 PM, the concern was discussed with the Director of Nursing and the Nursing Home Administrator (NHA) that the facility failed to develop a care plan for activities to meet the resident needs. The NHA indicated that they are already aware and were working to resolve the concern. Cross reference F679 2) On 3/20/24 at 10:53 AM, review of records revealed that Resident # 17 was a long-term resident of the facility. On 03/20/24, review of admission Minimum Data Set (MDS) section F, dated 11/15/23, under interview of daily preferences, revealed that resident reported it was somewhat important for him/her to do his/her favorite activities and very important for him/her to participate in religious services or practices. On 3/20/24 at 3:04 PM, review of Resident #17's care plan failed to reveal an activities care plan reflecting the resident's activity preferences. On 3/26/24 at 7:59 AM, during an interview with the MDS Coordinator (Staff #17), she reported that the expectation is that the MDS Coordinator ensured that all the sections of the MDS are completed. The MDS coordinator confirmed that smoking was the only activity listed in the care plan for Resident #17. On 3/26/24 at 8:30 AM, the concerns regarding the lack of an activity care plan for Resident #17 were discussed with the Director of Nursing and the Administrator. The DON and Administrator failed to provide any additional information prior to the end of the survey. 4) On 3/26/24 at 1:19 PM, a review of Resident #43's medical record revealed the resident was readmitted to the facility in mid-March 2024 following an acute hospitalization and had diagnoses that included anxiety disorder and major depressive disorder (depression), and the resident reported symptoms of PTSD. Post-traumatic stress disorder (PTSD) is a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event. A trigger is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening. Review of a Social History Assessment ([NAME]) for Resident #43, with an effective date of 3/18/24 at 10:38 AM, revealed a section labeled PTSD with questions asked to identify symptoms of trauma, followed by a checklist of possible responses that would be checked, or unchecked, depending on a resident's response. The PTSD assessment asked if the resident experienced behavioral, cognitive, and emotional responses to the traumatic event(s), especially within the last month, with responses positively marked indicating that Resident #43 experienced a) a sudden feeling of acting as if the event(s) were actually happening again, or as if s/he was actually reliving it (flashbacks), b) a negative emotional or physical reactions when reminded of the event c) feeling distant from or distrustful of others, often leading to disengagement within social settings, and d) the resident had experienced significant difficulty experiencing positive emotions. The [NAME] indicated that when s/he was in the hospital, Resident #43's symptoms of trauma occurred every couple of days, and, in the past month, the resident had been moderately bothered, inconvenienced, or worried about his/her symptoms. The [NAME] also documented the symptoms severely impacted, or markedly impaired Resident #43's relationships with other people and that few aspects of his/her social function were still intact. The [NAME] documented that Resident #43 had a mental health diagnosis, and the resident self-reported s/he had depression and PTSD. Further review of this assessment failed to reveal documentation of potential triggers. Review of Resident #43's care plans, revealed a care plan, [Resident #43] gives a positive interview for PTSD, initiated on 3/18/24, with the goal, Resident will verbalize to staff, techniques used to calm self-down when triggered, that had 2 interventions, Encourage slow / deep breathing exercise, reassuring conversation with pleasant topics, and observe for increased agitation, anxiety, and offer quiet areas and comfort items. The care plan was not comprehensive, with measurable goals, and resident centered interventions to address Resident #43's PTSD. There was no indication of the resident's symptoms of trauma in the care plan, and there was no indication of the potential triggers which may re-traumatize the resident with a history of trauma along with interventions to address the potential triggers. On 3/28/24 at 12:55 PM, the above concerns were discussed with Staff #12, Social Service Director (SSD). In response, Staff #12 acknowledged the above concern, and stated that a care plan for PTSD was initiated whenever a resident answered the PTSD screening questions positively, even when a resident did not have an actual diagnose of PTSD. Based on medical record review and interview, it was determined that the facility failed to ensure that comprehensive person centered care plans were developed. This was found to be evident for 4 (Resident #59, #17, #82 and #43) out of 43 residents whose medical records were reviewed during the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Minimum Data Set (MDS) is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. 1) Review of Resident #59's medical record on 3/20/24 revealed that the resident was admitted to the facility in the fall of 2023 with diagnoses of, but not limited to, dementia and major depressive disorder. The resident had adequate hearing and speech for communication. Review of the Minimum Data Set Assessment (MDS), with an Assessment Reference Date (ARD) of 10/23/23, revealed the resident was interviewed in regard to Activities and indicated that it was somewhat important to have books, newspapers and magazines to read. Review of Section V Care Area Assessment Summary of the 10/23/23 MDS revealed that Activities triggered and there was a decision to proceed with a care plan to address activities for this resident. Review of the resident's current care plans failed to reveal a care plan addressing activities. Review of a sign-in sheet for a care plan meeting held on 2/16/24 failed to reveal documentation to indicate that the Activity Director attended the meeting. Further review of the medical record revealed that two additional Activity Preference Interviews were conducted by the Activity Director (Staff #7) with the resident on 11/10/23 and 2/26/24. Review of the 2/26/24 Activity Preference Interview revealed the resident liked to play bingo, had a current interest in crafts, liked to listen to music, did not watch much tv, and enjoyed spending time outdoors with family. On 3/20/24 at 2:04 PM, an interview was conducted with the Activity Director who reported that MDS nurse (Staff #17) determined the need for an activity care plan. The Activity Director denied attending care plan meetings for residents. Surveyor reviewed the concern that there was no care plan addressing activities for this resident.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

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Based on observations, interviews, and records review, it was determined that the facility failed to provide an ongoing program of activities based on the comprehensive assessment, care plan, and the preferences of the residents. This was evident for 4 (Resident #82, #75, #23, and #2) of 7 residents reviewed for activities. The findings include: 1) Based on medical record review, Resident #82 was admitted to the facility in late 2023 and was cognitively intact. The resident was interviewed and observed on multiple occasions throughout the survey process, and the only activity the resident was observed in was watching TV. On 3/17/24 at 5:10 PM, Resident #82 was observed in bed watching TV. On 3/18/24 at 11:05 AM, the resident was observed in bed watching TV and was interviewed about activities. The resident reported that the facility held activities downstairs and that s/he could attend if there were enough staff to get him/her up to sit in one of the Geri chairs. There was no alternative other than watching TV in the resident's room. The resident stated, sometimes I want to get up, but they don't have enough chairs or staff. So, when that happens, I just stay in bed. On 3/20/24 at 11:15 AM, the resident was observed in bed watching TV and reported at that time that no one had asked if s/he wanted to be out of bed. Geri chair - these chairs are useful for those with mobility issues and can also be used for bedridden patients who have difficulty sitting upright in a conventional wheelchair. On 3/20/24 at 2:05 PM, the Activities Director (AD) was interviewed, and she explained her process with activities with residents in the facility. The AD also reported that she does the activities section of the minimum data set (MDS) assessment, activity preference interview, and provides feedback and information to the interdisciplinary team when they conduct care plan meetings, and stated, I don't attend the actual care plan meeting, am I supposed to attend? I don't know. The AD indicated that they are trying to come up with a plan to do more activities with residents on the 3rd floor (Resident #82 resides on the 3rd floor). She further reported that if a resident from the 3rd floor wanted to attend a scheduled activity, they would try to bring them down to the ground floor where they usually hold their group activities stating, I'm not going to lie, it's hard right now because it's just the 2 of us (referring to herself and the Activity leader, Staff #30). She also reported that they document in the resident's chart whenever a resident attends group activities. On 3/21/24 at 8:08 AM, Resident #82's medical record was reviewed and revealed an activity preference interview conducted by the AD on 1/30/24. This document identified 8 specific indoor and outdoor activity preferences identified for the resident. Further review of the resident's medical records at 8:22 AM failed to reveal a care plan that focused on the resident's activities. The Task tab in the resident's electronic medical record was also reviewed and revealed staff had documented 13 days in the last 30 days for activity participation.10 days for relaxation/self-directed activity, 1 day for 1:1/conversation/social time/family visits, and 2 days for beverage/snack cart/socials. No other activity was marked for group or outdoor activity that the resident participated in, nor did the resident refuse to attend one. Later, at 10:22 AM, the AD was interviewed again, and she confirmed that Resident #82 had no care plan for activities. She also confirmed that she does not update resident care plans for activities. Also, the AD indicated that she does not document when a resident refused an invitation to attend activities, and stated, I guess I should start documenting the refusals. In this interview, the AD also reported that some documentation could not be found in the electronic medical records, but were stored as paper documents in the activities binder that was kept on each unit. On 3/21/24 at 11:01 AM, a review of the paper document for activities for Resident #82, taken from the activity's binder in the resident's unit, revealed 1 paper that was started for the year 2024, titled Record of One-on-One Activities. This document had the residents name and room number on top, and 3 columns with a header for Date/Initials, Description of Activity, and Resident's Reaction/Response. This document had 7 entries for the 80 days that passed until the time of this review and demonstrated a pattern of Resident #82 wanting to get up but remained in bed. On 3/28/24 at approximately 2 PM, the concern was discussed with the Director of Nursing and the Nursing Home Administrator (NHA) that the facility failed to provide an ongoing program for activities. The NHA indicated that they were already aware and working to resolve the concern. 2) Resident #75 was admitted to the facility in late 2022. A quick review of the resident's medical record indicated that the resident had severe cognitive impairment. On 3/17/24 at 2:40 PM, the resident was observed watching TV in his/her room. On 3/18/24 at 1:03 PM, the resident was watching TV in the day room. On 3/20/24 at 10:49 AM, the resident was eating breakfast and watching TV in his/her room. On 3/20/24 at 2:05 PM, the Activities Director (AD) was interviewed, and she explained her process with activities with residents in the facility. The AD also reported that she does the activities section of the MDS assessment, activity preference interview, and provides feedback and information to the interdisciplinary team when they conduct care plan meetings, and stated, I don't attend the actual care plan meeting, am I supposed to attend? I don't know. The AD indicated that they are trying to come up with a plan to do more activities with residents on the 3rd floor (Resident #75 resides on the 3rd floor). She further reported that if a resident from the 3rd floor wanted to attend a scheduled activity, they would try to bring them down to the ground floor where they usually hold their group activities stating, I'm not going to lie, it's hard right now because it's just the 2 of us (referring to herself and the Activity leader, Staff #30). She also reported that they document in the resident's chart whenever a resident attends group activities. Minimum Data Set- The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. On 3/20/24 at 2:29 PM, Resident #75's medical records were reviewed. The review revealed the resident was not assessed for section F (Preferences for Routine & Activities in the last annual MDS with a reference date of 10/28/23. Further review of the resident's medical record revealed that an activity preference interview was documented by the AD on 12/07/23 which identified specific preferences for indoor, outdoor, individual, and group activities. The AD also indicated in the document that the resident needed assistance getting to and from activities. The Task tab in the resident's electronic medical record was also reviewed and revealed that staff had documented 14 days in the last 30 days for activity participation. The 14 days marked for Resident #75 consisted of: 13 days for relaxation/self-directed activity and 1 day for beverage/snack cart/socials. No other activity was marked for group or outdoor activity that the resident participated in, nor did the resident refuse to attend one. On 3/21/24 at 10:22 AM, the AD was interviewed and indicated that she does not document when a resident refused an invitation to attend activities, and stated, I guess I should start documenting the refusals. In this interview, the AD also reported that some documentation could not be found in the electronic medical records, but kept paper documents in the activity's binder on each unit. The AD also confirmed that she did not assess the resident in the last annual MDS assessment for section F, with a reference date of 10/28/23. Later, at 11:01 AM, a review of the paper document for activities for Resident #75, taken from the activities binder in the resident's unit, revealed 1 paper that was started for the year 2024, titled Record of One-on-One Activities. This document had the residents name and room number on top, and 3 columns with a header for Date/Initials, Description of Activity, and Resident's Reaction/Response. This document had 5 entries for the 80 days that passed until the time of this review and did not indicate any resident-specific activity. On 3/28/24 at approximately 2 PM, the concern was discussed with the Director of Nursing and the Nursing home Administrator (NHA) that the facility failed to provide an ongoing program for activities. The NHA indicated that they are already aware and working to resolve the concern. 3) Resident #23 had been a resident of the facility since 2017. The resident was observed on multiple occasions throughout the survey process, and the only activity the resident was observed in was watching TV. On 3/20/24 at 2:05 PM, the Activities Director (AD) was interviewed, and she explained her process with activities with residents in the facility. The AD also reported that she does the activities section of the MDS assessment, activity preference interview, and provides feedback and information to the interdisciplinary team when they conduct care plan meetings, and stated, I don't attend the actual care plan meeting, am I supposed to attend? I don't know. The AD indicated that they are trying to come up with a plan to do more activities with residents on the 3rd floor (Resident #23 resides on the 3rd floor). She further reported that if a resident from the 3rd floor wanted to attend a scheduled activity, they would try to bring them down to the ground floor where they usually hold their group activities stating, I'm not going to lie, it's hard right now because it's just the 2 of us (referring to herself and the Activity leader, Staff #30). She also reported that they document in the resident's chart whenever a resident attends group activities. Later at 3:46 PM, a review of the activity preference interview, conducted by the AD on 2/26/24, identified that Resident #23 had specific preferences for indoor, outdoor, individual and group activities, and preferred to participate at all times of the day. A review of the Task tab in the resident's electronic medical record at 4:03 PM on the same day, revealed that staff had documented 15 days in the last 30 days for activity participation. The 15 days marked for Resident #23 consisted of: 14 days for relaxation/self-directed activity and 1 days for beverage/snack cart/socials. No other activity was marked for group or outdoor activity that the resident participated in, nor did the resident refuse to attend one. The AD was interviewed again on 3/21/24 at 10:22 AM, and she indicated that she does not document when a resident refused an invitation to attend activities, and stated, I guess I should start documenting the refusals. In this interview, the AD also reported that some documentation could not be found in the electronic medical records, but she kept paper documents in the activity's binder in each unit. A review of the paper document for activities for Resident #75 at 11:01 on the same day, taken from the activity's binder in the resident's unit, revealed one paper that was started for the year 2024, titled Record of One-on-One Activities. This document had the residents name and room number on top, and 3 columns with a header for Date/Initials, Description of Activity, and Resident's Reaction/Response. This document had 6 entries for the 80 days that passed until the time of this review and revealed a pattern of the resident staying in bed. On 3/28/24 at approximately 2 PM, the concern was discussed with the Director of Nursing and the Nursing home Administrator (NHA) that the facility failed to provide an ongoing program for activities. The NHA indicated that they are already aware and working to resolve the concern. 4) Resident #2 was admitted to the facility in early 2023. On 3/18/24 at 3:18 PM, the resident was observed in the day room, sitting in a Geri chair asleep. Later that day at 4:31 PM, the resident representative of Resident #2 was interviewed over the phone. S/he indicated in the interview that the only activity the resident does is watch TV. On 3/20/24 at 9:15 AM, Resident #2's medical records were reviewed and revealed his/her care plan for activities with interventions such as, but not limited to, assist with transport to activities, ensure activities are compatible with the resident, encourage attendance to entertainment programs, large and small group activities, introduce to other residents with similar interests, and invite resident to scheduled activity. A documentation for activity preference interview conducted by the Activities Director (AD) on 2/27/24 was also reviewed and indicated the resident likes watching the Price is Right, any kind of music and different kinds of movies, likes to relax outdoors, likes to converse with others, and prefers to participate at all times of the day. On 3/20/24 at 2:05 PM, the AD was interviewed, and she explained her process with activities with residents in the facility. The AD also reported that she does the activities section of the MDS assessment, activity preference interview, and provides feedback and information to the interdisciplinary team when they conduct care plan meetings, and stated, I don't attend the actual care plan meeting, am I supposed to attend? I don't know. The AD indicated that they are trying to come up with a plan to do more activities with residents on the 3rd floor (Resident #2 resides on the 3rd floor). She further reported that if a resident from the 3rd floor wanted to attend a scheduled activity, they would try to bring them down to the ground floor where they usually hold their group activities stating, I'm not going to lie, it's hard right now because it's just the 2 of us (referring to herself and the Activity leader, Staff #30). She also reported that they document in the resident's chart whenever a resident attends group activities. A review of the Task tab in Resident #2's electronic medical record at 3:24 PM on the same day revealed staff had documented 14 days in the last 30 days for activity participation. The 14 days marked for Resident #2 consisted of: 13 days for relaxation/self-directed activity and 1 day for 1:1/conversation/social time/family visits. No other activity was marked for group or outdoor activity that the resident participated in, nor did the resident refuse to attend one. On 3/21/24 at 10:22 AM, in another interview with the AD, she indicated that she does not document when a resident refused an invitation to attend activities, and stated, I guess I should start documenting the refusals. In this interview, the AD also reported that some documentation could not be found in the electronic medical records, but she kept paper documents in the activity's binder in each unit. A review of the paper document for activities for Resident #2 at 11:01 on the same day, taken from the activity's binder in the resident's unit, revealed 1 paper that was started for the year 2024, titled Record of One-on-One Activities. This document had the residents name and room number on top, and 3 columns with a header for Date/Initials, Description of Activity, and Resident's Reaction/Response. The document had 1 entry dated 3/20, for the 80 days that passed until the time of this review. No other documentation was provided to the surveyor to show other activities the resident had participated in. On 3/28/24 at approximately 2 PM, the concern was discussed with the Director of Nursing and the Nursing home Administrator (NHA) that the facility failed to provide an ongoing program for activities. The NHA indicated that they are already aware and working to resolve the concern. Cross reference F656

