**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, and review of facility documents, the facility's staff failed to have a resident call system that consistently relayed calls directly to a staff member and/or to a centralized staff work area from each resident's bedside, toilet, and bathing area for 1 of 3 residents (Resident #1) in the survey sample. The findings included: Resident #1 was originally admitted to the facility from a local hospital on [DATE] for rehabilitation services after coronary artery bypass graft surgery. The admission diagnoses included coronary artery disease, hypotension, hyperlipidemia, chronic kidney disease, dysphagia, history of breast cancer, anxiety, depression, and obesity. Also, Resident #1 tested covid positive on [DATE]. The resident expired at the facility on [DATE] therefore a closed record review was conducted. The resident's Minimum Data Set (MDS) was not completed therefore the following information was obtained from the Nursing assessment dated [DATE]. The assessment revealed that the resident was oriented times (X )4. Also, the assessment read that the resident was coded as requiring limited assistance with ambulation/locomotion and limited assistance with transfers. A synopsis of an event dated [DATE] revealed that Resident #1 activated the call system and the facility's staff failed to respond to the resident's room due to the communication system's devices not functioning properly. An interview was conducted on [DATE] at 2:32 PM with the Administrator, Assistant Administrator, Director of Nursing (DON), Social Services Director, and MDS Coordinator. The Administrator stated that on [DATE] Resident #1 activated the call bell system and it took 54 minutes for the staff to respond to the resident's needs. The Administrator also voiced that an investigation was conducted, and it was determined that the call light was not answered promptly. The Administrator also stated that the call system has had issues in the last couple of months with the facility staff not being alerted on the [NAME] Phones. The call bell system report for room [ROOM NUMBER] dated [DATE] read that the call bell system was activated at 4:51 AM, 5:11 AM, and 5:31 AM. The call bell system report also read that it took a total of 54 minutes for the facility staff to respond to Resident #1's room after the call bell system was initially activated. A statement dated [DATE] written by Licensed Practical Nurse (LPN) #1 stated that on [DATE] LPN #1 had a conversation with Certified Nursing Assistant (CNA) #1 regarding why the call bells were not answered promptly. CNA #1 stated that the call bell system did not activate the beeper and that Resident #1 needed assistance. A statement dated [DATE] written by CNA #1 indicated that on [DATE] the call bell system did not send a notification to the beeper that Resident #1 needed assistance. CNA #1 did not respond to Resident #1's room until LPN#1 notified that assistance was needed. An interview was conducted on [DATE] at 4:50 PM with CNA #2. CNA #2 stated that the call bell system began having issues about a year ago. CNA #2 also voiced that he uses a pager due to the issues that have occurred with the [NAME] Phones not functioning properly. An interview was conducted on [DATE] at 1:10 PM with the Information Technology (IT) Manager. The IT Manager stated that six (6 ) months ago the facility's wireless system began having issues functioning properly and the facility's communication system was not relaying calls directly to the facility staff. The IT Manager also stated that these issues have not been resolved however the time frame on the conversion to a new communication system hopefully would be completed in the next two months. An interview was conducted on [DATE] at 2:43 PM with the Director of Life Safety and Security. The Director of Life Safety and Security stated that the facility's communication system was not always reliable due to the [NAME] Phones not functioning properly. The Director of Life Safety and Security also voiced that the facility will be converting to a new communication system once approval is given by the Chief Financial Officer. On [DATE] at approximately 5:40 PM, a final interview was conducted with the Administrator, Assistant Administrator, Director of Nursing (DON), Social Services Director, and MDS Coordinator. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above issue.

Based on staff interview and facility documentation review, the facility staff failed to implement their abuse policy regarding the screening of employees for 9 employees no reference checks were obtained and for 3 employees no sworn disclosure statements were obtained in a sample of 19 employee records reviewed. The findings included: On 8/11/22, a review of 19 employee files was conducted and revealed the following: 1. The facility staff failed to obtain employee References for nine employees. The employee record review revealed that 9 current employees did not have reference checks. Employee #1 hired on 10/11/21, employee #2 hired on 9/15/21, employee #3 hired on 12/08/21, employee #4 hired on 1/27/22, employee #5 hired on 2/28/22, employee #15 hired 4/20/22, employee #16 hired on 1/15/21, employee #17 hired on 4/18/22 and employee #18 hired on 8/01/21. 2. The facility staff failed to obtain Sworn Disclosure Statements for three employees: Employee #1 was hired on 10/11/21, employee #2 was hired on 9/15/21 and employee #3 was hired on 1/28/21. On 8/11/22 at approximately 4:50 PM., the above findings were shared with the Administrator. The administrator said that they were not able to locate the documents. An opportunity was offered to the facility's staff to present additional information but no additional information was provided. Review of the facility's policy entitled, Preventing Resident Abuse, Reads: It is the policy of Harbor's Edge to provide care in a manner that is professional, compassionate, and respectful of residents' rights. Abuse, neglect, mistreatment, and misappropriation of resident funds will not be tolerated. Harbor's Edge implements a program of screening, prevention, and facility response that minimizes the potential for resident abuse and protects the rights of all residents. PROCEDURE: I. Screening A. The organization will screen potential employees for a history of abuse, neglect, or mistreating residents. 1. All potential employees are required to accurately complete an employment application. 2. All potential employees are interviewed by the Department Director or designee to determine appropriateness for performing job duties of desired position. 3. Original licenses or certificates are requested for viewing during an applicant's interview. State licensure and certification agencies, and applicable registries, will be contacted, prior to hire, to validate current licensure and certification requirements and to determine if the potential employee is in good standing with the registry. 4. Reference checks (at least two) will be conducted on all candidates for employment prior to hire. 5. All applicants will sign a Sworn Disclosure Statement. 6. All criminal record checks are reviewed for barrier crimes and appropriateness of employment within 30 days of hire.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on information gleamed during a closed record review and staff interviews, the facility staff failed to complete an accurate discharge Minimum Data Set (MDS) assessment for 1 of 22 residents (Resident #27), in the survey sample. The findings included: Resident #27 was originally admitted to the facility 5/24/22 and discharged from the facility to the community 7/2/22. The discharge diagnoses included; right foot cellulites/septic arthritis, osteomyelitis and chronic kidney disease. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/30/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were intact. Review of the discharge MDS assessment dated [DATE] revealed the resident's discharge was planned (A0310G), and coded return not anticipated (A0310F) to an acute care hospital at (A2100). Resident #27 was selected by the Centers of Medicare and Medicaid Services (CMS) for a discharge to the hospital review but during the record review it was determined the resident wasn't discharged to the hospital. The physician's discharge summary read the resident was discharged from the facility after receiving rehabilitation services to her vacation home in another state and she would receive assistance from her five sons. An interview was conducted with Registered Nurse #2 on 8/11/22 at approximately 2:30 p.m., in regards to the resident's discharge status. RN #2 stated the resident was discharged to a private home not the hospital on 7/2/22 and she was accompanied from the facility by her husband. An interview was conducted with the MDS Coordinator on 8/11/22 at approximately 3:10 p.m. The MDS Coordinator stated after her review the discharge assessment dated [DATE] wasn't coded correctly and the discharge assessment was modified to read discharged to the community. A copy of the modified assessment was provided to the survey team on 8/11/22 at approximately 6:15 p.m. On 8/11/22 at approximately 6:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Assistant Director of Nursing. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and no further concerns were voiced.

