Every finding on record at Bayou Manor

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for the residents, consistent with residents' rights, that include measurable objectives and timeframes to meet the residents' medical, nursing, mental and psychological needs, for 1 (Resident # 1) of 6 residents reviewed for comprehensive person-centered care plan. The MDS Coordinator failed to develop a comprehensive person-centered care plan for Resident # 1 within the timeframe and measurable objective for Resident # 1 who was a fall risk and had actual falls on 05/17/2026 and 05/18/2026. This failure could place residents at risk for recurrent falls by not having their needs met.Findings included: Record review of Resident # 1's face sheet dated 04/23/2026 revealed she was an [AGE] year-old female with the following diagnoses: Generalized muscle weakness, unsteady on feet and other lack of coordination (A loss of overall physical power, often linked to fatigue, nerve damage from inactivity). Record review of Resident # 1's MDS dated [DATE] revealed she had a BIMS score of 09 (moderate problem with thinking and memory). The MDS section J1700 revealed Resident # 1 was admitted with a history of fall on admission. Record review of Resident # 1's care plan dated 5/19/2026 that was updated after surveyor's intervention revealed: -The resident is high risk for falls, related to weakness and unsteady gait. Goal: The resident will not sustain serious injury. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage resident to use the call light for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/ family/caregivers about safety and what to do is a fall occurs. Ensure the resident is wearing appropriate footwear non-skid soaks when ambulating or mobilizing in wheelchair. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter, remove any potential causes if possible. Educate resident/ family/caregivers/IDT as to cause.-The resident has bladder incontinence related to confusion, impaired mobility. Goal: The resident will remain free of skin breakdown. Interventions: Ensure the resident has unobstructed path to the bathroom.-The resident has had an actual fall on 05/17/2026 and 05/18/2028 with no injury due to poor balance, unsteady gait and confusion. Goal: The resident will resume usual activities without further accidents. Intervention: Determine and address causative factors of the fall. Monitor/document/ report PRN X 72 to MD for S/S of: pain, bruise, change in mental status, new onset of confusion, sleepiness, inability to maintain posture and agitation. Check BP lying/ sitting and standing X 1 in the first 24 hours. Record review of Resident # 1's hospital records dated 04/23/2026 revealed, impaired upper extremity strength, impaired endurance (physical capacity to sustain prolonged activity) impaired functional mobility, impaired trunk control. Patient presents as high fall risk. Record review of Resident # 1's clinical records dated 4/24/2026 revealed, she was admitted to the facility with a primary diagnosis of fall with AMS (altered mental status) and dehydration. In an interview with the MDS Coordinator on 05/19/2026 at 2:21 p.m., she said Resident # 1 had no comprehensive person-centered care plan because she had not completed one. She said it was her responsibility to complete care plans when residents are admitted into the facility. The MDS Coordinator said, the fact that Resident # 1 did not have a comprehensive person-centered care plan completed in a timely manner was that the nurses and CNAs would not have proper guidance that was needed to provide quality care to Resident # 1. She said the delay in competing a comprehensive person-centered care plan might lead to delayed care. In an interview with LVN A on 05/19/2026 at 2:35 p.m., she said she would normally refer to a care plan to know what care to provide to a resident. She said if there was no comprehensive person-centered care plan, the residents would not get the required care specifically for them. LVN A said her priority was safety for the residents, thus she needed a comprehensive person-centered care plan for directions. In an interview with LVN B on 05/19/2026 at 3:14 pm, she said, it was the responsibility of the MDS Coordinator to complete a Comprehensive person-centered care plan. She said if the comprehensive person-centered care plan was not completed in a timely manner for Resident # 1, staff would not know how to care for Resident # 1. She said Resident # 1 would not have had the proper care she deserved. In an interview with the DON on 05/19/2026 at 4:15 p.m., she said the baseline care plan was initiated within the first 21 days of admission. The baseline care plan revealed Resident # 1 had a history of fall. She said it was the responsibility of the MDS Coordinator to develop the comprehensive person-centered care plan. The DON said, if the comprehensive person-centered care plan was not developed for Resident # 1, specific triggered incidents such as falls would not be notified by the staff. She said in the absence of a comprehensive person-centered care plan for Resident # 1, the care would not have been individualized which would have resulted to staff missing pertinent care areas. In an interview with the ADM on 05/19/2026 at 4:44 p.m., he said a care plan was designed to make sure all parties involved in the care of a resident were on the same page with the care of the resident. The ADM said if a care plan was not completed in a timely manner, the risk was that staff would not understand everything about the residents. Record review of facility's Care Plan, Comprehensive Person-Centered revised on March 2022 revealed the following: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident physical, psychological and functional needs is developed and implemented for each resident. -The comprehensive person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant change in status), and no more than 21 days after admission. -Includes the resident's stated goals upon admission and desired outcomes.-Reflects currently recognized standards of practice for problem areas and conditions.-Interventions address the underlying source (s) of the problem area(s), not just symptoms or triggers.

Based on observations, interviews, and record reviews the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for two medications cart (300 hall nurses cart and 300 hall Medication Aides cart) of the facility's four medication carts reviewed for medication storage. The facility failed to ensure IV fluids were labeled and dated before administering the fluids to Resident#1.The facility failed to ensure that an opened bottle of acidophilus was dated and stored in the refrigerator.The facility failed to ensure that an opened bottle of vitamin B 1 100mg was dated after opening and before storing in the 300-hall nurses medication cart. The facility failed to ensure that an opened of vitamin B 12 500mg was dated after opening and before storing in the 300-hall medication cart.The facility failed to ensure that an opened of vitamin B 12 1000mg was not dated after opening and before storing in the 300-hall medication cart.These failures had the potential to result in compromised medication efficacy, unsafe administration, and increased harm to residents. The findings included:Review of Resident #1's Quarterly MDS Assessment, dated 11/24/2025 reflected the Resident #1 was a [AGE] year-old female and had a BIMs score of 15, indicating her cognitive function was intact. The resident had diagnoses which included cancer, anemia (a condition where your blood lacks enough healthy red blood cells to carry adequate oxygen to your body, causing fatigue, weakness, pale skin, and shortness of breath), and hypertension (means the force of blood pushing against your artery walls is consistently too high). Review of Resident #1's Comprehensive Care Plan, dated Date Initiated: 11/26/2025 Revision on: 11/26/2025, reflected The resident has potential nutritional problem r/t lung CA, brain CA Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia),muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3months, >10% in 6 months. Date Initiated: 11/26/2025 Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 11/26/2025Review of Resident #1's active physicians orders date 12/09/2025 at 10:15am reflected 0.9 NS at 100cc/hr IV x1HR. Review of Resident #1's notes dated 12/09/2025 at 12:20pm Health Status Note. Note Text: MA reported to this writer that resident blood pressure was low. assessment was done and PRN midodrine was given. Resident B/P reassessed B/P - 87/39, P-78. NP notified of the change in BP after PRN medication. New orders received FOR 0.9% NS at 100CC/HR IV X 1Lts and CBC, BMP, Resident and POA was notified of changes.0.9% NS was taken from pyxis (medication dispensing system). IV fluids was hanged at 10:15am. Labs was draw at 10:37am. This writer assessed resident at 11:40am. Vital signs obtained B/P-126, P-78. Lab results was given to NP. No new orders at this time. [sic] The entry was written by LVN C. Observation of Resident#1 on 12/09/25 at 1:42 PM revealed she was receiving Intravenous fluids. The fluids were not labeled with the type of fluid, Residents name, date of administration, rate of the fluid, or initial of the nurse administering the fluid.Interview on 12/09/25 at 1:45 PM with the DON revealed that Resident #1 was receiving normal saline fluids because her blood pressure was low.Observation on 12/09/25 at 2:08 PM with MA A and MA B on the 300-medication cart revealed one bottle of vitamin B 1 100mg that was open but not dated, one bottle of vitamin B 12 500mg that was open but not dated, and one bottle of vitamin B 1 1000mg was open and not dated. Interview on 12/09/25 at 2:12 PM with MA A and MA B revealed that they did not know that the medication bottles were not labeled. MA A and MA B stated all multi dose medication should be dated when opened. MA A and MA B both stated the risk to the residents was administering medication that was beyond the manufacturers' recommendations that might not be therapeutic. They stated that they had been in-serviced on medication storage.Observation on 12/09/25 at 2:21 PM with LVN C on the 300 nurses medication cart revealed one opened bottle of acidophilus in the cart (not refrigerated) with no open date.Interview on 12/09/25 at 2:25 PM with LVN C revealed that she opened the acidophilus bottle but forgot to label it and did not realize that it was supposed to be refrigerated. She stated she administered Resident #1's IV therapy. She stated the fluid (0.9% normal saline 1 liter) was from the emergency kit, which was why it was not labeled, and she forgot to label it. She stated that all IV fluids should have the resident's name, the fluid infusing, the rate, date, time, and initials of the person that administered the IV. She stated the risk to the resident receiving the wrong medication. She stated that she had been in-serviced on medication storage and IV administration.Interview on 12/11/2025 at 3:13 PM with the DON revealed that all medications including IV fluids should be labeled. She stated her expectations were the nurses and MAs did the medication rights before administering any medication. The risk of unlabeled IV fluids to the residents was it would be impossible to know what was infusing, and at what rate in case adjustments were to be made. The DON stated that the nurses and MAs were responsible for ensuring the medication carts were clean, all medications were within date, no medications were expired and all over the counter medications were dated when they opened. She stated that the MAs and nurse had been in-serviced on medication labeling and storage, and the nurse had been in-serviced on IV administration. Review of the facility policy titled Medication Storage in the Facility revised on 01/2018 reflected: Medication and biologicals are stored safely, securely, and properly, following manufacturers recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel or lawfully authorized to administer medications. Medication requiring refrigeration are kept in a refrigerator at temperatures between 36 degrees Fahrenheit and 8 degrees Fahrenheit with a thermometer to allow temperature monitoring. Medication requiring cool place are refrigerated unless otherwise directed on the label.When the original seal of the manufacturer's container or vial is initially broken, the container or vial will be dated.The nurse shall place a date opened sticker on the medication and enter the date opened and new date of expiration (NOTE: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations required different dating (See APPENDIX 28 - MEDICATIONS WITH SHORTENED EXPIRATION DATES).Infusion Therapy Storage and LabelingFacility should ensure the infusion therapy labels include:1)Residents Name2)Volume, infusion rate3)Name and quantity of each additive,4) Initials of the Pharmacist5) Date and time of administration6)Initial of person administering the medication7) Ancillary labeling8) Expiration date Policy Interpretation and Implementation1. Medication and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.3. Medication requiring refrigeration are stored located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly.are separately locked in permanently affixed compartments, except when using single unit package drug distribution system in which the quantity stores is minimal and a missing does cane be readily detected.Medication Labeling1.Labeling of medication and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.The medication label includes, at a minimum: Medications name.prescribed name.prescribed dose.Strength.Expiration date, when applicable.Residents name.Route of administration; andAppropriate and precautions.If medication containers are missing, incomplete, improper, or incorrect labels contact the dispensing pharmacy for instructions regarding returning or destroying these items.