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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3) Resident #10 had been residing in the facility since 2021. On 3/17/24 at approximately 2 PM, the resident indicated that s/he had no concern with oxygen (O2) therapy and had not used O2 since being moved to the 3rd floor. On 3/20/24 at 11:21 AM, the resident was observed in bed watching TV with no O2 being administered. The surveyor did not observe an oxygen tank, oxygen concentrator, or any oxygen tubing or supplies in the resident's room. On 3/20/24 at 12:55 PM, Resident #10's medical records were reviewed and revealed the treatment administration (TAR) record for the month of March, with an order that stated, O2 at 2 liters via nasal canula continuous every Day and night shift. This order was marked as administered by the Registered Nurse (RN Staff #6) on duty for day shift at the time. On the same day at 1:22 PM, Staff #6 was interviewed about Resident #10's O2 use, and she reported that the resident was on O2 but did not keep it on and would have documented that action as medication refused, even though O2 was a treatment. Staff #6 was specifically asked if she put the O2 on the resident this morning and she answered yes. Staff #6 was also asked if the resident used an O2 tank or an O2 concentrator, and she stated, I believe s/he has a concentrator. The unit nurse manager (UM Staff #32) who happened to be in the same room and heard the conversation between the surveyor and Staff #6, indicated that Resident #10 had not been on O2 since being transferred into their unit about a month ago. Later at 1:28 PM, Staff #6 stood up and started walking to go into Resident #10's room. The surveyor followed Staff #6 into the resident's room and Staff #6 stated to the surveyor, I think I'm confusing [him/her] with some other resident. I have corrected my documentation for today. Staff #6 was also asked if the ordering provider knew that the resident had not been on O2, and she answered yes. The unit nurse manager (Staff #32) was interviewed afterwards at 1:36 PM and confirmed that the resident had transferred to their unit about a month ago and staff had been documenting the O2 administration without checking it. Staff #32 reported that she would get an order for the O2 administration to be changed to as needed. Staff #32 also confirmed that the physician knew that Resident #10 had not been on O2 since the physician's note indicated that the residents O2 saturation was 97% on room air. The abbreviation prn or PRN (pro re nata) means as needed which is vital to distinguish between routine medication versus medication that is taken only when needed, The concern was discussed with the Director of Nursing (DON) on 3/20/24 at 4:36 PM that the nurses have been documenting the O2 as being administered even when the resident had not had O2 via nasal canula since coming up to the unit about a month ago. The DON confirmed the finding and indicated that they were in the process of getting the order changed to as needed. On 3/21/24 at 10:03 AM, a review of Resident #10's order for oxygen read as: Oxygen at 2 Liters per minute via nasal canula as need for shortness of breath, pulse oximeter of less than 92%. 4) Resident #42 had been a resident of the facility since 2019. Based on observations on 3/17/24 at 3:40 PM, the resident had a G-tube site. PEG: A percutaneous endoscopic gastrostomy (PEG) is a surgery to place a feeding tube. These feeding tubes are often called PEG tubes or G tubes. Feeding tubes, or PEG tubes, allow you to receive nutrition through your stomach. This type of feeding is also known as enteral feeding or enteral nutrition. You may need a PEG tube if you have difficulty swallowing or can't get all the nutrition you need by mouth. On 3/22/24 at 1:22 PM, Resident #42's enteral feeding orders were reviewed and revealed enteral feeding orders that included the flush orders at 150 ml of water every 6 hours for hydration. On 3/26/24 at 8:28 AM, Resident #42's medication administration record (MAR) for the month of March was reviewed and revealed the 150 ml water flush was scheduled to be administered at 12 AM, 6 AM, 12 PM, and 6 PM. Further review of the MAR revealed a pattern for licensed practical nurse (LPN Staff #15) for documenting the flush at 1500 ml of water for the 6 AM dose on 3/2/24, 3/5/24, 3/6/24, 3/8/24, 3/9/24, 3/12/24, 3/14/24, 3/16/24, 3/20/24, and 3/22/24. On 3/23/24 and 3/26/24, Staff #15 had documented 1000 ml water flush for the 6 AM dose. Also, the Registered nurse (RN Staff #10) had documented on 3/4/23 that she administered 240 ml of water flush at the 6 PM dose and 200 ml on 3/23/24 at the 12 PM dose. The findings were reviewed with the Unit Nurse Manager (UM Staff #32) at 9:01 AM on the same day and indicated that she would investigate and get back to the surveyor for an explanation. Later at 11:15 AM, the concern was discussed with the Director of Nursing (DON) that nurses had been documenting a different amount of flush than what has been ordered for a resident. The DON indicated that that the concern was already discussed with her by Staff #32 and that it must be a documentation error and would follow up to see if there was any explanation about the discrepancy. Approximately 5 minutes after, the DON came back to the surveyor and reported that she had no explanation for the discrepancy and confirmed that it was a documentation error. Based on observations, records review, and interviews, it was determined that the facility failed to maintain accurate documentation in the residents' medical records as evidenced by the facility's failure to ensure that staff documented behaviors to indicate the continued need for an antipsychotic medication; failed to ensure that skilled nursing notes accurately reflected a resident's status; and failed to ensure the social service director documented discharge summary/planning information.This was evident for 4 (Resident #56, #29, #10, and #42) of 43 residents reviewed during the survey. The findings include: 1) On 3/18/24, review of Resident #56's medical record revealed that the resident was admitted in September 2023. Review of the physician orders revealed that an order was in place from 1/10/24 until 2/20/24 for Risperdal to be administered two times a day for psychosis. On 2/20/24, there was an order for the Risperdal to be administered only at bedtime for 5 days and then discontinued. Risperdal is an antipsychotic medication. The above orders are called a gradual dose reduction (GDR) and it is a standard of practice to attempt a GDR yearly for an antipsychotic medication. Review of the behavior monitoring section of the Medication Administration Record (MAR) revealed a grid in which staff could enter a number to correspond to behaviors: 1 is for Yelling/Screaming out; 2 is for Pushing away/resisting staff and 3 is for repetitive word/conversation/delusional. Review of the Behavior Monitoring documentation found on the February MAR failed to reveal documentation of behaviors that would indicate the resident was experiencing delusions or other behaviors to indicate psychosis either before, or after, the GDR. On 2/29/24, there was a new order for the Risperdal to be administered two times a day for psychosis. Review of the progress notes revealed a nursing note written on 2/29/24 that stated: Failed GDR. Discussed with [name of primary care physician]. Risperdal reordered. RR [resident representative] aware. Further review of the medical record failed to reveal documentation to indicate why the GDR failed on 2/29/24, i.e. no documentation was found of the resident experiencing behaviors that indicated psychosis. Review of the paper chart revealed a note written by the hospice nurse, dated 3/12/24 at 10:15 AM, that included the following: . Upon entering pt's [patient] room, pt is currently receiving bed bath from [facility] aide; pt is yelling out, crying and pushing back against aide when aide trying to turn pt on [his/her] side to clean [his/her] back .Pt is crying throughout assessment and VS .Facility nurse updated on pt's current status. Further review of the March MAR failed to reveal documentation of the behaviors exhibited on 3/12/24 as evidenced by 0 being documented in this section for the 3/12/24 day shift. On 3/18/24 at 11:30 AM, surveyor, who was in the hallway, could hear the resident actively calling out and yelling at someone. Observation revealed there was no one in the room with the resident at this time. The nurse (Staff #23) acknowledged the residents behavior and stated: I do need to get [his/her] ativan [medication for agitation]. At 11:36 AM, the nurse reported that they just gave the ativan. At 11:55 AM, the resident appears calmer but continued to verbalize to someone not present in the room. On 3/26/24, review of the behavior monitoring sections of the MAR revealed that the nurse (Staff #23) had documented 0s for behaviors during the day shift on 3/18/24. No documentation was found in the medical record to indicate the resident's behaviors on 3/18/24 were documented by nursing staff. On 3/26/24 at 10:36 AM, surveyor reviewed with the DON the concern that surveyor observed the resident calling out to a person not there on the 18th, the nurse acknowledged the behaviors but review of behavior monitoring sheets and progress notes failed to reveal documentation of these behaviors, also reviewed a hospice note that indicated behaviors on 3/12/24 that were not reflected on the behavior monitoring sheets. On 3/28/24 at 12:02 PM, surveyor requested from the Director of Nursing (DON) any additional behavior notes for February or March, and the note regarding the failed GDR on 2/29/24. On 3/28/24, the DON confirmed that there were no additional behavioral notes. 2) Review of Resident #29's medical record revealed an admission in February 2024 for rehab and intravenous (IV) antibiotics following a hospitalization for an infection. The resident was discharged home in March 2024. The resident had a diagnosis of end stage renal disease and was dependent on dialysis. 2a) On 3/27/24, review of the Skilled Documentation being completed by the nurses revealed multiple examples of documentation of services that were not actually being provided or relevant for the resident. These include but were not limited to: - A note dated 2/22/24 at 6:50 PM: .general maintenance of cast, brace splint, general maintenance of ostomy, care/maintenance of foley/suprapubic catheter . -A note dated 2/25/24 at 3:40 AM included: Skilled Services being provided: .general maintenance of cast, brace, splint, general maintenance of ostomy, care/maintenance of foley/suprapubic catheter .psychotropic med changes recent orthopedic surgery, recent amputation .Multiple Sclerosis, Huntington -A note dated 3/2/24 at 12:06 PM again included: .general maintenance of cast, brace, splint, general maintenance of ostomy, care/maintenance of foley/suprapubic catheter . Further review of the medical record failed to reveal documentation to indicate the resident had a cast, brace or splint; an ostomy or a foley/suprapubic catheter, or recent orthopedic surgery and any amputations. The resident was not receiving psychotropic medications and did not have a diagnosis of Multiple Sclerosis or Huntingtons. On 3/27/24 at 3:00 PM, the DON demonstrated in the electronic health record what staff would check off when documenting, and then all the additional documentation that showed up in the actual note. The DON reported that nurses were not able to take out any of the information that was automatically populating in the note. Surveyor reviewed the concern that Resident #29's note includes references to orthopedic care and psychotropic medication changes, but neither were relevant to the resident. On 3/28/24 at 5:10 PM, surveyor reviewed the concern with the DON and the Nursing Home Administrator regarding the failure to ensure that skilled nursing documentation was accurate. 2b) Continued review of Resident #29's medical record revealed a discharge summary with an effective date of 3/18/24. The section Social Services Final Summary was noted to be blank. This section contains areas to document discharge goals and contact information for home health agency and community support programs. Further review of the medical record revealed a care conference note completed by the Social Service Director (Staff #12) on 3/17/24 which included a statement that the resident was agreeable to [name of a home health agency]. No documentation was found to indicate that the home health agency referral was made or that the resident was provided contact information for the home health agency. On 3/27/24 at 11:25 AM, Staff #12 reported that the resident was discharged with home health, and she confirmed that she made a referral to the home health agency and that a liaison saw the resident while still in the facility. Surveyor reviewed the concern that the Social Service section of the Discharge Summary was blank. Staff #12 requested to go look in the computer. At 11:30 AM, Staff #12 confirmed that she did not fill out the Social Service section of the Discharge summary, stating: not sure why not. Surveyor also reviewed the concern that there was no documentation to indicate thta information was provided to the resident regarding home health or transportation. Staff #12 reported she had provided a phone number for a local bus company for door to door transport, but confirmed that she did not document this occurred.

Jan 2024 13 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0551 (Tag F0551)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews, it was determined the facility staff failed to include a resident's Power of Attorney (POA) in the care of a resident (Resident #21) This was evident for 1 of 29 residents reviewed during a complaint survey. The findings include: Review of Resident #22's medical record on 1/3/24 for a concern from Resident #22's POA in February 2023, that he/she has been requesting Physician #1 to contact him/her since the Resident's admission in November 2022, revealed the Resident was admitted to the facility on [DATE] and has a POA listed. Further review of Resident #22's medical record revealed on 1/9/23 the facility staff held a care plan meeting with the Resident's POA and documented, Nursing Unit Manger to have doctor reach out to the POA to discuss lab results. Further review of Resident #22's medical record revealed the first documentation of a physician speaking to the Resident's POA is on 9/23/23 by the Medical Director who is currently the Resident's physician. During interview with the Social Worker on 1/3/24 at 1:07 PM, the Social Worker stated she emailed, phoned and texted Physician #1 several times to call Resident #22's POA and Physician #1 never returned her call and never called Resident's POA according to her knowledge. Interview with the Administrator on 1/9/24 at 2:20 PM confirmed Physician #1 no longer works at the facility.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to provide maintenance and housekeeping services to maintain a safe, clean, comfortable and homelike environment for residents (Residents #7, #21 and #27). This was evident for 3 of 29 residents reviewed during a complaint survey. The findings include: 1. Observation of Resident #7's room on 1/4/24 at 1:40 PM revealed the corner popcorn ceiling spackle hanging down exposing a gray material underneath. During interview of Resident #7 at that time, he/she stated the ceiling has been like that because every time it rains it leaks from the ceiling. Observation of the Resident's bathroom revealed 2 ceiling tiles that were stained, cracked and buckling. The Surveyor brought the Maintenance Director to Resident #7's room on 1/4/24 at 1:55 PM and the Maintenance Director confirmed the ceiling and bathroom tiles needed repair. 2. Observation of Resident #21's room on 1/9/24 at 11:50 AM revealed one bath basin on the bathroom floor and 3 bath basins stacked sitting on the back of the toilet unmarked and uncovered. At that time the front cover of the room's heating unit was loose from the unit, there was no string for the resident to turn on and off the light, and the closet door's bottom hinges were broken making it loose and unsecured. 3. Observation of Resident #27's room on 1/9/24 at 11:55 AM revealed no sheet on the bed, the entire mattress was stained with cracks, there was a TV leaning against the wall sitting on a nightstand, holes in the flooring, a shirt sitting on the bathroom plunger on the bathroom floor, bulletin board hanging on the wall crooked and not secure, a toilet seat cover on the bathroom floor under the sink. The Surveyor observed Resident #21 and #27's room on 1/9/24 at 12:00 PM with the Director of Nursing who confirmed the Surveyor's findings of rooms not safe, clean, comfortable and homelike.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on facility documentation review and interview it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ) for residents (Resident #8, #11 and #13). This was evident for 3 of 7 residents reviewed for facility reported incidents during a complaint survey. The findings include: 1. Review of the investigation of a facility reported incident for alleged abuse of Resident #8 revealed on 10/14/21 at 3:30 AM Resident #8 reported to RN #2 alleged abuse by GNA #4. Further review of the facility investigation revealed the facility staff called the police on 10/14/21 at 12:00 PM but failed to notify OHCQ until 10/15/21 at 9:15 AM. Interview with the Administrator and Director of Nursing on 1/5/24 at 10:25 AM confirmed the facility staff failed to notify OHCQ of an incident of alleged abuse of Resident #8 in a timely manner. 2. Review of the investigation of a facility reported incident for alleged abuse of Resident #11 revealed on 2/2/22 at 1:08 PM the Resident reported in a care plan meeting an allegation of alleged abuse by Certified Medicine Aide (CMA) #1 that occurred in March and April of 2021. Further review of the facility investigation revealed the facility staff called the police on 2/2/22 at 2:30 PM but failed to notify OHCQ until 2/3/22 at 12:50 PM. Interview with the Administrator and Director of Nursing on 1/3/24 at 1:49 PM confirmed the facility staff failed to notify OHCQ of an incident of alleged abuse of Resident #11 in a timely manner. 3. Review of the investigation of a facility reported incident for alleged abuse of Resident #13 revealed on 3/4/22 the Resident reported to the Business Office Manger (BOM) an incident of alleged abuse by the Activities Aide. Further review of the facility investigation revealed the facility staff called the police on 3/4/22 at 12:15 PM but failed to notify OHCQ until 3/5/22 at 11:16 AM. Interview with the Administrator and Director of Nursing on 1/5/24 at 10:18 AM confirmed the facility staff failed to notify OHCQ of an incident of alleged abuse of Resident #13 in a timely manner.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded (Resident #18). This was evident for 1 of 29 residents reviewed during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #18's medical record on 1/3/24 revealed the Resident was admitted to the facility on [DATE] and has a diagnosis to include history of falling. Further review of Resident #18's nurses' notes revealed it was documented the Resident slipped to the ground or fell on 9/28/22, 10/13/22, 10/14/22 and 10/29/22. Review of Resident #18's MDS Section J Health Conditions dated 10/31/22 revealed the facility staff coded the Resident as No in J1800 Any falls since admission/entry or the prior assessment. Interview with the Director of Nursing on 1/5/24 at 9:37 AM confirmed the facility staff failed to capture Resident #18's falls in the MDS assessment dated [DATE].

