Every finding on record at Bayview Nursing Home

Based on observation, staff interviews, record review and review of the facility's policy titled Using the Care Plan, the facility failed to follow the care plans for two out of 27 sampled Residents (R) (R51) related to falls, and R17 related to oxygen . Actual harm occurred on 12/3/2025 when R51, who had increased confusion and required assistance from staff with Activities of Daily Living (ADL) care, was left on the toilet unassisted and unsupervised by a Certified Nursing Assistant (CNA). Subsequently, R51 was found on the floor in a puddle of blood after attempting to get off the toilet. As a result of the fall, R51 sustained a laceration to the left scalp and a fractured right distal fibula.Findings include: A review of the facility's policy titled Using the Care Plan revised dated 4/18/2017 under Policy revealed, The care plan shall be used in developing the resident's daily care routines and will be available to staff personal who have responsibility for providing care or services to the resident. Under the section titled Policy Interpretation and Implementation, revealed, 2. The nurse supervisor uses the care plan to coordinate care. 1. A review of the electronic medical record (EMR) revealed prior to the incident on 12/3/2025, R51 had diagnoses that included but was not limited to, history of falling, repeated falls, unspecified osteoarthritis, urinary tract infection (UTI), and stroke. A review of R51's care plan dated 6/30/2021 revealed, a focus that indicated Resident has an ADL self-care performance deficit r/t (related to) Limited Mobility, the interventions included but not limited to, Toilet Use: Resident requires assistance from staff for toileting, Transfers: Resident requires assistance from staff to move between surfaces PRN (as needed) with revision date of 7/9/2021, Provide supportive care, assistance with mobility as needed dated 7/13/2021. Further review of the care plans revealed, a focus that indicated [R51's Name] is at risk for Falls r/t history of falls, impaired mobility. Interventions included but not limited to, anticipate and meet needs, attempt to re-orient when confusion is noted, and be sure call light is within reach and encourage her to use it for assistance as needed. Review of the Facility Reported Incident Case #202513561 dated 12/3/2025 at 9:27 pm revealed, Staff assisted resident to the restroom and stepped out to give her privacy. Staff came to check on resident and she was on the floor. She had a laceration to her head and was complaining of pain to her leg. Staff sent resident to [Name of Hospital], Resident's daughter Just notified facility that hospital says she does have a fracture in her leg. Resident Is currently on antibiotics for a UTI, which has contributed to more confusion. Resident's family members reported to nursing staff this afternoon that resident did not seem like herself, which is most likely due to the resident's confusion from UTI. Investigation will be conducted; however, we believe that resident attempted to get herself off the toilet due to her increased confusion from UTI, resulting in her fall. Review of progress note dated 12/8/2025 revealed, R51 returned to facility s/p(status post) hospitalization for fall, Fracture right distal fibula, laceration to scalp laceration. Alert with some confusion. A phone interview on 12/20/2025 at 1:05 pm with the MDS Nurse confirmed that nursing staff should be following the care plans. The MDS Nurse revealed that CNAs were made aware of any interventions that should be used for R51 which include that she was to receive supervision with transfers to and from restroom and touching assistance if needed. The MDS Nurse revealed that the best practice for the CNA that took her to restroom was that R51 should have been given privacy by cracking the door and staying in the room until she was finished. Interview on 12/21/2025 at 1:30 pm with the Administrator confirmed that it would have been best practice for CNA DD to have waited for R51 in the room or outside door of restroom when the resident was care planned for one person assist with transfers to and from the restroom with touching assistance. The Administrator confirmed that R51 was a one person assist with ADLs and transfers however, the CNA went to give a shower for another resident instead of staying in the room. [Cross Reference – F689] 2. Review of the electronic health record (EHR) for R17 revealed diagnoses including, but not limited to, COPD and atherosclerotic heart disease of native coronary artery without angina pectoris Review of the MDS for R17, dated 11/14/2025, for Section O (Special Treatment Procedures, Program) revealed the resident received oxygen therapy. Review of R17's care plan last revised on 12/13/2025, a Focus area that revealed, the resident has COPD. The Goal was for the resident to be free of s/sx (signs/symptoms) of respiratory infections. The Interventions included, but were not limited to, O2 (oxygen) by nasal prongs at 2 (two) L (liters) per minute continuously. Review of the physician orders for R17 revealed an order dated 11/14/2025 for oxygen at two liters per minute (LPM) via (by way of) nasal cannula continuous every shift. Observation on 12/19/2025 at 10:40 am to12:00 pm revealed R17 receiving oxygen at one and a half (1.5 ) liters per minute LPM via nasal cannula from the oxygen concentrator. Observation on 12/20/2025 at 11:20 am revealed R17 receiving oxygen at one (1) LPM via nasal cannula from the oxygen concentrator. During an interview on 12/20/2025 at 4:01 pm, the Director of Nursing (DON), confirmed that the oxygen was not set per the physician's order for R17. During an interview by phone with the MDS Coordinator BB on 12/21/2025 at 11:11 am, the MDS Coordinator reported that her expectation was for the resident to receive oxygen based on the physician order. [Cross Reference F695]

Based on observations, staff and family interviews, record review and review of the facility's policy titled Safety and Supervision of Residents, and Fall Management the facility failed to provide adequate supervision to prevent accidents for one of four sampled residents (R) (R51) reviewed for falls. Actual harm occurred on 12/3/2025 when R51, who had increased confusion and required assistance from staff with Activities of Daily Living (ADL) care, was left on the toilet unassisted and unsupervised by a Certified Nursing Assistant (CNA). Subsequently, R51 was found on the floor in a puddle of blood after attempting to get off the toilet. As a result of the fall, R51 sustained a laceration to the left scalp and a fractured right distal fibula.Findings include:A review of the facility 's policy titled Safety and Supervision of Residents dated 3/23/2017 under Policy revealed Our facility strive to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility -wide priorities. Under the section titled, Residents - Oriented Approach to Safety revealed, 4. Implementing interventions to reduce accidents risks and hazards shall include the following: (a.) communicating specific interventions to all relevant staff; (d.) ensuring that interventions are implemented.A review of the facility's policy titled Fall Management dated 5/17/2017 under the section titled Policy Statement revealed, It is the policy of this facility that the administration and staff provide a safe environment for all residents. The facility is aware that its residents are at a higher risk for falls and injury than the general population. The facility will assess residents with fall risk, will evaluate each resident individually and provide, to the best of the facilities ability, interventions to decrease the likelihood of falls.It is also the policy of the facility to provide fall management guidelines for the staff to utilize and developing a plan of care to decrease the likelihood of a resident experience in the fall. Under the section titled Post Fall Guidelines revealed, 5. The nurse is responsible for assuring adequate nursing attention and interventions. (either by the nurse and or the certified nursing assistant) are initiated in attempts to prevent further injury to the residents, to decrease the likelihood of additional falls, and to assure the residents that his or her needs are addressed. A review of the electronic medical record (EMR) revealed prior to the incident on 12/3/2025, R51 had diagnoses that included but was not limited to, history of falling, repeated falls, unspecified osteoarthritis, urinary tract infection (UTI), and stroke. Further review revealed, fracture of upper and lower end of right fibula and laceration without foreign body of scalp was added on 12/8/2025.A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R51 under Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition; Section GG (Functional Abilities) revealed that R51 was dependent with toileting hygiene which included the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movements. Dependent with chair/bed to chair transfers and Toilet transfer was not attempted due to medical condition or safety concerns.Review of the Facility Reported Incident Case #202513561 dated 12/3/2025 at 9:27 pm revealed, Staff assisted resident to the restroom and stepped out to give her privacy. Staff came to check on resident and she was on the floor. She had a laceration to her head and was complaining of pain to her leg. Staff sent resident to [Name of Hospital], Resident's daughter Just notified facility that hospital says she does have a fracture in her leg. Resident Is currently on antibiotics for a UTI, which has contributed to more confusion. Resident's family members reported to nursing staff this afternoon that resident did not seem like herself, which is most likely due to the resident's confusion from UTI. Investigation will be conducted; however, we believe that resident attempted to get herself off the toilet due to her increased confusion from UTI, resulting in her fall.Review of progress note dated 12/8/2025 revealed, R51 returned to facility s/p(status post) hospitalization for fall, Fracture right distal fibula, laceration to scalp laceration. Alert with some confusion.Review of the Follow up Report dated 12/10/2025 revealed witness statements from CNA DD and CNA EE. CNA DD revealed, Resident [R51] called to go the bathroom.Resident stated she wanted privacy and CNA told her to pull call light when finished. After CNA's got done they got another resident up for shower. Resident call light started to go off from the bathroom and another CNA went to grab sheets to make residents bed for when they got out the shower. CNA [EE] went to get bathroom call light at 6:44 pm and noticed resident laying on the ground. CNA called the nurse to come help with resident. CNA EE revealed, Resident had pulled emergency light in bathroom and when I had opened the door I found resident on floor face down in a puddle of blood. Resident lost balance when trying to wipe.Interview on 12/19/2025 at 9:58 am with R51's family revealed R51 had a fracture to her right ankle from the fall. R51's family expressed concerns about the resident's safety and the facility being short staffed. R51's family revealed that CNA DD left R51 on the toilet and forgot to go back and check on her.Interview on 12/20/2025 at 1:53 pm with CNA DD confirmed that she was the one who wheeled R51 in the bathroom and helped her sit on the toilet. She asked the resident if she wanted her privacy and she said yes. So, she shut the bathroom door. While resident was in the restroom, she went to another resident to give a shower. While taking the resident to the shower, she saw and heard the call light going off for R51. She asked CNA EE if they would go and check on her because the emergency call light was going off in the bathroom. Prior to CNA EE responding to the emergency call light, she stopped at the linen closet to get linen for the resident that CNA DD was showering. CNA DD stated she completed the shower, continuing to take the resident back to her room. CNA DD saw the CNA EE stick her head out the door calling for help. CNA DD confirmed that it was about 10 to 15 minutes before anyone went to check on her because she had finished giving the other resident a shower by the time CNA EE called for help. CNA DD admitted that she did not go back to check on her although she was the one who took her to bathroom and assisted her on the toilet.Interview on 12/20/2025 at 1:15 pm with Unit Manager (UM)/ Registered Nurse (RN) CC revealed that she was very familiar with R51, and she always asked for privacy. However, she revealed that CNA DD should have cracked the door and stayed in the room or close by the room to respond when R51 was ready to receive help. She confirmed that it was not best practice to leave the resident while using the toilet because she was a one person assist for transfers to and from and touching assist.Interview on 12/21/2025 at 1:30 pm with the Administrator confirmed that it would have been best practice for CNA DD to have waited for R51 in the room or outside door of restroom when the resident was care planned for one person assist with transfers to and from the restroom with touching assistance. The Administrator confirmed that R51 was a one person assist with ADLs and transfers however, the CNA went to give a shower for another resident instead of staying in the room.

Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure that one of 16 residents (R) (R17) receiving oxygen was administered oxygen therapy in accordance with the physician orders. This deficient practice had the potential to place R17 at risk for respiratory complications and a diminished quality of life.Findings include:Review of the facility policy titled Oxygen Administration, dated 2/25/2024, under the Policy Statement revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration. Under the Policy Interpretations and Implementation section revealed, 1. Verify that there is a physician's order for this procedure. Review the physician 's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident.Review of the electronic health record (EHR) for R17 revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD), hypertension, and atherosclerotic heart disease of native coronary artery without angina pectoris.Review of the admission Minimum Data Set (MDS) for R17, dated 11/21/2025, revealed that Section O (Special Treatment Procedures, Program) revealed the resident received oxygen therapy continuously. Section C (Cognitive Patterns) revealed a Brief Interview Mental Status Score (BIMS) score of eight, which indicated moderate cognitive impairments.Review of the physician orders for R17 revealed an order dated 11/14/2025 for oxygen (O2) via(by) NC (nasal cannula) at 2 (two) liters per minute (LPM) continuous every shift.Observation on 12/19/2025 at 10:40 am to12:00 pm revealed R17 sitting in wheelchair receiving oxygen with the flow rate set to one and a half (1.5 ) liters per minute (LPM) via nasal cannula from the oxygen concentrator.Observation on 12/20/2025 at 11:20am, R17 was observed in her room oxygen with the flow rate set to one (1) LPM via nasal cannula from the oxygen concentrator.During an observation of the resident oxygen concentration with Licensed Practical Nurse (LPN) AA on 12/20/2021 at 11:29 am, LPN AA confirmed that R17's oxygen was set to 1 LPM and adjusted it to 2 LPM. LPN AA reported that resident was not known to have a history of changing her oxygen setting on the concentrator.During an interview on 12/20/2025 at 4:01 pm, the Director of Nursing (DON) reported being unaware that R17 was receiving oxygen on an incorrect flowrate. She reviewed the photograph of the oxygen setting on 12/19/2025 at 1.5 O2 Sat (oxygen saturation) and on 12/20/2025 at 1 LPM O2 Sat. She reported that her expectations was for staff to ensure that the flowrate was set per physician order and to check to ensure the rating was set using an eye level position to ensure the correct setting. She reported having no known factual evidence from her staff that R17, the resident 's hired sitter, or the resident's spouse could have possibly adjusted the dial (flow meter) on the oxygen concentrator. She acknowledged that resident was not care planned for behaviors of adjusting her flow meter. The DON confirmed that if a resident with a diagnosis of COPD received less oxygen or too much oxygen, it placed them at risks of adverse effects.

Based on record review and staff interviews, the facility failed to develop a baseline care plan for one of two residents (R#353), who required treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Finding include: Review of the facility policy titled, Policy titled Care Plans-Preliminary (undated) documented A preliminary plan of care to meet the resident 's immediate needs shall be developed for each resident within forty-eight (48) hours of admissions. Review of R#353 's face sheet documented an original admitted [DATE]. Further record review revealed that R#353 was sent out to the hospital on 9/27/2021 due to complications of low sodium. R#353 was readmitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of document titled, Admission Nursing Assessment V 3 documented under section admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The document documented under section Assessment Resident readmitted to the facility after hospitalization , Dx (diagnoses) of [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]. Review of R#353's baseline care plan revealed that there was no evidence of a baseline care plan in the resident's record. In addition, review revealed that there was not a baseline plan of care to address the resident diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Capsule 300 MG Give 1 capsule by mouth two times a day for infection until 10/05/2021 20:59. Review of a nurse note for R#353 regarding treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident has no signs or symptoms of adverse reaction noted. The resident is encouraged to drink fluids throughout the shift. Interview on 10/6/2021 at 10:49 a.m., the Minimum Data Set (MDS) Coordinator confirmed and verified that R#353 did not have a baseline care plan to address her [CONDITION(S)] (urinary tract infection). She also stated that the nurse failed to create a baseline care plan after the resident returned (as a newly readmitted resident) from the hospital. The MDS Coordinator reported that any staff can create a baseline care plan in the system. The MDS Coordinator described the system protocol is that the baseline care plan should be created the same day or no later than the next day (after a resident admission to the facility). Interview on 10/7/2021 at 2:05 p.m., the Director of Nursing (DON) revealed that her expectation is that her nursing staff create a baseline care plan.

