Every finding on record at Burke Health & Rehabilitation Center

Based on observation, staff interview, and facility documentation review, the facility staff failed to implement a system to account for and reconcile controlled drugs on 1 of 2 nursing units. The findings included: 1. The facility staff failed to implement their system of reconciliation to ensure the appropriate quantity of controlled medications was accurate on 2 of 4 medication carts inspected. 1a. On 06/28/23 at 05:19 PM, a medication storage inspection was conducted of the second floor, medication cart 1 with LPN E. During the verification of the controlled medications, it was determined that the controlled count was not correct. For one Resident who had Gabapentin 100 mg capsules, the medication card had 25 capsules, the reconciliation sheet said there should be 24 capsules present. For another Resident who had Armodafinil 200 mg tablets, the medication card had 19 tablets and the count sheet/reconciliation sheet indicated that 18 tablets should be present. LPN E confirmed the above findings. When asked about the process, LPN E said that at each shift change the off-going and on-coming nurses are to count the narcotics together. LPN E stated she took the cart keys at 2 PM, meaning she assumed responsibility of the cart at that time. LPN E further confirmed that a count of the controlled medications had not been conducted and she did not know that the count was not correct. On 06/28/23 at 05:51 PM, the unit manager, RN D was made aware that the controlled count on cart 1 was incorrect. RN D stated, This is my first week here . A few minutes later, RN D told Surveyor C that the off-going nurse for cart 1 is coming back to correct the count, she was having trouble with her eyes and signed the wrong thing, she is correcting it. On 6/29/23, during the mid-morning, RN D approached Surveyor C and said she had given incorrect information on the day prior. RN D said, that with regards to the controlled count not being correct on cart 1, the day shift nurse was still in the building at the time of the inspection. When asked if the controlled count verification is supposed to be done prior to the on-coming nurse accepting the keys and assuming responsibility of the cart, RN D said, yes. 1b. On 06/28/23 at 05:34 PM, an inspection was conducted of the 2nd floor, medication cart two (2). This review was conducted with LPN F. During review of the narcotics/controlled medications, it was noted that one Resident had a bottle of Morphine 20 mg/ml concentrate, which contained 30 Ml. There was no count/reconciliation sheet present for the nursing staff to verify that the quantity on-hand was accurate. LPN F said, The day nurse said the nurse manager has it. 1c. During the inspection of medication cart 2, LPN F had a stack of controlled medication cards that were bound with a rubber band and the controlled count/reconciliation sheets were attached. She stated that they were controlled medications for Residents who had been discharged , but the box they put them in is full, so she was told to keep them on her cart. LPN F confirmed that they were not being counted at each shift change. Review of the stack of medications revealed there was controlled medications for 5 Residents. The medications included: oxycodone immediate release 5 mg, Percocet 5-325 mg, Tramadol, Gabapentin, Lorazepam concentrate, and morphine concentrate. 2. The facility staff failed to implement their system of reconciliation and disposal of controlled medications to ensure that there is a system to account for the controlled substances stored within the facility. On 6/28/23 at approximately 5:40 PM, LPN F took Surveyor C to the medication room, for the surveyor to observe the locked box where they normally put controlled medications once a Resident is discharged . Upon observation it was noted that the box was so full of medications that no additional medication cards could be inserted. Surveyor C then requested for the Director of Nursing (DON) and Corporate Clinical Director to come to the medication room. Upon their arrival the DON opened the box and pulled out a substantial amount of controlled medication cards. The DON and Corporate Clinical Director retrieved all the controlled medications and took them to the office to make an accounting of what was present and then destroy them. Surveyor C sat with the DON and Corporate Clinical Director while they made an accounting of what was present. There was a total of 84 cards of controlled drugs, that contained over 1600 capsules/tablets, that had been stored in the locked box on the second-floor medication room. During their reconciliation, it was determined that they had 12 cards of medications that they had no count sheet for, therefore they were unaware if there were any medications missing. In addition, they had 3 count sheets that they had no medication for. When asked if they had any way to identify if there were medications that were missing, the DON and Corporate Clinical Consultant both agreed that they had no way to know. When asked about the process for destruction of narcotic medications, the DON stated, every Friday we go to the medication cart and destroy. I knew we keep narcotics in the safe [referring to the box, similar to a drop box made of file cabinet material]. When asked why it is important to have a process to account for and reconcile narcotics, they indicated because controlled drugs are at risk for diversion and without counting, they would not know if Residents were getting the medications or if they are being diverted. Review of the facility policy titled; Shift Change Report was conducted. This policy read, . 3. Licensed nurses from the previous shift will complete the narcotic counts with a nurse coming on duty . The facility policy titled; Storage of Controlled Substances was reviewed. An excerpt from this policy read, . 5. Unless otherwise indicated in a facility policy and/or as required by state regulations, the following will be performed: a. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed personnel, and is documented . 6. Any discrepancy in controlled substance counts is reported to the Director of Nursing immediately and/or in accordance with facility policy .10. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are retained in the facility in a securely locked area with restricted access until destroyed in accordance with facility policy and state regulations. Accountability records for discontinued controlled substances are maintained with the unused supply until it is destroyed or disposed of, and then stored for five years or as required by applicable law or regulation . On 6/28/23, during an end of day meeting, the facility Administrator, Director of Nursing and Corporate staff were made aware of the above findings. No additional information was received.

Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to ensure nursing standards of practice were followed for 2 Residents (Resident #15 and #217) in a survey sample of 38 Residents. The findings included: 1) For Resident #15, LPN D failed to verify the right resident during medication pass. On 6/29/23 at 9:58 AM, LPN D was observed during the medication administration. LPN D pulled and prepared the medication for Resident #217, which was a total of 8 pills (tablets and capsules). The medications were: Amlodipine Besylate 10 MG tablet for hypertension/blood pressure, Oxycodone 5 mg immediate release tablet for pain, Budesonide extended release 3 mg capsule for Crohn's disease, Carvedilol 6.25 mg tablet for hypertension, Venlafaxine HCl extended release 150 mg capsule for depression, Prevacid delayed release 30 mg capsule for gastroesophageal reflux, Dicyclomine HCl 20 mg tablet for irritable bowel syndrome and Sodium Bicarbonate 650 mg tablet for hyponatremia. Upon entering the room, LPN D approached Resident #15, who was the roommate of Resident #217. LPN D made no attempts to verify the Resident's identity. LPN D then scooped the pills onto a spoon and was approaching Resident #15's face with the spoon while saying I have your medications. Surveyor C intervened and asked the Resident to state her name. Resident #15 stated her name and LPN D then realized she was giving Resident #15 the medications that belonged to Resident #217. LPN D apologized and then approached Resident #217 and administered the medications. Had Surveyor C not intervened LPN D was going to administer all the medications noted above to the wrong Resident. Review of the facility policy titled; Administration Procedures for All Medications was conducted. This policy read, .IV. Administration 2. Identify the resident before administering the medication . On 6/29/23, during an end of day meeting, the facility administrator, Director of Nursing (DON) and corporate staff were made aware of the above observations. The Corporate Clinical Director indicated that it could be very dangerous and result in the need for clinical interventions. No further information was provided/received. 2) For Resident #217, the facility staff failed to correctly document medications that were administered. On 6/29/23 at 9:58 AM, LPN D was observed during the medication administration. LPN D pulled and prepared the medication for Resident #217, which included Oxycodone 5 mg immediate release tablet for pain and Budesonide extended release 3 mg capsule for Crohn's disease. Following the administration, LPN D returned to the medication cart and proceeded to sign out the narcotic oxycodone 5 mg tablet onto the sheet as if she had pulled oxycodone 10 mg tablet. LPN D realized her error and said she would let her manager know so it could be corrected. On 6/29/23 at approximately 11:10 AM, a review of the MAR (medication administration record) of Resident #217 was conducted. It was noted that LPN D had administered Budesonide extended release 3 mg capsule during the observation, but failed to sign off on the MAR that the medication was given. A review of the facility policy titled, Administration Procedures for All Medications was conducted. This policy read, .IV. Administration . 7. After administration, return to cart, replace medication container (if multi-dose and doses remain), and document administration in the MAR or TAR and the controlled substance sign out record, if necessary . On 6/29/23, during an end of day meeting, the facility Administrator, Director of Nursing and Corporate staff were made aware of the above findings. No further information was received.

Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to ensure the medication error rate was less than 5%. There were 9 medication errors in 31 opportunities, resulting in an 29.03% error rate. The findings included: On 6/29/23 at 9:58 AM, LPN D was observed during medication administration. LPN D pulled and prepared the medication for Resident #217, which was a total of 8 pills (tablets and capsules). The medications were: Amlodipine Besylate 10 MG tablet for hypertension/blood pressure, Oxycodone 5 mg immediate release tablet for pain, Budesonide extended release 3 mg capsule for Crohn's disease, Carvedilol 6.25 mg tablet for hypertension, Venlafaxine HCl extended release 150 mg capsule for depression, Prevacid delayed release 30 mg capsule for gastroesophageal reflux, Dicyclomine HCl 20 mg tablet for irritable bowel syndrome and Sodium Bicarbonate 650 mg tablet for hyponatremia. Upon entering the room, LPN D approached Resident #15, who was the roommate of Resident #217. LPN D made no attempts to verify the Resident's identity. LPN D then scooped the pills onto a spoon and was approaching Resident #15's face with the spoon while saying I have your medications. Surveyor C intervened and asked the Resident to state her name. Resident #15 stated her name and LPN D then realized had the wrong resident. LPN D apologized and then approached Resident #217 and administered the medications. Review of Resident #15's physician orders revealed she did not have an order for any of the 8 medications that LPN D was stopped from administering. On 6/29/23 at 9:58 AM, LPN D was observed to prepare and administer medications to Resident #41. Resident #41's scheduled medications included Tiotropium Bromide Monohydrate Capsule 18 MCG, also known as Spiriva. LPN D looked in the medication cart, went to another cart and looked and indicated that it was not available. LPN D then administered the other medications and returned to the medication cart and proceeded to the next Resident for medication administration. LPN D made no attempts to call the pharmacy to inquire about the delivery of the Spiriva, nor did she attempt to notify the provider that the medication was not available. On 6/29/23 at 9:45 AM, LPN D was asked about the process if medications are not available. LPN D said, If it isn't available in the cart, we go downstairs to the machine [referring to the Omnicell, which is a medication dispensing machine]. LPN D then said, If the medication isn't available in the machine, we call the pharmacy and the doctor. During the late morning of 6/29/23, the Corporate Clinical Consultant let Surveyor C know they had removed LPN D from the medication cart. Review of the facility policy titled; Administration Procedures for All Medications was conducted. This policy read, .IV. Administration 2. Identify the resident before administering the medication . The facility policy titled, Medication Management/Medication Unavailability was received and reviewed. This policy read, . 3. If medications are determined to be unavailable for administration, licensed nurse will notify the provider of the unavailability. Licensed nurse will document notification to the provider of the unavailability in the medical record . On 6/29/23, during an end of day meeting, the facility administrator, Director of Nursing (DON) and corporate staff were made aware of the above observations and medication error rate being greater than 5%. No further information was provided/received.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide COVID-19 bivalent vaccines for 4 residents, Residents #19, #31, #54, and #67, out of 5 residents reviewed for COVID-19 bivalent immunization. The findings included: The facility staff failed to provide COVID-19 bivalent immunization for Residents #19, #31, #54, and #67. On 6/28/23 at approximately 2:30 PM, clinical record reviews were performed and revealed the following: A. For Resident #19, the clinical record review revealed no evidence of an offer to provide the resident with a COVID-19 bivalent vaccine or documentation of resident refusal or medical contraindication. B. For Resident #31, the clinical record review revealed no evidence of an offer to provide the resident with a COVID-19 bivalent vaccine or documentation of resident refusal or medical contraindication. C. For Resident #54, the clinical record review revealed no evidence of an offer to provide the resident with a COVID-19 bivalent vaccine or documentation of resident refusal or medical contraindication. D. For Resident #67, the clinical record review revealed no evidence of an offer to provide the resident with a COVID-19 bivalent vaccine or documentation of resident refusal or medical contraindication. On 6/28/23 at approximately 2:45 PM, an interview was conducted with the Director of Nursing (DON) who accessed the clinical records for the residents sampled and verified the findings stating it appears to be an oversight. A facility policy was requested and received. On 6/28/23 at approximately 3:00 PM, a review of the facility policy entitled, COVID-19 Vaccinations, effective date 5/01/23, was conducted. It stated under the subtitle, Procedure, item 1, CDC [Centers for Disease Control and Prevention] recommends that everyone stay up to date with COVID-19 vaccination and item 2c read, If contraindicated or refused, document in the patient's immunization record, including that the patient and/or RP [Responsible Party] was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. The CDC (Centers for Disease Control and Prevention) document titled, Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States, updated May 12, 2023, page 2, Recommendations for the use of COVID-19 vaccines, read, COVID-19 vaccination is recommended for everyone ages 6 months and older in the United States for the prevention of COVID-19 and CDC recommends that people ages 6 months and older receive at least 1 bivalent mRNA COVID-19 vaccine. On 6/28/23 at approximately 5:15 PM, the Facility Administrator and Director of Nursing were made aware of the findings. No further information was provided.