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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Based on clinical record review and staff interview it was determined that the facility staff failed to ensure a resident had baseline care plans created and initiated for a resident. This was evident for 1 (#12) out of 29 residents in the survey sample. The findings are: A baseline care plan must be prepared for all residents within 48 hours of a resident's admission. Its purpose is to provide the minimum healthcare information necessary to properly care for a resident until a comprehensive care plan can be completed for the resident. The baseline care plan, along with a copy of their medications, is given to the resident and details a variety of components of the care that the facility intends to provide to that resident. This allows residents and their representatives to be more informed about the care that they receive. An investigation into intake #MD00180291 was initiated by the survey team on 1/9/24. The clinical record review revealed an absence of baseline care plans. The resident had cervicalgia, dysphagia, cognitive decline, vascular disease and had other conditions which would have benefited from the development of a baseline care plan. On 1/9/24 at 10:32 AM the Director of Nursing, was interviewed and revealed that no basic care plan meeting occurred on admission.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of a complaint, medical record review and interview with staff, it was determined that the facility failed to implement an effective discharge planning process for residents (Resident #3 and #9). This was evident for 2 of 29 residents reviewed during a complaint survey. The findings include: 1. Review of a complaint from Resident #3's Representative that he/she was not advised of the Resident's care needs or the Resident's discharge on [DATE] to the Representative's home. Review of Resident #3's medical record on 1/4/24 revealed the Resident was admitted to the facility on [DATE] from the hospital. Further review of the Resident's medical record revealed no Social Worker's notes or care plan meeting discussing Resident #3's discharge plan or communication with the Resident's representative regarding the Resident's discharge on [DATE]. Interview with the Director of Nursing and Administrator on 1/4/24 at 10:35 AM confirmed the facility staff failed to have an effective discharge plan in place for Resident #3. 2. Review of a complainant regarding Resident #9 discharge on [DATE] stating the Resident was discharged with no home health or prescriptions. Review of Resident #9's medical record on 1/4/24 revealed the Resident was admitted to the facility on [DATE] from the hospital. Further review of the Resident's medical record revealed a Discharge summary dated [DATE] that did not include the home health company and contact information the Resident was to receive services from. The Resident's medical record did not include copies of any prescriptions the Resident was to receive. Review of the nurses' notes did not include documentation the Resident was given any prescriptions at discharge. Interview with the Director of Nursing on 1/5/24 at 11:20 AM confirmed the facility staff failed to have an effective discharge plan in place for Resident #9.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility staff failed to perform activities of daily living for a dependent resident (Resident #1). This was evident for 1 of 29 residents reviewed during a complaint survey. The findings include: Review of Resident #1's medical record on 1/3/24 for a complaint about not being changed for 5 hours on 3/4/23 revealed the Resident was admitted to the facility on [DATE] and was discharged from the facility on 4/27/23. Interview with Resident #1 on 1/3/24 at 10:25 AM, the Resident stated on 3/4/23 he/she was not changed for about 5 hours and had to lay in his/her own urine and feces. Further review of Resident #1's medical record revealed on 2/21/23 the facility staff completed Resident's annual MDS (Minimum Data Set) Assessment and coded the Resident in Section G0110 Activities of Daily Living (ADL) Assistance as an extensive assistance and 2+ person physical assist for Toilet Use. Review of the facility investigation for this incident revealed a statement from GNA #1 that stated on 3/4/23 the Resident was changed at 5:00 PM and at 6:00 PM he/she stated needed to be changed again, we asked the guys to come from the 3rd floor. GNA #1 stated they did come down but we asked him to wait a minute and when we came back he was gone. Finally someone came down at 10:00 PM to help change the resident. The statement from GNA #2 stated the Resident was changed at 4:30 PM to 5:00 PM and at 6:00 PM he/she told us he/she needed to be changed again. GNA #2 stated we asked the guys on the 3rd floor to come and help, one them came down, we told them to hold on and then he left so we kept calling to get and no one showed up. During interview with GNA #1 and #2 on 1/3/24 at 3:10 PM, GNA #1 and #2 stated they remembered that day in March 2023 we had changed Resident #1 about 5:00 PM and about 6:00 PM the Resident stated he/she needed to be changed again. GNA #1 and #2 stated they can't do it by ourselves so we called for a GNA from another floor and GNA #3 came. We asked him to wait a minute but when we went back to get him he was gone. We told Resident #1 we were sorry but there was nothing we could do since we couldn't do it by ourselves. It was around 10:00 PM when we got more help and changed Resident #1. Interview with the Director of Nursing on 1/4/24 at 9:30 AM confirmed the facility staff failed to provide incontinence for Resident #1 on 3/4/23 in a timely manner.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review on 1/9/24 at 10 AM complaint Reported MD00180291 alleged Resident #12 was discharge from the hospital on [DATE] and admitted into the facility. The compliant stated that he/she was never made aware of any pressure ulcers for Resident #12. Further review of the medical record revealed a weekly skin assessment on 11/3/2021, 11/10/2021, 11/17/2021, 11/24/2021 and 12/12/2021 that revealed that Resident #12 did not have any skin conditions or changes, ulcers, or injuries. On 11/2/21 a Comprehensive skin and wound evaluation for new admission to facility was completed for no wounds by the Certified Nurse Practitioner with the following recommendation: Wound plan of care no open wounds on today's skin assessment; please keep patient's skin clean and dry, apply barrier cream as necessary to prevent skin breakdown, and avoid pressure to any bony prominence by adhering to turn protocols and floating heels as applicable. The Resident was seen by the Wound Care Specialist on 12/8/2021 who documented daily treatment orders for the Resident's Unstageable sacral Pressure Ulcer that was acquired in the facility. Further medical record reviewed revealed on the November and December 2021 Treatment Administration Records and nurses' notes revealed the facility staff failed to provide preventive treatment to the Resident by not following the recommendations of turning and reposition, avoid pressure to any bony prominence and floating heels. Interview with the Director of Nursing on 1/9/24 at 11 AM confirmed the facility staff failed to provide preventive treatment for Resident #12's sacral pressure ulcer. Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #10 and #12). This is evident for 2 of 29 residents reviewed during a complaint survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). A deep tissue injury (DTI) is a unique form of pressure ulcer. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as A pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. 1. Review of Resident #10's medical record on 1/9/24 revealed the Resident was admitted to the facility with diabetes and foot ulcers. Further review of Resident #10's medical record revealed the Resident was seen and assessed regularly by the Wound Nurse Practitioner (Wound NP). A. On 10/5/21 the Wound NP documented the Resident had left buttock (MASD) moisture associated skin damage and to apply Greers [NAME] three times a day. Review of Resident #10's October 2021 Treatment Administration Record (TAR) revealed the facility staff did not document the administration of Greers Goo. B. On 10/12/21 the Wound NP documented the Resident had right knee MASD originally and now with slough and to apply wound cleanser, medihoney and bordered gauze daily. Review of Resident #10's October 2021 TAR revealed the facility staff did not begin the right knee treatment until 10/19/21, 7 days later. C. On 11/30/21 the Wound NP assessed the Resident's right plantar foot wound and added silver alginate to the treatment daily until the Resident was reassessed on 12/7/21. Review of Resident #10's December 2021 TAR revealed the facility staff did not order or administer the silver alginate to right plantar foot wound from 12/1/21 until 12/7/21. D. On 12/14/21 the Wound NP assessed the Resident to have a left heel wound and to apply Betadine twice a day. Review of Resident #10's December 2021 TAR revealed the facility staff administered Betadine once a day instead of twice a day as recommended. Interview with the Director of Nursing on 1/10/24 at 9:41 AM confirmed the facility staff failed to provide treatment for the Resident #1's wounds per the Wound NP's recommendations.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0711 (Tag F0711)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview it was determined physician progress notes were not in a resident's medical record the day the resident was seen (Resident #22). This was evident for 1 of 29 residents reviewed during a complaint survey. The findings include: Review of Resident #22's medical record on 1/3/24 revealed the Resident was admitted to the facility on [DATE] and currently resides in the facility. Further review of Resident's medical record revealed the first physician note is on 4/27/23 by the Medical Director. Prior to 4/27/23 the Resident was under the care of Physician #1. Interview with the Director of Nursing on 1/9/24 at 2:12 PM confirmed their are no physician notes for Resident #22 from admission on [DATE] until 4/27/23. The Director of Nursing also confirmed at that time Physician #1 no longer works at the facility.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility staff failed to provide dental care for a resident (Resident #14). This was evident for 1 of 29 residents reviewed during a complaint survey. The findings include: During interview with Resident #14's representative on 1/8/24 at 1:33 PM, he/she stated the Resident was admitted to the facility on [DATE] with his/her dentures and when he/she visited the Resident on 5/29/21, the Resident's dentures were missing. The Resident's representative stated the facility staff stated they were going to replace the dentures but it never happened and the Resident returned home on 4/26/23 without dentures. Review of Resident #14's medical record on 1/8/24 revealed the Resident was admitted to the facility on [DATE] and the facility staff documented on the Resident's Personal Effects Inventory the Resident had both upper and lower dentures. Review of Resident #14's Speech Therapy Treatment Encounter Notes revealed on 5/20/21 the Speech Therapist (ST) documented, Patient mastication presents nonexistent and ST cued patient to chew each bite; however dentures coming out of oral cavity and patient regurgitation full bites taken. On 7/15/21 ST documented, Patient requests dental consult be completed in order to achieve new dentures to assist with mastication. ST discussed consult is planned and staff is notified. On 1/18/22 ST documented, Patient reports that his/her spouse is questioning status on dentures. Interview with the Administrator on 1/8/24 at 2:50 PM, the Administrator stated Healthdrive provides dental services for the facility. Interview with Healthdrive Customer Service Rep on 1/9/24 at 9:28 AM, Healthdrive received a request for dental service on 11/10/21. Healthdrive stated at that time a notice was sent to the Resident's representative to consent for treatment and billing which was not returned by the Resident's representative so the Resident was placed on a do not treat. Healthdrive stated they would not have follow up on the dental service request unless the nursing home contacted them. Interview with the Administrator on 1/9/24 at 10:00 AM confirmed the facility staff failed to obtain dental services for Resident #14.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #2 and #7) This was evident for 2 of 29 residents reviewed during a complaint survey. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1. Review of Resident #2's medical record on 1/4/24 revealed the Resident was admitted to the facility on [DATE] from the hospital following joint replacement surgery. On 9/27/21 the facility staff completed a Minimum Data Set discharge assessment and coded the Resident as an unplanned discharge to the hospital. Further review of Resident #2's medical record revealed no nurse's note or assessment to explain the events that lead up to the resident's discharge of why he/she was sent to the hospital and what time the discharge occurred. Interview with the Director of Nursing on 1/3/24 at 4:09 PM confirmed the facility staff failed to maintain a complete and accurate medical record for Resident #2. 2. Review of Resident #7's medical record on 1/4/24 revealed the Resident was admitted to the facility on [DATE] and does not have an emergency contact listed on his/her facesheet. During interview with Resident #7 on 1/4/24 at 1:40 PM, he/she stated he/she would like his/her daughter to be listed as an emergency contact. Interview with Administrator on 1/4/24 at 1:50 PM confirmed the Resident #7's medical record does not include an emergency contact.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility staff failed to have quarterly care plan meetings for residents (Resident #1, #7 and #21). This was evident for 3 of 29 residents reviewed during a complaint survey. The findings include: Once the facility staff completes an in-depth assessment (MDS) of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. Care plan meetings are held each quarter and as needed. 1. Review of Resident #1's medical record on 1/3/24 revealed the Resident was admitted to the facility on [DATE] and discharged on 4/27/23. During interview with Resident #1 on 1/3/24 at 10:25 AM, Resident #1 stated the facility was not having regular care plan meetings. Further review of Resident #1's medical record revealed in 2022 the Resident had only one care plan meeting on 6/23/22. Therefore the facility failed to have three of four quarterly care plan meetings. Interview with the Social Worker on 1/3/24 at 3:30 PM confirmed the only care plan meeting held for Resident #1 in 2022 was in June. Interview with the Director of Nursing on 1/4/24 at 9:30 AM confirmed the facility staff failed to have three of four quarterly care plan meetings for Resident #1 in 2022. 2. Review of Resident #7's medical record on 1/4/24 revealed the Resident was admitted to the facility on [DATE] and currently resides in the facility. During interview with Resident #7 on 1/4/24 at 1:40 PM, the Resident stated the facility is not holding care plan meetings. Further review of Resident #7's medical record revealed no documentation of any care plan meetings in 2022 and 2023. Interview with the Director of Nursing and Administrator on 1/8/24 at 1:00 PM confirmed the facility staff failed to have quarterly care plan meetings for Resident #7 in 2022 and 2023. 3. Review of Resident #22's medical record on 1/3/24 for a complaint regarding lack of communication from the facility to the Resident's Power of Attorney (POA) revealed the Resident was admitted to the facility on [DATE]. Further review of Resident #22's medical record revealed the last care plan meeting held with the Resident and the POA was on 2/6/23. Interview with the Social Worker on 1/3/24 at 1:07 PM confirmed the last care plan meeting held for the Resident was 2/6/23. Interview with the Director of Nursing on 1/9/24 at 2:12 PM confirmed the facility staff failed to have quarterly care plan meetings for Resident #22 since 2/6/23.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected multiple residents

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Based on medical record review and interview, it was determined the facility staff failed to provide urinary catheter care to Resident #28 as ordered. This is evident for 1 of 1 resident reviewed during the complaint survey process. The findings include: Investigation of complaint MD00200031 revealed the following: On 1/11/24 at 11:30 AM a review of Resident #28's clinical record revealed that the resident's primary physician wrote an order on 6/21/23, Patient has Foley catheter 16Fr; Balloon size 10 ml, to continuous drain. Diagnosis for use Neurogenic Bladder Provide privacy bag and to change indwelling Catheter and drainage bag every 30 days and when needed. An indwelling urinary catheter (tube) in the bladder is a pliable catheter that drains urine from the bladder into a bag outside the body. A common reason to have an indwelling catheter is urinary retention (not being able to urinate). A neurogenic bladder (urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problem). Further review of the electronic medical record for Resident #28 revealed that the indwelling Catheter and drainage bag was not changed for the months of September, October, and November 2023. On 1/11/24 at 12 PM . After surveyor inquiry, the Director of Nursing reviewed the electronic medical record for Resident #28 and found that the indwelling Catheter and drainage bag were not changed Per Physician order for the months of September, October, and November 2023.

May 2019 31 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on surveyor observation and interview with staff it was determined that the facility failed to keep speech language pathology instructions for the resident in a private setting and failed to promote dignity for the resident by giving instructions and feeding the resident at the nursing station which is also located in front of the elevator. This was true for 1 out 7 residents (Resident #52) reviewed for dignity during the investigation stage of the survey. The findings include: During the initial tour of the facility on 4/24/19, Resident #52 was noted to be sitting on the side of the nursing station visible to all residents, staff and visitors. Further observation revealed the resident frequently yelling I wanna eat. Further tour of the facility revealed a dining area. On 4/25/19 review of the lunch service revealed staff passing out trays leaving Resident #52 to be served last. During an interview with Staff #12 the surveyor asked why the resident was being served last and she replied because Resident #52 needs to be fed. After trays had been passed the surveyor observed Staff #9 sit down and began feeding Resident #52 without moving him/her to the dining area with the other residents. The surveyor asked Staff #9 why she was feeding the resident at the elevator and not in the dining area she verbalized no reason. Observation of the dinner meal on 4/26/19 revealed the Resident #52 with Staff #31 and Staff #9 at the nursing station and in front of the elevator. Staff #31 was instructing the resident on safe eating, encouraging the resident to swallow. An interview with Staff #12, the surveyor asked again why the resident was not in the dining area and she replied: we can put him/her in there. Observation of the lunch meal on 4/29/19 revealed Resident #52 was in the dining area with staff assisting him/her with eating. During an interview with the Director of Nursing on 4/29/19 the concern with staff instructing the resident and feeding the resident in front of a common area was reviewed and acknowledged.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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2. On 4/26/19 at 09:00 AM a medication administration was observed. GNA #21 poured medications into the medication cup for Resident #27 and stated the gentamycin eye drops was not available. Review of Resident #27's medical record on 4/26/19 revealed an active physician order for Gentamycin 1 (gtt) drop QID (four times a day), was written on 4/24/19. Nurse #10 who was assisting on the unit, was made aware the medication was unavailable during an interview on 4/26/19 at 9:45 AM. Another interview was conducted with Nurse #10 on 4/26/19 at 11:20 AM and s/he stated the physician was notified of the medication being unavailable after surveyor intervention. Nurse #10 went on to say the physician wrote an order to hold until medication arrives. The new order was submitted to the survey team on 4/26/19 at 12:30 PM. Based on medical record review and interview with family and facility staff, it was determined that the facility failed to 1. have a system in place to document a change in condition timely and further notify a resident's representative timely of a change in condition for Resident #212 evident during the review of a fall; 2. notify the physician that scheduled medication was unavailable to administer to a resident (Resident #27). This was found to be evident for 2 of 27 residents reviewed during the facility's annual survey. The findings include: 1. During tour of the facility on 4/24/19 at 11:06 AM, Surveyor was notified by Resident #212's family member that Resident #212 had a fall either the previous night or the morning of 4/24/19 and the representative was not notified until he/she had arrived at the facility on 4/24/19. Review of Resident #212's medical record on 4/24/19 at 11:09 AM failed to reveal any documentation of a fall within the past 24 hours. On 4/30/19 at 9:16 AM surveyor requested all investigations related to falls that occurred with Resident #212 in the past 3 months. Staff #10 presented the survey team with 2 fall investigations, 1 of which occurred on 4/24/19 with documentation that the family was notified at 9:30 AM. Further review of the investigation report failed to reveal any documentation of when the fall occurred. Staff #10 who assisted in the gathering and review of medical records reviewed the investigation with the survey team. She concurred that there was no documentation of when the fall occurred. She could only determine when the assessment for the investigation was opened but not when the incident occurred. Resident #212 also had a fall on 4/19/19. Review of the fall investigation revealed that the assessment was opened on 4/20/19. Notification to the representative was attempted at 2:30 AM. Again, there was no documentation in the assessment, or the progress note as to when the fall occurred. The Director of Nursing (DON) and Staff #10 were interviewed on 4/30/19 at 10:06 AM. The concern that the fall/incident assessments failed to include the time the incidents occurred and therefore, the survey team could not ascertain the timeliness of when the representative was notified in relation to the incident was reviewed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews it was determined that the facility failed to maintain the physical environment of the facility in good repair as evidenced by multiple cracked and damaged floor tiles in hallways and resident rooms; damage to walls and doors; loose fitting plumbing fixtures; and resident sinks with a tanish colored build-up on the ledges. The findings include: The following observations were made during the survey: 04/26/19 10:27 AM 3rd floor shower room: approximately 4 inch area of door way into shower noted to be in disrepair; caulking in the shower noted to be cracked. On 4/26/19 at 11:26 AM room [ROOM NUMBER]: damage to doorframe approximately 4 inches x 3 inch; floor noted with stains; crack running almost the entire width of the room noted in the paint on the ceiling near where the ceiling meets the wall above the window. On 4/26/19 at 11:53 AM in the 2nd floor therapy room: damage to wall approximately a 10 inch x 4 inch area noted at the level where a hand sanitizer dispenser could of been attached to the wall. On 4/29/19 at 12:56 PM room [ROOM NUMBER]: bathroom sink noted with a tanish colored build-up on the ledge of the sink; caulking around the sink was not intact. On 4/29/19 at 12:59 PM room [ROOM NUMBER]: approximately 3 inch x 3 inch x 3 inch triangle of floor tile was missing, this tile was in the middle of the room and damage was noted to at least one other tile in the middle of the room. On 4/29/19 at 1:02 PM room [ROOM NUMBER]: bathroom faucet observed to be very loose; toilet with black stains of approximately 6 inches in length along the back inner part of the bowl; sink noted with tanish colored build up on ledge (similar to room [ROOM NUMBER]). room [ROOM NUMBER] bathroom floor tile missing approximately 1.5 inch x 1.5 inch x 1.5 inch area. On 4/29/19 at 1:16 PM first floor main hallway: cracks in more than 20 floor tiles in the hallway between the nursing station and the elevator; tiles are approximately 10 inches x 10 inches and most of the cracks run entire length of the tile. 4/29/19 at 4:00 PM floor tile outside of room [ROOM NUMBER] with an approximately quarter size damage to the tile. On 4/30/19 at 1:37 PM room [ROOM NUMBER] bathroom: black smudge across door into rooms [ROOM NUMBERS]; splatter stains noted; sink with the tanish/greenish color buildup found on other sinks; damage to the wall above the baseboard on room [ROOM NUMBER] side of the wall next to the toilet. On 5/1/19 between 1:30 and 2:30 PM the Environmental Service Director (ESD) and the surveyor toured the facility. The above observations were reviewed and discussed. Additional observations made during this tour included: 5/01/19 at 1:34 PM damage to wall between the the 3rd floor linen room and stairwell, approximately 12 inches x 5 inches. The ESD reported this damage had been reported to maintenance but was not sure if it was in the TELS system. ESD had previously reported environmental services does not have access to TELS. TELS is a system to report and keep track of maintenance both routine and as needed. Bathroom between room [ROOM NUMBER] and 327 observed to have stained floor; build-up on sink as previously observed in other rooms. ESD reported that build-up on the sinks is old lime build up and that environmental services staff have been using pumice stones to get it out. room [ROOM NUMBER]'s ceiling was noted to have cracks in paint. ESD reported several rooms had cracks like the ones observed in this room. Circular crack in floor tile near elevator on the third floor. room [ROOM NUMBER] ceiling was noted to have cracks in the paint where the ceiling meets the wall above the window; damage noted to the wall under the soap dispenser. 05/01/19 01:51 PM second floor main hallway: 8 tiles along hall between nurse's station and elevator; cracks running the length of the tile. 05/01/19 02:04 PM again observed the bathroom between rooms 105/107. The ESD reported the black smudges could be a result of the wheelchair tires; additional observations included damage to the doors from the bottom to approximately 12 inches up; damage to the wall along the base; the greenish/tanish (as observed on several other sinks) build-up on the sink; stains on floor tiles; cracks and missing sections of floor tile and cracks in the caulking. On 5/01/19 at 3:20 PM surveyor reviewed environmental observations with the Maintenance Director and the Administrator. The Administrator reported ESD had given him a list of the observations ESD and surveyor had reviewed/observed earlier in the day. The Administrator went on to report that the facility may be starting renovations.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

