Every finding on record at Brookridge Retirement Community

Based on observation, record review, and interviews with staff, resident, and the Physician the facility failed to change the dressing for the peripherally inserted central catheter (PICC) for intravenous antibiotic administration according to the order. This deficient practice affected 1 of 3 residents reviewed for intravenous access devices (Resident #63). The findings included: Resident #63's hospital Discharge summary dated [DATE] documented she had a PICC line placed on 7/14/25 into her right antecubital space (front of the elbow) and a clear dressing was placed. The resident was receiving antibiotics for endocarditis (infection of the heart tissue) and sepsis (infection of the blood) through the PICC line. Resident #63 was receiving Ceftriaxone (antibiotic) 2 grams every 12 hours intravenously to continue at the facility. There was no mention of the PICC line dressing change in the hospital discharge summary. Resident #63 was admitted to the facility on [DATE] with diagnoses including septicemia (infection of the blood) and endocarditis. Resident #63's admission nursing note dated 7/16/25 documented she was admitted from the hospital with a PICC line in the right arm. The resident was alert and oriented and able to make her needs known. The care plan for Resident #63 dated 7/16/25 included she was at risk for infection related to peripheral intravenous access. The intervention included monitoring the catheter site for any signs or symptoms of infection. Resident #63's PICC line dressing change order was initiated on 7/21/25 by Nurse #1. The order specified that the PICC line dressing change was to be changed each week on Sunday using aseptic technique. A review of Resident #63's July 2025 Medication Administration Record documented Nurse #1 signed her initials for the PICC line dressing change completion on 7/27/25. On 7/31/25 at 3:00 pm an interview was conducted with Nurse #1. Nurse #1 stated she input the PICC line management order on 7/21/25 for Resident #63 to have the dressing on the PICC line changed once a week on Sunday. The resident was admitted on [DATE] from the hospital with the PICC line in place and a clear dressing dated 7/14/25. Nurse #1 stated she signed for completion of the dressing change on Sunday 7/27/25 in error. The shift was very busy on 7/27/25 and the electronic medical record had been updated which caused problems and error. After the date calendar was reviewed, Nurse #1 stated when she input the PICC line order it was Monday (7/21/25) and the day before Sunday was a missed opportunity to change the dressing within a week from 7/14/25 because the order was not started on admission. On 7/28/25 at 11:10 am an observation and interview were completed with Resident #63. The resident was able to state why she had a PICC line and her antibiotic treatment. The PICC line was observed in the right antecubital space and had an intact clear dressing that was dated 7/14/25. The resident stated the site was without pain and the observation revealed no signs and symptoms of infection. The resident stated the PICC line and dressing was placed at the hospital and the dressing had not been changed at the nursing home. On 7/29/25 at 10:45 am an observation of Resident #63's PICC line was completed with the Administrator. The PICC line had a clear dressing and was dated 7/14/25 and appeared the same as the day before. The Administrator was interviewed on 7/29/25 at 10:50 am. The Administrator stated nursing should have changed the dressing. It was dated 7/14/25 and was required to be changed every week. On 7/30/25 at 11:10 am the Physician was interviewed and informed that Resident #63's PICC line dressing was the original dressing from the hospital dated 7/14/25 when it was placed and the dressing change due on 7/27/25 at the facility was missed. The physician stated it takes a village in response.

Based on observations and dietary staff interviews, the facility failed to ensure facial hair was covered during food preparation. This practice had the potential for cross-contamination of food served to residents. Findings included: During the initial tour of the kitchen on 5/6/24 at 10:00 a.m., the dietary staff were observed cleaning after the breakfast meal service and preparing food for the lunch meal. There were four dietary staff members preparing food in the preparation areas with exposed facial hair (ranging from approximately 1/2 inch to 3 inches in length). On 5/9/24 at 11:33 a.m. during the meal tray line service in the kitchen, seven dietary staff were observed with exposed/uncovered facial hair ranging from 1/2 inch to 3 inches in length. During this observation the staff were noted to perform various food service tasks including meal production and service without hair coverings over their facial hair. Three of these staff members were identified as the cook, Executive Chef, and the Kitchen Manager. During an interview on 5/9/24 at 11:40 a.m., the Executive Chef and the Kitchen Manager acknowledged the male dietary staff were required to cover all hair while in the food preparation areas of the kitchen. the Executive Chef and the Kitchen Manager supplied each of the male dietary staff with chin guards. The dietary staff were observed donning the chin guards.

Based on observations and dietary staff interviews, the facility failed to ensure waste was contained in 1 of 1 trash compactor and had no opened areas with exposed trash, debris, and accessibility to animals. These practices had the potential to affect all residents. Findings included: On 5/6/24 at 10:54 a.m., during the observation of the facility's trash compactor accompanied by the Executive Chef and the Clinical Nutritionist, the opened chute area of the compactor consisted of multiple large white bags of trash and a live opossum. The Executive Chef immediately notified the Maintenance Director to remove the opossum. A follow-up observation of the trash compactor was conducted with the Executive Chef, Kitchen Manager, and the Clinical Nutritionist on 5/9/24 at 11:54 a.m. There were multiple large bags of trash observed in the opened chute area of the compactor. During an interview on 5/9/24 at 11:57 a.m., the Executive Chef stated the trash compactor's provider emptied the compactor two times each month. He also stated he routinely checked the trash compactor twice each day (upon his arrival in the morning and at 4:00 p.m.). He revealed the dietary department only used black colored trash bags and the white/clear bags in the compactor were the type used by the facility's housekeeping department.