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of one resident (CR #1) of four residents reviewed for medication administration. -CR #1 had an order for an extended-release anti-Parkinsonism medication but was given the regular-release medication instead.-The error was repeated for one month before the resident's family member discovered the error.The failure placed residents at risk for health conditions not being adequately treated. Findings Include:Record review of the admission Record for CR #1 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Her diagnoses included, but were not limited to, Parkinson's disease (a progressive movement disorder that occurs when brain cells stop producing enough of the brain chemical dopamine, leading to symptoms like tremor, stiffness, and slowness of movement), dementia, lack of coordination, and cognitive communication disease. She was discharged on 07/06/2025 to a hospital.Record review of a physician's order dated 06/05/2025 (date of admission) revealed CR #1 was to receive Carbidopa-Levodopa oral tablet (Regular-Release) 25-100 mg tablets, two tablets by mouth three times a day for Parkinson's.Record review of a different physician's order dated 06/05/2025 revealed CR #1 was to receive Carbidopa-Levodopa ER (Extended-Release) oral tablet 25-100 mg, one tablet by mouth at bedtime (8:00 p.m.) for Parkinson's. Record review of a physician's order dated 06/06/2025 revealed staff was to crush medications and/or open capsules for CR #1.Record review of the June 2025 MAR for CR #1 revealed the staff initialed that the Carbidopa-Levodopa ER 25-100 mg tablet scheduled for 8:00 p.m. was administered nightly from 06/05/2025 to 06/30/2025.Record review of the July 2025 MAR for CR #1 revealed the resident refused the Carbidopa-Levodopa ER on [DATE]. The staff had initialed that the Carbidopa-Levodopa ER tablet was administered nightly from 07/02/2025 to 07/05/2025 with no missed doses.n an interview via telephone on 11/10/2025 with CR #1's family member, the family member said the facility was not administering CR #1's Carbidopa-Levodopa ER. She said she went to the facility to visit CR #1. She said she noticed increased tremors and ataxia (loss of ability to control muscle movement). She said she was talking with the medication aide who was preparing CR #1's nighttime medications. She said she noticed that CR #1's Carbidopa-Levodopa ER tablets were not in the drawer. She said the medication aide was going to administer a regular-release tablet instead of the ER. The family member said she and the medication aide looked in the bottom drawer of the cart, and the Carbidopa-Levodopa ER tablets were in a locked compartment. She said she called EMS to take the resident to the hospital. In an interview on 11/10/2025 at 3:30 p.m., the[BR1] DON said CR #1 was not administered the Carbidopa-Levodopa ER from the admission date (06/05/2025) to the date of discharge (07/06/2025), but she was administered the regular-release. Record review of the Medication Error Report dated 06/06/2025 revealed CR #1 was administered the Carbidopa-Levodopa regular-release tablets.In an interview via telephone on 11/10/2025 at 4:20 p.m., Physician A said he was aware CR #1 had one order for the Carbidopa-Levodopa immediate release and one order for Carbidopa-Levodopa ER. He said the resident went to the hospital for syncope (fainting).In an interview via telephone on 11/10/2025 at 4:30 p.m., Pharmacist B said that a possible complication of administering immediate-release Carbidopa-Levodopa instead of ER would be breakthrough tremors during the night. Record review of the facility policy Administering Oral Medications (revised October 2010) read, in part, .Steps in Procedure.6. Check the label on the medication and confirm the medication name and dose with the MAR.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 4 residents (Resident #26) reviewed for pharmacy services. The facility failed to administer the physician prescribed decreased dose of Amlodipine (a medication used to lower blood pressure) for Resident #26's peripheral edema (swelling of lower legs or hands). This failure could place residents at risk of unwanted side effects and inadequate therapeutic outcomes. Findings include: Record review of Resident #26's face sheet, dated 08/15/2024, reflected an [AGE] year-old who was admitted to the facility on [DATE]. Resident #26 had diagnoses which included spontaneous bleeding in the brain, paralysis affecting right dominant side, stroke, imbalance of blood cholesterol, buildup of fluid around the brain, difficulty speaking and Hypertension (elevated blood pressure). Record review of Resident #26's Physician's Progress Note, date of service 6/17/2024, reflected a diagnosis which included diabetes. Record review of Resident #26's quarterly MDS (a Resident Assessment and Care Screening tool) dated 05/09/2024, reflected a BIMS score of 00 out of 15 ,which indicated severe cognitive impairment. Resident #26 had impairment to one side of the upper extremity and impairment to both sides of the lower extremity. Resident #26 was dependent on staff assistance for all ADLs. Resident #26 had an abdominal feeding tube. Record review of Resident #26's care plan reflected the resident had an ADL self-care performance deficit r/t Stroke with weakness affecting the right dominant side, date initiated was 02/13/2024. The resident had hypertension; date initiated was 2/13/2024. Interventions included to give anti-hypertensive medications as ordered. Monitor for and document any edema and notify MD. Record review of Resident #26's active orders as of 08/15/2024 reflected an order for Amlodipine 5mg, give one tablet via Gastrostomy tube or G-tube (feeding tube inserted into the abdomen) one time a day for Hypertension, dose decreased due to peripheral edema, date ordered 08/14/24 and start date was 08/15/24. Record review of Resident #26's MAR for August 2024 reflected, LVN A documented the administration of Amlodipine 5mg tablet on 08/14/2024 at 8:00 AM. Further review reflected Amlodipine 10mg tablet was started on date 02/01/2024 and discontinued on 08/14/2024. In an observation and interview on 08/15/2024 at 6:50 AM, Resident #26 was alert but did not speak. The head of the bed was elevated. Resident #26's hands, fingers and lower arms were swollen, and her fists were softly clenched. LVN A washed her hands, donned (put on) PPE. LVN A checked Resident #26's blood sugar, it was 193. LVN A checked Resident #26's blood pressure and it was 147/55, with a pulse of 102. LVN A removed the PPE and performed hand hygiene. LVN A prepared Resident #26's medications. LVN A sanitized her hands and placed each of the following medications into individual medicine cups: Amlodipine 10mg tablet, Fenofibrate 145mg tablet, Lisinopril 10mg tablet, Metoprolol 50mg tablet, Famotidine 20mg tablet and potassium chloride 20meq powder packet. LVN A crushed each tablet individually and prepared the NPH (Neutral Protamine [NAME]) insulin (a type of insulin which regulates the amount of glucose in the blood). LVN A washed her hands at the sink and donned PPE. LVN A added 10ml of warmed water from the faucet to each medication cup and added 120ml of water to the cup with the potassium chloride powder. LVN A disconnected the feeding tube from the G-tube and checked Resident #26's G-tube for placement using the stethoscope then checked for residual. There was zero residual. LVN A attached the 60ml syringe barrel to the end of G-tube and poured 30ml of water to flush via gravity. LVN A poured medication from the first cup into the syringe barrel, followed by 10ml of water and repeated the process with the remaining medications. After all medications were infused, LVN A poured 30ml of water to flush and closed the end of the G-tube. LVN A stated she would not connect the tube feeding d/t it was time for the resident to have bowel rest for 4 hours. LVN A removed gloves, performed hand hygiene, donned clean gloves, cleansed Resident #26's skin on the abdomen and administered 12units of NPH insulin to Resident #26's lower right quadrant. In an interview on 08/15/2024 at 10:00 AM, LVN A stated she missed correctly reading the dose for Resident #26's Amlodipine. LVN A stated she should have given 5mg of Amlodipine instead of 10mg. LVN A stated the order was changed yesterday (8/14/2024) d/t peripheral edema. LVN A stated the risk to Resident #26 was edema if the ordered dose was not given. LVN A stated her last in-service on Medication Administration was about one month ago. LVN A stated when she administered medications she should check for the right person, right medication, right dose, this time she did not see the right dose and she should check for the right time. LVN A stated she would let the DON know of the medication error. In an interview on 08/15/2024 at 10:15 AM, the DON stated she expected the nurses to be looking at the physician order, compare the blister pack to the MAR, if the medication required a blood pressure, then it should be explained to the resident and then the nurse would sign for the medication. The DON stated she would start a medication error report. The DON stated she instructed LVN A to notify the MD and RP and to always check the MAR when administering a medication. When asked what the risks were to the resident, the DON stated she did not have the lab results in front of her but assumed the labs were better than what they were, and the MD wanted to reduce the dose of the Amlodipine. When asked how she ensured the nurses and medication aides were administering medications per policy and procedures, the DON stated she conducted end of the month in-services for reminders on medication pass, which included to make sure they told the alert residents what medications they were given. Record review of the facility's policy on Administering Medications through an Enteral Tube, revised April 2007, read in part: The purpose of this procedure provide guidelines for the safe administration of oral medications .General Guidelines, follow the medication administration guidelines in the policy entitled Administering Medications .Steps in the Procedure .6. Check the label on the medication and confirm the medication name and dose with the MAR. 7. Check the expiration date on the medication .8. Check the medication dose. RE-check to confirm the proper dose

