Every finding on record at Ashby Ponds Inc

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide care and service for a complete dialysis (1) program for one of one dialysis residents in the survey sample, Resident #93. The findings include: For Resident #93 (R93) the facility staff failed to ensure dialysis communication forms were on 01/26/2024, 01/29/2024, 02/07/2024, 02/09/2024, 02/12/2024, 02/14/2024, 02/16/2024, 02/19/2024 and on 02/21/2024. R93 was admitted to the facility with diagnosis that included but was not limited to end stage renal disease. R93's most recent comprehensive MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 02/08/2024, coded (R93) as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. The physician's order for R93 dated 01/25/2024 documented in part, Dialysis M/W/F ([NAME]/Wednesday/Friday) . The comprehensive care plan dated 01/26/2024 for R93 documented in part, Check my wt (weight) & (and) VS (vital signs) pre and post dialysis, nurse to check/fill recomm (recommendations) spots on my dialysis binder/folder, to read binder when back from HD (hemodialysis) if any recommendations. The facility's dialysis communication worksheets for R93 documented in part, Resident/Guest Name, Pre-dialysis information: Pre-dialysis VS (vital signs), Licensed Nurse Signature, Post-dialysis information: Licensed Nurse Signature, Licensed Nurse Signature reviewing Communication Worksheet upon return to the facility. Signature:, Date:, Time:. Review of the facility's dialysis communication worksheets for R93 revealed the following: failed to evidence the signature of the facility nurse for the pre and post dialysis information on 01/26/2024, 01/29/2024, 02/07/2024, 02/09/2024, 02/12/2024, 02/14/2024, 02/16/2024, 02/19/2024 and 02/21/2024; failed to evidence the resident's name on 01/29/2024 and 02/12/2024; failed to evidence R93's vital signs on 01/26/2024 and 02/12/2024; and failed to evidence the signature of the facility nurse who reviewed the communication worksheets on 2/7/24 and 2/19/24. On 02/22/2024 at approximately 10:40 a.m., an interview was conducted with RN (registered nurse) #1, clinical nurse manager and RN #2, charge nurse. When asked about the procedure a nurse needs to follow when completing the facility's dialysis communication form RN #1 stated that the resident's name should be completed and that nurse complete the section for pre-dialysis vital signs, sign the pre- and post-dialysis information sections, sign, date and document the time the dialysis worksheet was reviewed at the time the resident returned to the facility. After reviewing and being informed of the incomplete dialysis communication forms stated above, RN #1 agreed that the forms were not completed. The facility's policy Dialysis documented in part, Procedure: 4. The Clinical Manager/designee will create a Communication Book for each resident who is receiving dialysis. The Dialysis Communication Worksheet accompanies the resident during each dialysis visit to enhance communication. 5. Prior to dialysis, the worksheet will be completed by the licensed nurse or designee of the community which will indicate the status of the resident. 7. Upon return of the resident to the community, the licensed nurse or designee will review the worksheet and follow up on any concerns written by the dialysis team. On 02/22/2024 at approximately 3:05 p.m., ASM (administrative staff member) # 1, administrator, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/000500.htm.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to implement a complete pain management program for two of 16 residents in the survey sample, Residents #1 and #8. The findings include: 1. For Resident #1 (R1), the facility staff failed to conduct a complete pain assessment and failed to attempt non-pharmacological interventions prior to the administration of a prn (as needed) pain medication of morphine (1). R1 was admitted with diagnoses that included but not limited to pain. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 01/11/2024, R1 scored 8 (eight) out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. Section J Pain Management coded R1 as having frequent pain at a pain level of five out of ten, with ten being the worse pain. The physician order for R1 documented in part, Morphine concentrate 100mg (milligrams)/5 ml (five milliliter) oral solution. Indication: Pain and/or shortness of breath. Pain in Left Hip. Quantity: 0.25ml. Route: Sublingual (beneath the tongue). Frequency: As needed every four hours starting 12/04/2023. The eMAR (electronic medication administration record) for R1 dated February 2024 documented the physician's orders as stated above. The eMAR revealed that R1 received morphine on 02/13/2024, 02/18/2024, 02/20/2024 and 02/22/2024 with no documented evidence of R1's location of pain, the level of pain, or the attempt of non-pharmacological interventions. The facility's progress notes for R1 for the dates listed above on the eMARs dated February 2024 failed to evidence documentation of R1's location of pain, the level of pain or the attempt of non-pharmacological interventions. On 02/22/2024 at approximately 2:45 p.m., an interview was conducted with LPN (licensed practical nurse) #1 regarding the administration of prn (as needed) pain medication. When asked to describe the procedure for administering prn pain medication to a resident LPN #5 stated she would attempt non-pharmacological intervention first, assess the resident's pain, the location and level of pain using a scale of one to ten, with ten being the worse pain and if the resident is non-verbal would use the resident's facial expressions or facial grimacing. When asked about documenting the resident's pain level, location of pain and the attempt of non-pharmacological interventions she stated it would be documented on the eMAR. After reviewing the February 2024 eMAR for R1, LPN #1 stated there was no documentation of the resident's pain level, location of pain and the attempt of non-pharmacological interventions. The facility's policy Pain Management documented in part, Policy: Guests/residents are screened and assessed for the existence of pain, the effectiveness of pain relief efforts and determination of potential underlying causes to ensure highest practicable level of well-being. Procedure: 3. Nurse uses the Numerical Pain Intensity Scale and/or physical observations to identify presence of pain. 5. Nurse will notify provider of existing pain and/or history of pain presently relieved or not relieved by medications and non-medicinal approaches. 7. Pain level will be assessed before and after administration of analgesic and documented in the Physical Monitors in the eMAR. On 02/22/2024 at approximately 3:05 p.m., ASM # 1, administrator, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) Used to treat pain severe enough to require daily, around-the-clock, long-term opioid treatment and when other pain medicines did not work well enough or cannot be tolerated. This information was obtained from the website: Morphine (Oral Route) Description and Brand Names - Mayo Clinic. 31753 2. For Resident #8 (R8), the facility staff failed to initiate a complete pain assessment and failed to attempt non-pharmacological interventions when the as needed pain medication morphine was administered on multiple dates in February 2024. R8's comprehensive care plan dated 6/7/23 documented, Monitor for expressions/behavior changes and assess for pain and administer pain medication as needed. Expresses pain by actions and expressions, facial grimacing. These are the non-medicinal routine(s) or action(s) I take to alleviate pain: Relaxation, Repositioning, Quiet Room . A review of R8's clinical record revealed a physician's order dated 2/7/24 for morphine 20mg/ 1ml (milligrams per milliliter)- five milligrams (0.25 ml) every four hours as needed for shortness of breath or pain. A review of R8's February 2024 MAR (medication administration record) revealed the resident was administered as needed morphine on 2/11/24, 2/12/24, 2/13/24, 2/15/24, 2/16/24, 2/17/24, 2/18/24, 2/19/24, and 2/20/24. Further review of R8's clinical record (including the February 2024 MAR and February 2024 nurses' notes) failed to reveal a complete pain assessment (such as location, intensity, and duration) was attempted prior to administration of as needed morphine on all dates, and failed to reveal non-pharmacological interventions were attempted prior to administration of as needed morphine on all dates. On 2/22/24 at 2:43 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that prior to administering as needed pain medication, the nurse should assess the location and level of pain, either on a scale from one to ten or by looking for facial grimacing, then the nurse should see if he/she can use a non-pharmacological approach. LPN #2 stated nurses should evidence that this is done by documenting in the prn (as needed) follow up box, and by making a note. A review of nurses' notes and the prn follow up notes for February 2024 only revealed the effectiveness of the medication. On 2/22/24 at 3:13 p.m., ASM (administrative staff member) #1 (the administrator), and ASM #2 (the director of nursing) were made aware of the above concern.