Based on record reviews, staff and resident interviews, and review of the facility policy titled, Abuse Prohibition Policy and Procedures, the facility failed to protect two of four sampled residents (R), R#3 and R#4 from abuse. Findings include: Review of the facility policy, Abuse Prohibition Policy and Procedures, updated January 2017, revealed, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. During a review of the facility policy, Abuse Prohibition Policy and Procedures, updated January 2017, under Definitions, number 2, Verbal abuse is defined as any use of oral, written or gestured language that willfully included disparaging and derogatory terms to the resident or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, . 1. Record review revealed that R#3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented that R#3 had a Brief Interview for Mental Status score (BIMS) of six which indicated a cognitive deficit. Further review of Section G revealed a physical functioning level that required two staff to assist with Activities of Daily Living (ADL) care related to bathing, dressing, transfers, and toilet use. Review of witness statement by Certified Nursing Assistant (CNA) MM dated 1/27/2020 revealed that on 1/24/2020 CNA NN grabbed R#3's cheeks and said, I can bite a lot harder than you can. This took place while ADL care was being provided to R#3 after a shower. Review of a second witness statement by CNA OO dated 1/27/2020 revealed that R#3 was resistant to get on the mechanical lift and became resistant. The statement indicated that CNA NN then grabbed R#3 on her cheeks and said don't you try and bite me. I can bite a lot harder than you can. Review of the Separation Notice dated 2/3/2020 documented the following, in pertinent part: CNA NN's last day of employment was 1/26/2020 and the circumstances of the separation was due to Company policy violation. Review of the Facility Follow-up Report dated 2/10/2020 documented, in pertinent part: CNA MM reported that R#3 was not treated right when she and two other CNAs were assisting R#3 back to bed on 1/24/2020. CNA went on to report that CNA NN placed her hand on R#3's face and lightly pressed her head into the pillow telling the resident to hush. R#3 attempted to bite CNA NN. CNA NN is then reported as placing R#3's face in her hand and stated Don't bite me. I can bite a lot harder than you can. CNA NN acknowledged cupping R#3's face and admitted to telling R#3 not to bite her because she was stronger than R#3. CNA OO was attempted to be reached by phone on 3/10/2021 at 1:08 p.m. but did not answer the phone for comment. CNA OO is no longer working at this facility. CNA MM was attempted to be reached by phone on 3/10/2021 at 1:20 p.m. but did not answer the phone for comment. CNA MM is no longer working at this facility. During an interview with the Administrator on 3/10/2021 at 1:54 p.m. she indicated that since there were two witnesses that confirmed this situation, she did terminate CNA NN. She stated there was enough suspicion that CNA NN did hold her hand over R#3's mouth and tell her not to bite her because she could bite harder. The Separation Notice for CNA NN indicates her last day of work was 1/26/2020 and that she was terminated for Company Policy Violation. On 3/10/2021 at 3:10 p.m. R#3 was observed in bed and told surveyor that she did not want to speak to her. 2. R#4 admitted to the facility on [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#4 also had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE] (most recent assessment prior to incident) indicated a BIMS score of 13 which indicated intact cognition. Further review revealed limited assistance with one-person physical assistance needed related to toileting. R#4 was also coded as being occasionally incontinent of urine indicating less than seven episodes of incontinence during the review period. R#4 was coded as frequently incontinent of bowel, indicating two or more episodes of incontinence but at least one continent bowel movement during the review period. Review of a witness statement dated 12/22/2018 documented the following: CNA QQ reported that CNA PP entered the room and found that R#4 needed a new set of sheets on his bed due to an incontinent episode. She called for CNA QQ to assist her and bring in a new set of sheets. When CNA QQ entered the room, she witnessed CNA PP using profanity while speaking with R#4. CNA QQ reported that CNA PP would not stop using profanity toward R#4 and began using profanity towards her, so she left the room. Review of a witness statement dated 12/22/2018 by CNA RR revealed CNA RR was at the nurse's station when she heard CNA PP being loud and speaking aggressively in resident's room and Licensed Practical Nurse (LPN) BB was notified. On 12/25/2018 when CNA PP returned for her next shift at work she was counseled by the Director of Nursing (DON). This DON is no longer working in the facility. The follow-up report to the state indicates that after interviewing the witnessing CNAs and charge nurse (QQ, RR, and BB), the decision was made by the Administrator and DON to terminate the employment of CNA PP for Residents' Rights Policy violation and that she would not be eligible for re-hire. Review of the Facility Incident Report Form dated 12/25/2018 revealed an incident of staff to resident abuse occurred on 12/22/2018 between R#4 and CNA PP. CNA PP is reported as using profanity while providing care to R#4. There is an email verification of report being made on 12/26/2018. CNA PP, CNA QQ, and CNA RR are no longer employed at the facility and did not answer or return call to surveyor. During an interview on 3/10/2021 at 2:55 p.m. with LPN BB who reported that she does not remember 2018 very well, but she recalled the incident involving R#4. She went on to say that she heard noise and voices from R#4's room and upon entry to the room, R#4 reported that CNA PP cursed at him. LPN BB reported that CNA PP denied the incident and the incident was reported to the Director of Nursing and the Administrator. LPN BB reported that she believes that the incident happened as the resident stated it happened. During an interview on 3/10/2021 at 3:15 p.m. with R#4, he stated that he is treated very well by the staff at the facility and none have ever been rude or mean to him. R#4 also stated that he feels safe here and that he always gets what he needs and denies that he has never seen anyone mistreated. R#4 stated that he had no memory of this event. During an interview with the Administrator on 3/11/2021 at 1:53 p.m. she reported that she spoke with CNA PP on 12/25/2018 when she came in for her next shift after the alleged incident. She stated that through the facility investigation and witness statements CNA PP was terminated of her employment for violation of Resident Rights and that this CNA was still within her 90 days of employment and was not eligible for re-hire by this facility.

Based on record reviews, resident and staff interviews and review of the facility policy, Abuse Prohibition Policy and Procedures, the facility failed to timely report initial reports and follow-up investigations of alleged violations of abuse, injury of unkown origin, and missing property for four of seven residents (Resident (R) R#1, R#2, R#3, and R#4) that were submitted. Findings include: Review of the facility policy titled, Abuse Prohibition Policy and Procedures, dated [DATE] revealed . Reporting: A. Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property the incident will be immediately reported. If it is an allegation of abuse it should be reported to the state within 2 hours. B. Regarding reasonable suspicion of a crime, each covered individual shall report to the State Agency and one or more law enforcement entities for the location in which the facility is located. C. A written report of investigation will be submitted to the administrator and to the Long Term Care Section Complaint Coordinator, within five (5) working days of the incident. 1. Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] to another long-term-care facility. Resident #1 admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) was an Admission assessment dated [DATE] and R#1 had a Brief Interview for Mental Status score (BIMS) of nine, indicating some cognitive deficits. She was also coded for the physical functioning level as needing the assistance of two staff members to complete her Activities of Daily Living (ADL). Review of Facility Incident Report Form dated [DATE] revealed an injury of unknown origin for R#1. The document further reported that R#1 complained of pain in the right shoulder and an in-house x-ray was scheduled. The x-ray showed there was a fracture at the surgical neck of the right humerus. This form was emailed to the intake unit on [DATE]. Review of the Facility Follow-up Report date [DATE] revealed that R#1 received an x-ray on [DATE] after complaints of pain and family request. The result of the x-ray showed acute displaced comminuted fracture at the surgical neck of right humerus. During an interview on [DATE] at 8:33 a.m. with the Administrator it was reported that the facility was unable to determine if R#1 injured her shoulder at her initial fall at home prior to her hospitalization and then entry to this facility. She also stated that after the R#4 discharged from this facility it was reported that R#1 stated a Nurse pulled on her arm. The Administrator reported that they didn't have time/information to investigate this. There is no evidence to support that an investigation was completed related to the allegation of nurse pulling R#1's arm. The facility also failed to timely report the injury of unknown origin that was identified on [DATE]. 2. Resident #2 was admitted to the facility on [DATE] and discharged [DATE] to the hospital with COVID-19 and expired in the hospital on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His most recent MDS was an Annual assessment dated [DATE] at which time he had a Brief Interview for Mental Status score of 15 which indicated no cognition deficit. Review of a Facility Incident Report Form dated [DATE] revealed an incident of missing money with an indication that law enforcement was notified. Review of a Facility Follow-up Report dated [DATE] which resulted in no evidence to support that there was any missing money due to family dynamics. During an interview on [DATE] at 11:09 a.m. with the Administrator it was reported that the report regarding R#2 was completed the same day that she was notified. The Administrator acknowledged that she did not make the follow-up reports until investigations have been completed and hence follow-up reports were late. There was no email or fax confirmation to confirm that reports were submitted related to missing money for R#2. 3. Record review revealed that R#3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented that R#3 had a Brief Interview for Mental Status score (BIMS) of six which indicated a cognitive deficit. Further review revealed a physical functioning level that required two staff to assist with Activities of Daily Living (ADL) care related to bathing, dressing, transfers, and toilet use. Review of the Facility Incident Report Form dated [DATE] indicated staff to resident abuse took place on [DATE]. It was reported that Certified Nursing Assistant (CNA) MM observed CNA NN place her hand over R#3's mouth to silence her when speaking. Review of a Facility Follow-up Report dated [DATE] revealed that CNA NN acknowledged that she had placed her hand over R#3's face and had cupped her face and made the statement to not bite her. CNA NN was terminated on [DATE]. Review of witness statement by CNA MM dated [DATE] revealed that on [DATE] CNA NN grabbed R#3's cheeks and said, I can bite a lot harder than you can. This took place while ADL care was being provided to R#3 after a shower. Review of a second witness statement by CNA OO dated [DATE] revealed that R#3 was resistant to get on the mechanical lift and became resistant. The statement indicated that CNA NN then grabbed R#3 on her cheeks and said don't you try and bite me. I can bite a lot harder than you can. This alleged incident occurred on [DATE] and was reported to the Administrator on [DATE]. There is no fax or email confirmation to confirm that the Facility Incident Report or the Facility Follow-up report were submitted. 4. Resident #4 was admitted to the facility on [DATE] and his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His most recent MDS was an Annual assessment dated [DATE] at which time his cognitive functioning was coded as a 14 out of 15 indicating a small amount of cognitive deficit. His physical functioning level was coded as being independent just needing over-sight and assistance from the staff. Review of the Facility Incident Report Form dated [DATE] revealed an incident of staff to resident abuse occurred on [DATE] between R#4 and CNA PP. CNA PP is reported as using profanity while providing care to R#4. There is an email verification of report being made on [DATE]. Review of the Follow up Report dated [DATE] CNA PP was terminated for Resident's Rights and Policy Violation. There was a fax confirmation dated [DATE] that the follow up report was submitted. This alleged incident occurred on [DATE] and was reported to the Administrator on [DATE]. During an interview with the Administrator on [DATE] at 12:03 p.m. she indicated that she was unaware that the weekend days counted in the timeframe of reporting incidents to the State. She stated that going forward this would be corrected. She stated that she had been waiting for the completion of the investigation before submitting the final report to the State. The Administrator acknowledged that she did not meet the guidelines for the reporting timely for R#1, R#2, R#3, and R#4.