Based on interview and record review, the facility failed to ensure an irregularity noted by the pharmacist was acted upon for 1 (Resident #4) of 6 residents reviewed for pharmacy review. The facility failed to ensure: 1. The pharmacist's Physician Notification Letter dated 03/07/2023 reflected Resident #4 had a routine order for a medication (Robitussin Nighttime DM [Dextromethorphan]) that was not recommended for routine use in the elderly. 2. The pharmacist's Physician Notification Letter dated 05/09/2023 reflected Resident #4 was still receiving the medication routinely as of 6/14/23. The physician signed the 05/09/2023 letter, agreeing to discontinue the routine administration of the medication . These failures could place residents at risk for complications resulting from receiving a medication contraindicated for routine use. Findings Include: Record review of the Admission Record (printed 06/15/2023) revealed Resident #4 was 84-years-old, admitted to the facility on [DATE]. Diagnoses included muscle weakness, asthma (breathing difficulty), insomnia (difficulty sleeping), and chronic respiratory failure (breathing difficulty). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed she scored 15/15 on the BIMS, indicative of intact cognition. She required limited assist for bed mobility and transfers. She used a wheelchair for mobility. The MDS reflected Resident #4 received a hypnotic (medication to help sleep) for all seven days of the seven-day look-back period. Record review of Resident #4's Care Plan dated 05/16/2023 read in part . Resident #4 receiving a sedative or hypnotic . Goal: the resident will be free of any discomfort or adverse side effects. Intervention: Administer sedative/hypnotic medications as ordered by the physician . Record review of Resident #4's Medication Regimen Review note dated 03/07/2023 read in part that a Physician Notification Letter was sent on 03/07/2023 . Record review of Resident #4's pharmacy Physician Notification Letter dated 03/07/2023 read in part that Resident #4 was receiving Robitussin Nighttime DM (dextromethorphan), 20 ml routinely at bedtime for cough. The letter reflected .Routine use of this drug is not recommended in the elderly due to its strong anticholinergic (can affect nerves) properties. Recommendation to discontinue the Robitussin Nighttime DM and consider switching to Robitussin DM (not the nighttime formula) . Accept/decline' and physician signature areas were blank. Record review of Resident #4's Medication Regimen Review note dated 04/12/2023 read in part Check for response to 3/7/2023 letter to PCP to stop routine Robitussin Nighttime cough. Follow up: change the medication to PRN . Record review of Resident #4's Medication Regimen Review note dated 05/09/2023 read in part . Re-send the letter to discontinue the routine Robitussin Nighttime DM. Nurse Follow-Up: Noted . Record review of Resident #4's pharmacy Physician Notification Letter dated 05/09/2023 read in part . Receiving Robitussin Nighttime DM (dextromethorphan), 20 ml routinely at bedtime for cough. Routine use of this drug is not recommended in the elderly due to its strong anticholinergic (can affect nerves) properties. Recommendation to discontinue the Robitussin Nighttime DM and consider switching to Robitussin DM (not the nighttime formula). Accept/decline' and physician signature areas marked 'accept' and scribed D/C Robitussin Nighttime DM by Nurse Practitioner (05/11/2023) . Record review of Resident #4's Medication Regimen Review note dated 06/13/2023 read in part . Routine Robitussin Nighttime DM medication to be discontinued . Record review of Resident #4's MAR dated June 2023 read in part . Routine Robitussin Nighttime Cough DM . The MAR reflected Resident #4 received the medication every night up to 06/13/23 . Observation and interview on 06/14/2023 at 3:40 p.m., the DON said per the facility protocol for pharmacy reviews, she was responsible for reviewing the Medication Regimen Review notes, then on the following day she gave the Physician Notification Letters to the physician. She said the recommendations were to be implemented within seven days. The Surveyor presented Resident #4's pharmacy review note scribed in nurse's follow-up notes on 4/12/23. The DON said the note scribed in the 04/12/2023 Nurse Follow-Up area for the medication to be changed to PRN was her writing. This Surveyor asked if Resident #4 was still receiving the routine Robitussin medication. The DON pulled up the electronic MAR dated June 2023. She verbally acknowledged Resident #4 was still receiving the routine Robitussin Nighttime Cough DM nightly. Interview on 06/14/2023 at 3:50 p.m., the DON said she had spoken to Resident #4, and the resident wanted to receive the medication every night. When asked if the physician had been informed, the DON said she would notify the physician at this time. Interview on 06/15/2023 at 3:15 p.m., the DON said the Charge Nurse was responsible to update the orders when a pharmacy recommendation was received. She said the order for Resident #4 had just been overlooked. Record review of the facility policy Medication Regimen Review (revised 04/07/2022) revealed .The Director of Nursing will be responsible in assuring that each resident's Medication Review Record is reviewed and follow-up actions to recommendations are documented.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #4) of 6 residents reviewed for pharmacy services had a drug regimen that was free from an unnecessary drug, which was administered for an excessive duration. The facility failed to ensure: 1. The pharmacist's Physician Notification Letter dated 03/07/2023 reflected Resident #4 had a routine order for a medication (Robitussin Nighttime DM [Dextromethorphan]) that was not recommended for routine use in the elderly. 2. The pharmacist's Physician Notification Letter dated 05/09/2023 reflected Resident #4 was still receiving the medication routinely as of 6/14/23. The physician signed the 05/09/2023 letter, agreeing to discontinue the routine administration of the medication. 3. The MAR for Resident #4 for March, April, and May 2023 reflected the medication was administered to the resident nightly. 4. The June 2023 MAR for Resident #4 reflected the medication was administered to the resident nightly until 06/13/2023. 5. The surveyor inquired about the medication on 06/14/2023. The routine order was discontinued that day. These failures could place residents at risk for complications resulting from receiving a medication contraindicated for extended routine use. Findings Include: Record review of the Admission Record (printed 06/15/2023) revealed Resident #4 was 84-years-old, admitted to the facility on [DATE]. Diagnoses included muscle weakness, asthma (breathing difficulty), insomnia (difficulty sleeping), and chronic respiratory failure (breathing difficulty). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed she scored 15/15 on the BIMS, indicative of intact cognition. She required limited assist for bed mobility and transfers. She used a wheelchair for mobility. The MDS reflected Resident #4 received a hypnotic (medication to help sleep) for all seven days of the seven-day look-back period. Record review of Resident #4's Care Plan dated 05/16/2023 read in part . Resident #4 receiving a sedative or hypnotic . Goal: the resident will be free of any discomfort or adverse side effects. Intervention: Administer sedative/hypnotic medications as ordered by the physician . Record review of Resident #4's Medication Regimen Review note dated 03/07/2023 read in part that a Physician Notification Letter was sent on 03/07/2023 . Record review of Resident #4's pharmacy Physician Notification Letter dated 03/07/2023 read in part that Resident #4 was receiving Robitussin Nighttime DM (dextromethorphan), 20 ml routinely at bedtime for cough. The letter reflected .Routine use of this drug is not recommended in the elderly due to its strong anticholinergic (can affect nerves) properties. Recommendation to discontinue the Robitussin Nighttime DM and consider switching to Robitussin DM (not the nighttime formula) . Accept/decline' and physician signature areas were blank. Record review of Resident #4's Medication Regimen Review note dated 04/12/2023 read in part Check for response to 3/7/2023 letter to PCP to stop routine Robitussin Nighttime cough. Follow up: change the medication to PRN . Record review of Resident #4's Medication Regimen Review note dated 05/09/2023 read in part . Re-send the letter to discontinue the routine Robitussin Nighttime DM. Nurse Follow-Up: Noted . Record review of Resident #4's pharmacy Physician Notification Letter dated 05/09/2023 read in part . Receiving Robitussin Nighttime DM (dextromethorphan), 20 ml routinely at bedtime for cough. Routine use of this drug is not recommended in the elderly due to its strong anticholinergic (can affect nerves) properties. Recommendation to discontinue the Robitussin Nighttime DM and consider switching to Robitussin DM (not the nighttime formula). Accept/decline' and physician signature areas marked 'accept' and scribed D/C Robitussin Nighttime DM by Nurse Practitioner (05/11/2023) . Record review of Resident #4's MARs dated March. April, and May 2023 revealed the order for routine Robitussin Nighttime Cough DM was in place, and the facility administered the medication nightly for those three months. Record review of Resident #4's Medication Regimen Review note dated 06/13/2023 read in part . Routine Robitussin Nighttime DM medication to be discontinued . Record review of Resident #4's MAR dated June 2023 read in part . Routine Robitussin Nighttime Cough DM . The MAR reflected Resident #4 received the medication every night in June 2023 up to 06/13/23 . Observation and interview on 06/14/2023 at 3:40 p.m., the DON said per the facility protocol for pharmacy reviews, she was responsible for reviewing the Medication Regimen Review notes, then on the following day she gave the Physician Notification Letters to the physician. She said the recommendations were to be implemented within seven days. The Surveyor presented Resident #4's pharmacy review note scribed in nurse's follow-up notes on 4/12/23. The DON said the note scribed in the 04/12/2023 Nurse Follow-Up area for the medication to be changed to PRN was her writing. This Surveyor asked if Resident #4 was still receiving the routine Robitussin medication. The DON pulled up the electronic MAR dated June 2023. She verbally acknowledged Resident #4 was still receiving the routine Robitussin Nighttime Cough DM nightly. Interview on 06/14/2023 at 3:50 p.m., the DON said she had spoken to Resident #4, and the resident wanted to receive the medication every night. When asked if the physician had been informed, the DON said she would notify the physician at this time. Interview on 06/15/2023 at 3:15 p.m., the DON said the Charge Nurse was responsible to update the orders when a pharmacy recommendation was received. She said the order for Resident #4 had just been overlooked. Record review of the facility policy Medication Regimen Review (revised 04/07/2022) revealed .The Director of Nursing will be responsible in assuring that each resident's Medication Review Record is reviewed and follow-up actions to recommendations are documented.