Based on observation, staff interview, and facility document review, it was determined facility staff failed to store and serve food in a sanitary manner in one of one facility kitchens. The findings include: On 02/20/2024 at approximately 6:30 p.m. an inspection of the kitchen was conducted with OSM (other staff member) #1, the chef which revealed the following: 1. On 02/20/2024 at approximately 6:30 p.m., an observation of inside of the walk-in refrigerator during the initial tour of the facility kitchen revealed four ladder racks with several hotel pans and sheet pans containing several different food items. Observation of the first ladder rack revealed a Mid hotel pan, measuring 21 inches long by 13 inches wide and three inches deep, containing quartered ham slices. Further observations revealed it was approximately half full and partially covered with plastic wrap, exposing the ham to the environment. Observation of a second ladder racked revealed two sheet pans filled with hash browns uncovered, exposing the hash browns to the environment; three other sheet pans, two with three pies on them and a third sheet pan with four pies on it, and all of them uncovered, exposing the pies to the environment; and one sheet pan containing raw scallops uncovered, exposing the scallops to the environment. 2. On 02/20/2024 at approximately 6:50 p.m., an observation of the bottom shelf of a food preparation table revealed four food storage containers/bins. Observation of the storage bins that contained the sugar, rice and breadcrumbs revealed each bin contained a scoop in each resting and in contact with the food product. 3. On 02/21/2024 at approximately 11:55 a.m., an observation in the facility's kitchen, during the lunch preparation and steam table set up with food, revealed OSM #2, assistant general manager for dining, ASM #5, general manager for dining, were observed in the kitchen without a hair net. Further observation at approximately 12:00 p.m., revealed OSM #4, maintenance mechanic, walked through the kitchen, one end to the other, without a hair net. 4. On 02/21/2024 at approximately 12:05 p.m., an observation in the kitchen revealed a kitchen staff member pushing a cart out of the kitchen to the resident dining area with six, two-quart stainless steel food containers on the top shelf of the cart. Observation of the two-quart containers revealed they were filled with mechanical soft and pureed food for lunch. Further observation revealed that the food was not covered while being transported to the resident dining area. On 02/21/2024 at approximately 12:05 p.m., an interview was conducted with OSM #1, the chef, regarding the observation stated above. When asked about the food in the walk-in refrigerator being uncovered and the food being uncovered when it was taken out the dining area OSM #1 stated that the food should be covered to prevent contamination. When asked about the scoops laying in the food product in the storage bins, he stated that the scoops should not have been laying in the food product to prevent contamination. When asked about the use of hair nets and informed of the observation of the staff members not wearing a hair net in the kitchen, he stated that hair nets should be worn when anyone is in the kitchen. He further stated that the hair nets keep hair from falling into the food and prevent contamination. On 02/21/2024 at approximately 5:50 p.m., ASM (administrative staff member) # 1, administrator, and ASM #2, director of nursing, were made aware of the above findings. On 02/22/2024 at approximately 11:48 a.m., an interview was conducted with OSM #4. OSM #4 stated he did not have a hair net on when he went into the kitchen the day before. He further stated he went into the kitchen to check the refrigerator temperature and forgot to grab a hair net. No further information was provided prior to exit.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for one of 16 residents in the survey sample, Resident #93. The findings include: For Resident #93 (R93) the facility staff failed to implement the comprehensive care plan for completing dialysis communication forms on 01/26/2024, 01/29/2024, 02/07/2024, 02/09/2024, 02/12/2024, 02/14/2024, 02/16/2024, 02/19/2024 and on 02/21/2024. R93 was admitted to the facility with diagnoses that included but was not limited to end stage renal disease. R93's most recent comprehensive MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 02/08/2024, coded (R93) as scoring a 15 on the brief interview for mental status (BIMS) which indicated the resident was cognitively intact for making daily decisions. The physician's order for R93 dated 01/25/2024 documented in part, Dialysis M/W/F ([NAME]/Wednesday/Friday) . The comprehensive care plan dated 01/26/2024 for R93 documented in part, Check my wt (weight) & (and) VS (vital signs) pre and post dialysis, nurse to check/fill recomm (recommendations) spots on my dialysis binder/folder, to read binder when back from HD (hemodialysis) if any recommendations. The facility's dialysis communication worksheets for R93 included in part, Resident/Guest Name, Pre-dialysis information: Pre-dialysis VS (vital signs), Licensed Nurse Signature, Post-dialysis information: Licensed Nurse Signature, Licensed Nurse Signature reviewing Communication Worksheet upon return to the facility. Signature:, Date:, Time:. Review of the facility's dialysis communication worksheets for R93 revealed the following: failed to evidence the signature of the facility nurse for the pre and post dialysis information on 01/26/2024, 01/29/2024, 02/07/2024, 02/09/2024, 02/12/2024, 02/14/2024, 02/16/2024, 02/19/2024 and 02/21/2024; failed to evidence the resident's name on 01/29/2024 and 02/12/2024; failed to evidence R93's vital signs on 01/26/2024 and 02/12/2024; and failed to evidence the signature of the facility nurse who reviewed the communication worksheets on 2/7/24 and 2/19/24. On 02/22/2024 at approximately 10:40 a.m., an interview was conducted with RN (registered nurse) #1, clinical nurse manager and RN #2, charge nurse. When asked about the procedure a nurse needs to follow when completing the facility's dialysis communication form RN #1 stated that the resident's name should be completed and that nurse complete the section for pre-dialysis vital signs, sign the pre- and post-dialysis information sections, sign, date and document the time the dialysis worksheet was reviewed at the time the resident returned to the facility. After reviewing and being informed of the incomplete dialysis communication forms stated above, RN #1 agreed that the forms were not complete. On 02/22/2024 at approximately 4:35 p.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. When asked to describe the purpose of a resident's care plan, she stated that the care plan documents what the resident wants. After reviewing R93's comprehensive care plan for dialysis and the dialysis communication worksheets for the dates stated above, she was asked if R93's care plan was implemented. ASM #2 stated the care plan was not being followed. On 02/22/2024 at approximately 3:05 p.m., ASM # 1, administrator, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/000500.htm.

Based on staff interview and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary psychotropic medication, for one of 16 residents in the survey sample, Resident #26. The findings include: For Resident #26 (R26), the facility staff failed to ensure the physician documented the clinical rationale and intended duration of use for prn (as needed) lorazepam (1) which was ordered for more than 14 days. A review of R26's clinical record revealed a physician's order dated 12/4/23 for lorazepam 0.5mg (milligrams) every four hours prn for anxiety, nausea/vomiting, or shortness of breath. A review of R26's December 2023 and January 2024 MARs (medication administration records) revealed the resident was administered prn lorazepam on 12/5/23, 12/8/23, 12/12/23, 12/13/23, 12/19/23, 12/20/23, 12/21/23, 12/22/23, 12/25/23, 12/26/23, 12/27/23, 12/28/23, 12/29/23, 12/30/23, 12/31/23, 1/2/24, 1/3/24, 1/4/24, and 1/8/24. Further review of R26's clinical record failed to reveal the physician documented the clinical rationale and intended duration of use for the prn lorazepam used more than 14 days. On 2/22/24 at 3:04 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated the doctor needs to document the reason to continue prn anti-anxiety medication when it is used more than 14 days. On 2/22/24 at 3:13 p.m., ASM #1 (the administrator), and ASM #2 were made aware of the above concern. The facility policy titled, Psychoactive Medication Management failed to document specific information regarding prn anti-anxiety medication. Reference: (1) lorazepam is used to treat anxiety. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682053.html

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to promote dignity for one of 16 residents in the survey sample, Resident #18. The findings include: For Resident #18 (R18), the facility staff failed to close the window blinds while completing treatment for the resident's sacral wound. On 2/22/24 at 9:57 a.m., an observation of RN (registered nurse) #3 and LPN (licensed practical nurse) #2 performing wound care on R18's sacrum was conducted. During wound care, R18 was lying in bed with his sacrum and buttocks exposed. The window blinds in the room remained open and the room was visible from an outside sidewalk and parking lot. One person was observed walking outside. On 2/22/24 at 2:43 p.m., an interview was conducted with LPN #1. LPN #1 stated staff should make sure window blinds and shades are closed before performing wound care on a resident's sacrum. On 2/22/24 at 3:13 p.m., ASM (administrative staff member) #1 (the administrator), and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Resident Rights - Continuing Care documented, The facility will promote and protect the rights of each resident and places a strong emphasis on individual dignity and self-determination.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow infection control practices for one of 16 residents in the survey sample, Resident #35. The findings include: For Resident #35 (R35), the facility staff failed to perform hand hygiene when changing gloves during wound care. On 02/22/2024 at approximately 9:37 a.m., an observation was conducted of LPN (licensed practical nurse) #1 providing wound care to R35. After donning a pair of clean gloves, LPN #1 removed the soiled dressing from R35's left heel, removed her gloves with the dressing, disposed of the gloves and dressing in a trash can, donned a clean pair of gloves, cleaned R35's wound and applied a clean dressing. Observation revealed that LPN #1 failed to wash or sanitize her hands before putting on a clean pair of gloves after removing the old dressing. On 02/22/2024 at approximately 9:50 a.m., an interview was conducted with LPN #1. When informed of the observation she stated that she should have washed or sanitized her hands when she changed her gloves to maintain infection control. The facility's policy Infection Prevention it documented in part, A. Hand Hygiene .Hand hygiene should be performed immediately after exposure or possible exposure to infectious materials or sources of potentially infectious materials. On 02/22/2024 at approximately 3:05 p.m., ASM # 1, administrator, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain the kitchen in a sanitary manner. The facility staff failed to date and dispose of expired or opened food during the facility task kitchen observation on [DATE] at 4:17 PM in one of three kitchen areas. The findings include: On [DATE] at 4:17 PM, an observation was conducted in the main kitchen. In the dry storage room a 12 ounce box of penne pasta was loosely wrapped with saran wrap and had a green label which revealed, date opened [DATE] and date expired [DATE]. The penne pasta box was approximately one half full. In addition, there was a plastic bag with shell pasta that was tied together with both ends of the bag. The shell pasta bag contained approximately one pound of shells. There was no label on bag of date opened or date expired. An interview was conducted on [DATE] at 4:25 PM with OSM (other staff member) #2, the dietary aide. When asked to review the penne pasta box and the shell pasta bag, OSM #2 stated, They should not be like that. We are to put unused pasta in a plastic container and label it. OSM #2 left room with the penne and shell pasta. Approximately five minutes later at 4:30 PM, OSM #2 was observed re-entering the dry storage room with a plastic container. The shell pasta was in a plastic container and labeled with an open date of [DATE] and the penne pasta was left in the original box and labeled with an open date of [DATE]. On [DATE] at 4:45 PM, an interview was conducted with OSM #1, the dining manager. When the findings were discussed and he was shown the shell pasta and the penne pasta both labeled opened [DATE], OSM #1 was asked if this was the process for unopened and or undated food. OSM #1 stated, No, that is not the process. I will dispose of both of these pastas now. The ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing were made aware of the findings on [DATE] at 5:30 PM. The facility's Food Labeling and Dating policy dated ,d+[DATE], revealed the following, All food and non-food supplies will be clearly labeled, and food items dated. All opened items or items not in original containers will be covered, clearly labeled and dated. No further information was provided prior to exit.