Based on observations, Resident and family interview, staff interviews and facility documentation review, the facility staff failed to maintain a sanitary and comfortable environment for Residents on 2 nursing halls in a sample of 6 nursing halls inspected. The findings included: On 6/27/23, during initial tour observations were made in multiple rooms on the first floor, halls 2 and 3 of privacy curtains (located to wrap around the bed for each Resident) to have brown stains and brown solid matter on them. On the afternoon of 6/27/23, an interview was conducted with Resident #320, who had a family member visiting. Resident #320 pointed out to Surveyor C the privacy curtain which had brown stains and solid matter that the Resident identified as feces. Resident #320 reported he had let facility nursing staff know but nothing had been done. The family member of Resident #320 showed Surveyor C her bag that she brings in daily with a disinfectant cleaner and Lysol spray because when she arrives, she, has to empty, clean and disinfect the bedside commode, because the facility staff do not do it. The family member also pointed out the trash can within the room that had a large quantity of dried brown substance on it. In addition, Resident #320 lifted his body off the sheets to show Surveyor C that his bed linen had what he identified as feces on it. Resident #320 stated that his family member has to change his sheets when she comes daily because the facility staff do not. During the end of day meeting held on 6/27/23, the facility Administrator, Director of Nursing and Corporate staff were made aware of the concerns with regards to the cleanliness and sanitary conditions of Resident rooms, including privacy curtains. On 6/28/23 at approximately 1:30 PM, Resident #320 was visited in his room. The privacy curtain remained stained with the solid brown matter on it. Resident #320 reported they had changed his roommate's curtain the night before, but not his. On 6/28/23 at 3:24 PM, an interview was conducted with the housekeeping supervisor/Employee F. Employee F said that privacy curtains are changed by housekeeping and maintenance staff when staff make them aware that they are soiled. As for routine cleaning/changing of the curtains, he reported it is done when the rooms are deep cleaned, which is monthly. Employee F stated they had changed a lot of privacy curtains the night before, but he was made aware of another one that needed changing and was getting ready to go do that. When asked which room he was going to, Employee F identified the room of Resident #320. Review of the schedule for deep cleaning, that Employee F provided, revealed that Resident #320's room was scheduled to be deep cleaned on the first Friday of each month. In addition, Employee F provided the survey team with a document titled, Admission/Discharge Cleaning. Review of this document read, . Procedure: Discharge: Discharge rooms should be turned over either one hour after discharge or the following day if discharge happened after hours. In addition to the general method of cleaning, discharge rooms require additional attention, as follows: . 6. Curtains should be replaced, and any remote controls, pull lights and call bells should also be disinfected . On 6/29/23, during the end of day meeting, the facility Administrator, Director of Nursing and Corporate staff were again made aware of the above concerns. No further information was provided.

Based on observation, staff interview, clinical record review and facility documentation the facility staff failed to properly store medications on 2 of 4 medication carts inspected. The findings included: For 2 of 4 medication carts inspected, the facility staff failed to label insulin with the open date to ensure it is not used beyond the expiration date. On [DATE] at 05:19 PM, an inspection was conducted of the second-floor cart 1, in the presence of LPN E. The following was noted: A Lantus Solostar pen was open, had been used, and had no open date. A Humalog 100-unit multi-dose vial was dated [DATE]. LPN E stated, today is last day, indicating it was good for 31 days. On [DATE] at 05:34 PM, an inspection of the 2nd floor, cart 2, was conducted. LPN F was present during the inspection and confirmed the findings. The following was noted. An Insulin Aspart 100 U/ML multi-dose vial was opened and had no date to indicate when it was opened. The label said, discard after 28 days. LPN F confirmed she had no way to know when to discard it because she didn't know when it was opened. There was a Humalog 100 U/ML 3 ml multi-dose vial, which had no open date. The facility administration provided the survey team with a document titled, Medications with shortened expiration dates. It noted the following: Lantus Solostar Pen: Once opened, do not refrigerate. Store at room temperature. Product expires 28 days after first use or removal from refrigerator, whichever comes first. Humalog vial: Once opened, store below 86 degrees Fahrenheit. Product expires 28 days after first use or removal from refrigerator, whichever comes first. This means that the Humalog noted on the second floor, cart 1 should have not been used beyond [DATE]. NovoLog/Aspart vial: Product expires 28 days after first use or removal from refrigerator, whichever comes first. By not having the insulins dated with an open date, the facility staff had no way of knowing if the insulin being administered was expired or not. On [DATE], during the end of day meeting, the facility Administrator, Director of Nursing and Corporate staff were made aware of the above findings. No additional information was provided.

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to provide a clean homelike environment for 1 Resident (Resident #38) in a survey sample of 38 Residents. The findings included: For Resident #38, the facility staff failed to provide a clean and homelike environment by ensuring cobwebs were removed. On 6/27/23 at approximately 2:00 PM, Surveyor C visited Resident #38 in his room. Surveyor C noticed 2 cobwebs in the ceiling corner of the room over the Resident's bedside table. On 6/27/23 at 2:50 PM, LPN C accompanied Surveyor C to Resident #38's room. LPN C was shown the cobwebs and confirmed them. On 6/27/23 at approximately 3 PM, the Director of Nursing came to the room and confirmed the above findings. The DON confirmed that this was not acceptable and reported rooms are cleaned by housekeeping. On 6/28/23, an interview was conducted with the housekeeping manager/Employee F. Employee F confirmed that housekeeping cleans rooms daily and performs deep cleaning of rooms monthly. Employee F provided Surveyor C with a calendar of scheduled deep cleaning, which listed Resident #38's room as being scheduled to be deep cleaned the third Friday of each month. On the facility provided Detailed Cleaning Check Off List form it noted the following to be completed, . 4. Sanitize all ceilings . 14. Sanitize all walls thoroughly . On 6/28/23, during an end of day meeting the facility Administrator was made aware of the above findings. No further information was received.

Based on observation, Resident interview, clinical record review and facility documentation review, the facility staff failed to provide assistance with eating for 1 resident (Resident #84) in a survey sample of 38 Residents. The findings included: For Resident #84, who was dependent upon facility staff for assistance with eating, the facility staff failed to provide meal set-up and feeding assistance. Resident #84's most recent MDS (minimum data set) assessment with an assessment reference date of 5/24/23. This assessment noted Resident #84 as having required extensive assistance of one staff member for eating. Review of the clinical record was conducted. This review revealed Resident #84 was on hospice care. Resident #84 was identified in his care plan as being at risk for weight loss. It read, Nutritional Risk: [name redacted] is at nutritional risk d/t [due to] hx [history] pressure ulcers, on hospice care with expended medical decline. The goal read, [different Resident name, not Resident #84, name redacted] will have adequate nutrition for comfort/autonomy through next review. Interventions read, Provide diet as ordered. Monitor intake and record each meal. Offer substitute when intake less than 50%, provide supplements as ordered, treat risk factors as ordered, weights per protocol. Resident #84 was also noted on the care plan to needs assistance for ADL's due to impaired mobility/ cognition/ communication/ swallowing. On 6/27/23 at 2:13 PM, Resident #84 was observed lying in bed. His lunch tray was on a tray table by the bed, cover in place and none of the items opened. The tray was out of reach of the Resident. Resident #84 didn't verbally respond when spoken to. On 6/27/23 at 2:15 PM, an interview was conducted with Resident #320, who was the roommate of Resident #84. Resident #320 verbalized concern over Resident #84. When asked about meals, Resident #320 said they just drop off the tray and leave the room. On 6/27/23 at approximately 2:30 PM, an interview was conducted with CNA B. CNA B acknowledged she was assigned to Resident #84. When asked about Resident #84's ability to feed himself, CNA B stated, the Resident feeds himself. When asked, how he could feed himself with the tray not set-up and out of reach, CNA B stated she had asked the Resident if he wanted to eat, and he told her no. On 06/29/23 at 01:44 PM, Resident #84 was noted to be in bed asleep. His meal tray was at the bedside, out of reach and not set-up, covered with a tray lid. Surveyor C talked with LPN B who was assigned to Resident #84. LPN B stated the Resident could feed himself. LPN B accompanied Surveyor C to the room and acknowledged the tray was not set-up and the Resident could not reach it. LPN B then set-up the meal tray and encouraged Resident #84 to eat. Review of Resident #84's activities of daily living sheets, revealed the resident required limited to extensive assistance of facility staff for eating. The forms also indicated Resident #84 