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to ensure: -Previously opened frozen foods were not sealed or labeled with the date they were opened. -Previously opened refrigerated foods were not sealed or labelled with the date they were opened. -Non-perishable foods in the pantry were not labelled with the date they were opened. The failure placed residents at risk for food-borne illness associated with improper food storage. Findings include: Findings include: Observation on 06/13/2023 at 8:00 a.m., revealed the facility was part of a campus that included assisted and independent living. All three entities were serviced by the same kitchen. Observation and interview on 06/13/2023 at 8:22 a.m., revealed the DM accompanied the surveyor to tour the kitchen area. Observation of the walk-in freezer revealed an unsealed box of frozen cookies. There was no label to indicate the date it was opened. Observation revealed an open and unsealed box of Beyond Burgers plant-based patties. There was no label to indicate the date it was opened. Observation revealed an opened/resealed box of flat bread. There was no label to indicate the date it was opened. The DM said they do not date the packages when they open them. Observation on 06/13/2023 at 8:25 a.m., of the walk-in refrigerator revealed a five-pound bag of Zesty Peeled Garlic was open on the shelf. It was a resealable bag, but it was not sealed. There was no label to indicate the date it was opened. Observation on 06/13/2023 at 8:29 a.m., revealed the dry pantry contained a previously opened large bag of uncooked ziti. It was sealed with transparent plastic wrap. There was no label to indicate when the bag was opened. The bag was in a box with sealed ziti. Interview on 06/13/2023 at 8:30 a.m., the DM said if the foods were in the original containers, they do not date them because they have a year shelf life. He said they should have dated them. Record review of the facility policy Food Storage Policy (no date) provided by the facility on 06/15/2023 revealed .When item is removed from stock and opened for use and subsequent storage, an open on date should be placed on the package. The United States Public Health Service Food Code, 2013, page 92, reflects .at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for kitchen sanitation in that: - The fryer, stove, and oven vent hood were dirty. - The facility stored expired liquid eggs in the walk-in-cooler. - The facility had clean plates, bowls, and pots and pans with dried food particles on them. - The facility's equipment was not cleaned and in proper working condition. - The Dry Storage Room had food that was opened and not sealed. - The facility's kitchen had broken tiles and trash behind equipment. - Facility staff were not washing their hands between soiled and clean dishes. These failures could affect all residents who receive meals from the kitchen and place them at risk for food borne illness. Findings Include: Observation of the kitchen on [DATE] at 9:30 AM revealed the following: - Clean plates and bowls had dried food particles on them; - Chipped bowls; - Clean pots and frying pans with dried food particles in them; - The stove vent hood had dust and grease on build-up; - The oven and oven racks had an accumulation of burnt food particles and grease on them; - The chopping boards had brown food stains on them; - There were broken tiles between the grill and the deep fat fryer; and - There were trash and food particles behind the stove, deep fat fryer, and oven. In an interview on [DATE] at 9:35 AM with the Food Service Manager he said chipped bowls should not be with the regular bowls. He immediately discarded them. Observation of the dish machine with the Food Service Manager on [DATE] at 9:45 AM revealed the following: - The Thermometer to the dish machine was not working. - The Dishwasher Aide did not wash her hands after cleaning the soiled dishes and before removing the clean dishes from the dishwasher. At that time the Food Service Manager instructed the Dishwasher Aide to wash her hands and change gloves before removing clean dishes and utensils. Interview and testing with the Food Service Manager on [DATE] at 10:20 AM revealed the thermometer was not working and they had an order for [REDACTED]. At that point it was pointed out that the machine was a high temperature machine and it should be 180 degrees Fahrenheit. The Food Service Manager agreed it should be 180 degrees Fahrenheit. He then instructed the staff to sanitize the dishes in the three compartment sink until the machine was fixed to ensure they were sanitized. Observation of the walk-in-cooler on [DATE] at 10:25 AM revealed the following expired foods: - 8 16 oz. containers of liquid eggs had an expiration date of [DATE]. - 4 32 oz. containers of whole liquid eggs had an expiration date of [DATE]. During an interview on [DATE] at 10:30 AM with the Food Service Manager revealed that the liquid eggs came in on [DATE]. He then proceeded to show the surveyor the received date. At that point he was asked if the eggs were checked when they were received and he said, No. Observation of the Dry Storage Room on [DATE] at 10:35 AM revealed a box with chocolate chips that was open and not sealed. At that time the Food service Manager pulled the plastic bag and tied it. Observation of the walk-in- freezer on [DATE] at 10:40 AM revealed the following: - An open box with Baguette bread not sealed. - An open box with corn not sealed. - Boxes stacked to the ceiling of the freezer preventing proper circulation. During an interview on [DATE] at 10:50 AM with the Food Service Manager he said he was going to in-service the staff. He said he was going to call the company to come in and fix the dish machine. Record review of the Texas Food Establishment Rules dated (YEAR), page 71, section §228.75(g)(2)(B) revealed the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety for retention and use of a food product. Record review of the facility's undated Service/Distribution 5.7 , Dating Information read in part, . Purpose: Food safety and/or quality issues can result from use of food beyond its recommended shelf life. Standard: Critical: Manufacturer's dating information on foods must be adhered to without exception. Solution and helpful information: In all cases, packaged products with expired sell by, best if used by, or similar markings must be removed from Compass Group inventories and display/service area.

Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections involving 2 of 2 staff (LVN HHH and RN JJJ) and 2 of 4 residents (Resident #26 and # 27) reviewed for infection control. -LVN HHH failed to perform hand hygiene and contaminated clean items while providing care for Resident #26. -RN-JJJ was walking in the hallway with one glove on. -Resident #27's oxygen equipment was not changed. These failures could affect all residents and place them at risk of cross contamination and infection. Findings include: Resident #26 Record review of the admission sheet for Resident # 26 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #26's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 15 out of indicating he was cognitively intact. He required extensive assistance from two persons physical assist for dressing, toilet use, and personal hygiene. He was always incontinent of bowel and occasionally incontinent of bladder. Record review of Resident # 26's care plan initiated 12/31/19 revealed the following care plan: Focus: Resident is occasionally incontinent of bladder and incontinent of bowel on toileting program. Goal: Resident will reduce the incontinent episode and will be well cleaned and odor free daily x 90 days. Interventions: Clean peri-area with each incontinence episode. Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 1/24/2020 at 8:50 am revealed LVN GGG and LVN HHH provided incontinent care to Resident #26. LVN HHH did not complete hand hygiene prior to entering the resident's room, nor prior to donning clean gloves. LVN GGG removed Resident #26's brief and tucked it under the resident's buttocks. LVN GGG did not retract the foreskin or clean the head of the penis. LVN GGG assisted Resident #26 turn onto his left side in order to clean his buttocks. LVN HHH removed the soiled brief and discarded it into the biohazard bag. LVN HHH, during care, removed her gloves, did not wash or sanitize her hands, donned new gloves, and continued with incontinent care. LVN HHH completed incontinent care and with the same soiled gloves touched the Resident's clean shirt and brief. LVN HHH then left the biohazard bag on the bathroom floor, washed her hands, and left the room. In an interview on 1/24/2020 at 9:30 am with LVN GGG, she said she had been working at the facility full-time during the 6am-6pm shift. She confirmed she did not clean the head of the penis or retract the foreskin. She said she had been in-serviced on hand washing/ infection control a couple of months ago. She said she got nervous and forgot to properly clean the resident. In an interview on 1/24/2020 at 9:35 am with LVN HHH, she said she had been working at the facility for the past two years as a full-time employee as a floor nurse. She said she recently took the role of an infection control nurse. She said she should have washed her hands or used hand sanitizer after removing her gloves while providing care to the Resident. She said the failure placed the resident at risk for infections. She said she was taking the CDC infection control modules online. In an interview on 1/24/2020 at 10:00 am with the DON, he said he expected staff to provide appropriate care to residents based on their needs. He said the nurse should have either washed or sanitized her hands after touching a dirty area prior to moving to a clean area when performing incontinent care. He said the staff should wash their hands when entering a residents room if they were going to provide any care. He said nurses had their skills check offs twice a year in the month of (MONTH) and December. Resident #27 Record review of Resident #27's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #27's physician orders for (MONTH) 2020 revealed an order dated 12/31/19 for oxygen at 2 liters nasal cannula continuous every shift to keep oxygen saturation above 90%. Record review of Resident #27's MDS assessment dated [DATE] revealed she had a BIMS score of 7 out of 15 indicating moderately impaired cognitive skills for daily decision making. She required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. She was coded as receiving oxygen therapy. Record review of Resident #27's care plan dated 01/13/20 revealed a care plan for oxygen inhalation due to risk for shortness of breath. Observation on 1/22/20 at 9:45 a.m. revealed Resident #27 was resting quietly in bed with her eyes closed. She was wearing a nasal cannula that was delivering her oxygen. Resident #27's oxygen tubing was not labeled with a date. Her oxygen humidifier bottle had a date that read 01/12/20. Observation and interview on 01/23/20 at 5:45 a.m. revealed RN JJJ was coming down the hallway with one glove on her hand. RN JJJ said she was going to Resident #27's room because staff CNAs were in the resident room. RN JJJ said she needed to look at the resident's wound. RN JJJ removed the one glove from her hand. The surveyor and RN-JJJ went to Resident #27's room where there were no CNAs present. Resident #27 was resting quietly in bed with hher eyes closed. Further observation was made of the oxygen humidifier bottle now dated 01/23/20. Interview on 01/23/20 at 6:00 a.m. with RN JJJ said she was not supposed to walk down the hallway with gloves on due to infection control and that she went against the facility protocol. She said oxygen tubing and equipment was to be changed once a week and she had changed Resident #27's oxgen equipment on her shift. RN JJJ said the reason the facility changed resident oxygen equipment every week was for infection control. Interview on 01/23/20 at 6:05 a.m. with the ADON, the ADON said the nursing staff were not to walk in the hallways with gloves on because of cross contamination/infection control. The ADON said oxygen equipment was changed once a week for infection control. Interview on 01/23/20 at 6:08 a.m. with the DON said respiratory/oxygen equipment was changed once a week to avoid any infections. The DON said the nursing staff were not to wear gloves in the hallways for infection control purposes. Record review of the facility policy on Departmental (Respiratory Therapy)-Prevention of Infection revised 2011 read in part, . Change the oxygen cannula and tubing every seven (7) days. Record review of the facility's Managing Infection policy dated 5/22/19 read in part, .Appropriate precautions shall be used either at all times (standard precautions) or for individuals who are documented or suspected to have infections or communicable diseases that can be transmitted to others (Transmission-Based Precautions).D. wear gloves (clean, non-sterile) when entering the room.E. while caring for a resident, change gloves, after having contact with infected material (for example, fecal material and wound drainage). F. Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. [NAME] After removing gloves and washing hands, do not touch potentially contaminated environment surfaces or items in the resident's room .