Based on observations and staff interview the facility staff failed to follow infection control practices for one of seven residents in the medication administration observation, Resident # 34 (R34). The facility staff placed their ungloved finger on the inside of the medication cup while administering medications to (R34). The findings include: (R34) was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/024/2022, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately impaired of cognition for making daily decisions. On 04/27/2022 at approximately 8:19 a.m., the medication administration observation was conducted with LPN (licensed practical nurse) # 1. LPN # 1 unlocked and opened the medication cabinet and removed several medication bubble packs and a small 30 ml (milliliter) plastic medication cup. LPN # 1 then verified (R34's) medication bubble packs with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further observation revealed LPN # 1 placed the medication cup on their cart and poured the Pro Source into the cup to the 15 ml mark then administered it to (R34). (R34) was observed to consume all of the contents from the medication cup. On 04/27/22 11:23 AM an interview was conducted with LPN # 1. When asked to describe the procedure for handling a medication cup during medication administration LPN # 1 stated that the cup should be held from the outside. When informed of the observation during their medication administration to (R34) LPN # 1 stated that they did not recall placing their finger inside the medication cup. When asked why it was important not to place their fingers inside a medication cup LPN # 1 stated that they could contaminate the inside of the cup. On 04/27/2022 at approximately 5:30 p.m., ASM (administrative staff member) # 1, administrator, and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit

Based on observation, staff interview, and facility document review it was determined facility staff failed to store food in a sanitary manner. In the walk in refrigerator, a bottle of zesty orange sauce without an open or use by date and a ten pound container of sweet-and-sour duck sauce, was observed available for use past the labeled use by date of [DATE] on the container. Then findings include: On [DATE] at approximately 8:36 a.m., an observation of the facility's kitchen was conducted with OSM [other staff member] # 1, general manager for continued care dining. Observation of the walk-in refrigerator in the facility's kitchen revealed the following: - One 5.4 pound bottle of zesty orange sauce approximately three-quarters full found on a top shelf available for use. Further observation failed to evidence an open date or a use-by-date. OSM # 1 was then asked to observe the bottle of orange sauce for a manufacturer's use-by-date. OSM # 1 agreed that a use-by date was not on the bottle. - One 10 pound container of sweet-and-sour duck sauce approximately three-quarters full found on a top shelf with an open date of [DATE] and a use by date of [DATE] available for use. OSM # 1 was then asked to observe the container of duck sauce for a manufacturer's use-by-date. OSM # 1 agreed that a use-by date was not on the container. OSM # 1 immediately removed the above item from the walk-in refrigerator. On [DATE] an interview was conducted with OSM # 1. After review of the facility's Food Storage Guidelines and the observation of the above items found in the facility walk-in refrigerator, OSM # 1 agreed that that the items should not have been available for use. When asked to describe the process to prevent expired food items being available for use OSM # 1 stated that the facility's sous-chef and lead cook conduct inspections of food items every Friday and look for expired items and ensure that there are correct dates on all food items. The facility policy Food Storage Guidelines. [Version 04.2018] documented in part, Food or Product. Sauces (soy, Steak, ect). Under If Unopened it documented, 1 [one] year. Under After Opening it documented, 2 [two] months - refrig [refrigerated]. On [DATE] at approximately 10:40 a.m., ASM [administrative staff member] # 1, director of continuing care and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement a comprehensive program for [CONDITION(S)] services for one of 24 residents in the survey sample, Resident #6. The facility staff failed to obtain physicians' orders for Resident #6's [CONDITION(S)] services and for assessment of the resident's [CONDITION(S)] access site, and failed to maintain regular communication with the [CONDITION(S)] provider. The findings include: Resident #6 was admitted to the facility on [DATE], and was most recently readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/18/20, Resident #6 was coded as being severely cognitively impaired for making daily decisions, having scored seven out of 15 on the BIMS (brief interview for mental status. She was coded as being dependent on staff assistance for ADLs (activities of daily living), including bed mobility, transferring, bathing, dressing, and personal hygiene. She was coded as having received [CONDITION(S)] (4) services during the look back period. A review of Resident #6's clinical record revealed a physician note dated 12/14/20. The note documented, in part: Clinical note: she is getting HD (hemodialysis) three times a week. The note did not contain information related to the resident's hemodialysis access site. A review of Resident #6's comprehensive care plan dated 3/10/21, most recently updated on 3/23/21, revealed, in part: I am on [CONDITION(S)]. Go to [CONDITION(S)] center M W F (Monday, Wednesday, Friday) .Send medication list with resident, Assess for bruit (5) and assess for bleeding on the day of [CONDITION(S)] .I will go for [CONDITION(S)] at [name of [CONDITION(S)] center] M, W, F. On 3/24/21 at 3:25 p.m., RN (registered nurse) #1, the clinical manager, was interviewed, regarding physicians' orders for a resident receiving [CONDITION(S)]. RN #1 stated there should be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked to provide Resident #6's [CONDITION(S)] communication log/book, RN #1 stated the [CONDITION(S)] center has not been responding to the worksheets the facility staff has been sending to the center. She stated she could not provide any evidence that the facility has been attempting to communicate regularly with the [CONDITION(S)] center. RN #1 stated this communication is important so that both the facility and the [CONDITION(S)] center can be constantly updated on the resident's status. On 3/24/21 at 4:25 p.m., LPN (licensed practical nurse) #1 was interviewed. When asked about Resident #6's [CONDITION(S)] status, she stated the resident goes to [CONDITION(S)] three times a week, and that the resident has a [CONDITION(S)] access site which the staff assesses for bruit and thrill, and for bleeding. LPN #1 stated the resident should definitely have physicians' orders related to the resident's [CONDITION(S)] needs. She stated the facility and [CONDITION(S)] should exchange information at least every [CONDITION(S)] day, and more often, if needed. LPN #1 stated she thought there was some sort of folder used to exchange information for Resident #6, but was unsure of its location or how often it was used. On 3/24/21 at 5:40 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing were informed of these concerns. On 3/25/21 at 4:00 p.m., ASM #2 stated the facility staff could not locate any additional information related to [CONDITION(S)] orders or a [CONDITION(S)] communication system for Resident #6. A review of the facility policy, [CONDITION(S)], revealed, in part: Communication between the Continuing Care team and the [CONDITION(S)] center will be 24 hours a day to relay resident guest concerns/issues regarding [CONDITION(S)]. The Clinical Manager/Designee of each neighborhood will be the designated contact person to provide communication, coordination and collaboration .to the [CONDITION(S)] team. The Clinical Manager/designee will create a Communication Book for each resident who is receiving [CONDITION(S)]. The [CONDITION(S)] Communication Worksheet accompanies the resident during each [CONDITION(S)] visit to enhance communication. No further information was provided prior to exit. (1) End-stage kidney disease (ESKD) is the last stage of long-term (chronic) kidney disease. This is when your kidneys can no longer support your body's needs. End-stage kidney disease is also called end-stage renal disease ([CONDITION(S)]). This information is taken from the website https://medlineplus.gov/ency/article/ 0.htm. (2) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html. (3) Dementia is a gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information is taken from the website https://medlineplus.gov/ency/article/ 6.htm. (4) When your kidneys are healthy, they clean your blood. They also make hormones that keep your bones strong and your blood healthy. When your kidneys fail, you need treatment to replace the work your kidneys used to do. Unless you have a kidney transplant, you will need a treatment called [CONDITION(S)]. There are two main types of [CONDITION(S)]. Both types filter your blood to rid your body of harmful wastes, extra salt, and water. Hemodialysis uses a machine. It is sometimes called an artificial kidney. You usually go to a special clinic for treatments several times a week. This information was taken from the website https://medlineplus.gov/[CONDITION(S)].html. (5) Your access is your lifeline. You will need to protect your access. Wash the area around your access with soap and warm water every day. Check the area for signs of infection, such as warmth or redness. When blood is flowing through your access and your access is working well, you can feel a vibration over the area. Let your [CONDITION(S)] center know if you can't feel the vibration. This information is taken from the website https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/hemodialysis.

