**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** , Based on record reviews and staff interviews, the facility failed to ensure the completion of a new Preadmission Screening and Resident Review (PASARR) for residents with a newly added psychiatric diagnosis. This deficient practice had the potential to affect three (3) of three (3) residents reviewed for the PASAAR care area. Resident identifiers: #62, #12 and #6. Facility census: 86. Findings include: a) Resident #62 During a medical record review on 02/06/24, revealed a new PASARR had not been completed when the psychiatric diagnosis of a major depressive disorder had been added to the medical diagnoses list on 11/02/22. In an interview with the Director of Nursing (DON) on 02/07/24 at 10:45 AM, they verified the new PASARR had not been completed when Resident #62 received a new diagnosis of major depressive disorder on 11/02/22. b) Resident #6 On 02/07/24, a record review of the resident's electronic medical record (EMR), the resident's Pre-admission Screening (PAS), dated 03/22/21, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated None. A continued record also revealed the resident received a psych diagnosis of Major Depressive Disorder, Recurrent on the diagnosis listed on admission [DATE] and Delusional Disorder on 11/01/23 but did not receive a new PAS to address whether or not specialized services were needed. On 02/07/24 at 10:00 AM, an interview with the Director of Nursing confirmed the admission PAS presented to the surveyor did not indicate a diagnosis of Major Depressive Disorder or Delusional Disorder. She verified a new PAS was not completed when she received the psychiatric diagnosis. She confirmed a new pas should have been completed. c) Resident #12 Review of Resident #12's medical records showed a Preadmission Screening and Resident Review (PASRR) had been completed for the resident on 09/27/19. The PASRR showed the resident had diagnoses of dementia and major depressive disorder. Further review of Resident #12's medical records showed the resident was diagnosed with schizoaffective disorder, bipolar type, on 01/10/23. The medical records showed no updated PASARR was completed for the resident after the diagnosis of schizoaffective disorder, bipolar type, was made. During an interview on 02/06/24 at 1:41 PM, the Director of Nursing (DON) confirmed no updated PASAAR had been completed for Resident #12 when the resident received a diagnosis of schizoaffective disorder, bipolar type, to determine whether the resident's placement in the facility was appropriate. No further information was provided through the completion of the survey process.

. Based on record review and staff interview the facility failed to develop a comprehensive person-centered care plan for bladder incontinence and dehydration. Resident Identifiers: #86 and #111. Facility Census: 86 Findings Include: a) Resident #86 On 02/05/24 at 2:00 PM during an interview with the resident, she discussed her needs for bladder incontinence. On 02/06/24 at 01:57 PM a record review found documentation of 73 urinary episodes, she was incontinent 67 of the 73 episodes. Further review of the record found there was no comprehensive care plan in place for bladder incontinence. This was confirmed with the Director of Nursing on 02/06/24 at 2:20 PM. b) Resident #11 An observation on 02/05/24 at 3:19 PM revealed, Resident #11 had an IV in his hand. A record review of Resident #11's order on 02/05/24 at 3:30 PM revealed Resident # 11 was receiving Sodium Chloride Intrevenous Solution for dehydration. Further review of the medical record showed no care plan was developed for Dehydration. During and Interview on 02/06/24 at 9:30 AM with the Director of Nursing it was confirmed a careplan was not developed for dehydration for Resident #11.

. Based on record review and staff interview the facility failed to revise a person-centered care plan for a change in a resident's condition. This was true for one (1) of 23 care plans reviewed during the Long Term Care Survey Process. Resident #27 had a change in nutritional status which was not revised on the person centered care plan. Resident identifiers: #27. Facility census: 86. Findings include: a) Resident #27 During a medical record review on 02/07/24, the care plan had an intervention to educate and limit resident's salt intake. There was an order on 01/20/24 for sodium chloride tablet one (1) gram four (4) times a day as a supplement. Her diet orders were a regular diet, mechanical texture and regular consistency with a start date of 01/12/24. An interview with the Director of Nursing (DON) on 02/06/24 at 3:05 PM, verified the care plan had not been revised to remove the intervention for limiting salt intake.

. Based on observation, record review, resident, staff interview the facility failed to assist a dependent Resident with activities of daily living (ADL's) in accordance with the Residents assessed needs for care. This is true for one (1) of two (2) residents reviewed for ADL care. Resident Identifier: #240. Facility census: 86. Findings Include: a) Resident #240 showers On 02/05/24 at 12:12 PM, Resident #240 stated he hasn't received or been offered a shower or bath since his admission. A review of Resident #240's ADL documentation found; no showers documented. During an Interview on 02/06/24 at 11:09 AM the Director of Nursing (DON) verified there was no documentation that Resident #240 received showers. She stated, he should have been put on the shower list and been offered a shower before 02/05/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This deficient practice had the potential to affect three (3) of 23 residents reviewed in the long-term care survey sample. The facility failed to follow physician's orders for Resident #12 and Resident #90. The facility also failed to complete neurological evaluations after an unwitnessed fall for Resident #240. Resident Identifiers: #12, #240, #90. Facility census: 23. Findings included: a) Resident #12 Review of Resident #12's medical records showed a physician's order written on 03/16/22 for no water pitcher at bedside. Further review of Resident #12's medical records showed the resident had a diagnosis of hyponatremia, or low sodium in the blood. During an observation on 02/06/24 at 10:30 AM, Resident #12's room was noted to have a large plastic glass, or pitcher, on the overbed table. The large plastic pitcher had some water in it. A small glass of water and ice was also on the resident's bedside table. However, the resident was not in the room at this time. On 02/06/24 at 11:08 AM, Resident #12 was observed to be in bed. The large plastic pitcher containing water and the small glass of water and ice were still on the resident's overbed table. On 02/06/24 at 3:11 PM, Resident #12 was observed to be in bed. The small glass of water and ice was empty. The large plastic pitcher containing water was still on the resident's overbed table. The Director of Nursing (DON) confirmed Resident #12 had a water pitcher at her bedside despite a physician's order to not have a water pitcher. The DON stated the reason for the order for no pitcher at bedside was due to the resident's diagnosis of hyponatremia. (Limiting the amount of fluids taken in can help balance sodium levels.) The DON stated she would remove Resident #12's water pitcher. No further information was provided through the completion of the long-term care survey process. Review of facility policy titled, Neurological Checks (Neuro-Checks), read in part, Frequency of Neuro-checks: For stable or unchanged neuro-checks use the following schedule: 1. Every 15 minutes times four (4) 2. Every 60 minutes times four (4) 3. Every four (4) hours times four (4) 4. Daily times four (4) days b) Resident #240 During an interview and observation on 02/05/24 at 12:12 PM, Resident #240 was in a low bed with two fall mats located on each side of the bed. He stated that he fell after his admission to the facility. A medical record review for Resident #240 found, unwitnessed fall on 01/26/24 at 1:45 AM. Subsequent review of medical record and neurological assessments (Neuro Check) for Resident #240 showed neuro checks started on 01/26/24 at 1:45 AM for the unwitnessed fall. The neuro checks were not completed on 01/29/24 or 01/30/24. Neuro-checks were not completed per protocol. During an Interview on 02/06/24 at 2:37 PM the Regional Director, verified the neuro-checks were not completed as ordered. c) Resident #290 According to record review on 02/06/24 at 2:07 PM, Resident #290 was admitted on [DATE] status post left hip replacement. On 02/01/24 there was a Physicians order to: Cleanse post op surgical site to left hip with saline wound cleanser, pat dry, skin pre & apply dry dressing every day shift for skin care treatment. According to review of the Treatment Administration Record (TAR) the physicians order was not followed on 02/03/24 when the surgical site was not treated. This was confirmed with the Director of Nursing on 02/06/24 at 2:10 PM.

Based on observation, record review, and staff interview, the facility failed to ensure care of a resident with a tracheostomy within professional standards of care. The facility failed to follow the physician's order to always have a smaller size of trach tube at the bedside. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of tracheostomy. Resident Identifier: #68. Facility census: 86. Findings included: a) Resident #68 Review of Resident #68's physician's orders showed an order written on 01/11/24 which stated, Trach-Type: cuffed size: Shiley 6XLT. Another physician's order also written on 01/11/24 stated, Have same size trach and one smaller at bedside at all times. A smaller tracheostomy tube may be needed in case of emergencies. An observation of the emergency equipment at Resident #68's bedside was made on 02/07/24 at 10:23 AM. Shiley size 6XLT tracheostomy tubes were located at the bedside. However, no smaller size tracheostomy tube could be found at the bedside. On 02/07/24 at 10:27 AM, Registered Nurse (RN) #64 confirmed no smaller size tracheostomy tube was located at Resident #68's bedside. RN #64 stated she would obtain a smaller size tracheostomy tube to keep at the resident's bedside. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to document specific behaviors to monitor the efficacy of psychotropic medications. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifier: #12. Facility census: 86. Findings included: a) Resident #12 Review of Resident #12's physician's orders showed the resident was receiving the following psychotropic medications: - Ativan (lorazepam) for anxiety - Risperdal (risperidone) for schizoaffective disorder, bipolar type - Cymbalta (duloxetine) for depression - Depakote (divalproex sodium) for schizoaffective disorder, bipolar type Further review of Resident #12's physician's orders showed an order written on 12/21/22 to monitor behaviors every shift. The behaviors to be monitored were as follows: - Cursing, physical aggression, hitting - Yelling - Suicidal ideation Non-pharmacological Interventions to be implemented were as follows: - If resident is able to physically able, involve in activity such as walking or some other physical activity to burn off excess energy. - If resident refuses care attempt redirection, if unable, ensure resident safety, leave and attempt care at a later time. - Redirect when restless and fidgety by folding clothes, dusting, sort/rearrange collection of items such as paperwork. (Non-pharmacological interventions typed as written.) Behavior monitoring was documented on Resident #12's Treatment Administration Records (TARs). Review of the resident's TARs since 12/01/23 showed only one instance when behaviors were reported. On 02/04/24 on night shift, the TAR showed the response yes for behaviors observed. No further information regarding the specific behaviors observed or the non-pharmacological interventions implemented to manage the behaviors. During an interview on 02/06/24 at 1:48 PM, the Director of Nursing confirmed the medical records contained no information regarding Resident #12's specific behaviors on 02/04/24 during night shift or the non-pharmacological interventions implemented. No further information was provided through the completion of the survey process.

. Based on observation resident interview and staff interview, the facility failed to serve a balanced meal. A resident was not served all items listed on the tray ticket. This was true for one (1) of two (2) residents reviewed for food. Resident identifier: #10. Facility census: 86. Findings Included: a) Resident #10 Review of the Menu for the lunch meal on 02/07/24 was homestyle meatloaf, au gratin potatoes, seasoned green peas, dinner roll, caramel apple upside down cake. An observation on 02/07/24 at 1:00 PM of lunch meal pass found Resident #10 was served meatloaf, peas, and caramel apple upside down cake. A review of Resident #10's tray ticket found dislikes: scalloped potatoes. During an interview with the Dietary Manager (DM) on 02/07/24 at 1:07 PM verified Resident #10 was only served meatloaf, peas, and caramel apple upside down cake. She stated that she should have had a roll and a substitute of mashed potatoes. The DM continued to say that she has a new employee working the tray line.

. Based on observation, record review, and staff interview, the facility failed to provide an assistive device to help a resident receive hydration. Resident #15 did not have a Kennedy cup as ordered. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of nutrition. Resident identifier: #15. Facility census: 86. Findings included: a) Resident #15 Review of Resident #15's physician's records showed an order written on 01/24/24 for a Kennedy cup with meals and at bedside. A Kennedy cup is a small lightweight cup with a handle and a lid, which allows residents with disabilities to independently take fluids better. Review of Resident #15's medical records showed the resident had diagnoses of unspecified lack of coordination and generalized muscle weakness. On 02/06/24 at 11:05 AM, Resident #15 was noted to be in bed. A large plastic water pitcher with a handle and lid with a straw was noted on the overbed table. The resident did not have a Kennedy cup at the bedside. On 02/06/24 at 3:10 PM, Resident #15 was noted to be in bed. The large plastic water pitcher remained on the overbed table. A bottle of orange soda was also on the overbed table, along with a small plastic cup with a straw but no handle or lid. The small plastic cup contained orange soda. The resident did not have a Kennedy cup at the bedside. On 02/06/24 at 3:15 PM, the Director of Nursing (DON) confirmed Resident #15 did not have a Kennedy cup at the bedside, as ordered by the physician. The DON stated she would obtain a Kennedy cup for the resident's bedside. No further information was provided through the completion of the survey.

. Based on observation, record review, staff interview, the facility also failed to ensure staff donned appropriate personal protective equipment (PPE) prior to entering an Enhanced Barrier room. These failed practices had the potential to affect every resident currently residing in the facility. Resident Identifier: #5. Facility census: 86. Findings included: a) Resident #5 An observation on 02/05/24 at 1:50 PM found Nurse Aide (NA) #5 and NA #63 in Resident #5s room. The signage on Resident #5s door showed the room was on Enhanced Barrier. The TBP sign stated, Providers and Staff Must: put on gloves and gown before room entry. Both NA #5 and NA #63 was observed in Resident #5's room without gowns providing care. A medical record review for Resident #5 revealed, an active Physician orders: -- Enhanced barrier precautions related to: MDRO When dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting and peri-care, providing care to resident with history of or colonized multi-drug resistant organism. Start date 12/26/23. During an interview on 02/05/24 at 1:59 PM, with NA #5 stated that there was a PPE cart outside the door. NA #5 and #63 stated that they should have had a gown on while providing personal care since the sign was still on the door. No further information was provided prior to the end of the survey on 02/07/24 at 2:00 PM.

. Based on Resident Council and staff interview the facility failed to provide reasonable access to mail services to residents by not delivering mail on Saturday's. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 86. Findings Include: During a meeting with Resident Council on 02/06/24 at 10:30 AM the Resident Council made a complaint that the mail is not delivered on Saturdays. An interview on 02/06/24 at 11:11 AM, with Receptionist #(4) four confirmed The mail is delivered to the mailbox at the top of the road. Sometimes the mailman will bring mail into the facility, but if not activities will go get it. I sort the mail from the weekend on Monday's and give it to the Activity department to pass out to resident's.

. Based on Resident Council, observation, and staff interview the facility failed to display the most recent State inspection in a readily accessible area frequented by residents. It was discovered the State inspection was placed too high for residents in a wheelchair to reach. This had the potential to affect more than a limited number of residents. Facility census 86. Findings include: a) State inspection During the Resident Council meeting on 02/06/24 at 10:30 AM, Resident Council voiced they did not know if they had access to the State inspection or where it was located. An observation on 02/06/24 at 11:21 AM, revealed the State inspection was located in the lobby beside the receptionist office at a height too high for residents in wheelchairs to reach. During an interview on 02/06/24 at 1:26 PM the administrator stated, Someone can hand it to them, we have people here all the time. This statement confirmed residents in wheelchairs could not reach the State inspection with having to ask a staff member for help.

. Based on observation and staff interview, the facility failed to ensure that the resident environment remains as free of accident hazards as possible when a medication cart was left unlocked and unattended. This was a random opportunity for discovery. Facility Census: #86 Findings included: a) Medication cart 200 Hall On 02/06/24 at 8:40 AM an observation was made of the medication cart on the 200 hall cart left unattended and unlocked. There were numerous residents near the medication cart. According the the facility Policy # NS-1197-05 Medication Administration it is stated . Procedure: I. General Procedures: k. Do not leave medication cart unlocked . According to a list provided by the Director of Nursing there are six (6) residents that are at risk for elopement. This was confirmed with Licensed Practical Nurse (LPN) #7 at 8:41 AM. This was also confirmed with the Administrator on 02/06/24 at 9:28 AM.

. Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered the reach-in freezer floor was dirty and the ice machine was not draining properly. The deficient practice had the potential to affect any residents receiving nourishment from the kitchen. Facility census: 86. Findings included: a) Kitchen tour During the kitchen tour on 02/05/24 at 11:45 AM, it was discovered the reach-in freezer had a large amount of crusted particles on the floor and the ice machine drain line did not have the proper spacing of one (1) inch above the floor drain to prevent back flow. The Dietary Manager (DM) on 02/05/24 at 11:55 AM, verified the floor of the reach-in freezer needed to be cleaned and the ice machine was not draining properly to prevent back flow.

. Based on record review, staff interview and family interview the facility failed to notify Resident #46's representative in advance of care. The facility did not notify the Medical Power of Attorney (MPOA) prior to administering vaccinations and for resident's change of condition and treatment of the shingles. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #46. Facility census: 85. Findings include: a) Resident #46 A record review of a physician's determination of capacity showed Resident #46 demonstrated incapacity to make medical decisions as of 4/15/23. Resident #46's record also contained a Resident RSV (Respiratory Syncytial Virus Infections) Consent and Screen form completed on 12/01/23. The form was used to obtain verbal consent from Resident #46's Medical Power of Attorney (MPOA) for of the RSV vaccination. The consent was signed by two (2) nurses and indicated the Resident's Representative was contacted via phone on 12/01/23 and gave permission for the RSV vaccine to be administered. The consent form also indicated the resident's representative was educated on RSV and the possible side effects of the vaccine. Review of the Resident's Medication Audit Report (MAR) showed the RSV vaccine was administered on 12/15/23. During an interview on 01/18/24 at 3:15 PM, Resident #46's MPOA was asked if the facility had contacted her to obtain permission to administer the RSV vaccine? The MPOA stated, No ma'am no one told me about the vaccine. They [facility] called here this morning to tell me about taking her off of PT [physical therapy] and they called a while back to let me know about adjusting her depression medication. The MPOA further stated her mom had shingles a few years back but never has been offered a Shingles vaccine either. The MPOA was asked if she was notified about her mother having shingles recently on 12/12/23? The MPOA replied, What! Not one told me mom had shingles in December. This all really upsets me. Did they treat her for it? The MPOA was told the facility initiated 3 medications to treat the Shingles and her mom was also placed in isolation. The MPOA stated. This is the first time I've ever heard any of this. You [Surveyor] should not be the one telling me. Record Review showed a Nurses Note dated 12/12/2023 at 8:18 PM which stated: Per LPN floor nurse resident with areas to abdomen and back with shingle rash like area. This nurse assessed and resident with a red cluster like rash from mid lower back around right side to abdomen, to belly button area. New orders for contact precautions-initiated at this time per facility protocol. MD is aware and NP in facility aware and will assess. POA to be made aware. Review of resident's MAR showed the following medications were administered to treat Shingles: Gabapentin Capsule 100 MG Give 1 capsule by mouth three times a day for herpes zoster pain for 2 Weeks with start date of 12/12/2023. Valtrex Oral Tablet 1 GM (Valacyclovir HCl). Give 1 tablet by mouth three times a day for shingles for 7 Days. Start date 12/12/2023. Dermoplast pain relief spray to be applied to affected areas daily & PRN for discomfort of shingles.one time a day for shingles for 14 Days. Start Date 12/13/2023. Record review also showed an order for Resident #46 to be placed in contact Isolation related to Shingles every shift for Shingles for 7 Days with start date 12/12/2023. On 01/18/23 at 3:32 PM a second phone interview was conducted with Resident #46's MPOA in the presence of the Director of Nursing (DON) and Corporate RN #113. The MPOA confirmed to the DON and Corporate RN #113 she was never contacted in December to give consent to administer the RSV vaccine and she had no idea her mother had shingles a few weeks ago in December. On 01/22/24 at 12:03 PM, the Director of Nursing (DON) stated she spoke with Resident #46's MPOA during the Immunization Audit on 01/18/24. The DON stated Resident #46's MPOA told her he remembered them calling around the 1st of December for the Covid-19 vaccine. Consent for the Covid vaccine was documented on 11/10/23 and given on 11/15/23. When asked about the Shingles, the MPOA once again stated she knew nothing about it. The DON stated she initiated a grievance for these issues on 01/18/24. A record review showed a concern/grievance form dated 01/18/24 completed by the DON. Nature of the concern was that the Resident Representative verbalized she did not consent to the RSV vaccine and had only consented to the Covid vaccine on 12/01/23. MPOA stated she did want her mother to receive a vaccine for RSV and was okay with Administration. Verbalized she was unaware Resident had shingles on 12/12/23. MPOA was contacted on 01/19/24 at 3:52PM to review the information and verbalized she would be in the center next week for signature. During an interview, on 01/22/24 at 9:53 AM, the Administrator stated they [the DON and Corporate RN #113] had done an audit on 01/18/24 and 01/19/24 regarding verbal consents for the RSV vaccination. The Administrator stated, It was very alarming to us we were giving vaccines to people that did not consent. We did reach out to [Resident #46's MPOA name] and spoke with her again and she stuck to her story that we never called her prior to administration of the RSV vaccine. On 01/22/24 at 12:30 PM the DON stated she did not have any other explanation as to why the MPOA was not notified but should have been.

Based on record review and staff interview the facility failed to maintain accurate documentation for administration and dispensing of narcotic medication for three (3) of three (3) medication carts reviewed. This failed practice had the potential to affect more than a limited number of residents. Facility census: 85. Findings include: a) Medication Controlled Drugs Policy Record review of the facility's undated policy titled, Medication Controlled Drugs and Security, found: Controlled drugs as well as controlled drug count sheets and cards are counted every shift change by the nurse reporting on duty with the nurse reporting off duty. The inventory of the controlled drugs, count sheets, and number of cards must be recorded on the narcotic records and signed for correctness of count. The controlled drug record must be signed by the nurse coming on duty and going off duty to verify that the count of all controlled drugs is correct after the count has been completed. b) Shift Change Controlled Substance Inventory Tracker Record review showed the facility used a logbook with forms labeled Shift Change Controlled Substance Inventory Tracker for documentation and inventory of narcotics and controlled substances. The document required the following information to be completed: Date, Shift time/key exchange, Nurse signature (nurse coming on duty, nurse going off duty) Total number of cards, Total number of count sheets. On 01/18/24 at 2:00 PM the Director of Nursing (DON) verified each medication cart has its own specific Controlled Substance Inventory log book with the expectation the logbook is completed at each shift change by both the oncoming nurse and off going nurse to ensure accuracy. c) Hall 100 Medication Cart During observation of the 100 Hall Mediation Cart on 01/18/24 at 11:15 AM, the Shift Change Controlled Substance Inventory Tractor Log was noted to be incomplete for the following dates for December 2023 - present : -12/05/23 at 1:30 PM - Off Duty Nurse signature missing -12/05/23 at 6:00 PM - Off Duty Nurse signature missing and total number of cards missing -12/07/23 at 6:00 AM - Off Duty Nurse signature missing with total number of cards incorrect -12/10/23 at 6:00 PM - Off Duty Nurse signature missing -12/11/23 at 6:00 PM - Off Duty Nurse signature missing -12/25/23 at 10:00 AM - Off Duty Nurse signature missing -12/29/23 at 6:00AM and 6:00 PM - Off Duty Nurse signature missing and total number of cards missing -01/13/24 at 6:00 PM - Total Number of Card count not entered correctly (illegible) -01/14/24 at 6:00 AM - Total Number of Card count not entered correctly (illegible) At 11:20 AM on 01/18/24 Licensed Practical Nurse (LPN) #68 verified the records were incomplete for 100 medication cart and stated that is process used to verify the narcotic count to be correct at the end of each shift. LPN #68 stated this should be done each time a new nurse accepts keys to the mediation cart for use. LPN #68 stated both nurses are to count the number of cards (controlled substance medication cards) in the locked drawer and then count each pill within the cards for accuracy. LPN #68 stated, I don't like to take the keys unless we know its right. d) Hall 500 Medication Cart During observation of 500 Hall Mediation Cart on 01/18/24 at 11:35 AM, the Shift Change Controlled Substance Inventory Tractor Log was noted to be incomplete for the following dates for December 2023 - present: 12/08/23 at 6:00 AM - Total Number of Card count not entered correctly (illegible) 12/09/23 - No shift change time entered. 12/014/23 at 6:00 AM - total number of count sheets missing 12/19/23 at 10:00 PM- Off Duty Nurse signature missing 12/24/23 at 6:00 AM - Two(2) entries made for 6:00 AM with (2) different counts 12/29/23 at 10:00 PM - Off Duty Nurse signature missing 12/30/23 at 10:00 AM - On Duty Nurse signature missing 12/30/23 at 2:00 PM - Off Duty Nurse signature missing 01/08/24 at 6:00 PM - On Duty Nurse signature missing 01/13/24 at 6:00 PM - On Duty Nurse signature missing 01/14/24 at 6:00 AM - On Duty Nurse signature missing 01/14/24 at 10:00 PM - Off Duty Nurse signature missing At 11:40 AM on 01/18/24 Licensed Practical Nurse (LPN) #75 verified the records were incomplete for 500 Hall medication cart and stated, We verify the count at the end of each shift when we hand the keys over. LPN #75 stated both nurses are supposed to sign the count sheets in the logbook. e) Hall 600 Odd Medication Cart During observation of 600 Hall odd Mediation Cart on 01/18/24 at 11:45 AM, the Shift Change Controlled Substance Inventory Tractor Log was noted to be incomplete for the following dates for December 2023 - present: -12/01/23 at 6:00 AM - Off Duty Nurse Signature missing -12/05/23 at 3:30 PM- Off Duty Nurse signature missing -12/05/23 at 6:00 PM- Off Duty Nurse signature missing -12/07/23 at 6:00 AM- Off Duty Nurse signature missing -12/08/23 at 6:00 PM- Off Duty Nurse signature missing -12/09/23 at 6:00 PM- Off Duty Nurse signature missing -12/11/23 at 6:00 PM- Off Duty Nurse signature missing -12/13/23 at 6:00 PM- Off Duty Nurse signature missing -12/14/23 at 6:00 PM- Off Duty Nurse signature missing -12/28/23 at 6:00 AM- Off Duty Nurse signature missing -01/13/24 at 6:00 PM- On Duty Nurse signature missing At 11:50 AM on 01/18/24 Licensed Practical Nurse (LPN) #75 verified the records were incomplete for 600 Hall Odd medication cart and stated, I have the odd number rooms for 600 halls also and it has its own separate narcotic book. They are separated between even and odd room numbers. Looks like its [Controlled Substance Logbook] is wrong too with lots of holes in it. I hope none of those are mine. f) Staff Interview On 01/22/24 at 2:00 PM the Director of Nursing (DON) verified the Shift Change Controlled Substance records were incomplete and not accurate. The DON stated, We pulled all the logbooks from every cart and are working on it. We need to get that under control. During an interview, on 01/22/24 at 10:00 AM Regional Director of Operations stated, We have an audit going on from last week when you all were here for the narcotic book issues. They are working on that right now. That needs to be addressed so moving forward we have accuracy.

. Based on record review, family interview and staff interview, the facility failed to maintain an accurate medical record. This is true for two (2) of three (3) residents reviewed for the Respiratory Syncytial Virus (RSV) Consent during the complaint survey. Resident Identifiers: #32 and #80. Facility census: 85. Findings included: a) Resident #32 During a record review on 01/17/24 at 11:15 AM, Resident #32's medical record revealed a immunization record of RSV vaccine received on 12/29/23 in the left deltoid. Further record review revealed a verbal consent was obtained from the resident's representative, consent was witnessed by two (2) staff members, and contained no date. During an interview on 01/18/24 at 3:34 PM, Resident #32's representative stated They call me about everything. They called me today for consent for the RSV Vaccine. I told them I thought he already had it a few weeks ago, but they never responded. I went ahead and gave my consent for the vaccine again. During an interview on 01/22/24 at 12:08 PM the Director of Nursing acknowledged the RSV Consent forms did not contain a date as to when they were completed. b) Resident #80 During a record review on 01/17/24 at 12:00 PM, Resident #80's medical records revealed a immunization record of RSV vaccine received on 12/29/23 in the right deltoid. Further record review revealed that a verbal consent was obtained from the resident's representative, consent was witnessed by two (2) staff members, and contained no date. During an interview on 01/22/24 at 12:08 PM the Director of Nursing acknowledged the RSV Consent forms did not contain a date.

. Based on observation and staff interview, the facility failed to provide and maintain infection prevention and control programs designed to provide a safe sanitary environment to help prevent the development and transmission of communicable diseases and infections in the facility. This facility failed to provide medication barriers during medication administration for one (1) resident. Resident identifiers: #26. Facility Census: 85. Findings included: a) Resident #26 During a tour of the facility, on 01/18/24 at 9:20 AM, Licensed Practical Nurse (LPN) #75 was administering medication to Resident #26. LPN #75 did not place a barrier on the over the bed table prior to placing the following medications directly on the over the bed table: -Refresh Tear Solution -Trelegy Inhaler -Ipratropium Bromide Nasal Solution During an immediate interview, LPN #75 stated, I used the activity sheet for the barrier, I should have used the wax paper barrier that is on my medication cart. During a record review, on 01/18/24 at 10:00 AM, Resident #26's medical records revealed the following physician orders: -Refresh Tear Solution 0.5 % Instill two (2) drops in both eyes two (2) times a day for dry eyes. -Trelegy Ellipta Aerosol Powder Breath Activated 100-62.5-25 MCG/INH (microgram/inhalation) one (1) puff inhale orally one time a day for COPD rinse mouth after use. -Ipratropium Bromide Nasal Solution one (1) spray in both nostrils two (2) times a day for Rhinorrhea During an interview, on 01/18/24 at 10:54 AM, the Director of Nursing (DON) and Corporate Registered Nurse #113 acknowledged the above medication should have been placed on a barrier for Resident #26's mediation prior to administration. The DON stated the nurses should be using the wax tissue paper barriers provided on the medication cart. During an interview, on 01/18/23 at 11:30 AM, the Corporate Registered Nurse #113 stated there was no facility policy about using barriers during medication administration. It is just common sense and a given that a barrier is to be used. During an interview on 01/22/23 at 10:32 AM Corporate Regional Director #114 stated we completed a Medication Barrier Audit over the weekend. It looked good.

. Based on record review and staff interview the facility failed to provide information and/or offer the Respiratory Syncytial Virus (RSV) immunization per recommendation of the CDC in a timely manner. This failed practice had the potential to affect more than a limited number of residents who currently resided in the facility. Facility census 90. Findings included: a) RSV immunization Review of the facility documents regarding immunization, found zero (0) out of 90 residents had been provided educational information about the risk and benefits of receiving the RSV vaccination. On 11/28/23 at 3:45 PM the Infection Preventionist (IP) stated she had not had time to start giving the information or offer the RSV vaccine to anyone, yet IP went on to say she did not know when she would have time to do it. b) The Centers for Disease Control and Prevention (CDC) Respiratory syncytial virus, or RSV, is a common respiratory virus that usually causes mild, cold-like symptoms. Most people recover in a week or two, but RSV can be serious. Infants and older adults are more likely to develop severe RSV and need hospitalization. Vaccines are available to protect older adults from severe RSV. Monoclonal antibody products are available to protect infants and young children from severe RSV. CDC recommends RSV vaccines to protect adults ages 60 and older from severe RSV, using shared clinical decision-making. According to the CDC the RSV vaccine was made available on early August of 2023. Information from the Centers for Disease Control and Prevention (CDC) also indicates simultaneous administration of vaccines remains a best practice. According to the CDC providers should continue to simultaneously administer the vaccines for which a patient is eligible, including COVID-19, influenza, and pneumococcal vaccines. Simultaneous administration of RSV vaccine with other vaccines for older adults is also acceptable. When deciding whether to simultaneously administer other vaccines with RSV vaccine on the same day, providers should consider whether the patient is up to date with recommendations for currently recommended vaccines, the feasibility of administering additional vaccine doses later, risk for acquiring vaccine-preventable disease, vaccine reactogenicity profiles, and patient preferences.