Based on observation, interview, and record review, the facility failed to implement interventions to prevent the development of pressure sores for 1 of 12 residents (Resident #10) reviewed for pressure sores in that, -Resident #10's heel protectors were not applied according to the physician's orders [REDACTED]. This failure could affect all residents with pressure reducing interventions and place them at risk of skin breakdown, pain, and hospitalization . Findings include: Record review of Resident #10's face sheet revealed he was an [AGE] year old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #10's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 04 out of 15 indicating severely impaired cognitive skills for daily decision making. He required extensive assistance from two persons physical assist for dressing, toilet use, and personal hygiene. He was always incontinent of bowel and bladder. Further review of the Section M M0150. Risk of Pressure Ulcers/Injuries reflected Resident was at risk of developing pressure ulcers/injuries. Record review of Resident #10's care plan initiated 3/26/2018 revealed the following care plan: Focus: Potential for decubitus ulcer formation r/t decreased mobility and incontinence. Goal: Resident will reduce risk of skin breakdown daily x 90 days. Interventions: CNA to notify nurse if any reddened areas of skin, facility staff to turn and reposition as needed, notify m.d./family and hospice if any signs of skin breakdown noted: redness, irritation and breaks in skin integrity. Record review of Resident #10's physician's orders [REDACTED]. Record review of Resident #10's Braden scale for predicting pressure sore risk dated 11/11/19 revealed he was high risk for the development of pressure sores. Attempted interview and observation on 1/22/2020 at 9:47 am revealed Resident #10 lying in bed. He did not have his heel protectors applied. Record review of Resident #10's TAR for the month of (MONTH) 2020 revealed nurses documented heel protectors were applied on (MONTH) 22, 2020 and (MONTH) 23, 2020 on each shift. In an interview and observation with the RN F on 1/23/2020 at 9:32 am, Resident #10 was observed lying in bed, he did not have his heel protectors applied. RN F said CNAs were responsible for applying the heel protectors on the residents, but the nurses documented the presence of heel protectors in the TAR. He said he documented the Resident had his heel protectors on assuming the night CNA had applied them. He said heel protectors should be on while the resident was in bed. He said it helped to protect the heel from rubbing against the sheet. In an interview and observation with CNA Q on 1/23/2020 at 11:11 am, Resident #10 was observed lying in bed. He did not have his heel protectors applied. CNA Q located Resident #10's heel protectors in the bottom of the drawer in his storage dresser. CNA Q said she was going to put the heel protectors on Resident #10. She said most of the time the resident refused. She said she did not notify the charge nurse of the resident's refusal. Record review of Resident #10's nurses notes revealed no documentation of resident's refusal to apply/remove heel protectors. In an interview on 1/23/2020 at 11:15 am with the ADON, she said CNAs applied the heel protectors and the nurses monitored if staff were applying heel protectors per care interventions and documented in the TAR. In an interview on 1/24/2020 at 10: 06 am with the DON, he said it was the evening/night shift CNA's responsibility to apply the heel protectors. He said before staff signed the TAR to reflect completion of the task, the nurses were to assess the residents to ensure the heel protects had been applied according to the physician's orders [REDACTED]. Record review of the facility's Wound Care Prevention Equipment policy dated 2/28/19 read in part: .Policy Statement-Residents come to our facility with varying degrees of skin compromise. Licensed personnel shall ensure that all equipment either used to prevent skin breakdown or reduce the effects of broken skin shall be applied per provider's order. The nurse shall document the placing or removal of any piece of equipment in the EMR as ordered by the physician.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #26) reviewed for incontinent care in that: - LVN GGG did not completely clean Resident #26 during incontinent care. This failure could affect all residents who were incontinent and place them at risk for urinary tract infections, urethral erosions, discomfort, skin breakdown, and a decreased quality of life. Findings include: Record review of the admission sheet for Resident # 26 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #26's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating he was cognitively intact. He required extensive assistance from two persons physical assist for dressing, toilet use, and personal hygiene. He was always incontinent of bowel and occasionally incontinent of bladder. Record review of Resident # 26's care plan initiated 12/31/19 revealed the following care plan: Focus: Resident is occasionally incontinent of bladder and incontinent of bowel on toileting program. Goal: Resident will reduce the incontinent episode and will be well cleaned and odor free daily x 90 days. Interventions: Clean peri-area with each incontinence episode. Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 1/24/2020 at 8:50 am revealed LVN GGG and LVN HHH provided incontinent care to Resident #26. LVN HHH did not complete hand hygiene prior to entering the resident's room, nor prior to donning clean gloves. LVN GGG removed Resident #26's brief and tucked it under the resident's buttocks. LVN GGG did not retract the foreskin or clean the head of the penis. LVN GGG assisted Resident #26 turn onto his left side in order to clean his buttocks. LVN HHH removed the soiled brief and discarded it into the biohazard bag. LVN HHH, during care, removed her gloves, did not wash or sanitize her hands, donned new gloves, and continued with incontinent care. LVN HHH completed incontinent care and with the same soiled gloves touched the Resident's clean shirt and brief. LVN HHH then left the biohazard bag on the bathroom floor, washed her hands, and left the room. In an interview on 1/24/2020 at 9:30 am with LVN GGG, she said she had been working at the facility full-time during the 6am-6pm shift. She confirmed she did not clean the head of the penis or retract the foreskin. She said she had been in-serviced on hand washing/ infection control a couple of months ago. She said she got nervous and forgot to properly clean the resident. In an interview on 1/24/2020 at 9:35 am with LVN HHH, she said she had been working at the facility for the past two years as a full-time employee as a floor nurse. She said she recently took the role of an infection control nurse. She said she should have washed her hands or used hand sanitizer after removing her gloves while providing care to the Resident. She said the failure placed the resident at risk for infections. She said she was taking the CDC infection control modules online. In an interview on 1/24/2020 at 10:00 am with the DON, he said he expected staff to provide appropriate care to residents based on their needs. He said the nurse should have either washed or sanitized her hands after touching a dirty area prior to moving to a clean area when performing incontinent care. He said the staff should wash their hands when entering a residents room if they were going to provide any care. He said nurses had their skills check offs twice a year in the month of (MONTH) and December. Record review of the facility's Perineal Care policy dated 2/28/19 read in part, .the purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.1. Retract foreskin of the uncircumcised male. 2. Wash and rinse urethral area using a circular motion. 12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 13. Reposition the bed covers. Record review of the facility's undated Peri-Care Skills Checklist read in part, .Skill-washes hand prior to initiation of care. Change gloves appropriately- between washing, rinsing, drying. Disposes of soiled linen appropriately. Record review of the facility's Managing Infection policy dated 5/22/19 read in part, .Appropriate precautions shall be used either at all times (standard precautions) or for individuals who are documented or suspected to have infections or communicable diseases that can be transmitted to others (Transmission-Based Precautions). D. wear gloves (clean, non-sterile) when entering the room. E. while caring for a resident, change gloves, after having contact with infected material (for example, fecal material and wound drainage). F. Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. [NAME] After removing gloves and washing hands, do not touch potentially contaminated environment surfaces or items in the resident's room.