Based on staff interview and clinical record review, the facility's staff failed to ensure a resident who had elected hospice services, their written care plan included both the most recent hospice care plan as well as the facility's care plan for 1 of 22 residents (Resident #3), in the survey sample. The findings included: Resident #3 was originally admitted to the facility 1/3/22 and had never been discharged from the facility. The current diagnoses included; Afib, heart failure and stage 4 sacral pressure ulcer. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/25/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #3's cognitive abilities for daily decision making were moderately impaired. Review of Resident #3's clinical record revealed she was admitted into hospice services on 4/11/22 for chronic heart failure. A review of the care plan in the clinical record revealed a problem which read; (name of the resident) is receiving hospice care (began 4/11/2022). The goal read; (name of the resident) will receive enhanced services for end of life needs through the review period. The interventions included; activities of daily living (ADL) care will be coordinated with both facility and hospice company, Hospice Nurse to collaborate with primary physician as needed, and facility social services will maintain communication with Hospice point of contact. A further review of the clinical record revealed the hospice agency didn't include their care plan with the facility's care plan, therefore the services to be provided by the hospice agency were not known by the facility staff and the problems and goals the hospice agency were working towards weren't available for the facility staff to be involved in all of the resident's ongoing healthcare needs. An interview was conducted with Registered Nurse (RN) #2 on 8/10/22 at approximately 4:10 p.m. RN #2 stated the hospice agency doesn't provide documents for the individual resident record for they utilized one binder to store records for all residents they serviced in the facility. As the Director of Nursing (DON) looked through the binder which held multiple resident documents she stated the last records available were dated 7/20/22, therefore she telephoned the agency to obtain the most recent documentation. On 8/11/22, at approximately 11:30 a.m., the DON stated the hospice agency stated the documents were submitted to another email address and that's why they were not available to them her and going forward they would ensure the hospice documents were obtained timely and integrated into the individual resident's record. On 8/11/26 at approximately 1:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Assistant Director of Nursing. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and no further concerns were voiced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to have one (Resident #2) of 18 residents in the survey sample, attend quarterly person centered care plan meetings and failed to conduct quarterly care plan meetings. The findings included: Resident #2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses for Resident #2 included but not limited to, Acute Kidney Failure and Dementia with lewy bodies. The current Minimum Data Set (MDS), a quarterly revision with an Assessment Reference Date (ARD) of 06/14/19 coded the resident with a 12 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Resident #2 was coded as requiring extensive assistance requiring a two person physical assistance with toilet use, bathing, personal hygiene and bed mobility; requiring one person physical assist with transfers and dressing; and eating requiring set-up help only. During the initial tour on 09/09/19 at approximately 11:38 AM, an interview was conducted with Resident #2. She was asked if she was attending quarterly care plan meetings? She stated, No one has approached me. An interview was conducted with Social Worker (SW) #1 on 09/10/19 at approximately 11:58 AM. When asked if Resident #2 was invited to care plan meetings SW #1 initially stated, Resident gets invites and attends care plan meetings. After verifying information in the computer she then stated, Her last care plan meeting was on 1/31/19 family was present; We lost a social worker, Resident didn't attend care plan meetings; She missed April and July meetings; No invite letters were sent out; We met with daughter in between. On 09/10/19 received a care plan invite letter from the Social Worker at approximately 12:00 PM. The care plan meeting invite letter was addressed to Resident #2 and her family dated on January 24, 2019. The meeting was scheduled for January 31, 2019. Received IDT (interdisciplinary team note) from Social Worker #1 on 9/10/19 at approximately 12:15 PM. The note was dated on 5/10/19 and read the following: The Social Worker met with the daughter to address a concern on 5/06/19 at 5:18 PM. Social worker #1 was asked if she had any documentation stating that a Personal Centered Care Plan meeting was held since January 2019; she stated, No. The Administrator, the DON (Director of Nursing) and Registered Nurse #1, MDS Coordinator (Minimum Data Set Coordinator) were informed of the findings during a briefing on 09/10/19 at approximately 3:44 PM. The Administrator stated that the care plan meetings should be quarterly. She also stated that they stayed in touch with the Resident's daughter and stated It may have been an oversight; The CNA (Certified Nursing Assistant), nursing and family are involved in the care plan meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and clinical record review, the facility staff failed to convey comprehensive care plan goals for 1 of 18 residents (Resident #21), in the survey sample, after she was transferred to an acute care hospital on 8/27/19. The findings included: Resident #21 was originally admitted to the facility 8/7/19, and readmitted on [DATE], after an acute care hospital stay for an infection. The current diagnoses included, osteoarthritis and a pantalar fusion with use of an external fixator of the left ankle and foot. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/14/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of two people with transfers, extensive assistance of one person with bed mobility, locomotion, dressing, toileting, personal hygiene and bathing and supervision after set-up with walking and eating. Review of the discharge MDS assessment dated [DATE], it revealed Resident #21 was discharged return-anticipated. During an interview on 9/4/19, at approximately 1:45 p.m., Resident #21 stated she had been hospitalized for 2 days after an orthopedic appointment since she was been admitted to the nursing facility. She stated upon discharge from the hospital the orthopedic physician said she would require 4-6 months of antibiotic therapy because the infection was in her left lower extremity bones. The resident also stated the goals the nursing facility's staff were working towards with her were not addressed during the hospital stay. A nurse's noted dated 8/27/19, at 22:56 (10:56 PM) read; Per the Assistant Director of Nursing, a report was received from the resident's orthopedic physician office stating the resident was a direct admit to a local hospital for left lower extremity cellulitis. The note further stated the resident's daughter came by and spoke with the supervisor in reference to holding Resident #21's room and the supervisor instructed the daughter that the social worker will be informed of the inquiry and would call her with details. During the pre-exit interview with the Administrator, Director of Nursing, Assistant Director of Nursing, and the MDS Coordinator on 9/10/19, at approximately 4:15 p.m., the above findings were shared with the facility's team and they were asked: how did Resident #21's care plan and or care plan goals reach the hospital staff? The Administrator stated since the resident was admitted to the hospital while out at a physician's appointment they should have sent the information by the daughter when she came in but there was no indication it was done. The Administrator further stated they would develop a more feasible mean for documents necessary for a resident care to be transferred from the facility to the hospital staff under non-facility imitated transfers to the hospital. She also stated they have a staff member who visits the hospital routinely and that may be the better answer.