Based on observation, record review and staff interview, the facility failed to maintain an appropriate infection control and surveillance program to prevent the development and transmission of Covid-19 during an active Covid-19 outbreak. This failed practice was a random opportunity for discovery and had the potential to affect more than an isolated number of residents currently residing in the facility. Resident identifiers: #84, #7, #73. Facility census: 90. Findings included: a) Covid-19 Visitor and Vendor Notification Record review of the facility's policy titled Criteria for Covid-19 Requirements revised on 05/11/23, showed under the surveillance topic for employees, contractors, vendors, and visitors, The facility needs to ensure all who enter the facility are aware of recommended IPC practices in the facility. Post signs and visuals at the entrance, lobby, elevators, break rooms, therapy, activity room, and on the units that include instructions about current infection prevention and control recommendations. The signage should contain the source control necessary according to outbreak status and or community transmission level of Covid-19. On 11/28/23 at 8:35 AM when surveyors entered the building observation revealed signage was posted at the main entrance indicating the facility was in active Covid-19 outbreak. Laboratory personnel technician (LT) #109 from a local hospital was observed in hallway 100 preparing to enter a resident room to draw labs without any type of face mask on. The Director of Nursing was alerted to the LT #109 not wearing a mask. DON stated, What, who don't have one on? Oh, that's lab. The DON provided LT #109 with an N95 mask and asked her to put it on. The DON verified the facility was still in an active Covid-19 outbreak and LT #10 should have been wearing a mask. At that time the observation was made of a sign posted on the front door entrance that stated, Facility is Experiencing a Covid-19 Outbreak. What does this mean? Source control is required. N-95 mask eye protection. Visitors should wear source control that is either a cloth mask or surgical mask and may wear eye protection. On 11/28/23 at 8:40 AM, LT #109 was asked what door she used to enter the building. LT #109 pointed to her left and stated, The one we always use over there, on the side of the building. LT #109 stated she did not know she was supposed to have a mask on, or the facility was in a Covid-19 outbreak. LT #109 further said, I'm sorry, glad I was just getting started and hadn't been in and out of all these rooms yet. During an interview, on 11/28/23 at 8:53 AM, Registered Nurse (RN) #90 verified no signage was posted at the service door/employee entrance that was used by LT #109. On 11/28/23 at 10:30 AM, the Director of Plant Maintenance (DPM) #50 provided surveillance footage of LT #109 entering the building through the service entrance door at 8:14 AM. LT #109 did not use hand sanitizer or place a mask on. DPM #50 stated, Oh my, I saw her at the nurse's station and didn't even realize she wasn't wearing a mask. During an Interview, on 11/28/23 at 12:00 PM, the DON was asked how they screen visitors. The DON stated, We are not. The signage is posted, and we make family calls to notify of positive cases. On 11/29/23, an interview with the DON/director of local Health Department RN verified the facility had been in outbreak status since August 26th. The Health Department considered an outbreak to be 3 or more cases. The first case for the facility was reported as August 16th. The Health Department DON stated, They have been in outbreak for a long time. I am going to reach out to my regional manager and have her work with them. Health Department DON stated the facility last reported 21 total positive residents on 11/28/23. b) Current Covid-19 Resident Positives On 11/28/23 at 11:41 AM DON provided a list titled; Current Resident Positives updated 11/28/23. The DON explained this list was provided to managers daily and used as communication for current cases of Covid-19. The list contained the following Residents: #37. #41, #29, #8, #24, #73, #3, #7, #49, #34, #65, #59, #30, #25, #78, #89, #35, #39, #26, #44. When the Patient Line List for Covid-19 list was reviewed, Resident #84 was not included on the list that was provided to the facility but was on the master line listing as Covid-19 positive on 11/21/23. The DON stated, Yea we missed him, I'll add him to the Current Positives. He needs to be on there. c1) Facility Policy Facility policy titled, Criteria for COVID-19 Requirements revised: 05/11/23. *Residents who are asymptomatic (showing no signs or symptoms) but have had close contact with someone diagnosed with COVID -19 will be tested immediately (not earlier than 24 hours). If the COVID-19 test is negative, the resident will test again in 48 hours and if negative, the resident will test again in another 48 hours. (Testing cadence day 1,3, and 5.) * Residents who have symptoms of COVID-19 will be placed in quarantine and will be tested immediately. * Residents can be removed from transmission-based precautions after 7 days following the exposure (the day of exposure is day 0), and if vial testing described above is negative. If testing is not performed, the resident can be removed from transmission-based precautions after 10 days. * All positive results (residents and employees) are documented on the electronic COVID-19 Tracker. COVID-19 Tracker will be included: Residents: 1. Resident name 2. Room Number 3. Lab test positive date 4. Symptoms 5. Hospitalization 6. Recovery date Employee 1. Employee name 2. Lab test positive date 3. Symptoms 4. Hospitalization 5. recovery and return to work 6. Assigned work area. If a signal new case of COVID-19 is identified, the facility can perform outbreak testing in two ways; contact tracing or broad-based testing. Contact Tracing: When close contact can be established, contact tracing testing is required. Staff and residents who have had a close contact with a positive person will be tested immediately (but not earlier than 24 hours after exposure), if negative test again in 48 hours, and if negative, test again in 48 hours. This is typically on days 1, 3, and 5 where day 0 is the day of exposure. Broad based testing: If contact tracing is unable to be identified or additional positive results are obtained, a broad base testing approach will be required. Staff and Residents will be tested every three (3) days until no new cases for 14 days. c2) Center for Disease Control A review of Center for disease control (CDC) recommendations last updated on 05/08/23 revealed: Responding to a newly identified SARS-CoV-2-infected HCP or resident. When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test instead of a nucleic acid amplification test (NAAT) is recommended. This is because some people may remain NAAT positive but not be infectious during this period. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP are not generally necessary unless residents meet the criteria described in Section 2 or HCP meet criteria in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. However, source control should be worn by all individuals being tested. In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of Empiric use of Transmission-Based Precautions for residents and work restriction of HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction's public authority recommends these and additional precautions. If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP who met criteria can be discontinued as described in Section 2 and the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered. c3) Facility record review and Staff interviews. After facility record review, it was found the facility failed to follow its own policy for testing residents and staff who have been exposed to COVID-19 from a person who was positive with COVID-19. A review of facility documents found the facility had been in an active COVID-19 since 08/16/23. In addition, the facility was continuing to receive positive test results. On 11/28/23 the total number of positive residents was 20 and three (3) additional positive employees. On 11/28/23 at 11:03 AM Infection Preventionist (IP) was asked what days the COVID-19 testing occurs. IP stated residents and employees are only being tested as they become symptomatic. IP stated the facility was controlling the outbreak with Contact Tracing not Broad Based testing. It was pointed out to the IP the facility policy read the same as the CDC recommendations. It says if the Contact Tracing is not stopping the spread of COVID-19 then to initiate the Broad Base Testing. It was also pointed out that the Contact Tracing instructions are to test individuals who are asymptomatic but have been exposed to a positive person. The testing dates were requested, and the only test results provided were those listed on another line list form. On 11/28/23 at 4:12 PM Director of Nursing (DON) was asked about the facility using the Contact Tracing instead of the Broad Base Testing method. DON stated they tried that method once and it did not work. The DON stated, The facility cannot be cleared from the current outbreak because the community level is high. An internet search revealed the community level of COVID-19 was green/LOW. On 11/29/23 at 9:11AM the DON stated again the Contact Tracing method was what worked best for this facility. DON provided a Typed sheet of paper and stated it was the Contact Tracing information. This paper started with the date of 11/13/23. Information from the paper included: 11/13- (Named a resident) positive with symptoms. 11/08- Appointment with transport with (named Medical records Coordinator MRC#85) (S/S) (named Transport person #12) s/s with 48 hr testing completed and negative. 11/14 MRC #85 positive testing with continued nonreporting since 11/08 since with education on timely reporting. 11/14 (named Nurse Aide NA #21 positive testing with S/S onset 11/08 (resides with MRC #85) with continued nonreported S/S and education provided .etc . This paper contained more of the same as above. What it did not contain was a complete list of all employees and residents that were exposed to COVID-19 48 hours prior to having symptoms and/or testing positive. Also, it did not mention testing and placing all who were exposed in Transmission Based Precautions (TBP). Via telephone an interview on 11/29/23 at 10:05 AM with the Director of Nursing (DON) of the county health department revealed the following: The DON of the health department said she received emails from (named the facility IP) almost daily with new positive COVID-19 cases. The last few dates she sent emails on 11/22/23, and on 11/28/23 the IP reported five (5) new cases on 11/28/23, for a total of 21 residents and 3 staff. The county health department DON stated she would have to contact the epidemiologist to contact the facility about this ongoing outbreak. The surveyor was given numerous renditions of line listings used for surveillance of the COVID-19 outbreak. One (1) of the renditions had employees and residents mixed. This line listing had missing components such as the dates employees Registered Nurse (RN) #73 and Former employee #111 had onset of symptoms or date of positive test for COVID-19. Additional missing information was job titles, dates last worked, and assigned work area the positive employees. On 11/28/23 at 11:43 AM Infection Preventionist (IP) stated she would correct the missing information. IP went on to say this was the line listing form the corporate wanted her to use. A different line listing revealed two (2) residents were placed in TBP at the time of onset of symptoms. Resident #7 had onset of symptoms on 11/16/23 and was not placed in isolation until 11/21/23 for a total of five days. Resident #73 was documented to have symptoms on 11/19/23 and not placed in isolation until 11/21/23. On 11/28/23 at 1:30 PM, the IP acknowledged the findings.

. Based on record review and staff interview the facility failed to offer immunization to all residents when a COVID-19 vaccine/booster was available. This was true for five (5) out of five (5) reviewed for immunization. Resident identifiers: #76, #8, #89, #35, and #26. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 90. Findings included: a) Resident #76 A review of the medical records for Resident #76 found there was not any documentation to show this resident was offered the 2023-2024 COVID-19 booster. b) Resident #8 A review of the medical records for Resident #8 found there was not any documentation to show this resident was offered the 2023-2024 COVID-19 booster. c) Resident #89 A review of the medical records for Resident #89 found there was not any documentation to show this resident was offered the 2023-2024 COVID-19 booster. d) Resident #35 A review of the medical records for Resident #35 found there was not any documentation to show this resident was offered the 2023-2024 COVID-19 booster. e) Resident #26 A review of the medical records for Resident #26 found there was not any documentation to show this resident was offered the 2023-2024 COVID-19 booster. On 11/28/23 at 1:10 PM the Infection Preventionist (IP) was asked for a copy of the consent and/or refusals for the current COVID-19 2023-2024 booster vaccine. The IP stated she had been too busy to do that. The IP said the only residents that were offered the 2023-2024 COVID-19 booster were the residents who resided on the 100 hall. On 11/28/23 at 3:34 PM, the Director of Nursing (DON) was informed of the issues above. The DON said she would see if she could find any additional information. At the close of this survey no additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure two (2) of three (3) discharged residents reviewed were care planned for their discharges to home. In addition the facility failed to ensure Resident #36 was care planned for a significant weight loss. Resident identifiers: #36, #92 and #93. Facility census: 89. Findings included: a) Resident #92 The Resident was admitted to the facility on [DATE] and was discharged to home on [DATE]. The Resident's admission Minimum Data Set (MDS) with assessment reference date (ARD) of 07/19/23 found she participated in her assessment and expected to be discharged to home. An interview with Social Worker #110 at 9:01 AM on 09/26/23 confirmed the resident was not care planned to return home. b) Resident #93 The Resident was admitted to the facility on [DATE] and discharged to home on [DATE]. The admission MDS with ARD of 05/03/23 noted the resident participated in her assessment and expected to be discharged to the community. Social Worker #110 confirmed at 9:01 AM on 09/26/23, the Resident was not care planned for her discharge to home even though the Resident indicated she planned to return home and did so on 07/15/23. c) Resident #36 Record review found the resident has had a 23.66 % weight loss from 05/15/23 through 09/11/23. The Resident was seen by the Registered Dietician (RD) on 06/05/23 and the RD noted a 5.7 % weight loss may have been attributed to a brief stay at the hospital for 05/23/23 through 05/25/23. On 06/08/23 the RD recommended starting 8 ounces (oz) of Nepro daily, which was in place from 06/08/23 through 06/29/23. On 07/17/23 the RD saw the resident and ordered house shakes three times a day (TID.) On 07/26/23, the RD saw the resident and ordered a snack 3 times a day. On 08/13/23 the RD noted a 21.6% weight loss and recommended discontinuing the house shakes with lunch and dinner but continue to provide in the evening, Also a frozen treat was added with lunch and dinner. On 09/18/23 the RD noted a 23.7% weight loss and noted the Resident was comfort care with current orders to be continued. Review of the current plan of care with the Director of Nursing (DON) at 12:12 PM on 09/26/23 found the only care plan for weight loss was a focus: Resident with potential for altered nutritional status. Interventions included: Provide snacks per facility protocol Provide supplements pre physician's orders Provide meals per diet ordered The DON confirmed the resident was no longer a potential for altered nutritional status, she has a significant weight loss. In addition the DON confirmed the individual interventions for weight loss: the house shakes, the snacks and frozen supplements were not added to the care plan. The care plan was not individualized for Resident #36.