consumed 0-25% of most meals. On 6/27/23, Resident #84 was only recorded as having been offered one meal. The facility administration was asked to provide the survey team with a policy regarding activities of daily living (ADL's). The facility stated they did not have a policy but follow Mosby's standards for the practice of nursing assistants. The facility provided copies from Mosby's Textbook for Long-Term Care Nursing Assistants Seventh Edition which addressed bathing. On 6/29/23, during the end of day meeting, the facility Administrator and Director of Nursing were made aware of the above findings. No further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide an influenza vaccine for 1 resident, Resident #54, out of 5 residents reviewed for influenza immunization and facility staff failed to provide a pneumococcal vaccine for 1 resident, Resident #67, out of 5 residents reviewed for pneumococcal immunization. The findings included: 1. The facility staff failed to provide influenza immunization for Resident #54. On 6/28/23 at approximately 2:30 PM, a clinical record review was performed for Resident #54 and revealed that Resident #54 had received influenza immunization on 10/19/21, however there was no documentation of the flu vaccine being offered, refused, contraindicated, or administered for the current year, 2022. On 6/28/23 at approximately 2:45 PM, an interview was conducted with the Director of Nursing (DON) who accessed the clinical records for Resident #54 and verified the findings stating, it appears to be an oversight. A facility policy was requested and received. On 6/28/23 at approximately 3:00 PM, a review of the facility policy entitled, Influenza Vaccination, effective date 5/01/23, was conducted. It stated under the subtitle, Procedure, item 1a, Influenza vaccine should be offered annually .optimal time to administer influenza vaccine is in late September or early October of each year. The vaccine can be given after the flu season begins .Those who have not had a flu vaccine will be offered one upon admission. On 6/28/23 at approximately 5:15 PM, the Facility Administrator and Director of Nursing were made aware of the findings. No further information was provided. 2. The facility staff failed to provide pneumococcal immunization for Resident #67. On 6/28/23 at approximately 2:30 PM, a clinical record review was performed which revealed Resident #67, who was admitted to the facility on [DATE], had no clinical assessment with regard to pneumococcal immunization, to include the resident's current pneumonia vaccination status, offer to provide immunization against pneumococcal infection, or documentation of resident refusal or medical contraindication. On 6/28/23 at approximately 2:45 PM, an interview was conducted with the Director of Nursing (DON) who accessed the clinical records for Resident #67 and verified the findings stating, it appears to be an oversight. A facility policy was requested and received. On 6/28/23 at approximately 3:00 PM, a review of the facility policy entitled, Pneumococcal Vaccinations, effective date 5/01/23, was conducted. It stated under the subtitle, Policy, Vaccination against pneumonia will be offered to center patients. On 6/28/23 at approximately 5:15 PM, the Facility Administrator and Director of Nursing were made aware of the findings. No further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to offer and/or provide Advance Directive planning for 1 Resident, (Resident #317), in a survey sample of 38 Residents. The findings included: The facility staff failed to identify the wishes of Resident #317 with regards to code status, to uphold the Residents wishes in the event of cardiac arrest. On [DATE], a clinical record review of Resident #317's record was conducted. This review revealed that in the hospital records Resident #317 was noted as a code status of DNR (do not resuscitate). Review of the physician orders noted there was no order with regards to code status, which would direct facility staff in the event of cardiopulmonary arrest, if they were to perform CPR (cardiopulmonary resuscitation) or not. Review of the care plan for Resident #317 was reviewed and the code status and advance directive wishes of Resident #317 were not addressed. All the progress notes for Resident #317 were reviewed and there was no evidence of a discussion being held with Resident #317, to identify her wishes. In the banner section of the clinical record code status was blank. [DATE] at 04:56 PM, an interview was conducted with the director of discharge planning/social work, Employee J. Employee J was asked to explain the process with regards to Advance Directives and code status. Employee J said, we would discuss that [referring to advance directives] after admission, we inquire if they have a POA [power of attorney], advanced directive, etc. and we have a packet that is premade that has information to include notary publics Code status is done from the clinical team during the jump start meeting or initial 5-day assessment and would be documented in the progress notes. During the end of day meeting held on [DATE], the facility Administrator, Director of Nursing and Corporate staff were made aware that the hospital records indicate Resident #317 was a do not resuscitate. However, the facility doesn't address code status and even note in the admission assessment that the Resident is a full code. Surveyor C made them aware that there was no evidence of a discussion being held to determine the Resident's current wishes. The facility staff were asked to provide any information they may have with regards to this. On [DATE] at 12 Noon, an interview was conducted with LPN C. When asked what the process is to determine someone's wishes, she stated, When they come in, the MDS (minimum data set) nurse comes out to them and does an interview and asks about code status. When asked if she, as an admitting nurse has this conversation with Residents, LPN C said no. On [DATE] at approximately 12:15 PM, an interview was conducted with RN D, who was the MDS coordinator. RN D stated that during the jump start meeting social work asks about advance directives. RN D accessed in the clinical record a Discharge Planning Admission Assessment that noted on the very last page the following: 9. Identify code status: Full code. This assessment had been completed by Employee K, a discharge planner. On [DATE] at approximately 12:25 PM, an interview was conducted with Employee K. Employee K was asked about the discussion of code status when completing the assessment. Employee K said he doesn't ask about code status and discuss full code versus do not resuscitate, he just marks the box based on what is the in the banner of the Resident's information in the clinical chart. Employee K accessed Resident #317's record and stated, since nothing was there, we mark full code. Review of the admissions agreement revealed that there were forms for a Resident to indicate if they have/had an advance directive and forms to execute one if they so desired. On [DATE] at approximately 1 PM, an interview was conducted with Employee L, the admissions director. Employee L stated that the admissions agreement is conducted electronically, usually the day after admission. It is completed with the Resident if they can complete it and if not, then the family. Employee L confirmed that admissions do not discuss code status and explain a do not resuscitate during the admission process. On [DATE], the facility administration provided the survey team with a copy of a progress note entered Resident #317's record on [DATE]. This note read, This DCP [discharge planner] and DCP [name redacted] spoke with [Resident #317's name redacted] on this date about her wishes regarding code status. Full code vs DNR was thoroughly reviewed, and the patient stated she wishes to be a DNR and has a DNR at home on her refrigerator. Patient's hospital records reflect patient has a durable DNR. This dcp also reviewed AD/POA [advance directives/power of attorney] again and patient stated she has both and that she's already been asked about these and was displeased we asked for them again. Patient stated her son will be in to visit today around noon. This dcp will f/u [follow up] with son [son's name redacted] to obtain DNR/AD/POA. NP [nurse practitioner] [name redacted] made aware on this date of the dcp's conversation with [Resident #317's name redacted] regarding wish to be DNR. The facility administration was asked to provide any policies and procedures they had with regards to advance directives and code status. The facility provided a policy titled, Advance Directives. This policy read, Social work and discharge planning staff will assist with requests for information regarding Advance Directives upon patient's admission to the center and throughout the patient's stay to allow each patient an opportunity to plan in advance for medical treatment. Procedure: 1. Upon patient and/or responsible party requests, provide information and education to patients/responsible party regarding living wills, durable power of attorney for healthcare and anatomical gifts. Include preproperate medical and clinical staff as needed for clarification and assistance. 2. If requested, assist patient/responsible part with resources for obtaining Advance Directive forms .4. If patient/responsible party expresses a desire to pursue a Do Not Resuscitate order (DNR), escort them to the licensed nurse or attending physician for further assistance. Do not independently initiate any DNR directives or proceedings. 5. Provide a written summary note of initiatives and outcomes in Social Work and Discharge Planning Progress Notes and indicate status of Advance Directive throughout assessment process. On [DATE], during the end of day meeting, Surveyor C shared with the facility administrator, Director of Nursing and Corporate staff that the facility had failed to provide any evidence that the discussion had been had with Resident #317 regarding her wishes and advance directives. No further information was provided.