Based on clinical record review, staff interview, and facility documentation review, the facility's staff failed to electronically transmit an encoded and completed discharge Minimum Data Set (MDS), assessment to the Centers for Medicare/Medicaid System (CMS), for 1 of 18 residents (Resident #1), in the survey sample. The findings included: Resident #1 was originally admitted to the facility 3/25/19, and was discharged from the facility to the community 4/12/19. The diagnoses included adult failure to thrive, age related physical abilities and asthma. The admission MDS assessment with an assessment reference date (ARD) of 4/1/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring supervision after set-up with locomotion, extensive assistance of two with bed mobility and transfers, extensive assistance with one dressing, eating, toileting, personal hygiene and bathing. During the Resident Assessment review, Resident #1 triggered for not having an MDS assessment completed in greater than 120 days (the prior MDS assessment accepted in the CMS databank was dated 4/1/19), therefore, an interview was conducted with the MDS Coordinator on 9/9/19, at approximately 2:10 p.m. The MDS Coordinator stated Resident #1's discharge MDS assessment with an ARD of 4/12/19, was in the computer, it was completed 4/23/19, and it showed it had not been batched to transmit to the CMS databank. The above findings were shared with the Administrator, Director of Nursing, the Assistant Director of Nursing and the MDS Coordinator during the pre-exit meeting on 9/10/19, at approximately 4:15 p.m. The MDS Coordinator presented the validation report indicating she had transmitted the resident's 4/12/19, discharge MDS assessment to CMS on 9/10/19. The MDS Coordination also stated she had spoken with administration about the findings and they were working on a solution for locating any additional un-transmitted MDS assessments and submitting then to CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, facility document review and clinical record review, it was determined that facility staff failed to ensure that the resident assessment was accurately coded for 2 of 18 residents in the survey sample. The assessment inaccurately reflected Resident #33's discharge status; and the facility staff failed to accurately document the number of days that injections of Lovenox were received for Resident #19. The findings included: 1. Resident #33 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Stroke and Type 2 Diabetes Mellitus. Resident #33's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of [DATE] was coded with a BIMS (Brief Interview for Mental Status) score of 14 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #33 as requiring extensive assistance of 1 with eating, toilet use and personal hygiene and extensive assistance of 2 with bed mobility, transfer and dressing. On [DATE] at approximately 12:30 p.m., a review of Resident #33's clinical record revealed the following: An MDS assessment dated [DATE] was coded as Death in facility tracking record. The Clinical Note dated [DATE] at 10:50 p.m., was reviewed and nurse documentation revealed and is documented in part, as follows: Resident complained of Chest pain - 10/10 crushing, tightness, gripping pain. Resident alert and requesting to go to hospital. Resident very restless and anxious. Resident stated that she doesn't want to die here. VS (Vital Signs) 97.6, 98, 18, 105/69, 93 % - Nitrostat 1 dose given; VS 97.1, 77, 18, 153/62, 97 % - Nitrostat 1 dose given. Informed MD (Medical Doctor) and ordered to send to ER (Emergency Room) via 911. Husband at bedside and aware of the pain. Resident went to ER via 911 stretcher. Clinical Note for [DATE] at 4:32 a.m., was reviewed and nurse documentation revealed and is documented in part, as follows: Received report from Nursing supervisor that Res (Resident) was admitted at (Hospital abbreviation name). On [DATE] at approximately 12:45 p.m., an interview was conducted with the MDS Coordinator and she was asked if Resident #33 expired in the facility. The MDS Coordinator stated, No, (Residents Name) was sent to the hospital and I was told that she died at 3:00 a.m. while in the ER. The MDS Coordinator was asked, Why was Resident #33's assessment coded as Death in the facility? The MDS Coordinator stated, I coded the assessment as Death in facility because the resident was at the hospital and per my manual instructions if the resident expires during LOA (Leave of Absence) and in the hospital less than 24 hours then I'm suppose to code the resident as Death in facility. An interview was conducted with the DON on [DATE] at 1:10 p.m., and the DON was asked, Where was Resident #33 when she expired? The DON stated, She expired in the hospital. The assessment was not coded accurately. The DON was asked, What are your expectations of MDS nurses when documenting assessments? The DON stated, I expect the nurses to know what to do and be accountable. On [DATE] at approximately 4:00 p.m., at the pre-exit meeting the Administrator, Director of Nursing and MDS Coordinator was informed of the finding. The facility did not present any further information about the finding. Definitions: Death in facility - refers to when the resident dies in the facility or dies while on a leave of absence (LOA) . Leave of Absence (LOA) - occurs when a resident has a: temporary home visit; or temporary therapeutic leave; or hospital observation stay less than 24 hours and the hospital does NOT admit the resident. References: Center's for Medicare and Medicaid Services Long - Term Care Facility Resident Assessment Instrument 3.0 RAI https://www.cms.gov>medicare>nursinghomequalityints>mds30ramanual.html 2. Resident #19 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Rheumatoid Arthritis and Type 2 Diabetes Mellitus. Resident #19's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of [DATE] was coded with a BIMS (Brief Interview for Mental Status) of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #19 as requiring extensive assistance of 1 for bed mobility, transfer, dressing, toilet use and personal hygiene and limited assistance of 1 with eating. On [DATE] at approximately 10:30 a.m., Resident #19's clinical record was reviewed and revealed the following: Review of the admission MDS with an Assessment Reference Date of [DATE], Section N - N0300 Injections - revealed that the resident was coded as receiving injections of any type for 1 (one) day during the last 7 (seven) days or since admission/entry; and review of Section N - N0410 Medications Received revealed that the resident was coded as receiving a anticoagulant for 7 (seven) days during the last 7 (seven) days or since admission/entry. Review of [DATE] Medication Record revealed that Resident #19 received Lovenox 30 mg (Milligram)/0.3 ml (Milliliter) subcutaneous syringe - [Enoxaparin] - 1 inj (Injection) subcutaneous every 12 hours for DVT (Deep Vein Thrombosis) prophalaxis for 7 days during the period of [DATE] through [DATE]. On [DATE] at 10:43 a.m., the MDS Coordinator was asked, Can you explain why Resident #19's admission MDS is coded as the resident received injections for one day? The MDS Coordinator stated, It was an oversight, should have been coded as seven days. The MDS Coordinator modified the MDS on [DATE] as a correction and provided the surveyor a copy of the modified MDS. On [DATE] at approximately 4:00 p.m., at the pre-exit meeting the Administrator, Director of Nursing and MDS Coordinator was informed of the finding. The facility did not present any further information about the finding. Definitions: Lovenox Subcutaneous - [Enoxaparin Injection] - Enoxaparin is used to prevent blood clots in the leg in patients who are on bedrest or who are having hip replacement, knee replacement, or stomach surgery. https://medlineplus.gov/druginfo/meds/a601210.