Based on observations, staff interviews and record review, the facility failed to provide intervention for fall prevention for 1 of 4 residents (Resident #14) reviewed for falls. Findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses that included, in part, dementia, osteoporosis and repeated falls. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had severe cognitive impairment. She required extensive assistance with transfers and bed mobility. She was coded on the MDS as having one fall with no injury. The care plan, updated 11/24/22, included a focus area of risk for falls. A care plan intervention stated, Fall mats next to bedside while in bed. The monthly physician orders for January 2023 were reviewed and included an order to ensure floor mat is in place by bedside when resident is in bed. A nurse's note dated 11/23/22 and authored by Nurse #2 read, in part, Resident's behavior restless. Attempting to get out of bed. Bed lowered as low as it can go. Mats on either side of bed . On 1/23/23 at 10:10 AM, Resident #14 was observed in bed. The bed was in the low position. A fall mat was observed on the floor to the right of the bed. There was no fall mat on the left side of the bed; however, a fall mat was leaned up against the dresser. Nurse #1 was interviewed on 1/24/23 at 1:49 PM. She reported Resident #14 needed one person to assist her when she got out of bed. She acknowledged the resident was unable to use her call light due to confusion and was at risk for falls. She said fall prevention interventions used for Resident #14 included the use of a low bed and staff placed two floor mats on either side of the bed when the resident was in bed. During an observation on 1/24/23 at 1:53 PM, Resident #14 was asleep in bed. A fall mat was on the floor to the right of the resident's bed. There was no fall mat on the floor to the left of the resident's bed. A second fall mat was leaned up against the clothes closet. Interviews were completed with Nurse Aide (NA) #1 on 1/25/23 at 2:15 PM and 1/26/23 at 10:53 AM. She shared Resident #14 required assistance with transfers. NA #1 said the resident had at times tried to get up unassisted and fell . She explained fall prevention interventions included a fall mat on both sides of the bed, frequent rounds by staff and the bed placed in the low position. NA #1 verified she worked with Resident #14 on 1/23/23 during the day. When asked why there was only one fall mat observed on the floor next to the resident's bed, NA #1 said she forgot to put the second mat down after she fed the resident breakfast. An attempt to interview NA #2 (who worked with Resident #14 on 1/24/23) was unsuccessful. The Director of Nursing was interviewed on 1/25/23 at 9:37 AM and 1/26/23 at 1:23 PM. She stated Resident #14 was at risk for falls and had a history of attempting to get out of bed unassisted. She shared fall prevention interventions included fall mats at bedside times two, frequent rounding and positioning checks. She added when a new fall prevention intervention was added, the staff were educated and she expected the fall mats be placed down on both sides of the bed when Resident #14 was in the bed and when staff finished providing care.

Based on observations, staff interviews and record review, the facility failed to 1) follow the care plan to place floor mats next to the bedside for fall prevention for 1 of 4 residents (Resident #14) reviewed for falls, and 2) failed to implement a care plan for ileostomy care for 1 of 1 resident (Resident #10) reviewed for ileostomy bowel care. Findings included: 1) Resident #14 was admitted to the facility on [DATE] with diagnoses that included, in part, dementia, osteoporosis and repeated falls. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had severe cognitive impairment. She required extensive assistance with transfers and bed mobility. She was coded on the MDS as having one fall with no injury. The care plan, updated 11/24/22, included a focus area of risk for falls. A care plan intervention stated, Fall mats next to bedside while in bed. On 1/23/23 at 10:10 AM, Resident #14 was observed in bed. The bed was in the low position. A fall mat was observed on the floor to the right of the bed. There was no fall mat on the left side of the bed; however, a fall mat was leaned up against the dresser. Nurse #1 was interviewed on 1/24/23 at 1:49 PM. She reported Resident #14 needed one person to assist her when she got out of bed. She acknowledged the resident was unable to use her call light due to confusion and was at risk for falls. She said fall prevention interventions used for Resident #14 included the use of a low bed and staff placed two floor mats on either side of the bed when the resident was in bed. During an observation on 1/24/23 at 1:53 PM, Resident #14 was asleep in bed. A fall mat was on the floor to the right of the resident's bed. There was no fall mat on the floor to the left of the resident's bed. A second fall mat was leaned up against the clothes closet. Interviews were completed with Nurse Aide (NA) #1 on 1/25/23 at 2:15 PM and 1/26/23 at 10:53 AM. She shared Resident #14 required assistance with transfers. NA #1 said the resident had at times tried to get up unassisted and fell . She specified staff looked on the computer and accessed the care plan which revealed to them what fall prevention interventions were to be used when staff cared for a resident. She explained current fall prevention interventions for Resident #14 included a fall mat on both sides of the bed, frequent rounds by staff and the bed placed in the low position. NA #1 verified she worked with Resident #14 on 1/23/23 during the day. When asked why there was only one fall mat observed on the floor next to the resident's bed, NA #1 said she forgot to put the second mat down after she fed the resident breakfast. An attempt to interview NA #2 (who worked with Resident #14 on 1/24/23) was unsuccessful. The Director of Nursing was interviewed on 1/25/23 at 9:37 AM and 1/26/23 at 1:23 PM. She stated Resident #14 was at risk for falls and had a history of attempting to get out of bed unassisted. She shared fall prevention interventions included fall mats at bedside times two, frequent rounding and positioning checks. She added when a new fall prevention intervention was added, the staff were educated to review the care plan and point of care charting system on their tablets and she expected staff to adhere to the interventions listed on the care plan. 42900 2) Resident #10 was admitted to the facility on [DATE] with diagnoses that included a functional intestinal disorder with ileostomy. A review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #10 was cognitively intact and always incontinent of bowel and bladder. The diagnoses section identified the Resident had an ileostomy. A review of the most recent care plan dated 11/14/2022 did not include a care plan focused area for ileostomy care. An observation was conducted on 1/24/2023 at 9:28 a.m. of Resident #10 and she had a bowel elimination bag attached to her abdomen with a red moist stoma (an artificial opening made into a hollow organ, especially one on the surface of the body leading to the gut or trachea). The elimination bag had a small amount of brown stool. There were no lingering odors. An interview was conducted with Resident #10 on 1/24/2023 at 9:28 a.m. and she stated staff assist her with changing of the ileostomy bag and emptying the bag. She revealed some staff had been hesitant or did not assist quickly, as if they were not aware she had the bag or did not know how to provide the care. She added they always return with someone to assist them. An interview was conducted with the MDS Nurse Coordinator on 1/26/2023 at 12:28 p.m. and revealed she was responsible for updating the care plan for a resident. She reviewed the most recent MDS for Resident #10 and the diagnoses list. She then reviewed the most recent care plan dated 11/14/2022 and reported she did not see a focused area for ileostomy/bowel elimination. She added this was a care area that she would place on the care plan and would be added immediately. An interview was conducted with the Administrator on 1/26/2022 at 12:42 p.m. and she revealed she expected a resident to have a care plan focused area for any diagnoses that required specialized care such as an ileostomy.