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to provide respiratory care as ordered by the physician and consistent with professional standards of practice for 1 Resident (Resident #38) in a survey sample of 38 Residents. The findings included: For Resident #38, the facility staff failed to 1) provide oxygen via a concentrator, at the level ordered by the physician 2) failed to store the suction Yankauer in a manner to prevent contamination, 3) failed to replace the suction tubing routinely, 4) failed to change the oxygen tubing weekly as ordered, 5) failed to change the humidifier bottle weekly as ordered, 6) failed to change the nebulizer tubing weekly as ordered. On 6/27/23 at approximately 2:00 PM, Surveyor C visited Resident #38 in his room. Resident #38 was able to communicate and when asked about the oxygen, the Resident was not able to recall the rate of oxygen flow ordered. Surveyor C noted the oxygen concentrator was set on 5 liters of oxygen. Further observations in the room revealed a suction machine at the bedside and the canister had some brown appearing liquid in it. The tubing had copious amounts of scattered brown residue and stains throughout the tubing. The yankauer suction tip (an oral suctioning tool used in medical procedures and is the part that enters the oral cavity) was noted to be on the bedside table wrapped in a medical procedure glove. Further observations revealed the oxygen tubing and humidifier bottle were not dated. There was also a nebulizer mask on the bed, open to air, which was dated 5/29/23. When Resident #38 was asked about the frequency of suctioning, he stated it is not often. On 6/27/23 at 2:50 PM, LPN C accompanied Surveyor C to Resident #38's room. LPN C stated that Resident #38, had a change in condition on Sunday, spiked a fever and should be on 2 liters of oxygen, she looked at the oxygen concentrator settings and confirmed that it was running at 5 liters. LPN C confirmed that suction yankauer should be stored in a bag when not in use to prevent contamination that could cause respiratory infections. At this time, it was noted to be laying on the floor, still wrapped in a medical procedure glove. LPN C found the bag the suction tip was to be stored in and it was dated 4/5/23. LPN C also confirmed that Resident #38 would not have been able to adjust/change the setting for the rate of oxygen flow. LPN C looked at the oxygen concentrator confirmed that there was no date as to when the tubing was changed or the humidifier bottle. LPN C stated that it is done weekly, every Saturday on night shift and should be dated. LPN C also confirmed that the nebulizer mask was laying on the bed, open to air, had not been disassembled and cleaned and was dated 5/29/23. LPN C said the nebulizer tubing and masks are changed every Monday, Wednesday and Friday, on night shift. On 6/27/23 at approximately 3 PM, the Director of Nursing came to the room and confirmed the above findings. The DON confirmed that this was not acceptable. A clinical record review was conducted. This review revealed that Resident #38 had a physician order dated 6/24/23, that remained active that read, Supplemental Oxygen via NC [nasal cannula] at 2L AS NEEDED/PRN for SOB [shortness of breath]/SPO2 [oxygen saturation] <92%-WEAN AS ABLE, every 8 hours as needed. Resident #38 was also noted to have a diagnosis of chronic obstructive pulmonary disease. This review revealed that Resident #38 had a physician order for Oxygen and nebulizers as needed. The facility provided the survey team with a policy titled, Respiratory/Oxygen Equipment. This policy read, Policy: Licensed staff will administer and maintain respiratory equipment, oxygen administration, and oxygen equipment per provider's order and in accordance with standards of practice . Medicated Nebulizer Treatment: . 5. Rinse out nebulizer reservoir with tap water, dry and place in a plastic bag when not in use. Nebulizers and bags should be changed weekly . Oxygen Therapy via Nasal Cannula, Simple Mask, Venturi Mask, and Oximizer . 3. Set appropriate flow rate and place oxygen delivery device on patient . 6. Nasal cannulas, simple masks, Venturi mask, and oximizer and tubing should be changed weekly. 7. If flow rate is greater than 4 liters/minute, a pre-filled disposable humidifier bottle should be used. Humidifier bottles are to be changed weekly. 8. Store oxygen tubing/mask in plastic bag when not in use . The policy titled, Suctioning was received and reviewed. This policy read, Oral Suctioning .4. Suction catheters are to be changed after each use . General Considerations: . 2. Disposable suction canisters and connecting tubing are to be disposed of and changed every day and dated if used . On 6/27/23, during the end of day meeting, the facility Administrator, Director of Nursing and Corporate staff were made aware of the above findings. When asked about the associated risks to a Resident receiving oxygen at a higher rate of flow than ordered, the Corporate Clinical Consultant stated that it could cause them to retain more carbon dioxide and could cause a medical emergency. No further information was received.