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Based on observation, medical records review and interview it was determined that the facility failed to have a system in place to keep track of a resident's purchases. This was true for 1 out of 3 residents (Resident #22) reviewed for personal property. The findings include Review of complaint MD00137346 on 5/1/19 revealed Resident #22 reported that the facility had put the resident's belonging in storage, however when the resident asks for certain items the facility had not been able to provide the resident with the requested items. During an interview with the Administrator or 5/1/19 he verbalized that he was very familiar with the resident. He also stated that the resident in the past was constantly ordering things from the television. He further reported that when the boxes arrived, he would take them to the resident's room where they would be opened, and the resident would decide which items to keep in the room and which items would be put in storage. On 5/1/19 the administrator provided the survey team with 4 pages of itemized purchases with the price of each item that the resident ordered and the date it was delivered. The surveyor asked the administrator where the items were located, and he replied some of the items were in the resident's room and some of them were located out in storage. It was revealed that the items were put in storage by maintenance. Maintenance Director was interviewed on 5/1/19, he revealed that staff removes the items from the resident's room, and he puts in storage. He further revealed that he does not remove anything from the resident's room he just puts it in storage. The surveyor requested to go to the storage area and see the resident's items. On 5/1/19 at approximately 2:30 PM surveyor toured the storage area, which was a locked shed located in the parking area, with the maintenance director and another surveyor. Observation of the storage shed revealed various items such as recliners, bed side commodes and bed frames. The surveyor asked where Resident #22's belongings were located and the maintenance director stated, right here to the right. Upon observing the area designated for Resident #22 while reviewing the 4 pages of itemized purchases only 2-3 items could be identified. When the surveyor requested assistance from maintenance to help locate the resident's belongings he stated again I just put things in here. The surveyor asked who has the keys to the storage area and he replied; the activity department, social services and housekeeping. After observation of the storage shed the surveyor informed the Administrator that only 2 items on the list could be located. The Administrator replied that the resident also has things in his/her room and that he does not keep track of what is in the resident's room and what is in storage. The Administrator acknowledged that even though there is an itemized list of all the resident's belongings he does not keep track of what is in the room and what is in storage. The Administrator also acknowledged that there was no way to know what items were removed from the room or what was removed from storage. The surveyor discussed concern with not being able to supply the resident with requested items due to not being able to locate them. All findings discussed during the survey exit on 5/1/19.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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2. A medical record review for Resident #96 was completed on 04/26/19 at 9:55 AM Resident # 96 was noted to be hospitalized twice since his/her admission to the facility. Further review of the resident's medical record, interview with the resident and the resident's family failed to reveal documentation that anyone was notified in writing of the reason for the resident's transfer. According to complaint #MD000138115 the resident's family was notified that the resident was being discharged . However, further review of the medical record revealed that the facility was planning on the resident returning to the facility after surgery. The family was unaware of this plan according to documentation and interview on 4/25/19 at 2:51 PM. Further review of the medical record failed to reveal any documentation that was given to the resident or family for either hospitalization in January or February 2019. 3. Review of the medical record for Resident #211 on 4/29/19 at 10:46 AM revealed an emergent hospitalization in January 2019. Further review failed to reveal any documentation of notification to the resident or the resident's representative of the reason for the hospitalization. The concern with Resident #96 and #211 was reviewed with the Second floor Unit Manager, Staff #13, and the Director of Nursing on 4/29/19 at 12:10 PM. Staff #13 stated that when a resident is sent to the hospital non-urgently a resident is told the reason for the hospitalization but not in writing. When a resident is sent urgently to the hospital, they are sent without verbal explanation as it is urgent. Interview with the Ombudsman on 5/1/19 confirmed that they are not notified of hospitalizations. Based on medical record review, interview with family, staff and the ombudsman determined that the facility failed to have a system in place to ensure that the resident and/or resident's representative and the ombudsman were notified in writing of the resident's transfer to the hospital and the rationale for the transfer. This was found to be evident for 3 of 5 residents (Resident #54, #96, #211) reviewed for hospitalization during the investigative portion of the survey and related complaints. Findings include: 1. On 4/30/19 review of Resident #54's medical record revealed the resident had been discharged to the hospital in March 2019. Further review of the medical record failed to reveal documentation that the resident, or a responsible party, had been provided with the required transfer information in writing. On 5/1/19 at 1:24 AM surveyor reviewed the concern with the Director of Nursing regarding the failure to provide the required information when residents are discharged to the hospital.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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2. A medical record review for Resident #96 was completed on 04/26/19 at 9:55 AM Resident #96 was noted to be hospitalized twice since his/her admission to the facility. Further review of the resident's medical record, interview with the resident and the resident's family failed to reveal documentation that anyone was notified in writing of the facility bed-hold policy According to complaint #MD000138115 the resident's family was notified that the resident was being discharged . However, further review of the medical record revealed that the facility was planning on the resident returning to the facility after surgery. The family was unaware of this plan according to documentation and interview on 4/25/19 at 2:51 PM. Further review of the medical record revealed the resident was sent to the hospital in January and February 2019. Interview with the resident's family on 4/25/19 at 2:51 PM and Resident #96 throughout the survey and initially on 4/22/19 at 10:30 AM revealed that they were unaware of the facility bed-hold policy and were concerned about where the resident was going to go post hospitalization. 3. Review of the medical record for Resident #211 on 4/29/19 at 10:46 AM revealed an emergent hospitalization in January 2019. Further review of the record failed to reveal notification to the resident or resident's representative of the facility bed-hold policy. The concern with Resident #96 and #211 was reviewed with Second floor Unit Manger staff #13 and the DON on 4/29/19 at 12:10 PM. They confirmed that the facility bed-hold policy is not given to anyone. Based on review of recent facility discharge practices and interview with facility staff, it was determined that the facility failed to provide residents and or their representative (RP) with the proper paper documentation of the facilities bed-hold policy. This was evident for 3 of 5 residents (Resident #54, #96, #211) reviewed for hospitalization during the investigative portion of the survey and related complaints. The findings include: 1. On 4/30/19 review of Resident #54's medical record revealed the resident had been discharged to the hospital in March 2019. Further review of the medical record failed to reveal documentation that the resident, or a responsible party, had been provided with the required bed-hold policy in writing at the time of transfer. On 5/1/19 at 1:24 AM surveyor reviewed the concern with the Director of Nursing (DON) regarding the failure to provide the required information when residents are discharged to the hospital.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0638 (Tag F0638)

Could have caused harm · This affected 1 resident

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Based on review of medical records and interview with staff it was determined that the facility failed to have an effective system in place to ensure Minimum Data Set (MDS) assessments were completed at least once every three months. This was found to be evident for the 2 out of 2 residents (Resident #1 and #3) reviewed as part of the Resident Assessment task during the annual survey. The findings include: The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. Information on the MDS should reflect the seven days up to and including the Assessment Reference Date (ARD). 1. On 4/30/19 review of Resident #1's medical record revealed a quarterly MDS, with an assessment date of 12/18/19 was submitted to CMS on 1/6/19. Further review of the medical record revealed an annual MDS, with an assessment reference date of 3/20/19, which was currently In Progress and as such was neither completed nor submitted to CMS. 2. On 4/30/19 review of Resident #3's medical record revealed an MDS with an assessment reference date of 12/19/18. Further review of the medical record revealed the next MDS assessment had an assessment date of 3/19/19 but was not completed or submitted to CMS until 4/20/19. On 4/30/19 at approximately 10:00 AM the MDS Nurse #14 reported that the goal is to have the assessments completed within a 14 day window, but stated that was not always do able with only me as the MDS coordinator. At 10:10 AM the Corporate MDS Nurse #15 acknowledged that the facility was out of compliance. On 5/1/19 at time of exit surveyor reviewed the concern regarding failure to ensure MDS assessments were completed at least quarterly with the Director of Nursing and the Administrator.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

MDS Data Transmission (Tag F0640)