Based on staff interview and clinical record review, it was determined that the facility staff failed to ensure the medication regimen was free from unnecessary medications for one of 24 residents in the survey sample, Resident # 16. The facility staff failed to conduct a pain assessment and failed to attempt / provide non-pharmacological interventions prior to the administering as needed pain medication Tylenol, to Resident #16. The findings include: Resident # 16 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] fracture of the femur [2], dementia [3] and pain. Resident # 16's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 02/09/2021, coded Resident # 16 as scoring a 01 [one] on the brief interview for mental status (BIMS) of a score of 0 - 15, 1 - being severely impaired of cognition for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 16 as having occasional pain at a level of 5 [five] on a pain scale of zero to ten, with ten being the worse pain. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . TABLET Oral As Needed Every Four Hours Starting 02/09/2021. Order Date: 2/9/2021. Resident # 16's eMAR [electronic medication administration record] dated February 2021 documented the above physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the eMAR revealed the administration of Tylenol on: 02/11/2021 at 8:33 a.m., 02/13/2021 at 9:11 a.m., 02/17/2021 at 3:06 p.m., 02/18/2021 at 10:14 a.m., and on 02/23/2021 at 9:12 a.m. Resident # 16's eMAR [electronic medication administration record] dated March 2021 documented the above physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the eMAR revealed the administration of Tylenol on: 03/04/2021 at 10:19 a.m. and on 03/20/2021 at 11:32 a.m. The comprehensive care plan for Resident # 16 dated 02/09/2021 documented in part, Goals: I will need assistance with monitoring effectiveness of pain management throughout the day. I will receive my pain medication as prescribed by physician. I will appear comfortable as evidenced by no facial grimacing, guarding, or groaning throughout the day. Under Other Goals it documented in part, These are non-medical routine(s) or action(s) I take to alleviate pain: Distraction. Relaxation. Date Begun: 02/09/2021. Review of Resident # 16's progress notes dated 02/09/2021 through 03/24/2021 failed to evidence documentation of a pain assessment and the implementation of non-pharmacological interventions prior to the administration of the as needed Tylenol on 02/11/2021 at 8:33 a.m.,., 02/17/2021 at 3:06 p.m., 02/18/2021 at 10:14 a.m., 02/23/2021 at 9:12 a.m., 03/04/2021 at 10:19 a.m. and on 03/20/2021 at 11:32 a.m. Further review of the notes failed to evidence the implementation of non-pharmacological interventions prior to the administration of the as needed Tylenol on 02/13/2021 at 9:11 a.m. On 03/23/20 at approximately 11:58 a.m., an interview was conducted with RN [registered nurse] # 1, regarding the procedure nurses should follow when administering an as needed pain medication. RN #1 stated that the resident should be assessed for pain by determining a pain level and for Resident # 16, the nurse would look for nonverbal cues such as grimacing, yelling or moaning to determine Resident # 16's level of pain because of Resident # 16's confusion and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . If it doesn't help check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if the pain assessment and attempted non-pharmacological strategies are documented in the clinical record, RN # 1 stated that they are documented in the nurse's notes. RN # 1 was then asked to review the eMAR and nurse's notes for the dates list above for the administration of Resident # 16's as needed Tylenol. RN # 1 agreed that there was no documented evidence staff completed a pain assessment or attempted/ provided non-pharmacological strategies prior to administering the as needed Tylenol to Resident #16 on the dates and times documented above. RN # 1 further stated that if it wasn't documented then they couldn't say that it was being done. The facility's policy Pain Management documented in part, Policy: Guests/residents are screened and assessed for the existence of pain, the effectiveness of pain relief efforts and determination of potential underlying causes to ensure highest practicable level of wellbeing. Process: 1. Guest/residents will be assessed at admission/re-admission, significant change of condition and per state/federal regulations. 2. Nurse completes pain section of the Holistic Assessment with the input from the guest/resident, responsible party (if appropriate), the interdisciplinary team and/or designated care associates as appropriate. 3. Nurse uses the Numerical Pain Intensity Scale and/or physical observations to identify presence of pain. 4. Assessment will include cultural, spiritual and / or ethnic beliefs that may impact an individual's perception of pain. 5. Nurse will notify provider of existing pain and/or history of pain presently relieved or not relieved by medications and non-medicinal approaches. 9. Care/Service plan is developed addressing causative factor(s) of pain as well as nonmedicinal approaches to relieving pain. On 03/25/2021 at approximately 10:40 a.m., ASM # 1, director of continuing care and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit. References: [1] Acetaminophen is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of [CONDITION(S)] (arthritis caused by the breakdown of the lining of the joints). Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 4.html. [2] The thigh bone, or femur, is the large upper leg bone that connects the lower leg bones (knee joint) to the pelvic bone (hip joint). This information was obtained from the website: https://medlineplus.gov/ency/imagepages/8844.htm. [3] A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/ 9.htm.

Based on staff interview and clinical record review, it was determined that the facility staff failed to implement a complete pain management program consistent with professional standards of practice, and the comprehensive person-centered care plan for one of 24 residents in the survey sample, Resident # 16. The facility staff failed to conduct a pain assessments and failed to attempt/provide non-pharmacological interventions prior to the administration of physician prescribed as needed pain medication Tylenol to Resident #16 on multiple occasions. The findings include: Resident # 16 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] fracture of the femur [2], dementia [3] and pain. Resident # 16's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 02/09/2021, coded Resident # 16 as scoring a 01 [one] on the brief interview for mental status (BIMS) of a score of 0 - 15, 1 - being severely impaired of cognition for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 16 as having occasional pain at a level of 5 [five] on a pain scale of zero to ten, with ten being the worse pain. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . TABLET Oral As Needed Every Four Hours Starting 02/09/2021. Order Date: 2/9/2021. The comprehensive care plan for Resident # 16 dated 02/09/2021 documented in part, Goals: I will need assistance with monitoring effectiveness of pain management throughout the day. I will receive my pain medication as prescribed by physician. I will appear comfortable as evidenced by no facial grimacing, guarding, or groaning throughout the day. Under Other Goals it documented in part, These are non-medical routine(s) or action(s) I take to alleviate pain: Distraction. Relaxation. Date Begun: 02/09/2021. Resident # 16's eMAR [electronic medication administration record] dated February 2021 documented the above physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The eMAR failed to evidence documentation of pain assessment that included Resident # 16's pain level, location of pain and the non-pharmacological interventions attempted or provided. Further review of the eMAR revealed the administration of Tylenol on: 02/11/2021 at 8:33 a.m., 02/13/2021 at 9:11 a.m., 02/17/2021 at 3:06 p.m., 02/18/2021 at 10:14 a.m., and on 02/23/2021 at 9:12 a.m. Resident # 16's eMAR [electronic medication administration record] dated March 2021 documented the above physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the eMAR revealed the administration of Tylenol on: 03/04/2021 at 10:19 a.m. and on 03/20/2021 at 11:32 a.m. Review of Resident # 16's progress notes dated 02/09/2021 through 03/24/2021 failed to evidence documentation of a pain assessment and the attempted/ provided non-pharmacological interventions prior to the administration of as needed Tylenol on 02/11/2021 at 8:33 a.m.,., 02/17/2021 at 3:06 p.m., 02/18/2021 at 10:14 a.m., 02/23/2021 at 9:12 a.m., 03/04/2021 at 10:19 a.m. and on 03/20/2021 at 11:32 a.m. Further review of the notes failed to evidence the implementation of non-pharmacological interventions prior to the administration of as needed (prn) Tylenol on 02/13/2021 at 9:11 a.m. On 03/23/20 at approximately 11:58 a.m., an interview was conducted with RN [registered nurse] # 1, regarding to the procedure staff follows when administering an as needed pain medication. RN #1 stated that the resident should be assessed for pain by determining a pain level and for Resident # 16, the nurse would look for nonverbal cues such as grimacing, yelling or moaning to determine Resident # 16's level of pain because of Resident # 16's confusion and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . If it doesn't help check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if the staff document the pain assessment and attempted non-pharmacological strategies in the clinical record, RN # 1 stated that they are documented in the nurse's notes. RN # 1 was then asked to review the eMAR and nurse's notes for the dates list above for the administration of Resident # 16's as needed Tylenol. RN # 1 stated that there was no evidence of documentation of a pain assessment or the attempts of non-pharmacological strategies documented. RN # 1 further stated that if it wasn't documented then they couldn't say that it was being done. The facility's policy Pain Management documented in part, Policy: Guests/residents are screened and assessed for the existence of pain, the effectiveness of pain relief efforts and determination of potential underlying causes to ensure highest practicable level of wellbeing. Process: 1. Guest/residents will be assessed at admission/re-admission, significant change of condition and per state/federal regulations. 2. Nurse completes pain section of the Holistic Assessment with the input from the guest/resident, responsible party (if appropriate), the interdisciplinary team and/or designated care associates as appropriate. 3. Nurse uses the Numerical Pain Intensity Scale and/or physical observations to identify presence of pain. 4. Assessment will include cultural, spiritual and / or ethnic beliefs that may impact an individual's perception of pain. 5. Nurse will notify provider of existing pain and/or history of pain presently relieved or not relieved by medications and non-medicinal approaches. 9. Care/Service plan is developed addressing causative factor(s) of pain as well as nonmedicinal approaches to relieving pain. On 03/23/2021 during the entrance conference a request was made to ASM [administrative staff member] # 1, director of continuing care and ASM # 2, director of nursing, for the standard of nursing that the facility follows. At 12:41 p.m. a copy of the front page of the Lippincott Manual of Nursing Practice was provided by email to the survey team. According to Fundamentals of Nursing- Lippincott, Williams and Wilkins 2006 page 158, Standards of Care Guidelines: Assess pain repeatedly by questioning patient, looking for nonverbal signs of pain, and using appropriate pain rating scale. Help the patient employ non-pharmacologic measures. To provide effective pain management, nursing assessment physical examination, 1. Screen for pain at each visit. Evaluate objectively the nature of the patient's pain including location, duration, quality, and impact on daily activities 3. Use a pain intensity scale of 0 (no pain) to 10 (worst possible pain) or other scale as appropriate. On 03/25/2021 at approximately 10:40 a.m., ASM # 1, director of continuing care and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit. References: [1] Acetaminophen is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of [CONDITION(S)] (arthritis caused by the breakdown of the lining of the joints). Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 4.html. [2] The thigh bone, or femur, is the large upper leg bone that connects the lower leg bones (knee joint) to the pelvic bone (hip joint). This information was obtained from the website: https://medlineplus.gov/ency/imagepages/8844.htm. [3] A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/ 9.htm.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provided respiratory care, consistent with professional standards of practice and the plan of care for one of 24 residents in the survey sample, Resident #8. The facility staff failed to store Resident #8's incentive spirometer in a sanitary manner when not in use. The findings include: Resident # 8 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 8's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 01/ 21, coded Resident # 8 as scoring a 10 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 10- being moderately impaired of cognition for making daily decisions. On 03/23/2021 at approximately 11:29 a.m., an observation of Resident #8's room revealed an incentive spirometer [1] on the resident's computer table uncovered. On 03/23/2021 at approximately 2:10 p.m., an observation of Resident #8's room revealed an incentive spirometer on the resident's computer table uncovered. On 03/24/2021 at approximately 9:08 a.m., an observation of Resident #8's room revealed an incentive spirometer on the resident's computer table uncovered. The POS [physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] # 8 dated February 2021 documented, Incentive Spirometer. Notes: While awake. Order Date: 10/20/2020. Frequency: Three times Daily. The comprehensive care plan for Resident # 8 dated of 01/11/2021 failed to evidence the use of an incentive spirometer. On 03/23/2021 at approximately 11:29 a.m., an interview with Resident # 8. When asked about the incentive spirometer Resident # 8 stated that they used it every day. On 3/24/21 at 12:20 p.m., ASM [administrative staff member] # 2, director of nursing, provided this surveyor a copy of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician's Telephone Order dated 03/24/2021 for Resident # 8 documented, D/C [discontinue] incentive spirometer. When asked what time the order was signed by the physician ASM # 2 stated Around 11:00 a.m. On 03/23/20 at approximately 1:00 p.m. an interview was conducted with RN [registered nurse] # 1. When asked if an incentive spirometer was a piece of respiratory equipment, RN # 1 stated yes. When asked about storage of the incentive spirometer when not in use, RN # 1 stated, Traditionally it is not stored in anything. On 03/23/2021 during the entrance conference a request was made to ASM [administrative staff member] # 1, director of continuing care and ASM # 2, director of nursing, for the standard of nursing that the facility follows. At 12:41 p.m. a copy of the front page of the Lippincott Manual of Nursing Practice was provided by email to the survey team. Wash the mouthpiece in warm water and dry it. Avoid immersing the spirometer itself in water because water enhances bacterial growth and impairs the internal filter's effectiveness in preventing inhalation of extraneous material. Place the mouthpiece in a plastic storage bag between exercises, and label it and the spirometer, if applicable, with the patient's name to avoid inadvertent use by another patient. Keep the incentive spirometer within the patient's reach. Lippincott's Nursing Procedures (6th Edition) 2013. On 03/25/2021 at approximately 10:40 a.m., ASM # 1, director of continuing care and ASM # 2, director of nursing, were made aware of the findings. During this conversation ASM # 2 stated that after the this surveyor's interview with RN # 1, they informed ASM # 2 that they were nervous during the interview regarding Resident # 8's incentive spirometer. ASM # 2 further stated that RN # 1 could not clearly explain how the incentive spirometer should have been stored during the interview. ASM # 2 stated that RN # 1 knew the correct way to store the incentive spirometer and verbally confirmed that the incentive spirometer should have been covered or placed in a bag when not in use during this conversation. No further information was provided prior to exit. References: [1] A device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. Using the incentive spirometer teaches you how to take slow deep breaths. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/ 1.htm. [2] A type of movement disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/parkinsonsdisease.html.