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and review of the facility's policy, the facility staff failed to ensure 1 of 18 residents in the survey sample (Resident #24) did not receive as needed anti anxiety medication Ativan for greater than 14 days without the physician and/or prescribing practitioner thoroughly evaluating the resident for the appropriateness of continuous as needed use and indication of the duration of use. The findings included: Resident #24 was originally admitted to the facility on [DATE]. The resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included but were not limited to, hypertension and atrial fibrillation. Resident #24's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 08/21/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #24 as requiring extensive assistance of 2 with bed mobility, transfer and dressing, extensive assistance of 1 with toilet use and personal hygiene, physical help of 1 with bathing and supervision with set up help only for eating. On 09/09/2019 at approximately 2:00 p.m., Resident #24's clinical record was reviewed and revealed a physician order for Ativan (Lorazepam) 0.5 mg (Milligram) tablet- 1 tab By Mouth Once Daily as Needed for anxiety. Order Date, 08/14/2019 and start Date 08/14/2019. The Medication Administration Record for August 2019 was reviewed and revealed that Resident #24 was administered Ativan 0.5 mg tablet [Lorazepam] 1 (one) tab by mouth once daily as needed for anxiety on 08/14, 08/15, 08/16, 08/17, 08/18, 08/19, 08/22, 08/23, 08/24, 08/25, 08/27, 08/28, 08/29, 08/30 and 08/31/19. Medication Administration Record for September 2019 was reviewed and revealed that Resident #24 was administered the Ativan 0.5 mg tablet 1 (one) tab by mouth once daily as needed for anxiety on 09/01, 09/02, 09/03, 09/04, 09/05, 09/06, 09/07 and 09/08/19. A Physician Note dated 08/15/2019 was reviewed and revealed the following: Anxiety-PRN (as needed) Ativan started in hospital for feeling claustrophobic in CT (Computerized Tomography) scan. Counseled goal to d/c (Discontinue) Ativan and not reorder once current supply runs out. Physician Note dated 08/22/2019 was reviewed and revealed the following: Anxiety / Depression: First dose of Sertraline (zoloft)on 08/21; pt (Patient) understands that his Ativan is only once prn for severe anxiety. Pharmacist Consultation Report dated 08/30/2019 was reviewed and revealed the following: Comment: (Resident Name) has a PRN order for an anxiolytic, without a stop date: Lorazepam prn must have a stop date in the order and eMAR per CMS (Center's for Medicare and Medicaid Services) regs. Recommendation: If the medication cannot be discontinued at this time, current regulations require that the prescriber document the indication for use, the intended duration of therapy, and the rationale for the extended time period. Rationale for Recommendation: CMS requires that PRN orders for non-antipsychotic psychotropic drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order. The Consultation Form provided the following responses for the Physician to elect a response from: I accept the recommendation above, please implement as written; I accept the recommendation above WITH THE FOLLOWING MODIFICATIONS; I decline the recommendation above and do not wish to implement any changes due to the reasons below. The physician elected the response: I decline the recommendation above and do not wish to implement any changes due to the reasons below. Rationale: Severe Anxiety. Physician's Response was dated 09/04/19. On 09/10/2019 at approximately 3:30 p.m., after review of Resident #24's clinical record, there was no evidence that the physician indicated the duration for the PRN order as required. On 09/10/2019 at approximately 11:26 a.m., an interview was conducted with the DON and she stated, I expect the nurses to review the medications and if they note that a resident has a PRN psychotropic medication and it does not have a stop date they should escalate notification to the physician to re-evaluate resident. We should be escalating to clarify with the physician if to make the medication routine. On 09/10/2019 at approximately 4:00 p.m., at the pre-exit meeting the Administrator, Director of Nursing and MDS Coordinator was informed of the finding. The facility did not present any further information about the finding.

Based on observation and staff interviews the facility staff failed to use clean equipment and perform appropriate hand hygiene during wound care for 1 of 18 residents (Residents #27), in the survey sample. The findings included: Resident #27 was originally admitted to the facility 8/10/19 and had not been discharged from the facility. The resident's diagnoses included; an abdominal surgical wound related to a ventral hernia causing a small bowel obstruction. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/17/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring supervision after set-up with eating and walking, supervision of one person with bathing, extensive assistance of one person with locomotion, limited assistance of one with bed mobility, dressing, toileting, and personal hygiene. In section M (Skin Condition) the resident was coded as having a surgical wound present. A Physician's order dated 9/3/19 read: Change abdominal wound packing with 1/4 plan packing and cover with gauze and hypafix tape twice daily. The current care plan dated 8/11/19 read: Disruption of skin surface layers and tissue related to a surgical incision to the abdomen. The goal read; The surgical incision will heal without complication. The interventions included; reinforce initial dressing and change as indicated. Use strict aseptic techniques. Inspect the wound regularly, noting characteristics and integrity. Assess amounts and characteristics of drainage. Caution the resident not to touch the wound. Resident #27's surgical wound care was observed on 9/4/19, at approximately 1:30 p.m. Registered Nurse (RN) #2 washed her hands, the resident pulled down her pants to expose the wound. RN #2 removed the old dressing, removed her gloves, applied a new pair of gloves. RN #2 removed gauze from the package, held it over the trash can and poured normal saline on to the gauze, and cleaned the wound from inner to outer area. She wet another gauze and again cleaned from inner to outer and the same for a third time. RN #2 then removed her gloves and patted the wound with a dry gauze. RN #2 then changed her gloves, obtained the packing from the bottle. She opened her personal scissors (RN#2's name was engraved on the scissors) which were removed from her pocket, cut the packing and inserted the packing into the abdominal opening using a cotton tip applicator. RN #2 then applied an abdominal pad followed by application of hypafix tape. RN #2 gathered all products utilized and trashed the table protectors and the unused saline; she then removed her gloves washed her hands and returned her personal scissors to her pocket without cleaning them. An interview was conducted with Registered Nurse (RN) #2, on 9/10/19. RN #2 stated the scissors during Resident #27's wound care were her personal scissors and she had cleaned then after her last use but she didn't clean them after removing them from her pocket or prior to cutting the products to complete Resident #27's wound care. RN#2 also stated she normally only washes her hands before and after wound care not in between or when going from soiled to clean. RN #2 reviewed the facility's protocol for wound care and returned later stating, yeah the policy stated the scissors should have been cleaned prior to cutting the products and handwashing is required after removing the soiled dressings, before cleaning the wound and prior to applying the new dressing. On 9/10/19 at approximately 4:15 p.m., the above findings were shared with the Administrator, Director of Nursing, the Assistant Director of Nursing and the MDS Coordinator. An opportunity was provided for additional information to be introduced but none was offered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined that facility staff failed to ensure that the Comprehensive Care Plan was developed within 7 (seven) days after completion of the admission assessment for 4 Residents (Resident #24, #19, #14,#17) of 18 residents in the survey sample. The findings included: 1. For Resident #24, the facility staff failed to develop a comprehensive person-centered care plan. Resident #24 was originally admitted to the facility on [DATE]. The resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included but were not limited to, hypertension and