Based on record review and staff interview, the facility failed to complete a discharge tracking Minimum Data Set (MDS) assessment for 3 of 6 residents (Resident #35, #16, and #36) reviewed for closed records. Findings included: 1. Resident #35 was admitted to the facility on [DATE] to a skilled bed and a comprehensive MDS was completed on 9/6/22. The medical record revealed that Resident #35 was discharged to the assisted living section within the facility on 9/20/22 and a discharge MDS was not done. On 1/26/23 at 2:41 PM an interview was completed with MDS Coordinator had been in that position since December 2022. She stated she the discharge MDS assessment should have been completed by the 14th day after discharge. She added that it was the responsibility of the MDS Coordinator to make sure those assessments completed and should have been done by the previous coordinator. 2. Resident #16 was admitted to the facility on [DATE] and a comprehensive MDS was completed on 9/13/22. The medical record revealed that Resident #16 passed away in the facility on 11/10/22 and a discharge MDS was not done. On 1/26/23 at 2:41 PM an interview was completed with MDS Coordinator had been in that position since December 2022. She stated she the discharge MDS assessment should have been completed by the 14th day after discharge. She added that it was the responsibility of the MDS Coordinator to make sure those assessments completed and should have been done by the previous coordinator. 3. Resident #36 was admitted to the facility on [DATE] and a comprehensive MDS was completed on 8/5/22. The medical record revealed that Resident #36 was discharged to an out-of-state assisted living facility on 10/19/22. No discharge MDS was done. On 1/26/23 at 2:41 PM an interview was completed with MDS Coordinator had been in that position since December 2022. She stated she the discharge MDS assessment should have been completed by the 14th day after discharge. She added that it was the responsibility of the MDS Coordinator to make sure those assessments completed and should have been done by the previous coordinator.

Based on record review and nurse practitioner interview, the facility failed to maintain an accurate medical record regarding code status for 1 of 13 residents reviewed for advanced directives (Resident #20). The findings included: Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The electronic health record included a portable DNR dated 3/18/21. A progress note dated 3/22/21 by the Nurse Practitioner #1 read, visit for evaluation of new patient. Code status: full code. Discussed with patient 3/22/21 and she wants all measures of resuscitation. A progress note dated 6/8/21 by Nurse Practitioner #2 read, seen for emergency room visit. Active advanced directive MOST (medical orders for scope of treatment) form updated on 5/27/21. Patient is a DNR with limited interventions. A progress note dated 6/21/21 by Nurse Practitioner #1 read, Code status: full code. Discussed with patient 3/22/21 and she wants all measures of resuscitation. A progress note dated 7/14/21 by Nurse Practitioner #1 read, Code status: full code. Discussed with patient 3/22/21 and she wants all measures of resuscitation. An interview was conducted on 8/4/21 at 3:09 PM with Nurse Practitioner #1. She stated Resident #20 went out to the hospital and she had not updated her note.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of transfer status, medications and active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: 1. Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's progress note dated 6/8/21 by the physician revealed Resident #27 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had severely impaired cognition. For transfer assistance, the MDS was coded as totally dependent with assistance of 1 person. [CONDITION(S)] was not added to Resident #27's active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note dated 7/19/21 at 9:10 AM revealed Resident #27 was non-ambulatory and required 2 person assist via a mechanical lift for transfers. A nurse's note dated 7/29/21 at 2:26 AM revealed Resident #27 required 2-person assistance for transfers. An interview was conducted with NA #1 on 8/3/21 at 11:30 AM. She stated Resident #27 used a mechanical lift and 2- person assistance for transfers. On 8/5/21 at 10:30 AM, the MDS nurse was interviewed. She stated she was new to her role and received a lot of training. She added one of the things she learned was about medications and she had a list that indicated [MEDICATION(S)] was to be coded as a hypnotic on the MDS. She further stated [CONDITION(S)] should have been added as a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #33 was admitted to the facility on [DATE] from the hospital. A discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was discharged to the hospital. A nurse's note dated 7/18/21 at 2:24 PM revealed Resident #33 was transferred back to his independent living apartment. On 8/3/21 at 3:05 PM, the Admissions Director was interviewed. She stated Resident #33 was admitted following a procedure on 6/15/21 and went back to his living apartment on 7/18/21. On 8/5/21 at 10:30 AM, the MDS nurse was interviewed. She stated Resident #33 was discharged back to independent living and the MDS was coded incorrectly.