Based on observation, interview, and record review, the facility failed to ensure there was a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day for 1 of 12 residents (Resident #23) reviewed for hospice services in that: -There was no hospice communication documentation for Resident #23 after 12/16/19 in his medical record or hospice communication binder. This failure could affect all residents on hospice and place them at risk for services and treatments not being coordinated. Findings include: Record review of the face sheet for Resident #23 revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #23's quarterly MDS assessment dated [DATE] revealed he was coded 0 for his BIMS indicating he was rarely/never understood and was cognitively impaired. He was coded as receiving hospice care while a resident. Observation of Resident #23 on 1/23/20 at 8:50 am revealed he was sitting in his wheelchair in the hallway by the dining room. A staff member was observed sitting with him. He was receiving O2 and appeared to be well groomed. Record review of Resident #23's care plan's revised on 03/01/19 read in part, .work cooperatively with hospice team . The care plan did not address hospice communication. Record review of Resident #23's physician order's for (MONTH) 2020 revealed an order for [REDACTED]. Record review of Resident #23's patient visit log from hospice revealed hospice staff visited him on the following days: 12/4/19, 12/5/19, 12/9/19, 12/10/19, 12/11/19, 12/12/19, 12/16/19, 12/17/19, 12/19/19, 12/23/19, 12/24/19, 12/26/19, 12/27/19, 12/30/19, 12/31/19, 1/2/20, 1/6/20, 1/7/20, 1/8/20, 1/9/20, 1/13/20, 1/14/20, 1/16/20, 1/20/20 and 1/22/20. Record Review of Resident #23's medical file revealed no documentation of any coordination of care or any communication with hospice since 12/16/19. Interview, observation, and record review with RN F on 1/23/20 at 9:07 am, he said he was the nurse for Resident #23. He said Resident #23 was receiving hospice services. He said he was not sure exactly what days the hospice came but he knew they came weekly. He said when the hospice staff came they gave the resident a shower and the nurse would do assessments. He said the hospice staff always announced when they were there and asked the nurse if there were any concerns or anything they should be aware of. When asked how the hospice staff communicated with the facility, he said they always logged in their binder when they were there. He said they told them verbally what they did, and they also documented in their binders. When asked when was the last time the hospice came and what they did when they were there, he said, Let's check the binder. He reviewed the binder for Resident #23 with the surveyor and said, Looks like they were last here on 1/20/20. When asked what they did on 1/20/20 when they were there, he checked the binder and said he could not find the documentation. He checked the binder and said the last documentation he saw was from 12/16/19. When asked who was responsible for ensuring they were documenting in the binder, he said the ADON or DON were responsible. Interview and record review with the ADON on 1/23/20 at 9:25 am, she said the hospice visited Resident #23 three times a week. She said the hospice aides came three times a week and did his ADL's and also the hospice nurse came weekly to do assessments. She said the hospice staff always told them when they were there. When asked how do they know what hospice did when they were there, she said they told them verbally and also they should be documenting in the hospice binder. She reviewed Resident #23's binder with the surveyor and confirmed the last documentation by hospice was from 12/16/19. The ADON said, I know they've been here since then. She said they were computerized, but they still should be printing the documentation out and leaving it in the binder. She said hospice staff were responsible for ensuring they were printing out their notes and leaving it in the binder. When asked who in the facility was responsible for following up to ensure that was being done she said, Well, I give them reminders. She said she would call them (hospice)to get the rest of the documentation. Record review of the facility's hospice care services agreement updated on 09/12/18 read in part, .SNF/Hospice responsibilities .documentation of communication between hospice and SNF .the hospice RN shall be responsible for .communication and coordination of services.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in that Food items in the dry storage room and the freezer were not sealed. Dented can of tuna . Plated and pans stored with clean items had food particles. Equipment not clean. Hair found in food. These failures have the potential to affect all residents who ate food from the facility's kitchen by placing them at risk of foodborne illness. Findings include: Observation on 03/06/19 09:15 AM deli counter revealed a small container of mayonnaise with hair in it. This was pointed out to the Director of Dining room Services who immediately removed it and discarded the bottle. Further observation at the time revealed the white chopping boards at the deli counter and the one near the cook top had deep marks and black stains on them. Observation on 3/6/19 at 9:22 AM of the metal shelf that store clean plates and pans revealed plates and pans were observed with dried food particles and water on them. Interview on 03/06/19 9:25 a.m. the Director of Dining Room Services (DDS) said the plates were not used, they were extra plates. He then instructed the staff washing the pots and pans to ensure they were air dried properly before they were packed away. Observation on 03/06/19 at 9:30 AM of the dry storage room revealed an opened box of white chocolate and one with rice not sealed. There was a dented can of tuna with undented cans of tuna. During an interview on 03/06/19 at 9:35 a.m. with Staff A regarding the boxes not sealed he said they usually pour the contents of open boxes into containers and that those were missed. Observation on 3/6/19 at 9:50 AM of the walk-in-Freezer revealed an open box with cookie dough and bag with raw chicken opened but not sealed. During an interview at that time with the DDS he said that open containers with food items should be sealed labeled and dated. He said he was going to in-service the staff and ensure that the foods are sealed, labeled and dated. Further observation on 3/5/2019 at 9:55 a.m. revealed the convection oven had grease and burnt food particles in them. At that point the DDS said he was going to ensure that the ovens were clean that evening. Record review of the food safety requirements policy (dated 2/8/18) read in part . nursing home residents risk serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure for residents .

Based on interview, and record review the facility failed to ensure assessments accurately reflected the resident's status for two (Resident#12 and Resident #13) of two resident reviewed for assessments in that. - Resident #12 coding of [DIAGNOSES REDACTED]. - Resident #13's MDS assessment did not accurately reflected Resident #13's hospice care status. This failure affected two resident placing them at risk of not getting the care and services needed based on their [DIAGNOSES REDACTED]. Findings include: Resident #12: Record review of Resident #12's face sheet revealed [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #12's Admission Physician order [REDACTED]. Record review of Resident #12's Physician order [REDACTED]. Record review of Resident #12's Quarterly MDS assessment dated [DATE] indicated the resident BIMS was 3 indicating severely impaired cognitive skills. Staff assessment for mental status was conducted resident was unable to complete the interview. Further review of the MDS revealed that he required extensive assistance from staff for dressing, toilet use and personal hygiene. Resident was incontinent of bowel and bladder. Record Review of section I: Active [DIAGNOSES REDACTED]. Record review of the MAR for January, (MONTH) and (MONTH) 2019 revealed that Resident #12 received medications mentioned above as ordered for the [DIAGNOSES REDACTED]. In an interview with the RN MDS Coordinator on 3/8/19 at 8:57 am, she said she started working at this facility 2 weeks ago. She said she knew they had issues with MDS that needed to be fixed. She said nurses were responsible for adding orders in residents chart. She said she went through the resident's medical chart and added the [DIAGNOSES REDACTED]. She said [MEDICAL CONDITION] was not one of Resident #12's medical [DIAGNOSES REDACTED]. She said, we can get that updated. In an interview with LVN MM on 3/8/19 at 1:32pm, she said Resident #12 had moved from assisted living to long term care. She said he was taking [MEDICAL CONDITION] medication upon admission on 10/11/18. She said the nurse who entered his orders forgot to add the diagnosis. In an interview with the DON on 3/8/19 at 10:57 am, he said nurses should have added the medical [DIAGNOSES REDACTED]. He further said if the resident came from the hospital, then medical records updated the diagnosis. Resident #13 Record review of Resident #13's admission record revealed Resident #13 was admitted to the facility on [DATE]. Resident #13 was an [AGE] year-old male with [DIAGNOSES REDACTED]. Record review of Physician order [REDACTED].#13 to hospice with a [DIAGNOSES REDACTED]. Start date was 7/27/18. Record review of Resident #13's quarterly MDS assessment, dated 10/23/18, revealed Section O for Special Treatments, Procedures, and Programs did not indicate Resident #13 was receiving hospice care. In an interview on 03/08/19 at 9:55 a.m., the RN MDS Coordinator said she was responsible for the MDS assessments for Resident #13 but he just started 2 weeks ago. He said he was aware that Resident #13 was on hospice care. In an interview with ADON/LVN A on 3/8/19 at 11:30 a.m., regarding hospice not coded on MDS , she said it was oversight and they fired the nurse who was doing the care plan and MDS two weeks ago

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' physical, mental, and psychosocial needs for 2 of 12 residents (Resident #10, and Resident #11 ) reviewed for comprehensive care plans -The facility did not develop and implement a comprehensive person-centered care plan to address Resident #11's ADL care needs - The facility did not develop and implement comprehensive care plan for Resident #10 to address ADL's and incontinence. These failures affected two residents placing them at risk of not receiving the required care and services need to improve their medical, physical, and psychosocial needs. Findings Include: Resident #11: Record review of Resident #11's face sheet revealed she was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #11's quarterly MDS, dated [DATE] revealed a BIMS of 3, indicating severe cognitive impairment. Her functional status indicated she required total dependence from one staff member for bed mobility, eating, and toilet use. She required total assistance from two staff for transfers, dressing, and personal hygiene. Section H: Bladder and Bowel . reflected Resident #11 was always incontinent of bladder and bowel. Section K: Swallowing/Nutritional Status . reflected the Resident had mechanically altered diet (pureed diet). Record review of initial care plan dated 01/22/19 and revised on 02/28/19 for Resident #11 reflected no Focus, goals or interventions for: ADLs needs and Urinary Incontinence. Observation of Resident # 11 on 3/6/19 sitting on the wheelchair at 9:00 a.m., revealed she was been fed by the facility staff and was totally dependent on ADL's. In an interview with CNA F on 3/8/19 at 9:35 a.m. she said Resident #11 was totally dependent on staff for ADL's. In an interview with ADON/LVN A on 3/8/19 at 11:30 a.m., she said that the care plan was not done for Resident #13 and it was oversight and they fired the nurse who was doing the care plan and MDS two weeks ago Resident #10: Record review of Resident #10's admission face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #10's Initial MDS dated [DATE] and quarterly MDS dated [DATE] revealed a BIMS Score of 0 indicating that the resident was severely cognitively impaired. For functional status resident needed extensive assistance of one person assisted bed mobility, transfer, toilet and personal hygiene, dressing and bathing and was incontinent of bowel and bladder. Behavior issues were not coded. Observation on 3/06/2019 at 12:25 PM Resident #10 was observed in the dining for for lunch. Resident drank only coffee and said she had finished eating. Staff asked resident what she wanted to eat she yelled I have already eaten. Interview with 3/8/19 at 10:15 a.m. CNA Z said she worked with Resident #10 and she had a lot of behavior issues such as refusing care, refusing to eat and yelling. Record review of the care plans initiated 8/06/2018 and last review dated 1/22/19 revealed it did not address incontinent of bowel and bladder activities of daily living needs or behavior problems. Interview 3/8/19 at 8:52 a.m. the RN MDS Coordinator said she was new and was aware of the MDS and care plan issues. Further interview revealed that the care plans should be done based on triggered areas, interview and assessments. She said she was going to update the resident's clinical records. She also said she was working on getting the charts updated but she had not gotten to these charts as yet In an interview on 3/8/19 at 11:15 AM with ADON/LVN A regarding the care plans and MDS she said they in-service staff on documentation of resident's behavior. She said the behavior issues should be included on the care plans and on the MDS. She said they just got a new MDS person and they were working on updating the care plan and nurse's notes documentation to match the resident's current status. Record review of the facility Nursing Services Policy and Procedure Manual for Long Term Care revised (MONTH) 2010 read in part: . Care Plans- Comprehensive Policy Statement An individualized comprehensive care plan that includes measurable objectives and time tables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation 7. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change .