atrial fibrillation. Resident #24's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 08/21/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #24 as requiring extensive assistance of 2 with bed mobility, transfer and dressing, extensive assistance of 1 with toilet use and personal hygiene, physical help of 1 with bathing and supervision with set up help only for eating. On 09/09/2019 at approximately 4:00 p.m., the surveyor requested a copy of Resident #24's Comprehensive Care Plan. The MDS Coordinator stated, The Comprehensive Care Plan is not completed. The Director of Nursing was present. On 09/09/2019 at approximately 5:00 p.m., an interview was conducted with the MDS Coordinator and she was asked, When was Resident #24's admission MDS completed? The MDS Coordinator stated, On 08/21/2019. The MDS Coordinator was asked, When is the Comprehensive Care Plan due to be completed? The MDS Coordinator stated, Fourteen days after the Comprehensive MDS. On 09/09/2019 at approximately 5:15 p.m., the above discussion with the MDS Coordinator were reviewed with the Director of Nursing (DON). The DON stated, I am new to Long Term Care and not familiar with all the regulations. The DON was asked, What are your expectations of the nurses completing the comprehensive care plans? The DON stated, I expect them to learn and be correct. I will do some more checking behind the nurses. On 09/10/2019 at approximately 4:00 p.m., at the pre-exit meeting the Administrator, Director of Nursing and MDS Coordinator was informed of the finding. The facility did not present any further information about the finding. 2. For Resident #19, the facility staff failed to develop a comprehensive person-centered care plan. Resident #19 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Rheumatoid Arthritis and Type 2 Diabetes Mellitus. Resident #19's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 08/15/2019 was coded with a BIMS (Brief Interview for Mental Status) of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #19 as requiring extensive assistance of 1 for bed mobility, transfer, dressing, toilet use and personal hygiene and limited assistance of 1 with eating. On 09/10/2019 at 10:15 a.m., Resident #19's comprehensive person centered care plan was requested but not received. An interview was conducted with the MDS Coordinator on 09/10/2019 at 10:33 a.m., she stated, The comprehensive care plan was not completed because the resident was discharged from the facility on 09/04/2019. The MDS Coordinator was asked, When was Resident #19 admitted to the facility? The MDS Coordinator stated, August 08, 2019. The MDS Coordinator was asked, When was the admission MDS completed? The MDS Coordinator stated, August 15, 2019. The MDS Coordinator was asked, Should the comprehensive care plan have been completed? The MDS Coordinator stated, Yes. On 09/10/2019 at approximately 4:00 p.m., at the pre-exit meeting the Administrator, Director of Nursing and MDS Coordinator was informed of the finding. The facility did not present any further information about the finding. 4. The facility staff failed to develop a comprehensive person-centered care plan for Resident #17. Resident #17 was admitted to the facility on [DATE] with diagnoses that included but not limited to Hypertension and Muscle Weakness. Resident #17's most recent MDS (Minimum Data Set) an admission assessment with an ARD (assessment reference date) of 08/06/19 coded the resident with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. Resident #17 was coded as requiring extensive assistance requiring a two person physical assistance with bed mobility, transfers and toilet use; requiring one person assist with locomotion on and off the unit, dressing, personal hygiene and bathing; and eating requiring set-up help only. On 09/10/19 at approximately 10:30 AM Registered Nurse #1 (RN #1, MDS Coordinator) was approached to provide a copy of Resident #17's Comprehensive Care Plan. RN #1, (MDS Coordinator) stated, I didn't do her Comprehensive Care Plan. On 09/10/19 at approximately, 11:50 AM, an interview was conducted with RN #1. She was asked if Resident #17's comprehensive care plan completed? She stated, No. She was then asked should it have been completed? She stated, Yes; I didn't complete the comprehensive, related to the turn-over of admissions and discharges. She stated Moving forward I've spoken with administration about coming up with a plan. On 09/10/19 at approximately 3:44 PM a pre-exit interview was conducted with the Administrator, Director of Nursing (DON) and Registered Nurse #1. No further comments were voiced. The facility Policy titled: Comprehensive Person-Centered Care Planning. Comprehensive Care Plan means an interdisciplinary communication tool developed after completion of a comprehensive MDS and review of the care Area Assessments (CAAs). POLICY: A person centered comprehensive that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs shall be developed for each resident. To the extent practicable, the resident/resident representative will be provided with opportunities to participate in the care planning process. PROCEDURE: section III-A comprehensive care plan for each resident must be developed within seven days of the completion of the resident's MDS assessment. Section IV-The comprehensive care plan shall be developed by a Care Planning/Interdisciplinary Team which includes at a minimum: The resident's attending physician, a licensed nurse responsible for caring for the resident, a nursing assistant responsible for the resident's care, a member of food and nutrition services staff, a social worker, activities worker, Rehab. Therapists, consultants and others as appropriate or necessary to meet the needs or request of the resident. 3. The facility staff failed to develop and implement a comprehensive person-centered care plan for Resident #14. Resident #14 was originally admitted to the facility 7/31/19, and had never been discharged from the facility. The resident's diagnoses included bilateral deep vein thrombosis, hematuria and urinary retention. The admission MDS assessment with an assessment reference date (ARD) of 8/7/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #14's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring supervision after set-up with eating, extensive assistance of two with bed mobility, extensive assistance of one with walking, locomotion, dressing, toileting, personal hygiene and bathing. A review of Resident #14's person-centered care plan was conducted secondary to a physician's orders dated 8/8/19, for time voiding every six hours with bladder scan as post-void residual every six hours. If bladder scan results are greater than 250 milliliters, in and out catheterization and notify the medical team. One every six hours for urinary retention for voiding trial. The care plan dated 7/31/19 read (name of resident) has urinary incontinence. The goal read; (name of resident) will remain clean, dry and free of breakdown related to incontinence. The interventions included: perineal cleansing and apply protective skin barrier after each incontinence episode. provide adult incontinence products and monitor for incontinence every two hours. Assess and report signs of impaired skin integrity or breakdown. The care plan didn't reference urinary retention, bladder scans, post-void residuals, or in and out catheterization. A physician's progress note dated 8/8/19 read: Foley catheter placed initially. Removed on 7/31/19, passed voiding trial by voiding twice. Foley had been inserted 8/8/19, due to a failed voiding trial, Macrobid (an antibiotic) was started earlier this week. Another physician's progress note dated 8/13/19, read; Bladder scan 300 milliliters at lunch, resident was in and out cathed. Denies dysuria today. Due around dinner today for another post void residual. The above findings were shared with the Administrator, Director of Nursing, the Assistant Director of Nursing and the MDS Coordinator during the pre-exit meeting on 9/10/19 at approximately 4:15 p.m. The MDS Coordinator stated she had spoken with administration about the findings and they were working on a solution for she had not completed comprehensive care plans due to the heavy workload.