Based on interviews and record reviews, the facility failed to develop a comprehensive care plan that included monitoring of vital signs for a high risk medication for three of four residents receiving the heart medication, [MEDICATION NAME], Resident (R) #56, R#22 and R#6. The sample size was 31 residents. The facility census was 55 residents. Findings include: [MEDICATION NAME] is a prescription medication used to treat heart failure and heart rhythm problems. It is used to improve the strength and efficiency of the heart, or to control the rate and rhythm of the heartbeat. The U.S. National Library of Medicine notes the amount of [MEDICATION NAME] needed to help most people is very close to the amount that could cause serious problems from overdose. It also states that some early warning signs of overdose include but are not limited to an uneven, pounding or slow heartbeat. A drug guide notes that [MEDICATION NAME] has a heightened risk of causing significant patient harm when it is used in error. It further states to monitor apical pulse for one full minute before administering and to withhold the dose and notify the physician if pulse rate is less than 60 beats per minute or if there is a significant change in rate, rhythm, or quality of the pulse. (reference Davis's Drug Guide for Nurses, sixteenth edition, Copyright 2019 by F. A. Davis Company). 3. R#6 is an [AGE] year old resident with [DIAGNOSES REDACTED]. A review of current physician's orders [REDACTED]. The original order is dated 5/15/18. There is no order to monitor or check the apical pulse rate and hold the medication if the pulse is less than 60 beats per minute. A review of the care plans for R#6 reveals a care plan focus stating the resident is on [MEDICATION NAME]/[MEDICATION NAME] therapy r/t (related to) [MEDICAL CONDITIONS]. The goal states the resident will be free from discomfort or adverse reactions related to [MEDICATION NAME] use through the review date. Interventions include but are not limited to: report to physician if pulse falls below 60 or rises above 110 or if you detect skipped beats or other changes in rhythm. An interview was conducted on 10/18/18 at 1:23 p.m. with the MDS Coordinator revealed taht she usually puts high risk medications like [MEDICATION NAME] in the care plans. She also acknowledged that two other residents did not have care plans for [MEDICATION NAME]. 2. Resident (R)#56 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. R#56 was noted to have a physician order [REDACTED]. Further review of Medication Administration Record [REDACTED]. During review of the care plans for R#56, it was noted that there was no care plan developed to communicate treatment plan and risk factors for a resident who is prescribed [MEDICATION NAME]. During an interview 10/18/18 at 11:15 a.m., the Director of Nursing (DON) verified that R#56 was admitted with a medication order for [MEDICATION NAME] at the time of her admission, received [MEDICATION NAME] the month of (MONTH) (YEAR) and (MONTH) (YEAR), and was not care planned for the medication. Further interview revealed that the Minimum Data Set (MDS) Coordinator is responsible for all care plans. The DON further stated that she does not supervise what care plans should be developed or created. During an interview on 10/18/18 at 1:14 a.m., with the (MDS) Coordinator, verified that R#56 's did not have a care plan to address her use of [MEDICATION NAME] and that the facility's policy is that any residents who have a [DIAGNOSES REDACTED]. A review of policy titled Care Plans-Comprehensive Policy Statement revealed that the facility 's care plan stated that residents 'care plan should: (i) Reflect currently recognized standards of practice for problem areas and conditions. and (11) A list of current medications and dietary instructions, and Services and treatments to be administered by the facility and personnel acting on behalf of the facility

Based on observations, interviews and review of a facility policy dated 4/5/17 entitled Handwashing/Hand Hygiene, the facility failed to distribute and serve food in a manner that prevents the spread of infection. During the observation of hall tray service for lunch on 10/16/18, a total of two Certified Nursing Assistants (CNAs), one on each hall, failed to sanitize their hands between passing trays to residents. The census was 55 residents. Findings include: 1. Review of the facility policy (4/5/17) entitled Handwashing/Hand Hygiene reveals the facility considers hand hygiene the primary means to prevent the spread of infections. The policy also notes 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . b. Before and after direct contact with residents . l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . p. Before and after assisting a resident with meals. During observation of lunch service on the 300 Hall at 11:45 a.m. on 10/16/18, Certified Nursing Assistant (CNA) EE served a tray to the resident in room [ROOM NUMBER]-A, came out of room, did not sanitize her hands, removed another tray from the cart, entered room [ROOM NUMBER]-B and set up the tray by removing lids from beverages, opening packages and cutting up food items. Another staff member entered room [ROOM NUMBER]-B and assisted CNA EE, to reposition the resident by physically pulling her up in the bed. CNA EE then left room [ROOM NUMBER]-B, removed another tray from cart without sanitizing her hands, entered room [ROOM NUMBER]-B and set the tray in front of the resident. CNA EE left room [ROOM NUMBER]-B and sanitized her hands. An interview was conducted with the Director of Nursing (DON) on 10/16/18 at 12:17 p.m. where she confirmed the facility policy is for staff to wash or sanitize their hand between passing trays. She stated that if the staff member only takes a tray into a resident and doesn't touch the resident they do not have to sanitize or wash their hands. 2. Observation on 10/16/18 at 09:00 a.m. observation revealed LPN AA administering medications to Resident # 37. LPN AA entered resident's room with three medication cups of pills, a bottle of nasal spray, a bottle of eye gtts, a tube of icy hot topical cream, and a plastic cup of light tan liquid with a straw. LPN AA placed all of the medication on paper towel on bedside table. LPN AA administered the pills in the plastic medication cups and gave the resident the liquid to drink. LPN AA picked up the inhaler and put it in the resident's mouth. LPN administered medication per inhaler. LPN AA administered the nasal spray in each nostril, handed the resident a tissue, LPN AA then opened the bottle of eye gtts and administered one gtt in each eye and gave the resident more tissues to wipe her eyes. LPN AA then applied icy hot topical cream to the resident's bilateral knees. LPN then removed the gloves and threw them in the trash can. LPN AA left the resident's room walked to her med cart and sanitized her hands with gel hand sanitizer. Interview on 10/16/18 at 9:15 p.m. with LPN AA revealed that she confirmed that she did wear the same pair of gloves during the medication pass to Resident # 37 and stated this is always how she does it and doesn't know if it's right or wrong. Interview on 10/18/18 at 11:02 a.m with the Director of Nursing (DON) revealed that it is not her expectation for nurses to change gloves between administering medications through various routes. Further interview revealed that if a resident was receiving eye drops, nasal spray, and inhaler, it would not be her expectation for nurses to change gloves between administering the medications. 3. Observation on 10/16/2018 at 11:40 a.m. during lunch service, CNA (CC) was observed going into resident (R#9) with her meal tray. CNA CC placed the tray on the residents bed side table, assisted the resident out of bed into her wheelchair, then went around the residents bed, moved the bed side table with the tray on it and put it in front of the resident. She removed the lid on the plate and removed the dinner roll from the package with her ungloved hands and removed the silverware from the napkin. CNA CC dropped the spoon on the floor. She picked the spoon up off the floor and left the room. She walked to the kitchen, got a new set of silverware, and handed the dirty spoon the the kitchen helper and returned to the residents room and handed her the new set of silverware. She did not sanitize her hands any time during the above. She the went to the 100 wing, went into the food cart and removed the tray for R#7, she did not sanitize hands after leaving R#9's room and going into food cart, or before going into R#7's room. She assisted resident to sit up in the bed and put the food tray in front of resident. She removed the dinner roll from the bag with her ungloved hands and put it on the residents tray. She did not sanitize or wash her hands after leaving R#7's room. Interview with the Infection Control Nurse on 10/18/2018 at 10:26 p.m. revealed that she has inserviced the staff on hand washing. She does daily spot checks to ensure proper handwashing during daily care. She stated that an employee should wash there hands or sanitize hands when ever care was done on a resident, during meals if they came in contact with a resident or equipment. She would expect the employee to sanitize there hands after positioning a resident for meals and after before passing another tray. Interview with the DON on 10/18/2018 at 10:33 a.m. revealed she would expect the staff to wash there hands or sanitize there hands between care of residents. She would expect the staff to sanitize or wash there hands after positioning a resident for a meal and before passing a tray to another resident. Review of policy titled Hand washing/Hand Hygiene dated 4/5/18 revealed use of alcohol-based hand rub to be used before and after direct care with residents, before and after assisting a resident with meals.