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the the facility staff failed to follow professional standards of practice for transcribing physician orders into the clinical record for one of 24 residents in the survey sample, Resident #12. The facility staff failed to transcribe and Resident #12's hospital physician's orders for non-weight bearing status of her right arm, sling and surgical wound at the time of her readmission. The findings include: Resident #12 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/21/21, Resident #12 was coded as moderately cognitively impaired for making daily decisions, having scored a nine out of 15 on the BIMS (brief interview for mental status). She was coded as requiring the extensive assistance of one or two staff members for med mobility, transferring from bed to chair, dressing, toileting, and personal hygiene. She was coded as being totally dependent on the assistance of two staff members for bathing. Resident #12 was coded as being unsteady, requiring staff assistance, for moving from a sitting to standing position, walking, getting on and off the toilet, and transferring from surface to surface. On the following dates and times, Resident #12 was observed in her room, sitting in her wheelchair, wearing a sling on her right arm: 3/23/21 at 12:23 p.m. and 3/24/21 at 11:45 a.m. A review of Resident #12's clinical record revealed no evidence of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #12's clinical record revealed a hospital discharge summary dated 3/1/21. The discharge summary described the resident's stay, including a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary included, in part: Postoperatively the patient was made non-weight bearing Right Upper Extremity. A review of Resident #12's comprehensive care plan dated 3/2/21 revealed no information regarding the resident's surgical wound or the resident's non-weigh bearing status for her right arm. On 03/23/2021 during the entrance conference a request was made to ASM [administrative staff member] # 1, director of continuing care and ASM # 2, director of nursing, for the standard of nursing that the facility follows. At 12:41 p.m. a copy of the front page of the Lippincott Manual of Nursing Practice was provided by email to the survey team. On 3/24/21 at 3:25 p.m., RN (registered nurse) #1, the clinical manager, was interviewed, regarding how staff know the care to provide for a resident who has a surgical wound and is non-weight bearing with a sling. RN #1 stated the staff can look at the documents in the resident's hard chart on the unit, on the care plan, and in the electronic medical record (EMR). She stated the facility maintains a hard chart which contains hospital discharge summaries, information from consulting physicians, and other information or direction from outside providers. RN #1 stated the admitting nurse is responsible for transcribing orders for the resident's care from the hospital discharge summary to the EMR. After reviewing Resident #12's orders, RN #1 stated she did not see orders for non-weight bearing status, sling, or care of the surgical wound. She stated these orders should have been transcribed from the hospital discharge summary to the EMR (electronic medical record) when the resident was admitted to the facility. On 3/24/21 at 4:11 p.m., OSM (other staff member) #2, an occupational therapy assistant, was interviewed regarding how facility staff know the care required for a resident with non-weight bearing status to the right arm. OSM #2 stated the information should originally come from the discharging hospital or consultant specialist. She stated the facility staff needs to know which arm is affected, needs to know how to correctly position the arm in the sling to maintain the non-weight bearing status, needs to know how long each day or night the resident needs to wear the sling, and needs to assess the resident's skin behind the neck. When asked if this information should be included in the resident's orders, OSM #2 stated, Yes. Absolutely. On 3/24/21 at 4:25 p.m., LPN (licensed practical nurse) #1 was interviewed. When asked if information about a resident's non-weight bearing status, sling, and surgical wound should be included in the physician's orders, LPN #1 stated it should. She stated the process is for the admitting nurse to review the discharge orders from the hospital, and transcribe those orders to the resident's EMR (electronic medical record) and care plan. LPN #1 stated the nurse then passes on that information to CNAs (certified nursing assistants) and other nurses who care for the resident in the shift-to-shift report. On 3/24/21 at 5:40 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing were informed of these concerns. On 3/25/21 at 4:00 p.m., ASM #2 stated the facility staff could not locate any additional information related to Resident #12's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the facility policy, admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .When the signed physician discharge summary arrives with the resident, the licensed nurse will notify the medical provider .The nurse will review the orders with the medical provider prior to entering the orders into the electronic order entry system. According to Fundamentals of Nursing- Lippincott, Williams and Wilkins 2007 page 169, After you receive a written medication order, transcribe it onto a working document approved by your health care facility .read the order carefully, concentrate on copying it correctly, check it when you're finished. No further information was provided prior to exit. (1) Dementia is a gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information is taken from the website https://medlineplus.gov/ency/article/ 6.htm.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for one of 24 residents in the survey sample, Resident #6. The facility failed to update Resident #6's comprehensive care plan to address a UTI (urinary tract infection) and treatment with an antibiotic. The findings include: Resident #6 was admitted to the facility on [DATE], and was most recently readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/18/20, Resident #6 was coded as being severely cognitively impaired for making daily decisions, having scored seven out of 15 on the BIMS (brief interview for mental status). A review of Resident #6's clinical record revealed the following order, dated 3/16/21: [MEDICATION(S)] (4) 250 mg (milligrams) po (by mouth) BID (twice a day) X 7 days (for seven days) for UTI (5). Further review of Resident #6's clinical record revealed a physician's progress note dated 3/16/21, which documented, in part: Reason for visit: Urinary burning/UTI .Antibiotic as ordered. On 3/24/21 at 3:25 p.m., RN (registered nurse) #1, the clinical manager, was interviewed regarding the purpose of a resident's comprehensive care plan. RN #1 stated, It tells us what the resident needs. When asked if a care plan should include new infections and antibiotics prescribed for a resident, RN #1 stated it should. RN #1 was asked to review the comprehensive care plan for Resident #12 for information related to her UTI and antibiotic for treatment. After her review, RN #1 stated she did not see any such information. She stated the nurse who receives the order from the provider is responsible for making sure this kind of information is added to the resident's care plan. On 3/24/21 at 4:25 p.m., LPN (licensed practical nurse) #1 was interviewed. When asked if information about a resident's UTI and antibiotic for treatment should be included in the comprehensive care plan, LPN #1 stated it should. LPN #1 stated the nurse who receives the order should update the care plan. She stated the nurse then passes on that information to CNAs (certified nursing assistants) and other nurses who care for the resident in the shift-to-shift report. On 3/24/21 at 5:40 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing were informed of these concerns. A review of the facility policy, Care/Service Plans, revealed, in part: Each guest/resident will have an individualized Care/Service plan developed. Care/Service Plans will include guest/resident preferences, strengths, routines, personal and cultural preferences and choices as well as clinical needs .A comprehensive person centered care plan will be developed by the Interdisciplinary Team and be completed within 72 hours of admission and will include measurable objectives, preferences, goals .resident's discharge plan and will address the resident's medical, nursing, mental and psychosocial needs as identified from the resident's comprehensive assessment .Care plans will be reviewed, revised if applicable, on an ongoing basis by the interdisciplinary team with any change in condition, and after each assessment. No further information was provided prior to exit. (1) End-stage kidney disease (ESKD) is the last stage of long-term (chronic) kidney disease. This is when your kidneys can no longer support your body's needs. End-stage kidney disease is also called end-stage renal disease ([CONDITION(S)]). This information is taken from the website https://medlineplus.gov/ency/article/ 0.htm. (2) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html. (3) Dementia is a gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information is taken from the website https://medlineplus.gov/ency/article/ 6.htm. (4) [MEDICATION(S)] is used to treat certain infections caused by bacteria, such as [CONDITION(S)] (infection of the airway tubes leading to the lungs); gonorrhea (a sexually transmitted disease); Lyme disease (an infection that may develop after a person is bitten by a tick); and infections of the skin, ears, sinuses, throat, tonsils, and urinary tract. [MEDICATION(S)] is in a class of medications called cephalosporin antibiotics. It works by stopping the growth of bacteria. This information is taken from the website https://medlineplus.gov/druginfo/meds/a 6.html. (5) Urinary tract infection (UTI) is a collective term that describes any infection involving any part of the urinary tract, namely the kidneys, ureters, bladder and urethra. The urinary tract can be divided into the upper (kidneys and ureters) and lower tract (bladder and urethra). This information is taken from the website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 97/#:~:text=Urinary%20tract%20infection%20(UTI)%20is%20a%20collective%20term%20that%20describes,tract%20(bladder%20and%20urethra).