Based on record review and staff interview, the facility failed to provide activities of daily living (ADL) care for dependent residents to maintain personal hygiene. Resident identifier: #36. Facility census: 89. Findings included: a) Resident #36 Review of the bathing activity with the Director Of Nursing (DON) at 1:25 PM on 09/26/23, found the Resident had not received a shower in the past 30 days. At 2:49 PM on 09/26/23, the DON verified the resident should receive two (2) showers a week on Wednesdays' and Saturdays'. During the month of September 2023, the resident received 1 bed bath on 09/09/23. Review of August 2023, bathing schedule found the resident refused bathing activity on 08/12/23. The resident received two (2) bed baths in August 2023, one (1) on 08/05/23 and one (1) on 08/23/23. Review of the current care plan with the DON found no information indicating the resident refuses showers. The DON did not know why showers were not provided as directed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident #39 Resident #39 was diagnosed with phantom limb pain and saw a pain specialist. She had an order to monitor for pain every shift which was being documented with a check mark, not a numerical scale. She was ordered Neurontin 100 mg by mouth three times a day. MAR revealed she received this medication as ordered. She had Tylenol 325 mg give by mouth every six hours as needed for pain (Start date 07/30/23) none documented as given. 09/26/23 at 2:00 PM Licensed Practical Nurse #4 said she had asked Resident #39 she was in pain. She replied that she was, so the nurse reposition her for comfort. She did not offer resident pain medication. She said the Resident stated, it hurt when she gets up or down. She did not go back to monitor effectiveness of treatment or offer any pain medication. When ask about the physician order on the MAR for: Monitor for Pain every shift start date 12/04/22 there was a check mark on day, evening and night shift from 09/01/23 until 09/26 ; she said it meant to ask if having pain. She agreed that from those check marks, one would not know if resident was or was not in pain. On 09/26/23 at 2:10 PM, asked Director of Nursing what the check mark, under the pain assessment in Resident #39's, MAR meant. She said, that they assessed her for pain but agrees that nurses notes do no not reflect whether Residents had pain or not. 09/26/23 at 3:00 PM, Resident #39 was sleeping, when awakened, this Surveyor was unable to ascertain if resident was having any discomfort. She said she could not understand what she was being asked. After multiple attempts, Surveyor was unable to ascertain her level of pain control. She had no visible evidence of pain at this time. Spoke with LPN #45 and LPN #58 and asked what the check mark under monitor for pain every shift on the MAR meant. They both said it just meant they asked about pain. They agree this information does not tell if resident was or was not in pain. c) Resident #79 On 09/26/23 at 3:00 PM, Resident #79, was sitting in her wheel chair talking with a relative. When asked about pain, she said she was old so of course she had pain. She said she had arthritis of both knees and they hurt all the time. She said she was most definitely not satisfied with her pain control. She said she was supposed to get medicine twice a day. Sometimes I do sometimes I don't, and quite frankly I hurt to bad to walk up to the nursing station to get it. When asked about the call light she admitted she very rarely turns on her light because the nurses are so busy she doesn't want to bother them. Her visitor said she agreed the resident's pain was not controlled. Resident #79's record review reveals a history of several bone fractures and bilateral knee arthritis. She had an order on her MAR to monitor for pain every shift, start date 02/18/23. Her MAR from 09/01/23 until 09/26/23 had a check mark that she was monitored for pain but there was no way to identify from the nurses notes to identify if resident was or was not in pain. Her Treatment Administration Record (TAR) revealed she was getting Voltaren External Gel 1%, 4 grams, apply to bilateral knees topically every day and evening shift for discomfort she was approved for self-administration after provided by nurse who will document. This medication was recorded 09/01/23 until 09/26/23 as being done with no indication of pain level or effectiveness. Resident #79's MAR for 09/01/23 to 09/26/23 at 2:00 PM had a physician's order to: monitor for pain every shift start date 12/04/22. The day, evening, and night shifts all had a check mark to note pain was being monitored, but no indication if the resident was or was not in pain. She had a history of neuropathy. She was ordered and received Gabepentin 100 mg three (3) times a day start date 08/02/00. She also had an order for PRN (as needed) Tylenol 345 mg give two (2) tablets by mouth every eight (8) hours as needed for pain start date 06/04/21. There was none given for this time frame. Based on resident interview, record review, and staff interview, the facility failed to ensure pain management was provided to Resident #8 and failed to ensure residents #85 and #39 were properly evaluated for pain. This was found for three (3) of three (3) resident's reviewed for the care area of pain. Resident identifiers #8 and #85 and #39. Facility census:89. a) Resident #8 Resident #8 admitted to the facility on [DATE] after a car wreck which resulted in broken ribs and a fractured tibia. According to the medical record, the resident is alert and oriented and has capacity to make her own medical decisions. The resident was ordered Morphine Sulfate, oral tablet, 15 mg. give 1 tablet every 4 hours as needed (PRN) for pain. At 4:30 PM on 09/26/23, the resident stated her pain medicine did not come in from the pharmacy about 2 weeks ago. There was some kind of a mix up at the pharmacy. My nurse talked to me about it and called the doctor. The doctor ordered Oxycodone 10 mg. When the nurse went to get the medicine, they didn't have 10 mg's, they only had it in 5 mg's at the facility. My nurse kept trying to call the doctor to ask about giving me two (2) 5 mg tablets, but the doctor wouldn't call her back. I believe the nurse was telling the truth because she has treated me very well and has always tried to help me. I went all day with no pain medicine. I was about ready to tell them just to send me to the hospital just to get some relief. That was a bad day. Finally the next day my medicine came and I haven't had any more problems. It is hard to get my pain under control after going without the medicine. I have Lupus also which causes pain and I am still sore and bruised from the car wreck and all the broken bones. Review of the Medication Administration Record (MAR) and nurses notes found the resident's story was true. The resident received no Morphine Sulfate on 09/13/23. Further review found the resident normally receives the Morphine Sulfate an average of 4 times a day. On 09/13/23, an order was written for oxycodone 10 mg's and the order was discontinued on 09/13/23 with no doses given. A second order was written for Oxycodone 5 mg's give 2 tablets one time only for pain on 09/14/23. According to a nurses note, dated 09/14/23 at 8:00 PM, this order was discontinued because the Morphine Sulfate had arrived. The resident had an order on the MAR to monitor pain every shift. Every shift included a check mark and the nurses initials. There was no indication from the check mark if the resident had any pain or not. On 09/13/23, the MAR included check marks for all 3 shifts. At 5:19 PM on 09/26/23, the Director of Nursing (DON) said the 13th of September was the day we changed to a new pharmacy, I guess that was why she did not have her Morphine Sulfate. The DON reviewed the MAR with the surveyor and confirmed Morphine Sulfate was not given on 09/13/23. The DON confirmed Oxycodone 5 mg. is the dose available in the facility's cubex. The DON said the nurse would have needed a new order to give to two (2) - 5 mg tablets. The DON confirmed the resident did not receive Oxycodone on 09/13/23. The DON said she was unaware of the issues and was unaware the physician was not responding to the nurses request to use the 5 mg. tablets instead of the 10 mg. tablets ordered.

. Based on observation, policy review and staff interview the facility failed to ensure Resident #41 was provided care in a manner which preserved her dignity. Resident #41 was receiving medication in the facility hallway. This was a random opportunity for discovery. Resident Identifiers:Resident #41. Facility Census: 90. Findings Included: a) Resident #41 A review of an undated facility policy titled Medication Administration read as follows. .II. Preparation .e. Provide for privacy/dignity . During a tour of the facility on 09/18/23 at 12:04 PM Resident # 41 was sitting in a gerichair on 500 hall. Licensed Practical Nurse (LPN) #47 was assisting Resident #41 with her ice cream, when LPN #47 saw this surveyor, she began feeding her very fast and spilling the ice cream down Resident #41's chin and on her shirt. LPN #47 was asked Was there medication in the ice cream LPN #47 stated Yes, they were taking her to the dining room so I needed to give it to her. It was her Lortab and was due at noon. LPN #47 acknowledged she should not have gave resident #41 medication in the hallway.

. Based on observation, record review, staff interview the facility failed to ensure diabetic medication was available and administered appropriately. This failed practice was true for one (1) of two (2) residents reviewed for insulin medication regimen. Resident identifier: #21. Facility census: 90. Findings included: a) Resident diagnosis Record review showed Resident #21 had a diagnosis of Type 2 Diabetes with mild nonproliferative diabetic retinopathy without macular edema, diabetes due to underlying condition with hyperglycemia. b) April 2023 - Trulicity Insulin Administration Record review showed an order with a start date of 03/21/23 to administer Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML (Dulaglutide). Inject 1 application subcutaneously one time a day every Friday for diabetes. Give in addition to 1.5mg for a total dose of 3mg. EMAR (Electronic Medication Administration Record) note dated 4/21/2023 (Friday) at 3:54 PM stated Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML was not available. Pharmacy to bring. Power of attorney (POA) and doctor aware. Record review showed an order for administration of Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML for a total of 3mg was changed to be administered on Sunday starting 04/30/23. Review of Resident #21's Medication Administration Record (MAR) showed Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML for at total dose of 3 mg was administered on Sunday 04/30/23. c) May 2023 - Trulicity Insulin Administration Record review showed an order with a start date of 03/21/23 to administer Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML (Dulaglutide). Inject 1 application subcutaneously one time a day every Sunday for diabetes. Give in addition to 1.5mg for a total dose of 3mg. EMAR (Electronic Medication Administration Record) note dated 5/21/2023 (Sunday) at 2:52 PM stated Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML was not available. Pharmacy notified to send. POA and doctor aware. Record review showed the order for administration of Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML 3mg was changed to be administered on Monday starting 05/22/23. Review of Resident #21's Medication Administration Record (MAR) showed Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML for at total dose of only 1.5 mg was administered on 05/22/23. The additional 1.5 mg was not administered. d) July 2023 - Trulicity Insulin Administration Record review showed an order with a start date of 05/22/23 to administer Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML (Dulaglutide). Inject 1 application subcutaneously one time a day every Monday for diabetes. Give in addition to 1.5mg for a total dose of 3mg. EMAR (Electronic Medication Administration Record) note dated 07/17/2023 (Monday) at 7:31 AM stated Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML was not unavailable, awaiting from pharmacy. Power of attorney (POA) and doctor aware. Nurses note dated 7/17/2023 at 8:44 AM stated Trulicity not available at this time. Doctor made aware and order to change administration day to Tuesdays. POA aware, pharmacy aware. Record review shows the order for administration of Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML for a total of 3mg was changed to be administered on Tuesday starting 07/18/23. Review of Resident #21's Medication Administration Record (MAR) showed Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML for at total dose of 3 mg was administered on Tuesday 07/18/23. e) August 2023 - Trulicity Insulin Administration Record review showed an order with a start date of 07/18/23 to administer Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML (Dulaglutide). Inject 1 application subcutaneously one time a day every Tuesday for diabetes. Give in addition to 1.5mg for a total dose of 3mg. Two (2) exact orders were shown due to both 1.5 mg dose vials that needed to be given to equal the 3mg dose. EMAR note dated 08/22/23 stated Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML Inject 1 application subcutaneously one time a day every Tuesday for DM Give in addition to 1.5mg to give total of 3mg, Duplicate order. Review of Resident #21's Medication Administration Record (MAR) showed 0n 08/22/23 Trulicity Subcutaneous Solution Pen-injector 1.5 MG/0.5ML for at total dose of 3mg was administered for 1.5mg only. The second 1.5mg dose was signed off as not administered, duplicate order. f) Staff Interviews On 09/18/23 Liscened Practical Nurse (LPN) #95 stated, Yea we had been having trouble getting the Trulicity for Resident #21. Had to change the day of the week it was scheduled to be given a bunch of times. We started getting two (2) 1.5 mg doses to equal 3 mg because we can't get the 3 mg dose. During an interview on 09/19/23 at 12:01 PM the Director of Nursing (DON) confirmed only half of the ordered 3mg dose of Trulicity was given on 05/21/23 and 08/22/23. The DON also verified the several changes made to the Trulicity schedule dates in order to accommodate the unavailability of the medication. DON stated, I didn't realize it was that bad, I'll look into it and see why we are having trouble getting it ordered. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to provide an ongoing assessment and oversight for hemodialysis treatments, that included communication with the dialysis center for monitoring the resident's condition prior to and after treatment. This failed practice was true for three (3) of (3) residents reviewed for dialysis services with the potential to affect only a limited number of residents. Resident identifiers: #20, #48, #84. Facility census: 90. Findings included: a) Hemodialysis Policy Record review of the facility's undated policy titled, Hemodialysis Care and Monitoring, showed: Pre dialysis evaluation is to be completed within four (4) hours of transportation to dialysis to include accurate weight, vital signs, mediations administered or withheld prior to dialysis. Post dialysis a nurse to review notes from the dialysis center fir resident tolerance of treatment, medications that may have been given during dialysis, review if blood transfusion was given, check for labs hemoglobin hematocrit values. Post dialysis notes will be uploaded in the into to the EHR or placed on hard medical record. Nurse is to complete post dialysis evaluation upon return for the dialysis center to include thrill absence or presence bruit absence or presence, pulse in access limb, vital signs, visual inspection of site for bleeding, and any abnormal or unusual occurrence resident reports while at dialysis center. Shared communication section stated a 24 hours per day communication method is established to communicable resident clinical status between the dialysis center and the facility. b) Resident #20 Record review showed and order that indicated Resident receives dialysis on Monday, Wednesday, and Friday at [local dialysis clinic name]. EMS (emergency medical services) to transport with pick up time 7:00 AM, chair time of 7:15 AM. Record review showed no Hemodialysis Communication Record for 07/10/23. Dialysis communication form was sent from local dialysis center on 09/18/23 post surveyor intervention at 12:57 PM via fax. The form sent was a document created by the Dialysis center that contained the Resident's vital signs and weight. The facility had no documentation of the original form that may have been sent with the Resident to the dialysis center appointment for 07/10/23, or that communication from the Dialysis center was received and reviewed upon return for any complications or orders. c) Resident #48 Record review showed and order that indicated Resident receives dialysis on Monday, Wednesday, and Friday at [local dialysis clinic name]. Facility to transport with pick up time 6:15 AM, with a chair time of 6:45AM. Nurses Note dated 09/11/2023 at 6:32 PM stated Resident left facility via facility van and one staff member at this time for dialysis. Mask encouraged to be worn while out of facility. No pre dialysis assessment was done on 09/11/23. This was verified by Director of Nursing (DON) on 09/19/23 at 10:50 AM. She stated the nurse documented vital signs but did not complete the entire pre dialysis assessment. Record review showed no Hemodialysis Communication Record for 09/15/23. Dialysis communication form was sent from local dialysis center on 09/18/23 post surveyor intervention at 12:57 PM via fax. The form sent was a document created by the Dialysis center that contained the Resident's vital signs and weight. The facility had no documentation of the original form that may have been sent with the Resident to the dialysis center appointment for 09/15/23, or that communication from the Dialysis center was received and reviewed upon return for any complications or orders. d) R #84 Order dated 09/01/23 indicated Resident #84 was to receive dialysis on Tuesday, Thursday, and Saturday at [ Local Dialysis Clinic]. EMS to transport. Pick up time 11:45 AM, with a chair time of 12:00 PM Entered at 2:49 PM on 09/01/23. admission Initial Evaluation assessment dated [DATE] did not indicate the Resident's any need for dialysis services in the provided space under additional information. At 10:30 AM on 09/20/23 Regional Director of Clinical Operations Nurse verified the admission Assessment was not completed accurately for dialysis services. e) Dialysis Center Staff Interview During an interview on 09/18/23 at 1:42 PM, Registered Nurse (RN #322) of the Dialysis Clinic stated the facility called earlier and wanted a bunch of treatment sheets sent down for Resident #20, Resident #48 and Resident #84. RN #322 further stated sometimes the Residents show up without any communication sheets, and then the Dialysis Clinic will use their own documentation sheet. RN #322 stated, That is why I created our own communication sheet so I could make sure they were getting something back.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, policy review, record review and staff interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This practice was found true for five (5) of five (5) Residents reviewed during the complaint survey process. Resident Identifiers: resident #28, Resident #53, Resident #70, Resident #11 and Resident #78. Facility Census: 90. Findings Included: a) Activity Calendars During the initial tour of the facility on 09/18/23 at 10:00 AM the Daily Activity Sheet posted outside the Main Dining Room (MDR) read as follows: -10:30 AM SFL(Strength for Life) exercise -2:00 PM Outdoor Social During an observation on 09/18/23 at 10:57 AM in the 400 Hall Lounge, where the group activities was to be held. The Residents in attendance were four (4) ladies which had just finished getting their fingernails painted by the Activity staff. An immediate interview Activities Leader (AL) #111 stated The residents got their nails done. The AL #111 was asked where is the exercise activity taking place? AL #111 stated we didn't do it, we did nails instead. The AL #111 was asked How many Residents attended the nail activity? Al #111 stated I had four (4) ladies. During a dining room observation on 9/18/23 beginning at 11:47 AM there was no pre meal activity taking place. During the dining room observation on 09/18/23 at 12:18 PM there continued to be no pre meal activity taking place. There were four (4) Nurses Aide and an Activities Leader standing in a circle socializing. There was no Resident involvement. During the observation a few Residents were drinking coffee, most of the residents were sleeping. During an observation on 09/18/23 at 2:07 PM there were five (5) residents participating in outdoor social activity held on the front porch. A September Monthly Activities calendar that is posted in each resident's room was provided to this surveyor. The September Monthly Activities Calendar revealed the following activities for Monday 09/18/23 -9:30 AM Hydration Pass -10:30 AM Nails -2:00 PM Toss the Dice During a tour of the facility on 09/19/23 at 9:00 AM the Daily Activity Sheet posted outside the MDR read as follows: -10:30 Strength for Life exercise -2:00 PM Outdoor Social -6:30 PM Ice Cream Sandwiches The September Monthly Activities Calendar revealed the following activities for Tuesday 09/19/23 -10:30 AM Strength for Life exercise -2:00 PM Flower arrangement for dining room tables -6:30 PM Bingo On 09/19/23 at 10:39 AM an observation of the 10:30 AM Strength for life exercise four (4) residents were in attendance. The activity was over at 10:43 AM. During an interview on 0919/23 the AL #111 stated there were five (5) residents outside again today. During a tour of the facility on 09/20/23 at 9:15 AM the Daily Activity Sheet posted outside the MDR read as follows: -10:30 Church with (name) -2:00 Movie The September Monthly Activities Calendar revealed the following activities for Wednesday 09/20/23: -9:30 AM Hydration Pass -10:30 Church with (name) -2:00 Movie -6:30 Board Games b) Resident Interviews 1) Resident #28 During an interview on 09/18/23 at 2:16 PM Resident #28 stated the activities have nothing I like to do, so I sit in my room to do my diamond art. 2) Resident #53 During an interview on 09/18/23 at 2:35 PM Resident #53 stated I don't attend many group activities, that don't have anything. I like bingo and we rarely have it. 3) Resident #70 During an interview on 09/18/23 at 2:37 PM Resident #70 stated I am blind in my Left eye and going blind in my right, it's hard for me to go to things anymore. I do the church services on Sundays because the facility did not have any services on Sunday. I am afraid I will have to give it up soon due to my vision, but I hate to the Residents depend on me for the Sunday service and for something to do. 4) Resident #78 During an interview on 09/18/23 at 2:40 PM Resident #78 stated I have not been here that long, but I have not attended any group activities. The activities just don't met my interest. c) Staff Interviews 1) Activities Leader #111 During an interview on 09/19/23 at 1:56 PM AL #111 stated the Activity Director does the monthly calendar and the daily activity sheets. The AL #111 was asked why do the monthly calendar and daily sheets not have the same activities on them for 09/18/23 and 09/19/23? The AL #111 stated she changed the activities on 09/18/23 because some of the residents wanted to go outside. (The Activity Director name) changed the activities on 09/19/23 because she was leaving early for a conference and did not want me to do the flower arrangement activity by myself. The bingo scheduled for 6:30 was canceled because the residents on 200 hall and 300 hall are not allowed to attend group activities, due to being in a COVID unit. I was told that no one on the 200 and 300 halls were allowed out of their rooms, even if they were not positive for COVID. AL #111 stated We usually don't follow the calendar, we do what the residents want to do. The AL #111 was asked about the attendance in group activities, The AL #111 stated we had four (4) Residents in exercise this morning, five for porch social yesterday and about the same for today for porch sitting. We would have more if the other Residents could attend. This surveyor stated you have three (3) other halls that can attend, why don't they come to the activities?. The AL #111 stated they probably don't like what we are doing. 2) Activities Director During an interview on 09/19/23 at 2:03 PM the Activities Director (AD) via facility speaker phone with the Director of Nursing present in the conference room. The AD was asked why does the monthly calendar and daily sheets have the same activities on them for 09/18/23 and 09/19/23? The AD stated The residents wanted to go outside on Monday (09/18/23) so I changed the activities, the Residents said it was too cold so I put it on the activities today (09/19/23) because it was supposed to be warmer. I changed Bingo because the residents wanted to wait till I had fall decorations for prizes. The AD was asked Do you know how many Residents have attended your activities on 09/18/23 and 09/19/23? The AD stated There were five(5)-six (6) for nails, five (5) outside on 09/18/23 and four (4) at exercise this morning. Our participation is low due to the 300 hall being in isolation. According to the Facility Resident list 17 Residents reside on 200 Hall and 10 Residents reside on 300 Hall. Upon entering the facility on 09/18/23,the Infection Preventionist provided a COVID positive Resident list which included three (3) Residents on the 300 Hall and one (1) on 200 Hall. The AD was asked Do you provide pre meal activity? Because you have a lot residents sleeping and waiting long periods of time for the meal to arrive. The AD stated No, we don't have a pre meal activities, we play the radio and there are some crayons and coloring pages on the stand if the residents want them. The AD was asked (Resident #11 name)Activity Preference Interview assessment dated [DATE] which coded his interest as going to church, exercise, enjoys outdoor socials and special events. The activity participation documentation for September and August was void for a large amount of days which the activities that he prefers, he was not invited to attend. The AD stated this is a new system, we are still trying to get used to it. We ask all the residents to attend all the activities. We probably asked him but did not document it correctly. The DON acknowledged there were voids of activity participation documentation for Resident #11 per his preferences. The AD was asked (Resident #53 name) and (Resident #70 name) activity preference interview assessment and the participation documentation was like Resident #11, Their interest/preferences activities the resident is not being invited or attending. Do you know why? The AD stated (Resident #53 name)does not come out of her room for activities and (resident #70 name) is self directed. We are new to these Assessments, but now that I see I need to improve on them. The AD acknowledged the Activity Preference Interview Assessments and the documentation needs a lot of improvement. The DON stated the Activity Department needs improvement by more training on the assessment, participation documentation and the care plans. d) Email A review of a facility email that was sent by The Infection Preventionist/Registered Nurse # 58 to all the Department Managers at the facility informing them of the COVID Outbreak dated 09/18/23 read as follows. (typed as written): It has came to my attention there has been some confusion regarding residents coming off halls/staying on halls. 300 Hall is currently isolated. Resident should remain on 300 hall. This is due to the increased cases on that hall with a recent staff member testing positive whom has worked down that hall recently. All other hallways (100, 200, 500 and 600) are able to go to dining/group activities if not on COVID isolation or showing s/s (Signs and Symptoms) e) Policy A review of a facility policy titled Criteria for COVID-19 Requirements with a revision date of 05/11/23 read as follows. .Communal Dining and Activities: Communal Dining and activities cannot occur for residents who are in transmission based precaution for COVID-19. For all other residents communal dining can occur based on the following criteria: Residents who are asymptomatic can attend communal dining and activities. Residents who are symptomatic but have completed the necessary testing and are negative should wear source control. During an interview on 09/20/23 at 2:34 PM The DON stated when we contacted the Health Department in the start of the outbreak, we were told to isolate everyone in the halls, so we followed the health department guidance. The DON acknowledged the facility could not isolate all the residents unless they were COVID positive. .