Based on staff interview, clinical record review and facility documentation, the facility staff failed to conduct COVID testing of a symptomatic Resident (Resident #107) as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #109 and #110). 1. For Resident #107, the facility staff failed to obtain COVID-19 testing as per physician orders. 2. For Residents #106, #107, #108, #109 and #110, the facility staff failed to document COVID-19 testing and the results of testing, in the clinical record. The findings included: 1. For Resident #107, the facility staff failed to obtain COVID-19 testing as per physician orders. During a clinical record review, Resident #107 was noted to have several physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. On 10/8/21, COVID 19 POC (Point of Care) test by BinaxNOW, BD Veritor or [NAME]. Every 24 hours as needed for Test for COVID 19 Document Results. 2. On 10/8/21, an order was entered that read, COVID-19 TESTING PER MD OR CDC RECOMMENDATION every 24 hours as needed for COVID 19 testing COVID-19 TESTING PER MD OR CDC RECOMMENDATION 3. On 10/17/21, the order entered read, Repeat Rapid COVID-19 Test ASAP-notify provider of results once completed one time a day. There was no end date on the physician order. The order dated 10/17/21, was initiated following an elevated temperature on two occasions during that day. The review of the vitals tab in the EHR (electronic health record) revealed 2 instances of elevated temperature recordings on 10/17/21. They were recorded as 99.0 at 2 AM and 99.3 at 7:05 PM. Review of the MAR (Medication Administration Record) revealed the COVID testing orders with no indication that testing had been conducted as ordered on 10/8/21. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This remained as an active order at the time of survey. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR for this order entry had an entry on 10/18/21, with the code 9. According to the legend contained within the MAR, 9 was referenced as Other/See progress notes. Review of nursing notes revealed an entry dated 10/19/2021 at 01:47 AM, which read, not done. No further notes were entered into the clinical record to indicate why not done, was noted. The Centers for Medicare & Medicaid Services (CMS) document, Ref: QSO-20-38-NH, revision date 09/10/21, read . Conducting testing: In accordance with 42 CFR 483.50(a)(2)(i), the facility must obtain an order from a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law, including the scope and practice laws to provide or obtain laboratory services for a resident, which includes COVID-19 testing . On 10/21/21, the Corporate Clinical Director/Employee E and the DON (director of nursing) were unable to provide any further information regarding COVID testing as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/21/21, RN F provided the survey team the COVID-19 testing logs for Residents and there was no indication of Resident #107 having had COVID-19 testing conducted as per the MD orders noted above. No further information was received. 2. For Residents #106, #107, #108, #109 and #110, the facility staff failed to document COVID-19 testing and the results of the testing, in the clinical record. On 10/19/21, at the time of survey entry the facility Administration notified the survey team that they were in a current COVID-19 outbreak. Further notification was provided that 3 Residents had tested positive for COVID-19 as recent as 10/19/21. The facility Administrator and Director of Nursing indicated the COVID-19 outbreak began in August and was ongoing. On 10/20/21 and 10/21/21, clinical record reviews were conducted for Residents #106, #107, #108, #109 and #110. This review consisted of review of nursing notes, results tab for labs, nursing notes, assessments tab, misc. tab and the care plan. The survey team was not able to find documentation of Resident COVID-19 testing and results. On 10/21/21 at 10:35 AM, an interview was conducted with Corporate Clinical Director/Employee E and the DON (director of nursing). When asked about COVID testing results documentation both confirmed that results would be under the misc. tab within the EHR. Several of the sampled Residents records were reviewed with testing results unable to be found. The DON then took the surveyor to Medical Records Coordinator who confirmed she had no COVID-19 testing information waiting to be uploaded into the EHR. On 10/21/21 RN E, the Infection Preventionist, was able to provide the survey team with COVID testing logs which she maintained on her computer. The following Resident information was noted: 1. Resident #106 was recorded on the logs as being tested for COVID-19 on 10/7/21, 10/12/21, 10/14/21, and on 10/19/21 the Resident tested positive for COVID. 2. Resident #107 was recorded on the testing logs as having been tested for COVID-19 on 10/12/21, 10/14/21, and 10/19/21. 3. Resident #108 was noted to have had COVID-19 testing on 10/1/21, 10/5/21, 10/7/21, 10/14/21, and 10/19/21. 4. Resident #109 was noted as having been tested for COVID-19 on 10/1/21, 10/5/21, 10/7/21, 10/14/21, and 10/19/21. 5. Resident #110, was not noted on the log as having been tested for COVID-19. Resident #110 was admitted to the facility on [DATE]. RN E stated she was not aware if all of the tests were recorded in the EHR for Residents. The facility policy titled COVID-19 Testing was reviewed and did not indicate facility staff are to document the COVID testing or results in the EHR. The Centers for Medicare & Medicaid Services (CMS), Memo: QSO-20-38-NH, revision date 09/10/21, read . Facilities may document the conducting of tests in a variety of ways, such as a log of community transmission levels, schedules of completed testing, and/or staff and resident records. For residents, the facility must document testing results in the medical record . No further information as received prior to the end of survey.

Based on staff interviews, facility documentation review and clinical record review, the facility staff failed to have policies for COVID immunizations and failed to offer the COVID vaccine to 2 Residents (Resident #110 and #113), in a survey sample of 13 Residents. The findings included: 1. The facility failed to have a policy and procedure regarding the administration of COVID-19 vaccine administration with regards to the vaccine the facility was eligible to receive and have administered. On 10/20/21, Surveyor D reviewed the policy and procedures provided regarding COVID-19 vaccines. The facility provided policy was titled, [NAME] COVID-19 Vaccination. Surveyor D asked the facility Administrator and Corporate Clinical Director if they have policies for the other COVID vaccines that are available. Review of the COVID immunization log of Residents revealed that 2 Residents who were immunized at the facility (Resident #108 and #109) received the Pfizer vaccine. On 10/21/21 at 10:35 AM, the Corporate Clinical Director/Employee E and the DON (director of nursing) stated, We only have a policy for the [NAME] (J&J) and there is good reason. When the vaccines were gradually being approved, J&J was the one with the potential for us to store here and give here, so we developed a policy for that. It had the best potential for us to manage internally because we had the resources to do so. We were able to manage the acquisition, storage, mixing and administration of the others. We have never given Pfizer or Moderna internally, the health department gives it and we follow their instruction. We don't have the resources to keep the Pfizer and Moderna the storage is the barrier, the storage is the greatest challenge. On 10/21/21 at 11:47 AM, a phone call was placed to the facility's contracted pharmacy. Surveyor C spoke with the Pharmacy Corporate Director of Quality Assurance/Other Staff C, who stated, we have all 3 vaccines in stock and available, however I have to call the Maryland office to find out what vaccine is assigned to that region. On 10/21/21 at 12:00 PM, Other Staff C called the survey team and said, I checked with the Maryland office and they have told me that in that area the Federal mandates say that Moderna vaccine is allocated for that area. The management of storage of vaccine is not difficult because we only deliver on the day of the clinic. We do not just send the vaccine you must let us know first the date and time of your clinic and we will arrange for the transportation of the vaccine. On 10/21/21 at 1:39 PM, Other Staff C emailed Surveyor D and provided a document titled, Nurse Guide - Phase 2 COVID Vaccination Portal. The text of the email from Other Staff C stated, Please see attached Nurse/Facility guide that we provide to the facilities we service. Additionally, I confirmed with their assigned [pharmacy name redacted] Pharmacy Rep that the facility has been instructed on how to schedule a vaccine clinic with us but has not scheduled one to date. No further information was provided to the survey team prior to exit. 2. For Residents #110 and #113, who were eligible to be vaccinated, the facility staff failed to document in the clinical record evidence that they provided education and offered the COVID vaccination. On 10/20/21 at 11:28 AM, Surveyor D asked for a copy of the immunization logs for staff and Residents with regards to COVID immunizations. Review of the EHR for Residents #110, and #113 revealed the following: 1. Resident #110 had no indication in the EHR (electronic health record) of being immunized for COVID-19, no record of being offered the vaccine or provided education of the vaccine. Hospital records prior to admission to this facility, revealed the hospital communicated Resident #110's unvaccinated status for COVID-19, to the facility. 2. Resident #113 had no indication in the EHR (electronic health record) of being immunized for COVID-19, no record of being offered the vaccine or provided education regarding the vaccine. Review of the entire EHR, to include but not limited to Medication Administration Records (MAR's), Treatment Administration Records (TAR's), nursing notes, and care plans for each of the Residents noted above, revealed no further information in regards to their immunization status, the immunization being offered and education provided. On 10/20/21 at 10:26 AM, RN F was asked where immunization records/information is found for Residents. RN F said, under the immunization tab in the EHR. Employee G, the Assistant Director of Nursing and Employee C were at the nursing station and demonstrated where in the EHR the immunization tab. When asked, what if nothing is recorded there? Employee C stated, If they are admitted and we don't know their vaccination status, we treat them as if they are not vaccinated. We have an infection control nurse and she comes and looks at it. On 10/21/21 at 10:35 AM, the Corporate Clinical Director/Employee E and the DON (director of nursing) described the facility process for vaccinating Residents. They (Employee E and the DON) stated, RN E creates a list of Residents needing the vaccine and then calls the health department discuss the list. A conversation isn't held with the Resident until we get a date from the health department that they are coming. They (Employee E and the DON) confirmed that no documentation is made into the Resident's clinical record during this process. On 10/21/2021 at approximately 11 AM, Surveyor D met with RN E/the infection preventionist, and asked to review of the log of Resident's needing vaccines that she maintains. RN E provided a listing of current Resident's vaccination status log. The vaccination status log revealed the following: 1. Resident #110 was noted as consented to receiving the vaccine but the vaccine had not been administered. Nor was RN E able to provide evidence that they had communicated this request to the health department for administration of the vaccine. RN E stated that a staff member had shared with her that Resident #110 had consented but she still had to go talk to him before notifying the health department. 2. Resident #113 was noted on this log as none, no additional notes gave any indication that a conversation had been held with the Resident to discuss vaccination. Review of the facility policy titled COVID-19 stated, .the center should continue to encourage vaccination among new admissions 13. Education. c. Educate and re-educate as needed regarding benefits of becoming vaccinated. On 10/21/2021 at approximately 11:30 AM, during an end of day meeting, the facility Administrator confirmed that the health department had been at the facility just the week prior administering COVID-19 vaccine boosters. They were made aware that Resident's vaccination status was not available in the clinical record and there was no evidence of the vaccine being offered. The DON and Corporate Clinical Director/Employee E acknowledged understanding of the concern regarding the delay in offering vaccines and the lack of documentation in the clinical record of COVID vaccination status. No further information was provided to the survey team prior to exit.

