Every finding on record at Addington Place at College Harbor

Based on observation, record review, and interview, the facility failed to ensure one resident (# 14) of eight residents sampled, was provided the opportunity to participate in care planning. Findings included: On 09/03/24 at 11:00 a.m., Resident #14 was observed lying down in bed with her call light in reach. She presented well-groomed with no signs of distress. She stated she was happy at this facility. She was the new council president, and the residents were very pleased with the staff. She stated she had been at the facility for a year and had never been invited to a care plan meeting. She said she would like to be informed and a part of her plan of care. On 09/04/2024 at 10: 00 a.m., Resident #14 was observed lying down in bed with her call light within reach. She was observed with no signs of distress. Review of an Admission Record dated 09/05/2024, showed Resident # 14 was admitted to the facility with diagnoses to include but not limited to myasthenia gravis with (acute) exacerbation, multiple sclerosis, and major depressive disorder, recurrent, unspecified. Review of an quarterly Minimum Data Set, (MDS) dated [DATE], showed a Brief Interview for Mental Status ( BIMS) score of 14, which indicated intact cognition. On 09/05/2024 at 1:00 pm., an interview was conducted with Staff A, the Minimum Data Set (MDS) Director. Staff A stated they invited residents or their family to care plan meetings quarterly. If the resident or the family did not want to come to the meeting, she asked them if there was anything they would like to address with the team. There was a letter that was sent out to the families or residents quarterly. The letter was scanned in the Electronic Medical Record. She said [Resident #14's] last meeting would have been in July or beginning of August. I don't see a letter for the month of July or August. She stated, come to think of it she had never seen Resident # 14 attend any of her care plan meetings. The facility did not have a care plan policy to provide for this citation. Review of resident handbook provided by facility revealed on page 5 section Care Conference/Care Plan. It showed A care plan conference is held on each resident. The care conference consists of representatives from each department and meets to discuss the resident's plan of care. Care conferences are held no later than the 21st day of admission. Resident and resident representative will be given advance notice of the scheduled care conference and will be invited to attend. If you cannot attend you will receive a care plan summary. No initial or revision date provided.

Based on observation, record review, and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was completed accurately for four (#1,#5,#6,#8) of 23 residents sampled for PASRR Findings include: 1. 09/03/2024 at 11:00 a.m. and at 1:00 p.m., Resident #8 was observed lying in bed with her call light in reach. She was observed with no signs of distress. Review of an Admission Record dated 09/05/2024, showed Resident #8 was admitted to the facility on [DATE] with diagnoses to include but not limited to, anxiety disorder, unspecified, unspecified mood affective disorder, and major depressive disorder, recurrent, mild. Review of an annual Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status, (BIMS) score of 13, which indicated intact cognition. Review of Resident #8's Preadmission Screening and Resident Review (PASRR) dated 7/4/2022 revealed no qualifying mental health diagnosis marked. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/9/2024, revealed a diagnosis of anxiety disorder, depression (other than bipolar). 2. Review of Resident #6's Admission Record showed an original admitted [DATE] with a readmitted [DATE]. Diagnoses included but were not limited to residual schizophrenia, schizoaffective disorder, anxiety disorder, major depressive disorder, deaf nonspeaking and drug induced subacute dyskinesia. A review of Resident #6's Preadmission Screening and Resident Review (PASRR) dated 12/25/2020, Section A Mental Illness or suspected Mental Illness (check all that apply) did not have schizophrenia checked as a current diagnosis. Section II: Other indications for PASRR screen decision-making for question 6 was checked as yes for a secondary diagnosis of dementia. Resident #6 did not have dementia listed as a diagnosis on the Admission Record. A review of Resident #6's Minimum Data Set (MDS) dated [DATE] for Section I-Active Diagnoses under Psychiatric/Mood Disorder had anxiety, depression, psychotic disorder and schizophrenia checked as active diagnoses. 3. Review of Resident #1's Admission Record showed an original admitted [DATE] with a readmitted [DATE]. Diagnoses included but were not limited to unspecified dementia unspecified severity without behavioral, psychotic, mood and anxiety disturbances, and major depression and major depressive disorder. A review of Resident #1's Minimum Data Set (MDS) dated [DATE] for Section I-Active Diagnoses under Neurological section had non-Alzheimer's dementia and under Psychiatric/Mood Disorder section had depression checked as active diagnoses. A review of the physician orders for Resident #1 showed an order dated 6/17/2024 for Duloxetine HCL delayed release particles 60 milligrams (mg) oral to give one time a day for depression. An order dated 8/15/2024 for Xanax 0.25 mg to give one tablet by mouth twice a day for anxiety. A review of Resident #1's care plan initiated on 8/02/2024 showed a Focus area: [Resident] takes Xanax for episodes of increased restlessness with a goal to be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions included but were not limited to administer anti-anxiety medications as ordered by the physician, monitor for side effects and effectiveness every shift. monitor document report as needed any adverse reactions to anti-anxiety therapy and monitor and record occurrence of for target behavior symptoms and document per facility protocol. A review of Resident #1's psychiatric progress notes dated 6/20/2024 stated she is anxious today. Psychiatric progress notes dated 8/15/2024 had an added diagnosis of Generalized anxiety disorder and Xanax 0.25 mg oral tablet to take one by mouth at noon and HS (at night) was ordered. A review of Resident #1's Preadmission Screening and Resident Review (PASRR) dated 5/09/2024, Section A Mental Illness or suspected Mental Illness (check all that apply) did not have depression checked as a current diagnosis. 4. Review of the electronic medical record for Resident #5 showed an admission to facility on 1/30/21 with diagnoses which included major depressive disorder and anxiety disorder. Review of Resident #5's PASRR dated 1/28/2021 showed no mental illness or suspected mental illness box marked on page 2 section A. Review of Minimum Data Set (MDS) dated [DATE] revealed: - Section C Brief Interview for Mental Status (BIMS) score of 13 which indicated no cognitive impairment. - Section N showed resident was marked for taking an antianxiety and antidepressant. Review of physician orders revealed: - Xanax Oral Tablet 0.25 Milligrams (MG) (Alprazolam) *Controlled Drug* Give 1 tablet by mouth every 12 hours as needed for anxiety. - Buspirone HCl Oral Tablet 5 MG (Buspirone HCl) Give 1 tablet by mouth one time a day for Anxiety. - Venlafaxine HCl Oral Tablet 75 MG (Venlafaxine HCl) Give 1 tablet by mouth one time a day for Depression. Review of care plan dated 07/25/24 revealed: - A focus of takes Buspar and Xanax for episodes of increased anxiousness R/T [related to] hyper focus on health conditions. Interventions included Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness. - A focus of takes Effexor daily for depression. Interventions included Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Review of a psychologist note dated 08/22/24 objective section revealed: Resident presents at mostly alert and oriented. She does become easily preoccupied at times and appears anxious. She admits to some ongoing occasional depression. The anxiety seems to be more prevalent, however. Discussed need for treatment and is agreeable. With a plan to add Xanax .25mg twice daily as needed. On 9/05/2024 at 2:48 p.m., an interview was conducted with the Social Services Director (SSD)/ Admissions Director (AD). The SSD stated he was responsible for the initial process of new admissions regarding the PASRR. The SSD stated he would review the PASRR prior to the new admission for accuracy. If there was a discrepancy, the SSD stated he would have the outside agency correct the concerns prior to the resident's admission into the facility. He stated he did not review current residents after their admission. He stated the Director of Nursing would review residents to update their PASRRs if needed. The SSD agreed Resident #5's PASRR was incorrect, it should have had the mental illness of anxiety and major depression marked on page 2 of the PASRR. He agreed Resident #6's PASRR was incorrect, it should have had the mental illness of schizophrenia marked. The SSD agreed Resident #1's PASRR was incorrect, is should have had the mental illness of depression marked. He agreed Resident #1 was having issues with anxiety and stated he was aware of her medication of Xanax. The SSD agreed Resident #8 PASRR was incorrect and should have been corrected at the time of admission or redone another PASRR. He stated weekly meetings were conducted with the Nursing Home Administrator (NHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), MDS coordinator, SSD, the Rehab Director, and Medical Records to discuss all residents. On 9/05/2024 at 3:15 p.m., an interview was conducted with the DON. The DON stated the SSD/AD was responsible for the PASRRs for all new admissions. The DON stated he did not review residents currently residing in the facility for updates to their PASRRs. Review of facility PASRR Policy with an implementation date of 07/25/20222 revealed: It is the policy of the facility to assure that all residents admitted to the facility receive a Preadmission Screening and Resident Review, in accordance with State and Federal Regulations. 48441 49497