Based on observation, record review, and resident and staff interviews, the facility failed to assess the ability of a resident to self-administer medications that were left at bedside for 1 of 5 residents reviewed for unnecessary medications (Resident #24). The findings included: Resident #24 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set assessment dated [DATE] revealed Resident #24 was cognitively intact. On 8/2/21 at 2:51 PM, a bottle of roll-on aspercreme with [MEDICATION(S)] was observed on the bedside table. During an interview with Resident #24 on 8/2/21 at 2:51 PM, she stated she used the roll-on aspercreme for her back and sometimes her knees. On 8/2/21 at 4:13 PM, Nurse #1 was interviewed. She stated Resident #24 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #1 added she did not know if the medication should be left on the bedside table and that Resident #24 ' s family member may have brought the medication in. A comprehensive medical record review conducted on 8/2/21 did not include an order an assessment to self-administer medications was completed on Resident #24. On 8/5/21 at 11:00 AM, the Administrator was interviewed. She stated she was not aware Resident #24 had medications at the bedside but thought her family member may have brought them in.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Managing Infections, the facility failed to implement their infection control procedures for personal protective equipment (PPE) when a housekeeper failed to don a gown prior to entering a resident's room who was on enhanced droplet-contact precautions for 1 of 3 staff observed working on the facility's new admission unit (Housekeeper #1). This failure occurred during a COVID-19 pandemic. Findings included: The facility's policy titled, Managing Infections, updated 1/2021, was reviewed. The policy stated, in part, .For residents who are tested prior to hospital discharge and are COVID-19 negative, admit and cohort with other residents of similar status if possible .All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves and gown . Resident #1 was admitted to the facility on [DATE] from the hospital. COVID-19 tests performed on 1/4/21 and 1/11/21 revealed Resident #1 was negative for [MEDICAL CONDITION]. A continuous observation of Resident #1's room (on the new admission unit) was completed on 1/12/21 from 10:15 AM-10:20 AM. An enhanced droplet-contact isolation sign was posted on the door, along with a bin that contained PPE (gowns and gloves). The enhanced droplet-contact isolation sign had the following instructions: Perform hand hygiene, N95 (may use KN95), eye protection, gown when entering room, gloves when entering room. Housekeeper #1 approached the room and wore a facemask, gloves and eye protection. She entered the room with a bottle of cleaning solution and closed the door. She did not put on a gown before she entered the room. Resident #1 was observed in the room prior to when the housekeeper closed the door. Housekeeper #1 exited the room at 10:18 AM. Housekeeper #1 was interviewed on 1/12/21 at 10:18 AM. She confirmed she had not worn a gown when she entered Resident #1's room. She said the facility had educated her that full PPE (gown, gloves, eye protection and facemask) was to be worn when she entered the room of a resident on enhanced droplet-contact precautions. Housekeeper #1 explained she hadn't worn a gown in the room since the resident was COVID-19 negative and had returned from the hospital. She acknowledged she should have donned a gown before she entered the room. At the conclusion of the interview, Housekeeper #1 re-entered Resident #1's room without a gown. On 1/12/21 at 10:25 AM, Nurse #1 was interviewed. She was the nurse on the new admission unit. She reported Resident #1 was negative for COVID-19 and was on observation for 14 days since she returned from the hospital. She said all new admissions or re-admissions to the facility were placed on enhanced droplet-contact precautions for 14 days and all staff were required to don full PPE before they entered a room of a resident on precautions. She added Housekeeper #1 should have donned a gown before she entered Resident #1's room. An interview was completed with the Administrator and Director of Nursing (DON) on 1/12/21 at 2:01 PM. The Administrator explained the enhanced droplet-contact precautions signs on room doors informed staff what PPE needed to be worn prior to entering a resident's room. She indicated all staff were to follow the instructions, not just the nursing staff. She stated staff had been provided education about specific PPE that was worn in resident rooms who were on enhanced droplet-contact precautions. She added Housekeeper #1 had previously worked on a COVID-19 unit with enhanced droplet-contact precautions and had worn full PPE. The DON stated Housekeeper #1 should have put on a gown before she entered Resident #1's room.