Based on observation, interview, and record review the facility failed to maintain a clean, sanitary, comfortable, and homelike environment for residents, staff and the public as evidenced by: A. Two dirty lint traps in the laundry room B. One of the dryer in the laundry room was missing lint collection insulation. C. Refrigerator in resident's room had no temperature log These failures could place all residents at risk for a diminished quality of life, clean and homelike environment. Findings include: Observation on 3/6/19 at 8:40 am, during initial tour revealed the refrigerator in Resident #19's room had no temperature log. There was food in the refirgerator. Observation on 3/7/19 at 12:44 pm, in the laundry room revealed both lint traps from the dryers were full of lint and one of the dryers was missing insulation. In an interview with Resident #19 on 3/7/19 at 1:02pm, she said she brought her refrigerator from the assisted living to long term care. She said nobody has ever came to her room to clean or monitor the refrigerator. She said it would be nice if someone can assist in cleaning out the refrigerator since she cannot do it herself. In an interview with the DON on 3/8/19 at 10:35 am, he said he looked at the policy on monitoring resident's refrigerators and it was very vague. He said nobody was monitoring Resident #19's refrigerator. He said if temperature was incorrect it could build up bacteria and spread it to other residents. He said he will come up with a place in the TAR for nurses to monitor refrigerator's temperature. He said he ordered the thermometer for the Resident #19's refrigerator. In an interview and observation with Housekeeping Aide A on 3/8/19 at 12:56 pm, she said she has been working at this facility for last [AGE] years. She said lint traps were supposed to be emptied every two hours. She said she last emptied the lint traps at 9:00am. She said she forgot to empty them at 11:00am. She said they do not have a lint trap cleaning log to keep a record. In front of the surveyor Housekeeping Aide A emptied both lint traps. Housekeeping Aide A confirmed one of the dryer's was missing a part. She said the technician came to the facility a week ago and had told them it was okay to continue using the dryer. In an interview with Housekeeping supervisor on 3/8/19 at 1:15pm, she said lint traps were emptied every morning, after 1-2 use and at the end of shift. She said there was no lint trap cleaning log, but they should. She said beginning of (MONTH) 2019 they had placed a work order to fix one of the dryer's part which stop working in one of the dryer and washing machine leakage. She said a week ago, the technician came and fixed everything except for the dryer insulation. She said technician had brought the insulation, but it was big. She said technician told them that he would be back, and it was okay to continue using the dryer. She said it was risk for catching fire, she will tell housekeeping aide to stop using the dryer without insulation. In an interview with the Administrator on 3/8/19 at 1:31pm, he said the Housekeeping Supervisor just informed him about the missing insulation on the dryer. He said the Housekeeping Director was off today and he was trying to get a hold of her. He said he told Housekeeping aide A to stop using the dryer until the technician is back. Record review of the food safety requirements policy (dated 2/8/18) read in part . nursing home residents risk serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure for residents .Facility staff will be appointed to check resident refrigerators for proper temperatures, food containment and quality, and disposal of items . Facility staff will be appointed to check resident rooms through daily housekeeping process for food and beverage items for safe and sanitary storage and handling .

Based on interview and record review the facility failed to ensure all irregularities identified by the licensed pharmacist were reported to the attending physician and acted upon for 1 of 12 (Residents #4) reviewed for drug regimen. -The facility failed to act on a pharmacy medication regimen review for Resident #4. This failure affected one Resident and placed him at risk for adverse drug consequences and decline in their physical and mental health status. Findings Included: Record review of Resident #4 's face-sheet, revealed he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included but were not limited to [MEDICAL CONDITION], cerebral infarction, [MEDICAL CONDITION], other specified [MEDICAL CONDITION], and [MEDICAL CONDITION]. Record review of the significant change MDS, dated [DATE], revealed Resident #4 had a cognitive skill score of 3, indicating severe cognitive impairment. Further review of the MDS indicated an altered mood score of 4/30, indicating minor depression. The behaviors section identified no behaviors for Resident #4. His active diagnoses listed depression. Record review of the comprehensive care plan for Resident #4, date initiated 3/1/19, revealed, in part: .Focus: The Resident is on [MEDICATION NAME] sprinkles and is at risk for adverse reactions . Interventions: .monitor for effectiveness . notify family about risk and benefit of medications . Focus: Resident #4 is on antidepressant medication [MEDICATION NAME] and is at risk for adverse reactions . Focus: Resident #4 uses [MEDICATION NAME] and is at risk for adverse reaction. Record review of Resident #4's physician orders dated, 1/14/19 revealed an order for [REDACTED]. Record review of the informed consent for [MEDICATION NAME], dated 1/14/19 revealed no specific condition to be treated . identified. Further review of the informed consent revealed no beneficial effects expected . listed for the medication. Record review of Resident #4's MAR, dated 3/1/19 -3/31/19 revealed he had been administered [MEDICATION NAME] every 12 hrs from 3/1/19 to 3/7/19. Record review of Resident #4's MRR, dated 2/5/19 revealed the Pharmacist identified: . need to clarify the [DIAGNOSES REDACTED].need to also specify correct potential side effects with [MEDICATION NAME]- should be mood stabilizer . During interview with the ADON on 03/08/19, at 09:31 a.m. she said she was in the process of receiving the [DIAGNOSES REDACTED]. She said the hospice company was providing the [DIAGNOSES REDACTED]. She said today the company understood the urgency to provide the diagnosis, so they are providing it via fax. She said she had no documentation to support that the pahrmacy recommendations were acted upon by the doctor prior to 3/8/19. Interview with the DON on 03/08/19, at 12:00 p.m. he said there had been a longstanding problem between hospice physicians, nurses and facility physician communicating pharmacy recommendations. He said the nurses communicate to the physician and the Physician communicates to the hospice physician. Adjustments were then made accordingly. He confirmed the facility should have followed-up on the MRR for Resident #4 from 2/5/19. He said the facility would contact the Hospice physician to have the medication discontinued because the resident was not delusional. Record review of the facility policy, Medication Regimen Review, date issued 3/2018, read in part: .The DON ensures that medication regimen reviews are addressed in a timely manner . non- urgent recommendations are addressed prior to the consultant's next scheduled facility visit .actions are documented on the review .Irregularities in the medication regimen identified by the consultant pharmacist are reported to the attending physician, the DON and the medical director .if the attending physician fails to address the irregularity, the Medical Director is contacted to assist in addressing the irregularity is notified .

Based on interview and record review, the facility failed to ensure residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 12 resident's reviewed for [MEDICAL CONDITION] medication (Resident #4). -The facility did not have a [DIAGNOSES REDACTED]. This failure affected one Resident and placed the resident at risk of receiving unnecessary antipsychotic medication. Findings Included: Record review of Resident #4 's face-sheet, revealed he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included but were not limited to [MEDICAL CONDITION], cerebral infarction, [MEDICAL CONDITION], other specified [MEDICAL CONDITION], and [MEDICAL CONDITION]. Record review of the significant change MDS, dated [DATE], revealed Resident #4 had a cognitive skill score of 3, indicating severe cognitive impairment. Further review of the MDS indicated an altered mood score of 4/30, indicating minor depression. The behaviors section identified no behaviors for Resident #4. His active diagnoses listed depression. Record review of the comprehensive care plan for Resident #4, date initiated 3/1/19, revealed, in part: .Focus: The Resident is on [MEDICATION NAME] sprinkles and is at risk for adverse reactions . Interventions: .monitor for effectiveness . notify family about risk and benefit of medications . Record review of Resident #4's physician orders dated, 1/14/19 revealed an order for [REDACTED]. Record review of the informed consent for [MEDICATION NAME], dated 1/14/19 revealed no specific condition to be treated . identified. Further review of the informed consent revealed no beneficial effects expected . listed for the medication. Record review of Resident #4's MAR, dated 3/1/19 -3/31/19 revealed he had been administered [MEDICATION NAME] every 12 hrs from 3/1/19 to 3/7/19. Record review of Resident #4's MRR, dated 2/5/19 revealed the Pharmacist identified: . need to clarify the [DIAGNOSES REDACTED].need to also specify correct potential side effects with [MEDICATION NAME]- should be mood stabilizer . During interview with the ADON on 03/08/19, at 09:31 a.m. she said she was in the process of receiving the [DIAGNOSES REDACTED]. She said the hospice company was providing the [DIAGNOSES REDACTED]. She said today the company understood the urgency to provide the diagnosis, so they are providing it via fax. She said she had no documentation to support that the pahrmacy recommendations were acted upon by the doctor prior to 3/8/19. Interview with the DON on 03/08/19, at 12:00 p.m. he said there had been a longstanding problem between hospice physicians, nurses and facility physician communicating pharmacy recommendations. He said the nurses communicate to the physician and the Physician communicates to the hospice physician. Adjustments were then made accordingly. He confirmed the facility should have followed-up on the MRR for Resident #4 from 2/5/19. He said the facility would contact the Hospice physician to have the medication discontinued because the resident was not delusional. Record review of the Federal Drug Administration website accessed on 03/15/19 revealed in part: .[MEDICATION NAME] is an anti-epileptic drug indicated for: · treatment of [REDACTED]. · Monotherapy and adjunctive therapy of complex partial [MEDICAL CONDITION] and simple and complex absence [MEDICAL CONDITION]; adjunctive therapy in patients with multiple [MEDICAL CONDITION] types that include absence [MEDICAL CONDITION] · [MEDICATION NAME] of migraine headaches Record review of the facility policy, Medication Regimen Review, date issued 3/2018, read in part: .The DON ensures that medication regimen reviews are addressed in a timely manner . non- urgent recommendations are addressed prior to the consultant's next scheduled facility visit .actions are documented on the review .Irregularities in the medication regimen identified by the consultant pharmacist are reported to the attending physician, the DON and the medical director .if the attending physician fails to address the irregularity, the Medical Director is contacted to assist in addressing the irregularity is notified .