Based on observation, interview, and record review, the facility failed to 1. ensure oxygen administration orders were followed for two (#239, #2) of seven residents who received oxygen therapy. Findings included: 1. A review of Resident #239's Admission Record revealed he was admitted to the facility on [DATE] with diagnoses to include pneumonia and chronic obstructive pulmonary disease. A Review of Resident #239's physician's orders dated 08/20/2024 revealed Oxygen at 2 L/min (liters/minute) via NASAL CANNULA PRN (as needed) to keep O2 (oxygen) sat (saturation) greater than 90% every shift for SOB (shortness of breath). On 09/03/2024 at 9:38 a.m., Resident #239 was observed lying in bed with a nasal cannula in use. The oxygen concentrator was on the ground to the right of the bed and was set at 3 liters. On 09/04/2024 at 9:53 a.m., Resident #239 was observed lying in bed sleeping with a nasal cannula in use. The oxygen concentrator was set at 3 liters. On 09/04/2024 at 12:20 p.m., Resident #239 was observed sitting in a wheelchair in his room with a nasal cannula in use. The oxygen concentrator was set at 3 liters. During an interview on 09/04/2024 at 3:47 p.m., Staff C, Registered Nurse (RN) stated she was currently assigned to the resident. She was not sure what the resident's oxygen orders were and would have to check. She was responsible for checking the resident's oxygen saturation and ensuring the orders were followed. On 09/05/2024 at 9:05 a.m., Resident #239 was observed lying in bed with a nasal cannula in use. The oxygen concentrator was set at 3 liters. During an interview on 09/05/2024 at 10:39 a.m., the Director of Nursing (DON) stated nurses should know the resident's orders and know if the resident was on the correct liters and have the correct delivery method. [NAME], [NAME] A. 2. A review of Resident #2's Admission Record showed an original admitted [DATE] with a readmission of 3/18/2024. Diagnoses included but were not limited to acute diastolic congestive heart failure, chronic obstructive pulmonary disease with acute exacerbation, atherosclerotic heart disease of native coronary artery without angina pectoris and other asthma. On 9/03/2024 at 9:30 a.m., an observation was made of Resident #2 in his room asleep with a nasal cannula appropriately placed connected to an oxygen concentrator set at 3.5 liters per minute (LPM) of oxygen. On 9/04/2024 at 11:45 a.m., an observation was made of Resident #2 in his room asleep with a nasal cannula appropriately placed connected to an oxygen concentrator set at 3.5 LPM of oxygen. On 9/05/2024 at 1:10 p.m., an observation was made of Resident #2 in his room asleep with an oxygen concentrator set at 3 LPM of oxygen. A review of Resident #2's physician orders showed an order dated 3/19/2024 for oxygen at 2 LPM via nasal cannula as needed to maintain oxygen saturations above 92% every 24 hours as needed for shortness of breath (SOB) related to acute diastolic congestive heart failure. A physician order dated 9/05/2024 showed to check oxygen saturation every shift and as needed (prn) to maintain oxygen saturation greater or equal to 92%. A review of Resident #2's Minimum Data Set (MDS) dated [DATE] under Section O-Special Treatments, Procedures, and Programs for respiratory treatments had oxygen therapy checked. In the MDS under Section C- Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) of 3 which indicated severe cognitive impairment. A review the medical record for Resident #2's oxygen saturation documentation under vital signs showed an entry dated 9/02/2024 of 96% on room air. The next documented entry for oxygen saturation had an entry date of 8/02/2024 of 96% on room air. [Photographic evidence obtained] A review of the facility's policy titled Oxygen Administration, dated 07/02/2022/revised 1/2024 revealed: Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.

Based on observation, interview, and record review the facility failed to implement the comprehensive care plan related to hearing for one resident (#15) of one resident sampled for hearing. Findings included: An interview was attempted with Resident #15 on 02/28/2022 at 10:42 a.m. Resident #15 was making the bed and when asked questions she continually stated she did not understand due to hearing issues. The resident stated she did not have hearing aids. A review of Resident #15's Admission Record revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #15's care plan, initiated on 1/13/2020, revealed a communication deficit related to hearing loss and [CONDITION(S)] in the right ear. This focus area had a target date of 03/30/2022. Interventions for this deficit included ensuring availability of adaptive communication equipment and ensuring a left hearing aid was in place. A review of Resident #15's Quarterly Minimum Data Set (MDS), dated [DATE], revealed in Section C - Cognitive Patterns the resident had a Brief Interview for Mental Status score of 14. A score of 14 indicated the resident had intact cognition without signs of disorganized thinking. Further review of the MDS revealed in Section B - Hearing, Speech, and Vision the resident used a hearing aid. An interview with Resident #15's Responsible Party confirmed the resident was hard of hearing and never had hearing aids . she never got them. Interviews conducted with Staff A, Certified Nursing Assistant on 03/01/2022 at 10:40 a.m., and Staff B, Registered Nurse on 03/01/2022 at 10:55 a.m. confirmed the resident was extremely hard of hearing, however, neither direct staff member were aware of any hearing aids belonging to Resident #15. An interview on 03/01/2022 at 11:01 a.m. with the Social Services Director (SSD) revealed Resident #15 never had hearing aids and confirmed both the resident's care plan and MDS indicated the resident had hearing aids. The SSD was unsure how the care plan was created and the MDS indicating the resident had hearing aids when she never did. On 03/01/2022 at 11:27 a.m. the Director of Nursing (DON) stated the MDS and the care plan had incorrect information. The DON stated she contacted the Responsible Party who did not think Resident #15 would benefit from hearing aids due to her age and memory. However, the resident can voice her wants and when asked, the resident stated she was willing to participate in a hearing assessment to verify if she would benefit from hearing aids. Resident #15 was added to the hearing evaluation list. A policy review of Hearing and Vision Services, implemented on 10/15/2021, revealed, It is the policy of this facility to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities. The facility, if necessary will assist the resident in making appointments and arranging transportation to and from the office of a practitioner . Assistive devices to maintain hearing include hearing aides and amplifiers. A policy review of Comprehensive Care Plans, revised on 10/15/2021, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a residence medical, nursing, and mental and psychosocial meats that are identified in the resident's comprehensive assessment . 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed . 3. A comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the residence highest practical physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the residents exercising her right to refuse treatment 5. The comprehensive care plan will include measurable objectives and timeframes to meet the residents needs as identified in the residence comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on observation, interview and record review, the facility did not ensure the medication error rate was less than 5.00%. A total of twenty-six medications were observed administered, and four errors were identified for three residents (#14, #25 and #28) of six residents observed. These errors constituted a medication error rate of 15.38%. Findings included: On 02/28/2022 at 10:11 a.m., an observation of medication administration with Staff C, Registered Nurse (RN) was conducted with Resident #25. Staff C, RN was observed administering the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Aerosol Powder Breath Activated 200-62.5-25 MCG/INH (microgram/inhaled) 1 puff inhale orally one time day, Aspirin Tablet Give 81MG (milligram) orally, Multivitamin Adult Tablet orally, [MEDICATION(S)] Tablet 150 MG orally. A review of the March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Aerosol Powder Breath Activated 200-62.5-25 MCG/INH 1 puff inhale orally one time day for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An immediate interview with Staff C, RN was conducted and she confirmed she administered the [MEDICATION(S)] Aerosol medication first, then the other medications, and Resident #25 did not rinse his mouth after the aerosol medication was administered. A review of facility policy titled, Specific Medication Administration Procedures, Dated April 2018, Page 125, under Metered Dose and Dry Powder Inhalers revealed: Q. For steroid inhalers, provide resident with cup of water and instruct him/her to rinse mouth and spit water back into cup. On 02/28/2022 at 10:40 a.m., an observation of medication administration with Staff C, RN was conducted with Resident #14. Staff C, RN was observed administering the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] Aspirin Tablet Chewable 81MG orally, [MEDICATION(S)] HCL Tablet 100MG orally, Senna [MEDICATION(S)] Sodium Tablet 8.6-50MG, [MEDICATION(S)] tablet 50 MCG orally, [MEDICATION(S)] HCL Tablet 50 MG orally, [MEDICATION(S)] Patch ([MEDICATION(S)]) Applied to each knee, Chocolate Boost (237ml [milliliters]). A review of the March 2022 MAR for Resident #14 revealed the above medications were scheduled to be administered at 9:00 a.m., and the resident had a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An immediate interview was conducted with Staff C, RN, who confirmed the above medications were scheduled to be administered at 9:00 a.m. Staff C also revealed she did not have Med Pass 2.0 and had to substitute it for Boost during medication administration. She was asked if the facility and physician or dietician was aware of the substitution and she stated, I have to tell them. On 02/28/2022 at 11:05 a.m. an observation was conducted on Staff D's, Licensed Practical Nurse(LPN) medication cart, which had Med Pass 2.0 on it, in a container on ice. Staff D, LPN confirmed the Med Pass 2.0 on the cart and revealed it is located in the supply room. On 02/28/2022 at 11:00 a.m., an observation of medication administration for Resident #28 was conducted with Staff D, LPN. Staff D, LPN was observed administering the following medication: [MEDICATION(S)] Pen Fill Solution Cartridge 100Unit/ML (Insulin [MEDICATION(S)]) of five units for Blood sugar of 215, on a sliding scale of 201-250=5 units. Staff D, LPN was seen to dial five units into the flex pen and administer the insulin in Resident #28's left upper arm. Staff D, LPN did not prime the pen prior to administering the medication. An immediate interview was conducted with Staff D, LPN after administration of the insulin, related to not priming the pen and she stated, I didn't realize that that was something that needed to be done before you use it. A review of the March 2022 MAR for Resident #28 revealed [MEDICATION(S)] Pen Fill Solution Cartridge 100Unit/ML (Insulin [MEDICATION(S)]) inject per sliding scale of 201-250=5 units. Review of (Vendor Name) Pharmacy Policy titled, Insulin Pen Administration, with Manufacturer Instructions from Novo [MEDICATION(S)] revealed: Priming Your Pen-Must Prime before each injection! Step 5: Priming the pen means removing air from the Needle and Cartridge that may collect during normal use and ensures that the pen is working correctly. -If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your pen, turn the Dose Knob to select 2 units. Step 7: Hold your pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles art the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. An interview with the Director of Nursing (DON) was conducted on 02/28/2022 at 11:50 a.m., and she indicated it was her expectation that nursing staff prime Flex Pens per facility policy prior to the administration of insulin. She further revealed medications should not be given late at any time, and she was going to call the physician herself to inform him, and see if he wanted to give new orders considering they were late. The DON further indicated it is not standard practice for a nurse not to follow physician orders, and substitute a supplement for another supplement, and she was unaware that Staff C, RN did this. She stated, The facility has Med Pass 2.0 in stock. The DON asked the Nursing Home Administrator (NHA) at this time to replace it on Staff C's, medication cart. The DON stated, This is a medication error. On 03/01/2022 at 11:18 a.m., a telephone interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant was informed of the observations made of Staff C, RN and Staff D, LPN, and revealed it is standard nursing practice to prime the pen first, prior to administering insulin to a resident. He further indicated that nursing staff must follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Pharmacy Consultant said all corticosteroid inhalers have instructions for the resident to rinse and spit out afterwards and nursing staff should follow the pharmacy label directions placed on each medication prior to and during medication administration. During a subsequent interview with the Pharmacy Consultant, on 03/02/2022 at 9:25 a.m., he indicated his expectation was 9:00 a.m. medications are given on time and that 10:40 a.m. is a late administration and not within the scope of facility policy. A review of a facility policy titled, Preparation and General Guidelines, dated April 2018, revealed: B. Administration 2. Medications are administered in accordance with written orders of the prescriber. 12. Medications are administered within (60 minutes) of scheduled times. Unless otherwise specified by the prescriber, routine medications are administered according to established medication administration schedule for the facility.