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to implement or develop a comprehensive care plan for three of 24 residents in the survey sample, Residents # 16, # 8 and # 12. 1. The facility staff failed to implement Resident # 16's comprehensive care plan for the use of non-pharmacological interventions prior to the administration of the physician prescribed as needed pain medication, Tylenol [1]. 2. The facility staff failed to develop a comprehensive care plan for the use of an incentive spirometer [1] for Resident # 8. 3. The facility staff failed to develop a comprehensive care plan to address Resident #12's use of a sling and a surgical wound dressing present on readmission. The findings include: 1. Resident # 16 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 16's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 02/09/2021, coded Resident # 16 as scoring a 01 [one] on the brief interview for mental status (BIMS) of a score of 0 - 15, 1 - being severely impaired of cognition for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 16 as having occasional pain at a level of 5 [five] on a pain scale of zero to ten, with ten being the worse pain. The current physician's order for Resident # 16 dated March 2021 documented, Tylenol 325 MG [milligrams] tablet (2). TABLET Oral As Needed Every Four Hours Starting 02/09/2021. Order Date: 2/9/2021. Resident # 16's eMAR [electronic medication administration record] dated February 2021 documented the above physician's order for Tylenol. The eMAR failed to evidence documentation of pain assessment that included Resident # 16's pain level, location of pain and non-pharmacological interventions. Further review of the eMAR revealed the administration of Tylenol on: 02/11/2021 at 8:33 a.m., 02/13/2021 at 9:11 a.m., 02/17/2021 at 3:06 p.m., 02/18/2021 at 10:14 a.m., and on 02/23/2021 at 9:12 a.m. Resident # 16's eMAR [electronic medication administration record] dated March 2021 documented the above physician's order for Tylenol. The eMAR failed to evidence documentation of pain assessment that included Resident # 16's pain level, location of pain and non-pharmacological interventions. Further review of the eMAR revealed the administration of Tylenol on: 03/04/2021 at 10:19 a.m. and on 03/20/2021 at 11:32 a.m. The comprehensive care plan for Resident # 16 dated 02/09/2021 documented in part, Goals: I will need assistance with monitoring effectiveness of pain management throughout the day. I will receive my pain medication as prescribed by physician. I will appear comfortable as evidenced by no facial grimacing, guarding, or groaning throughout the day. Under Other Goals it documented in part, These are non-medical routine(s) or action(s) I take to alleviate pain: Distraction. Relaxation. Date Begun: 02/09/2021. Review of Resident # 16's progress notes dated 02/09/2021 through 03/24/2021 failed to evidence documentation of a pain assessment and the implementation of non-pharmacological interventions prior to the administration of as needed Tylenol on 02/11/2021 at 8:33 a.m., 02/17/2021 at 3:06 p.m., 02/18/2021 at 10:14 a.m., 02/23/2021 at 9:12 a.m., 03/04/2021 at 10:19 a.m. and on 03/20/2021 at 11:32 a.m. Further review of the notes failed to evidence the implementation of non-pharmacological interventions prior to the administration of as needed Tylenol on 02/13/2021 at 9:11 a.m. On 03/23/20 at approximately 11:58 a.m., an interview was conducted with RN [registered nurse] # 1, regarding the purpose of a resident's comprehensive care plan. RN # 1 stated, To identify resident's needs and for staff to follow to meet the needs of the resident. RN # 1 was then asked to review the eMAR and nurse's notes for the dates list above for the administration of Resident # 16's as needed Tylenol. RN # 1 agreed that there was no evidence of documentation of non-pharmacological strategies on 02/11/2021 at 8:33 a.m., 02/13/2021 at 9:11 a.m., 02/17/2021 at 3:06 p.m., 02/18/2021 at 10:14 a.m., 02/23/2021 at 9:12 a.m., 03/04/2021 at 10:19 a.m. and on 03/20/2021 at 11:32 a.m. RN # 1 further stated that if it wasn't documented then they couldn't say that it was being done. When asked if Resident # 16's comprehensive care plan was being implemented for the use of non-pharmacological interventions if there was no documentation that they were being attempted, RN # 1 stated no. On 03/25/2021 at approximately 10:40 a.m., ASM # 1, director of continuing care and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit. References: [1] Acetaminophen is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of [CONDITION(S)] (arthritis caused by the breakdown of the lining of the joints). Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 4.html. [2] The thigh bone, or femur, is the large upper leg bone that connects the lower leg bones (knee joint) to the pelvic bone (hip joint). This information was obtained from the website: https://medlineplus.gov/ency/imagepages/8844.htm. [3] A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/ 9.htm. 2. The facility staff failed to develop a comprehensive care plan for the use of an incentive spirometer [1] for Resident # 8. Resident # 8 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 8's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 01/ 21, coded Resident # 8 as scoring a 10 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 10- being moderately impaired of cognition for making daily decisions. On 03/23/2021 at approximately 11:29 a.m., an observation of Resident #8's room revealed an incentive spirometer on the resident's computer table uncovered. On 03/23/2021 at approximately 2:10 p.m., an observation of Resident #8's room revealed an incentive spirometer on the resident's computer table uncovered. On 03/24/2021 at approximately 9:08 a.m., an observation of Resident #8's room revealed an incentive spirometer on the resident's computer table uncovered. The POS [physician's order sheet] for Resident # 8 dated February 2021 documented, Incentive Spirometer. Notes: While awake. Order Date: 10/20/2020. Frequency: Three times Daily. The comprehensive care plan for Resident # 8 dated of 01/11/2021 failed to evidence the use of an incentive spirometer. On 03/23/2021 at approximately 11:29 a.m., an interview with Resident # 8. When asked about the incentive spirometer Resident # 8 stated that they used it every day. On 3/24/21 at 12:20 p.m., ASM [administrative staff member] # 2, director of nursing, provided a copy of a physician's order to discontinue the use of the incentive spirometer for Resident # 8. The Physician's Telephone Order dated 03/24/2021 for Resident # 8 documented, D/C [discontinue] incentive spirometer. When asked what time the order was signed by the physician, ASM # 2 stated Around 11:00 a.m. On 03/25/2021 at approximately 10:40 a.m., ASM # 1, director of continuing care and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit. References: [1] A device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. Using the incentive spirometer teaches you how to take slow deep breaths. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/ 1.htm. [2] A type of movement disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/parkinsonsdisease.html. 3. The facility staff failed to develop a comprehensive care plan to address Resident #12's use of a sling and a surgical wound dressing present on readmission. Resident #12 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), an admission assessment with an a]ARD (assessment reference date) of 2/21/21, Resident #12 was coded as moderately cognitively impaired for making daily decisions, having scored a nine out of 15 on the BIMS (brief interview for mental status). She was coded as requiring the extensive assistance of one or two staff members for bed mobility, transferring from bed to chair, dressing, toileting, and personal hygiene. She was coded as being totally dependent on the assistance of two staff members for bathing. She was coded as being unsteady, requiring staff assistance, for moving from a sitting to standing position, walking, getting on and off the toilet, and transferring from surface to surface. On the following dates and times, Resident #12 was observed in her room, sitting in her wheelchair, wearing a sling on her right arm: 3/23/21 at 12:23 p.m. and 3/24/21 at 11:45 a.m. A review of Resident #12's clinical record revealed no evidence of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of Resident #12's clinical record revealed a hospital discharge summary dated 3/1/21. The discharge summary described the resident's stay, including a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary included, in part: Postoperatively the patient was made non-weight bearing Right Upper Extremity. A review of Resident #12's comprehensive care plan dated 3/2/21 revealed no information regarding the resident's surgical wound or the resident's non-weight bearing status for her right arm. On 3/24/21 at 3:25 p.m., RN (registered nurse) #1, the clinical manager, was interviewed, regarding how the staff know the care to provide a resident who has a surgical wound and is non-weight bearing for the right arm with a sling. RN #1 stated the staff can look at the documents in the resident's hard chart on the unit, on the care plan, and in the electronic medical record (EMR). RN #1 stated the facility maintains a hard chart which contains hospital discharge summaries, information from consulting physicians, and other information or direction from outside providers. When asked if information related to a resident's non-weight bearing status and surgical wound should be included in the care plan, RN #1 stated, Yes. The care plan tells us basically how to take care of a resident. When asked to review the comprehensive care plan for Resident #12 for information related to her non-weight bearing status of the right arm and surgical wound, RN #1 did so. After her review, RN #1 stated she did not see any such information. RN #1 stated the admitting nurse is responsible for making sure this kind of information is added to the resident's care plan. On 3/24/21 at 4:11 p.m., OSM (other staff member) #2, an occupational therapy assistant, was interviewed regarding how the facility staff knows a resident's non-weight bearing status of an arm. OSM #2 stated the information should originally come from the discharging hospital or consultant specialist. OSM #2 stated the facility staff needs to know which arm is affected, needs to know how to correctly position the arm in the sling to maintain the non-weight bearing status. OSM #2 stated the staff needs to know how long each day or night the resident needs to wear the sling, and they need to assess the resident's skin behind the neck. When asked if this information should be included in the comprehensive care plan, OSM #2 stated, Yes. Absolutely. On 3/24/21 at 4:25 p.m., LPN (licensed practical nurse) #1 was interviewed. When asked if information about a resident's non-weight bearing status, sling, and surgical wound should be included in the care plan, LPN #1 stated it should. She stated the process is for the admitting nurse to review the discharge orders from the hospital, and transcribe those orders to the resident's EMR (electronic medical record) and care plan. LPN #1 stated the nurse then passes on that information to CNAs (certified nursing assistants) and other nurses who care for the resident in the shift-to-shift report. On 3/24/21 at 5:40 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing were informed of these concerns. On 3/25/21 at 4:00 p.m., ASM #2 stated the facility staff could not locate any additional information related to Resident #12's care plan. On 3/26/21 at 10:08 a.m., RN #3 was interviewed about the care planning process. She stated once the resident is admitted or readmitted , the admitting nurse begins the care plan process. RN #3 stated once she completes her assessment, she shares triggered items for the care plan with clinical managers. She stated any updates for care plans are written in the documents contained in the care plan binders in each resident's room. When asked specifically about Resident #12's care plan for the non-weight bearing status, the sling, and the surgical wound, RN #3 stated she relies on therapy heavily for these care plan goals. RN #3 stated, Ideally, therapy goals would also be included in the comprehensive plan of care. Ideally, that's how that would work. RN #3 stated, however, Resident #12's care plan did not contain these items. A review of the facility policy, Care/Service Plans, revealed, in part: Each guest/resident will have an individualized Care/Service plan developed. Care/Service Plans will include guest/resident preferences, strengths, routines, personal and cultural preferences and choices as well as clinical needs .A comprehensive person centered care plan will be developed by the Interdisciplinary Team and be completed within 72 hours of admission and will include measurable objectives, preferences, goals .resident's discharge plan and will address the resident's medical, nursing, mental and psychosocial needs as identified from the resident's comprehensive assessment. No further information was provided prior to exit. (1) Dementia is a gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information is taken from the website https://medlineplus.gov/ency/article/ 6.htm.