. Based on observation, staff interview, and family interview the facility failed to maintain an appropriate infection control program in order to maintain a safe and sanitary environment to help prevent the development and transmission Covid-19 during an active Covid-19 outbreak. This failed practice was a random opportunity for discovery and had the potential to affect all residents. Resident identifiers: #85, 58, #86, #13, #80. Facility census: 90. Findings included: a) Covid-19 Visitor Notification On 09/18/23 at 9:30 AM when surveyors entered the building, the main entrance to the facility for visitors was open and easily accessed without any code required to enter the building. No signage was posted on the door to alert visitors that the facility was in an active Covid-19 outbreak. No one was present at the front desk in the lobby. Some staff were observed wearing face masks throughout the facility. Surveyor was greeted by the Director of Nursing (DON) asked asked if the facility was in an active outbreak. The DON replied, Yes we have been for a while. The DON verified the receptionist was off sick and leaving the front desk unoccupied for the day. During an interview on 09/18/23 at 2:15 PM the DON was asked how visitors were alerted to the active Covid-19 outbreak status of the facility. The DON stated, The sign on the door, and we identified that it was not there this morning and put one up after you all came in. At that time observation was made of a sign posted on the front door entrance that stated, Facility is Experiencing a Covid-19 Outbreak. What does this mean? Source control is required. N-95 mask eye protection. Visitors should wear source control that is either a cloth mask or surgical mask and may wear eye protection. On 9/18/23 at 3:29 PM Infection Preventionist (IP) Registered Nurse (RN #58) stated August 18th, 2023 initiated this last outbreak and the facility had not been able to get out of it yet. The RN #58 further stated they had three (3) new positive Resident cases on Monday (09/17/23). Record review of the facility's policy titled criteria for Covid-19 Requirements, revised on 05/11/23, showed under the surveillance topic for employees, contractors, vendors, and visitors the facility needs to ensure all who enter the facility are aware of recommended IPC practices in the facility. Post signs and visuals at the entrance, lobby, elevators, break rooms, therapy, activity room, and on the units that include instructions about current infection prevention and control recommendations. The signage should contain the source control necessary according to outbreak status and or community transmission level of Covid-19. b) Hand Hygiene On 09/19/23 at 12:40 PM observation of RN #85 taking lunch tray into the Resident #39's room. Tray was set down on over bed table and no hand hygiene was offered to the resident. RN #85 then reentered room and gave mustard to the resident without offering hand hygiene. During an interview on 09/19/23 at 1:23 PM, RN #85 was asked if she provided hand hygiene to Resident #39 after she delivered the meal tray. RN #85 stated, No, I thought the nurse aide (NA) did it before I got there. At 1:25 PM on 09/19/23, NA #87 stated she did not provide hand hygiene to Resident #39, she was busy changing another resident's bed prior to meal tray pass. On 09/19/23 at 12:46 PM observation of RN #58 IP taking lunch tray into the Resident #36's room. Tray was set down on over bed table and no hand hygiene was offered to the resident. Resident #36's son was in the room and confirmed the Resident was not offered hand hygiene. The son stated, Mom wouldn't know to wash her hands anyway, they would have to do it for her. During a dining observation on 09/19/23 at 12:16 PM on 100 Hall, Nurse Aide (NA) # 108 was observed passing lunch trays to Resident #86, Resident #13, and Resident #80. During the observations hand hygiene was not offered to the residents prior to receiving their lunch trays. Surveyor intervened and inquired about hand hygiene at 12:17 PM. NA #108 was asked What did you use to provide hand hygiene to the Residents? NA #108 walked into a Resident #80's room, and she stated, I keep the wipes in the drawers. NA #108 was unable to locate any wipes in the resident's room after looking in all the drawers. NA #108 was asked did you provide any hand hygiene before bringing the trays into the rooms for Resident #86, Resident #13, and Resident #80? NA #108 stated, No I didn't. c) Clean Linen Cart During an observation on 09/18/23 at 4:47 PM, the clean linen cart on 600-hall revealed a nurse's aide documentation tablet. The tablet was laying on top of the clean linens and was being used by the nurse aide on that hallway to complete documentation. During an interview on 09/18/23 at 4:52 PM the DON acknowledged the Nurse Aide documentation tablet was located within the clean linen cart. The DON stated all the linens needed removed and laundered, and the cart needed to be cleaned and restocked. d) Emergency Medical Staff (EMS) On 09/19/23 at 10:44 AM two (2) EMS staff entered the facility through the designated EMS entrance on 600-hall with a stretcher. The EMS staff did not use hand sanitizer upon entering the building and or place a obtain and use a face mask before coming down the hallway. EMS crew came down the hallway and stopped at the nurse's station that is centered within the six (6) resident hallways. The EMS staff remained at the nurse's station until 10:50 AM until the IP approached them and asked them to put a face mask on. Signage was posted at the EMS entrance door. e) Hydration Pass 09/19/23 at 12:55 PM NA #87 went into Resident #8's room obtained Resident's water pitcher from the resident's over the bed table. NA #87 went down 300 hall out the double doors didn't not use hand sanitizer upon exiting the unit or resident #8 room. The double doors were closed on hallway 300 due to the Covid-19 positive residents residing on that hallway. NA #87 used the keypad to gain entry to the nourishment room (NR) and entered the NR with the water pitcher. NA #87 came back out of the NR with a pitcher of ice covered with a paper towel, entered double doors of 300 hall. NA #87 went back into Resident #8's room and left the ice pitcher on her table. 09/19/23 at 1:45 PM The DON stated the Nurse Aide should have got a clean cup of ice from the nourishment center or a clean pitcher and not brought out the Resident's pitcher from her room. .

. Based on observation and staff interview the facility failed to provide a safe, clean and home like environment. The facility failed to maintain clean and sanitary wheelchair for Resident #89. The facility also failed to keep the residents' wheelchairs in good repair to maintain clean and sanitary equipment. Resident Identifiers: Resident #89, Resident #85, Resident #7 and Resident #11. Facility Census:90. Findings Included: a) Resident #89 During the initial tour of the facility on 09/18/23 at 9:56 AM Resident #89's wheelchair has a large amount of food built up on the seat, the wheels and on the foot rests. The left armrest missing material exposing the mesh lining. The arm rest could not be cleaned and sanitized. A review of the facility wheelchair cleaning schedule Resident # 89 wheelchair was scheduled to be cleaned on Fridays (09/15/23). No other documentation was provided. During an interview on 09/19/23 at 12:31 PM the Director of Plant Maintenance acknowledged Resident #89's left wheelchair armrest needed to be replaced. b) Resident #85 During an observation on 09/18/23 at 11:53 AM The left arm rest missing material exposing the mesh lining. The armrest could not be cleaned and sanitized. During an interview on 09/19/23 at 12:31 PM the Director of Plant Maintenance acknowledged Resident #85's left wheelchair armrest needed to be replaced. c) Resident #7 During an observation on 09/18/23 at 11:54 AM Resident #7's wheelchair armrest was missing material exposing the mesh lining. The armrest could not be cleaned and sanitized. During an interview on 09/19/23 at 12:31 PM the Director of Plant Maintenance acknowledged Resident #7's wheelchair armrests needed to be replaced. d) Resident #11 During an observation on 09/18/23 at 1:30 PM Resident #11's Broda chair on inside the chair, below the armrests is missing material exposing the mesh lining. The outside of the chair had several large areas of missing material. The Broda chair could not be cleaned and sanitized. During an interview on 09/19/23 at 12:31 PM the Director of Plant Maintenance stated I knew about this chair and the whole thing needs throw away. We are unable to get replacement parts for it. THey should not be using it. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide evidence that a copy of the Notice of Discharge was sent to the Office of the State Long-Term Care Ombudsman. This was true for one (1) of four (4) reviewed during the complaint survey. Resident identifier: Resident #89. Facility Census: 87. Findings included: a) Resident #89 During a record review on 06/21/23 at 2:00 PM Resident #89 medical records revealed a discharge to home on [DATE] with a transfer/discharge form dated 05/22/23. A further review did not reflect the Notice of Transfer/discharge was sent to the Ombudsman. During an interview on 06/21/23 at 1:00 PM the Director of Nursing acknowledged the facility failed to notify the Ombudsman of the discharge.

. Based on medical record review and staff interview, the facility failed to ensure complete and accurate medical records. This was true for two (2) of four (4) residents reviewed during the Complaint Survey Process. Resident identifiers: Resident #32 and #67. Facility Census: 87. Findings included: a) Resident #32 During a record review on 06/21/23 at 10:23 AM, Resident #32's medical record revealed a Physician Orders for Scope of Treatment (POST) form showed that verbal consent was obtained from the resident's representative which was not dated. The consent was witnessed by two (2) staff members. However, the resident representative's actual signature was never obtained. The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals, 2021 edition, available on-line, stated, If the incapacitated patient's MPOA [medical power of attorney] representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity. During an interview on 06/21/23 at 3:06 PM, the Regional Director of Clinical Operations #116 acknowledged Resident #32's representative had not signed the POST form even though verbal consent had been obtained. b) Resident #32 During a record review on 06/21/23 at 10:30 AM, Resident # 32's medical records revealed a Physician Determination of Capacity Form dated 05/17/23. Resident #32's form was void of being coded for determination for capacity or incapacity to make medical decisions. During an interview on 06/21/23 at 3:06 PM, the Regional Director of Clinical Operations #116 acknowledged Resident #32's Physician Determination of Capacity Form was not filled out to its entirety. c) Resident #67 During a record review on 06/21/23 at 1:15 PM, Resident # 67's medical records revealed a Physician Determination of Capacity Form dated 05/21/23. Resident #67's form was void of being coded for determination for capacity or incapacity to make medical decisions. During an interview on 06/21/23 at 2:18 PM, the Director of Nursing acknowledged Resident #67's Physician Determination of Capacity Form was not filled out to its entirety.