Based on observation, staff interviews, clinical record review, and review of facility documents, the facility staff failed to implement infection control practices as recommended by CDC (Center for Disease Control) to prevent the transmission and spread of COVID-19 within the facility. The facility staff failed to 1) utilize appropriate source control while in an active COVID outbreak, 2) failed to properly don [put on] and doff [take off] PPE (personal protective equipment) when providing care to Residents on isolation for COVID-19, and 3) failed to properly wear N95 masks to prevent the spread of infection. The findings included. 1. Facility staff failed to implement CDC and CMS source control during an active COVID-19 outbreak. On 10/20/21 at approximately 11 AM, Surveyors C & E went to the laundry room. Upon entrance to the laundry room, Employee K, the Housekeeping/laundry supervisor was observed to be wearing a procedure mask and no eye protection. Surveyors C & E questioned him about it, and he indicated this was permissible. Around the corner, observation of the clean laundry area revealed 5 employees standing in close proximity, not socially distanced and 4 of the 5 were not wearing PPE. Three employees (Employee J, the maintenance assistant, and 2 housekeeping/laundry workers, Employee L and Employee M) were all observed with no mask. When asked they stated they were on break. On 10/20/21 at approximately 11:32 AM, the DON (Director of Nursing) and the Corporate Clinical Director/Employee E approached the Surveyors in the lobby. When questions were asked N95 mask use, Employee E stated they are worn in patient care areas. When asked about employees gathering in laundry, not socially distanced, and not wearing masks, Employee E stated, we allow fully vaccinated staff mask breaks. On 10/20/21 at 2:20 PM, an interview was conducted with RN E, the infection preventionist and Employee C, the staff development coordinator. They were asked about mask use. Employee C stated, we've talked to everyone there was a time that just on the COVID units we required N95's, but now all clinical staff should be wearing a N95. When asked about non-clinical staff, Employee C said We recommend N95's but some wear a surgical mask, if they are not in a mask they are to be socially distanced. Employee C confirmed that laundry for the COVID positive/hot unit and the COVID exposed/warm unit are laundered in the same laundry area. Review of the CDC community transmission rate for the County, revealed the County was at a substantial level. Accessed online 10/20/21, at: https://covid.cdc.gov/covid-data-tracker The CDC guidance read, Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission. Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html 2. Facility staff failed to properly don and doff PPE when caring for Residents under isolation for COVID-19 and; 3. Failed to wear N95 properly. On 10/19/21 at 1:15 PM, CNA B was observed in the hallway on the first floor/hall 3, with an isolation gown on. Upon approach and inquiry by Surveyor D, CNA B stated that Resident #106, whom she had been providing care to, had tested positive for COVID-19. CNA B confirmed she should have doffed her isolation gown before exiting the room. During this interview, it was observed that CNA B had no eye protection on. When asked, CNA B said my face shield is down there [pointing towards the nursing station]. CNA B confirmed she had been providing care to Resident #106, who was COVID positive without the eye protection. CNA B acknowledged she should have had eye protection on. CNA B was also observed to have a procedure mask underneath of her N95. Surveyor D asked why she was wearing 2 masks and CNA B said for my own protection I double mask. Continued observations of CNA B throughout the day revealed no correction to the order of which she had masks on. On 10/19/21 at 1:41 PM, LPN C was observed standing at a medication cart on the second floor in the warm zone which housed Residents who had a direct exposure to COVID-19, with an isolation gown on. LPN C confirmed that hall 3 was the hot unit and contained COVID positive Residents and she had been working the hot unit and was still wearing the isolation gown she had worn in the hot unit and should have doffed it before entering the warm area of the unit. On 10/20/21 from 10:14 AM until 10:35 AM, observations were made of LPN D, who was observed at a medication cart on the 2nd floor/hall 2. LPN D confirmed this hall was the warm unit and housed COVID exposed Residents. Signage was noted outside of each room to indicate the Residents were on transmission based precautions. LPN D was observed to have a procedure mask on under her N95 mask, and had no eye protection on. LPN D was observed to enter rooms [ROOM NUMBERS] during the observation period. LPN D did not don [put on] eye protection or make corrections of her mask while providing medication to the Residents and being in close contact with the Residents. On 10/20/21 at 1:34 PM, a telephone interview was conducted with the public health nurse with the local Department of Health, [further identified as: Other B]. Other B stated for source control, the health department has recommended all staff to wear masks at all times, but consistent adherence to PPE use has been an ongoing challenge for facility staff to comply with. On 10/20/21 at 2:20 PM, an interview was conducted with RN E, the infection preventionist. RN E was asked about double masking and said, We don't recommend 2 masks. If I see it I tell them not to, the N95 and eye protection is enough. Employee C, the staffing coordinator said wearing the procedure mask under the N95 breaks the seal. We have talked to them [the staff] so much about this. Employee C and RN E both confirmed that Residents on the 2nd floor hall 2 are in the warm zone and are on TBP. Employee C stated that staff compliance with donning proper PPE and proper wearing of N95 masks has been an ongoing challenge. RN E confirmed the observations noted above were not compliant with facility requirements or CDC guidance. The CDC gives the following guidance regarding PPE to be worn: HCP [health care personnel] caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html CDC guidance on wearing an N95 stated, The respirator must fit snugly against the user's face to ensure that there are no gaps between the user's skin and respirator seal. Accessed online at: https://www.cdc.gov/niosh/npptl/pdfs/KeyFactorsRequiedResp 018-508.pdf Additional CDC guidance read, How to Properly Put On and Take off a Disposable Respirator: Do not allow facial hair, hair, jewelry, glasses, clothing, or anything else to prevent proper placement or come between your face and the respirator. Accessed online at: https://www.cdc.gov/niosh/docs/2010-131/ No further information was provided prior to the conclusion of the survey.