Based on observations, staff interviews and review of the facility's COVID-19 Infection Control Assessment and Response Tool, the facility failed to implement infection control procedures for wearing face masks when 2 of 2 facility staff failed to wear a facemask or face covering that covered their nose and/or mouth when they worked inside the facility. This failure occurred during a COVID-19 pandemic. Findings included: A review of the COVID-19 Long-Term Care Infection Control Assessment and Response Tool dated 5/2020, that was utilized by the facility specified there would be universal face mask use by all staff. 1. Observations on 5/28/20 at 10:45 am of the facility's front entrance revealed the front door receptionist, was not wearing a mask, while seated at a desk with other staff members nearby. On 5/28/20 at 11:02 am the receptionist was observed at the front desk wearing her mask, but it was not covering her nose. There were several staff members walking out of a room behind her. No residents were nearby. Interview with the receptionist on 05/28/20 at 11:02 am revealed that all staff checked in at the front desk when they came to work in the morning. She stated that she was responsible for taking their temperatures when they entered the facility and stopping any visitors that may try to enter the facility during this pandemic. During an interview with the Administrator on 5/28/20 at 12:02 pm, she explained she was fully aware of the CMS COVID-19 guidelines and the facility was using the COVID-19 Long-Term Infection Control Assessment and Response Tool for policy during the pandemic. She stated that the staff had three in-services discussing the need to wear a mask at all times while in the facility. She stated that, the receptionist, was a part of each in-service and had been trained on the need to wear a mask while in the facility at all times and the proper application of the mask. 2. Observations on 5/28/20 at 11:34 am, revealed Staff member #2, was wearing a mask that was positioned underneath her chin. Staff member #2, who did not have her mouth or nose covered, was observed to deliver meal trays to residents who were in rooms; #618, #620 and #622. She then proceeded to deliver meal trays to residents who were in four more rooms; #606, #608, #610, and #612 with her mouth and nose uncovered. Interview with Staff member #2 on 5/28/20 at 11:45 am revealed that she was just helping out to deliver resident meal trays and that she usually worked in the beauty salon and activities. During an interview with the Administrator on 5/28/20 at 12:02 pm, she explained she was fully aware of the CMS COVID-19 guidelines and the facility was using the COVID-19 Long-Term Infection Control Assessment and Response Tool for policy during the pandemic. She stated that the staff had three in-services discussing the need to wear a mask at all times while in the facility. She stated that Staff member #2, worked in the beauty salon and activities department. She explained that Staff member #2 helped pass lunch meal trays to residents and had been trained on the need to wear a mask at all times while in the facility. The administrator, again, stated that she expected all staff to be wearing facemasks correctly while in the facility.

Based on observations and staff interviews the facility failed to remove expired medications and blood glucose test strips, date and label multi-dose eye ointment when opened, and ensure there were no loose pills in medication/treatment cart for one of one medication/treatment carts and one of one medication rooms observed. The findings included: Observations on 7/11/19 at 10:20 AM of the medication/treatment cart used for 600 Hall residents revealed the following expired medications: [REDACTED]. In the top drawer of the cart, there was a loose white oblong pill, and an opened multi-use [MEDICATION NAME] PM eye ointment tube that was not labeled or dated. Observations of the medication room for 600 Hall residents at 7/11/19 at 10:32 AM revealed 15 expired Triple Antibiotic Ointment Packets (0.9g weight), and 1 - [MEDICATION NAME] Zinc Ointment Packet (Expired 5/2017). During an interview with the Treatment Nurse on 7/11/19 at 10:25 AM she stated that third shift nursing staff was responsible for checking carts and the medication room for expired medications and supplies. During an interview with the Administrator on 7/11/19 at 11:20 AM, she stated that it was her expectation that there were no expired medications or supplies in the carts or medication rooms. She stated that a pharmacy company was hired to audit medication storage and had been signing off weekly for the last few weeks that they were checked for expired medications and supplies. She stated that in between those audits, it was her expectation that third shift employees were auditing the carts and medication rooms.