Based on observations, resident record review and staff/resident interviews, the facility failed to honor/maintain residents in a respectful manner for 3 (#31, #19, and #99) related to: 1. Resident #31 observed four of four days (3/2/20 - 3/4/20) wearing a bright yellow wrist band that identified as Fall Risk; 2. Staff observed speaking to Resident #19 in a manner of non-caring and disinterest; 3. Staff observed referring to Resident #99 as Feeder during tray pass; 4. Staff not knocking/announcing prior to entering resident rooms four of four days observed (3/2/20 - 3/5/20); and 5. Staff not wearing name badges routinely in order to identify the staff member to residents providing care/services. Findings included: 1. On 3/2/2020 at 10:00 a.m., 3/3/2020 at 7:45 a.m., 1:00 p.m., 3/4/2020 at 7:30 a.m., 8:30 a.m. Resident #31 was observed in different areas of the facility to include her room, the hallways, the dining room and activity room, seated in her wheelchair. Further observations revealed her left arm/wrist area was observed with a bright yellow plastic band that read in bold black letters, FALL RISK. On 3/4/2020 at 8:30 a.m., Resident #31 was asked about the band and she pointed at it and said she did not know, but stated, I have had since hospital. She was asked how long has that been. She replied, A long time ago. She was asked if the band is something she likes to wear, and she shook her head No, and made a frown face. On 3/5/2020 at 7:40 a.m., Resident #31 was observed seated in a wheelchair in the main dining room at a table with two other residents. She was dressed for the day and well groomed and awaiting her breakfast meal. She was still noted with a bright yellow plastic bracelet that read, FALL RISK. Review of Resident #31's medical record revealed she was admitted to the facility on [DATE] and readmitted from the hospital on [DATE]. Review of the most current MDS (Minimum Data Set) assessment (Annual) and dated 1/26/2020 revealed: (Cognition/BIMS Brief Interview Mental Status score 4 of 15, which is low cognition). On 3/5/2020 at 1:45 p.m., during an interview with the Social Service Director, the staff member could not provide a reason as to why Resident #31 was wearing a Fall Risk wrist band, and did not know if this was an intervention that the facility takes to identify a risk. On 3/5/2020 at 3:00 p.m. an interview with the Director of Nursing revealed she was not aware of why Resident #31 was wearing a bracelet on her Left wrist that identified Fall Risk. She further indicated that this was not an intervention the facility puts in place for residents who are at risk for falls. She further added that this wrist band came from the hospital and confirmed the resident has been back from the hospital for about six months. She confirmed that Resident #31 should not have a wrist band on with indicators of fall risk. 2. On 3/2/2020 at 10:15 a.m. Resident #19, who was noted in his room, was overheard yelling aloud and stated I need a cup of coffee, hello, and I need my [MEDICAL CONDITION] bag changed, it smells. He said hello aloud several more times and with his call light on. At 10:16 a.m. an aide, Employee A., who had no identification badge on, was observed to walk down the hall to the room and walked directly in without first knocking and or announcing. She went into the room and was overheard telling the resident, I'm still busy, I will be back when I can. She did not turn off the call light. The aide then walked briskly out from the room. The call light was observed still on. At 10:21 a.m. he was yelling aloud, again, for someone to come in. The Director of Nursing was observed to answer the light at 10:23 a.m. and assisted resident. Then again at 10:50 a.m., Employee A walked into the room, again without first knocking and announcing, and was overheard telling the resident, Look, I told you I am busy and I will get to you when I get to you . got it? Employee A was observed to walk out from Resident #19's room and went down the hall. At 12:00 p.m. Resident #19 was interviewed and he was asked how staff treat him. He explained that staff were generally ok. This surveyor then asked him about Employee A and how she spoke with him earlier. He said he did not like it and he did not know her very well. He further indicated he had not reported her to staff yet. Review of Resident #19's medical record found he was admitted to the facility for rehab services on 12/16/2020 and was now long term. He was his own responsible party with family involvement. Review of the most current MDS assessment revealed (Cognition/BIMS Brief Interview Mental Status) score was 10 of 15, which indicated the resident was able to make his needs known. On 3/5/2020 at 2:00 p.m., an interview with the Director of Nursing and Nursing Home Administrator both indicated that staff should not be speaking to residents in that type of manner. It was explained that Employee A was agency staff, but still she should know better than speaking to residents so rudely. 3. On 3/4/2020 at 8:12 a.m. the hallway at the Main Dining room was observed with a meal tray cart and with staff gathered around the cart and conversing loudly with each other. They were all trying to figure out where each meal tray goes. Staff members Employee I, J, and K were all overheard each saying Resident #99 is a Feeder, and is a Feed. There were several residents within earshot of the area and all three staff members were overheard loudly saying She is a Feeder. The employees were overheard saying Feeder over four times between them. On 3/5/2020, review of Resident #99's medical record revealed she was admitted to the facility for rehab services on 3/3/2020. Review of the advance directives revealed the resident had a Power of Attorney in place. Resident #99 had had a previous admission and during that time the last MDS assessment completed 11/1/2019 (Discharge) revealed (Cognition/BIMS Brief Interview Mental Status score 3 of 15, low cognition function), (ADL - Eating supervision). Review of the admission evaluation/progress note dated 3/20/2020 21:35, revealed Resident not interviewable and family not available, dining preference in the dining room, eating assistance performed by staff. 4. a. On 3/2/2020 at 10:15 a.m., Employee A walked into resident room [ROOM NUMBER] without first knocking or announcing. She walked into the room as the call light was on and told Resident #223, You know I'm busy right now, and then walked out of the room, leaving the call light on. b. On 3/2/2020 at 10:25 a.m., Employee A walked into room [ROOM NUMBER], again, without first knocking or announcing. The resident was still in the room. c. On 3/2/2020 at 11:34 a.m., Employee B was observed to walk into resident room [ROOM NUMBER] without first knocking or announcing. The resident was in the room at the time. d. On 3/3/2020 at 7:24 a.m., Employee C was observed to walk into resident room [ROOM NUMBER] without first knocking or announcing. The resident was in the room at the time. e. On 3/3/2020 at 7:30 a.m., Employee D was observed to walk into resident room [ROOM NUMBER] without first knocking or announcing. The resident was in the room at the time. f. On 3/3/2020 at 10:45 a.m., Employee D was observed to walk into resident room [ROOM NUMBER] without first knocking or announcing. The resident was in the room at the time. g. On 3/4/2020 at 7:58 a.m., housekeeping staff Employees E and F were observed to walk into room [ROOM NUMBER] without first knocking and or announcing. A resident was in the room at the time. h. On 3/4/2020 at 8:04 a.m., Employees E and F were observed to walk into room [ROOM NUMBER] without first knocking and/or announcing. The resident was in the room at the time. i. On 3/4/2020 at 8:06 a.m., Employees E and F were observed to walk into room [ROOM NUMBER] without first knocking or announcing. A resident was in the room at the time. j. On 3/4/2020 at 8:08 a.m., Employees E and F were observed to walk into room [ROOM NUMBER] without first knocking and/or announcing. A resident was in the room at the time. k. On 3/4/2020 at 8:10 a.m., Employee D was observed to walk into room [ROOM NUMBER] without first knocking and announcing prior to entering. Resident was observed in the room at the time. On 3/2/2020 through 3/5/2020, over five random residents, who all wished to not be identified, revealed that staff always just walk into the room and rarely ever knock or announce. They would like their privacy and would like to have staff knock. Some residents indicated that this has been brought up to administration and things get better, but always gets bad again. The residents indicated that they do not bother to complain anymore. On 3/5/2020 at 2:00 p.m. an interview with the Nursing Home Administrator and Director of Nursing both indicated that all staff, to include regular and agency, should honor resident respect and dignity and should either knock or announce prior to entering the room. The DON revealed they do not have a specific policy for knocking and or announcing. 5. a. On 3/2/2020 at 10:15 a.m. an employee walked into resident room [ROOM NUMBER], and the resident had asked who she was. She did not answer and just told him that she will come back when she can. She was not wearing a name badge. It was later found out that Employee A, who is an agency aide, was the person who would not identify herself to the resident. b. On 3/2/2020 at 10:25 a.m., the aide Employee A was observed to walk down the hallway with a linen cart and parked it just outside resident room [ROOM NUMBER]. She then walked inside and shut the door. She did not call out or knock prior to entering the room. The resident was still observed in the room. The aide could be overheard talking to the resident and said, Look, you know I'm busy and I will get to that when I get to it. She was not wearing her name badge. c. On 3/3/2020 at 7:15 a.m., Employee H was observed to walk into room [ROOM NUMBER] without first knocking and/or announcing. She went into the room and closed the door at 7:22 a.m. She came out from the room with a bag of soiled linen. She was noted not to be wearing a name badge. When asked her name, she replied with her name and then indicated she did not have her name badge on. d. On 3/3/2020 at 7:23 a.m., 10:00 a.m. and 11:10 a.m., Employee G was observed going in and out from resident rooms. She had not been wearing a name badge. When verifying staffing, it was determined that the employee was Staff G. When asked, she had no reason as to why she was not wearing her name badge. e. On 3/4/2020 at 7:45 a.m., 11:03 a.m. a nurse was observed walking the hallway, preparing and passing medications and assisting with residents. She was noted not to be wearing a name badge. She was later found out to be Employee N. She was asked by the surveyor what her name was and what her position title was. She gave no word as to why she did not wear a name badge. She did say she was a facility nurse and is PRN or as need. On 3/5/2020 at 2:00 p.m., an interview with the Nursing Home Administrator and Director of Nursing indicated that all staff should wear name badges in order for residents to identify who they are. They further indicated that agency staff are aware of this as well. They had no documentation on how they monitor staff wearing or not wearing name badges. Further, there was no Policy or Procedure related to wearing of name badges.