Could have caused harm · This affected 1 resident

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3. Review of the medical record of Resident #88 on 4/30/19 at 9:00 AM revealed multiple MDS assessments noted as in progress from March and the beginning of April 2019. Resident #88 had a hospitalization and was readmitted to the facility in April 2019. As of review on 4/30/19 the residents discharge return anticipated assessment initiated on 3/31/19 was noted as still in progress. In addition, review of the resident's admission MDS scheduled for 4/8/19 was not submitted until 4/29/19, and the 4/18/19, 14-day assessment was noted as still in progress. This was reviewed with the facility MDS Coordinator Staff #14 and Staff #15, the Corporate MDS Coordinator on 4/30/19 at 10:10 AM. They reported they were aware and working on getting the MDS for all the residents identified back in compliance Based on review of medical records and interview with staff it was determined that the facility failed to have an effective system in place to ensure Minimum Data Set assessments were transmitted within the required timeframes. This was found to be evident for the 3 out of 3 residents (Resident #1, #3 and #88) reviewed as part of the Resident Assessment task during the annual survey. The findings include: The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. Information on the MDS should reflect the seven days up to and including the Assessment Reference Date (ARD). 1. On 4/30/19 review of Resident #1's medical record revealed a quarterly MDS, with an assessment date of 12/18/19 was submitted to CMS on 1/6/19. Further review of the medical record revealed an annual MDS, with an assessment reference date of 3/20/19, which was currently In Progress and as such was neither completed nor submitted to CMS. 2. On 4/30/19 review of Resident #3's medical record revealed an MDS with an assessment reference date of 12/19/18. Further review of the medical record revealed the next MDS assessment had an assessment date of 3/19/19 but was not completed or submitted to CMS until 4/20/19. On 4/30/19 at approximately 10:00 AM the MDS Nurse #14 reported she was the only MDS coordinator in the facility. At 10:10 AM the Corporate MDS Nurse #15 acknowledged that the facility was out of compliance. On 5/1/19 at time of exit surveyor reviewed the concern regarding failure to ensure timely submission of MDS information with the Director of Nursing and the Administrator.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by failure to accurately code the resident vision in section B. This was found to be evident for 1 out of 7 residents (Resident # 28) reviewed during the investigative stage of the survey. The findings include: The Minimum data Set (MDS) is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Its designed to collect the minimum amount of data to guide care planning and monitoring for residents in long-term care settings. MDS assessments need to be accurate to ensure each resident receives the care they need. On 5/1/19 Resident #28's medical records were reviewed and revealed that the resident was admitted to the facility for rehabilitation and long-term care with diagnosis that included legal blindness as defined in the United States. The resident's MDS with an Assessment Reference Dates (ARD) of 1/30/19, 2/3/10 and 2/22/19 reveal the following: Section B: Hearing Speech and Vision. On 1/30/19 the resident was coded a for vision indicating no visual issues, and on 2/3/19 and 2/22/9 reveal the resident was coded a 1 indicating the resident has some impairment but can see large print, but not regular print. During an interview with the resident on 5/1/19 the surveyor asked about his/her vision, the resident reported can't see nothing On 5/1/19 During an interview with Staff #15 while reviewing the medical records and informing her of what the resident reported, Staff #15 acknowledged that the MDS was inaccurate. She further reported that social service will no longer be completing that part of the assessment. All findings discussed with the Director of Nursing and the Administrator during the survey exit on 5/1/19.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/24/19 Resident #57's medical record review revealed that the resident was admitted to the facility on [DATE] for long term care and with diagnoses which includes Pneumonia, Heart Disease, Acute, and Respiratory Failure. Review of the medical records for the Baseline Care Plan revealed that on admission the facility began to obtain information and assess the resident, from the gathering of information, the facility uses the information to build an interim care plan. That interim care plan or baseline care plan was incomplete with no information on pages 2 and 3. The Base Line Care Plan is discussed with the resident or the responsible party (RP) and a summary of the interim care plan is given to the resident or the RP and documented. This was not documented for a copy to be given to the resident and/or RP for Resident #57. During an interview with social services Staff #18 on 4/25/19 at 3:58 PM revealed that the baseline care plan for Resident #57 was not completed and a copy was not given to the resident or the RP. Summaries are not being provided to the residents or their responsible party. The concern regarding the failure to complete and provide baseline care plan summaries to residents or responsible parties was reviewed with the Director of Nursing and the Administrator on 4/26/19 during the review of concerns for that day. Based on review of the medical record and interview with staff it was determined that the facility failed to have a system in place to provide a summary of the interim plan of care to the resident or responsible party. This was found to be evident for 2 out of 3 residents (Resident #312 and #57) reviewed for care planning in the investigative stage of the survey process. The Findings Include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1. On 4/26/19 Resident # 312's medical records were reviewed and revealed that the resident was admitted in March 2019 for respite care and with diagnosis and concerns including seizure disorder stroke and tooth pain Further review of the medical record failed to reveal documentation to indicate a baseline care plan and the summary of the initial care plan had been provided to the resident or the responsible family member. On 4/26/19 the surveyor requested a copy of the baseline care plans and documentation indicating that they were given to the resident or responsible family member. Staff #10 revealed that she is unable to locate and baseline care plans or care plan signature sheet indicating a baseline meeting was held. The concern regarding the failure to provide care plan summaries to residents or responsible parties was reviewed with the Director of Nursing and the Administrator during the survey exit on 5/1/19.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview with facility staff, it was determined that the facility failed to have an updated physician discharge summary and a completed discharge summary on a resident to include a recapitulation of the resident's stay. This was evident in 1 of 3 residents (Resident #311) reviewed for discharge. The findings include: On 5/1/19 Resident #311's closed record was reviewed, and revealed that the resident was discharged from the facility in March 2019. Further review of the closed records revealed a physician discharge summary. This physician discharge summary was missing the date of admission for the resident and a missing signature of who the discharge instructions were given to at the time of discharge. Review of the discharge summary; recapitulation of stay was incomplete. Information for follow-up appointments was missing dates and time. Review of the social service final summary was missing all information, such as discharge date , discharge location discharge goals and any additional information the resident may need on discharge. There was no information from the facility/staff or dietary services on the discharge summary. Further review of the discharge summary; recapitulation of stay signatures from the resident/resident representative and physician were all missing. The findings were reviewed with the Director of Nursing and the Administrator during the survey exit on 5/1/19.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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Based on medical records review and interview with resident and facility staff it was determined that the facility failed to consistently ensure the resident's personal hygiene needs were adequately met when the resident received limited showers. This was evident for 1 of 8 residents (Resident #18) reviewed for activities of daily living in the investigation stage of the survey. The findings include: 1. During an interview with Resident #18 on 4/24/19 the resident revealed that he/she had not had a shower in weeks. The resident further reported that the shower days should be twice a week. On 4/25/19 medical records were reviewed and revealed that the resident was admitted to the facility for rehabilitation and for long term care with diagnoses that included anxiety disorder, diabetes and major depression. During an interview with Staff #9 on 4/25/19 the surveyor asked her what days the resident shower days were, Staff #9 reported that the resident shower days were changed to accommodate the resident. She further reported that the shower days were Wednesday and Saturday. Review of the April shower log failed to reveal any documentation on the resident's scheduled showered days that a shower was given or offered to the resident, or documentation that the resident refused showers. All concerns discussed with Director of Nursing and the Administrator during the survey exit regarding the lack of documentation indicating that the resident was offered a shower.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on observation, interview with staff and family members and review of medical record, it was determined that the facility staff failed to provide activates of daily living specific to grooming on a daily basis to the resident. This was evident of 1 out of 27 residents (Resident #91) reviewed in the investigational process of the survey. Findings include: Observation of Resident #91 on 4/22/19 at 10:06 AM revealed a basin of water and a dry wash cloth on his/her bedside tray. The resident was again observed at 11:02 AM with the same basin of water and a dry wash cloth in the same place as earlier observed. The resident was dressed in a hospital gown and had stringy, matted hair on his/her head. Observation of Resident #91 on 4/23/19 at 10:41 AM and at 2:44 PM revealed the resident to be awake, dressed in a green hospital gown and her/his hair was matted and oily looking. Interview with Geriatric Nursing Assistant (GNA) #23 on 4/23/19 at 11:07 AM revealed the resident was resistive to care. Interview with the resident's brother and mother on 4/26/19 at 10:27 AM revealed the staff leave Resident #91 in a hospital gown for 3 or 4 days in a row. The resident's family had requested to have the residents hair washed and cut several times in the past month and was told the facility would put the resident on a list for a haircut. At the time of the interview the resident was on the list for a haircut. The brother still wanted the resident's hair washed on a weekly basis. The brother stated that the resident's hair had only been washed twice since her admission 2/13/2019. Interview with unit manager Staff #3 on 4/26/19 at 11:40 AM stated she will schedule a haircut and staff will encourage acceptance by the resident for more frequent hair washing. The Director of Nursing (DON) and the Administrator were made aware of concerns on 4/26/19 at 4:17 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation and interview with facility staff it was determined that the facility failed to provide activities for an individual based on their assessment. This was evident in the review 2 of 4 residents (Resident #30 and #211) reviewed for activities. The findings include: 1a. Resident #30 was observed on 4/23/19 at 10:42 AM and was noted asleep in the bed. On 4/29/19 at 12:00 PM, Resident #30 was noted in the room with the television on. Various tours of the second floor between those times failed to reveal any involvement of Resident #30 with any activities or staff other than the television occasionally on. Review of the medical record for Resident #30 revealed diagnoses including a history of a traumatic brain injury (TBI), cognitive communication deficit and paraplegia. Review of the resident's care plan on 4/25/19 at 12:00 PM revealed initiation of an activities care plan on 3/11/19 that the resident is dependent on staff for activities, cognitive stimulation and social interaction. In addition, the intervention included that the resident would attend/participate in activities of choice 1-2 times weekly by next review date. The care plan also documented that the resident liked to cook spaghetti in the past, travel and relax outside. Interview with Staff #11, the activities coordinator on 4/25/19 at 12:31 PM was asked what type of activities are provided for Resident #30. She stated that the family wants him/her brought down to music but the spouse is there most of the time and so they do not do anything else as most of the time the music is in the afternoon and if the resident is sleepy, they do not wake him/her. She was asked if any 1:1 activity was provided for Resident #30 as s/he was unable to initiate activities independently. She stated, no, as she thought the spouse was usually there all day and residents are only are on the 1:1 list if they don't get a visitor. She also revealed that there is no documentation when activities are provided for residents when they participate in group settings. On 4/29/19 the visitation log for Resident #30 was reviewed. It was noted that the resident's spouse only visited in the evening after 5 PM and only for 1-2 hours. On 4/29/19 at 1:55 PM Staff #15 and the activities coordinator Staff #11 were interviewed again. Staff #11 was asked again about the care plan and how they are implementing what is identified, including the identified likes from the resident's past, even if they are no longer a functional ability such as cooking. Staff #11 stated that she just puts in what was reported. The survey team asked if the care plan is used, as it stands to further develop a plan for the residents' activities and Staff #11 did not have a response. The concern that the care plan initiated does not reflect the individual needs of the resident was reviewed with Staff #11 and Staff #4. 1b. Resident #211 was observed on 4/22/19 at 10:24 AM up in bed during a medication pass. At that time there was no television or radio on observed on in the room. Resident #211 was observed again at 11:10 AM and was noted asleep. On 4/23/19 at 12:00 PM Resident #211 was observed sitting up in a chair quietly mumbling to his/herself. There was no one in the room and no television or music noted on in the room. The resident was also noted on strict contact isolation. On 4/29/19 Resident #211's care plan was reviewed. The intervention/task initiated on 2/24/19 included to provide 1 to 1 bedside/in-room visits and activities if unable to attend out of room events. In addition, the care plan documented to provide materials for individual activities as desired, [resident] likes the following independent activities: (specify). No activities were identified. The care plan further identified Resident #211's previous likes such as cooking and certain specific magazines. On 4/29/19 at 1:55 PM Staff #15 and the activity coordinator, Staff #11 were interviewed again. Staff #11 was asked about Resident #211's care plan and how they are implementing what was identified, including the identified likes from the residents past such as the specific magazines. Staff #11 stated that she just puts in the care plan what was reported and currently does not get any newspapers at the facility. The survey team asked if the care plan as it stands is used to further develop a plan for the residents' activities and Staff #11 did not have a response. Staff #22, an activities assistant, was interviewed with Staff #11 and Staff #15 at 2:22 PM on 4/29/19. Staff #22 was asked what 1:1 activity she provides to Resident #211 and she stated that she will do trivia and show him/her fruit and colors. During the medical record review of Resident #211, s/he was noted to have a Brief Interview for Mental Status (BIMS) score of 11, meaning that s/he is mildly cognitively impaired with recall. Staff #22 and Staff #11 were further asked how they determine what level of activities a resident gets and if they are privy to a resident's cognitive status. Staff #22 stated that she did not know she just goes in and talks to them and for Resident #211, she decided to take in fruit and review colors with him/her. Staff #22 and Staff #11 stated that they have an activity cart but could not verbalize how they determine what type of activity one resident gets versus another. This concern that Resident #30 and Resident #211 were not provided with activities identified by either their families or identified by the activities staff to meet the residents individualized needs and cognitive abilities was reviewed on 4/29/19 with Staff #15, Staff #22 and Staff #11.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview it was determined that the facility failed to ensure daily weights were obtained as ordered by the physician. This was found to be evident for 1 out of 6 residents (Resident #81) reviewed for unnecessary medications. The findings include: On 5/1/19 review of Resident #81's medical record revealed diagnoses that include, but not limited to, congestive heart failure (CHF), major depressive disorder and anxiety. CHF is when the heart is not pumping adequately enough to remove excess fluid from the body. Further review of the medical record revealed an order, in effect since 1/3/19, for Daily weight in the morning related to Chronic Diastolic (Congestive) Heart Failure. An increase in weight can be the first indicator of fluid overload and may require medication adjustments. Review of the April 2019 Treatment Administration Record (TAR) revealed the order Daily Wts (weights) - CHF every day shift. Staff had documented that the weights were obtained on 26 out of the 30 days in April 2019. Of the other four days: two days were noted to be missing any documentation, one day there was a reference to the nursing notes, and the fourth day had documentation that the resident refused. Review of the documentation of the weight measurements for April only revealed weight values on 4/3/19, 4/4/19, 4/10/19 and 4/17/19. On 5/1/19 at 12:02 PM the Director of Nursing reported that a check mark [on the TAR] would indicate that a weight was obtained. Surveyor then discussed the concern that the nurses were documenting that the weights were being obtained but frequently no values were found or documentation in the medical record that the weights were refused.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview it was determined that the facility failed to have an effective system in place to ensure that therapy recommendations for splinting devices and restorative nursing services were addressed and implemented if needed. This was found to be evident for 1 out of 5 residents (Resident #62) reviewed for positioning and mobility. The findings include: On 4/26/19 review of Resident #62's medical record revealed the resident had functional limitations in range of motion on one side for both upper and lower extremities. Further review of the medical record revealed a care plan addressing activities of daily living which included the following interventions: PT[physical therapy/OT [occupational therapy] evaluation and treatment as per physician orders. No documentation was found in the current active care plan regarding splinting devices or restorative nursing services for this resident. A.) Further review of the medical record revealed the most recent restorative services found in the TASKS [area of electronic health record for geriatric nursing assistant documentation] was discontinued in January 2018. This corresponds to the resident's most recent occupational therapy services. Further review of the medical record failed to reveal discharge documentation for the end of OT services. On 4/26/19 at 12:02 PM the Rehab Director #20 reported that when residents are discharged from therapy there is a form they complete that includes restorative recommendations. She went on to report this information is given to nursing and that therapy will train the staff just in case the recommendations are ordered. Surveyor then requested any discharge summaries and recommendations for restorative services for Resident #62. On 4/26/19 at 2:40 PM the Rehab Director reported that she was still looking for the discontinuation documentation from the 2018 OT discharge because it is in an email. On 4/29/19 at 12:23 PM surveyor requested the discharge forms for the end of OT services in February 2018 from the Director of Nursing. On 4/29/19 at 4:11 PM surveyor addressed with the Director of Nursing (DON) the concern that the d/c summary from Feb OT has not been provided for review. Further review of the medical record revealed a hand written physician order, dated 1/2/18 for OT order for carrot [a splint device] to be worn on L [left] hand two hours on two hours off while awake. Check after every time taken off for skin breakdown/integrity. Wash and thoroughly dry L hand PRN [as needed] to maintain skin hygiene. No order to discontinue this order was found. Review of the electronic health record revealed the order had been entered into the system on 1/3/18 and included one time only for 30 days. This order was discontinued on 1/4/18 due to clarification. The order was entered again in 1/4/18 and included the following: one time only for Therapy regimen for 30 days and included an end date of 2/3/18. There was no documentation found in the physician order section of the paper chart to that this order was to be limited to 30 days. On 4/30/19 review of the Restorative Nursing Care Referral form for the February 2018 discharge from OT revealed the following: Continue with contracture management and wearing carrot. Frequency 6x/week with a start date of 2/15/18. On 4/30/19 at 12:27 PM the Rehab Director reported that there was no current active order for a splint device, however an order was written in January 2018 for the carrot and when it was transcribed the nurse put in a 30 days stop date. She went on to report they are trying to find out why. The Rehab Director confirmed that OT was still under the impression that the carrot was still being utilized in February [of 2018]. On 4/30/19 at 5:07 PM surveyor reviewed with the DON and the Administrator the concern regarding the failure to implement the order for the carrot due to the the order being put in the system as a one time only order with a 30 day stop date. Also reviewed that OT notes and interview revealed that OT had been under the impression that the carrot splint was continuing to be used. B.) Further review of the medical record revealed the resident #62 had received PT services this spring and the last day of therapy was 4/10/19. Review of the Restorative Nursing Care Referral revealed a recommendation for PROM [passive range of motion] and stretching of the left lower extremities 6 x/week. Further review of the medical record failed to reveal documentation that these recommendations had been reviewed or addressed by the interdisciplinary team. On 4/29/19 at 12:18 PM the DON reported that therapy writes a restorative referral and that if they feel it is appropriate then a restorative plan is written and put into TASKS. The DON reported that the restorative has a meeting to discuss the recommendations. The regional Nurse #15 added that typically the recommendations are discussed within a week from discharge from PT. Surveyor then discussed the concern that there was no documentation found that the restorative recommendations had been addressed by the interdisciplinary team after discharge from PT.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview it was determined that the facility failed to ensure assessments were completed when residents returned from dialysis treatment and failed to ensure an effective system of communication with the dialysis center. This was found to be evident for 1 out of 1 resident (Resident #31) reviewed for dialysis during the survey. The findings include: Review of Resident #31's medical record revealed the resident goes out of the facility for dialysis treatment 3 times a week. Review of the physician orders revealed orders, in effect since November 2018, for a pre-dialysis assessment and a post-dialysis assessment to be completed every day shift every Monday, Wednesday and Friday. On 4/26/19 at 12:50 PM the Unit Nurse Manager #3 stated that there is a communication book that the resident takes to dialysis with him/her. She went on to report that there is a pre-dialysis form that the nurse's complete and send in the communication book. On 4/26/19 at 1:23 PM Unit Nurse Manager #3 reported that there are orders for pre and post dialysis assessment and confirmed that the nurses are expected to assess the residents when they return from dialysis. At 1:32 PM the Nurse #33 reported the resident's return with post weight and post vitals from the dialysis center and stated that is what I put in we do the pre-assessment for them. When asked if any assessment is completed upon return Nurse #33 report nothing that I record. At 1:39 PM Nurse #33 clarified that he does take the resident's vitals himself upon the residents return. At 1:42 PM the Unit Nurse Manager #3 confirmed that nurses should complete a post dialysis assessment form in the electronic health record. On 4/26/19 further review of the medical record for Resident #31 revealed several days in April 2019 when there was no documentation of post dialysis assessment when due. At 1:46 PM this information was reviewed with the Unit Nurse Manager #3. On 4/30/19 further review of the medical record for April 2019 revealed post dialysis assessment forms were completed on 4/10/19, 4/15/19, 4/26/19 and 4/29/19 only. Review of the nursing progress notes for April 2019 failed to reveal any documentation of assessments post dialysis. On 4/30/19 at 1:17 PM review of the dialysis communication book revealed that on 4/3/19 and 4/8/19 the staff failed to complete their section of the pre-dialysis form; no dialysis communication forms were found for 4/17/19 or 4/19/19; and the 4/24/19 form failed to include any documentation from the dialysis unit. Further review of the medical record failed to reveal any documentation of follow up calls to the dialysis unit regarding the missing assessment information for 4/17/19, 4/19/19 or 4/24/19. On 4/30/19 at 1:59 PM surveyor reviewed with the Director of Nursing the concerns regarding failure to complete post dialysis assessments as ordered and failed to ensure communication of pertinent assessment information with the dialysis center.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0711 (Tag F0711)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview with facility staff it was determined that the facility staff failed to document an accurate overview of the resident during a physician visit. This was evident during 1 of 1 physician records reviewed for Resident #22. The findings include: During a telephone interview with Staff #29 in the presence of the survey team, the Director of Nursing (DON) and Staff #15 on 5/1/19 at 7:00 PM, Staff #29 verbalized that secondary to the plethora of medications that Resident #22 is on he did not feel it was appropriate to put him/her on any additional medications related to the residents noted and documented increased anxiety and hoarding behavior. A review of Staff #29's physician notes from December 2018 to April 2019, revealed that Staff #29 documented Resident #22 as receiving 12 main medications, besides antibiotics and skin creams that were administered in January 2019. A review of the residents Medication Administrator Record (MAR) failed to reveal the administration of those same medications December 2018 through April 2019. Resident #22 was noted only to receive 3 of the 12 listed medications, 2 of which were at different dosages prior to December. Resident #22 was receiving 15 other medications not included on Staff #29's physician note under medications attached to this encounter. Staff #29 documented in the physician note under medications attached to this encounter, that Resident #22 was receiving 4 medications for pain including 2 narcotics; Mobic, Ultram, Lyrica and Dilaudid, and a sedative for sleep, all which Resident #22 was not receiving, and had not received in minimally 5 months, according to the review of the resident's MAR. This concern was reviewed with the DON and Staff #15 on 5/1/19 at 8 PM prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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Based on review of employee files and interview with staff it was determined that the facility failed to ensure that a Geriatric Nursing Assistants (GNA), demonstrated competency in skills and techniques to care for residents. This was found to be for 2 out of 2 GNA's (Staff #24 and #25) hired in the past year and selected for review of competencies. The findings include: 1. Review of the employee file for Staff #24 failed to reveal any competencies. Interview on 4/23/19 with the Human Resources director, Staff #4, confirmed Staff #24 was hired on 3/20/19 as a GNA, according to the corporations qualified hire authorization form. Further review of Staff #24's file on 5/1/19 revealed that she had orientation on 3/21/19 and 3/25/19 according to a schedule given to the survey team by Staff #1. Interview on 5/1/19 at 12:54 PM with Staff #15 revealed that for new staff, even if they are new to the field, will be scheduled for 2 shifts per floor. The Director of Nursing (DON) was also present and stated that the new employee will orient on more than one floor so the preceptor will change but their new hire check off sheet will get checked off as they go along. The survey team inquired who determines when the new hire will be able to work independently. Staff #15 and the DON stated that they would have to confirm if the new hire could work on their own before or after the orientation skills check off sheet was completed. They were also asked who reviewed the skills check off sheet prior to the new employee working on their own. At 1:06 PM on 5/1/19 the staffing scheduler, Staff #5, was interviewed and stated that she will start scheduling new hires when the new hire has completed designated training in Relias (a computer-generated training program), they have a month to complete it and they also need to verbalize that they are comfortable on the floor. She further stated that she follows-up with the other staff and Unit managers on the floor on how the new hire is doing. A printout out of Staff #24's Relias training and her orientation check off was requested on 5/1/19. A review of the staffing schedule and observation of the second-floor unit on 4/23/19, 4/24/19, 4/26/19 and 4/29/19 revealed Staff #24 working on the floor independently with no apparent oversight. In addition, Staff #7 a hospitality aide was noted coming to her for guidance on 4/29/19. The staffing scheduled documented Staff #24 working independently on 4/14/19, /4/16/19, ,4/18/19, 4/19/19, 4/20/19 and 4/21. The scheduled documented that she had orientation on 4/9/19, 4/11/19 and 4/13/19. Only three days of orientation were documented and all on the second floor. The DON returned to the survey team on 5/1/19 and stated that the employee is in possession of her new hire check off sheet, not the facility, and the Relias training only had wandering and elopement essentials completed no other mandatory training that were required including; corporate compliance and ethics, abuse and neglect and multiple courses related to care with persons with dementia. 2. Review of the employee file for Employee #25 on 4/22/19 at 1:47 PM revealed in the facility's case status review packet under professional licensing, the status was marked with an X. Further review of the employee's licensure status, it was revealed as suspended. According to the employees file provided by the facility, documentation from the Board of Nursing reported that the license was suspended as: subject violated rules set forth by the Board. Review of Staff #25's punch card revealed that the employee worked on 4/17/19, 4/19/19 and was scheduled to work again the evening of 4/22/19 independently with residents according to the schedule given to the survey The human resources director staff #1 was interviewed on 4/22/19 at 2:06 PM and the packet was reviewed. She confirmed that she missed the information in the packet and further did sign off that the prospective employee could work. The Administrator was interviewed at 2:54 PM regarding Staff #25. The qualified hire authorization form was reviewed. Both Staff #1 and the Administrator's signature was on the form under a statement saying I have reviewed the above required document necessary for the candidate to be qualified for hire. The candidate is qualified to be hired by our facility. Included in the required documents was; license verified and active. The Administrator confirmed his signature on the form and stated that he does not have an answer for that, in reference to Staff #25's suspended license status who was currently on the schedule and working with residents. In addition, there was no training documentation in Staff #25's record for review, including Relias and the orientation check off sheet although Staff #25 was already cleared to work on the floor. On 4/28/19 the DON presented paperwork to the survey team that staff #25's suspension was lifted, and he was cleared to work on the floor according to the Board of Nursing. On 4/28/19 Staff#25 was observed working on the floor independently with no apparent supervision on the second floor. Although Staff #25 was cleared to work on 4/28/19 he/she still was not afforded an orientation program according to what Staff #15 and Staff#1 stated new hires are given. No orientation paperwork or training for Staff #25 was available or provided to the survey team prior to exit. (Cross reference to F 839)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Staffing Information (Tag F0732)