Based on observations, resident and staff interviews and record review, the facility failed to update the care plan with appropriate interventions in the area of fall prevention for 3 of 4 residents (Resident #15, Resident #19 and Resident #17) reviewed for accidents. Findings included: 1. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident had severe cognitive impairment. She required one person limited assistance for transfers and walking. Further review of the MDS revealed Resident #15 had one fall with injury in the look back period of the assessment. A review of the current care plan revealed a problem of, At risk for falls related to poor safety awareness and dementia, and a stated goal of, Will not experience any major fall related injuries. Care plan approaches included, Observe for unsteady/unsafe transfers or ambulation and provide stand-by or balance support as needed, monitor resident for signs of fatigue during ambulation, observe cognitive deficits and accommodate forgetfulness regarding safety devices and environmental risks. A care plan approach updated 10/25/18 revealed, Education provided to staff and spouse on signs and symptoms of agitation and how to handle certain behaviors, and to be alert while resident is awake to avoid falls and/or injuries. On 7/8/19 at 2:03 PM an observation of Resident #15 revealed she was in her bed resting. Fall prevention floor mats were placed on either side of the bed. An interview with Resident #15's family member revealed the resident fell a couple of months ago and fractured her wrist but the family member was unable to recall the circumstances that surrounded the fall. A review of an incident report dated 5/1/19 revealed, Certified Nursing Assistant (CNA) reported to this writer that she was walking this resident down the hall and this resident pulled away from her, lost her balance and fell . CNA stated this resident hit the back of her head on the hall banister. This writer assessed this resident. No raised areas found at this time. Has a small skin tear just below the left elbow. Cleansed with normal saline, applied anti-biotic ointment, and covered with bandaid. Notified responsible party. In doctor communication book. Staff to do frequent checks. Will continue to monitor. Further review of the care plan revealed no additional fall prevention interventions were added to the care plan after Resident #15 fell on [DATE]. On 7/11/19 at 1:09 PM an interview was completed with Nurse Aide (NA) #1. She witnessed Resident #15's fall on 5/1/19. NA #1 said she walked with Resident #15 in the hallway and when the resident tried to go into another resident's room NA #1 attempted to redirect Resident #15 who then pulled away from NA #1 and fell . NA #1 said she could not remember if Resident #15 fell into the wall, door or on the floor but recalled the resident used her arm to break the fall. NA #1 reported she immediately notified the nurse after Resident #15 fell . On 7/10/19 at 1:51 PM an interview was completed with Nurse #1. She said Resident #15 typically walked around the unit with a steady gait most days but had times when she became unbalanced and required supervision. Nurse #1 stated when she arrived for her shift the day after Resident #15 fell she assessed the resident's wrist as swollen, notified the physician and obtained an x-ray. Nurse #1 said the x-ray revealed a fractured wrist. Resident #15 was scheduled for treatment of [REDACTED]. On 7/10/19 at 8:22 AM an interview was completed with the Director of Nursing (DON). She stated whenever a resident fell , an investigation of the fall was completed at the time of the incident. She said the interdisciplinary team met daily and discussed falls from the previous day and fall prevention interventions were added to the resident's care plan within 24 hours of a fall. On 7/10/19 at 11:30 AM an interview was completed with the Administrator. She said when a resident fell the care plan was updated within 24-48 hours by the MDS nurse, nurse supervisor or DON. On 7/10/19 at 3:29 PM a follow up interview was completed with the DON. She said the facility had several different MDS nurses in the past eight months and the current MDS nurse had been in her role for only a few weeks. The DON stated Resident #15's care plan should have been updated after the fall on 5/1/19. She acknowledged care plans had been an issue the facility had identified in their Quality Assessment and Performance Improvement process. 2. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident was cognitively intact. She required one person limited assistance for transfers and used a wheelchair. Further review of the MDS revealed Resident #19 had two or more falls with no injury in the look back period of the assessment. A review of the current care plan revealed a problem of, At risk for falls related to history of falls, and a stated goal of, Will not have any major fall related injuries. A care plan approach updated 7/31/18 revealed, Staff to remind resident to not bend over while sitting in the wheelchair, to call for assistance to retrieve dropped items. A care plan approach updated 8/12/18 revealed, .Items that are most often used will be kept within resident's reach. The care plan was last updated on 3/23/19 with an approach that stated, Reminded and re-educated resident to always call for assistance prior to transferring or standing. On 7/8/19 at 3:47 PM an interview was completed with Resident #19. She reported she fell a couple of weeks ago when she attempted to pick something up off the floor while she sat in her wheelchair. A review of an incident report dated 6/26/19 revealed, Certified Nursing Assistant (CNA) answered resident's call light and located resident sitting upright in the floor in front of her wheelchair. 'I was bending over trying to pick a book up off the floor.' Staff action at time of incident: Head to toe assessment administered. Large raised area to the left side of resident's forehead noted. Resident refuses to go to the hospital. Neuro checks initiated. Resident reminded not to bend over in wheelchair and to use call light for assistance with toileting and transfers . Further review of the care plan revealed no additional fall prevention interventions were added to the care plan after Resident #19 fell on [DATE]. On 7/10/19 at 8:51 AM an interview was completed with Nurse #1. She said she was the nurse on duty 6/26/19 when Resident #19 fell . She reported Resident #19 was in her wheelchair, bent over to pick up a book, fell out of the chair and hit her head. On 7/10/19 at 8:22 AM an interview was completed with the Director of Nursing (DON). She stated whenever a resident fell , an investigation of the fall was completed at the time of the incident. She said the interdisciplinary team met daily and discussed falls from the previous day and fall prevention interventions were added to the resident's care plan within 24 hours of a fall. On 7/10/19 at 11:30 AM an interview was completed with the Administrator. She said when a resident fell the care plan was updated within 24-48 hours by the MDS nurse, nurse supervisor or DON. On 7/10/19 at 3:29 PM a follow up interview was completed with the DON. She said the facility had several different MDS nurses in the past eight months and the current MDS nurse had been in her role for only a few weeks. The DON stated Resident #19's care plan should have been updated after the fall on 6/26/19. She acknowledged care plans had been an issue the facility had identified in their Quality Assessment and Performance Improvement process. 3. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident was cognitively impaired. She required one-person extensive assistance for transfers and used a wheelchair. Further review of the MDS revealed Resident #17 had two or more falls with no injury in the look back period of the assessment. Review of incident reports revealed that the resident fell on [DATE], 3/12/19, 3/27/19, and 5/31/19. A review of the current care plan revealed a problem of, At risk for falls related to frequent fall history and decrease in mobility, and a stated goal of, resident will remain free of injuries and falls through next review. A care plan approach updated 3/21/19 revealed, instructed on how to use the call bell for assistance. A care plan approach updated on 3/27/19 revealed .to be monitored by staff at all times due to confusion. A care plan approach updated 6/2/19 revealed a problem of, At risk for falls related to non-compliance with assistance to the bathroom with the intervention of re-educated resident on the importance of requesting assistance for ADL's. During an interview with Nurse Aide #2 on 7/10/19 at 4:12 PM she stated that Resident #17 was confused, she tried to get up from her wheelchair frequently, and that she has to be monitored more closely. She stated that the resident did not use her call bell often, if at all. During an interview with Nurse #1 on 7/10/19 at 4:16 PM she stated that Resident #17 was not oriented and was confused. She stated that she tried to go to the bathroom on her own at times and staff have to monitor her closely. On 7/11/19 at 4:32 PM an interview was completed with the Director of Nursing (DON). She stated whenever a resident fell , an investigation of the fall was completed at the time of the incident. She said the interdisciplinary team met daily and discussed falls from the previous day and fall prevention interventions were added to the resident's care plan within 24 hours of a fall. She stated that she expected the interventions to be individualized to each resident and that providing education to a confused resident was not an appropriate intervention. She also stated that the only way a resident can be monitored by staff at all times was if they had a one on one sitter, Resident #17 had not had a one on one sitter, so that intervention was not appropriate either. On 7/11/19 at 4:40 PM an interview was completed with the Administratorand and DON. They said when a resident fell , it was their expectation the care plan was updated within 24-48 hours by the MDS nurse, nurse supervisor or DON with appropriate interventions for each resident.