Based on interview and record review of the Grievance Log, the facility failed to ensure that that a nursing/customer service concern was addressed in a timely manner for one (#98) out of thirty sampled residents. Findings Included: On 3/3/2020 at 12:40 p.m., a family interview was conducted with Resident #98's stepdaughter, as she spoke about the lack of care he had received at the facility. She stated call lights were not answered timely. And when a nurse came in the bedroom, she was told about a toileting concern. She shut the light off and said someone will return. Well, no one did. We had to put the call light back on. Another concern she spoke about was when her stepfather was given his medications. She said, I was there when she gave them to him. She stated the nurse gave him too many pills at a time. He began to cough and choke. The nurse never asked him his name to confirm it was him, nor did she tell him what the medications were. She was asked what the nurses name was she stated, I don't know; half of the staff don't wear name tags. She wasn't wearing one at that time. The stepdaughter spoke about his pain medications not being given when they were due. She said that On his last day at the facility, I went in to visit him and found him having severe pain to his leg. She said, That was when I requested him to be sent back out to the hospital. The stepdaughter was asked if she had told anyone at the facility of her concerns. She stated, I told the Minimum Data Set (MDS) guy. She said that no one had called her from the facility to follow up with her. Medical record review was conducted that revealed Resident #98 was admitted to the facility in early February 2020 for eight days before he was transferred back to the hospital for pain. History and Physical, dated on 2/14/2020, reflected [MEDICAL CONDITION] with an unwitnessed ground level fall (GLF) at home. X-ray of the femur showed mildly displaced greater trochanter fracture. Computerized tomography (CT) of the pelvis confirmed presence of traumatic fracture with intact femoral head. The facility Grievance Tracking Log was reviewed that revealed Resident #98's name. It was dated on 2/27/2020. Listed on the log was a section that indicated the date resolved. The resolved section was blank. The log section summary was documented nursing/customer service. On 3/4/2020 at 12:00 p.m., an interview was conducted with the facility social worker (SW) as he was asked about Resident #98's unresolved grievance. He said that his daughter had told our MDSC about her concerns. He filled out a grievance form and brought it to our attention. The SW was asked what the concern had entailed. He stated, She said the nurse didn't give the medications on time. When the nurse gave him his medications, she did not explain what the medications were. The SW said that she spoke about the call lights being answered by the nurse, the nurse shutting off the light indicating someone would be coming back, and no one came back. The SW continued to read off the grievance form that An aide told her we don't give one on one care. The SW at that time stated, We do provide one on one care if it's needed. The SW was asked if the form contained any additional information; he said when she came to visit him, he was found sitting in stool. The SW said apparently, he had just been brought back to his room after therapy. The SW was asked what the investigation had revealed thus far. He did not respond at first, as he was then asked, Was Resident #98's medication given late? The SW said, The resident is no longer in the facility. You would need to ask the Assistant Director of Nursing about that. The SW picked up his phone at that time and called the ADON. He said that there would be a call light in-service, but one had not been conducted as of yet. At 12:54 p.m., the ADON was in her office, as she confirmed no call light in-service had been conducted. She said I guess I will have to do everyone for the call lights. I guess I misunderstood that. The ADON was asked about the nurse that was in the grievance. She stated, I have not talked to any nursing as of yet. She then stated, I believe it was . then stated, No, it was from the evening before. The SW was asked for a copy of the facility policy on grievances. He was asked about the timeliness on the resolution process. He stated, It's supposed to be done within five to seven days. The SW confirmed that today is was the sixth day. The facility provided a copy of their policy and procedure Grievance Program that had no date. Purpose: Right to file Grievances: the right also includes the right to prompt efforts by the facility to resolve residents grievances, including grievances with respect to the behavior of other residents. Definition: a grievance is a concern that cannot be resolved to the satiation of the person making the objection at the bedside and or immediately. All facility grievance investigations will be initiated as soon as possible after the grievance is filed. Completed and timely followed up will be conducted by the department supervisor, the Grievance Officer and/or the Administrator.

Based on observations, record review and staff interviews, the facility failed to ensure the monitoring and safety for one of thirty sampled residents (#14), related to fall hazards. Resident #14 who was a Fall Risk, and had a history of [REDACTED]. Findings included: On 3/2/2020 at 11:00 a.m., Resident #14 was observed in her room and lying in bed with her legs hanging off the left side of the bed. Most of her lower body was hanging off the side of the bed. There were no floor mats on the floor, and she was observed dangerously hanging off the side of the bed and at risk to fall down. She was again observed in the same position at 1:20 p.m. Various staff had been observed to go in the room to assist the roommate, and none attempted to reposition Resident #14 as her legs were hanging off the side of the bed. On 3/3/2020 at 7:30 a.m., a CNA (Certified Nursing Assistant), Employee D, was observed to walk to Resident #14's room and entered and closed the door. The resident was in the room at the time and it was determined that the aide was assisting with getting her dressed for the day. There were no odors coming from the room. Resident #14 was not overheard presenting with any behaviors, pain or discomfort. At 9:30 a.m., Resident #14 was noted in her room. The bed was not made and covers were observed disheveled. After the room was entered further, Resident #14 was observed lying at the head of the bed flat on back, with head on a pillow and with her legs hanging off the left side of the bed. She was observed with her eyes closed. The bed side table next to her legs appeared to have liquid spilled all over it. There was some liquid puddled on the floor under the table. At 10:43 a.m., Resident #14's room was approached, again, and she was still observed in the same position with her legs hanging off the left side of the bed and her eyes closed. At 10:45 a.m. an aide, Employee D, went into the room and walked in without knocking or announcing. She walked over to Resident #14's roommate's bed and changed the sheets. She pulled the privacy curtain and continued to make up the roommate's bed. Employee D did not first try and attempt to reposition Resident #14, while hanging dangerously off the side of the bed. At 10:46 a.m. a Nurse, Employee O, was observed to walk up to the room and asked the aide if she had seen another staff member. Employee O also did not attempt to observe or reposition the Resident #14 while her legs still hanging off the side of the left side of the bed. Resident #14 could be seen from this position at the doorway. Neither staff member attempted to address the positioning of the resident. At 10:50 a.m. the aide, Employee D, was finished making Resident #14's roommate's bed and then walked over to Resident #14 and awoke her and asked if she wanted to get back into bed. The resident awoke and Employee D lifted her legs gently back straight and into the bed. An interview with the aide, Employee D, indicated that both residents in the room were on her assignment today, but today was the first day she has had this assignment. She was unaware if Resident #14 has had falls in the past and was also unaware if Resident #14 was at risk for falls. Employee D was unaware if there were any fall risk interventions at this point as she has never worked with the resident before. She was asked if she noticed the resident in that previous position with her legs hanging off the side, and she said she had noticed earlier today but did not think anything of it. She was asked if she reported the positioning or behavior to the nurse and she said she had not. Employee D indicated that she would, though. Review of Resident #14's medical record revealed she was admitted to the facility for long term care on 12/21/2019. Review of the Advance Directives revealed resident had a Power of Attorney in place. Review of the cumulative [DIAGNOSES REDACTED]. The Fall scale assessment dated [DATE] revealed a score of 19, which was moderate risk. The Post Fall safety risk evaluation dated 12/25/2019 revealed a score of 12, which was moderate risk. The Post Fall safety risk evaluation dated 1/4/2020 revealed a score of 14, which was moderate risk. The Post Fall safety risk evaluation dated 1/30/2020, revealed a score of 14, which was moderate risk. Review of the SBAR Change of condition dated 3/2/2020, revealed Resident #14 had a Ground level fall, hitting her head and complaining of right leg pain The Fall screen evaluation, dated 3/2/2020, revealed a score of 12, indicating low risk. Review of the following nurse progress notes, dated, revealed: - 12/22/2019 06:13 - Writer summoned to resident's room by CNA. Upon entering, resident observed in a sitting position by her bed. Writer asked what happened. Resident states, I fell stupid for not using the thing to call for help and Lost my balance when coming back to the bathroom. Resident denies hitting head and no apparent injury noted. Resident assisted back to bed and resident promised to use the call light from now on. Message left with emergency person. - 1/4/2020 19:26 - Resident noted kneeling on knees at bedside. Call light on. Resident tried to self transfer to get in w/c. No injuries noted. Denies having to use to the toilet. Denies hitting head. Will continue with plan of care. MD and rep notified. (IDT 1/6/2020 Reviewed resident found kneeling next to bed. On therapy caseload. RP and MD notified. Resident educated on using call light when needing help). - 1/23/2020 - 04:32 CNA noted resident sitting on floor by doorway in 230. - 1/29/2020 - 00:19 - Resident observed on floor outside of bathroom door in resident's room. Resident states she walked to the bathroom by herself and on her way back to bed, she became unsteady and fell on her buttocks. Educated resident on safety awareness. Resident to request help from staff with all transfers. - 3/2/2020 - 22:47 - CNA approached writer and stated that resident was on the floor. Writer entered room and observed resident sitting on the floor next to bed, when writer asked what happened she stated she rolled out of bed and hit her head on the floor and was complaining of head pain and right lower extremity pain. Resident vitals taken. Call placed to MD. Orders to go to the hospital for treatment and eval. Call placed to daughter. - 3/2/2020 01:45 - Resident returned from Hospital. It was determined per review of the fall incident log/report, and nurse progress notes, Resident #14 had four incidents out of six since 12/22/2019 where she was found on floor next to her bed. Review of the current care plans with next review of 4/22/2020, revealed Resident #14 had problem areas to include Falls/Fall risk. The care plan had interventions in place but nothing related to bed safety positioning. It was determined only after the State surveyor identified several observations of resident being unsafe in bed, did they add new interventions related to bed safety, which was on 3/3/2020. The annual survey inspection was from 3/2/2020 through to 3/5/2020. Review of the Nurse Aide Information sheet Kardex book, which is kept at the nurse station, revealed a section for Resident #14. The information sheet had various indicators of care for the resident. In the comments section, revealed, Fall Risk. There was no other information as to what interventions needed to be in place related to Fall Risk. On 3/4/2020 at 10:30 a.m., a second interview with the aide (Employee D) was obtained. The aide indicated that she should have read the Kardex yesterday (3/3/2020) with regards to resident #14. She indicated that she did not receive any information from other staff about her and her irregular positioning while in bed and she should have read the Kardex to identify if resident was a Fall Risk. The aide was asked if there was any information in the Kardex that specified what to do in relation to Fall Risk. Employee D did not have an answer as to what to do intervention wise. She was also unaware Resident #14 just had a recent fall on 3/2/2020. In an interview on 3/3/2020 at 1:00 p.m., the DON (Director of Nursing) explained that they do have many agency staff that work in the facility, and they and regular staff are to always look and review the resident Kardex to see what is needed, assistance wise, and that includes with falls. She explained that on Resident #14's Kardex, it only indicated Fall Risk. She was asked how staff identify or determine what to do when there is only indication of Fall Risk. The DON indicated that staff should know what to do. There was no written information to show what know what to do meant. The DON also confirmed that Employee D, though regular staff, was new to the assignment to care for Resident #14. The DON confirmed that Employee D and Nurse Employee O should have repositioned Resident #14 when they entered the room on 3/2/2020 and 3/3/2020. The DON further confirmed that Resident #14 had a fall from her bed later in the evening on 3/2/2020 and staff should have better monitored her and repositioned her on 3/3/2020, when she was hanging off the side of the bed. Review of the facility's Fall Prevention Program, dated 1/2019, revealed that Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. Under Policy Explanation and Compliance Guidelines section, #5 revealed, Low/Moderate Risk Protocols, (a) Implement universal environmental interventions that decrease the risk of resident falling, including but not limited to: (ii) Bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. There were no details in the policy that included what the aides are responsible under Fall Risk precautions. Further, review of the Kardex only indicated resident was at Fall Risk, it did not indicate if resident was low, moderate, or high risk. It was determined that Employee D would not have known what type of risk Resident #14 was prior, during and after her fall.