Based on observation, interview, and record review, the facility failed to have a person-centered comprehensive care plan developed and implemented to meet each Resident's preferences and goals, and address the Resident's medical, physical, mental and psychosocial needs for 5 of (#182, #185, #233, #84, #87, #) 12 Residents reviewed for care plans. Resident #182 was not care planned for Activities Resident #185 was not care planned for her psychosocial well-being Resident #233 did not have Interventions weight loss issues. Resident #84 was not care planned for hospice. Resident #87 was not care planned for wanderguard use and activities This failure affected five Residents and placed 22 other Residents in the facility at risk for unmet care needs. Findings Included: Resident #182 Record Review of the Face Sheet for Resident #182 revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of Resident #182's significant change in status MDS assessment dated [DATE] revealed a BIMS score of 11 indicating she was moderately impaired. Further review of the MDS revealed that the following activities were somewhat important to her: have books, newspapers, magazines, be around animals such as pets, keep up with the news, do things with groups of people, do your favorite activities, go outside to get fresh air when the weather is good and participate in religious services or practices. Further review of section V titled care area assessment revealed that she was triggered for activities. Record Review of Resident #182's Care Plans initiated on 09/30/16 and revised on 03/20/18 revealed no care plan for Activities. Resident #185: Record Review of the Face sheet for Resident #185 revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of Resident #185's Annual MDS assessment dated [DATE] revealed a BIMS score of 13 indicating she was cognitively intact. Review of section D for mood revealed that she has little interest or pleasure in doing things 2-6 days a week. Further review of section V for care area assessment revealed that she was triggered for psychosocial well-being. Record Review of Resident #185's Care Plans started on 01/25/18 and revised on 03/20/18 revealed no care plan to address her psychosocial well-being. Interview with Resident #185 on 03/19/18 at 12:25 pm, she said that she was doing fine. She was able to answer all of surveyor's questions. She said she was happy at the facility and had no problems. In an Interview with the MDS Nurse on 03/22/18 at 10:30 am, she said that she was responsible for doing the nursing care plans and each department had to do their own care plans. She said it was her job however to review care plans for completion and accuracy. Resident #233 Record review of Resident #233's face sheet revealed she was an [AGE] year-old female admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #233's comprehensive MDS, dated [DATE] revealed a BIMS of 7, indicating significant cognitive impairment. Her functional status indicated she required extensive assistance with bed mobility, transfers, dressing, and eating. Section K. Swallowing/Nutritional Status reflected actual weight loss had occurred. Record review of the care plan (no date) for Resident #233 reflected Focus: .Unplanned/Unexpected weight gain r/t she is down -8.79% in a month .she has also been on puree diet . Further review revealed no interventions listed for weight loss. During an interview with the MDS coordinator on 03/21/18, at 11:35 AM, she said if interventions were not listed or a new problem was identified, the nursing department created care plan addendums, located within the clinical chart to reflect newly identified care needs. She said in each chart there was a care plan addendum. She said there should be a care plan addendum, located in the clinical chart, with appropriate interventions for weight loss for Resident #233. In an interview at 11:54 am, on 3/21/18, the MDS Coordinator confirmed she was unable to locate an addendum with appropriate interventions listed for Resident#233's actual weight loss. She also confirmed nursing interventions for Problem: Actual Weight Loss should be listed on Resident #233's current care plan. Resident #84 Record review of Resident #84 revealed she was a 101 female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED].#84 was admitted to Hospice Care on 02/09/16 with [DIAGNOSES REDACTED]. Record review of the care plan initiated 02/20/16 and revised 03/20/2018 revealed it did not address the services that hospice was going to provide for the Resident; example bathing, pain management, pressure ulcer prevention, medications and nutrition. There were no goals and approaches to meet desired outcome. Observation on 3/19/17 at 10:20 a.m., 11:00 a.m. 11:30 and 12:30 p.m. Resident was observed in chair in room. Lunch tray noted at 12:45 p.m. Resident#84 was self-fed with set up and cuing. During an interview on 3/19/18 at 12:55 p.m. with Sitter A she said that Resident #84 likes to sit in the chair. She said they tried to put her back in bed after breakfast but sometimes she fights. However, they always put her back in bed after lunch and she said she was also on hospice. During an interview on 3/21/18 at 12:10 p.m. with the MDS Nurse she said hospice provides a shower to Resident #84 on Tuesday and the facility shower her on Thursday. She also said that hospice provides bathing and medications. She further stated that each discipline does their care plan. Record review of Hospice Nursing Facility Hospice Service Agreement dated 13th October, (YEAR) read in part . Part 1 Definitions D. Plan of Care: A written plan prepared for each Hospice patient, containing an assessment of the patient needs, identification of the services to be provided and a detailed description of the scope and frequency of services needed. The plan of care specifies which services and supplies are related to the patient's terminal illness and therefore will be furnished by hospice. Resident #87: Record review of Resident #87's admission face sheet revealed she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Observation on 3/19/1018 at 9:50 a.m., 10:20, 11:00 and 12:00 noon and on 3/20/18 at 9:00 a.m. 10:00 a.m., 11:00 a.m. 12:30 p.m. Resident #87 was noted in her wheel chair. She was alert with some confusion and was wearing a wander guard and a chair alarm. Record review Resident #87's Annual MDS assessment dated [DATE] revealed F0500 coded Activity preferences as 1 for favorite activity and going outside for fresh air and 2 for listening to music, keeping up with the news, participating in religious, and doing group activities. Further review of the Resident activities care area assessment summary triggered activities and checked to be care planned. Record review of the care plan initiated 11/26/17 and updated 03/08/2018 revealed the care plan did not address activities preferences, wander guard and chair alarm use. In an interview with CNA HH on 3/20/2018 at 1:45 p.m. she said that Resident #87 goes to activities. She said, however sometimes she will argue but will eventually go. In an interview with the MDS nurse on 3/22/18 at 10:22 a.m.he said that Resident #87's chair alarm was supposed to be discontinued. She said each discipline does their own care plan. In an interview and observation with the Activity Director on 3/22/2018 at 10:00 a.m. she said she was told by the MDS nurse that surveyor wanted to look at her activity book. There was no care plans in the activities book. The book had only the assessment notes for Resident #87. An example of what the care plan should look like was shown to the Activity Director and she said she did not have a care plan. Observation and interview on 03/22/18 at 10:55 a.m. with the ADON she acknowledge the wander guard bracelet on Resident #87 and she said she was going to look for the order. No order was given to the survey team prior to exit. Record Review of the Facility's policy for Care Plans-Comprehensive revised on (MONTH) 2010 read in part, an individualized comprehensive care plan that includes measurable objectives and timetables to meet the Resident's medical, nursing,mental and psychological needs is developed for each Resident .each Resident's comprehensive care plan is designed to .incorporate identified problem areas .areas of concern that are triggered during the Resident assessment are evaluated using specific assessment tools before interventions are added to the care plan Record Review of the Facility's Resident Roster dated 03/19/18 listed 27 Residents.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen in that: - Foods on the steam table were not at the correct holding temperature - Foods were not sealed, labeled and dated - Dry storage room was not free of dented cans - Foods that were expired were stored with unexpired foods - Dirty plate was stored with clean plates These failures has the potential to affect all 27 residents who ate food prepared by the kitchen and could placed them at risk of food borne illness and disease. Findings include: Observation on [DATE] at 09:04 a.m. of the walk-in- freezer revealed green beans and beef patties open but not sealed. Cookie dough, biscuits, and garlic butter were not labeled or dated. Observation on [DATE] at 9:15 a.m. of the dry storage room revealed dented cans of apple sauce and chili con carne with other cans that were not dented. Observation on [DATE] at 9:25 a.m. of the walk- in - cooler revealed seven one pint bottles of chocolate milk with an expiration date of [DATE]. In an interview on [DATE] at 9:30 a.m. Dietary Supervisor A she remove the unlabeled, unsealed and undated food items and said she was going to have them labeled and dated. The expired chocolate milk was discarded and the dented cans were removed and placed with other dented cans. Observation of lunch on the third floor on [DATE] at 12:00 p.m. revealed Menu items not at the correct holding temperature, the menu items were broccoli at 111 degrees F, egg rolls at 113 degrees F and snow peas at 124 degrees F. In an interview at that time with Wait staff R she said the steam table would not hold all the menu items. She said the temperature should be over 140 degrees and she was going to call the kitchen.The wait staff C she said when the steam table cannot hold all the menu items the extra menu items should be placed in the warmer to maintain the correct holding temperature. At that point she said, she was going to the kitchen to get new menu items that were at the correct holding temperature. According to the Facility's Policy on Food Storage dated ,[DATE] read in parts . Procedure: 14. Refrigerated Food Storage: F: All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe used by dates or discarded. Record review of the Facility's Policy and Procedures on Food Temperatures dated 2013 read in parts . Policy: The temperatures of the food items will be taken and properly recorded for each meal. Procedures: 1. All hot food items must be cooked to appropriate internal temperature, and held and served at a temperature of at a temperature of at least 135 degrees F. Take temperature often to monitor for safe food holding temperature ranges at or below 41 degrees F for cold foods; and or above 135 for hot foods. 5. Tray line and alternative meal preparations and service area will avoid the following methods: . Holding foods in the temperature danger zones (41 degrees F-135 degrees F. . Using the steam table to heat foods. The facility's Resident Census and condition listed a census 27 and the all eat food prepared by the kitchen.