Based on staff interviews and record review, the facility failed to 1) develop a care plan that addressed discharge goals and plans for 1 of 1 resident (Resident #27) reviewed for discharge to the community and 2) develop a care plan that addressed antidepressant medication use for 1 of 1 resident (Resident #29) reviewed for hospitalization . Findings included: 1. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #27 discharged home on[DATE]. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had moderately impaired cognition. Further review of the MDS assessment revealed active discharge planning was in place for Resident #27. A review of the care plan updated 4/12/19 revealed there was no care plan that addressed discharge planning. On 7/10/19 at 10:20 AM an interview was completed with the Social Worker. She stated she assisted residents with the discharge planning process but typically had not completed any care plans that addressed discharge planning. The Social Worker said the MDS Nurse completed all the care plans. On 7/10/19 at 10:42 AM an interview was completed with the Former MDS Nurse. She said discharge planning information was documented in the interdisciplinary notes. She stated discharge planning was not included in the comprehensive care plan and said she was unaware of the regulation that discharge goals and plans were supposed to be addressed in the care plan. On 7/10/19 at 11:33 AM an interview was completed with the Administrator. She stated discharge planning had not been included in the electronic medical record care plan and said she expected discharge plans and goals be included in a resident's comprehensive care plan. 2. Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #29 discharged to the hospital for a scheduled surgery on 5/8/19. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had impaired cognition and required one-person extensive assistance for activities of daily living. It did not state that the resident received an antidepressant or have a [DIAGNOSES REDACTED]. Review of Resident #29's hospital discharge summary revealed the resident was on chronic antidepressant therapy. Review of physician orders [REDACTED]. Review of Resident #29's Medication Administration Record [REDACTED]. Review of Resident #29's care plan revealed there was no care plan that addressed antidepressant or [MEDICAL CONDITION] medications. During an interview with the MDS Nurse on 7/9/19 at 3:41 PM she stated that Resident #29's MDS from 4/18/19 should have documented the 7 days of antidepressant medication administered and that would have triggered the system to alert the MDS nurse to initiate an antidepressant/[MEDICAL CONDITION] care plan. It is expected that both care plans and MDS assessments address antidepressant use. On 7/10/19 at 4:33 PM an interview was completed with the Administrator and the Director of Nursing. They both stated that it is their expectation that both MDS assessments and care plans both accurately address antidepressant use.

Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessments for antidepressant medication use for 1 of 1 resident (Resident #29) reviewed for hospitalization . Findings included: 1. Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #29 discharged to the hospital for a scheduled surgery on 5/8/19. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had impaired cognition and required one-person extensive assistance for activities of daily living. It did not state that the resident received an antidepressant or have a [DIAGNOSES REDACTED]. Review of Resident #29's hospital discharge summary revealed the resident was on chronic antidepressant therapy. Review of physician orders [REDACTED]. Review of Resident #29's Medication Administration Record [REDACTED]. During an interview with the MDS Nurse on 7/9/19 at 3:41 PM she stated that Resident #29's MDS from 4/18/19 should have documented the 7 days of antidepressant medication administered and that would have triggered the system to alert the MDS nurse to initiate an antidepressant/[MEDICAL CONDITION] care plan. It is expected that both care plans and MDS assessments address antidepressant use. On 7/11/19 at 4:33 PM an interview was completed with the Administrator and the Director of Nursing. They both stated that it is their expectation that both MDS assessments and care plans both accurately address antidepressant use.

Based on record review and staff interviews the facility failed to accurately code 1 of 1 sampled resident's Minimum Data Set (MDS) reviewed for pressure ulcers (Resident #20). Findings included: Resident #20 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the admissions notes dated 04/25/13, indicated Resident #20 had a Stage 2 pressure ulcer to the mid back along her spine. A review of Resident #20's quarterly MDS assessment dated [DATE] and quarterly MDS assessment dated [DATE] indicated Resident #20 was coded as having no pressure ulcers, under Section M: Skin Conditions. A review of Resident #20's physician orders [REDACTED].#20 had a Stage 2 Pressure ulcer to back. A review of Resident #20's physician orders [REDACTED].#20 had a Stage 2 Pressure ulcer to back. On 06/07/18 at 10:40 AM, an interview was conducted with the MDS Coordinator, who stated she coded Section M: Skin Conditions on Resident #20's quarterly MDS assessment dated [DATE], and quarterly MDS assessment dated [DATE]. The MDS Coordinator stated Resident #20 had not been coded as having a Stage 2 pressure ulcer to the mid back on the two assessments and it was an error in coding. The MDS Coordinator stated she would need to submit a modification to Resident #20's MDS assessments. On 06/07/18 at 10:50 AM, an interview was conducted with the Director of Nursing (DON), who stated her expectation was that Resident #20's quarterly assessment dated [DATE], and quarterly MDS assessment dated [DATE], would have been accurately coded under Section M: Skin Conditions to reflect a Stage 2 pressure ulcer to the mid back. The DON stated her expectation was that those two assessments would be modified and submitted to accurately reflect a Stage 2 pressure ulcer to the mid back for Resident #20.