Based on observation, interview and medical record review, the facility did not ensure that the medication error rate was below 5 % for one (# 43) of 4 sampled residents who were administered medications. This resulted in 4 errors from 25 medication administration opportunities, for a medication error rate of 16%. Findings Included: On 3/2/2020 at 10:24 a.m., a medication administration was conducted with Licensed Practical Nurse Q (LPN Q). She stated, Today was the first day I have ever worked at the facility. The electronic medication administration (EMR) was red in color as LPN Q confirmed the medications were late. She was asked if any of the facility licensed staff had asked if she needed assistance; she looked at the surveyor and shook her head in the no gesture. LPN Q went on to say that she started the medication pass late. As she stated, The night nurse gave me a verbal report that was an hour in length. At 10:25 a.m., the unit manager on the 200 unit approached the medication cart and was observed looking at the EMR. She said that she would start getting vital signs from the residents for her. She then asked the LPN if she needed anything at that time. The LPN told her there had been a medication she could not find in the cart. The unit manager said she would get it from the storage room. LPN Q began preparing medications for Resident #43 that consisted of a total of ten medications. Resident #43 was given her medications at 11:00 a.m. The LPN had also indicated at that time Residents #5, 22 and 24 had not yet received their scheduled morning medications. Medication reconciliation was conducted for Resident #43 that revealed four of the ten Physician ordered medications were scheduled to be administered more than one time a day: [MEDICATION NAME] 25-100 mg 1 tablet by mouth every 4 hours for parkinsonism every 4 hours for 6 doses while awake that was dated on 3/2/2020, a.m. Eliquis tablet (apixaban) give 5 mg by mouth two times a day for A-fib dated on 3/2/2020. [MEDICATION NAME] HCL tablet 10 mg give 1 tablet By mouth two times a day [MEDICAL CONDITION] for SBP under 110, dated on 3/2/2020, and memantine HCI tablet 10 mg give one tablet by mouth every 12 hours for dementia, dated on 3/2/2020. Nursing Progress notes for Resident #43 did not indicate that the Physician had been notified of the late administration of the medications until 3/5/2020. The facility provided a copy of their policy titled Medication Administration - General Guidelines that contained a revision dated on January 2018. Policy: Medications are administered as prescribed in accordance with good nursing principles and practices. The facility has sufficient staff and medication disproportion system to ensure safe administration of medications without unnecessary interruptions. FIVE RIGHTS- right resident, right drug, right dose, right route mand right time are applied for each medication being administered.

Based on observations, interviews, medical record review and contact precautions, the facility failed to ensure that contact precautions were utilized as posted for two (#40 & #29) of two residents who were on contact precautions. Findings Included: 1. On 03/02/20 09:51 a.m., Resident #40 was lying in his bed with his eyes closed. Home Health Aide (HHA M) was sitting in a chair at his bedside. HHA M was asked why she was wearing a gown and gloves. She said she was told she needed to wear them when she was in the room. The HHA spoke about being at the facility three days a week for twelve hours each day. She said the resident was confused and attempted to get out of bed unassisted. Outside of the doorway entrance, personal protective equipment (PPE) hung on the door, along with a posted sign that read Contact Precautions. Visitors must report to nursing station before entering. Wear gloves when entering room or cubicle, and when touching patients' intact skin, surfaces or articles in close proximity. Wear gown when entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces. Medical record review was conducted for Resident #40 that revealed Physician orders [REDACTED]. Contact precautions:[MEDICAL CONDITION]/wound gown/gloves when providing care every shift [MEDICAL CONDITION], until 3/8/2020, dated on 3/5/2020, and [MEDICATION NAME] HCL capsule 300 mg give 1 capsule by mouth two times a day [MEDICAL CONDITION] for 10 days, dated on 2/25/2020. On 03/03/20 at 12:51 p.m. a Home Health Aide L (HHA L) was in Resident #40's bedroom as he was observed sitting up in his wheelchair. She indicated that she cares for the resident during 12-hour shifts. HHA L was standing next to the resident on her personal cell phone. As she leaned toward him, her clothing came in contact with the over bedside table that was sitting in front of him. The HHA was not wearing a gown or gloves. She was asked about the sign that was posted on the bedroom door, along with the PPE that was present. She stated, one of the aides told me I only needed to wear it when I'm providing care to him. HHA L did not recall which of the aides had told her this. Resident #40's left lower extremity contained a white gauze dressing that was clean, dry and in place. Resident #40 was pleasantly confused as he tried to propel his wheelchair with the locks in place. He verbalized his name when asked as cognitive deficit was noted. Resident #40's roommate was noted, along with his wife, entering and exiting the bedroom throughout the day. No PPE was utilized by the family as they walked past Resident #40 each time they exited and entered the shared bedroom. At 3:15 p.m. the roommate of Resident #40's wife was overheard in the hallway asking for staff to lay her spouse in bed. Two staff members stood in front of the doorway entrance and were overheard talking if they needed to wear the PPE to cross the room with the mechanical lift. They decided not to as they both walked past the first bed, where Resident #40 laid, to his roommate. The curtain divider was noted moving after being contacted with the staff members frequently during the mechanical transfer. On 03/03/2020 at 3:45 pm an interview was conducted with the Assistant Director of Nursing (ADON). She was asked about staff and family's entering resident bedroom and not utilizing the PPE. As the sign that was posted indicated, the room was on contact precautions. The ADON stated the staff don't have to wear the PPE if they're not providing care. [MEDICAL CONDITION] is in his leg and that is wrapped. She was asked if his roommate was being also treated for [REDACTED]. She didn't respond. On 03/04/20 at 10:00 a.m. Resident #40's roommate was no longer in the bedroom, as all of his belongings were no longer present. At 11:00 a.m. Registered Nurse N stated that she was ready to perform Resident #40's dressing change to his left lower leg. As she stood outside of the resident bedroom door, she was unable to reach a gown that that hung off the door. She stated out loud, The bag is causing the door to stick and I don't want to cross the threshold of the room without a gown. After a gown and gloves were donned the room was entered as a different HHA was in the room, sitting in a chair on the resident's right side of the bed. The resident at that time was attempting to get out of the bed. As he did this, he utilized his left leg where the kerlix dressing was located. The dressing was noted to be moving in an upward motion, and not securely in place. The HHA at that time stood up from the chair and walked around the bed to the left side stating, You have to wait for your treatment before you can get up. The HHA was wearing a gown, gloves and a face mask. She was asked at that time about the PPE she was wearing. She said when she came in this morning, she asked a nurse after she saw the sign posted about contact precautions. She stated, The nurse just looked at me and did not answer. During the observation of the wound care treatment, the old dressing was observed. The old dressing was noted containing a moderate amount of yellow and red drainage. On 3/4/2020 at 10:41 a.m. an interview was conducted with the facility Vice President of Clinical Services. She was asked about the facility current contact precautions, as signs were no longer in place as they had been. She said that it would make sense to separate the residents, indicating both Residents #40 and Resident # 29, and reinforce precautions on both residents' beds. The vice present went on to say they need to relook at cohorting guidance. The DON indicated at that time there weren't open beds to put them in. She was informed that there were two rooms on that unit that were empty when the facility was entered. She said they had just discharged . On 03/05/20 at 1:33 p.m., Resident #40's bedroom door was noted without Contact Precautions. A different sign was in place, stating to see nurse prior to entry. HHA Was noted in the bedroom with no gown in place as she was sitting at the resident bedside on her phone. Based on the current evidence, the CDC continues to recommend the use of Contact Precautions [MEDICAL CONDITION]-colonized or infected patients. CDC will continue to evaluate the evidence on Contact Precautions as it becomes available. In addition, CDC continues to work with partners to identify and evaluate other measures to decrease transmission of MDROs in healthcare settings. JAN2020, https://www.cdc.gov/mrsa/healthcare/inpatient.html To [MEDICAL CONDITION] infections, doctors, nurses, and other healthcare providers: o Clean their hands with soap and water or an alcohol-based hand rub before and after caring for every patient. o Carefully clean hospital rooms and medical equipment. o Use Contact Precautions when caring for patients [MEDICAL CONDITION]. Contact Precautions mean: o Whenever possible, patients [MEDICAL CONDITION] will have a single room or will share a room only with someone else who also [MEDICAL CONDITION]. o Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients [MEDICAL CONDITION]. o Visitors may also be asked to wear a gown and gloves. o When leaving the room, hospital providers and visitors remove their gown and gloves and clean their hands. https://www.cdc.gov/mrsa/pdf/SHEA-mrsa_largertext.pdf Contact Precautions Ensure appropriate patient placement in a single patient space or room if available in acute care hospitals. In long-term and other residential settings, make room placement decisions balancing risks to other patients. In ambulatory settings, place patients requiring contact precautions in an exam room or cubicle as soon as possible. Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. https://www.cdc.gov/infectioncontrol/basics/transmission-based precautions. 2. On 03/02/20 at 2:11 p.m., the door to Resident #29's room was observed to have a caddy on the door that held personal protective equipment (PPE) and a sign that revealed contact precautions. The sign indicated to perform hand hygiene before entering and before leaving the room, wear gloves when entering room or cubicle, and when touching patient's intact skin, surfaces, or articles in close proximity, wear gown when entering room or cubicle and whenever anticipating that clothing will touch patients items or potentially contaminated environmental surfaces, and use patient dedicated or single use disposable shared equipment or clean and disinfect shared equipment (BP cuff, thermometers) between patients. This room was not on contact isolation earlier that day. Staff Q, Licensed Practical Nurse (LPN), was observed in the room near bed B and was not wearing PPE. On 03/02/20 at 2:12 p.m., Staff Q, LPN, exited the room and she stated she did not know who was on contact isolation because the PPE was not there this morning. Staff Q stated that she would find out. On 03/02/20 at 2:15 p.m., Staff Q stated that she guessed the PPE was for A bed. She stated that when she pulled up his name, an order for [REDACTED].>A record review of the Admission Record revealed that Resident #29 was initially admitted into the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. A review of the Order Review Report revealed that the resident had the following current order: Contact isolation- ESBL/urine every shift until 03/09/20. A progress note dated 03/02/20 revealed that a new order was received to start contact isolation for ESBL in urine. A review of the labs, dated 03/01/20, revealed that the resident had ESBL in the urine, but the order for contact isolation was not received until 03/02/20. On 03/03/20 at 1:45 p.m., the Director of Nursing (DON) reported that contact isolation was communicated to the staff through 24 hour report, nurse to nurse report, and huddles which was the report for all staff. The DON stated that she would verbally tell the nurses or leave them a copy of the telephone order. The DON stated that she was in the process of putting the orders in, therefore Staff Q was unaware of the contact isolation. On 03/03/20 at 2:02 p.m., the DON reported that staff wears PPE depending on the type of organism. If Bed A was on contact isolation and staff was not caring for Bed A, staff would not have to wear PPE.