Based on physician, pharmacist and staff interviews and record reviews the facility's consulting pharmacist failed to recognize and report an irregularity in the medication regimen for one resident (R), R#56 and report the irregularity to the facility and the physician. The sample size was 31 residents. Findings include: [MEDICATION NAME] is a prescription medication used to treat heart failure and heart rhythm problems. It is used to improve the strength and efficiency of the heart, or to control the rate and rhythm of the heartbeat. The U.S. National Library of Medicine notes the amount of [MEDICATION NAME] needed to help most people is very close to the amount that could cause serious problems from overdose. It also states that some early warning signs of overdose include but are not limited to an uneven, pounding or slow heartbeat. A drug guide notes that [MEDICATION NAME] has a heightened risk of causing significant patient harm when it is used in error. It further states to monitor apical pulse for one full minute before administering and to withhold the dose and notify the physician if pulse rate is less than 60 beats per minute or if there is a significant change in rate, rhythm, or quality of the pulse. (reference Davis's Drug Guide for Nurses, sixteenth edition, Copyright 2019 by F. A. Davis Company). A review of a document entitled Current resident listing for Bayview Nursing and Rehab with medication regimen review activity between 9/18/18 and 9/18/18 reveals the medication regimen for R#56 was reviewed by the consulting pharmacist on that date. The document is signed electronically by the facility's consulting pharmacist. Review of the Medication Administration Records (MARs) for R#56 (MONTH) and (MONTH) of (YEAR), there was not an order on the MAR indicated [REDACTED]. There was evidence of R#56's pulse being checked daily during the months of (MONTH) and (MONTH) (YEAR) but not consistently at the medication administration time of 9:00 a.m. There were three occasions when the pulse was documented as checked after the time the medication was administered. The MARs revealed that on 9/30/18, the pulse was checked at 11:52 a.m. with a result of 61 beats per minute, but the medication was documented as administered at 9:00 a.m. The MARs reflect that on 10/10/18 the pulse was checked at 1:26 p.m. with a result of 54 beats per minute but the medication is documented as administered at 9:00 a.m. Again, on 10/12/18, the pulse was checked but not until 12:24 p.m. with a result of 63 beats per minute and the medication was documented as administered at the 9:00 a.m. time. The (MONTH) MAR indicated [REDACTED]. The medication is documented as administered at 9:00 a.m. There is no documentation that the medication was held when the pulse was less than 60 beats per minute. During an interview conducted on 10/18/18 at 11:15 a.m., the Director of Nursing (DON) stated it is her expectation that nurses will monitor a resident's apical pulse prior to administering [MEDICATION NAME] and will hold the medication if the resident's pule's is less than 60 beats per minute. She also stated she would expect the nurses to notify the physician if medications were held. An interview was conducted on 10/18/18 at 10:34 a.m. with the consulting Pharmacist, who confirmed she reviewed the medication regiment of R#56 on 9/18/18 and provided one recommendation to the facility and physician regarding a needed [DIAGNOSES REDACTED]. There were no other recommendations provided to the facility or the physician. The pharmacist confirmed that R#56 was receiving [MEDICATION NAME] 125 micrograms (mcg) daily. She also confirmed that she would expect the nurses to have an order for [REDACTED].#56, the pharmacist stated the resident was a new admission (9/14/18) and had a [MEDICATION NAME] blood level checked in the hospital so they would not have done another level yet. She confirmed that she reviews the physician's orders [REDACTED]. She confirmed that she did not write any recommendations to the facility or physician to include monitoring of the apical pulse prior to administering [MEDICATION NAME], documenting the pulse and holding the medication if the pulse rate is below 60 beats per minute. The consulting pharmacist stated she would not expect the nurses to contact the physician for one missed dose but if the resident's pulse is less than 60 for several days and they hold the [MEDICATION NAME], she would expect the physician to be notified. During an interview conducted on 10/18/18 at 11:45 a.m., the attending Physician for R#56 who is also the facility medical director, confirmed it is his expectation that nurses would monitor a resident's pulse rate if they are taking [MEDICATION NAME]. He also stated that he would expect the nurses to monitor for signs of [MEDICATION NAME] toxicity. If a resident's pulse level is less than 60 and the nurses hold the medication the physician stated he would expect the nurses to get a [MEDICATION NAME] blood level and notify him if the level was abnormal. When asked to clarify his expectations, he confirmed again, that he would expect the nurses to monitor a resident's pulse, and if it was below the 60 beats per minute, to obtain a [MEDICATION NAME] level blood test and contact him if the level was abnormal.

Based on physician, consulting pharmacist and staff interviews, record reviews, and a review of a facility policy entitled Administering Medications, the facility failed to follow accepted standards of practice by not adequately monitoring the apical pulse for two residents (R), R#56 and R#6 receiving the cardiac medication [MEDICATION NAME] and administering the [MEDICATION NAME] when a resident's pulse was below 60 beats per minute. The sample size was 31. Findings include: [MEDICATION NAME] is a prescription medication used to treat heart failure and heart rhythm problems. It is used to improve the strength and efficiency of the heart, or to control the rate and rhythm of the heartbeat. The U.S. National Library of Medicine notes the amount of [MEDICATION NAME] needed to help most people is very close to the amount that could cause serious problems from overdose. It also states that some early warning signs of overdose include but are not limited to an uneven, pounding or slow heartbeat. A drug guide notes that [MEDICATION NAME] has a heightened risk of causing significant patient harm when it is used in error. It further states to monitor apical pulse for one full minute before administering and to withhold the dose and notify the physician if pulse rate is less than 60 beats per minute or if there is a significant change in rate, rhythm, or quality of the pulse. (reference Davis's Drug Guide for Nurses, sixteenth edition, Copyright 2019 by F. A. Davis Company). Findings include: Based on a review of R#56's Medication Administration Records (MARs) for (MONTH) and (MONTH) of (YEAR), there was not an order on the MAR indicated [REDACTED]. There was evidence of R#56's pulse being checked daily during the months of (MONTH) and (MONTH) (YEAR) but not consistently at the medication administration time of 9:00 a.m. The MARs revealed that on 9/30/18, the pulse was checked at 11:52 a.m. with a result of 61 beats per minute, but the medication was documented as administered at 9:00 a.m. The MARs reflect that on 10/10/18 the pulse was checked at 1:26 p.m. with a result of 54 beats per minute but the medication is documented as administered at 9:00 a.m. Again, on 10/12/18, the pulse was checked but not until 12:24 p.m. with a result of 63 beats per minute and the medication was documented as administered at the 9:00 a.m. time. The MAR indicated [REDACTED]. The medication is documented as administered at 9:00 a.m. There is no documentation that the medication was held when the pulse was less than 60 beats per minute. Based on a review of R#6's MARs for (MONTH) and (MONTH) of (YEAR), the facility staff did not have an order on the MAR indicated [REDACTED]. There was evidence of R#6's pulse being checked daily during the months of (MONTH) and (MONTH) (YEAR); however, there was one day, 10/9/18 at 9:17 a.m. when R#6's pulse was documented as 48 beats per minute and regular. The (MONTH) MAR indicated [REDACTED]. Also, on 9/2/18, the MAR indicated [REDACTED] During an interview conducted on 10/18/18 at 11:15 a.m., the Director of Nursing (DON) stated it is her expectation that nurses will monitor a resident's apical pulse prior to administering [MEDICATION NAME] and will hold the medication if the resident's pulse is less than 60 beats per minute. She also stated she would expect the nurses to notify the physician if medications were held. An interview was conducted on 10/18/18 at 10:34 AM with the consulting pharmacist,The pharmacist confirmed that she would expect the nurses to have an order for [REDACTED]. During an interview conducted on 10/18/18 at 11:45 a.m., the attending physician for R#56 who is also the facility medical director, confirmed it is his expectation that nurses would monitor a resident's pulse rate if they are taking [MEDICATION NAME]. He also stated that he would expect the nurses to monitor for signs of [MEDICATION NAME] toxicity. If a resident's pulse level is less than 60 and the nurses hold the medication the physician stated he would expect the nurses to get a [MEDICATION NAME] level and notify him if the level was abnormal. When asked to clarify his expectations, he confirmed again, that he would expect the nurses to monitor a resident's pulse, and if it was below the 60 beats per minute, to obtain a [MEDICATION NAME] level blood test and contact him if the level was abnormal. Review of a facility policy dated 3/22/17 entitled Administering Medications includes Medications shall be administered in a safe and timely manner, and as prescribed. 5. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facilty's Medical Director to discuss the concerns.