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to prepare and serve food in a sanitary manner. The facility staff failed to keep from touching the food contact surfaces of the resident's dishes with their bare hands while serving the resident's dinner in main dining room. The findings include: On 7/10/19 between 4:47 PM and 5:59 PM, an observation of the dinner meal tray-line service in the kitchen area of the main dining room was conducted. OSM (Other Staff Member) #4, the Dining Associate, was observed as she prepared each plate for the dining room and trays for residents eating in their rooms. OSM #4 was observed wearing gloves for preparing the plates. She was noted to handle serving spoon handles, tongs, and other items potentially contaminating her gloves before handling the plates. OSM #4 was observed to lifting each plate with her gloved hand with her thumb on the food contact surface. OSM #4 was not wearing gloves, was observed picking up saucers for soup bowls with her thumb on the food-contact surface area of the saucer. OSM #2 then placed the saucers on a serving tray, during the soup service. On 7/11/19 at 11:00 AM, an interview with OSM #4 was conducted. OSM #4 was asked about the process for serving resident food. OSM #4 stated, You hold the soup bowl on the bottom. I can't touch the inside or the rim. Everything by the bottom or handle. The plates by the bottom. You cannot put your hands or thumb inside the plate. When asked if she should touch the food-contact surface area of saucers, OSM #4 stated, I have to put it in the dirty dishes. It is contaminated and get a new one. When informed of observations, she stated, I have to switch out my gloves all the time. I did not change my gloves. On 7/11/19 at 11:12 PM, an interview was conducted with OSM #2, the Dining Service Manager. OSM #2 was asked about the process staff follows for serving resident food. OSM #2 stated, You wash your hands. Only handle tools and grab the plate, not using thumbs, put hand under plate, the thumb should not touch the rim of the plate. When asked what should happen if the top of the food contact surface area is touched, OSM #2 stated, They have to wash their hands and put on new gloves. A review of the facility's policy Food Handling Sanitation documented in part, Purpose .To ensure the prevention of food borne illness Policy: High standards of sanitation will be maintained and practiced in all community food preparation and service areas .Procedure: Continuing care staff will practice proper sanitation at all times when handling food. A review of the facility's ServSafe Food Handler Guide documented in part, Preventing Cross-Contamination When Serving Food .Surfaces that touch food are called food-contact surfaces Plates, glasses, forks, and tongs are examples. You can contaminate these surfaces if you are not careful when handling them .Do NOT touch the parts of dishes or glassware that come in contact with food . On 7/11/19 at 4:21 PM, ASM (Administrative Staff Member) #1, the Administrator and ASM #2, the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to complete a quarterly MDS assessment within the required time frames, and/or at all, for five of 31 residents in the survey sample; Residents #2, #4, #6, #10, and #8. 1. For Resident #2 the facility staff failed to complete a quarterly MDS assessment with an ARD of 5/1/19 in the required time frame. The quarterly MDS assessment should have been completed on or approximately 5/15/19. 2. For Resident #4, the facility staff failed to complete a quarterly MDS assessment within the required time frame. The quarterly MDS assessment should have been completed on or approximately 5/10/19. 3. For Resident #6, the facility staff failed to complete a quarterly MDS assessment within the required time frame. The quarterly MDS assessment should have been completed on or approximately 5/27/19. 4. For Resident #10, the facility staff failed to complete a quarterly MDS assessment within the required time frame. The quarterly MDS assessment should have been completed on or approximately 5/15/19. 5. For Resident #8, the facility staff failed to complete a quarterly MDS assessment within the required time frame. The quarterly MDS assessment should have been completed on or approximately 6/7/19. The findings include: 1. For Resident #2 the facility staff failed to complete a quarterly MDS assessment with an ARD of 5/1/19 in the required time frame. Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/29/19 coded the resident as being cognitively intact in ability to make daily life decisions. The resident was coded as requiring total care for dressing and toileting; and extensive care for all other areas of activities of daily living. A review of the electronic clinical record revealed a list of the resident's MDS assessments. This list revealed that a quarterly assessment was scheduled with an ARD of 5/1/19. This list further revealed that this MDS was not completed until 7/10/19. On 7/11/19 at 10:16 AM, in an interview with ASM #2 (Administrative Staff Member) the Director of Nursing, she was notified of the concern. ASM #2 stated that the MDS coordinator had been on FMLA (Family Medical Leave Act) since (MONTH) 2019, and was out on leave from (MONTH) (YEAR) through (MONTH) 2019. ASM #2 stated that an MDS coordinator from another facility had been trying to fill in to help. On 7/15/19 at 11:40 AM, ASM #2 stated that she didn't have anything more to offer regarding the timely completion and/or transmission of MDS assessments that were not completed and/or transmitted timely or at all. A review of the facility policy, MDS Completion and Management documented, Resident Assessments will be completed for all residents accurately and in compliance with the most current RAI (Resident Assessment Instrument) MDS 3.0 User's Manual According to the RAI Manual, Version 1.16, dated (MONTH) (YEAR), the table on page 2-17 documented that a quarterly assessment is due no later than the ARD date plus 14 calendar days, making the due date for this assessment on or approximately 5/15/19. 2. For Resident #4, the facility staff failed to complete a quarterly MDS assessment within the required time frame. The quarterly MDS assessment should have been completed on or approximately 5/10/19. Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a significant change assessment with an ARD (Assessment Reference Date) of 2/8/19. The resident was coded as being severely impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing, toileting, and transfers; extensive care for dressing and hygiene; and supervision for eating. A review of the electronic clinical record revealed a list of the resident's MDS assessments. This list revealed that a quarterly assessment was scheduled with an ARD of 6/21/19. This assessment should have been scheduled on or approximately 5/10/19 and was late. As of the date of survey of 7/11/19, this assessment's status was documented as current and had no completion date. There were no other completed assessments since the 2/8/19 quarterly MDS. On 7/11/19 at 10:16 AM, in an interview with ASM #2 (Administrative Staff Member) the Director of Nursing, she was notified of the concern. ASM #2 stated that the MDS coordinator had been on FMLA (Family Medical Leave Act) since (MONTH) 2019, and was also out on leave from (MONTH) (YEAR) through (MONTH) 2019. ASM #2 stated that an MDS coordinator from another facility had been trying to fill in to help. On 7/15/19 at 11:40 AM, ASM #2 stated that she didn't have anything more to offer regarding the timely completion and/or transmission of MDS assessments that were not completed and/or transmitted timely or at all. A review of the facility policy, MDS Completion and Management documented, Resident Assessments will be completed for all residents accurately and in compliance with the most current RAI (Resident Assessment Instrument) MDS 3.0 User's Manual According to the RAI (Resident Assessment Instrument) Manual, Version 1.16, dated (MONTH) (YEAR), the table on page 2-17 documented that a quarterly assessment is due no later than the ARD date of the previous assessment plus 92 calendar days, making the due date for this assessment on or approximately 5/10/19. 3. For Resident #6, the facility staff failed to complete a quarterly MDS assessment within the required time frame. The quarterly MDS assessment should have been completed on or approximately 5/27/19. Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was an admission assessment with an ARD (Assessment Reference Date) of 2/25/19. The resident was coded as severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring extensive care for bathing, toileting, dressing, and transfers; and extensive assistance for eating and hygiene. A review of the electronic clinical record revealed a list of the resident's MDS assessments. This list revealed that a quarterly assessment was scheduled with an ARD of 6/21/19. This assessment should have been scheduled on or approximately 5/27/19 and was late. As of the date of survey of 7/11/19, this assessment's status was documented as current and had no completion date. There were no other completed assessments since the 2/25/19 admission MDS. On 7/11/19 at 10:16 AM, in an interview with ASM #2 (Administrative Staff Member) the Director of Nursing, she was notified of the concern. ASM #2 stated that the MDS coordinator had been on FMLA (Family Medical Leave Act) since (MONTH) 2019, and was out on leave from (MONTH) (YEAR) through (MONTH) 2019. ASM #2 stated that an MDS coordinator from another facility had been trying to fill in to help. On 7/15/19 at 11:40 AM, ASM #2 stated that she didn't have anything more to offer regarding the timely completion and/or transmission of MDS assessments that were not completed and/or transmitted timely or at all. A review of the facility policy, MDS Completion and Management documented, Resident Assessments will be completed for all residents accurately and in compliance with the most current RAI (Resident Assessment Instrument) MDS 3.0 User's Manual According to the RAI Manual, Version 1.16, dated (MONTH) (YEAR), the table on page 2-17 documented that a quarterly assessment is due no later than the ARD date of the previous assessment plus 92 calendar days, making the due date for this assessment on or approximately 5/27/19. 