Based on observation, staff interviews, and review of the facility's policy, the facility staff failed to ensure that food was prepared, distributed and served under sanitary conditions. The finding included: On 09/04/19 at approximately 11:10 AM an initial tour of the kitchen was conducted with Other Staff # 4. The following was observed during the tour: 2 - 4 lb containers of classic Hummus with use by date 9/01/19. (Located in the Walk-in refrigerator) 1 large pan of fresh salmon not dated or labeled. (Located in the walk-in refrigerator) 1 container of ranch dressing opened (1/2 filled) no opened date listed. (Located in the reach-in refrigerator) 3 loaves of bread found in dry storage with expiration dates of 8/31/19. The above findings were discussed with the Food Service Manager (FSD-Other Staff #2) on 09/05/19 at approximately 10:15 AM. She was asked what should have been done with the above concerns. The FSD stated, Anything expired should be discarded and Anything not labeled or dated should be. On 09/10/19 at approximately 3:44 PM a pre-exit interview was conducted with the Administrator, Director of Nursing (DON) and Registered Nurse #1. No further comments were voiced. Policy entitled: Food Dates and disposition. The dining services will label and date all prepared foods with the date prepared and disposed of food items after three days for prepared foods and by manufactures expiration date for commercially packaged food items complying with all rules and regulations. PROCEDURE: Labels will be attached to all prepared food items with date prepared. Foods are removed from original packaging will be placed into containers or wrapped in a manner to maintain quality and labeled identifying the product along with the current date. DISPOSITION: Prepared food items will be disposed in a proper manner 3 days after the date of preparation. Expired foods will be disposed of prior to the date of expiration. DOCUMENTATION: Prepared foods will have an affixed label or marked on a disposable container with the current date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to review and revise the plan of care of 1 of 18 residents in the final survey sample, Resident # 3. The findings included The facility staff failed to revise the care plan for Resident # 3 to reflect that he did not have a Foley catheter. Resident # 3 is an [AGE] year-old-male who was originally admitted to the facility on [DATE] with a readmission date of 3/27/18. Diagnoses included but were not limited to: benign prostatic hyperplasia, hypertension, polymyalgia, and abscess of epididymis or testis. On 4/10/18 at 9:32 pm, the surveyor observed Resident # 3 in the hallway traveling via motorized scooter without difficulty. Resident # 3 was well groomed wearing a tan pants, grey shirt, and grey shoes. There was no catheter drainage bag observed on Resident # 3 at this time. The clinical record for Resident # 3 was reviewed on 4/10/18 at 2:08 pm. The most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 1/20/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff coded that Resident # 3 had a BIMS (brief interview for mental status) score of 9/15, which indicated moderate cognitive impairment. Section H of the MDS assesses bladder and bowel. In Section H0100, the facility staff documented that Resident # 3 had an indwelling catheter. The current plan of care for Resident # 3 was initiated on 3/27/18. The plan of care had a problem area documented as Resident # 3 has DX (diagnosis) of neurogenic bladder indwelling Foley catheter. Resident pulls on Foley at times. Interventions included but were not limited to: Foley Catheter FR (French) # 16/ 10cc (cubic centimeters) indwelling, connected to bedside drainage bag. Upon review of the current physician's orders, the surveyor did not locate any orders for a Foley catheter for Resident # 3. On 4/11/18 at 10:53 am, the surveyor interviewed CNA (certified nursing assistant) #1 and asked if Resident # 3 had a Foley catheter. CNA # 1 stated, He used to have one, but he doesn't have it anymore. On 4/11/18 at 9:03 am during an interview with Resident # 3, this surveyor did not observe a catheter drainage bag and when asked if he had a catheter Resident # 3 stated that he did not have a catheter. On 4/11/18 at 2:40 pm, the administrative team was made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 4/11/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure that 1 of 18 residents in the final survey sample received services in accordance with physician's orders, Resident # 25. The findings included The facility staff failed to obtain daily weights as ordered by the physician for Resident # 25. Resident # 25 is a [AGE] year-old-female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to: right hip intertrochanteric fracture, chronic diastolic heart failure, hypertension, and hypothyroidism. The clinical record for Resident # 25 was reviewed on 4/10/18 at 11:26 am. The most recent MDS (minimum data set) assessment was a 14-day assessment with an ARD (assessment reference date) of 3/29/18. Section C of the MDS assesses cognitive patterns. In Section C 0500, the facility staff documented that Resident #25 had a BIMS (brief interview for mental status) score of 15/15, which indicated that she was cognitively intact. The current plan of care for Resident # 25 was reviewed and revised on 3/27/18. The facility staff has documented a problem area as Resident # 25 is at nutritional risk related to therapeutic diet. Interventions included but were not limited to: Monitor weight per MD (medical doctor) orders. Resident # 25 had current orders that were signed by the physician on 3/15/18 for Daily weights due to history of heart failure and daily Lasix consumption-every morning. Upon review of the weights for Resident #25, this surveyor did not locate weights in the clinical record for 3/24/18, 3/26/18, 4/1/18, and 4/7/18. On 4/10/18 at 12:15 pm, the surveyor spoke with the director of nursing about the missing weights for Resident # 25. The director of nursing stated that she knew that there was a problem with weights in the facility and that she was working on making improvements. On 4/11/18 at 2:40 pm, the administrative team was made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 4/11/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, clinical record review, and facility document review, the facility staff failed to ensure that 1 of 18 residents in the final survey sample received treatment and services consistent with physician's orders to promote healing of pressure ulcers, Resident # 25. The findings included: The facility staff failed to implement interventions to prevent the development of 2 Stage 2 pressure ulcers and failed to ensure that heelz up was applied as ordered by physician for Resident # 25. Resident # 25 is a [AGE] year-old-female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to: right hip intertrochanteric fracture, chronic diastolic heart failure, hypertension, and hypothyroidism. The clinical record for Resident # 25 was reviewed on 4/10/18 at 