Based on observation, staff interview and record review, the facility failed to: discard rotten produce from refrigerator and freezer; failed to clean a plate warmer; a steam table; four carts that dishes and trays were stored. The findings included: a. On 5/16/17 at 10:00 AM, during the tour of the kitchen, the freezer had a ½ box of rotten green peppers mixed with fresh peppers. The refrigerator had the following items: 2 sliced rotten tomatoes, rotten cucumber, rotten bag of lettuce and molded cheese. On 5/16/17 at 10:00 AM, during an interview, the Dietary Manager (DM) stated that items should have been checked and discard when found rotten prior to being placed in the refrigerator and freezer. b. On 5/16/17 at 10:05 AM, during the tour of the kitchen the plate warmer had a large volume of dried foods, liquids on the inside and outside. There were two rows of clean plates stored on the inside. On 5/16/17 at 10:05 AM, during an interview, the DM stated the kitchen equipment should be cleaned in accordance to the kitchen checklist. The DM provided a checklist that indicated the designated frequency for cleaning kitchen equipment. c. On 5/16/17 at 10:05 AM, during the tour of the kitchen the steam table surfaces and lids had large volumes of dried food, liquids and grease build up. Inside the steam table there was left over food floating in the water. On 5/16/17 at 10:05 AM, during an interview, the DM stated the kitchen equipment should be cleaned in accordance to the kitchen checklist. The DM provided a checklist that indicated the designated frequency for cleaning kitchen equipment. d. On 5/16/17 at 10:05 AM, during the tour of the kitchen the four tray carts had a large volume of dried food and liquids in the grooves and edges where clean trays were stored. On 5/18/17 at 11:05 AM, during an interview, the Dietary Aide (DA) #1 stated the produce should be checked and labeled prior to placement in refrigerator or freezer. The kitchen equipment should be cleaned and wiped down in accordance to the kitchen checklist. On 5/18/17 at 11:10 AM, during an interview, DA#2 stated that the expectation was to wipe down kitchen equipment daily and deep clean weekly. DA#2 also stated any spoiled or rotten foods should be discarded prior to putting them in the refrigerator or freezer. On 5/18/17 at 11:10 AM, during an interview, Cook #2 stated produce should be checked for spoiled/ rotten areas prior to placement in refrigerator or freezer. The kitchen equipment should be wiped down daily and deep cleaned weekly. On 5/18/17 at 1:30 PM, during an interview, the Administrator indicated the expectation was for the dietary manger to maintain the kitchen in accordance to kitchen policy and procedures and designated by checklist.

Based on observations and staff interviews the facility failed to remove nine expired medications from 1 of 2 medication carts on six east hall. (Resident #1, #3, #10, #28, #34, #36) Findings Included: On 5/17/17 at 9:00 AM, during the observation with Nurse # 1 there were nine plastic containers of topical ointment which were expired on the medication cart on six east hall. Observation revealed Resident # 3 had two containers expired on 4/20/17, Resident # 34, had one expired container on 4/30/17, Resident #1 had one container which expired on 5/11/17, Resident # 10 had two containers which expired on 5/11/17, Resident # 36 had two containers expired on 5/11/17, and Resident # 28 one expired container on 5/13/17. On 5/17/17 at 9:10 AM, during an interview, Nurse # 1 indicated that the third shift nurses were responsible to check for expired medications. The nurse confirmed that she had not checked the expiration date on topical creams in her medication administration cart. On 5/17/17 at 9:40 AM, during an interview, the Director of Nursing revealed that the night nurses were responsible to check all medication carts on a nightly basis. Her expectation was that no expired items be left in the medication carts.

Based on record reviews and staff and resident interviews the facilities Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place on 5/1/16. For a recited deficiency which was originally cited on a Recertification survey dated 4/7/16 which was cited at F431. The deficiency was in the area of medication storage. The continued failure of the facility during a federal survey of record show a pattern of the facilities inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referred to: F 431 Based on observations and staff interviews the facility failed to remove nine (9) expired medications from 1 of 2 medication carts on six east hall. (Resident #1, #3, #10, #28, #34, #36) The facility was cited for failing to remove expired medications from the medication cart during a recertification survey conducted on 04/07/16. F 431: Based on observations and staff interviews the facility failed to remove expired medications from 2 out of 2 refrigerators in the medication storage rooms. The expired medications included 6 out of 6 pneumococcal vaccine vials and 6 out 21 Tylenol suppositories, which are to be stored in the refrigerator. During an interview on 05/18/2017 at 1:37 PM, the Director of Nursing indicated to maintain compliance the facility would set up a schedule for audits and vary the time and the shift. The facility would review concerns based on the audits, and improve and identify the weakness in the system.

Based on observations and staff interviews the facility failed to remove expired medications from 2 out of 2 refrigerators in the medication storage rooms. The expired medications included 6 out of 6 pneumococcal vaccine vials and 6 out 21 Tylenol suppositories, which are to be stored in the refrigerator. Findings Included: 1.During an observation on 4/6/16 with Nurse #1 at 10:23 am, there was noted to be 6 out of 6 expired pneumococcal vaccine vials in the refrigerator in the medication storage room located on the 600 west hall. The expiration date on the vaccines was 3/16/16. An interview with Nurse #1 at this time revealed the night shift nurse is responsible for checking the medication storage room and refrigerators for expired items. 2.During an observation on 4/6/16 with Nurse #2 at 11:09 am, there was noted to be two Tylenol suppositories expired on 12/15/15 and four expired Tylenol suppositories on 7/27/15. The six expired suppositories were found in a box with fifteen other non-expired suppositories located in the refrigerator in the medication storage room on the 600 east hall. An interview with Nurse #2 at this time revealed the night shift supervisor or nurse is responsible for checking for expired medications as a nightly task. An interview with the Director of Nursing on 4/6/16 at 11:30 am revealed the expectation was that no expired items be left in the medication storage rooms or the refrigerators. The night nurse is expected to check all medication storage rooms and refrigerators on a nightly basis.