Could have caused harm · This affected 1 resident

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Based on review of pertinent documentation and interview it was determined that the facility failed to retain the posted daily staffing information. This was found to be evident for the entire facility. The findings include: On 4/22/19 the facility was unable to provide posted staffing documentation for the past week. It was found that the posting was only being recorded on a wipe board on the units, per the Director of Nursing upon interview on 4/22/19.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0740 (Tag F0740)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview with facility staff, it was determined that the facility failed to put interventions in place regarding a resident's diagnosis (Resident #22). The findings include: Surveyor interview with Resident #22 on 4/24/19 at 1:08 PM revealed concerns that some of his/her personal items were missing and that the facility had not attempted to find/replace them. The facility Administrator was interviewed on 5/1/19 about Resident #22's items and he stated that s/he has so much that s/he has his/her own storage shed. The Administrator provided the survey team with an itemized list of items that the facility was keeping track of that the resident was buying since December 2018. Members of the survey team asked to see the items on the list. The storage shed was observed with 2 members of the survey team and staff #27 on 5/1/19 at 4:38 PM. Staff #27 stated that he along with the Administrator and the Activities director all have a key to this storage shed. With the assistance of Staff #27, members of the survey team were unable to locate the specific items on the itemized list of Resident #22's belongings. The Administrator was interviewed again on 5/1/19 at 4:50 PM and notified that the items on the list could not be found. He stated that the psych team had been in to see the resident and nothing had changed with him/her. The Administrator came back in at 5:00 PM and stated that the survey team needs to contact the ombudsman and that Resident #22 is a hoarder and there is nothing that they can do with him/her. S/he just keeps buying things and they have nowhere to put it. The survey team asked if the facility is aware of the residents identified hoarding behavior what type of interventions have they tried. The Administrator stated that the psych team had been in and there had been no change. Further review of Resident #22's medical record revealed that on 12/13/18 psych services were asked to see Resident #22 secondary to his/her hoarding behavior. Recommendations were made to discontinue his/her current antidepressant and to start a new one that would be more directed at treating hoarding behavior. There were further directions on how to wean the one medication and start the next. A review of the physician orders and residents Medication Administration Record (MAR) for December 2018 failed to reveal that this intervention occurred. Resident #22 was seen again by psych services on 12/27/18 and the recommendations were repeated to address the residents ongoing anxiety and hoarding behavior. No documentation in the resident's medical record supported this intervention. According to the psych notes, Resident #22 was still verbalizing anxiety, low mood and continuing to order items online with nowhere for them to go. On 1/3/19 Resident #22's antidepressant was stopped abruptly without weaning and the new medication recommended by the nurse practitioner was started, 3 weeks after the initial recommendation. On 3/12/19 the psych nurse practitioner saw Resident #22 again and recommended adding an antipsychotic related to delusional thinking and disturbing thoughts. causing distress. A review of the physician orders and residents MAR for March and April 2019 failed to reveal that this intervention occurred. The Administrator was presented with information on 5/1/19 at 5:00 PM that the psychiatric team was involved and made multiple recommendations related to the residents hoarding behavior that were not followed. He had no answer but wanted the survey team to speak to the resident's attending physician. On 5/1/19 at 7:02 PM the survey team along with the Director of Nursing (DON) and Staff #15 spoke with Staff #29 over the phone. The concern related to medical and non-medical interventions with Resident #22 were reviewed. Staff #29 why asked why the recommendations by the psych team were not followed and he stated that he does not have to follow their recommendations. He believes the resident has a borderline personality disorder. He was asked why he made a recommendation for the resident to see psych, as per physician note 1/28/19, and further not adjust her medications accordingly. He stated that he did not feel that she met the criteria to go on an antipsychotic and did not want to get cited by CMS for putting a resident on that medication. The survey team tried to clarify with Staff #29 why he had Resident #22 seen by the psychiatric and psychology team if he did not believe in their diagnosis and treatment and he stated that he was the attending and did not have to go by what they said. At exit on 5/1/19, Resident #22 still was noted to display hoarding behaviors and has complained of missing items of which the facility had been unable to show the resident or survey team where all those items were located although they were attempting to itemize them once they arrive at the facility. This concern was reviewed at the time of exit on 5/1/19 with the DON, Staff #15 and the Administrator.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview with facility staff, it was determined that the facility failed to provide adequate indications for the usage of an anxiety medication. This was evident for 1 of 5 residents (Resident #88) reviewed for unnecessary medication use. The findings include: Review of the medical record for Resident #88 on 4/29/19 at 3:44 PM revealed diagnoses including anxiety and major depressive disorder. Further review revealed a recent discharge from the hospital. Review of the hospital summary documented under the medication list for the resident to 'STOP' taking previously prescribed anxiety medication. Review of the Resident #88's admission medication orders on 4/1/19 did not include the anxiety medication. On 4/4/19 an order was noted in the computer for the anxiety medication at a dose twice what the resident was taking prior to the hospitalization from .125 mg to .25 mg every 12 hours. Physician note from 4/12/19 document that the family was concerned related to the residents increased sleepiness during the day and recommended that the resident receive no narcotics. On 4/15/19 when the physician saw the resident his/her night time sleeping aid was decreased as there was still reports of him/her sleeping during the day time. On 4/18/19 the facility nurse practitioner who saw the resident for psychiatric medication management acknowledged that the resident's anxiety was 'pretty well controlled per the staff.' The psychiatrist had no medication recommendations. The resident's antianxiety medication was noted at .25 mg every 24 hours. The physician notes for 4/19/19 documented that the family was still concerned related to the residents increased sleepiness during the day. The physician visited the resident on 4/22/19 and noted that s/he is doing fairly well and tolerating the changes to his/her sleeping pills. Further review of Resident #88's medical record revealed that the anxiety medication was changed on 4/25/19 from every 12 hours to once a day. On 4/27/19 an order was noted in the computer to increase the resident's anxiety medication and double it from .25 mg a day to .5 mg a day. Further review of the medical record failed to reveal a note from the physician about the medication changes, rational to the medication changes or corresponding electronic orders put in by the physician. This concern was reviewed with the Director of Nursing and Staff #15 on 5/1/19 at 12:33 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview with facility staff, it was determined that nursing staff failed to sign off the administration of a narcotic on the Medication Administration Record (MAR) and the Controlled Substances Record consistently. This was evident during the review of 1 of 5 residents (Resident #88) for unnecessary medications. The findings include: 1. Review of the medication administration record (MAR) for Resident #88 on 4/30/19 at 11:31 AM revealed discrepancies for the months of March and April 2019, between his/her MAR and controlled drug receipt/record/disposition form. The purpose of the controlled drug receipt is to consistently count controlled substances or narcotics and to monitor narcotic administration and ensure accountability of all substances and narcotics. According to the MAR, Resident #88's sedative was ordered every 12 hours as needed. On 3/30/19 at 8:46 PM the medication was signed off as administered but there was no corresponding sign-out on the controlled drug log. On 4/17/19 at 9:34 PM and 4/30/19 8:41 AM, the medication was also signed off as administered, however the medication was not signed out on the controlled drug receipt. Review of the controlled drug receipt showed that the sedative was administered on 3/28/19 at 10 PM. There was also another one signed out after 3/29/19. There was no date documented when the medication was taken from the narcotic box, only a time documented of 8:45 PM. On 4/23/19 at 8 PM and 4/28/19 at 8:42 AM the medication was signed out of the narcotic box, however, there was no record on the MAR of the medication administration to the resident. These concerns, along with the documentation was reviewed with Staff # 15 and the Director of Nursing on 5/1/19 at 12:50 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0790 (Tag F0790)

Could have caused harm · This affected 1 resident

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Based on medical records review and interview with staff it was determined that the facility failed to arrange a dental appointment for the resident in a timely manner this was true for 1 out of 1 resident (Resident #312) reviewed for dental in the investigative stage of the survey. The Findings Include: During an interview with Resident #312 on 4/24/19 the resident verbalized his/her main concern was tooth pain. The resident reported that his/her tooth was very painful. The resident further reported that staff was aware of the tooth pain. On 4/26/19 Resident #312's medical records were reviewed and revealed that the resident was admitted to the facility 3/30/19 for respite care (temporary institutional care of a sick, elderly, or disabled person, providing relief for their usual caregiver) and with diagnosis which included seizure disorder. Review of the nursing note revealed a note written on 4/1/19 which stated: Resident complained of extreme tooth pain rated at greater than 10. Resident states he/she sustained damage to her/his teeth during a seizure. Resident was ordered pain medication for tooth pain. Nursing note revealed the resident had been receiving pain medication related to frequently complaints of oral discomfort. Medical records revealed an order dated 4/11/19 for Dental consult for tooth pain, further review revealed that the resident had an appointment May 16, 2019. During an interview with the Director of Nursing (DON) and the Administrator on 4/26/19 the surveyor expressed concern with the delay in obtaining a dental consult for a resident that had been having dental pain since admission. The DON informed the surveyor that arrangements had been made for the resident to have dental consult on 4/30/19 and not 5/16/19. All concerns discussed with the DON and the Administrator during the survey exit on 5/1/19.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0839 (Tag F0839)

Could have caused harm · This affected 1 resident

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Based on review of employee files and interview with facility staff it was determined that the facility failed to employee staff with active professional licenses relevant to their hired job descriptions. This was evident during the review of 2 of 2 employee files, (Staff #24 and #25) The findings include: 1. Review of the employee file for Staff #25 on 4/22/19 at 1:47 PM revealed the employee was hired for the position of a geriatric nursing assistant (GNA) with a start date of 4/17/19. Review of the facility's case status review packet under professional licensing, the status was marked with an 'X.' Further review of the employee's licensure status as a geriatric nursing assistant (GNA), it was revealed as suspended. According to the employees file provided by the facility, documentation from the Board of Nursing reported that the license was suspended as: subject violated rules set forth by the Board. Review of Staff #25's punch card revealed that the employee worked on 4/17/19, 4/19/19 and was scheduled to work again the evening of 4/22/19 independently with residents according to the schedule given to the survey The human resources director Staff #1 was interviewed on 4/22/19 at 2:06 PM and the packet was reviewed. She confirmed that she missed the information in the packet and further did sign off that the prospective employee could work. The Administrator was interviewed at 2:54 PM regarding Staff #25. The qualified hire authorization form was reviewed. Both Staff #1 and the Administrator's signature was on the form under a statement saying I have reviewed the above required document necessary for the candidate to be qualified for hire. The candidate is qualified to be hired by our facility. Included in the required documents was; license verified and active. The Administrator confirmed his signature on the form and stated that he does not have an answer for that, in reference to Staff #25's suspended license status who was currently on the schedule as a GNA and working with residents. 2. Review of the employee file for staff #24 on 4/23/19 revealed that the employee was hired as a GNA on 3/20/19. Review of the facility's case status review packet under professional licensing, the status was marked with an 'X.' Further review of the employee's license revealed that she had a certified nursing assistant license through the state of Delaware, not a GNA license, which would be someone with specific geriatric education and passed the state examination. Interview on 4/23/19 with the Human Resources director, Staff #4, confirmed Staff #24 was hired on 3/20/19 as a GNA, according to the corporations qualified hire authorization form. Staff #1 was questioned about the employee's license and she stated that she was monitoring when the employee's GNA licensure went through. She further stated that when she was hired, she had a scheduled date of when she was taking her GNA exam. Further review of Staff #24's file on 5/1/19 revealed that she had class orientation on 3/21/19 and 3/25/19 according to a schedule given to the survey team by Staff #1. Staff #4 had worked on the floor on 4/9/19, however, her GNA licensure did not go through the Board of Nursing until 4/10/19 and therefore, she was not licensed as a GNA in the state of Maryland when she was working hands on with residents on 4/9/19 according to the schedule given to the survey team by the facility on 4/22/19. Interview on 5/1/19 at 12:54 PM with Staff #15 revealed that for new staff, even if they are new to the field, will be scheduled for 2 shifts per floor. The Director of Nursing (DON) was also present and stated that the new employee will orient on more than one floor so the preceptor will change but their new hire check off sheet will get checked off as they go along. According to the schedule, staff#24 had floor orientation on 4/9/19, 4/11/19 and 4/13/19 on the second floor. However, the staffing scheduled documented staff #24 working independently on 4/14/19, 4/16/19, 4/18/19, 4/19/19, 4/20/19 and 4/21/19 and on 4/23/19, 4/24/19, 4/26/19 and 4/29/19 Staff #24 was observed working on the floor independently with no apparent oversight.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During the medical record review on [DATE] at 11:25 AM for Resident #30, 2 active MOLST's with differing dates and resuscitation orders were noted on the chart. One MOLST had an order for the resident to be incubated one with a more recent date stated do not intubate (DNI). At 11:56 AM on [DATE] the Unit Manager, Staff #13 was interviewed regarding the process when a resident is found in need of cardiopulmonary resuscitation and the code status is not known. She stated that you always check the MOLST, if the resident requested cardiopulmonary resuscitation (CPR) you grab the cart and initiate. Staff #30 was asked to review the medical record for Resident #30. She was further asked in the situation where there is 2 MOLST's what you would do. She stated in this case you would look at the date. Surveyor stated concern about staff actually looking through the chart for additional MOLST's in a code situation or going by the first MOLST that they come to. Staff #30 stated that she understood the concern. On [DATE] at 12:13 PM the DON and the Administrator were notified of the concern regarding the findings of the 2 MOLST forms on Resident #30's chart. Interview with the facility social work designee, Staff #18 on [DATE] at 11:43 AM revealed that she was aware of the surveyor's findings on [DATE]. Staff #18 was asked if she reviewed MOLST's with the residents or representatives on admission and she stated yes within 48 hours with the care plan. The concern that 2 MOLST's dated [DATE] and [DATE] were actively on the chart were reviewed with her at that time. 5. Review of the medical record for Resident #88 on [DATE] at 11:31 AM revealed an order on [DATE] for a CHEM-8, ( a blood test for electrolytes such as sodium and potassium). Further review of the medical record for Resident #88 failed to reveal the presence of the lab on the chart. Staff #10 was asked if the lab was in medical records or if she could locate it. On [DATE] the lab was presented to the survey team by Staff #10 and had been printed by the DON. They both acknowledged that it was not on the chart and could not confirm if the physician had reviewed the lab or not. Review of the physician notes for the [DATE] visit after the [DATE] order did not mention review of the lab work. Based on medical record review and interviews it was determined that the facility failed to: 1) ensure reports from outside providers were available in the medical record for review by other health care providers; 2.) failed to ensure certifications of medical ineffectiveness and or end stage/terminal condition were completed and on the chart for a resident whose surrogate decision maker made the decision for the resident to have a No CPR (cardiopulmonary resuscitation) order; 3.) failed to ensure physician notes were maintained on the medical record for other health care providers to review;. 4.) failed to have the correct Maryland Order for Life Sustaining Treatment (MOLST), active on a resident's chart.; 5.) failed to have completed labs on the chart. This was found to be evident for 5 out of 27 residents (Resident #90, #23, #81, #30 ,#88) reviewed during the investigative stage of the survey. The findings include: 1. On [DATE] the Resident #90 reported having had a sleep study about the first of the month. On [DATE] review of the medical record revealed a sleep study report dated [DATE] which recommended a CPAP (continuous positive airway pressure) titration study. There was a hand written note on this report that a CPAP titration study had been set up for [DATE] at 8:00 PM. This hand written note was signed by the Unit Nurse Manager #3. A corresponding physician order for the [DATE] sleep study was found. Further review of the medical record failed to reveal a report from the [DATE] sleep study or any nursing notes regarding the [DATE] sleep study. On [DATE] at 12:30 PM the unit nurse manager #3 reported the resident needs to return for another titration study because they did not do the test correctly. When asked specifically about the report from the [DATE] sleep study the Unit Nurse Manager #3 reported that they did not fax a report over, they had just called and told her the test needed to be re-done. At 12:49 PM the Unit Nurse Manager #3 confirmed there was no nursing note regarding the need to re-schedule the sleep study. On [DATE] at 4:15 PM surveyor reviewed with the Director of Nursing the concerns regarding the failure to have a care plan addressing oxygen use, sleep apnea and the need for a follow-up CPAP titration study for this resident. The facility later provided a copy of the CPAP titration study report, signed [DATE], which revealed the following assessment/plan: Obstructive sleep apnea and probably obesity hypoventilation syndrome: CPAP retitration beginning at 18 cm H2O is recommended. Further review of this report revealed it was printed by the DON on [DATE]. 2. On [DATE] review of Resident #23's medical record revealed the resident was originally admitted to the facility in 2017 and whose diagnosis included dementia. Review of Resident #23's MOLST form revealed that the orders were entered as a result of a discussion with and informed consent of the patient's surrogate as per the authority granted by the Health Care Decisions Act. A hand written notation indicated this was the resident's spouse. The MOLST included current orders for No CPR. The MOLST was dated [DATE]. Further review of the medical record, including the chart on the unit and the electronic health record miscellaneous documentation section, failed to reveal any advance directives, certifications of incapacity to make informed decisions, certification of end stage/terminal condition or certifications of medical ineffectiveness regarding CPR. On [DATE] at 12:11 PM surveyor requested any certifications of incapacity from the medical records staff #10, explaining that none could be found in the chart on the unit. On [DATE] at 12:12 PM an interview was conducted with the social service designee (SSD)#18. The SSD was unable to verbalize the required paperwork that was needed for a resident with certs of incapacity, prior to making the resident a DNR [No CPR]. After the interview the SSD presented with the Physician Certification of Incapacity to Make an Informed Decision signed by two physicians in [DATE]. On [DATE] at 2:49 PM in a follow-up interview the SSD reported that once the certification of incapacity was completed the decisions were made by the spouse. She confirmed there was no advance directive. When asked if there was any certifications of medical ineffectiveness the SSD responded: no, I believe [resident] only has certs for incapacity. On [DATE] at 2:56 PM the Director of Nursing (DON) verbalized that additional documentation was required prior to initiating a No CPR order for a resident who was incapable of making health care decisions and lacked an advance directive. Surveyor reviewed the concern with the Administrator and the DON that the resident had a No CPR order based on the decision made by the surrogate decision maker in the absence of additional required documentation. On [DATE] at 9:42 AM a copy of a medical ineffectiveness form, dated [DATE], was provided for review by the DON. 3. On [DATE] review of Resident #81's medical record revealed diagnoses that include, but not limited to, congestive heart failure (CHF), major depressive disorder and anxiety. The resident receives antidepressant and antianxiety medication on a daily basis. Further review of the medical record revealed that on [DATE] the antianxiety medication dosage had been increased. No documentation was found in the primary care physician, psychiatry or the nursing progress notes regarding the need to increase the anti-anxiety medication. This concern was reviewed with the Director of Nursing (DON). On [DATE] at 12:31 PM the DON presented with a note written by the psychiatric nurse practitioner, dated [DATE]. Review of this note revealed documentation about the need for and the plan to increase the antianxiety medication. Surveyor then reviewed the concern with the DON regarding the need for provider notes to be on the chart for review by other providers.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected 1 resident