11:26 am. The most recent MDS (minimum data set) assessment was a 14-day assessment with an ARD (assessment reference date) of 3/29/18. Section C of the MDS assesses cognitive patterns. In Section C 0500, the facility staff documented that Resident #25 had a BIMS (brief interview for mental status) score of 15/15, which indicated that she was cognitively intact. Section G of the MDS assesses functional status. In Section G0110 activities of daily living was assessed. For bed mobility and transfers, the facility staff documented that Resident # 25 is 3/3, which indicated that Resident # 25 required extensive assistance of 2 or more people. Section M of the MDS assesses skin conditions. Section M0210 assesses unhealed pressure ulcer(s). The question was asked, Does the resident have one or more unhealed pressure ulcers(s) at Stage 1 or higher? The facility staff documented 1 which indicated yes. Section M 0300 assesses the current number of unhealed pressure ulcer(s) at Stage 1 or higher. M0300 B Stage 2, the facility staff documented that Resident #25 had 2 Stage 2 pressure ulcers. Facility staff also documented that the Stage 2 areas were not present upon admission, and documented the date of the oldest Stage 2 pressure ulcer was 3/26/18. Upon review of the Braden Scale for Resident # 25, that was completed upon admission, the facility staff documented that Resident # 25 had a Braden score of 17, which indicated low risk. The current plan of care for Resident # 25 was reviewed and revised on 3/27/18. The facility staff documented a problem area Resident # 25 is at risk for skin breakdown due to incontinence and needs help for bed mobility due to her generalized weakness, poor endurance, and easily fatigues. Interventions include but were not limited to Encourage frequent position change, consult dietitian as needed and monitor skin during baths weekly. Resident # 25 had current physician's orders that were signed by the physician on 3/25/18 that included but is not limited to: Float both heels with heelz up while in bed every shift. The physician wrote orders on 3/26/18 that stated Fluid filled blister to right heel- apply skin prep every shift, and Fluid filled blister to left heel- apply skin prep every shift. Upon further review of the clinical record, this surveyor did not locate any dietary notes that had been written to address dietary interventions to promote wound healing. On 4/10/18 at 3:12 pm, the surveyor entered Resident # 25's room to speak with her. Resident # 25 was observed lying in bed and heels were resting on the mattress. The heelz up device was not in place on bed and was observed in a chair next to Resident # 25's bed. On 4/11/18 at 8:33 am, the surveyor observed two staff members pulling Resident # 25 up in bed so that she would be positioned properly in bed to eat her breakfast. Resident # 25 gave the surveyor permission to look at her heels. The surveyor observed an area on the right heel that was circular in shape and about the size of a 50-cent piece. The area was noted to be hardened and dark purple in color. The surveyor also observed an area on the left heel that was circular in shape and about the size of a dime. The area was noted to be light brown in color. Resident # 25 asked the surveyor what was going on with her heels. Resident # 25 then stated, People keep looking at my heels but I don't know what is going on with them. The surveyor explained her observations to Resident # 25. Resident # 25 then stated to the surveyor, You see what just happened, how they came in here and got me all fixed up, well that doesn't happen all the time. According to the facility policy on Wound Care Assessment and Documentation, Documented under I. Assessment of Residents at Risk: A. Identify resident who are particularly prone to the development of pressure ulcers. This includes: (but is not limited to) Residents with an alteration in mobility 10. Residents who score 17 or below on skin assessment tool. Documented under II. Pressure Ulcer Prevention, includes but is not limited to: 3. Use of heelz up cushion to support heels or residents and decrease shearing and pressure (physician order required) 12. Provision and assurance that the resident receives optimum nutrition. Also documented within the policy in Section V, which addresses the Braden Scale includes but is not limited to A. 15 PLUS = low risk Interventions to include but not limited to: 1. Dietitian Review 2. Frequent Repositioning 3. Floating heels On 4/11/18 at 2:40 pm, the administrative staff was made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 4/11/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to ensure that 1 of 18 resident's in the final survey sample received appropriate care and treatment to prevent urinary tract infections, Resident # 15. The findings included The facility staff failed to ensure that Resident # 15 received catheter care and failed to ensure that catheter tubing was secured to facilitate the flow of urine preventing kinking of the tubing and position below the level of the bladder. Resident # 15 is a [AGE] year-old-male who was originally admitted to the facility on [DATE], with a readmission date of 3/27/18. Diagnoses included but were not limited to: urinary tract infection, urinary retention, clostridium difficile, and malignant neoplasm of the prostate. The clinical record for Resident # 15 was reviewed on 4/10/18 at 1:54 pm. The current plan of care for Resident # 15 was initiated on 3/26/18. The facility staff documented a problem area Resident # 15 has indwelling catheter use with potential for infection diagnosis urinary retention with 3 failed voiding trials, diagnosis benign prostatic hyperplasia. Interventions included but were not limited to: Secure catheter to leg to avoid tension on urinary meatus. and Provide catheter care per protocol. The physician signed the current physician's orders for Resident # 15 on 3/27/18. This surveyor did not locate any orders for catheter care. On 4/11/18 at 10:27 am, Resident # 15 gave the surveyor permission to look at his indwelling catheter. Upon observation of the indwelling catheter, this surveyor observed a #14 Fr (French) catheter with 10 ml (milliliter) bulb. The stat lock was not secured to the resident's leg and was connected to the catheter that was positioned upward along the left thigh of Resident # 15 promoting the flow of urine back into the bladder. The tubing that connects the Foley catheter to the urinary drainage bag was observed curled underneath of the left leg of Resident # 15. On 4/11/18 at 2: 00 pm, the surveyor spoke with the director of nursing to ask about catheter care for Resident # 15. The director of nursing reviewed the current physician's orders along with the surveyor and agreed that Resident # 15 did not have any current orders for catheter care. Director of nursing stated, I will have to get that updated. On 4/11/18 at 2:40 pm, the administrative team was made aware of the findings as stated above. No further information was provided to the survey team prior to the exit conference on 4/11/18.