Based on observations, record review and staff interview, the facility failed to ensure residents were treated in a dignified manner related to staff did not knock or announce themselves prior to entering occupied resident rooms during two of three days observed (12/2/18 and 12/3/18), and a staff member stood up and behind one resident (#4) of 19 sampled residents, while feeding the resident in the restorative dining room. Findings included: The following observations were made of staff not knocking, or announcing prior to going into occupied resident rooms and a staff member stood while assisting Resident #4 with feeding in the restorative dining room: 1. On 12/2/18 at 12:55 p.m. Staff A, Certified Nursing Assistant (CNA) was observed to walk up to Resident room [ROOM NUMBER] and walked in without first knocking or announcing herself. There was one resident in the room at the time. 2. On 12/3/18 at 7:45 a.m. Staff A, CNA was observed to walk down the hall from the nurse station and walked right into Resident room [ROOM NUMBER] without first knocking or announcing herself. There was a resident in the room at the time. 3. On 12/3/18 at 7:47 a.m. Staff A, CNA was observed to walk from Resident room [ROOM NUMBER] and then into Resident room [ROOM NUMBER] without first knocking or announcing herself. There was one resident in the room during that time. 4. On 12/3/18 at 7:48 a.m. Staff A, CNA was observed to walk out from Resident room [ROOM NUMBER] and then into Resident room [ROOM NUMBER] without first knocking or announcing herself prior to entering. There was one resident in the room at the time. 5. On 12/3/18 at 7:49 a.m. Staff A, CNA was observed to walk out from Resident room [ROOM NUMBER] and then into Resident room [ROOM NUMBER] without first knocking or announcing herself. There was one resident in the room at the time. 6. On 12/3/18 at 8:00 a.m. Staff A, CNA was observed walking down the hall and walked into Resident room [ROOM NUMBER] without first knocking or announcing herself. There was one resident in the room at the time. 7. On 12/3/18 at 8:06 a.m. Staff A, CNA was observed walking right into Resident room [ROOM NUMBER] without first knocking and or announcing herself. There was one resident in the room at the time. 8. On 12/3/18 at 8:06 a.m. Staff C, CNA was observed to take a breakfast tray and walk into Resident room [ROOM NUMBER] without first knocking and or announcing herself. There was one resident in the room at the time. 9. On 12/3/18 at 8:52 a.m. to 8:59 a.m. Staff A, CNA was observed in the restorative dining room and assisting Resident #4 with the breakfast meal. She was observed standing up directly over the resident on her left side, and was feeding her with a spoon. Resident #4 had to look up at the CNA several times in order to take a bite of food from the spoon, and her head was not at a level position. Review of Resident #4's medical record revealed that Resident #4 was admitted to the facility for long term care on 1/8/02. Review of the most current Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was totally dependent with a one person assist for the activity of daily living (ADL) of eating. A review of the current care plan with next review date of 12/5/18 revealed a problem area related to weight loss and impaired swallowing. The interventions included but not limited to, assist resident with meals. On 12/4/18 at 9:45 a.m. interviews with five random alert and interviewable residents, who all wished to remain confidential, and indicated that staff routinely come in their rooms before knocking and or announcing themselves. One resident indicated that she was startled at times, when they just walk right in. On 12/4/18 at 12:20 p.m. an interview with the Director of Nursing (DON) confirmed that it is the expectation of any staff member to knock before entering resident rooms. She provided the facility's Promoting/Maintaining Resident Dignity, policy and procedure, dated (YEAR) for review. The policy statement revealed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. The compliance guideline #12 revealed, Maintain resident privacy. Knock on doors, announce yourself, and allow for a response time prior to entering.

Based on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed timely for three residents (#3, #4, and #86) of 19 sampled residents. It was determined that the Annual MDS assessments were twelve and thirteen days late. Findings included: On 12/4/18 review of Resident #3's medical record revealed a MDS Annual assessment dated [DATE] was still in progress and incomplete. The assessment should have been completed thirteen days earlier. It had been almost two weeks since it's due date. The facility had completed MDS assessments to include 2/18/18 (Admission), 5/21/18 (Quarterly), 8/21/18 (Quarterly), therefore the next assessment was due on 11/21/18. A review of the medical record revealed the resident was admitted to the facility on [DATE] and readmitted from the hospital on [DATE]. Resident #3 was admitted to the facility for long term care. On 12/4/18 at 9:25 a.m. an interview with Staff D, Care Plan and MDS Coordinator confirmed that the resident's Annual MDS dated [DATE] was still in progress and had not been completed. She confirmed it should have been completed, but they just did not finish it. Review of Resident #4's medical record revealed the following MDS assessments: 11/21/17 (Annual), 2/21/18 (Quarterly), 5/22/18 (Quarterly), 8/22/18 (Quarterly). There was an Annual MDS dated [DATE] which was still in progress and not completed. The MDS was almost two weeks late and this was confirmed by the MDS Coordinator. Review of the record revealed Resident #4 was admitted to the facility for long term services on 11/18/14. A review of Resident #86's medical record revealed the following MDS assessments: Admission Medicare 5-day dated 11/14/18 , which indicated still in progress and not completed, and the 14 Day MDS assessment dated [DATE] , which indicated still in progress and not completed. It was determined that the 14 Day MDS was still not complete and was due for completion fifteen days ago at admission on 11/19/18. Also the 5-Day MDS assessment was ten days late. A review of the medical record revealed the resident was admitted to the facility on [DATE] for rehabilitation and then long term care services. On 12/4/18 at 1:00 p.m. an interview with the Director of Nursing (DON) confirmed that the MDS assessments were not completed timely, and that they were catching up by adding another MDS coordinator.

Based on observations, resident interview and record review, the facility failed to ensure necessary services for grooming were provided to one resident (#87) of 19 sampled residents related to not shaving the resident as per the resident's preference, for a period of five days. Findings included: On 12/2/18 at 11:30 a.m. Resident #87 was observed in his room and seated upright in bed. The resident was being visited by his wife and had a magazine in front of him. Resident #87 was not dressed for the day and was not groomed or shaven. He was observed with about a 1/4 inch of facial hair to include a beard on his cheeks and over the lips. Resident #87's wife indicated that the facility had not shaved him since his admission, which had been over three days. She further indicated she and her daughter had provided the facility an electronic shaver, but he needed staff to help him. The resident's wife also stated she had told various aides who had been caring for him about shaving him, but they still have not. In an interview with Resident #87's daughter on 12/2/18 at 1:00 p.m., she confirmed that her father usually was clean shaven, and that she and her mother have both provided an electric shaver and have asked staff for over three days to shave him. On 12/3/18 at 11:50 a.m. Resident #87 was observed in his room and seated upright in bed being visited by his daughter and wife. Resident #87 was observed not to be shaven. On 12/4/18 at 8:25 a.m. Resident #87 was observed in his room and seated upright, and with his meal in front of him on the over the bed table. He was observed to nod on and off and was not really eating. He was still observed not to be shaven and with over a 1/4 inch of facial hair. Review of the medical record for Resident #87 revealed he was admitted to the facility on [DATE] for short term rehabilitation. Review of the new admission data collection assessment dated [DATE] revealed that the resident: prefers shower, bathing assisted by staff, shaving performed by staff, grooming performed by staff, no behaviors exhibited, forgetful and needs reminders, and memory loss. The assessment indicated interventions to include: provide assistance with showers, dressing, grooming, toileting, transfers, bed mobility, locomotion and meal intake, encourage showers two times a week and more often as needed. Review of all progress notes from admission on 11/29/18 to 12/3/18 revealed a note on 11/29/18 at 13:58 (1:58 p.m.) as, admission eval - Assisted by staff: Shaving/Facial grooming, Prefers showers. Review of all progress notes did not reveal the resident had non-compliant behaviors with showers and shaving, nor was there documentation in the notes to indicate a shower and shaving was completed. A review of the current care plans with the next review date of 2/27/19 indicated a problem area of Dry/Flaky/Cracked skin with interventions to include but not limited to, encourage showers twice a week and more often if needed. Additional review of the current care plans with the next review date of 2/27/19 revealed a problem area of neurological disorder with interventions to include but not limited to, allow sufficient time for completion of any task that I (Resident #87) am not capable of completing. On 12/4/18 at 10:00 a.m. an interview with the Director of Nursing (DON), revealed that she had a conversation with Resident #87's in-house care sitter, who stays with the resident daily. The DON stated that she found out that the family, as of today, wants Resident #87 to grow a beard and not be shaved. However, this surveyor followed up with the in-house care sitter at 10:50 a.m. and she indicated that she told the DON, He's growing a beard. She meant that to say the resident was growing a beard, because of the lack of being shaved. The in-house care sitter was not the medical decision maker. Continued interviews with Resident #87's Power of Attorney revealed that they still maintain they have always wanted Resident #87 shaved, since his admission on 11/29/18.