Based on observations, interviews and review of a facility policy dated [DATE] entitled Discarding and Destroying Medications the facility failed to provide safe and secure storage for discontinued or expired controlled medications. Findings include: During a review of the facility's one medication storage room conducted on [DATE] at 11:30 a.m., Licensed Practical Nurse (LPN), DD stated their process for destruction/removal of discontinued or expired controlled substances is to place the controlled drug along with their count sheets into a locked/secured drawer in the medication room. She stated the drawer is supposed to be secured with a lock for which the Director of Nursing (DON) maintains the key. The drawer has two rectangular shape openings enabling the nurses to slide in the discarded controlled substances without accessing them for security purposes. The drawer for storage of discontinued or expired controlled medications was found unlocked and confirmed by LPN DD. During a review of the medication room with the DON conducted on [DATE] at 11:58 a.m., she confirmed the storage drawer was not locked and that she is the only person in the facilty with a key to the drawer. She confirmed that access to the medication room was limited to herself, the Registered Nurse (RN) supervisor, and the three nurses on duty who had keys to the medication carts. The DON further confirmed that neither she nor the nurses account for or monitor the amount of controlled medications that are in the drawer on a regular basis. Review of a facility policy dated [DATE] and entitled: Discarding and Destroying Medications reveals that medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. 1. All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of.

Based on observation, policy review, and staff interviews the facility failed to assure that foods were used by the expiration date; temperatures were monitored for both the refrigerator and freezer in main dining room resident refrigerator and in food pantry refrigerator; and failed to assure that residents and staff food were kept separate. This affected fifty-eight (58) residents who received oral feedings out of a census of sixty (60). The findings include: 1. Observation on 9/2/16 at 11:19 a.m. during initial tour with Dietary Services Manager revealed the following: three (3) containers of Table grind black pepper five (5) pound (lb) containers with an expiration date of 8/13/15 and one (1) container with an expiration date of 9/5/14. One (1) container of Extra Virgin Olive Oil with an expiration date of 3/31/16. One forty (40) ounce (oz) container of Thick and Easy Instant Food thickener with an expiration date of 6/17/16. One (1) one (1) gallon of White distilled Vinegar with a best by date of 6/19/15. There were two (2) different stickers indicating receive dates of 2/22/15 and 2/22/16. Eleven (11) three (3) pound (lb) cans of Heinz Chicken Noodle Soup with a best by date of 7/8/16. Six (6) packages of Meritta Hamburger buns 8 (eight) count with use by dates: four (4) for [DATE]; Sarah Lee whole wheat bread one (1) lb observed to have mold on it with an expiration date of September 1, 2016; one (1) 16 oz loaf of Swirl Cinnamon Raisin Bread with use by date of July 24, 2016. Dietary Service Manager (DSM) acknowledged that these items where not identified as expired prior to today. The DSM reported that no one has typically been checking expiration dates when items are received from the vendor as they are assumed to be good. The DSM reported that the Heinz Chicken Noodle Soup was received on 8/30/16. It was revealed that bread was delivered on 9/2/16 because there was no bread on 9/1/16. DSM also reported that she hasn't been looking at expiration dates during delivery. Once an item has been identified as expired it should be placed on top shelf of bread cart and a sign should be posted stating to not use the bread. Upon observation there were no signs posted to indicate that bread on the top shelf should not be used. Further observation revealed that expired bread was spread throughout the bread cart. 2. Observation and interview with the DSM on 9/08/2016 at 11:50 a.m. revealed refrigerator temperature of thirty-two (32) degrees Fahrenheit (F) in the refrigerator in main dining room. There was ice cream in the freezer that remained firm to touch but there was no log of freezer temperatures. DSM reported that the facility is not currently keeping log of freezer temperatures. 3. Observation on 09/08/2016 at 11:55 a.m. in the resident food pantry there was no thermometer found in the refrigerator or in the freezer. In the freezer there was one Orange Bar that was not labeled and did not have an expiration date. In the refrigerator was three (3) eight (8) fluid (fl)oz Ensure Shakes with an April 1, 2016 expiration date on bottom of each container; four (4) eight (8) fl oz containers of Glucerna 1.0 Cal Specialized Nutrition with an expiration date of April 1, 2016; one (1) four 4 oz container of Peach Activia yogurt and two (2) four (4 oz) strawberry yogurts with expiration of [DATE]; one (1) six (6) oz container of blueberry non-fat yogurt with an expiration date of 8/22/16; seven (7) containers being eight (8) fl oz each of Boost complete nutritional drink with a use by date of August 30 2016. An interview on 9/08/2016 at 11:59 a.m. with the DDS who provided copy of the temperature log for refrigerator in main dining and confirmed that the refrigerator in pantry is used by both residents and staff. An interview on 9/08/2016 at 2:22 p.m. with the Director of Nursing (DON) reported that the housekeeping staff is responsible for cleaning of the food pantry and is unsure if logs are kept of temperatures for the refrigerator and freezer. The DON further reported that nursing labels and dates items placed in the refrigerator for the residents. An interview on 9/08/2016 at 2:31 p.m. with Housekeeping Supervisor (HSK) who reported that temperature logs are not done for the food pantry refrigerator. It was further reported that housekeeping staff clean the refrigerator daily but do not look at expiration dates. HSK reported that housekeeping staff have not been discarding anything that belongs to residents and confirmed that residents and staff share the refrigerator in the pantry on the hall. HSK reported that he/she was promoted to this position last week and he/she was not aware that temperature logs were needed for this refrigerator and freezer. An interview on 9/08/2016 at 2:49 p.m. with the Administrator who confirmed that there are no thermometers to monitor the freezer or refrigerator temperatures in the food pantry on the hall. The Administrator reported that this refrigerator has never been monitored and housekeeping is responsible for the upkeep of the food pantry refrigerator. The Administrator reported that sometimes families bring items in and staff need to check the items to assure that they are not expired. Review of the facility policy Title: Dietary Services Purpose: To prevent contamination of food products and therefore prevent foodborne illness. Policy: V. Food Storage E. Refrigerated foods must be stored at temperatures of 41 degrees F or less. Frozen foods must be stored at 0 degrees F or less. Interview on 09/09/2016 at 7:45 a.m. with the Administrator who reported that the food pantry refrigerator should have a thermometer for monitoring the temperature and he/she is unsure as to why there was no thermometer in the refrigerator.

Based on record review and staff interview, it was determined that the facility failed to provide the Notice of Medicare Non-Coverage (Form CMS- -NOMNC) for two (2) residents (# 80, and #74) who were discharged to home from Medicare Part A Skilled Services from a sample of twenty-seven (27). Findings include: 1. Record review revealed that Resident #80 was admitted to the facility on [DATE]. A Rehab Discharge Notification facility form dated 6/13/16 is on file to indicate resident # 80 end of skilled services. Further investigation revealed that resident #80 did not receive a Notice of Medicare Non-Coverage (Form CMS- -NOMNC), which would indicate the effective date the coverage of Skilled Services would end on 6/15/16 prior to being discharge home on 6/16/16. 2. Record review revealed that Resident #74 was admitted to the facility on [DATE]. A Rehab Discharge Notification facility form dated 4/21/16 is on file to indicate resident #74 end of skilled services. Further investigation revealed that resident #74 did not receive a Notice of Medicare Non-Coverage (Form CMS- -NOMNC) which indicated the effective date the coverage of Skilled Services would end on 4/27/16 prior to being discharge home on 4/23/16. During an interview with the Financial Coordinator on 9/8/16 at 3:50 p.m. revealed that resident #80 and resident #74 did not receive the Notice of Medicare Non-Coverage prior to being discharge to home. Financial Controller revealed that no residents who were discharged to home from Medicare Part A skilled services had received the CMS- form because she had been told the form were not needed for resident returning home and was not aware the form was required.