Based on observation, staff interview, and facility document review, the facility staff failed to ensure that drugs were stored and labeled according to accepted professional principles. The findings included The facility staff failed to ensure that 1 of 2 medication carts was locked when unattended, and failed to ensure that Budesonide inhalation suspension was dated when opened on 1 of 2 medication carts. On 4/09/18 at 6:51 pm, the surveyor observed a medication cart # 2 unlocked and unattended. On 4/9/19 at 6:53 pm, RN (registered nurse) #1 came into the hallway and the surveyor asked him if he was responsible for the medication cart. RN #1 stated, Yes what's wrong with it? RN # 1 looked at the medication cart, stated Oh God, and immediately locked the medication cart. According to the facility policy on Medication Administration Procedure includes but is not limited to XXIII. Never leave medication cart open and unattended. On 4/10/18 at 10:07 am, the surveyor checked the medication cart # 1. The surveyor observed a foil package of Budesonide Inhalation suspension in medication cart # 1 that was opened and undated. The surveyor spoke with RN # 2 about the opened undated pouch. The surveyor asked RN # 2 what the expiration date on the Budesonide Inhalation Suspension was. RN # 2 stated that they would look at the date on the vial. The surveyor brought to RN # 2's attention that according to the manufacturer's instructions on the box, the medication can be stored for 2 weeks after opening the protective foil. The surveyor asked RN # 2 if there is no date opened, how anyone is supposed to know when the two weeks are up. RN voiced understanding. On 4/11/18 at 2:40 pm, the facility staff was made aware of the findings as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 4/11/18.

Based on observation and facility document review, the facility staff failed to provide an environment that prevents the transmission of communicable diseases and infection in 1 of 1 rooms on contact isolation. The findings included The facility staff failed to ensure that soap was available to wash hands prior to leaving the room of a resident on contact isolation. On 4/11/18 at 10:27 am, the surveyor was conducting interview and observations with Resident # 15. Resident # 15's diagnoses included but were not limited to clostridium difficile. Upon concluding the observation and interview, the surveyor removed the personal protective equipment and went into the bathroom to wash hands prior to leaving the room. This room had an automatic soap dispenser that was located on the sink next to the faucet. The surveyor placed her hands underneath the soap dispenser to obtain soap to wash her hands. No soap was dispensed from the dispenser. The surveyor observed a bottle of soap on the counter next to the sink with a long clear hose affixed to the top. The surveyor attempted to remove the top off of the soap to obtain soap but was unsuccessful. The surveyor looked underneath the sink and observed that there was no soap connected to the automatic soap dispenser. According to the facility policy on Clostridium Difficile Implementation procedures include but are not limited to 5. When caring for residents with diarrhea or fecal incontinence, staff will maintain vigilant handwashing with soap and water, rather than alcohol-based hand rubs, for the removal of Clostridium spores from hands. On 4/11/18 at 2:40 pm, the administrative team was made aware of the findings as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 4/11/18.

Based on observation, staff interview and facility document review it was determined that the facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility kitchen. The Findings Included: On April 9, 2018 at 6 p.m., the surveyor made an initial tour of the dining room and small kitchen located on the second floor. The surveyor observed three Residents sitting in the dining room and eating their dinner. The surveyor observed a male dietary staff member walk from the kitchen into the dining room and then returned into the kitchen. The surveyor observed that the male dietary staff member had a mustache and a goatee. The surveyor did not observe that the male staff member had on a mustache or goatee guard. The surveyor continued to tour the kitchen and observed that food was still being kept hot on the steam table and was available for residents to consume. On April 9, 2018 at 6:10 p.m. the surveyor informed the male dietary staff member that he had facial hair and asked shouldn't your facial hair be covered? The male dietary staff member stated Yes and said he would get a beard/mustache guard. On April 10, 2018 at 12:50 p.m., the surveyor notified the Administrator (Adm) that a male dietary staff member did not have beard guard on yesterday evening when we first entered the building. The surveyor notified the Adm that the male dietary staff member had a mustache and a goatee. The surveyor notified the Adm that the male staff member walked from the kitchen into the dining room and then back into the kitchen. The surveyor notified the Adm that food was available and was being kept hot on the steam table. The surveyor requested the policy and procedure for handling and storage of food. On April 10, 2018 at 1:49 p.m., the Adm hand delivered a policy and procedure titled, Dining Services Sanitation Hair Restraints. The policy and procedure read in part . Policy: Employees are required to wear hair restraints that effectively keep their hair from containing food, clean equipment, utensils, and lines. Procedure: I. Employees who come in contact with food, clean equipment, utensils, and linens shall wear hair restraints such as hats, hair coverings or nets and beard guards. No additional information was provided prior to exiting the facility as to why the male dietary staff failed to wear a mustache/beard/goatee guard while working in the kitchen.

Based on staff interview and clinical record review it was determined that the facility staff failed to ensure a complete and accurate clinical records for the residents' of the facility. The facility staff failed to ensure that the monthly Drug Regimen Reviews (DRR's) completed by the pharmacy were contained in the clinical records of the facility residents'. The Findings Included: On April 10, 2018 at 8 a.m., the survey team started to review the clinical records of the Residents' that were assigned to each individual surveyor. The survey team noted that the clinical records failed to produce monthly Drug Regimen Reviews (DRR's) completed by the pharmacy. On April 10, 2018 at 12:35 p.m., the survey team notified the Interim Director of Nursing (IDON) that review of the residents' clinical records failed to produce documentation that the monthly DRR's being completed by the pharmacy. The survey team reviewed several Residents' clinical records with the IDON. This surveyor pointed out that the clinical records failed to produce documentation that the monthly DRR's were completed the pharmacy. The IDON stated that she would look and see what she could find. Within a few moments, the IDON approached the survey team and informed the survey team that the pharmacy vendor sent the files to the facility every month when the DRR's were completed. The IDON stated that the files were on a computer in a special file folder and that only the administration team had access to the files. The IDON stated that the supervisor that worked the night shift was supposed to scan each residents' DRR and put the scanned DRR's in the appropriate Resident electronic record. The IDON stated that she was the Interim DON and had just taken the position in March of 2018. The IDON stated that when she took the position as the IDON that she made sure that the March 2018 DRR's were in the residents' clinical records. The surveyor notified the DON that the survey team had a look back period of one year for the DRR's. The survey team informed the IDON that when the clinical records were reviewed the monthly DRR's were not in the clinical record. The IDON stated that the monthly DRR's were not included in the residents' clinical records as the files/DRR's had not been scanned by the night supervisor and placed into the appropriate resident record. On April 11, 2018 at 2:30 p.m. the survey team met with the Administrator (Adm), Assistant Administrator (AAdm) and the IDON. The survey team notified the Administrative Team (AT) that the facility staff failed to ensure complete and accurate clinical records for the facility residents'. The survey team notified the AT that the facility staff failed to ensure that the monthly pharmacy DRR's were contained in the residents' clinical records. No additional information was provided prior to exiting the facility as to why the facility staff failed to ensure complete and accurate clinical records for the residents' of the facility. The facility staff failed to ensure that monthly DRR's were contained in the clinical record.