. Based on record review and staff interview, the facility failed to implement written policies to prohibit and prevent abuse and neglect of residents. Resident #14 made an allegation of abuse which was not reported to all the required State authorities as mandated by the facility policy. This was true for one (1) of one (1) resident reviewed for the care area of abuse. Resident identifier: #14. Facility census: 83. Findings included: a) Resident #14 Review of the policy: Abuse Prohibition Policy and Procedure found: .When abuse, neglect or exploitation is suspected: Immediately report all alleged violations to the CEO (Chief Executive Officer)/Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's; . Review of the medical record found the following nurses note: 06/17/2022 17:48 (5:48 PM) Nurses Note - Note Text: Resident has had increased behaviors this evening, LPN (Licensed Practical Nurse) stated her and another CNA went to shower her and resident accused her of raping her when shower was complete. Resident accused staff members in shower room of stealing from her, mistreating her. Resident told staff when she was getting dressing that she was raped three times by a black woman, and staff was traumatizing her The facility reported the allegations as unusual occurrences to the State Survey Agency. The facility did not report the allegation to Adult Protective Services (APS). At 2:08 PM on 07/05/22, the Director of Nursing (DON) said she completed the report on 06/17/22 and attempted to fax the information to the State Survey Agency on 18 occasions for the next (4) days. (The fax confirmation sheets indicated the fax machine at the State Survey Agency was not working. Finally, on 06/21/22 at 5:59 PM the fax was delivered.) The DON provided proof of this information. The DON did not attempt to fax/mail/or notify Adult Protective Services (APS) of the allegation. The DON said she thought it was just an unusual occurrence and not abuse; therefore, she did not notify APS of the allegation. On 07/06/22 at 7:57 AM, the administrator said he believed the incident was a unusual occurrence because the DON investigated it immediately and knew the event did not happen; therefore, APS was not notified. .

. Based on record review and staff interview, the facility failed to ensure allegations of abuse were reported to all required State Authorities. This was true for one (1) of one (1) resident reviewed for the care area of abuse. Resident identifier: #14. Facility census: 83. Findings included: a) Resident #14 Review of the policy: Abuse Prohibition Policy and Procedure found: .When abuse, neglect or exploitation is suspected: Immediately report all alleged violations to the CEO (Chief Executive Officer)/Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's; . Review of the medical record found the following nurses note: 06/17/2022 17:48 (5:48 PM) Nurses Note - Note Text: Resident has had increased behaviors this evening, LPN (Licensed Practical Nurse) stated her and another CNA went to shower her and resident accused her of raping her when shower was complete. Resident accused staff members in shower room of stealing from her, mistreating her. Resident told staff when she was getting dressing that she was raped three times by a black woman, and staff was traumatizing her The facility reported the allegations as unusual occurrences to the State Survey Agency. The facility did not report the allegation to Adult Protective Services (APS). At 2:08 PM on 07/05/22, the Director of Nursing (DON) said she completed the report on 06/17/22 and attempted to fax the information to the State Survey Agency on 18 occasions for the next (4) days. (The fax confirmation sheets indicated the fax machine at the State Survey agency was not working. Finally, on 06/21/22 at 5:59 PM the fax was delivered.) The DON provided proof of this information. The DON did not attempt to fax/mail/or notify Adult Protective Services (APS) of the allegation. The DON said she thought it was just an unusual occurrence and not abuse; therefore, she did not notify APS of the allegation. On 07/06/22 at 7:57 AM, the administrator said he believed the incident was a unusual occurrence because the DON investigated it immediately and knew the event did not happen; therefore, APS was not notified. .

. Based on medical record review and staff interviews the facility failed to timely submit a correct discharge tracking Minimum Data Set (MDS) for Resident #85. The MDS was inaccurate in the area of discharge status. This was true for one (1) of 23 sampled residents reviewed during the Long-Term Care Survey Process. Resident identifier: #85. Facility census: 83. Findings included: a) Resident #85 A medical record review for Resident #85 revealed a discharge MDS was coded as a acute care hospital discharge for Resident # 85, who was discharged to the community on 05/25/22. In an interview with the MDS Coordinator on 07/06/22 at 4:00 PM, she verified the discharge MDS tracking completed for Resident #85 was inaccurate in the area of discharge status. She verified the resident was discharged to the community (home) not to a acute care facility. .

. Based on observation, record review, and staff interview the facility failed to implement the care plan in place for hemodialysis clamps at bedside. Resident identifier: #75 Facility Census #83 Findings Included: a) Resident #75 On 07/05/22 at 1:00 PM, during the initial interview phase of the survey it was observed that Resident #75 was a hemodialysis patient and has a right chest hemodialysis catheter. Observation found no hemodialysis catheter emergency clamps in his room. Record review of the care plan shows the Resident is to have the clamps at bedside and on the resident's person when he is self-mobile throughout the center. This was confirmed with Licensed Practical Nurse #96 on 07/05/22 at 2:50 PM. .

. Based on observation and staff interview, the facility failed to ensure the Foley catheter tubing was securely anchored to prevent excessive tension on the catheter and to prevent inadvertent catheter removal or tissue injury from dislodging the catheter. This was true for one (1) out of three (3) residents reviewed for catheter and incontinence care. Resident Identifier: #2. Facility census 83. Findings included: a) Resident # 2 During an observation on 07/06/22 at 9:23 AM, Nurse Aide (NA) #42 was observed providing catheter care. Observation revealed Resident #2 did not have an anchor to secure the Foley catheter tubing, to prevent tension and/or accidental removal causing tissue damage. On 07/06/22 at 11:00 AM, the Director of Nursing (DON) was informed of the above findings. .

. Based on observation, record review and staff interview the facility failed to provide the necessary hemodialysis services consistent with professional standards of practice. This was true for one (1) of one (1) hemodialysis resident reviewed during this annual survey. Resident identifier: 75 Facility census: 83 Findings included: a) Resident #75 On 07/05/22 at 1:00 PM it was observed that Resident #75 was a hemodialysis patient and has a right chest hemodialysis catheter. Observation found no hemodialysis catheter emergency clamps in his room. Record review of current orders and the care plan shows the Resident is to have the clamps at bedside and on the resident's person when he is self-mobile throughout the center. This was confirmed with Licensed Practical Nurse #96 on 07/05/22 at 1:05 PM. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview the facility failed to remove expired medical supplies from the medication storage room in accordance with currently accepted professional principles. This had the potential to affect a limited number of residents. Facility census: 83. Findings included: a) Medication storage room. Upon observation on [DATE] at 10:04 AM, the following items in the medication storage room were found to be expired. This was confirmed with Register Nurse - Director of Staff Education #5. The following items were expired: --Twenty (20) blue top blood collection vacutainers expired [DATE] --Twelve (12) red top blood collection vacutainers expired [DATE] --One (1) Intravenous Venous Fluid flow controller expired [DATE] --Three (3) administrator Intravenous Venous Fluid set expired [DATE] .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to store, label and date food in a sanitary manner in accordance with professional standards for food service safety. The facility also failed to keep the outside grease trap free from debris so it could drain properly. This deficient practice has the potential to affect more than a limited number of residents. Facility Census: 84. Findings Included: A facility policy Date Marking for Food Safety with a revision date 02/01/2019 stated (typed as written) .2. The food shall be clearly marked to indicate the date by which the food shall be consumed or discarded by. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a label containing the date of opening, and the date the item must be consumed or discarded. An initial tour of the kitchen with the Food Service Director (FSD) #71 beginning on 07/05/22 at 10:25 AM found the following issues a) Shelving Area On the shelved area above the cooking sink the following items were found: --an opened bag [NAME] gravy mix no open date --an opened bag of brown sugar no open date --an opened bag of confectioners sugar no open date --2 bags of opened instant mashed potatoes no open date --2 bags of opened grits no open date --an opened bag of chicken gravy mix no open date --an opened can of [NAME] no open date --an opened box of cream of wheat no open date --an opened package of 5 hot dog buns no open date b) Beverage Refrigerator The following items were found in the beverage refrigerator: -3 glasses of orange juices no labels -1 glass of thickened water no labels c) Reach in Freezer The reach in freezer contained the following opened items with no date to indicated when opened: -2 packages of bologna -1 package of opened box of biscuits -1 pizza dough -2 bags of hushpuppies -2 bags of chicken tenders -1 bag of fish nuggets -2 pans of peach cobbler -3 bags of french fries -2 bags of tater tots -an opened bag containing 5 hamburger patties d) Walk-in Freezer A walk in freezer found the following items with no dates to indicate when opened: -1 bag of chicken wings -2 bags of fried chicken -2 bags of broccoli -1 bag of cauliflower -1 chocolate cream pie -1 Boston cream pie e) Pantry The pantry found following items with no dates to indicate when opened: -1 bag of opened flour -1 bag of opened sugar The FSD acknowledged all the items needed to be discarded. f) Grease trap An initial tour of the kitchen with the FSD #71 beginning on 07/05/22 at 10:25 AM found several wet towels laying on the floor in front of the steamer. During an interview on 07/05/22 at 10:35 AM, the FDS #71 stated the steamer was leaking. It started about 30 minutes ago. During a second visit to the kitchen with the Assistant Food Service Director (AFSD) #46 on 07/05/22 at 12:10 PM, a puddle of water was on the floor in front of the steamer. AFSD #46 stated the drain is backed up by the grease trap. I have called Maintenance to let them know but no one has shown up. During an interview on 07/05/22 at 12:22 PM, the Administrator stated it's the outside grease trap clogged up, we will take care of that and get the floor sanitized. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to report alleged violation related to mistreatment exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigation to the proper authorities within prescribe timeframes. This failed practice had the potential to affect a limited number of residents. Resident identifier: #66. Facility census: 81. Findings include: a) Review of facility policy A review of the facility's policy entitled, Abuse, Neglect, and Exploitation revised on 02/01/2019, noted the following: Policy Explanation and Compliance Guidelines: 1. The center will establish policies and procedures on abuse, neglect, exploitation or misappropriation of resident property pertaining to the following components: b. Investigation and staff identification of allegations d. Reporting and response. 2. The center will have an Abuse Coordinator in the center (i.e., Director of Nursing, CEO/Administrator, or center appointed designee). The Abuse Coordinator will report allegations or suspected abuse, neglect, or exploitation immediately to: - CEO / Administrator - Other Officials in accordance with State Law - State Survey and Certification agency through established procedures 3. The center will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The components of the center abuse prohibition plan are discussed herein: VII. Reporting / Response of Abuse, Neglect, and Exploitation When abuse, neglect or exploitation is suspected: - Immediately report all alleged violations to the CEO/Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes . The CEO/Administrator should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. b) Resident #66 A review of Resident #66's medical record, revealed the following: -- 9/15/2019 5:50 PM Nurses Note Late Entry: Resident was going down to her room and was grabbed by another resident. She grabbed her left arm and wouldn't let go. Staff had to reinterate. The other resident stated she just wanted her purple bracelet. No redness or bruising was noted to wrist. Resident stated it hurts. (PHYSICIAN NAME) was notified. -- 9/15/2019 6:00 PM Nurses Note: 6a-6p I checked resident's left arm and noted no injuries. -- 9/15/2019 7:04 PM Nurses Note: Weekly note-Resident is alert and oriented and able to relate needs to staff. Takes meds whole. Assist of one with ADLs (Activities of Daily Living). Appetite is poor to fair. Feeds self and eats in the dining room. Ambulates with wheeled walker. Attends activities of choice. Goes in wheelchair most of the day. Is continent of bowel and bladder. -- 9/15/2019 10:42 PM Nurses Note Late Entry: resident left arm checked no injuries noted. -- 9/15/2019 10:43 PM Nurses Note: weekly 6p-6a; resident alert and oriented, ambulates self with wheel chair, skin warm and intact, lung sound clear, bowel sound present x4 quadrants, no complain of pain or discomfort noted so far during the shift, sleeping quality in bed at this time, call [NAME] in reach. will continue to monitor. -- 9/16/2019 10:23 AM Nurses Note Resident's left hand/wrist assessed- no redness, swelling. Resident moves hand/wrist without difficulty. Resident c/o slight pain with movement. DO (physician) notified. Resident capacitated. -- 9/16/2019 1:30 PM Nurses Note: New orders received for left hand/wrist x-ray. Resident aware. American Quality Imaging notified. -- 9/16/2019 3:48 PM Nurses Note: XRAY results received and noted, Negative left wrist, Negative Left hand. DR (physician). aware, resident aware. -- 9/16/2019 3:49 PM Social Service Note: Spoke with Resident this AM and she stated that another Resident had held on to wrist on her left hand and it hurt. Wrist had already been assessed by staff when incident occurred but the LPN (Licensed Practical Nurse) reassessed the wrist and an X-Ray was ordered which showed no issues. Continue to offer support. Resident has had no further concerns to Social Worker. Resident stated she was not afraid and knew that staff were there to make sure that she was O.K. She then went to talk with Social Worker about her craft activities. -- 9/16/2019 9:45 PM Nurses Note Late Entry: Resident left hand/ wrist assessed- no redness or swelling noted during this shift resident complain of no pain or discomfort noted well monitor resident during shift On 12/03/19 at 11:26 AM, during an interview with Employee #13, Social Worker (SW), was asked who submitted the reportable incidents. SW #13 stated that Employee #70, Social Worker, as well as SW #13 were responsible for the facility's reportable incidents. SW #13 stated that she did not report the incident for Resident #66, since there was no injury. On 12/03/19 at 2:48 PM, the findings were discussed with the Administrator. No further information was provided prior to the close of the annual survey on 12/04/19 at 3:30 PM. .

. Based on record review and staff interview, the facility failed to complete a discharge Minimum Data Set (MDS) assessment for one (1) of two (2) residents reviewed for the care area of discharge. Resident identifier: #42. Facility census: 81. Findings included: Review of Resident #42's medical records revealed he was discharged to the community on 10/25/19. Further review of Resident #42's medical records revealed no discharge Minimum Data Set (MDS) assessment. On, 12/04/19 at 10:41 AM, Registered Nurse Minimum Data Set Coordinator #74 confirmed Resident #42 did not have a discharge MDS completed. No further information was provided through the completion of the survey. .

. Based on record review and staff interview the facility failed to administer medication after a gradual dose reduction was completed. This failed practice had the potential to affect one (1) of five (5) Residents reviewed in the care area of unnecessary medications. Resident identifier: #11. Facility census: 81. Findings included: a) Resident #11 Review of the Medication Regimen Review (MRR) for July of 2019 revealed request from the pharmacist to evaluate and document the continued use of Lexapro (antidepressant) at the current dose of 10 milligrams (mg) daily. Documentation reflects the attending physician ordered dose reduction of 5 mg daily for four (4) weeks then discontinue medication, with sign date of 07/11/19 by the physician. Printed date on the MRR was 07/08/19. Review of the Medication Administration Record (MAR) indicated Lexapro 10 mg dose that was to be given at 8:00 PM daily was discontinued on 07/11/19, with no record of administration of Lexapro antidepressant medication given for that date. The reduced dose of Lexapro 5 mg daily was not started and administered until 07/12/19 at 8:00 AM. During an interview on 12/03/19 at 2:45 PM the Assistant Director of Nursing (ADON) verified the Lexapro antidepressant medication was not administered on 07/11/19, resulting in a missed dose. The ADON stated, I'm sure it was an order entry error that caused the missed administration when we changed the order over to the lower dose. .