Based on observation, record & policy review and interviews the facility failed to ensure that medications were delivered in the manner prescribed for four (Residents # 19, 26, 34, and 87), of seven sampled residents. This resulted in a medication being administered at a later time than prescribed for Resident # 34, and for medication being administered crushed in a manner that was not recommended by the manufacturer for Residents # 19, 26, and 87, and also without the approval of the prescribing physician for Residents #19 and 87. These five errors observed during medication administration observations of 30 total medications, represented an error rate of 16.67%. Findings included: 1) Resident # 19 was admitted to the facility for this admission on 07/03/17 with the primary [DIAGNOSES REDACTED]. A review of the active physician orders [REDACTED]. The physician orders [REDACTED].#19. On 12/4/18 at 8:45 a.m. a medication administration observation with Staff G revealed that Staff G crushed the medications for Resident #19. Staff G said there was a note on the Medication Administration Record [REDACTED]. Staff G dispensed 11 medications that were due at 9 a.m. and placed them in a small plastic sleeve/envelope, these medications included but were not limited to: One 60mg [MEDICATION NAME] capsule which Staff G opened and placed the slow-release granules into the plastic sleeve/envelope, one 500mg LevETIRAcetam tablet, and one 600mg [MEDICATION NAME] Tablet Extended Release. Staff G then crushed the contents of the plastic sleeve/envelope and then added the contents to a plastic container of applesauce and then Staff G administered the applesauce/medication mix to Resident #19 who complained about the taste, but swallowed the mix nevertheless. Record review of the Medication Administration Record [REDACTED]. The printed MAR indicated [REDACTED]. The medications [MEDICATION NAME] Capsule Delayed Release Particles 60mg, and [MEDICATION NAME] 600mg Tablet Extended Release appear on the Do not Crush list available from the Institute for Safe Medication Practices at https://www.ismp.org/recommendations/do-not-crush. These medications are slow-release, the medication LevETIRAcetam tablet 500mg is also on the list because of the bad taste when crushed. 2) Resident # 26 was admitted to the facility for this admission on 07/18/17 with the primary [DIAGNOSES REDACTED]. A review of the active physician orders [REDACTED]. On 12/02/18 at 08:30 p.m. a medication administration observation with Staff H revealed that Staff H crushed the medication for Resident #26. Staff H was asked why the medication was crushed, and Staff H replied he has trouble swallowing. Staff H took the [MEDICATION NAME] tablet and placed it in a plastic sleeve/envelope along with another prescribed tablet and crushed the medication, then added it to a small plastic container of applesauce and administered it to Resident # 26 who swallowed the medication/applesauce mix. Record review of the Medication Administration Record [REDACTED]. The printed MAR indicated [REDACTED]. The medication [MEDICATION NAME] HCl 120mg tablet appears on the Do not Crush list available from the Institute for Safe Medication Practices at https://www.ismp.org/recommendations/do-not-crush. The medication has a coating that is intended to release the drug over approximately 3 hours. 3) Resident # 34 was admitted to the facility for this admission on 08/01/18 with the primary [DIAGNOSES REDACTED]. A review of the active physician orders [REDACTED]. Pharmacy had timed the [MEDICATION NAME] capsule for 1900 hours (p.m.) and the evening [MEDICATION NAME] was timed for 2000 hours. On 12/02/18 at 20:45 p.m. a medication administration observation with Staff F revealed that Staff F dispensed the [MEDICATION NAME] 7.5mg capsule and the [MEDICATION NAME] 300mg capsule and placed them in a small plastic medication cup, Staff F then administered the medications to Resident #34. When Staff F returned to the computer screen to sign off the administration he was asked why the screen was pink on the check-off prompt for the [MEDICATION NAME] instead of yellow like the one for the [MEDICATION NAME], and he replied I was late with that one. Record review of the Medication Administration Record [REDACTED] 4) Resident # 87 was admitted to the facility on [DATE] with the primary [DIAGNOSES REDACTED]. A review of the active physician orders [REDACTED].½ tablet daily for hypertension, vital signs every shift for 7 days end date 12/06/18, Multivitamin daily for age related vitamin deficiency, Myrbetriq ER Tablet extended release 24 hour 50mg daily for bladder spasms. On 12/03/18 at 09:15 a.m. a medication administration observation with Staff E revealed that Staff E is an Agency LPN who is here and taking care of Resident # 87 for the first time. He is dispensing morning medications and stated that this resident takes his medications crushed and mixed with applesauce. He dispensed Tylenol, [MEDICATION NAME] and the Multivitamin without any problem, but when it came to the Myrbetriq tablet, Staff E could not locate the medication, but instead had a medication called mirabegron ER, the DON happened by and demonstrated the instructions to the nurse that he should Google the medication name to see if Myrbetriq ER and mirabegron ER are the same medications. Staff E determined that they were the same medications and proceeded with the administration of the medications. Staff E placed the medications in a sleeve/envelope suitable for the crushing apparatus, Staff E crushed the medications and then added them to a small plastic container of strawberry applesauce and administered it to Resident # 87 who swallowed the medication/applesauce mix. Record review of the Medication Administration Record [REDACTED]. The printed MAR indicated [REDACTED]. The printed MAR indicated [REDACTED]. The medication Myrbetriq tablet appears on the Do not Crush list available from the Institute for Safe Medication Practices at https://www.ismp.org/recommendations/do-not-crush. The medication is a slow-release formulation. A review of the facility provided policy for medication administration dated (MONTH) 2009 and updated (MONTH) (YEAR) revealed in section 2, bullet point 9 Crushing oral medications REQUIRES a physician's orders [REDACTED].g., time release capsules, coated tablets, etc.). Crush medications only in accordance with pharmacy guidelines and/or Facility policy. (Refer to the Do not crush medication list). On 12/4/18 at approximately 11:00 a.m. An interview with the DON revealed another policy for Crushed Medications this policy is undated except for a copyright (YEAR) The Compliance Store, LLC. All rights reserved stamp at the bottom left hand side of the document. It reads: Policy: Medications shall be crushed in accordance with standards of practice for safety and accuracy in medication administration. Policy explanation and compliance guidelines: Section 3. Medications shall be crushed in accordance with physician's orders [REDACTED]. Section 4. The pharmacist shall review medications to be crushed for safety and stability, and report irregularities or pertinent side effects in accordance with the facility's procedures for the drug regimen review. A copy of the do not crush list supplied by the DON revealed a partial list that started at the letter M with the drug [MEDICATION NAME]. The medication [MEDICATION NAME] appears on this list. The DON stated that this was the list available in the resources binder that the nurses can access when they need a reference. The DON also supplied the surveyor with an In-Service document that she had implemented that morning on 12/04/18 it read, if you're unaware of a medication and/or interactions etc. please refer to the medication book at the nurse's station (on book shelf) or call Pharmacy @ phone number. Use Internet explorer to research medication names or refer to pharmacy, thanks, signed DON/ADON this was accompanied by a sign-in sheet with the signatures of two nurses. On 12/4/18 at approximately 1:00 p.m. an interview with the consultant pharmacist revealed that he was not aware of any resident at this facility that was receiving crushed medications. When asked about his expectations for a situation where the resident was having difficulty swallowing pills he stated he would suggest to the physician an alternate delivery method like an [MEDICATION NAME], when asked what he would do with a request from Nursing to crush medications against the recommendations of the manufacturer per the Do not crush list, he stated that he would have to look into the contraindication reasoning, and then he would make the necessary recommendations to the ordering physician and the nurse.

Based on record review, interviews, and facility policy review the facility did not ensure a comprehensive care plan was developed for one resident (#67) of two residents reviewed for urinary incontinence. Findings included: Resident # 67 was admitted to the facility with a [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment dated [DATE], section H, bowel and bladder showed Resident #67 was always incontinent. Review of an undated Nurse Aide's Information Sheet showed Resident #67 was incontinent. On 10/26/2017 at 1:10 p.m., in an interview with Staff A, LPN (Licensed Practical Nurse) she said Resident #67 has urinary urgency and is incontinent at night. On 10/26/2017 3:43 p.m., during an interview with the MDS Coordinator he said Resident #67 has overactive bladder, recurrent urinary tract infections, and is also on diuretics. Review of the resident's care plan dated 10/19/2017 showed a care plan for urinary incontinence had not been created. In another interview with the MDS assessment Coordinator on 10/26/2017 at 4:34 p.m., he confirmed there wasn't an incontinence care plan for Resident #67. At 4:51 p.m., on 10/26/2017 in an interview with the DON (Director of Nursing) he stated that his expectation is that a care plan would be created for incontinence. Review of the policy Comprehensive Care Plans dated May 1, 2017 showed the following: Developing the Care Plan: 1. A comprehensive care plan will be: a. developed within 7 days after the completion of the comprehensive assessment. c. reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly assessments.

Based on record review, interviews, and policy review the facility did not ensure the plan of care was followed related to behavior monitoring for one resident (#35) of five residents reviewed for unnecessary medications. Finding included: Resident #35 was admitted to the facility with a [DIAGNOSES REDACTED]. The care plan dated 10/16/2017 was reviewed and the following information was found: Resident #35 has a behavioral problem yelling out, resists care, and hallucinations related to dementia. Interventions included: Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Review of the resident's MAR (Medication Administration Record) and TAR (Treatment Administration Record) showed behavior monitoring was not documented. On 10/26/2017 at 12:48 p.m., in an interview with the Minimum Data Set (MDS) assessment Coordinator he said there are behavior monitoring sheets in the (electronic medical record) under the assessments tab. On 10/26/2017 at 1:01 p.m., an interview was conducted with Staff A, LPN. She said Resident #35 does have behaviors. She gets agitated. She screams. She was seeing things, but since the new medication she hasn't been seeing anything anymore. She said they are monitoring behaviors. She said behavior monitoring would be found under orders, care plan, and tasks in the electronic record. Review of the physician's orders [REDACTED]. On 10/26/2017 at 4:08 p.m., an interview was conducted with the Director of Nurses (DON) who said when residents are admitted with [MEDICAL CONDITION] medications there is a button in the POS (physician's orders [REDACTED]. This one must've fallen through the cracks. There should be a TAR with behavior monitoring on it. Review of the policy Comprehensive Care Plans dated May 1, 2017 showed: Developing the Care Plan: 2. The services provided or arranged by the facility, as outlined by the comprehensive care plan, will meet professional standards of practice.