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Based on review of Quality Assurance (QA) sign in sheets and interview it was determined that the facility failed to ensure the QA committee met at least quarterly. This was found to be evident for the first quarter of 2018 and has the potential to affect all the residents. The findings include: On 5/1/19 review of the Quality Assessment Assurance Committee sign in sheets for 2018 failed to reveal any documentation of a meeting in January, February, March, April or May of 2018. On 5/1/19 at 7:47 PM the Director of Nursing reported that he was unable to provide sign in sheets for the QA meetings for January thru May 2018.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observations and interviews with facility staff it was determined the facility failed to adhere to infection control practices and procedures by ensuring that a resident room was kept clean and dry and free of drainage. This was evident for 1 (Resident #81) reviewed during the facility's annual survey. The findings include: An observation was made of Resident #81 on 4/22/19 at 11:30 AM. The resident was sitting in a wheelchair in his/her room and there was a large wet puddle on the floor underneath the wheelchair. On the same date at 12:10 PM GNA, Staff #9 was made aware and went into the room to assist the resident. The GNA stated the resident has edema (swelling) to both legs and seepage occurs occasionally. In a interview with the Unit Director (UD), Staff #12 on 4/22/19 at 12:20 PM s/he was made aware of the resident sitting in his/her wheelchair with a wet puddle on the floor underneath him/her. The UD stated the resident has bilateral edema to the legs. Another observation was made of Resident #81 on 4/26/19 at 10:45 AM. The resident was sitting in a wheelchair in his/her room and there was a large wet puddle underneath the wheelchair. The nurse working on the unit was made aware at that time. On 4/29/19 at 11:20 AM Resident #81 was observed sitting in a wheelchair in his/her room. A large wet puddle was observed on the floor underneath the resident wheelchair. At 11:45 AM on the same date the Nurse #32 was asked to accompany the surveyor to the resident room, where the resident was observed sitting in his/her wheelchair and a large wet puddle underneath him/her. The nurse told housekeeping staff to clean the resident room. Nurse #32 stated the resident positions him/herself in the wheelchair and urinates on the floor. The nurse went on to say the resident had been urinating on the floor for a long time. The Nurse was made aware that this was a concern as the resident was observed for 25 minutes with no assistance offered. The Director of Nursing was made aware on 4/29/19 at 12:00 PM of the multiple observations being of concern.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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6. Observation of Resident #57 on 4/22/19 at 9:32 AM, and 1:32 PM, and 4/23/19 at 2:10 PM revealed the resident had 2 liters of oxygen via nasal cannula. Interview with GNA #23 on 4/23/19 at 2:22 PM revealed that the resident would at times want to remove the nasal cannula but for the most part was compliant. Review of the medical record and care plan on 4/25/19 at 2:47 PM for Resident #57 revealed diagnosis including Pneumonia and Acute respiratory failure. Review of the 3 page care plan did not reveal any focus or interventions related to respiratory problems. On 4/30/19 at 4:45PM, staff Licensed Practical Nurse (LPN) #10 brought a 12 page resident care plan and revealed that the resident was returned to the facility 3/11/19 after a hospitalization but the care plan that was previously in place for the resident was not updated and revised upon the residents re-admission. The Director of Nurses (DON) and the Administrator were made aware of this concern on 4/30/19 at 5:05PM. 3a. Resident #30 was observed on 4/23/19 at 10:42AM. and noted asleep in the bed. Prior to that therapy was noted in the room providing in room care. On 4/29/19 at 12:00 PM, Resident #30 was noted in the room with the television on. Various tours of the second floor between those times failed to reveal any involvement of Resident #30 with any activities or staff other than the television occasionally on. Review of the medical record for Resident #30 revealed diagnoses including a history of a traumatic brain injury (TBI), cognitive communication deficit and paraplegia. Review of the resident's care plan on 4/25/19 at 12:00 PM revealed initiation of an activities care plan on 3/11/19 that the resident is dependent on staff for activities, cognitive stimulation and social interaction. In addition, the intervention included that the resident would attend/participate in activities of choice 1-2 times weekly by next review date The care plan also documented that the resident liked to cook spaghetti in the past, travel and relax outside. Interview with Staff #11, the activities coordinator on 4/25/19 at 12:31 PM was asked what type of activities are provided for Resident #30. She stated that the family wants him/her brought down to music but the spouse is there most of the time and so they do not do anything else as most of the time the music is in the afternoon and if the resident is sleepy, they do not wake him/her. She was asked if any 1:1 activity was provided for Resident #30 as s/he was unable to initiate activities independently. She stated no as she thought the spouse was usually there and they only are on the list if the residents don't get a visitor. She also revealed that there is no documentation when activities are provided for residents in a group. On 4/29/19 the visitation log for Resident #30 was reviewed. It was noted that the resident's spouse only visited in the evening after 5 and only for 1-2 hours. On 4/29/19 at 1:55 PM Staff #15 and the activity nurse were interviewed again. Staff #11 was asked again about the care plan and how they are implementing what is identified, including the identified likes from the resident's past, even if they are no longer a functional ability such as cooking. She stated that she just puts in what was reported. The survey team asked if the care plan is used, as it stands to further develop a plan for the residents' activities and Staff #11 did not have a response. The concern that the care plan initiated does not reflect the individual needs of the resident was reviewed with Staff #11 and Staff #4. 3b. Observation of Resident #211 on 4/22/19 at 10:24 AM revealed s/he up in bed, there was no television on, and medication pass was in progress. Resident #211 was observed again at 11:10 AM and was noted asleep. On 4/23/19 at 12:00 PM Resident #211 was observed sitting up in a chair quietly mumbling to his/herself. There was no one in the room and no television or music noted on. The resident was also noted on strict contact isolation. On 4/29/19 Resident #211's care plan was reviewed. The intervention/task initiated on 2/24/19 included to provide 1 to 1 bedside/in-room visits and activities if unable to attend out of room events. In addition, it documented to provide materials for individual activities as desired, [resident] likes the following independent activities: (specify). No activities were identified. The care plan further identified Resident #211's previous likes such as cooking eggs and scrapple and certain magazines. On 4/29/19 at 1:55 PM the Regional Nurse Staff #15 and the activity nurse were interviewed again. Staff #11 was asked about the care plan and how they are implementing what is identified, including the identified likes from the residents past such as the specific magazines. She stated that she just puts in what was reported and currently does not get any newspapers at the facility. The survey team asked if the care plan as it stands is used to further develop a plan for the residents' activities and Staff #11 did not have a response. Staff #22 was interviewed with Staff #11 and Staff #15 at 2:22 PM on 4/29/19. Staff #22 was asked what 1:1 activity she provides to Resident #211 and she stated that she will do trivia and show him/her fruit and colors. Staff #22 and Staff #11 were further asked how they determine what level of activities a resident gets and if they are privy to a resident's cognitive status. Staff #22 stated that she did not know she just goes in and talks to residents and for Resident #211, she decided to take in fruit and review colors with him/her. Resident #211 was noted with a Brief Interview for Mental Status (BIMS), of 11 indicating mild cognitive impairement. Staff #22 and #11 stated that they have an activity cart but could not verbalize how they determine what type of activity one resident gets versus another. This concern and the fact that the resident's care plan was not individualized regarding activities was reviewed at that time with the regional Resident Care Coordinator Nurse Staff #15, Staff #22 and Staff #11. 4. Review of the medical record for Resident #88 on 4/30/19 at 11:33 AM revealed diagnoses including; anxiety disorder, major depressive disorder and insomnia. Further review of the resident's medical record revealed hospital discharge instructions and admission physician orders for anxiolytics, antidepressants and hypnotics for sleep aids. A review of the resident's care plans at that time failed to reveal a care plan for any of those diagnoses or medication usages. This was reviewed with the Director of Nursing (DON) on 5/1/19 at 1:33 PM. 5. Review of the medical record for Resident #211 on 4/22/19 at 11:58 AM revealed a March 2019 hospitalization with a diagnosis of herpes encephalitis requiring the resident to be on contact precautions. Further review of the resident's medical record and care plans on 4/29/19 at 10:46 AM failed to reveal any care plans in place related to the resident's hospitalization history or the current antibiotic usage secondary to ongoing infections requiring contact precautions. This concern was reviewed with the second-floor unit manager Staff #13 on 4/29/19 at 11:55 AM. Based on medical record review and interview it was determined that the facility to ensure comprehensive care plans were developed for residents as evidenced by failure to address: 1) respiratory issues including sleep apnea and the use of oxygen; 2) the use of psychotropic medications; 3) individual's activity preferences 4.) psychotropic and hypnotic medications 5.) hospitalizations and infections; and 6.) failed to develop a care plan related to a resident's respiratory needs. This was found to be evident for 6 out of 27 residents (#90, #81, #30, #211, #88, #57) reviewed during the investigation stage of the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is valuable in preventing avoidable declines in functioning or functional levels. It must reflect immediate steps for assuring outcomes which improve the resident's status and progress. 1. On 4/23/19 the Resident #90 reported having had a sleep study about the first of the month. On 4/26/19 review of the medical record revealed a sleep study report dated 2/4/19 which recommended a CPAP (continuous positive airway pressure) titration study. There was a hand written note on this report that a CPAP titration study had been set up for 3/26/19 at 8:00 PM. This was signed by the unit nurse manager #3. A corresponding order for the 3/26/19 sleep study was found. Further review of the medical record failed to reveal a report from the 3/26/19 sleep study or any nursing notes regarding the 3/26/19 sleep study. (Cross reference F 842) On 4/26/19 at 12:30 PM the unit nurse manager #3 reported the resident needed to return for another titration study because they did not do the test correctly. When asked specifically about the report from the 3/26/19 sleep study the unit nurse manager #3 reported that they did not fax a report over, they had just called and told her the test needed to be re-done. At 12:49 PM the unit nurse manager #3 confirmed there was no nursing note regarding the need to re-schedule the sleep study. Further review of the medical record revealed a physician order, in place since 1/4/19, for oxygen via a nasal cannula. Review of the Minimum Data Set (MDS) with an assessment reference date of 2/15/19 revealed the use of oxygen for the resident. Further review of the medical record on 4/29/19 failed to reveal any documentation in the currently active care plans regarding the use of oxygen and the sleep apnea assessments. On 4/29/19 at 2:03 PM the unit nurse manager #3 confirmed that there was nothing in the care plan at present regarding the oxygen use; she went on to report that the resident had previously been off of oxygen and the care plan had not been re-established after the oxygen restart. She also reported she would add the care plan today. On 4/29/19 at 4:15 PM surveyor reviewed with the Director of Nursing the concerns regarding the failure to have a care plan addressing oxygen use, sleep apnea and the need for CPAP titration study for this resident. 2. On 5/1/19 review of Resident #81's medical record revealed diagnoses that include, but not limited to, congestive heart failure (CHF), major depressive disorder and anxiety. The resident receives antidepressant and antianxiety medication on a daily basis. Review of the resident's care plans failed to reveal any documentation regarding the use of the antidepressant or the antianxiety medication. This concern was reviewed with the Director of Nursing on 5/1/19.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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4. On 4/23/19 Resident #110 was interviewed, during the interview the resident revealed that he/she had not been to a care plan meeting in a very long time. The resident further revealed that if the care plan meetings will help with the care then then he/she will attend. On 4/25/19 Resident #110's medical records were reviewed, and revealed that the resident was admitted to the facility for long term care and with diagnosis that included chronic pain, neurogenic bladder requiring a foley to drain the urine. On 4/25/19 the surveyor requested documentation of attendance at the care plan meeting and documentation of the notes of the meetings from Staff #10. Review of the attendance records and notes provided by the facility revealed an attendance record without a date on when it was held. Staff #10 revealed that was the only care plan attendance documentation she could locate, she further revealed that she was not sure if there were any other meetings. Staff #10 also provided the care plan notes which revealed meetings were held 7/10/17, 8/3/18 and 8/13/18 no other documentation could be located. No other documentation was provided to indicate that the interdisciplinary team, including the responsible party, had met to review the resident's care after the completion of the Minimum Data Set Assessment in November 2018 and February 2019. All findings discussed at the survey exit with the Director of Nursing, Administrator and corporate staff on 5/1/19. 2. An observation was made of Resident #81 on 4/22/19 at 11:30 AM. The resident was sitting in a wheelchair in his/her room and there was a large wet puddle on the floor underneath the wheelchair. On the same date at 12:10 PM Geriatric Nursing Assistant (GNA), Staff #9 was made aware and went into the room to assist the resident. The GNA stated the resident has edema (swelling) to both legs and seepage occurs occasionally. In a interview with the Unit Director (UD), Staff #12 on 4/22/19 at 12:20 PM s/he was made aware of the resident sitting in his/her wheelchair with a wet puddle on the floor underneath him/her. The UD stated the resident has bilateral edema to the legs. Another observation was made of Resident #81 on 4/26/19 at 10:45 AM. The resident was sitting in a wheelchair in his/her room and there was a large wet puddle underneath the wheelchair. The nurse working on the unit was made aware at that time. On 4/29/19 at 11:20 AM Resident #81 was observed sitting in a wheelchair in his/her room. A large wet puddle was observed on the floor underneath the wheelchair. At 11:45 AM on the same date the Nurse, #32 was asked to accompany the surveyor to the resident room, where the resident was observed sitting in his/her wheelchair and a large wet puddle underneath him/her. The nurse told housekeeping staff to clean the resident's room. Nurse #32 stated the resident positions him/herself in the wheelchair and urinates on the floor. The nurse went on to say the resident has been urinating on the floor for a long time. Review of Resident #81's care plan on 4/29/19 revealed there was no care plan in place that identified resident had exhibited behaviors of urinating on the floor. Further review of the care plan did not identify the resident with edema, and treatment for drainage or seepage from legs. The Director of Nursing (DON) was made aware that there was no care plan in place for bilateral leg edema and resident with behaviors of urinating on the floor. 3. Medical record review for Resident #47 on 4/23/19 at 10:56 AM revealed resident with an area that began as a laceration to left ankle. The resident was followed by Physician #1. Review of the resident care plan on the same date revealed resident with friction pressure ulcer of the left plantar heel with history of resolved Osteomylitis, Peripheral Vascular Disease. An intervention listed under tasks/interventions indicated assess/record/monitor wound healing; measure length, width, and depth initiated and revised on 7/17/18. Wound sheets were reviewed and revealed that no measurements were obtained until October 2018. An interview was conducted with the DON on 4/29/19 at 12:55 PM and s/he stated the resident has a history of Peripheral Vascular Disease and Diabetes Mellitus. The DON stated s/he became the wound nurse in October 2018. The DON went on to say that s/he began to stage the wound because initially it began as a laceration. The DON confirmed the facility failed to obtain measurements of the wound and update the care plan to reflect if the wound improved and resolved. The DON stated that treatment was being provided to the resident's wound and provided a copy of the physician orders to the survey team. Based on medical record review, interview of residents, family and of facility staff, it was determined that the facility failed to: 1) have an interdisciplinary team (IDT) meeting consisting of the resident and or resident representative upon admission to the facility and with subsequent admission (Resident #96). During this meeting a care plan is developed or revised; 2) failed to update the resident care plan for a resident (Resident # 81) observed sitting in the bedroom with a large wet area underneath the wheelchair and 3) failed to update a care plan for a resident (Resident #47) receiving treatment for a pressure ulcer; 4.) failed to conduct quarterly care plan meetings with the resident or the responsible party to address the resident's current needs (Resident #110) This was evident for 4 of 27 residents reviewed during the investigative stage of the survey. The findings include: A Care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1. An interview was conducted on 4/22/19 at 10:30 AM with Resident #96. During that interview Resident #96 was asked if s/he had been invited to a care plan meeting. Resident #96 stated that s/he had never had a care plan meeting. Resident #96 was asked further if s/he had had a meeting with the IDT (Interdisciplinary team) about his/her care and plans when rehab is finished. Again, Resident #96 stated no, that things were mentioned in passing by the social worker but there was never a meeting set up. Resident #96's family was interviewed on 4/25/19 at 2:51 PM regarding complaint #MD000138115. The complainant who had signed consents for the resident in the medical record, stated that at no time was a care plan meeting held and he/she was concerned about the resident's discharge plan as one was never discussed. One day the social worker just said that the resident was going home, even though the resident was scheduled for surgery. Review of Resident #96's medical record on 04/29/19 at 11:16 AM failed to reveal any documentation that Resident #96, who was admitted initially in December 2018, ever had a care plan meeting. Further review of the medical record failed to reveal any documentation that was given to the resident or family for either hospitalization in January or February 2019. Staff #10 stated on 4/29/19 at 2:09 PM that she was unable to provide any documentation regarding care plan meetings because Staff #18 reported to her that no care plans occurred because the resident was hospitalized prior to the first care plan and the family member went back out of town after the resident's readmission. Interview with the facility social work designee Staff #18 on 4/29/19 at 2:09 PM revealed that there has been on the fly talks but nothing formal regarding care plan meetings with Resident #96. She further stated that there was no documentation regarding meetings and that she would do better.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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Based on review of staffing documentation, complaint MD00133305 and interviews it was determined that the facility failed to ensure sufficient nursing staff to provide services to maintain the highest practical physical, mental and psychosocial well-being of each resident. This deficient practice has the potential to affect all the resident's in the facility. The findings include: Review of MD00133305 revealed an allegation that the facility is short staffed, that residents have to wait 30 - 45 minutes to have their call light answered because the facilty only has 2 GNAs [geriatric nursing assistants] for 50 residents. On 4/22/19 at 10:51 AM Resident #18 reported the call bells go off and remain unanswered and that [s/he] closes the door so [s/he] doesn't have to hear it. On 4/23/19 at 10:51 AM Resident #110 reported that staffing is a major issue at this facility, s/he further reported that [s/he] puts on the light and sometimes they come right away but most times [s/he] has to wait, because they are short staff. The resident reported that staff does not take the time to pull [him/her] up, they rush pulling [him/her] therefore hurting [his/her] back in the process. 04/24/19 01:09 PM Resident #22 reported the previous night there was only 1 GNA available. On 4/24/19 at 2:56 PM the resident council expressed concern that way more staff were here during the survey then normally here. State regulations require a minimum of 2 hours of bedside care per licensed bed per day. The facility is currently licensed for 126 beds which would require a minimum of 252 hours of nursing services each day. Review of the actual hours worked for nurses and geriatric nursing assistants for the day/evening/night shift of 4/20/19 revealed only 239.25 hours had been worked. Review of the hours for the day/evening/night shift of 4/21/19 revealed only 236 hours were worked. Review of the scheduling sheets and the actual hours worked for the night shift of 4/20/19 revealed 3 nurses and 2 GNAs worked the entire night shift. A third GNA (#24) started her shift at 3:03 AM, this is 4 hours after the night shift started at 11 PM. Review of the scheduling sheets for Sunday 4/21/19 night shift revealed two GNAs were scheduled for each of the three floors. Review of the actual hours worked by staff revealed only three GNAs worked the night shift for the entire building. On 5/1/19 at 5:30 PM surveyor reviewed with the Director of Nursing the concerns expressed in the complaint about staffing and long call bell waits as well as the staffing over the weekend at less than the mandatory 2 hours of nursing care per licensed bed.