Based on observation and interview, the facility failed to ensure a clean and well maintained environment for ten (10) out of forty-four (44) rooms. Findings include: Observation on 09/06/2016 at 11:09 a.m., on 09/08/2016 at 12:06, 09/09/2016 at 08:11 a.m. in Room 313 revealed staining around the base of the toilet, missing paint on lower wall entering room and the baseboard on the wall next to the window and below the air conditioner had a thick build-up of powdery white dust. Interview and observation on 09/09/2016 at 09:35 a.m. in Room 313 with the Head of Maintenance and Head of Housekeeping confirmed that there was staining around the base of the toilet, missing paint on lower wall entering room and the baseboard on the wall next to the window and below the air conditioner had a thick build-up of powdery white dust. Observation on 09/06/2016 at 11:12 a.m., 09/08/2016 at 12:05 p.m., and 09/09/2016 at 08:09 a.m. in Room 310 revealed a build-up of dust on the housing unit for the air conditioner. In the bathroom there was a stain around the base of the toilet. The foam arm rest on the raised toilet seat was split and a brown stain was observed on the call cord in the bathroom. Interview and observation on 09/09/2016 at 09:34 a.m. with the Head of Maintenance and the Head of Housekeeping in Room 310 confirmed that there was a build-up of dust on the housing unit for the air conditioner. In the bathroom there was a stain around the base of the toilet. The foam arm rest on the raised toilet seat was split and a brown stain was observed on the call cord in the bathroom. Observation on 09/06/2016 at 11:15 a.m., 09/08/2016 12:04 p.m. and 09/09/2016 at 08:10 a.m. in Room 309 revealed that there was missing paint on the wall to the right of entrance into room and the bathroom call cord had brown and yellow stains. Interview and observation on 09/09/2016 at 09:32 a.m.with the Head of Maintenance and Head of Housekeeping in Room 309 confirmed that there was missing paint on the wall to the right of entrance into room and the bathroom call cord had brown and yellow stains. Observation on 09/06/2016 at 11:24 a.m., 09/08/2016 at 11:42 a.m. and 09/09/2016 at 08:07 a.m. in Room 105 bathroom revealed staining around the base of the toilet and a stained bathroom call cord. Interview and observation on 09/09/2016 at 09:31 a.m. with the Head of Maintenance and the Head of Housekeeping in Room 105 bathroom confirmed staining around the base of the toilet and a stained bathroom call cord. Observation on 09/06/2016 at 11:26 a.m., 09/08/2016 at 11:40 a.m. and 09/09/2016 at 08:06 a.m. in Room 109 bathroom revealed staining around the base of the toilet and a stained bathroom call cord. Interview and observation on 09/09/2016 at 09:00 a.m. in Room 109 bathroom confirmed staining around the base of the toilet and a stained bathroom call cord. Observation on 09/06/2016 at 03:00 p.m., 09/08/2016 at 12:00 p.m. and 09/09/2016 at 09:44 a.m. in Room 219 revealed peeling paint on the wall behind the bathroom sink and a loose baseboard behind the door to the room. Interview and observation on 09/09/2016 at 09:44 a.m. with the Head of Maintenance and the Head of Housekeeping in Room 219 confirmed peeling paint on the wall behind the bathroom sink and a loose baseboard behind the door to the room. Observation on 09/06/2016 at 3:12 p.m. in Room 214, 09/08/2016 at 11:56 a.m. and 09/09/2016 at 08:15 a.m. revealed scuff marks on the bottom of the bathroom door, a black substance on the floor at the foot of A-bed and a black scuff mark about half way up the wall beside A-bed. There was a build-up of dust on the air conditioner housing unit, missing paint on the wall and a brown stain on bathroom ceiling approximately three (3) inches in diameter. Interview and observation on 09/09/2016 at 09:41 a.m. in Room 214 revealed scuff marks on the bottom of the bathroom door, a black substance on the floor at the foot of A-bed and a black scuff mark about half way up the wall beside A-bed. There was a build-up of dust on the air conditioner housing unit, missing paint on the wall and a brown stain on bathroom ceiling approximately three (3) inches in diameter. Observation on 09/07/2016 at 02:11 p.m., 09/08/2016 at 11:48 a.m. and 09/09/2016 at 08:17 a.m. in Room 210 revealed that there was missing paint on the wall that the door to the room was on, the floor had a build-up of dirt near the baseboards and the bathroom call cord was stained yellow and brown. Interview and observation on 09/09/2016 at 09:39 a.m. with the Head of Maintenance and the Head of Housekeeping in Room 210 confirmed that there was missing paint on the wall that the door to the room was on, the floor had a build-up of dirt near the baseboards and the bathroom call cord was stained yellow and brown. Observation on 09/07/2016 at 1:51 p.m., 09/08/2016 at 11:49 a.m. and 09/09/2016 at 08:11 a.m. in Room 209 revealed that the emergency call cord in the bathroom was stained yellow and the tile around the toilet was stained. Interview and observation on 09/09/2016 at 09:36 a.m. with the Head of Maintenance and the Head of Housekeeping in Room 209 confirmed that the emergency call cord in the bathroom was stained yellow and the tile around the toilet was stained.

Based on record review and staff interview, the facility failed to develop care plans related to [MEDICAL CONDITION] drug use for one (1) resident #90; failed to develop individualized care plan related to planned weight loss for one (1) resident #48; failed to develop individualized care plan related to care and comfort for one (1) resident #31. Total sample is twenty-seven (27) residents. Findings include: 1. Resident #90 was admitted to the facility on [DATE] with the diagnose but not limited to Hypertension, Dementia with Behavior Disturbances, Alzheimer ' s Disease, Personality Changes, Major [MEDICAL CONDITIONS] and [MEDICAL CONDITIONS] as noted in Section I Active Diagnose of the Admission Minimum Data Set ((MDS) dated [DATE]. Section N medications: [REDACTED]. Review of the Physician's Orders dated 7/29/16 on 9/9/16 at 2:27 p.m. revealed that resident #90 has a [MEDICAL CONDITION] medication use of [MEDICATION NAME] capsule 20 milligram (mg) twice a day routinely, and antidepressant medication use of [MEDICATION NAME] XR 75 mg capsules Extended Release one time a day routinely. Review of resident #90 care plan dated 7/6/16 on 9/9/16 at 2:55 p.m. revealed that there was no mention of these specific medications which resident #90 was receiving, no individualized interventions for these [MEDICAL CONDITION] drugs, nor monitoring for possible gradual dose reduction of the medications on this care plan. During an interview with the MDS Coordinator on 9/9/16 at 3:34 p.m. revealed that she was aware of resident #90 was on [MEDICAL CONDITION] drugs and admitted she overlooked writing a care plan for [MEDICAL CONDITION] medications. 2. Resident #48 was readmitted to the facility on [DATE] with the diagnose but not limited to Sick Sinus Syndrome, [MEDICAL CONDITION], Abnormality of [MEDICATION NAME], Major [MEDICAL CONDITION], Pacemaker, [MEDICAL CONDITION], Diabetes Mellitus, [MEDICAL CONDITIONS] Stage 3, Gastro-[MEDICAL CONDITION] Reflux, [MEDICAL CONDITION], and [MEDICAL CONDITION] Fibrillation. A Review of a copy of the Progress Note dated 7/27/16 on 9/9/16 at 10:26 a.m. revealed an order that reads continue weight loss which is signed by the Medical Doctor and Family Nurse Practitioner. Review of resident #48 nutrition care plan dated 12/4/15 on 9/8/16 at 4:50 p.m. revealed that resident #48 is care planned as At Risk for weight loss related to resident ' s goals. Review of the interventions for the nutrition care plan included assist resident with healthier meal options; encourage resident to exercise as frequently as tolerated. These interventions revealed that they were not individualized for the actual planned weight loss or the expected outcome for resident #48. During an interview with the MDS Coordinator on 9/9/1616 at 3:34 p.m. revealed that resident #48 is an actual plan weight loss and that she did not care plan resident #48 as such. 3. Resident #31 was admitted to the facility on [DATE] with the diagnose but not limited to [MEDICAL CONDITION], Abnormal Posture, Stiffness of Unspecified Joint, Diverticulitis of Intestine, History of Falling, Difficulty in Walking, Altered Mental Status, Dementia without Behavioral Disturbance, Heart Failure, Dysphagia, Generalized Muscle Weakness, Major [MEDICAL CONDITIONS] Fibrillation. Review of resident #31 care plan dated 10/13/16 on 9/8/16 at 11:16 a.m. revealed that resident #31 is care planned as a resident with Advance directive choices which includes Do Not Resituate (DNR) and Care and Comfort status. Review of the interventions revealed interventions Advance directives will be shared with other medical providers as a need to ensure that advance directive choices are honored; Advance directives will be placed in the chart; Assist resident with DNR form, ensure all parties have signed and this form is in place on the chart. Provide copies to any other medical facility that provide service; Obtain order for DNR. However, there were no specific interventions to address the death and dying, spiritual, or type of comfort care to provide to resident #31. During interview with the MDS Coordinator on 09/8/16 at 1:05 p.m. revealed that she had not individualized resident #31 with specific interventions because she was waiting on a family member to verbalized specific end of life decisions for resident #31. And in regards to specific interventions for the facility staff, MDS Coordinator could not explain the lack of interventions. Review of the facility policy Care Plans-Comprehensive: Policy Interpretation and Implementation; number 2. The comprehensive care plan has been designed to: a. Incorporated identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident ' s strengths; d. Reflect treatment goals and objectives in measurable outcomes; e. Identify the professional services that are responsible for each element of care; f. Prevent decline in the resident ' s functional status and/or functional levels; and g. Enhance the optimal functioning of the resident.

Based on observation, interview and record review, the facility failed to maintain a safe environment for one (1) resident (#36 in Room 111) with an unsecured raised toilet seat. The sample size was twenty-seven (27). Findings include: 1. Observation on 09/06/2016 at 03:47 p.m. in Room 111 bathroom revealed a raised toilet seat that was not secured. Interview and observation on 09/06/2016 at 3:48 p.m. in Room 111 bathroom with Licensed Practical Nurse (LPN), KK confirmed that the raised toilet seat was not secure and that this was not acceptable practice. Observation on 09/06/2016 at 03:49 p.m. revealed that LPN, KK immediately called the Head of Maintenance to secure the raised toilet seat. Observation on 09/06/2016 at 04:00 p.m. revealed that the raised toilet seat had been secured. Received list of residents with raised toilet seats on 09/07/2016 at 08:25 a.m. and they included Room 111, Room 204, Room 308 and Room 310. Observation on 09/07/2016 at 08:29 a.m. of Room 308 bathroom revealed that the raised toilet seat was secure. Observation on 09/07/2016 at 08:32 a.m. of Room 310 bathroom revealed that the raised toilet seat was secure. Observation on 09/07/2016 at 08:52 a.m. of Room 204 bathroom revealed that the raised toilet seat was secure.

The facility failed to assure the monitoring of side effects and behaviors, in August 2016, for one (1) resident (#51) who was prescribed an antipsychotic medication of twenty seven (27) sampled resident . Findings include: Resident #51 admitted to this facility on 8/3/16 with multiple [DIAGNOSES REDACTED]. Review of the Order Summary Report from August 1-August 31, 2016 revealed a physician's orders [REDACTED]. Record review of the resident's care plan included: Use antidepressant medications and [MEDICAL CONDITION] medications related to depression. Goal: The resident will be free from discomfort or adverse reactions related to antidepressants therapy through the review date. Interventions: Administer antidepressant medications as ordered by physician; Monitor /document side effects and effectiveness every shift. Monitor/document/report PRN (as needed) for adverse reactions to antidepressant therapy. Interview on 9/09/2016 at 7:26 a.m. with Licensed Practical Nurse (LPN) CC revealed that the resident is encouraged to allow staff to help her but resident is independent. The resident ambulates safely with walker but has to be reminded to use it at times. Resident is also encouraged to attend activities. There are no behavioral concerns. LPN CC reported that the side effects from medications ([MEDICATION NAME] and [MEDICATION NAME]) was monitored in September Medication Administration Record (MAR) but was not monitored on the August 2016 MAR. Review of the MAR with LPN CC revealed that behaviors or adverse reactions where not being documented on the August 2016 MAR. Interview on 09/09/2016 at 11:49 a.m. with the Director of Nursing (DON) who reported that adverse reactions for antipsychotic medications are documented on the MAR. The DON reviewed the resident's MAR for August and September and confirmed that there was no tracking of side effects and behaviors in August 2016.

Based on observation and interview the facility failed to ensure that for one (1) of three (3) medication carts was locked when unattended. Findings include: Observation on 09/08/2016 at 07:55 a.m. of Licensed Practical Nurse (LPN), II during medication administration revealed that he/she left the medication cart unlocked and out of visual range when he/she entered room [ROOM NUMBER]. Observation on 09/08/2016 at 07:58 a.m. of LPN, II during medication administration revealed that he/she left the medication cart unlocked and out of visual range when he/she entered room [ROOM NUMBER] A, first to obtain vital signs and then to administer medications. Observation on 09/08/2016 at 08:06 a.m. of LPN,II during medication administration revealed that he/she left the medication cart unlocked and out of visual range when he/she entered room [ROOM NUMBER] B first to obtain vital signs and then to administer medications. Interview on 09/08/2016 at 08:10 a.m. of LPN, II confirmed that he/she forgot to lock the medication cart. He/she stated that they were having to manually lock the cart because the electronic key card was broken. He/she stated that the key card broke and the electronic key pad was broken also. The LPN stated that they had reported this to the Head of Maintenance. Review of Medication Storage Policy revealed that the medication carts were to be locked or attended by persons with authorized access. Interview on 09/08/2016 at 10:29 a.m. with LPN, II revealed that she thought that she reported that the electronic locking system for the medication cart was not working approximately a week ago. Interview on 09/08/2016 at 10:32 a.m. with the Head of Maintenance confirmed that he had been told that the electronic locking system for the 300 hall medication cart was not working. Interview on 09/08/2016 at 10:35 a.m. with the Administrator and the Director of Nursing confirmed that they expect the medication carts to be locked any time the nurse walks away from the medication cart. An interview with the Director of Maintenance during the Quality Assurance Review on 9/23/16 at 1:55 p.m., by telephone, revealed that he was aware that one (1) number on the key pad was not working but that the locking function, using the key, still worked. He revealed that a nurse had accidentally taken the key card home for this medicine cart on 9/8/16 and that with the key card the medicine cart could be locked automatically.

Based on observation and interview the facility failed to label and store personal care items in a sanitary manner in one (1) room out of forty-four (44) rooms. Findings include: Observation on 09/06/2016 at 11:15 a.m., 09/08/2016 at 12;04 p.m. and 09/09/2016 at 08:10 a.m. in room [ROOM NUMBER] shared bathroom revealed that there were two (2) unbagged and unlabeled basins and one (1) unbagged and unlabeled urine specimen measuring device stacked inside each other. Interview and observation on 09/09/2016 at 08:17 a.m. with the Assistant Director of Nursing/ Clinical Supervisor confirmed that in room [ROOM NUMBER] shared bathroom that there were two (2) unbagged and unlabeled basins and one (1) unbagged and unlabeled urine specimen measuring device stacked inside each other. She also confirmed that this was not accepted practice. Interview on 09/09/2016 at 09:28 a.m. with the Director of Nursing revealed that they do not have a policy for the storage of personal items.

Based on record reviews and staff interviews, it was determined that the facility failed to ensure that a Physician ordered laboratory test was obtained in a timely manner for two (2) residents (#51 and #65) from a sample of three (3) residents reviewed for laboratory tests and from a total sample of twenty-seven (27) residents. Findings include: 1. Resident #65 had a physician's orders [REDACTED]. Review of the medical record revealed that resident #65 received laboratory testing on 2/16/16, 2/23/16, 3/1/16, and 3/8/16 for CBC. Further review revealed that CMP testing was done for 2/16/16, 2/23/16, and 3/8/16 but did not have CMP testing on 3/1/16. 2. Resident # 51 had a physician's order [REDACTED]. Review of the medical record revealed that resident #51 received laboratory testing on 8/4/16 and 8/23/16 for CBC and CMP. Further review revealed that CBC and CMP testing was not done for the weeks of 8/7/16 and 8/14/16. Labs for August requested from RN Quality Assurance Performance Improvement (QAPI) DD for resident #51 on 9/9/16 at 8:04 a.m. Interview on 9/9/16 at 8:30 a.m. with RN QAPI DD who reported that a services with Clinical Laboratory Services, Incorporated (CLS) were began in July 2016. RN QAPI DD explained that the facility submitted requisitions for all orders on new admissions to the laboratory provider but when this was done it caused all follow up orders to override the initial order for weekly labs to be drawn for CBC and CMP. Interview on 9/9/16 at 8:36 a.m. with RN QAPI DD , who provided copies of lab requisitions for resident which revealed q week x 4 weeks for Comp and CBC with the first scheduled draw date 8/4/16. In another requisition Comp and CBC requested every 3 months (due February, May, August, and November) with the first scheduled draw date of 8/4/16. It was further reported that once this issue was identified as being a problem it was placed inot the facility's quality assurance meeting for monitoring. Interview on 9/9/16 at 11:49 a.m. with Director Of Nursing (DON) reported that if there is not an order on the file to discharge the two (2) weeks of labs that were missed for resident #51 that there probably was not an order. DON reported that the facility was following the instructions of the lab to submit two (2) separate requisitions for the labs (weekly and every three (3) months). DON reported that CLS sends a manifest but it is hard to read. DON further reported that it was by reviewing the manifest that the facility learned that the monthly lab was overriding the weekly labs. DON suggested that surveyor follow up with RN QAPI DD for further information about lab services. Interview on 9/9/16 at 12:23 p.m. RN QAPI DD reported that the laboratory services prior to July were with Mayo. Mayo services were reported as being present at the facility on Tuesdays. The requisitions were completed and faxed to them on Mondays. There was an appointment book in which RN QAPI DD reported residents needing to be seen for the week were written on the schedule and whenever the laboratory technician arrived to provide service the residents were seen.