. Based on observation, record review, and resident interview, the facility failed to ensure a resident receiving enteral (tube) feeding received appropriate care and services. This was true for one (1) of one (1) residents with enteral feeding in the long-term care survey sample. Resident identifier: #47. Facility census: 81. Findings included: a) Policy Review The facility's policy entitled Care and Treatment of Feeding Tubes with implementation date 11/27/17 stated, Tube placement will be verified before beginning a feeding and before administering medication. b) Resident # 47 On 12/03/19 at 9:25 AM, Resident #47 stated he was having pain. On 12/03/19 at 9:30 AM, Licensed Practical Nurse (LPN) #10 administered Tylenol 650 mg to Resident #47 via his Percutaneous endoscopic gastrostomy (PEG) tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications. Because a PEG tube can become dislodged from the stomach, the placement of the PEG tube should be checked before medications or feedings are administered through it. Placement can be checked by injecting a small amount of air through the tube with a syringe and listening for the air in the stomach with a stethoscope. This is called auscultation. Placement can also be checked by aspirating stomach contents from the tube using a syringe. LPN #10 administered Tylenol through Resident #47's PEG tube by crushing Tylenol tablets and dissolving them in water. The water containing the Tylenol was then infused by allowing it to flow through the PEG tube by gravity through the barrel of the syringe. LPN #10 did not check the PEG tube for placement before administering the medication to Resident #47. Resident #47 had an order written on 12/02/19 to Check tube placement prior to each feeding/flush/med administration. During an interview on 12/03/19 at 12:33 PM, Corporate Registered Nurse (RN) #137 was informed LPN #10 did not check Resident #47's PEG tube placement prior to administering medication. Corporate RN #137 had no additional information regarding the matter. No further information was provided through the completion of the survey. .

. Based on record review and staff interview, the facility failed to ensure that nursing assistants (NA's) received annual performance appraisals. This was true for two (2) of five (5) employee files that were reviewed. Employee Identifiers: #2 and #44. Facility census: 81. Findings include: a) Employee #2 A review of Employee #2, nursing assistant (NA), personnel record found she was hired 06/28/04. Further review of her personnel record found her last performance evaluation was dated 02/26/15. On 12/04/19 at 10:09 AM, during an interview with Employee #47, Human Resource Director (HR), HR #47 was asked if all employee evaluations were contained within their employee file. HR #47 stated that the employee file is the only place that the performance evaluation would be located. On 12/04/19 at 12:38 PM, the findings were discussed with the Administrator. No further information was provided at the end of the survey on 12/04/19 at 3:30 PM. b) Employee #44 A review of Employee #44, nursing assistant (NA), personnel record found she was hired 02/08/90. Further review of her personnel record noted that her last performance evaluation was dated 10/04/19. NA #44's performance evaluation was due to be completed on 02/08/19. NA #44's employee evaluation was completed approximately eight (8) months past her annual date. Moreover, NA #44's employee file noted that prior to the performance evaluation that was completed on 10/04/18, NA #44's previous employee evaluation had not been completed since 02/26/15. On 12/04/19 at 10:09 AM, during an interview with Employee #47, Human Resource Director (HR), HR #47 was asked if all employee evaluations were contained within their employee file. HR #47 stated that the employee file is the only place that the performance evaluation would be located. On 12/04/19 at 12:38 PM, the findings were discussed with the Administrator. No further information was provided at the end of the survey on 12/04/19 at 3:30 PM. c) Policy Review A review of the facility's policy entitled, Nurse Aide Education / Program noted the following: --Additional training will be provided to each nurse aide based on any areas of weakness as determined in the nurse aide's performance reviews. --The Director of Nursing shall communicate the educational needs of the employee to the Staff Development Coordinator upon final review of the annual performance appraisal. --Education that is needed based on the performance appraisal will be completed within 90 days of the appraisal, unless otherwise specified in the appraisal. .

. Based on record review and staff interview the attending physician failed to appropriately respond to the medication regimen recommendations made by the pharmacist during monthly medication regimens reviews. This failed practice had the potential to affect two (2) of five (5) Residents reviewed for the care area of unnecessary medications. Resident identifiers: #8, #11. Facility census: 81 Findings included: a) Resident #8 Record review of Medication Regimen Review (MRR) dated 04/05/19 revealed the Resident had a consult with the psychiatrist in March of 2019, and the Psychiatrist noted continued confusion with no reported physical aggression with staff on increased dose Seroquel 50 mg (antipsychotic medication) twice daily. The Pharmacist requested documentation to be provided for continued need of Seroquel as per noted in Psychiatric consult. The MRR was not signed or dated by the attending physician until 11/6/19 at which time the physician noted Seroquel was decreased on 09/04/19. During an interview on 12/03/19 at 3:10 PM the Assistant Director of Nursing (ADON) verified and agreed MRR dated 04/05/19 was not addressed appropriately by the attending physician, and the physician should have responded to the pharmacist's recommendations in a timelier manner. b) Resident #11 Record review of Medication Regimen Review (MRR) dated 04/04/19 revealed recommendation from the pharmacist to discontinue Lisinopril (ACE inhibitor used to treat high blood pressure) due to Resident's increased serum Potassium levels. The MRR was not signed or dated by the attending physician to indicate any acknowledgment or action to be taken for the recommendation. During an interview on 12/03/19 at 3:00 PM the Assistant Director of Nursing (ADON) verified and agreed MRR dated 04/04/19 was not completed appropriately by the attending physician to document acknowledgement of the recommendations and what action was to be taken. c) Administrator Interview During an interview on 12/04/19 at 1:35 PM the Administrator stated, We (the facility) identified an issue with those (Medication Regimen Review) in October (2019), so we (the facility) went all the way back to January 1st of 2019 to see what was missed. The pharmacist done her part. What happened is those (Medication Regimen Review) made it up to nursing and from there they never got looked at. The Administrator further stated the issues identified with the monthly Medication Regimen Reviews were added into the Quality assurance and performance improvement (QAPI) program agenda in October 2019. .

. c) Resident #66 A review of Resident #66's medical record, revealed the following: -- 1/7/2019 5:15 PM Social Service Note: The Social worker talked with the resident about not using inappropriate language and she stated that will not be using this anymore. -- 1/7/2019 5:18 PM Social Service Note: The Social Worker talked with the resident about how she treated her friend this past weekend who lives at the center. The resident knows that she should not cuss or be hurtful in any way to him. The resident stated that she apologized and she is very sorry for this. The resident stated that she did not feel good and she took her frustration out on her friend. The resident stated that she will no longer due this. -- 1/11/2019 09:53 AM Social Service Note: The Social Worker talked with the resident yesterday about the resident calling one of the staff members a cuss word and she stated that she never called her this. The Social Worker talked to the resident about using appropriate vocabulary. -- 1/11/2019 4:42 PM Social Service Note: The Social Worker talked with resident due to resident stating to assistant last night at sleep study that she was not given anything to drink when she was here at the center. The resident stated that she was given something to drink at the center and she denied ever saying anything like this. -- 2/27/2019 8:01 PM Social Service Note: The Social Worker talked with the resident about not helping her roommate and to always use the call bell if her roommate needs assistance. The resident stated that she would use the call bell for assistance. -- 7/1/2019 09:47 AM Social Service Note: It was reported by staff that Resident had been attempting to take Resident's to the porch area, asking visitors for food and making other comments, such as don't go in there there's warm death in there,saying she has hairs in her food in order to get more food to share with her friend, another Resident. The Resident denied all this and stated she has not done any of things noted above. When it was explained to her that these issues were reported by numerous visitors and staff she had nothing to say. It was explained to her that she is not to take any of the other Resident's outside. Staff will take Resident's outside because they are aware of who can be on the porch area without staff being present. It was also explained that asking visitors for food is unacceptable. If Resident wants more food she is to ask staff of the facility. When asked about the comment about warm death she stated that she had not said that. It was explained that comments of that nature are unacceptable. Resident then stated that she had said that the building was cold and her room was cold. It was explained that Social Services would speak with staff about keeping her heat on 70 in order that she would not be cold. The Resident has stated for several days she finds hair in her food; however, she does not want staff to take the food with the hair in it back to the kitchen and yet wants more food, which she shares with her friend. On numerous occasions she has been requested not to give food to her friend. He has digestive issues and his Resp. Party feels that extra food is not good for him. He has also been told if he is still hungry after meals to ask staff for food, so they can give him food that will not hurt his stomach. The staff will specifically check her tray in order to ensue that their is no hair in her food. She stated that she would stop the behaviors which she previously said she was not engaging in. She was also informed that if these behaviors continue her brother would be requested to meet with team members to discuss interventions/options for the Resident. Resident verbalized understanding. -- 7/2/2019 4:07 PM Social Service Note: Spoke with Resident about making remarks about not liking certain people. Suggested that she leave the room, activity, etc. without comment if there is someone present she has an issue with. She verbalized understanding. -- 7/9/2019 09:39 AM Social Service Note: Spoke with the Resident x2 (2 times) regarding report from weekend. It was reported that the Resident was asking visitors to take her out to buy beads and also that she was standing in the doorway of her room with only her bras and panties on. Resident stated and it was later confirmed that the visitor had offered to take her on an outing. Suggested and Resident agreed that a call to her brother would be acceptable in order to ensure that he had no concerns regarding her going on the outing. Reminded Resident that she is not to ask visitors to bring her in food or take her places and she stated she would not. Resident stated that she cannot sleep good with clothing on and it was suggested that she keep a robe by her bed and when she gets up put the robe on due to families visiting other Residents on her hall. She stated she understood and that was a good idea. Also, spoke with her about talking and being disruptive during activities and suggested if she needed to leave the activity quietly get up and leave. She agreed with this also. When Resident is observed engaged in a good activity she is reinforced/ verbally praised by staff. She is offered activities to keep her engaged in acceptable activities. -- 7/20/2019 2:49 PM Social Service Note Late Entry: Was informed by staff members that Resident had been acting in an unacceptable manner. She had made false reports about a C.N.A. (certified nursing assistant), had been acting in an unacceptable manner with her boyfriend and talks with visitors coming in to facility and tells them much inaccurate information. The Resident also became upset because she asked for a salad and the kitchen told her it would take a few minutes to prepare. Spoke with Resident in the 500 hall library and she had received her salad. Spoke about the need not to accuse people or tell untruths on staff. She stated that she had told a lie on one staff member but did tell her she was sorry. Explained the seriousness of making false accusations and Resident verbalized understanding. Also, explained that if Resident does not call ahead and ask for a food substitute she may have to wait a few minutes while the kitchen makes her request. She also verbalized understanding regarding this. Also spoke with her regarding her Resident friend and the acceptable behaviors she may engage in with him. She also verbalized understanding. She was very irritated but did state that she would stop the behaviors which she verbalized back to the Social Worker in order to ensure that she understood what behaviors had been talked about. -- 8/2/2019 12:50 PM Social Service Note: Resident has been exhibiting attention seeking behaviors; such as gagging, saying she is sick and making it difficult for other Residents to enjoy the activity due to this; she also continues to make up stories and telling visitors she is not being treated fairly by activities-- she later recants these allegations. When asked about these statements she states that she should not be engaging in these behaviors and she will stop. Staff continue to praise Resident for conducting herself in an acceptable manner. Her brother has also spoken with her regarding these issues. The Resident was encouraged to quietly leave the activities if she becomes ill and let the LPN (licensed practical nurse) know in order to be assessed and treated. She was also encouraged to be sure that information she gives regarding staff are accurate as this could lead to serious consequences for them. Continue to meet with Resident on a regular basis. -- 8/13/2019 09:17 AM Social Service Note: The Social Worker talked with the resident about modesty and also about not asking people who visit the center to take her shopping. The resident knows that Activities Department is available to shop for her. -- 8/29/2019 1:59 PM Social Service Note: Resident was asked about an issue that occurred in therapy with another Resident in which she kissed the Resident. Resident stated that the lady was very special and she just wanted her to know that she respected and liked her. Explained that kissing was not the best way to show that and suggested she just tell the Resident; she stated that she would from now on. Also talked with her about personal space and the fact that some people do not like to be hugged, etc. She stated that she understood. -- 11/7/2019 1:29 PM Social Service Note: Staff have approached Social Worker on several occasions this week to report that Resident has been going in to visit other Residents very early (6AM), has been asking staff for money, and has also been asking visitors for personal possessions. Have spoken with her about these behaviors and she initially denies them and admits to doing what she has been asked not to. Offer Resident praise for acceptable behavior but she continues to engage in the above behaviors. Have also asked staff to re-direct Resident to acceptable activities if they observe her engaging in behaviors noted above. The Resident would benefit from being re-directed while behavior is occurring due to the fact that when asked about behaviors she denies them. -- 11/15/2019 11:00 AM Care Plan Note: The Resident is alert and oriented x 3 (three times). She is able to make wants and needs known and is up daily in her wheel chair. She receives assistance with ADL (activities of daily living) care and eats independently in the dining room. Her intake is 85%. She is continent of bowel and bladder and has not had any falls this review period. She attends activities of choice and she and her friend do individual activities such as making beads and coloring together. The Resident is very intrusive at times and wants to give candy to Residents and wants to enter their rooms and water their flowers and just visit. Have explained that some Residents would prefer her not to go into their rooms and water their plants etc. Have also explained on several occasions that she is not to give food to others due to special diets. She expresses understanding but continues to engage in the same behaviors at times. Offer her praise for acceptable behavior and make sure she understands what is unacceptable. She exhibits poor judgement and limited insight. The Resident is long term due to level of care required. She is carried for her attention seeking/unacceptable behaviors. Continue to offer support and encouragement. Attendees: Social Worker, Resident Information obtained from: CCM/RN, Dietary, Activities and C.N.A. A review of Resident #66's behavior documentation noted the following: -- 6/11/19 11:47 - yelling/screaming -- 6/11/19 11:47 - threatening behavior -- 6/11/19 11:47 - rejection of care -- 6/11/19 11:57 - abusive language -- 7/20/19 13:17 - rejection of care -- 7/20/19 13:17 - threatening behavior -- 7/20/19 13:17 - yelling / screaming -- 7/20/19 13:17 - abusive language -- 10/10/19 12:25 - abusive language -- 10/20/19 19:99 - yelling/screaming -- 11/18/19 14:03 - yelling/screaming -- 11/24/19 13:56 - yelling/screaming A review of Resident #66's care plan did note the following: Focus: Although the Resident is deemed to have capacity she is very childlike and her judgement is impaired and her insight is poor. She continues at times to display episodes of agitation, anxiety, depression, anger most likely r/t (related to) intellectual disability. Goal: Resident will have improved mood and behaviors as evidenced by complying with requests without yelling, screaming, etc. and will verbalize no statements of self harm thru next review. Interventions include: Observe/document/report to MD (physician) new or increased s/sx (signs and symptoms) of depression: Sad, irritable, angry, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, needing constant reassurance. On 12/03/19 at 11:30 AM, during an interview with Employee #13, Social Worker, SW #13 was asked about Resident #66's behaviors. SW #13 stated Resident #66 likes to visit other residents, but does so in the middle of the night, in the morning before the other resident(s) wake up, or while other residents are getting dressed and / or receiving care. SW #13 noted Resident #66 is intrusive with others and into their personal space. SW #13 also stated Resident #66 does make false statements to staff and visitors. Resident #66 has attempt to solicit money and / or craft supplies from visitors. SW #13 stated that Resident #66 has yelling, cursed, and screamed at staff at times. Resident #66 has used inappropriate language to other residents. SW #13 stated Resident #66 does exhibit attention seeking behaviors. SW #13 stated she has discussed appropriate visiting times with Resident #66 on multiple occasions. SW #13 stated Resident #66 has exhibited behaviors of a sexual nature as well as removing clothing, or being seen in public in just her underwear. During an interview on 12/04/19 at 11:49 AM, SW #13 was asked if Resident #66's behaviors were contained in Resident #66's care plan. SW #13 stated Resident #66's behaviors should have been care planned; however, they were not care planned. SW #13 stated she did not care plan Resident #66's behaviors since SW #13 meets with Resident #66 and discusses resident's behavior. SW #13 stated interventions should be on the care plan, so that staff will know how to assist Resident #66 and how to address her behaviors. On 12/04/19 at 12:34 PM, the findings were discussed with the Administrator. No additional information was provided at the end of the survey on 12/04/19 at 3:30 PM. b) Resident #67 During a record review it revealed nursing notes that Resident #67 was on a fluid restriction. This was mentioned on: - 10/03/19 at 10:17 AM, Resident continues to be on fluid restriction and is non-compliant at this time. - 12/02/19 at 11:10 PM, Resident continues to be on fluid restriction and is non-compliant at this time. -12/02/19 at 9:57 AM, Resident continues to be on fluid restriction and is non-compliant at this time. -12/01/19 at 10:45 PM, Resident continues to be on fluid restriction and is non-compliant at this time. -12/01/19 at 10:24 AM, Resident continues to be on fluid restriction and is non-compliant at this time . act. The physician order dated: 10/25/19, states, she is to only have fluids with meals and medications. (There was no measurable amount or goals, for the amount of fluids she should receive). The care plan, date of initiated, 11/25/19 was as follows: Focus; Resident #67 has a diagnosis of Chronic Kidney Disease (CKD). Goals; Resident will be free from complications. Interventions; Fluid as ordered. Restrict or give as ordered. Focus: Risk of altered nutrition/hydration status related to diagnosis of Congestive heart failure and fluid restrictions. Interventi0ons; Fluid with meals and medication pass only. During an interview on 12/03/19 at 10:27 AM, Corporate Registered Nurse #137 states, that she did see the care, and it looked as though it was not personalized, and it was right out of a care plan book. She said, she has looked into the fluid restriction and this resident was not on a fluid restriction. She did not comment on why the nursing notes repeatedly referred to this resident was on a fluid restriction when she was not. Based on observation, record review, and resident interview, the facility failed to develop and/or implement the comprehensive care plan for three (3) of 21 residents reviewed during the long-term care survey process. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #47, #67, #66. Facility census: 81. Findings included: a) Resident # 47 On 12/03/19 at 9:25 AM, Resident #47 stated he was having pain. On 12/03/19 at 9:30 AM, Licensed Practical Nurse (LPN) #10 administered Tylenol 650 mg to Resident #47 via his Percutaneous endoscopic gastrostomy (PEG) tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications. Because a PEG tube can become dislodged from the stomach, the placement of the PEG tube should be checked before medications or feedings are administered through it. Placement can be checked by injecting a small amount of air through the tube with a syringe and listening for the air in the stomach with a stethoscope. This is called auscultation. Placement can also be checked by aspirating stomach contents from the tube using a syringe. LPN #10 administered Tylenol through Resident #47's PEG tube by crushing Tylenol tablets and dissolving them in water. The water containing the Tylenol was then infused by allowing it to flow through the PEG tube by gravity through the barrel of the syringe. LPN #10 did not check the PEG tube for placement before administering the medication to Resident #47. Resident #47's comprehensive care plan contained the focus, Resident has need for use of feeding tube. Interventions included, Check tube placement by aspiration and auscultation (listening) prior to administering any medication and/or feeding. During an interview on 12/03/19 at 12:33 PM, Corporate Registered Nurse (RN) #137 was informed LPN #10 did not implement Resident #47's comprehensive care plan regarding checking PEG tube placement prior to administering medication. Corporate RN #137 had no additional information regarding the matter. No further information was provided through the completion of the survey. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c) Resident #33 A review of Resident #33's care plan noted the care plan had been updated on 10/22/19. In Resident #33's medical record, the following note was revealed: -- 11/6/2019 5:45 PM Social Service Note: The Social Worker had quarterly care plan with the residents representative. The Social Worker went over all appointments and medications. The Social Worker also talked with the residents representative about the resident continuing to be non-complaint with his fluid restrictions. The Social Worker went over the Psychiatrist Dr. Hamms progress note with the representative. The Social went over the residents Code Status, BIM, PHQ-9 and the behaviors the resident has had. The Social Worker went over his nutritional status. The resident continues to people watch and he likes to self propel in his wheelchair. The resident will continue to make his home here at the center. No concerns voiced in care plan. On 12/03/19 at 1:07 PM , Employee #70, Social Worker, the 11/6/19 social services note was reviewed. SW #70 reviewed the medical record for documentation on the care plan meeting. SW #70 stated for quarterly care plans, the interdisciplinary team, consisting of nursing, activities, dietary, therapy, and social services does not document nor review the care plan as a group. SW #70 stated that she contacts the resident and / or resident representative to review the quarterly care plan. On 12/04/19 at 11:30 AM, the findings related to the quarterly care plans was discussed with the Administrator. On 12/04/19 at 11:50 AM, during an interview with SW #70 provided a paper document entitled, DOM Treatment Plan Conference Record. SW #70 stated that this form is completed every quarter with the inter-disciplinary team. When asked why this form could not be located in the electronic medical record, SW #70 stated that this form is not scanned into the medical record. SW #70 stated that this form is competed for every quarterly care plan, rather than a note placed in the resident's electronic medical record. On 12/04/19 at 12:48 PM, the findings related to components of Resident #33's medical record not being contained in the electronic medical record was discussed with Employee #137, Corporate Registered Nurse (RN). No further information was provided at the end of the survey on 12/04/19 at 3:30 PM. d) Resident #60 A review of Resident #60's care plan noted the care plan had been updated on 10/22/19. In Resident #60's medical record, the following note was revealed: -- 1/4/2019 8:25 PM Care Plan Note: The resident had care plan on January 3, 2019 and she has capacity and she scored a 15 on her BIM. The resident scored a 0 on her PHQ-9. The resident is a DNR. the resident is currently in restorative and her meal intake was 91%. The resident loves to attend church here at the center. She also enjoys Toss The Dice and Bingo. The resident I happy with her roommate and she will continue to make her home long term here at the center. Attendees: (NAME), Social Services (NAME), Director Of Rehab (NAME), Food Service Director Assistant -- 1/23/2018 12:11 PM Care Plan Note Late Entry : admission MDS Assessment and Care Plan Conference. CPT met. Face sheet, advance directives, capacity, dx & med lists, consults, lab, MDS, CAAs, POC Task lists, [NAME], and care plan reviewed. Resident and son attended. She is A/O x 3, has capacity, and is a DNR, limited interventions, feeding tube & IVF trials. She is able to communicate her needs without difficulty. She needs extensive assist of x 2 staff for mobility, transfer, dressing, bathing, and toileting. She has been participating well with her therapy programs and can walk using a hemi-walker up to 100 ft with limited assist but still needs help with sit to stand. She is occasionally incontinent of bladder but always continent of bowel. She has not fallen and skin integrity is currently intact. Her pain regimen includes Neurontin routinely and Tylenol PRN. She denied pain. She is taking Lasix for edema without exhibiting adverse effects. She takes a NAS regular diet and weight is 162#. Dietary will address her Nutritional Status care plan. Social Services will address her discharge plans when appropriate. Nursing will care plan for ADLs, Urinary Incontinence, Falls, Dehydration, and PU. Attendees: (NAME), RN; (NAME) MSW/LGSW,Social Services; (NAME), Activities Director; (NAME), PT -- 1/2/2018 12:46 PM Care Plan Note Late Entry: admission MDS Assessment and Care Plan Conference. CPT met. Face sheet, advance directives, capacity, dx & med lists, consults, lab, MDS, CAAs, POC Task lists, [NAME], and care plan reviewed. Resident and family attended. She is A/O x 3, has capacity, and is a DNR, limited interventions, Feeding tube trial and IVF trial x 2 weeks. She is able to communicate her needs without difficulty. She needs extensive assist of x 2 staff for mobility, transfer, dressing, bathing, and toileting. She has been participating well with her therapy programs. She is always continent of B&B. She has not fallen. skin integrity-has stage II PU to her right buttock on admission. Her pain regimen includes Neurontin 300mg TID. She denied pain when interviewed. She is taking antibiotics for cellulitis of RLE and pneumonia without exhibiting adverse effects. She takes a NAS regular diet, average intake is 51-75% and weight is 162#. Dietary will address her Nutritional Status care plan. Social Services will address her potential forCognitive Loss/Dementia in a care plan and assist with discharge plans. Nursing will care plan for ADLs, Urinary Incontinence, Falls, Dehydration, and PU. Attendees: [NAME] Canterbury, RN; [NAME] MSW/LGSW, Social Services; [NAME], Activities Director; [NAME], PT; [NAME], COTA. A review of Resident #60's medical record noted the resident's care plan was last updated on 10/29/19. A further review of the medical record noted the following social service note: -- 11/22/2019 4:00 PM Social Service Note: The resident had quarterly care plan with the resident and she went over BIM, PHQ-9, Code Status with resident. The Social Worker went over all medications, appointments and the residents diet. The resident is on a regular diet regular texture and the residents meal intake is 76% -100% on October 30, 2019. The Social Worker went over the residents low potassium diet which includes no baked potatoes, orange juice tomatoes or bananas. The resident is given one slice of tomato when on menu for sandwiches. The resident was well aware of her low potassium diet. The resident is alert and oriented times three and she has capacity. The resident currently has completed occupational therapy and she is in the restorative Nursing Program for Strengthening ambulation 5X a week for 8 weeks. The resident is assist of one for ADLS and she is assist of Two for staff transfers and she is continent of bowel and bladder. The resident currently participates in the following activities such as spiritual programs, exercise,special events, crafts family visits and reading. The resident has close friend on her hall who she visits with frequently. The resident will continue to make her home long term here at the center. No concerns voiced in care plan. On 12/03/19 at 1:07 PM , Employee #70, Social Worker, the 11/22/19 social services note was reviewed. SW #70 reviewed the medical record for documentation on the care plan meeting. SW #70 stated for quarterly care plans, the interdisciplinary team, consisting of nursing, activities, dietary, therapy, and social services does not document nor review the care plan as a group. SW #70 stated that she contacts the resident and / or resident representative to review the quarterly care plan. On 12/04/19 at 11:30 AM, the findings related to the quarterly care plans was discussed with the Administrator. On 12/04/19 at 11:50 AM, during an interview with SW #70 provided a paper document entitled, DOM Treatment Plan Conference Record. SW #70 stated that this form is completed every quarter with the inter-disciplinary team. When asked why this form could not be located in the electronic medical record, SW #70 stated that this form is not scanned into the medical record. SW #70 stated that this form is competed for every quarterly care plan, rather than a note placed in the resident's electronic medical record. On 12/04/19 at 12:48 PM, the findings related to components of Resident #60's medical record not being contained in the electronic medical record was discussed with Employee #137, Corporate Registered Nurse (RN). No further information was provided at the end of the survey on 12/04/19 at 3:30 PM. b) Resident #47 1. On 12/03/19 at 9:30 AM, Licensed Practical Nurse (LPN) #10 administered acetaminophen (Tylenol) 650 mg to Resident #47 via his Percutaneous endoscopic gastrostomy (PEG) tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications. Review of Resident #47's medical records on 12/03/19 at 9:40 AM revealed an order for Acetaminophen 325 mg, give 2 tablets by mouth every 6 hours as needed for pain. Resident #47's other medications were ordered to be given by PEG tube. During an interview on 12/03/19 at 12:33 PM, Corporate Registered Nurse (RN) #137 was informed Resident #47's acetaminophen was ordered orally but was administered through his PEG tube. Corporate RN #137 stated she would clarify the order with the physician. Review of Resident #47's medical records on 12/04/19 at 8:00 AM revealed the order had been changed to Acetaminophen 325 mg, give 2 tablets via PEG tube every 6 hours as needed for pain. 2. Review of Resident #47's medical records on 12/03/19 at 9:40 AM revealed an order written on 11/20/19 for Modular Protein two times a day for supplement via PEG tube. The order did not give the dosage of modular protein to be given. During an interview on 12/03/19 at 12:33 PM, Corporate Registered Nurse (RN) #137 was informed Resident #47's modular protein order did not contain the dosage. Corporate RN #137 stated she would clarify the order with the physician. Review of Resident #47's medical records on 12/04/19 at 8:00 AM revealed the modular protein order was rewritten for 30 ml (milliliters) twice a day. Based on record review, observation, and staff interview the facility failed to ensure medical record were complete and accurate. This was true for four (4) of 21 sampled residents. Resident identifiers: #83, #47, #33 and #60 . Facility Census: 81. Findings included: a) Resident #83 Observations of Resident #83 on 12/02/19 at 11:13 a.m. found she had missing teeth and her remaining teeth appeared to be in poor condition. A review of Resident #83's medical record found the following three (3) dental assessments: -- Dental assessment dated [DATE] indicated the resident had no natural teeth or tooth fragment(s) (edentulous). -- Dental assessment dated [DATE] indicated the resident had obvious or likely cavity or broken natural teeth. Resident with natural teeth, some broken and caries noted. Denies any pain or discomfort or difficulty eating/drinking. Oral mucosa is pink, moist. -- Dental assessment dated [DATE] indicated the resident had obvious or likely cavity or broken natural teeth. Resident with natural teeth, some broken and caries noted. Denies any pain or discomfort or difficulty eating/drinking. Oral mucosa is pink, moist. An interview with Registered Nurse (RN) #16 at 12/03/19 at 8:53 a.m. confirmed Resident #83 had some natural teeth and the assessment completed on 08/20/19 was inaccurate. .

. b) Resident #3 During the initial tour on 12/02/19 at 10:57 AM, Resident #3's Bilevel Positive Airway Pressure (bi-pap) mask was observed to be lying on the bedside table, not in a bag. A bag was observed to be hanging near Resident #3's bed, empty. On 12/02/19 at 10:59 AM, Employee #62, Licensed Practical Nurse (LPN) was asked to enter Resident #3's room. LPN #62 observed the bi-pap mask sitting out on Resident #3's bedside table. LPN #62 stated that the mask should have been wiped off and placed in a bag when not in use. On 12/04/19 at 11:30 AM, the findings were discussed with the Administrator. No further information was provided prior to the end of the survey on 12/04/19 at 3:30 PM. c) Resident #60 During the initial tour on 12/02/19 at 11:07 AM, the surveyor observed Resident #60's nebulizer was not in a bag, still connected to machine, unit fully assembled, and not in use. On 12/02/19 at 11:12 AM , Employee #49, LPN, was asked to enter Resident #60's room. LPN #49 observed the nebulizer sitting out on Resident #60's bedside table. LPN #49 stated that the nebulizer was supposed to be in a bag. A bag was noted beside the resident's bed, empty. On 12/03/19 at 8:30 AM, Resident #60's nebulizer was out on the bedside table. LPN #49 stated that the nebulizer was supposed to be in the bag. LPN #49 further noted that night shift must have left it out. LPN #49 stated that she would put the nebulizer in the appropriate bag after Resident #60 completed her nebulizer treatment. Resident #60 refused to use the nebulizer. A review of the facility's policy entitled, Small Volume Nebulizer revealed the following: V. Cleaning and Replacement Schedule: A. The Nebulizer Circuit should be disassembled after each treatment, rinsed with water and let to air dry. Place the nebulizer circuit in the equipment bag for infection control purposes. B. Daily, the nebulizer circuit should be washed with warm, soapy water, rinsed with water and let to air dry. C. The Nebulizer Circuit should be wiped clean with a damp cloth as necessary to avoid accumulation of dust. D. The air inlet filter should be checked and changed as needed. E. Replace disposable supplies every ten (10) days and as needed. F. Date each supply item (e.g., nebulizer circuit) or supply bag for documentation purposes and indication of the next scheduled replacement, as applicable. On 12/04/19 at 11:30 AM, the findings were discussed with the Administrator. No further information was provided prior to the end of the survey on 12/04/19 at 3:30 PM. Based on observation, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This failed practice had the potential to affect more than a limited number of residents residing at the facility. Resident identifiers: Resident #3 and #60. Facility census 81. Findings included: a) Laundry Room During an observation and tour of the laundry rooms on 12/04/19 at 8:39 AM, Laundry Staff #24 was witness to the airflow being pulled from the soiled laundry room into the clean laundry room. This was verified by using a piece of tissue paper along the door dividing the two rooms. The paper was being pulled into the clean laundry room, while standing in the soiled room. On 12/04/19 at 8:41 AM, Housekeeping supervisor #93 also verified that the tissue paper was being pulled into the clean laundry room from the soiled laundry room. He stated that he would find a fix for that as soon as possible. .