Nov 2017 7 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0272 (Tag F0272)

Could have caused harm · This affected 1 resident

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Based on review of medical record documentation and staff interview, it was determined that the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. These concern with inaccuracy were evident for 2 (Resident #11 and #52 ) of 24 residents reviewed during Stage 2 of the Quality Indicator Survey. The findings include: The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. At the end of the MDS assessment, the interdisciplinary team develops a plan for the resident to obtain optimal care. 1. Review of Resident #11's MDS with an ARD (Assessment Reference Date) of September 28, 2017, G0110 Activities of Daily Living (ADL) Assistance, was documented as extensive assistance for toilet use. Further review of the MDS with ARD of October 1, 2017, G0110 Activities of Daily Living (ADL) Assistance, was documented as total dependence for toilet use. During an Interview of the MDS coordinator on October 1, 2017 at 11:30 AM, s/he stated that Resident #11 was coded incorrectly as extensive assistance for toilet use by the Geriatric Nursing Assistant (GNA) on September 28, 2017. The MDS coordinator indicated that G0110 on September 28, 2017, should have been documented as total dependence for toilet use. The DON (Director of Nursing) was made aware of the findings prior to the exit. 2. On 11/2/17, a review of Resident #52's medical record was initiated. The concern exists that this Resident has a decline in Activities of Daily Living. Further review of the record reveals that the Resident was coded as totally dependent in transfers from 5/26/17 until 8/15/17 where the coding was documented as a change to extensive assistance in transfers. In an interview with the MDS coordinator on 11/2/17 at 10:30 AM, it was confirmed the Resident's transfer status was coded incorrectly because a GNA had documented that the Resident was given extensive assistance on 8/9/17 and not totally dependent in transfers. The resident had a bilateral knee amputation on 6/8/17 and 6/14/17 and requires a total transfer using the hoyer lift prior to and after the amputations. The Administrator and DON were made aware of the discreptancy in the coding of transfers prior to exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0279 (Tag F0279)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined that the facility staff failed to initiate a care plan in a timely manner for a resident that was determined to wander to a dangerous place. This was evident for 2 (Resident #79 and #52) of 24 residents reviewed during stage 2 of the Quality Indicator Survey. The findings include: 1. Review of Resident #79's Comprehensive Minimum Data Set (MDS) with Assessment Reference Date (ARD) of August 21, 2017, E0900 Wandering: Presence and Frequency, revealed documention that behavior of this type occurred 1 to 3 days and E1000 Wandering: Impact, if the wandering placed the resident at significant risk of getting to a potentially dangerous place, was documented as yes. Review of V0200 Care Area Assessment (CAAs) and Care Planning, it was documented that the Care Area for behavior symptoms was triggered and that Care Planning Decisions were made. The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. At the end of the MDS assessment, the interdisciplinary team develops a plan for the resident to obtain optimal care. Further review of the Care Plan revealed a care plan focusing on elopement, which was not initiated until September 11, 2017. The findings were discussed with the DON on October 2, 2017 at 10 AM. 2. On 11/3/17, a review of resident #52's medical record was initiated. The resident was receiving Dialysis 3 times a week on Monday, Wednesday and Friday. A review of the physician orders revealed that there was no physician's order for the resident to receive dialysis. In an interview with the Unit Manager on 11/3/17 at 9 AM, it was confirmed there is not a physician order for dialysis and not until after surveyor intervention, was a physican order obtained and written for dialysis.There is no care plan in place identifying the resident's dialysis treatment prior to 10/12/17 and the resident was on dialysis upon admission on [DATE]. The DON was made aware of the concern on 11/3/17 at 10:30 AM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0318 (Tag F0318)

Could have caused harm · This affected 1 resident

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Based on observation, staff interview and medical record review, it was determined that the facility staff failed to ensure that a resident with limited range of motion received appropriate treatment to prevent further decrease in range of motion. This was evident for 1 (Resident #11) of 24 residents reviewed during stage 2 of the Quality indicator Survey. The findings include: Surveyor observation of Resident #11 on November 1, 2017 at 11:30 AM revealed that the resident had a contracture to his/her right hand and no splint was observed by the surveyor at that time to the resident's right hand. Staff interview was conducted on November 1, 2017 at 11:45 AM. The DON stated that the resident has a right hand contracture, but does not have a splint due to the refusal. Review of Certified Occupational Therapy Assistant (COTA) #8's notes revealed documentation, dated September 26, 2017 and September 28, 2017, indicating that a carrot (shaped) contracture orthotic for the resident's right upper extremity was ordered. Interview of the COTA on November 3, 2017 at 9:30 AM confirmed that a carrot orthotic for Resident #11 was ordered on September 26, 2017. When the surveyor stated on November 1, 2017, that the resident failed to have a carrot orthotic applied, the COTA responded that carrot orthotics were delivered to the facility on October 27, 2017 and Occupational Therapy started applying the orthotic to the resident's right hand yesterday. The DON was made aware of the findings prior to the exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0329 (Tag F0329)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, it was determined that the facility staff failed to monitor and assess the continued need for an insomnia medication for resident # 61. This was evident for 1 of 24 residents selected for review in the stage 2 survey sample. The findings include: Review of resident #61's medical record revealed a physician order for Melatonin by mouth at bedtime for treatment of insomnia. Melatonin is hormone dietary supplement which helps regulate sleep and wake cycles. Insomnia is a disorder that can make it hard to fall asleep, hard to stay asleep or both. Review of the medical record revealed the resident was not having any problems sleeping during the night; however, the resident continued to receive the medication at bedtime. Interview with the Unit Manager confirmed that the resident sleeps without difficulty.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0371 (Tag F0371)

Could have caused harm · This affected 1 resident

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Based on observations during the tour of the main kitchen, it was determined that the facility staff failed to store food under sanitary conditions and failed to ensure that the dishes were cleaned under sanitary conditions. The findings include: Observations were made during the surveyor's tour of the main kitchen on October 31, 2017 at 10 AM. During that time, observation of of the walk in refrigerator revealed one 1 gallon jar of Golden Italian dressing with about 1/5 of the dressing remaining in the jar and one 1 gallon jar of mayonnaise with about 1/3 of the mayonnaise remaining in the jar was observed without documentation of the date of these 2 jars of were initially opened. Observation of the three compartment sink was conducted on October 31, 2017 at 10:15 AM. During that time, the Certified Dietary Manager (CDM) opened a sink trap in the sanitizing compartment and water overflowed the drain and spilled on the floor. The CDM confirmed that the drain appeared to be clogged, but s/he could not verify exactly how long the drain has been clogged. The CDM indicated that the Maintenance Department will be notified now. Interview of Maintenance Director on October 31, 2017 at 1:40 PM revealed that the clogged drain that overflowed water from the sanitizing sink was cleaned, food and grease was removed, after s/he was notified by the CDM this morning of the problem Two surveyors confirmed by their observation on October 31, 2017 at 1:50 PM that the issue of the clogged, overflowing drain under the sanitizing sink was corrected and now the drain was functioning properly. The DON was made aware of these finidngs before the exit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0514 (Tag F0514)

Could have caused harm · This affected 1 resident

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2. During review of Resident #35's medical record on November 1, 2017 at 9:15 AM, it was noted that the resident does not have an indwelling Foley catheter. On November 1, 2017 at 11 AM, Unit Manager #1 confirmed that the resident's Foley catheter was removed by the urologist in August, 2017. Further review of the medical record, revealed physician's notes dated September 16, 2017, September 20, 2017, September 23, 2017, September 30, 2017 and October 11, 2017, documenting having a Foley catheter. The DON was made aware of the findings before the exit. Based on medical record review and interview, it was determined that the facility staff failed to maintain the medical record in the most complete and accurate form for 2 residents (#52 and #35) selected for review in Stage 2 of the survey sample. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards and legal standards. All entries to the record should be legible and accurate. 1. Medical record review revealed Resident #52 is receiving Dialysis 3 times a week on Monday, Wednesday and Friday. A review of the physician orders revealed that there was not a physician's order for the Resident to receive dialysis. In an interview with the Unit Manager on 11/3/17 at 9:AM, it was confirmed that there was not a physician order for dialysis and not until after surveyor intervention was a physican's order obtained and written. The DON was made aware of the concern on 11/3/17 at 10:30AM.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0431 (Tag F0431)

Could have caused harm · This affected multiple residents

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Based on observation. it was determined that the facility staff failed to discard: 1) medications of a discharged resident; and 2) expired medical equipment. This occurred in 2 of 3 units observed for medical storage. The findings include: During observation on 10/30/17 at 9 AM on Unit 1, the surveyor accompanied by the Unit Manager observed several discharge medications sitting in the medication storage room for resident # 1, who was discharged on 9/19/17; and resident # 2, who was discharged on 9/4/17. The Unit manager stated that the medications should have been discarded and immediately removed. During observation of Unit 2 on 10/30/17 at 11 AM, the surveyor accompanied by the Unit Manager for Unit 2, observed discharge medications stored in the medication room cabinet for the following: resident #3, discharged on 10/4/17; resident #4, discharged on 3/23/17; resident #5, discharged on 10/25/17; resident #6, discharged on 10/26/17 and lastly, resident #7, who was discharged on 10/28/17. During surveyor observation of Unit 2 on 11/2/17 at 11 AM, accompanied by the Unit Manager for Unit 2, 30 yellow top vacutainers were observed in the cabinet with an expiration date of 10/31/17. The unit Manger for unit 2 discarded the expired medications and removed the expired vacutainers from the cabinet.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• 31% turnover. Below Maryland's 48% average. Good staff retention means consistent care.

Concerns

• 83 deficiencies on record. Higher than average. Multiple issues found across inspections.
• $10,033 in fines. Above average for Maryland. Some compliance problems on record.
• Grade D (48/100). Below average facility with significant concerns.

Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Anchorage Healthcare Center's CMS Rating?

CMS assigns ANCHORAGE HEALTHCARE CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Maryland, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Anchorage Healthcare Center Staffed?

CMS rates ANCHORAGE HEALTHCARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 31%, compared to the Maryland average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Anchorage Healthcare Center?

State health inspectors documented 83 deficiencies at ANCHORAGE HEALTHCARE CENTER during 2017 to 2024. These included: 83 with potential for harm. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.

Who Owns and Operates Anchorage Healthcare Center?

ANCHORAGE HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by COMMUNICARE HEALTH, a chain that manages multiple nursing homes. With 126 certified beds and approximately 107 residents (about 85% occupancy), it is a mid-sized facility located in SALISBURY, Maryland.

How Does Anchorage Healthcare Center Compare to Other Maryland Nursing Homes?

Compared to the 100 nursing homes in Maryland, ANCHORAGE HEALTHCARE CENTER's overall rating (2 stars) is below the state average of 3.0, staff turnover (31%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Anchorage Healthcare Center?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Anchorage Healthcare Center Safe?

Based on CMS inspection data, ANCHORAGE HEALTHCARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Maryland. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Anchorage Healthcare Center Stick Around?

ANCHORAGE HEALTHCARE CENTER has a staff turnover rate of 31%, which is about average for Maryland nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Anchorage Healthcare Center Ever Fined?

ANCHORAGE HEALTHCARE CENTER has been fined $10,033 across 1 penalty action. This is below the Maryland average of $33,179. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Anchorage Healthcare Center on Any Federal Watch List?

ANCHORAGE HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 126
Avg. Residents: 107
Occupancy: 85.4%
Ownership: For profit - Corporation
Chain: COMMUNICARE HEALTH
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
83 Deficiencies: -10
Fines ($10,033): -2
Final Score: 48/100

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Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 215339