Based on record review, interview, drug guide review, and policy review the facility did not ensure a pharmacy recommendation was acted upon in a timely manner for one resident (#39) of five residents reviewed for unnecessary medications. Findings included: Resident #39 was admitted to the facility with a [DIAGNOSES REDACTED]. Upon review of Resident #39's physician's orders [REDACTED]. Enoxaparin Sodium Solution 40 mg/0.4 ml inject 40 mg subcutaneously in the morning for prevent blood clotting Review of the Consultant Pharmacist Recommendation to Physician dated 9/15/2017 showed the following: Please clarify a stop date or stop parameters for the use of: 1. Lovenox 40 mg SQ QAM (daily) The Physician did not respond to the recommendation until 10/18/2017, 33 days later. On 10/26/2017 at 2:14 p.m., in an interview with the Director of Nurses (DON) he said ordinarily he would expect a pharmacy recommendation to be responded to within a week. Review of the policy Consultant Pharmacist Provider Requirements, dated July 2016, showed: 5. The consultant pharmacist provides pharmaceutical care services, including but not limited to the following: (bullet 5) Timely communication to the responsible physician and the facility, as required by state regulations, of potential or actual problems/issues detected, recommendations for changes in medication therapy and monitoring of medication therapy, and other findings/comments relating to medication therapy orders. the timing of these recommendations should enable a response prior to the next drug regimen review. The physician and Facility act upon medication problems or issues that cannot wait until the next medication review.

Based on record review and interview the facility failed to notify the physician of a change in condition for one (Resident #1) of three residents related to a significant weight gain. Findings included: A review of the medical record for Resident #1 revealed the following weights: 3/7/2017-Admission: 197.0 pounds (average of three day weights). 3/14/2017: 209.0 pounds 3/22/2017: 214.0 pounds 3/23/2017: 214.0 pounds An interview was conducted with the Director of Nurses (DON) on 5/16/2017 at 11:00 a.m. He said, Resident #1 had a 12 pound weight gain in his first week at the facility. For reasons unknown the weight increase was not communicated to the nursing department or the physician. The process is as follows: the restorative aides do all the weights on Tuesday and/or Wednesday. They write the weights in the weight book. On the same day the weights are done, the Certified Dietary Manager (CDM) reviews the weights and compares them to the previous weights. If there are any discrepancies, the CDM informs the nursing department and a reweigh is done. If the reweigh verifies a significant weight loss or gain, nursing informs the physician. On 5/16/2017 at 2:45 p.m. an interview was conducted with the resident's direct care nurse. She said she was unaware of the resident's weight of 212# on 3/14/2017. She said on 3/22/2017 the restorative aide weighed Resident #1 and told her the weight was over 200 pounds. Nurse called the physician and received new orders. On 5/16/2017 at 4:00 p.m., an interview was conducted with the Certified Dietary Manager (CDM) via the telephone. She said the restorative Certified Nurses Assistants (CNAs) do 3-day weights on all new admissions. She receives these weights, gets an average, and inputs the weights into the computer. She said the weights are done weekly for four weeks and then monthly thereafter. She said, when she puts the weights into the computer, she reviews the previous weight to check for any discrepancies. If the weight had significantly increased or decreased, she tells the nurses and recommends a re-weight. When asked if she remembered entering the weight on 3/14/2017 into the computer she said No. When asked if she remembered comparing the weight, dated 3/7/2017 with the weight dated 3/14/2017 she said, No. On 5/16/2017 at 3:00 p.m., an interview as conducted with the Medical Director/ Primary Care Physician for this Resident #1. When asked what his expectations as the physician and the medical director were related to the resident's weight gain, he said he would expect the nurses to assess the resident on a daily basis and report any abnormal findings to him. He said he would have expected to be notified of the resident's 12-pound weight gain but he was not.

Based on record review and interview the facility failed to assess one (Resident #1) of three residents related to a significant weight gain. Findings included: A review of the medical record for Resident #1 revealed the following weights: 3/7/2017-Admission: 197.0 pounds (average of three day weights). 3/14/2017: 209.0 pounds 3/22/2017: 214.0 pounds 3/23/2017: 214.0 pounds An interview was conducted with the Director of Nurses DON) on 5/16/2017 at 11:00 a.m. He said, Resident #1 had a 12 pound weight gain in his first week at the facility. For reasons unknown the weight increase was not communicated to the nursing department or the physician. The process is as follows: the restorative aides do all the weights on Tuesday and/or Wednesday. They write the weights in the weight book. On the same day the weights are done, the Certified Dietary Manager (CDM) reviews the weights and compares them to the previous weights. If there are any discrepancies, the CDM informs the nursing department and a reweigh is done. If the reweigh verifies a significant weight loss or gain, nursing informs the physician. On 5/16/2017 at 2:45 p.m. an interview was conducted with the resident's direct care nurse. She said she was unaware of the resident's weight of 212# on 3/14/2017. She said on 3/22/2017 the restorative aide weighed Resident #1 and told her the weight was over 200 pounds. Nurse called the physician and received new orders. On 5/16/2017 at 4:00 p.m., an interview was conducted with the Certified Dietary Manager (CDM) via the telephone. She said the restorative Certified Nurses Assistants (CNAs) do 3-day weights on all new admissions. She receives these weights, gets an average, and inputs the weights into the computer. She said the weights are done weekly for four weeks and then monthly thereafter. She said, when she puts the weights into the computer, she reviews the previous weight to check for any discrepancies. If the weight had significantly increased or decreased, she tells the nurses and recommends a re-weight. When asked if she remembered entering the weight on 3/14/2017 into the computer she said No. When asked if she remembered comparing the weight, dated 3/7/2017 with the weight dated 3/14/2017 she said, No. A review of the physician's progress note dated 3/14/2017 revealed the following information: Assessment 5. Swelling of lower extremity Treatment 5. Start [MEDICATION NAME] Tablet 20 mg, orally, once per day, 30 days. Notes: Check B-type Natriuretic Peptide (BNP) LE [MEDICAL CONDITION] noted Fluid restriction DASH diet Keep lower extremities elevated [MEDICATION NAME] 20 mg by mouth every day, will adjust dosing based on BNP. physician progress notes [REDACTED].>History of present illness: Constitutional: Significant lower extremity [MEDICAL CONDITION] noted. Mild cough and mild shortness of breath with exertion. No updated weights. During the interview with the DON, he said the physician assessed the resident on 3/14/2017. He noted [MEDICAL CONDITION] to the resident lower extremities and wrote treatment orders in the progress notes but not on the physician order [REDACTED]. The progress notes were at the physician's office and all were faxed on 4/5/2017 (after the resident was discharged to the hospital). On 5/16/2017 at 3:00 p.m., an interview as conducted with the Medical Director/ Primary Care Physician for this Resident #1. He said, on 3/14/2017 during the resident assessment he noticed that the resident had lower extremity [MEDICAL CONDITION]. He wrote orders accordingly in the progress notes. When asked what the process was for making sure the orders are received and carried out by the nurses, he said, he either writes the orders on the physician order [REDACTED]. He said he relied on the nurses to write the orders. He said, currently if he gives a verbal order he also makes sure to write the order on the physician's orders [REDACTED]. I believe I did, but I cannot say for sure. The nurse may have been busy and forgot to write down the orders. When asked what his expectations as the physician and the medical director were related to the resident's [MEDICAL CONDITION]. He said he would expect the nurses to assess the resident on a daily basis and report any abnormal findings to him. He said he would have expected to be notified of the resident's 12-pound weight gain but he was not. He said he was being told by the facility that the resident was having low blood pressure and fatigue. He made medication adjustments based on the information told to him. Though the physician noted lower extremity [MEDICAL CONDITION] on Resident #1 on 3/14/2017 and 3/20/2017, a review of the nurse's notes dated 3/6-3/23/2017 revealed no indication that the resident was assessed for lower extremity [MEDICAL CONDITION]. Per the nurse's notes dated 3/23/2017, the resident was discharged to the hospital on [DATE] for a cardiac evaluation due to frequent [MEDICAL CONDITION] and recent stent placement.

Based on observation, staff interview and facility record review, the facility failed to maintain an effective pest control program related to pests observed in the main kitchen's dishwashing machine while conducting a comprehensive kitchen tour. Findings Include: While observing dishwashing machine operation, with Certified Dietary Manage(CDM), Dining Service Director (DSD); and Third party consultant on 09/21/2016 at 2:00 PM, one pest (cockroach in resemblance) was observed moving around dishwasher's temperature gauges while staff operated the dishwasher. The pest was observed moving from back rear to the front of dishwashing machine. Pest was killed by the Director of Dinning using a paper towel. The DSD stated that the kitchen was recently fogged and when that happens, they (referring to pest, identified as roaches) move around. The DSD provided pest observation logs from the kitchen and stated that maintenance manager does the scheduling for pest control. Review of facility's records revealed that the facility has a contract with a pest control company that routinely visit the facility. Review of the kitchen's pest sighting log for the last 2 months, revealed annotated pest sightings of roaches on the following dates and locations: 9/21/16: Kitchen: Roach (dishwashing machine) 9/19/16: Kitchen: Roaches in front of cooking equipment on floor by drain; on floor by dishwasher 9/15/16: Roaches near 205 9/14/16: Kitchen: Roaches plates 8/30/16: Kitchenette SNF: Roaches SNF 2nd floor kitchen 8/29/16: SNF Dining room 8/28/16: Kitchenette: Roach 2nd Floor Skilled Kitchen; Kitchen: main kitchen Scoops; Main kitchen Robot Coupe; Main kitchen Toaster 8/26/16: Nurse Station; room 220 8/24/16: Kitchen: Roach Slicer Area 8/23/16: Kitchen: Roaches Front steam table, ladies, and slicer Area in Main kitchen; Kitchenette SNF: Dining service area on 2nd floor 8/19/16 Roaches shower room across room 203 8/17/16: Kitchen: Roaches on floor by hand sink, and dishwasher area 10-12 8/4/16: Roaches in 209 bathroom 8/2/16: Roach in Shopu wheels 30/40 of them Review of pest control invoice for treatments and services since for the past 60 days revealed that facility was visited by the contracted pest control company with services provided on the following dates: 7/28/16; 8/11/16; 8/25/16; 9/8/16; 9/15/16; 9/19/16 During interview with the maintenance director on 09/22/2016 at 11:21 AM, he explained the process and frequency of visits by pest control company. The noticed an increase of roach sightings, which was likely brought in by residents from the adjoined Assisted Living Facility, and have and action plan in place to address the increase. He stated that contract with prior pest control company was terminated for lack of results. New contract with current pest control company began in November 1, 2016.