4. For Resident #10, the facility staff failed to complete a quarterly MDS assessment within the required time frame. The quarterly MDS assessment should have been completed on or approximately 5/15/19. Resident #10 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a significant change assessment with an ARD (Assessment Reference Date) of 2/13/19. The resident was coded as severely impaired in ability to make daily life decisions. The resident was coded as requiring extensive assistance for bathing, dressing, and transfers; limited assistance for toileting and hygiene; and was independent for eating. A review of the electronic clinical record revealed a list of the resident's MDS assessments. This list revealed that a quarterly assessment was scheduled with an ARD of 6/21/19. This assessment should have been scheduled on or approximately 5/15/19 and was late. As of the date of survey of 7/11/19, this assessment's status was documented as current and had no completion date. There were no other completed assessments since the 2/13/19 significant change MDS. On 7/11/19 at 10:16 AM, in an interview with ASM #2 (Administrative Staff Member) the Director of Nursing, she was notified of the concern. ASM #2 stated that the MDS coordinator had been on FMLA (Family Medical Leave Act) since (MONTH) 2019, and was out on leave from (MONTH) (YEAR) through (MONTH) 2019. ASM #2 stated that an MDS coordinator from another facility had been trying to fill in to help. On 7/15/19 at 11:40 AM, ASM #2 stated that she didn't have anything more to offer regarding the timely completion and/or transmission of MDS assessments that were not completed and/or transmitted timely or at all. A review of the facility policy, MDS Completion and Management documented, Resident Assessments will be completed for all residents accurately and in compliance with the most current RAI (Resident Assessment Instrument) MDS 3.0 User's Manual According to the RAI Manual, Version 1.16, dated (MONTH) (YEAR), the table on page 2-17 documented that a quarterly assessment is due no later than the ARD date of the previous assessment plus 92 calendar days, making the due date for this assessment on or approximately 5/15/19. 5. For Resident #8, the facility staff failed to complete a quarterly MDS assessment within the required time frame. The quarterly MDS assessment should have been completed on or approximately 6/7/19. Resident #8 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 2/22/19. The resident was coded as being severely impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing, toileting, dressing, and transfers; extensive assistance for hygiene; and supervision for eating. A review of the electronic clinical record revealed a list of the resident's MDS assessments. This list revealed that a quarterly assessment was scheduled with an ARD of 5/25/19. This list further revealed that this MDS was not completed until 6/21/19. This assessment was completed late and there were no other completed assessments since the 2/22/19 quarterly MDS. On 7/11/19 at 10:16 AM, in an interview with ASM #2 (Administrative Staff Member) the Director of Nursing, she was notified of the concern. ASM #2 stated that the MDS coordinator had been on FMLA (Family Medical Leave Act) since (MONTH) 2019, and was out on leave from (MONTH) (YEAR) through (MONTH) 2019. ASM #2 stated that an MDS coordinator from another facility had been trying to fill in to help. On 7/15/19 at 11:40 AM, ASM #2 stated that she didn't have anything more to offer regarding the timely completion and/or transmission of MDS assessments that were not completed and/or transmitted timely or at all. A review of the facility policy, MDS Completion and Management documented, Resident Assessments will be completed for all residents accurately and in compliance with the most current RAI (Resident Assessment Instrument) MDS 3.0 User's Manual According to the RAI Manual, Version 1.16, dated (MONTH) (YEAR), the table on page 2-17 documented that a quarterly assessment is due no later than the ARD date plus 14 calendar days, making the due date for this assessment on or approximately 6/7/19.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide Notice of Medicare Non-Coverage and the right to appeal for one of 31 sampled residents, Resident #40. Resident #40 was admitted on [DATE], and discharged on [DATE], and had used 15 of 100 Medicare days. The facility staff failed to evidence that Resident #40 or the resident representative was provided with a Notice of Medicare Non-Coverage and their right to appeal prior to the coverage end date of 4/5/19. The findings include: Resident #40 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set), a significant change in status assessment, with an ARD (Assessment reference date) of 6/3/19, coded the resident as scoring a 2 out of 15 on the BIMS (Brief Interview for Mental Status) score, indicating the Resident had cognitive impairment for daily decision making. The resident was coded as requiring extensive care for eating; total care for hygiene, bathing, dressing, toileting, and transfers. Resident #40 was coded as occasionally incontinent of bladder and bowel. A review of the clinical record revealed a note dated 4/5/19 at 12:06 PM, which documented, SW (Social Worker) met with resident's wife for discharge planning, as his Medicare Part A/SNF/Rehab (skilled nursing facility/rehabilitation) stay is ending and she is planning for him to transition into long term care. NOMNC (Notice of Medicare Non-Coverage) reviewed for last skilled date 4/5/19; she verbalized understanding of last skilled date, appeal rights, and financial liability beginning 4/6/19. She signed form and SW gave copy of signed form to her . ABN (Advance Beneficiary Notice) reviewed for private pay date effective 4/6/19, she verbalized understanding of date, appeal rights, private pay amount but declined to sign form. She stated that she would choose option 3 but does not want to sign any more paperwork at this time .SW notified IDT (Interdisciplinary team) that resident is being discharged from SNF (skilled nursing facility) stay and will remain in LTC (long term care). A review of the Notice of Medicare Non-Coverage (NOMNC) for the resident documented that Services will end: Friday, (MONTH) 5, 2019. The date portion was hand-written in. At the end of the notice, is the following statement: Please sign below to indicate you received and understood this notice. I have been notified that coverage of my services will end on the effective date on this notice and that I may appeal this decision by contacting my QIO (quality insurance organization}. The document was signed by (name of), (Resident #40's representative, wife) and dated (MONTH) 5, 2019. A review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for the resident documented that Medicare doesn't pay for everything, even some care that you or your health care provider think you need. The Skilled Nursing Facility (SNF) or its Utilization Review Committee Believes that the care listed below does not meet Medicare Coverage requirements. Beginning on 'Saturday 4/6/19,' you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. The date portion was hand-written in. At the end of the notice, is the following statement: Options: Check only one box.Option 3. I don't want the care listed above. I understand that I'm not responsible for paying, and I can't appeal to see if Medicare would pay. The option was designated by a hand-written in X. The document was signed by (name of), (Resident #40's representative, wife) and dated 4/28/19. On 7/10/19 at 11:20 AM, an interview was conducted with ASM (Administrative Staff Member) #3, the Assistant Director of Nursing. ASM #3 was asked for documentation of a discussion with the resident and/or resident representative prior to the 4/5/19 date. ASM #3 stated, The SW does not have documentation regarding speaking with family prior to 4/5/19 date. She knows the policy and did not follow it. When asked how many Medicare A days Resident #40 used and how many Medicare A days remained, ASM #3 stated, He used 15 days and had 85 Medicare A days left. The last effective date was 4/5/19 and the resident no longer required skilled services. On 7/10/19 at 12:14 PM, an interview was conducted with OSM (Other Staff Member) #1, the Social Worker. OSM #1 was asked when the NOMNC information should be discussed with the resident and/or resident representative. OSM #1 stated, It should be at least 2-3 days before. I call the family and meet with them in person. I typically don't write in the notes that I left messages. We were unable to meet until Friday, 4/5/19. That is not how it is supposed to be. I don't recall if I left her messages. She lives on campus and visits often. On 7/10/19 at 12:51 PM, a follow up interview was conducted with OSM #1. OSM #1 stated, Provided NOMNC and ABN paper work on 4/5/19 date but wife did not want to sign at that time. NOMNC and ABN should be completed at least 2 days prior to last day of coverage. Her daughter brought the ABN form in on 4/28/19 and that is the day the wife signed it. A review of the facility's policy Medicare Part A Management that documented in part, .3. The Social Worker issues the approved Notice of Medicare Non-Coverage letter and the Advance Beneficiary Notice (ABN) when appropriate to the resident or responsible agent notifying the resident of non-coverage and the opportunity to appeal the decision with the Fiscal Intermediary .This notification must be given / received no less than 2 days from the proposed last day of coverage. If the responsible party is not available to receive the letter in person, Social Work .will attempt to contact the responsible party by phone to explain the contents of the letter and then follow up by faxing, emailing using email encryption, or mailing the letter via certified mail . A review of the facility's policy Process for issuing Notice of Medicare Non-Coverage & Detailed Explanation of Non-Coverage that documented in part, .Policy: A Notice of Medicare Non-Coverage is issued to a member or responsible party (RP) prior to termination of covered skilled services in the Skilled Nursing Facility .as directed by CMS (Centers for Medicaid and Medicare Services) guidelines. Medicare guidelines require the health plan deliver, or instruct the provider to deliver, the Notice of Medicare Non-Coverage no later than two days prior to the last covered day of service/s. The health plan member, or responsible party, must receive a valid Notice of Medicare Non-Coverage, including the appeals process, which meets the Medicare required timeframe for delivery . On 7/11/19 at 4:21 PM, ASM #1, the Administrator and ASM #2, the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey.