Every finding on record at Bertrand Nursing and Rehab Center

Based on interview and record review, the facility failed to provide an appropriate diagnosis for the use of a psychotropic medication (a medication that alters the levels of chemicals in the brain that influence mood, behavior, and perception) for one resident (Resident #38) out of five sampled residents. The facility census was 53.Review of the facility's policy titled, Antipsychotic (a medication that affects the brain activities associated with mental processes and behavior) Medication Use, revised December 2016, showed:Antipsychotic medications may be considered for residents with dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed;Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time in our subject to gradual dose (GDR) reduction and re-review;Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective;The Attending Physician and other staff will gather and document information to clarify, a resident's behavior, mood, function, medical condition, specific symptoms, and risk to the resident and others;The Attending Physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications;Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident;Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (a guidebook that helps physicians and other mental health professionals diagnose mental illness, current or subsequent editions): Schizophrenia (a long-term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations); Schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions); Schizophreniform disorder (hallucinations); Delusional disorder (a false belief that is not based on reality); Mood (an emotional state of mind or feeling) disorders (e. g. bipolar disorder (a mental disorder that causes unusual shifts in mood), depression (a serious medical illness that negatively affects how you feel, the way you think and how you act) with psychotic features, and treatment refractory major depression (a disease or condition that does not respond to treatment); Psychosis (a mental disorder with a severe loss of contact with reality) in the absence of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning); Medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania (emotional shifts in mood); Tourette's disorder (uncontrollable, repetitive movements or sounds); Huntington disease (a hereditary brain disorder that causes uncontrolled movements, cognitive (thinking, learning, and understanding) decline, and psychiatric problems worsening over time); Hiccups (not induced my other medications); Nausea and vomiting associated with cancer or chemotherapy; Antipsychotic medications will not be used if the only symptoms are one or more of the following: Wandering; Poor self-care; Restlessness; Impaired memory; Mild anxiety; Insomnia (difficulty falling asleep); Inattention or indifference to surroundings; Sadness are crying alone that is not related to depression or other psychiatric disorders; Fidgeting; Nervousness; Uncooperativeness;The Physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) while the benefits of the medication outweigh the risk or suspected or confirmed adverse consequences. 1. Review of Resident #38's July 2025 Physician's Order Sheet (POS) showed:admitted on [DATE];admitted to hospice on 11/15/24;discharged from hospice on 05/14/25;Diagnoses of unspecified convulsions (a sudden, irregular movement of the limb or of the body), unspecified dementia, unspecified severity, without behavioral (how a person acts or reacts) disturbance, psychotic (losing touch with reality) disturbance, mood disturbance, and anxiety (persistent worry and fear about everyday situations), Alzheimer's disease (progressive mental deterioration), unspecified and major depressive disorder (a serious medical illness that negatively affects how you feel, the way you think and how you act);An order for olanzapine (an antipsychotic medication) 2.5 milligram (mg) by mouth at bedtime related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, dated 11/15/24. Review of the resident's medical record showed:No documentation of an appropriate diagnoses for the use of olanzapine;No identified targeted behaviors;No documentation of any behaviors;No pharmacist recommendations for an appropriate diagnosis for the use of olanzapine. Observations of the resident showed:On 07/22/25 at 1:45 P.M., and 07/24/25 at 9:14 A.M., the resident lay in bed with his/her eyes closed and a private sitter in the room;On 07/23/25 at 10:54 A.M., the resident sat in a wheelchair, non-verbal, and with a private sitter in the room. Review of the resident's Care Plan, revised 05/27/25, showed:Need assistance with activities of daily living (ADLs) with interventions of staff to turn and reposition in bed, transfers x 2 staff and dependent assist with a Hoyer lift (a mechanical lift) for all transfers, need to be checked and changed routinely, perform peri-care and provide with preventative skin treatments, provide showers on the scheduled days, assist with dressing, and generally stays in his/her room throughout the day;Has a Power of Attorney (POA) who will make healthcare and financial decisions;Has private sitters that sit with the resident during the day;Rarely or never understood and has communication issues with a diagnosis of Alzheimer's disease;Has impaired cognitive function related to Alzheimer's and is non-verbal;At risk for side effects from the psychotropic medication with interventions that include monitor/document/report as needed (PRN) any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia (a neurological syndrome marked by rhythmical movements which occur as an undesired side effect of psychotropic drugs), extrapyramidal symptoms (EPS - shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person;At risk for mood problems related to Alzheimer's disease with interventions that include monitor/record/report to medical director PRN acute episode feelings or sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits, change in sleep patterns, diminished ability to concentrate and change in psychomotor skills (learned physical abilities that involve your mind and body working together smoothly).During an interview 07/25/25 at 10:24 A.M. and 07/25/25 at 12:24 P.M., the Director of Nursing (DON) said if a resident had a physician's order for an antipsychotic medication, it should have an appropriate diagnosis. Resident #38 received hospice services until May 2025. The resident's spouse, who was the POA, took him/her off hospice services and did not want the resident taken off the psychotropic medication. The POA took the resident to a psychiatric physician outside the facility. The resident had never had any behaviors. She had not received any psychiatric progress notes since the resident was admitted to the facility. She had made several requests and had not received any progress note documentation from the psychiatric physician or anyone from his/her office regarding the resident. During an interview 07/25/2025 at 11:15 A.M., the Administrator said if a resident had an order for an antipsychotic medication, there should be an appropriate diagnosis. He had a phone conversation with the psychiatric physician who prescribed the psychotropic medication for Resident #38. He explained the need for an appropriate diagnosis to meet the Center for Medicare and Medicaid Services (CMS) guidelines for antipsychotic medication use. The psychiatric physician did not and would not provide an appropriate diagnosis. During an interview on 07/25/25 at 11:34 A.M., the Pharmacist said based on the low dosage of the antipsychotic medication, the diagnosis was appropriate for the resident to receive the prescribed medication. The resident's psychotropic medications were scrutinized monthly along with GDR recommendations.

Based on observation, interview and record review, the facility failed to ensure the safety of a resident by not assessing and evaluating the mobility rail (a rail to assist residents with positioning in bed) for five residents (Resident #3, #8, #16, #45, #51) out of five sampled residents. The facility census was 53. Review of the facility's policy titled, “Assistive Devices and Equipment,” dated January 2020, showed: The facility maintains and supervises the use of assistive devices and equipment for residents; The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment: appropriateness for resident condition - the resident is assessed for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment. 1. Review of Resident #3's medical record showed: admitted on [DATE]; Diagnoses of hypertension (high blood pressure) and hypokalemia (decreased blood level of potassium); No assessment for the use of the mobility rail. Observations on 07/22/25 at 1:21 P.M., 07/23/25 at 1:20 P.M., and 07/24/25 at 10:20 A.M. showed: A U-shaped mobility rail in the upright position on the right side of the resident's bed. During an interview on 07/22/25 at 1:22 P.M., the resident said he/she used the mobility bar for getting up on the side of the bed. 2. Review of Resident #8's medical record showed: admitted to the facility on [DATE]; Diagnoses of cerebral infarction (stroke), major depressive disorder (a disorder characterized by persistently depressed mood or loss of interest in activities) and anxiety (intense, excessive, and persistent worry and fear about everyday situations); No assessment for the use of the mobility rail. Observations on 07/22/25 at 11:00 A.M., 07/23/25 at 3:20 P.M., 07/24/25 at 12:05 P.M., 07/25/25 at 1:25 P.M. showed: A U-shaped mobility rail in the upright position on the left side of the resident's bed. 3. Review of Resident #16's medical record showed: admitted on [DATE]; Diagnoses of left side hemiplegia (paralysis of one side of the body), hypertension and type II diabetes mellitus (DM - a condition that affects the way the body processes blood sugar); No assessment for the use of the mobility rail. Observations on 07/22/25 at 2:17 P.M., 07/23/25 at 10:10 A.M., and 07/24/25 at 2:10 P.M. showed: A U-shaped mobility rail in the upright position attached to right side of the resident's bed. During an interview on 07/22/25 at 2:20 P.M., the resident said he/she used the mobility rail for getting up on the side of the bed and turning side to side. 4. Review of Resident #45's medical record showed: admitted on [DATE]; Diagnoses of burst fracture of lumbar vertebra (vertebral fracture due to compression), heart attack, and chronic respiratory failure; No assessment for the use of the mobility rail. Observations on 07/22/25 at 11:11 A.M., 07/23/25 at 10:36 A.M., 07/24/25 at 8:17 A.M., and 07/25/25 at 9:43 A.M. showed: A U-shaped mobility rail in the upright position attached to the right side of the resident's bed. During an interview on 07/23/25 at 10:36 A.M., the resident said he/she used the mobility rail to turn in bed and with transfers out of the bed. 5. Review of Resident #51's medical record showed: admitted on [DATE]; Diagnoses of hypertension, anxiety, and depression (mood disorder that causes a persistent feeling of sadness and loss of interest); No assessment for the use of the mobility rail. Observations on 07/22/25 at 2:20 P.M., 07/23/25 at 3:24 P.M., 07/24/25 at 9:58 A.M., and 07/25/25 at 11:50 A.M. showed: U-shaped mobility rails in the upright position on both sides of the resident's bed. During an interview on 07/22/25 at 2:20 P.M., the resident said he/she used the mobility rail for getting up on the side of the bed and turning side to side while in bed. During an interview on 07/25/25 at 10:00 A.M., the Administrator said he visually inspected the rails on his daily rounds. He did not document the rail inspections. During an interview on 07/25/25 at 1:17 P.M., the Therapy Director said the facility did not document any assessments to determine if a resident needed or was able to use a mobility rail. During an interview on 07/25/25 at 1:57 P.M., the Maintenance Assistant said he/she did repair the mobility rails or added/removed them from the residents' beds when asked. He/She did not inspect the rails that were on the residents' beds.

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 28 opportunities with four errors made, resulting in an error rate of 10.71% for one resident (Resident #34) out of three sampled residents. The facility's census was 53. The facility did not provide a policy addressing priming of insulin pens. Review of the Fiasp/Novolog (fast-acting insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flex Pen administration instructions, dated September 2021, showed:To prime the pen, turn the dose selector to two units;Keep the needle upwards and press the push button until the dose selector reads zero;Turn the dose selector to select the number of prescribed units to administer the insulin.1. Review of Resident #34's Physician's Order Sheet (POS), dated July 2025, showed:An order for Novolog FlexPen 16 units subcutaneously (injection under the skin) two times a day, dated 02/27/25;An order for Novolog FlexPen per sliding scale for a blood sugar of 51-200 = 0 units, 201-200 = 3 units, 301-350 = 5 units, 351-400 = 8 units, 401-500 = 10 units subcutaneously before meals, dated 04/14/24.Observation of Resident #34's medication administration on 07/23/25 at 11:39 A.M., showed:Licensed Practical Nurse (LPN) A administered 19 units of Novolog subcutaneously for a blood sugar of 265 with the resident's Novolog FlexPen;- LPN A failed to prime the Novolog FlexPen per the manufacturer's instructions prior to the administration of the insulin to the resident.Observation of Resident #34's medication administration on 07/24/25 at 4:38 P.M. showed:LPN B administered 8 units of Novolog subcutaneously for a blood sugar of 358 with the resident's Novolog FlexPen:LPN B failed to prime the Novolog FlexPen per the manufacturer's instructions prior to the administration of the insulin to the resident.During an interview on 07/25/25 at 1:45 P.M., Certified Medication Technician (CMT) C said he/she dialed up two units of insulin to waste and prime the needle before dialing up the dose the order required.During an interview on 07/25/25 at 1:45 P.M., LPN D said before administering the ordered dose of insulin, he/she wasted two units of insulin to prime the needle.During an interview on 07/25/25 at 2:15 P.M., the Director of Nursing (DON) said she would expect staff to prime the insulin pen needle with at least two units before administering insulin to residents.

Based on observation, interview and record review, the facility failed to follow infection control protocols during wound care for one resident (Resident #7) out of two sampled residents. The facility census was 53. Review of the facility's policy titled, Dressings, Dry/Clean, last revised September 2013, showed:Wash and dry hands thoroughly;Put on clean gloves. Loosen tape and remove soiled dressing;Pull glove over dressing and discard into plastic or biohazard bag;Wash and dry your hand thoroughly;Put on clean gloves;Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress, and wound stage;Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually from the center outward);Use dry gauze to pat the wound dry;Apply the ordered dressing and secure with tape or bordered dressing per order;Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly.Review of the facility's policy titled, Dressings, Soiled/Contaminated, last revised August 2009, showed:Gloves must be worn when changing a dressing and/or when handling items contaminated with blood, body fluids, or potentially infective materials.1. Review of Resident #7's medical record showed:Diagnoses of Alzheimer's disease (progressive brain disorder), cerebral infarction (stroke), mood disorder, dysphagia (difficulty swallowing), and anxiety.Review of the resident's Physician's Order Sheet (POS), dated July 2025, showed:An order to clean the open areas to the left lower extremity (LLE) with wound cleanser, pat dry with 4x4s, apply a thin layer of Multidex powder (absorbs drainage from open wounds) to open areas, cover with Telfa (a non-adherent dressing), wrap the LLE with Kerlix (gauze wrap), and secure with tape daily and as needed (PRN), dated 07/25/25;- An order to clean shears to the left hip, right hip, and the right knee with wound cleanser and cover with bordered gauze, dated 07/22/25.Observation of the resident's wound care on 07/24/25 at 2:00 P.M. showed:Licensed Practical Nurse (LPN) A, LPN B, and the Director of Nursing (DON) entered the resident's room, did not perform hand hygiene, and put on gloves;LPN A cleaned the right hip wound with wound cleanser and gauze, did not change gloves, did not perform hand hygiene, and patted it dry with clean gauze; - LPN A did not change gloves, did not perform hand hygiene, cleaned the right knee wound with wound cleanser and gauze, did not change gloves, did not perform hand hygiene, and patted it dry with clean gauze;LPN A did not change gloves, did not perform hand hygiene, cleaned the left hip wounds with wound cleanser and gauze, did not change gloves, did not perform hand hygiene, and patted it dry with clean gauze;LPN A removed gloves, did not perform hand hygiene, and touched the clean dressing with his/her bare hands;LPN A put on gloves, did not perform hand hygiene, cleaned the LLE with wound cleanser and gauze, did not change gloves, did not perform hand hygiene, and patted it dry with clean gauze;LPN A removed gloves, did not perform hand hygiene, and applied the Telfa dressings, gauze, and tape to the LLE with his/her bare hands;LPN B and DON removed gloves;LPN A, LPN B, and DON did not perform hand hygiene and exited the resident room.During an interview on 07/25/25 at 1:48 P.M., LPN D said when providing wound care, he/she would perform hand hygiene and put on clean gloves, remove the dirty dressing, remove the dirty gloves, perform hand hygiene, and put on clean gloves. Next, he/she would clean the wound, remove the dirty gloves, perform hand hygiene, and apply a clean dressing. Should perform hand hygiene and put on clean gloves between each wound. He/She would never touch a clean dressing with a dirty glove or with a bare hand. During an interview on 07/25/25 at 2:04 P.M., the DON said staff should not use their bare hands in any portion of wound care. Staff should perform hand hygiene and put on clean gloves when going from soiled to clean care to lower the risk of contamination.

Based on observation, interview and record review, the facility failed to conduct inspections of all bed frames, mattresses, and side rails as a part of a regular maintenance program for five residents (Resident #3, #8, #16, #45, and #51) out of five sampled residents. The facility census was 53. Review of the facility's policy titled, “Assistive Devices and Equipment,” dated January 2020, showed: The facility maintains and supervises the use of assistive devices and equipment for residents; The policy did not address an inspection of the mobility rail as part of the facility's maintenance program. 1. Review of Resident #3's medical record showed: admitted on [DATE]; Diagnoses of hypertension (high blood pressure) and hypokalemia (decreased blood level of potassium); No maintenance inspection for the mobility rail. Observations on 07/22/25 at 1:21 P.M., at 07/23/25 at 1:20 P.M., and 07/24/25 at 10:20 A.M. showed: - A U-shaped mobility rail in the upright position on the right side of the resident's bed. During an interview on 07/22/25 at 1:22 P.M., the resident said he/she used the mobility rail for getting up on the side of the bed. 2. Review of Resident #8's medical record showed: admitted to the facility on [DATE]; Diagnoses of cerebral infarction (stroke), major depressive disorder (a disorder characterized by persistently depressed mood or loss of interest in activities) and anxiety (intense, excessive, and persistent worry and fear about everyday situations); No maintenance inspection for the mobility rail. Observations on 07/22/25 at 11:00 A.M., 07/23/25 at 3:20 P.M., 07/24/25 at 12:05 P.M., and 07/25/25 at 1:25 P.M. showed: - A U-shaped mobility rail in the upright position on the left side of the resident's bed. 3. Review of Resident #16's medical record showed: admitted on [DATE]; Diagnoses of left side hemiplegia (paralysis of one side of the body), hypertension and type II diabetes mellitus (DM - a condition that affects the way the body processes blood sugar); No maintenance inspection for the mobility rail. Observations on 07/22/25 at 2:17 P.M., 07/23/25 at 10:10 A.M., and 07/24/25 at 2:10 P.M. showed: A U-shaped mobility rail in the upright position attached to right side of the resident's bed. During an interview on 07/22/25 at 2:20 P.M., the resident said he/she used the mobility rail for getting up on the side of the bed and turning side to side. 4. Review of Resident #45's medical record showed: admitted on [DATE]; Diagnoses of burst fracture of lumbar vertebra (vertebral fracture due to compression), heart attack, and chronic respiratory failure; No maintenance inspection for the mobility rail. Observations on 07/22/25 at 11:11 A.M., 07/23/25 at 10:36 A.M., 07/24/25 at 8:17 A.M., and 07/25/25 at 9:43 A.M. showed: A U-shaped mobility rail in the upright position attached to the right side of the resident's bed. During an interview on 07/23/25 at 10:36 A.M., the resident said he/she used the mobility rail to turn in bed and with transfers out of the bed. 5. Review of Resident #51's medical record showed: admitted on [DATE]; Diagnoses of hypertension, anxiety, and depression (mood disorder that causes a persistent feeling of sadness and loss of interest); No maintenance inspection for the mobility rail. Observations on 07/22/25 at 2:20 P.M., 07/23/25 at 3:24 P.M., 07/24/25 at 9:58 A.M., and 07/25/25 at 11:50 A.M. showed: U-shaped mobility rails in the upright position on both sides of the resident's bed. During an interview on 07/22/25 at 2:20 P.M., the resident said he/she used the mobility rail for getting up on the side of the bed and turning side to side while in bed. During an interview on 07/25/25 at 10:00 A.M., the Administrator said he visually inspected the rails on his daily rounds. He did not document the mobility rail inspections. During an interview on 07/25/25 at 1:57 P.M., the Maintenance Assistant said he/she did repair the mobility bars or added/removed them from the residents' beds when asked. He/She did not inspect the rails that were on the residents' beds.

Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 51. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use personal belongings to the extent possible; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting; - These characteristics include a clean, sanitary and orderly environment; - Staff provide person-centered care that emphasizes the resident's comfort, independence and personal needs and preferences. Observations made on 07/07/24 at 8:40 A.M. , 07/08/24 at 9:44 A.M. and 07/09/24 at 8:22 A.M., showed: - Several areas of peeled paint on the walls behind the recliner near the window in room [ROOM NUMBER]; - A cable plate cover hanging out of the wall and not secured on the left side of the dresser with television in room [ROOM NUMBER]; - Several areas of exposed sheetrock and peeled paint on the right side of the headboard of bed 1 in room [ROOM NUMBER]; - Two nails sticking out of the wall with four feet (ft.) of missing trim by bed 1 near the door in room [ROOM NUMBER]; - Exposed sheetrock and peeled paint on the wall near the call-light plate and recliner in room [ROOM NUMBER]. Review of the repair sheet log dated 05/23/24 to 07/04/24 showed no documentation of area of concerns addressed. During an interview on 07/09/24 at 8:40 A.M., Housekeeper A said any environmental concerns are brought to the attention of maintenance supervisor or the administrator. There is also a repair log at the nurse's station that staff can write any needed repairs needed on. He/She has seen environmental concerns and has told maintenance. During an interview on 07/09/24 at 8:47 A.M., Housekeeper B said he/she verbally tells maintenance or the administrator if there is an environmental concern. There is also a repair log at the nurse's station that staff can write down things that need to be fixed. He/She has not seen any environmental concerns that needed to be addressed. During an interview on 07/10/24 at 8:20 A.M., Maintenance Supervisor said there is a repair log at the nurse's station for staff to write down any environmental concerns. Staff does verbally inform him/her of repairs needed, but staff also need to write down those concerns on the repair log so he/she doesn't forget when told in passing. During an interview 07/10/24 at 10:56 A.M., the Administrator said staff should write down any environmental concern on the repair log located at the nurse's station to be addressed in a timely manner. He said even if staff verbally tells someone about an area of concern, it should be written down for documentation purposes. 2. Observations made on 07/07/24 showed: - At 1:30 P.M., rooms 217-228 located in the newer added wing with self-closing devices on the resident room doors; - At 3:13 P.M., three out of five sampled doors between rooms 217-228 closed quickly, making it difficult to get through the door without it closing. Observations made on 07/08/24 showed: - At 10:08 A.M., resident in room [ROOM NUMBER], leaving his/her room with walker, and door closing onto resident's backside as he/she exited the room; - At 10:10 A.M., of room [ROOM NUMBER], a trashcan placed between door and doorframe, keeping it open. Observation made on 07/09/24 at 8:50 A.M., of room [ROOM NUMBER], showed: - Resident asked for help opening his/her door from the inside; - Resident attempted to open door approximately five times; - Resident door opened and shut quickly; - Resident continued to ask for help opening his/her door; - Resident wheelchair bound and unable to move through the door quick enough to exit the room. During an interview on 07/08/24 at 2:41 P.M., the resident in room [ROOM NUMBER] said he/she does not understand why his/her door has to stay shut, and the other rooms on the hall can leave their doors open. During an interview on 07/08/24 at 2:48 P.M., the Resident in room [ROOM NUMBER] said he/she has complained multiple times that the doors are heavy and difficult to open in the resident's room. During an interview on 07/09/24 at 11: 01 A.M., the resident in room [ROOM NUMBER] said he/she has a trash can propping the door open so the resident doesn't miss lunch. The resident said he/she is unable to open the door independently due to being in a wheelchair. During an interview on 07/10/24 at 9:58 A.M., the Director of Nursing (DON) said facility staff is aware the doors on the newest wing are more difficult to open than the rest of the building because they are equipped with automatic self-closing devices. Before a resident is placed in the newer room, staff does a review of therapy notes, case management and hospital notes to decide if residents are appropriate to be in the rooms with the self-closing devices on the doors. The DON said he/she would expect residents to be capable of going in and out of their room as they please, if they were physically able to do so. During an interview on 07/10/24 at 11:03 A.M., the Administrator said the doors in the newest addition are equipped with automatic self-closing devices that he was under the impression were required by the Life Safety Code. The Administrator said he would not expect every resident to be able to go in and out of their rooms as they wished, it would depend on the resident and the scenario. The Administrator said they were aware the doors to the newer rooms could not stay open and would close quicker than the others, so they made an effort to ensure only alert, oriented and capable residents were put back there. 50260

Based on interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for one resident (Resident #21) out of 13 sampled residents. The facility census was 51. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The care planning process will include an assessment of the resident's strengths and needs; - The comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Review of Resident #21's medical record showed: - An admitted [DATE]; - A diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of the resident's care plan, dated 06/26/24, showed the care plan did not address specific interventions related to dementia. During an interview on 07/10/24 at 11:25 A.M., the Minimum Data Set (MDS) Coordinator said he/she completes the care plans and would expect dementia to be on the resident's care plan. During an interview on 07/10/24 at 11:28 A.M., the Director of Nursing (DON) said the dementia diagnosis is not new for this resident and she would expect it to be on the resident's care plan.

Based on observation, interview and record review the facility failed to obtain orders to change the indwelling catheter (a tube inserted into the urinary bladder to drain urine) every 30 days and failed to ensure documentation of the catheter changes were maintained for one resident (Resident #31) and failed to obtain a physicians order for catheter care to be performed every shift for two residents (Residents #31 and #40) out of two sampled residents. The facility census was 51. Review of the facility's policy, titled, Catheter Care, Urinary, revised September 2014, showed: - Policy did not address frequency catheter care should be completed; - Policy did not address frequency catheter should be changed. 1. Review of Resident #31's medical record showed: - admitted [DATE]; - Diagnoses of intervertebral disc degeneration, thoracolumbar region (discs between vertebrae with loss of cushioning), Incontinence without sensory awareness (inability to control the flow of urine from the bladder), Acute Respiratory Failure (when the body is unable to exchange oxygen and carbon dioxide), Chronic obstructive pulmonary disease (COPD) (lung disease that makes it difficult to breathe), retention of urine (difficulty emptying the bladder of urine); Review of the resident's Physician's Order Sheet (POS), dated 06/06/24, showed: - A telephone order to place foley catheter related to urinary retention; Review of the POS dated June 2024 and July 2024, showed: - No orders for catheter care every shift, catheter change frequency and catheter size; Review of Treatment Administration Record (TAR), dated June 2024 and July 2024, showed: - No catheter care documented; 2. Review of Resident #40's medical record showed: - An admitted [DATE]; - Diagnoses of COPD, chronic respiratory failure, retention of urine, and chronic kidney disease, stage 3 (kidneys have mild to moderate damage and are less effective at filtering waste and extra fluid from the body); Review of the resident POS, dated July 2024, showed: - No orders for catheter care; Review of residents' TAR dated May 2024 showed blank space on date catheter ordered to be changed; Review of Medication Administration Record (MAR) dated June 2024, showed: - An order for a Urinalysis with culture and sensitivity collected on 06/04/24; - An order for Macrobid (antibiotic) 100mg by mouth two times daily for Urinary tract infection (UTI) for 10 days, dated 06/06/24 During an interview on 07/09/24 at 03:08 P.M. the Assistant Director of Nursing (ADON), said typically when a resident has a urinary catheter, orders are entered into the Electronic Medical Record (EMR) for frequency of change, size and catheter care. During an interview on 07/10/24 at 08:53 A.M., the Director of Nursing (DON), said if on the Treatment Administration Record (TAR) is blank, that means it wasn't charted, so it can be assumed it wasn't done. During an interview on 07/10/24 at 11:30 A.M., the DON said if a resident has a catheter, he/she would expect orders for changing the catheter every 30 days, catheter care every shift and as needed (PRN) and strict output every eight hours. Catheter care should be completed by the Certified Nurses' Aide (CNA).

Based on interview and record review the facility failed to ensure an appropriate diagnosis for the use of an anti-psychotic medication for one resident (Resident #32) out of five sampled residents. The facility census was 51. Review of the facility's policy titled, Medication Regimen Review, revised April 2007, showed: - The pharmacist will perform Medication Management Review (MMR) for every resident in the facility on a monthly basis; - The pharmacist will evaluate for appropriate dosage, interactions, and adverse consequences; - Findings and recommendations are reported to the Director of Nursing (DON) and the medical director. 1. Review of Resident #32's Physician Order Sheet (POS), dated February 2024 through July 2024 showed: - Diagnoses included dementia (a condition characterized by progressive loss of memory and thinking, sometimes resulting in personality change, resulting from disease of the brain), anxiety disorder (a mental health disorder characterized by feelings of worry, or fear that can be strong enough to interfere with daily activities, and altered mental status (a change in mental function); - An order for olanzapine (an anti-psychotic medication) 2.5 milligram (mg) one tablet daily at bedtime; - No documentation of a diagnosis or indication for use. Review of the resident's medical chart showed: - Start date for olanzapine 10/10/22; - Gradual dose reduction (GDR) attempted 04/12/24; - GDR request denied on 04/15/24 due to potential for mood destabilization; - Psychiatric referral made on 04/18/24; - No documentation of a diagnosis or indication for use. During an interview on 7/10/24 at 9:58 A.M., the Director of Nursing (DON) said the diagnosis for olanzapine 2.5 mg was dementia. The DON said the resident has behaviors, like asking for money, asking to drive, and seeing things that are not there. The DON said these are not normal behaviors for dementia. The DON said she would not expect another diagnosis for the resident to be on an anti-psychotic. The DON said she just goes off of what the psychiatric physician and the medical directors document.

Based on observation, interview, and record review, the facility failed to utilize proper technique during incontinent care and urinary catheter (a tube placed in the body to drain and collect urine from the bladder) care when staff did not change gloves or perform hand hygiene before or after care, or in between dirty and clean tasks for one resident (Resident #4) out of 13 sampled residents and two residents (Resident #9 and #31) outside the sample. The facility census was 51. Record review of the facility's Handwashing/Hand Hygiene policy, revised August 2019, showed: - This facility considers hand hygiene the primary means to prevent the spread of infection; - All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; - Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; - Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after coming on duty; before and after direct contact with residents; before and after handling an invasive device (e.g., urinary catheters); before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin; after contact with blood or bodily fluids; after handling used dressings, contaminated equipment, etc.; after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and after removing gloves; - Hand hygiene is the final step after removing and disposing of personal protective equipment; - The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections; - Single-use disposable gloves should be used when anticipating contact with blood or body fluids; - Applying and Removing Gloves: 1. Perform hand hygiene before applying non-sterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. 3. When removing gloves, pinch the gloves at the wrist and peel away from the hand, turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene. Record review of the facility's Personal Protective Equipment - Using Gloves policy, revised September 2010, showed: - Objective - to prevent the spread of infection; to protect hands from potentially infectious material; and to prevent exposure to the HIV (a virus that attacks the body's immune system) and hepatitis B (a serious liver infection) viruses from blood or body fluids; - When gloves are indicated, use disposable single-use gloves; - Wash hands after removing gloves. (Note: Gloves do not replace handwashing); - When to use gloves: When touching excretions (waste products that are eliminated from the body), secretions (process by which substances are produced and discharged from a cell, gland, or organ), blood, body fluids, mucous membranes (moist, inner lining of some organs and body cavities) or non-intact skin; when the employee's hands have any cuts, scrapes, wounds, chapped skin, dermatitis (inflammation of the skin), etc.; when cleaning up spills or splashes of blood or body fluids; whenever in doubt. Record review of the facility's Perineal Care policy, revised February 2018, showed: - The purposes 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; - Steps in the Procedure: Wash and dry your hands thoroughly; put on gloves; - For a female resident, wash perineal area (also known as peri area - the private areas of a resident), wiping from front to back, separate labia (folds of skin around the vaginal opening) and wash area downward from front to back (If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra (a hollow tube that lets urine leave your body) down the catheter about three inches. Gently rinse and dry the area.); continue to wash the perineum moving from inside outward to the thighs, rinse perineum thoroughly in same direction, using fresh water and a clean washcloth; if the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter; gently dry perineum; rinse wash cloth and apply soap or skin cleansing agent; wash rectal (relating to the large intestine closest to the anus) area thoroughly, wiping from the base of the labia towards and extending over the buttocks; rinse and dry thoroughly; - For a male resident, wash perineal area starting with urethra and working outward; if the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches; gently rinse and dry the area; retract foreskin (skin covering the end of the penis) of the uncircumcised male; wash and rinse urethral area using a circular motion; continue to wash the perineal area including the penis, scrotum (the external sac that contains the testicles), and inner thighs; thoroughly rinse perineal area in the same order, using fresh water and clean washcloth; if the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter; gently dry perineum following same sequence; reposition foreskin of uncircumcised male; wash the rectal area thoroughly, including the area under the scrotum, anus (opening of the rectum to the outside of the body), and buttocks; dry area thoroughly; - Remove gloves and discard into designated container; - Wash and dry hands thoroughly. Record review of the facility's Catheter Care, Urinary policy, revised September 2014, showed: - The purpose of this procedure is to prevent catheter-associated urinary tract infections; - Infection Control: Use standard precautions when handling or manipulating the drainage system; maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag; be sure the catheter tubing and drainage bag are kept off the floor; empty the drainage bag regularly using a separate, clean collection container for each resident. Avoid splashing, and prevent contact of the drainage spigot with the nonsterile container. - Procedure: place the clean equipment on the bedside stand or overbed table. Arrange the supplies so they can be easily reached; wash and dry hands thoroughly; put on gloves; place bed protector under resident; wash the resident's genitalia (external organs of the reproductive system) and perineum thoroughly with soap and water. Rinse the area well and towel dry; remove gloves and discard into the designated container. Wash and dry hands thoroughly; put on clean gloves; with nondominant hand, separate the labia of the female resident. Maintain the position of this hand throughout the procedure; assess the urethral meatus; for a female resident, use a washcloth with warm water and soap to cleanse the labia; use one area of the washcloth for each downward, cleansing stroke; change the position of the washcloth with each downward stroke; next, change the position of the washcloth and cleanse around the urethral meatus; do not allow the washcloth to drag on the resident's skin or bed linen; with a clean washcloth, rinse with warm water using the above technique; use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches downward; discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry hands thoroughly; reposition the bed covers. Make the resident comfortable; clean wash basin and return it to designated storage area; clean the bedside stand and/or overbed table; return the overbed table to its proper position; wash and dry hands thoroughly. 1. Observation of Resident #4 on 4/19/23 at 1:59 P.M. showed: - Certified Nursing Assistant (CNA) A and CNA B entered the resident's room to perform peri care and did not perform hand hygiene before donning gloves; - After releasing the disposable brief tape from both sides of the resident with the wet brief still under the resident, CNA A cleaned the resident's front peri area three times front to back with a disposable cleansing wipe folding it after each use, then CNA A and CNA B repositioned the resident on his/her left side; - CNA B used a new disposable cleansing wipe and cleaned the resident's back peri area and buttocks from back to front; - CNA A and CNA B removed the wet brief and dirty wipes lying inside the brief from the resident and placed in a trash bag sitting at the foot of the resident's bed; - CNA A and CNA B then removed their gloves and donned new gloves without performing hand hygiene and put a clean brief on the resident, touching the resident's clothing and bed linens; - CNA A then disposed of the trash bag. CNA A and CNA B did not sanitize hands before leaving the room. 2. Observation of Resident #31 on 4/19/23 at 2:10 P.M. showed; - CNA B stopped by the storage room to get supplies for the resident after exiting Resident #4's room; - CNA A and CNA B entered Resident #31's room and donned gloves without performing hand hygiene; - CNA B retrieved a plastic container from the resident's restroom, set it on the floor, and emptied the resident's urinary drainage bag into the container, reached inside the container to carry it, and flushed the contents down the toilet; - CNA B donned new gloves without performing hand hygiene; - CNA A wiped the resident's front peri area with a disposable cleansing wipe and, with the resident lying on his/her left side, wiped the resident's back peri area with a new wipe; - CNA A and CNA B placed a clean brief on the resident with the same soiled gloves, then removed gloves; - CNA A then disposed of the trash bag. CNA A and CNA B did not sanitize hands before leaving the room. 3. Observation of Resident #9 on 4/19/23 at 2:20 P.M. showed: - CNA A and CNA B entered the resident's room and donned gloves without performing hand hygiene; - CNA A and CNA B transferred the resident from the wheelchair to bed using a Lumex (piece of equipment used for sit-to-stand transfers); - During the transfer from the wheelchair to the Lumex, CNA B unhooked the resident's urinary drainage bag from underneath the wheelchair and it laid on the floor while transferring and, once resident was secure in the Lumex, CNA B laid the urinary drainage bag on the bottom part of the Lumex off the floor; - When transferring the resident from the Lumex to bed, the resident's catheter bag fell on to the floor and, after repositioning the resident in bed, CNA B picked the urinary drainage bag up off the floor and hooked it to the bed frame; - CNA B then retrieved a plastic container from the resident's restroom and set it on the floor and emptied the resident's urinary drainage bag into the container and took it to the restroom to empty it; - CNA B removed gloves and donned new gloves without performing hand hygiene; - CNA A removed gloves, turned on the light in the resident's room, and then donned new gloves without performing hand hygiene; - CNA A and CNA B untaped the resident's soiled disposable brief from the sides and laid the front of the brief down between the resident's legs to perform peri care; - CNA A assisted the resident to his/her left side, and CNA B cleaned the bowel movement from the resident's buttocks using disposable cleansing wipes by folding each cloth after each wipe to reuse the same cleansing wipe; - CNA B continued to wipe the bowel movement from the resident's buttocks from front to back and from back to front, picked up the dirty wipes lying on the bed pad and put them into the trash bag lying at the foot of the bed; - While CNA B cleaned the resident, CNA A, wearing the same soiled gloves, removed multiple wipes from the wipes container and laid them on the container for CNA B to use; - CNA A and CNA B, both wearing the same soiled gloves, each picked up a cleansing wipe from the wipes CNA A had laid on the container and continued wiping the resident's buttocks and front peri area until visibly free of bowel movement; - CNA B wiped from the resident's buttocks to the catheter insertion site multiple times with the same wipe, then got a new one and wiped multiple times again beginning at the buttocks, then wiping down the catheter from the insertion site to approximately three to four inches down the tubing with the same cleansing wipe; - CNA A bagged up the dirty wipes and brief, took the clean brief sitting on the resident's bed and, while wearing the same soiled gloves, placed the clean brief under the resident touching the resident's skin to roll the resident onto the brief; - CNA A removed the dirty bed pad from the resident's bed, put it in a trash bag and dropped the bag at the foot of the bed; - CNA A and CNA B attached the brief and pulled the resident's pants back up. CNA A touched the resident's blanket, chair, and the Lumex with the same soiled gloves, then removed his/her gloves; - CNA B removed his/her gloves, touched resident's floor to pick up a small item and touched the resident's nightstand, then left the room to get another bed pad for the resident and did not perform hand hygiene before leaving the room; - CNA A and CNA B, without performing hand hygiene or donning gloves, placed the bed pad on the bed and repositioned the resident, then CNA A placed the quilt over the resident; - CNA A and CNA B left the resident's room without performing hand hygiene. During an interview on 4/19/23 at 2:35 P.M., CNA A and CNA B said staff should wash or sanitize before and after resident care, when going from room to room, sanitize after taking the trash out, and sanitize once gloves are removed. They should wash and change gloves after touching dirty items during resident care before finishing that care. When cleaning up a bowel movement, staff should change gloves and get another wipe when gloves are visibly soiled. They should wash hands and change gloves after emptying the urinary drainage bag. For catheter care, clean from top where the catheter is inserted and clean down to where it hooks up together. They should get a clean cloth to clean the catheter and not use the same cloth used to clean up a bowel movement. A urinary drainage bag should not touch the floor; it should be hung on the bed. Staff should wipe front to back when performing peri care on a female resident. The facility uses wipes and not washcloths to clean everything. Staff has to carry their own sanitizer. There is no sanitizer in the rooms or bathrooms, but there is soap and water in all the rooms. During an interview on 4/20/23 at 11:00 A.M., the Administrator and Director of Nursing said staff should change their gloves when moving from dirty to clean during resident care, if they stop in the middle of resident care to grab supplies, and after resident care is complete. Staff should also change gloves after touching dirty items during resident care before they finish resident care. Staff are expected to perform hand hygiene between glove changes, between each resident when performing care, and they should wash when hands are visibly soiled. Staff should clean front to back during peri care on a female resident. Staff should not allow a catheter drainage bag to lay on the floor. Staff should follow the policy for peri care and catheter care. They should start cleaning in the area closest to the catheter and work their way out. Staff should make sure the urinary drainage bag is below the bladder.

Based on interview and record review, the facility failed to document preparation and orientation for transfer to the hospital for four residents (Resident #19, #22, #41, and #43) out of 12 sampled residents. The facility's census was 44. 1. Record review of Resident #19's progress notes showed the resident transferred to the hospital on [DATE] and returned to the facility on [DATE] and on 10/19/20 and returned to the facility on [DATE]. Record review of the resident's medical record did not contain documentation which showed the resident was prepped and oriented for transfer out of the facility. 2. Record review of Resident #22's progress notes showed the resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Record review of the resident's medical record did not contain documentation which showed the resident was prepped and oriented for transfer out of the facility. 3. Record review of Resident #41's progress notes showed the resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Record review of the resident's medical record did not contain documentation which showed the resident was prepped and oriented for transfer out of the facility. 4. Record review of Resident #43's progress notes showed the resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Record review of the resident's medical record did not contain documentation which showed the resident was prepped and oriented for transfer out of the facility. During an interview on 10/29/20 at 10:35 A.M., the Administrator said he would expect the residents to be oriented prior to transfer and for it to be documented in the nurse progress notes. Record review of the facility's policy titled, Transfer or Discharge, Emergency dated August 2018, showed: - Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: - Prepare the resident for transfer.

Based on observation and interview, the facility failed to maintain kitchen equipment in a clean, sanitary manner to prevent the potential for cross-contamination. The facility failed to date open food items that have the potential to cause food-borne illness if used. These practices could potentially affect all residents. The facility census was 47. 1. Observation of the kitchen on 7/8/19 at 9:05 A.M., showed: - A dirty metal rack with clean dishes, plastic container full of mug lids and straws; - A plastic tray with dried spilled coffee loaded with coffee mugs sitting on their rims under the coffee maker; - A plastic bag with five slices of toast, not dated; - A bag of seven hot dog buns opened and tied closed, no date; - A sleeve of crackers, open to air, no date; - Binder of recipes covered in a build up of grease; - Floor sticky; - A plastic container of coffee packets, with lid partially on and covered in dust and debris; - Toaster with a build up of brown and black crumbs; - A plastic trash can covered in streaks of grease accumulation, sitting next to the cook stove with burner on; - A metal rack above the cook stove with grease dripping; - Burner knob missing from cook stove; - Grease build up on and around stove knobs; - A six inch by four inch area of grease in the floor around front stove leg next to fryer; - Oven door handle with sticky brown substance dripping; - Deep fryer next to cook stove, covered in grease and food particles inside and out; - A gallon container of Worcestershire sauce, no open date, and with an expiration date of 2/9/19; - A two gallon container of instant potatoes, half full with no date; - A plastic drawer bin of snack cakes, no dates. - The refrigerator had a half gallon of buttermilk, one pint remaining, expiration date of 6/28/19, no open date, honey thickened tea dated 6/21/19, nectar thickened tea dated 6/24/19, and honey thickened orange juice dated 6/24/19. During an interview on 7/8/19 at 9:31 A.M. the Dietary Manager (DM) said the staff were in a rush putting things up and just did not date the items. Observation on 7/9/19 at 11:20 A.M., showed: - Door frame of supply room with a three inch by half inch area of chipped paint, bare wood showing below latch level, at the latch level an area of four inch by one and half inch area chipped paint, bare, splintered wood showing; - Inside the supply room, a metal rack with food and supplies, top shelf with a fly swatter and an electronic fly swatter next to quick oats. - A cooked sausage link behind fryer, - Cereal in plastic bins with no dates. Observation on 7/11/19 at 10:30 A.M., showed: - Food storage ceiling above four shelf wire rack, an area of two inch by four inch with peeling paint; - An uncovered plastic container holding salt and pepper shakers with debris in the bottom of container sitting on wire rack in storage room; - An electronic fly swatter on wire rack with over salt and pepper shakers; - A bag of macaroni opened with no date; - A five gallon jug of butter with butter dripping down the sides of jug; - Kitchen mixer with dried food on bottom of mixer head; - A measuring cup in a two gallon container of sugar, with half of gallon remaining; - A large open divided clean dish rack sitting near the serving area holding plates, bowls, saucers and divided plates with scattered food particles on the bottom and light tan colored streaks of substance on the upright dividers; - Three plastic stacked trays containing 42 glasses in the walk in freezer uncovered; - Wire shelving unit containing clean dishes and silverware sitting beside the DM's office with a mop and mop bucket up against it touching the silverware. During an interview on 7/11/19 at 10:45 A.M., the DM said: - The kitchen should be keep clean; - The measuring scoops should not be left in the food containers; - Food should be dated when opened; - The stove hood should be cleaned twice a week; - The glasses in the freezer should be covered; - The mop bucket should be in another room, not up against the clean dishes; - (MONTH) cleaning schedule was provided and filled out as completed. During an interview on 7/11/19 at 11:15 A.M. the Administrator said he knew the kitchen needed some cleaning and work done to it, however there was all new staff members and the DM had been in classes a few days a week off and on and was not there to help with the kitchen. Record review of the facility's Cleaning schedule policy, dated (MONTH) 2011, showed: - It is the responsibility of the Dietary Services Manager to enforce the cleaning schedule and to monitor the completion of the assigned cleaning tasks.

Based on interview and record review, the facility failed to recognize a significant change (a major decline or improvement in the resident's status) in status for three residents (Resident #27, #13, and #35) out of 12 sampled residents. The facility census was 47. 1. Record review of Resident #27's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by the staff, dated 11/16/18, showed: - Little interest or pleasure in doing things - symptom not present; - Behavior - No delusions; - Total dependence in bathing; - Pain effect on function to sleep at night- yes; - Pain intensity - very severe, horrible; - Does the resident have a condition or chronic disease that may result in a life expectancy of less than six months - Yes. Record review of the Quarterly MDS, dated [DATE], showed: - Little interest or pleasure in doing things - symptom present 7-11 days (half or more of the days); - Behavior - [MEDICAL CONDITION] of delusions (misconceptions or beliefs that are firmly held, contrary to reality); - Physical help in part of bathing activity; - Pain effect on function to sleep at night - no; - Pain intensity - moderate; - Does the resident have a condition or chronic disease that may result in a life expectancy of less than six months - No. A MDS significant change assessment should have been completed after 11/16/18, due to significant change in the resident's physical condition. 2. Record review of Resident #13's significant change MDS, dated [DATE], showed: - Walk in room activity occurred only once or twice; - Walk in room activity occurred with one person physical assist; - Total dependence in toilet use -full staff performance every time during entire 7 day period; - Toilet use - one person physical assist; - Balance during transitions and walking- moving on and off toilet - activity did not occur. Record review of the Quarterly MDS, dated [DATE], showed: - Walk in room activity did not occur; - Extensive assistance in toilet use - resident involved in activity, staff provide weight-bearing support; - Balance during transitions and walking - moving on and off toilet - not steady - only able to stabilize with staff assistance. A MDS significant change assessment should have been completed after 1/23/19, due to significant change in the resident's physical condition. 3. Record review of Resident #35's Quarterly MDS, dated [DATE], showed: - Extensive assistance with locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on the same floor); - Extensive assistance with locomotion off unit (how resident moves to and returns from off-unit locations); - Dressing (how the resident puts on, fastens and takes off all items of clothing) needs support on one person physical assist; - Urinary continence - always continent; - Weight loss - no or unknown. Record review of the Quarterly MDS, dated [DATE], showed: - Total dependence of full staff performance with locomotion on unit; - Total dependence of full staff performance with locomotion off the unit; - Dressing needs support on two plus person physical assist; - Urinary continence - occasionally incontinent; - Weight loss - yes, not on physician prescribed weight loss regimen. A MDS significant change assessment should have been completed after 3/13/19, due to significant change in the resident's physical condition. During an interview on 7/11/19 at 9:35 A.M., the MDS Coordinator said it only takes two changes to make a significant change MDS. He/she missed the significant change. During an interview on 7/11/19 at 10:50 A.M., the Director of Nursing (DON) said she would expect a significant change MDS to be completed when a resident had a significant change in two or more areas. Record review of the facility Change in Status policy, undated, showed: - A change in status is a change in two or more areas on the MDS; - It can be a decline or improvement; - It can be physical or mental.

Based on interview and record review, the facility failed to implement an individualized comprehensive care plan for one resident (Resident #13) at high risk for pressure sores (injury to skin and underlying tissue resulting from prolonged pressure on he skin) out of 12 sampled residents. The facility's census was 47. Record review of Resident #13's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by the staff, dated 1/23/19, showed: - Functional status for bed mobility, transfer, locomotion on and off unit, and personal hygiene requires extensive assistance of one person physical assist; - Functional limitation in range of motion for upper and lower extremity has impairment on one side; - Determination of Pressure ulcer risk by formal assessment instrument/tool (Braden scale) and clinical assessment; - At high risk for pressure ulcers. Record review of the Braden scale (for predicting pressure sore risk), dated 5/09/19, showed; - Sensory perception is slightly limited (responds to verbal commands, but cannot always communicate discomfort or the need to be turned or has some sensory impairment which limits ability to feel pain or discomfort in on or two extremities); - Degree to which skin is exposed to moisture - very moist (skin is often, but not always moist. Linen must be changed at least once a shift; - Degree of physical activity - chairfast (ability to walk severely limited or non-existent. Cannot bear own weight and /or must be assisted into chair or wheelchair); - Mobility - very limited ( makes occasional slight changes in body or extremity position but unable to make frequent of significant changes independently); - Nutrition - very poor (Never eats a complete meal - Rarely eats more that all of any food offered. Eats two servings or less of protein per day. Takes fluids poorly); - Friction and Shear - problem (requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance); - Scoring 11 (high risk 10-12). Record review of the Physical Therapy Screening form, dated 4/24/19, showed: - Patient exhibits the following problems: muscle weakness and joint limitations/contractors; - Patient refuses to participate in any therapy. Record review of the Progress Notes, showed: - On 7/08/19 at 2:29 A.M., cleanse buttocks with soap and water, pat dry thoroughly, apply med-line phytoples protectant Z-Guard (skin protectant) paste to the buttocks and peri-area after each incontinent episode every shift. - On 7/08/19 at 11:31 A.M., cleanse buttocks with soap and water, pat dry thoroughly, apply med-line phytoples protectant Z-Guard (skin protectant) paste to the buttocks and peri-area after each incontinent episode every shift. Resident has scratches to pelvic area redness increases with one episode of incontinence; - On 7/09/19 at 5:17 A.M., cleanse buttocks with soap and water, pat dry thoroughly, apply med-line phytoples protectant Z-Guard (skin protectant) paste to the buttocks and peri-area after each incontinent episode every shift. Redness and excoriation resolved. - On 7/09/19 at 12:36 P.M., skin has slight redness noted to buttocks with some scabbed over areas where resident has scratched self. - On 7/10/19 at 2:49 A.M., buttocks and peri-area are slightly red. Record review of the Care Plan, dated 2/04/19, showed: -Diagnoses: [REDACTED]. - Right sided paralysis; - Monitor for complication related to skin breakdown; - Staff will assist with turning and repositioning in bed. The facility failed to have a comprehensive care plan for a high risk resident for skin breakdown. During an interview on 7/11/19 at 10:55 A.M., the Director of Nursing (DON) and MDS Coordinator said they would expect a resident at high risk for pressure sores to have a care plan to reflect the care which is required. Record review of the Care Plans, Comprehensive Person - Centered policy, revised (MONTH) (YEAR), showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - Describe the services that ate to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; - Incorporate identified problem areas; - Incorporate risk factors associated with identified problems; - Reflect treatment goals, time tables and objectives in measurable outcomes; - Aid in preventing or reducing decline in the resident's functional status and /or functional levels; - Reflect currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review the facility failed to do a periodic, accurate reconciliation and account of all controlled medications. The facility census was 47. Record review of the Controlled Substances policy, revised (MONTH) 2012, showed: -The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. - Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. - The Director of Nursing Services will identify staff members who are authorized to handle controlled substances. - Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. Observation and record review of the medication storage room on 7/10/19 at 6:50 A.M., showed the narcotic count verification sheet between the out-going nurse and the on-coming nurse did not sign off: - From 5/21/19 - 5/31/19 out of 33 opportunities staff failed to sign off-going signature 12 times; - From 5/21/19 - 5/31/19 out of 33 opportunities staff failed to sign on-coming signature 8 times; - From 6/01/19 - 6/30/19 out of 93 opportunities staff failed to sign off-going signature 16 times; - From 6/01/19 - 6/30/19 out of 93 opportunities staff failed to sign on-coming signature 17 times; - From 7/01/19 - 7/09/19 out of 46 opportunities staff failed to sign off-going signature 11 times; - From 7/01/19 - 7/09/19 out of 46 opportunities staff failed to sign on-coming signature 9 times. During an interview on 7/10/10 at 6:55 A.M., Registered Nurse A said the narcotic count verification sheet should be signed by the off-going and on-coming nurse on every shift. During an interview on 7/11/19 at 10:45 A.M., the Director of Nursing (DON) said she did not know why the narcotic count verification sheet did not have all the nurses' signatures, because all the off-going and on-coming nurses that counted the narcotic should be signing the verification sheet.

Based on observation, interview and record review the facility staff failed to ensure two multi-dose vials that had been opened and accessed (e.g., needle-punctured), had been dated and discarded. The facility census was 47. During an observation on 7/10/19 at 6:10 A.M., showed two multi-dose vials open and undated of [MEDICATION NAME] ([MEDICATION NAME] PPD, diluted) (a sterile [MEDICATION NAME] solution of a purified protein fraction for intradermal administrations an aid in the [DIAGNOSES REDACTED]. During an interview on 7/10/19 at 6:55 A.M., Registered Nurse A said all open multi-dose vials should have the date that it was open and did not know why they were not dated. During an interview on 7/11/19 at 10:45 A.M., the Director of Nursing (DON) said the multi-vials of [MEDICATION NAME] should have been dated by the nurse when it was opened. During an interview on 7/11/19 at 11:00 A.M., the DON said the vials of [MEDICATION NAME] had been discarded due to not knowing when it had been opened. Record review of www.fda.gov showed [MEDICATION NAME] vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Record review of the Storage of Medications policy, revised (MONTH) 2007, showed: - The facility shall store all drugs and biological's in a safe, secure, and orderly manner; - The facility shall not use discontinued, outdated, or deteriorated drugs or biological's, all such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to label and store drugs in accordance with accepted professional standards of practice. This had the potential to affect all residents who resided in the facility. The facility's census was 47. Record review of the facility's policy titled, Medication-Controlled Substances, dated 12/2012, showed drugs listed in Schedules II, III and IV (drugs with potential of abuse and dependence) are to be stored under double-lock conditions. Observation on 9/26/18 at 9:15 A.M. of the medication storage room showed the Director of Nursing (DON) and Licensed Practical Nurse (LPN) A inspected the medication refrigerator. The narcotic storage box in the refrigerator sat on a shelf, unsecured without the lock in place. The storage box contained two boxes of liquid [MEDICATION NAME] (anti-anxiety medication and a Schedule IV drug) 2 milligram/milliliter vials for Resident #41. During an interview on 9/26/18 at 9:15 A.M., LPN A said the narcotic storage box should be locked. During an interview on 9/28/18 at 9:50 A.M., the DON said she would expect the narcotic medication to be double locked in the storage room.

Based on interview and record review, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) when benefits were not exhausted and the resident remained in the facility for one resident (Resident #26) out of three sampled residents. The facility's census was 47. Record review of the facility's undated policy titled, Skilled Nursing Facility (SNF) Beneficiary Protection Notification, showed the facility will use the NOMNC CMS Form when a resident has skilled benefit days remaining, is being discharged from Medicare Part A services, and will continue to live in the facility. Record review showed: - Medicare Part A skilled services start date of 6/18/18 and end date of 8/27/18; - The facility initiated a discharge on 8/23/18 from Medicare Part A Services when benefit days were not exhausted; -There was no NOMNC form issued. During an interview on 9/27/18 at 10:30 A.M., the Social Services Director (SSD) said he/she wasn't aware that the CMS NOMNC Form was supposed to be given when a resident's benefits have not exhausted and he/she remains in the facility. He/she will issue the correct forms at the appropriate times in the future. During an interview on 9/28/18 at 9:50 A.M., the Director of Nursing (DON) said she isn't really up on when the forms should be given

Based on interview and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS) (a federally mandated assessment to be completed by the facility), for one resident (Resident #9) out of 14 sampled residents. The facility's census was 47. Record review of the facility's policy titled, Certifying Accuracy of the Resident Assessment, dated (MONTH) 2009, showed all personnel who complete any portion of the MDS must sign and certify the accuracy of that portion of the assessment. Record review of the facility's policy titled, Resident Assessment Instrument, dated (MONTH) 2010, showed the purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. Record review of Resident #9's Care Plan showed the resident fell in the dining room on 3/16/18. Record review of the resident's MDS, dated [DATE], section J1800 showed no falls since last review dated 1/10/18. During an interview on 9/27/18 at 4:05 P.M., the Director of Nursing (DON) and MDS Coordinator said the resident's fall should have been noted in section J1800 of the MDS dated [DATE].

Based on interview and record review, the facility failed to implement an individualized comprehensive care plan for one resident (Resident #39) out of 14 sampled residents. The facility's census was 47. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated (MONTH) (YEAR), showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Record review of Resident #39's (MONTH) (YEAR) physician's orders [REDACTED]. - [DIAGNOSES REDACTED]. - an order written [REDACTED]. Record review of the resident's Nurses Notes showed: - [MEDICAL CONDITION] episode on 03/07/18; - [MEDICAL CONDITION] episodes twice on 05/04/18. Record review of the resident's care plan, dated 09/13/18, showed: - [MEDICAL CONDITION] not addressed in the care plan; - Levetiracetam not addressed in the care plan. During an interview on 09/28/18 at 09:38 A.M., the Minimum Data Set (MDS) (a federally mandated assessment to be completed by the facility), Coordinator said the resident takes Levetiracetam for [MEDICAL CONDITION]. He/she stated the [DIAGNOSES REDACTED]. During an interview on 09/28/18 at 09:50 A.M., the Director of Nursing (DON) said the resident takes Levetiracetam for [MEDICAL CONDITION] and she would expect the resident to have a care plan for the medication and [MEDICAL CONDITION].