Based on observation, staff interviews, and facility documentation review, the facility staff failed to secure 1 out of 3 treatment carts and 2 out of 3 medication carts, located on the first floor, within resident care areas. The findings included: The facility staff failed to secure 1 treatment cart and 2 medication carts, on the first floor, within resident care areas. On 10/19/21 during initial tour of the facility, Surveyor C and Surveyor D made the following observations: At approximately 1:12 PM, Surveyor C observed an unattended and unlocked treatment cart located on Hall 2 of the 1st floor. Surveyor C opened a drawer and found a variety of treatment items including labeled prescription ointments and creams. An interview was conducted with RN B who stated, The cart should be locked. RN B also stated, The risk of leaving it unlocked is that residents who are cognitively impaired could access treatment medications. At approximately 1:15 PM, Surveyor D observed an unattended and unlocked medication cart located on Hall 3 of the 1st floor with a medication card laying on top of the cart containing 24 tablets labeled Senna 8.6mg. An interview was conducted with RN B who stated, Medications should be secured because residents with cognitive impairments could get them with them laying on top of the cart, the cart should also be locked up. At approximately 1:30 PM, Surveyor C observed an unattended and unlocked medication care located on Hall 1, 1st floor. An interview was conducted with RN D who confirmed the observation and stated the medication cart should be locked at all times while unattended to prevent unauthorized access to the medications. Review of the facility policy entitled, Storage of Medications, revision date 08-2020, Policy read, Medications and biologicals are stored safely, securely, and properly the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The same policy with subheading, Procedures, item 2 read, Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access. The Facility Administrator and Director of Nursing were notified of the findings. No further information was provided. Complaint related deficiency

Based on staff interviews, clinical record review, and facility documentation review, the facility staff failed to follow professional practice standards in the administration of medications for 1 Resident, Resident #101, in a survey sample of 13 Residents. The findings included: For Resident #101, the facility staff failed to administer 2 medications, [MEDICATION(S)] and [MEDICATION(S)], as ordered by the physician on 6/30/21. Resident #101 was admitted to the facility on [DATE] and discharged on [DATE]. In the course of a complaint investigation, on 10/20/21, the closed clinical record for Resident #101 was reviewed in its entirety, with particular attention given to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .give 1 tablet by mouth one time a day for [CONDITION(S)] [hypertension, high blood pressure]. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] =Other/See Progress Notes was documented. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .give 1 tablet by mouth in the evening for fluid retention. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] =Other/See Progress Notes was documented. Review of Progress Notes revealed an entry on 6/30/21 at 15:44 PM that read, [MEDICATION(S)] LA Tablet Extended Release 24 hour 360mg .new order awaiting from pharmacy at this time. There was no Progress Note on 6/30/21 that referenced the [MEDICATION(S)] as noted on the MAR. An interview was conducted with the Director of Nursing (DON) who confirmed the ordered doses of [MEDICATION(S)] and [MEDICATION(S)] were not given to Resident #101 on 6/30/21. The DON stated, the nurse made a mistake, the nurse did not document a reason for not giving the medications, I'm not sure why but I would have expected to see a nurse note for a reason and also for notification to the doctor about this situation. The DON cited Lippincott as the resource used for professional nursing standards. Guidance was given from Lippincott, Fundamentals of Nursing, which reads: To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to these rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation Review of the facility's policy entitled, Administration Procedures for All Medications, revision date 08-2020, subheading Procedure, item III read, At a minimum, review the 5 rights at each of the following steps of medication administration. COMPLAINT RELATED DEFICIENCY

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to implement their immunization policy and ensure each Resident is offered an influenza and pneumococcal immunization, unless medically contraindicated or they have already been immunized for 2 Residents (Resident #106 and #107), in a survey sample of 13 Residents. The findings included: Review of clinical records for Residents revealed the following immunization information: 1. Resident #106 had been a Resident of the facility since 10/5/21. The immunization tab of the EHR (electronic health record) there was no record of pneumonia vaccine being offered or administered. Under the misc. (miscellaneous) tab there was an immunization record from VIIS (Virginia Immunization Information System) scanned in. Review of this document revealed no evidence of Resident #106 receiving a pneumonia vaccination. 2. Resident #107 had been a Resident of the facility since 10/8/21. The immunization tab of the EHR there was no record of influenza or pneumonia vaccines being offered, education provided, consent or refusal of the immunizations. Under the misc. (miscellaneous) tab there was an immunization record from VIIS scanned in. Review of this document revealed no evidence of Resident #107 receiving an influenza or pneumonia vaccination previously. Review of the entire EHR, to include but not limited to Medication Administration Records (MAR's), Treatment Administration Records (TAR's), nursing notes, and care plans for each of the Residents noted above, revealed no further information in regards to their immunization status, the immunization being offered and education provided. Both Residents (#106 and #107) had physician orders on the day of admission that read, Flu vaccine annually as indicated and Pneumonia vaccine per protocol. On 10/20/21 at 10:26 AM, RN F was asked where immunization records/information is found for Residents. RN F said that they are found, under the immunization tab in the EHR. Employee G, the Assistant Director of Nursing and Employee C were at the nursing station and demonstrated where in the EHR the immunization tab. When asked, what if nothing is recorded there? Employee C stated, If they are admitted and we don't know their vaccination status we treat them as if they are not vaccinated. We have an infection control nurse and she comes and looks at it. On 10/21/21 at 8:13 AM, the facility Administrator was made aware of the inability to find the above noted vaccine information for Resident #106 and #107 as aforementioned. The Administrator emailed Surveyor D and stated, [Resident #106 name redacted]: The pneumonia vaccine has not been offered yet but it will be. [Resident #107 name redacted]: Pneumonia is the same as above. On 10/21/21 at 9:19 AM, the facility provided the survey team with a document that Resident #107 was educated about the influenza vaccine and declined it on 10/19/21. This document was not in the EHR for Resident #107. On 10/21/2021 at approximately 10 AM, Surveyor D met with Employee C, the staff development coordinator and previous infection preventionist for the facility, and RN E, the current Infection Preventionist. RN E accessed Resident #106 and #107's EHR and was unable to find information about the above noted immunizations being offered to the Residents, it being administered or declined, or education being provided. On 10/21/21, Employee C and RN E stated that the facility was giving flu vaccines to Residents on 10/19/21. RN E stated, they were still working on pneumococcal vaccines. Review of the facility policy titled, Influenza and Pneumococcal Vaccinations was conducted. Excerpts from this document read, 1. Influenza Vaccination, c.The center will check the immunization status of patients admitted during the flu season. Those who have not had a flu shot will be offered one upon admission. Section 2 read, Pneumococcal Vaccination. f. A patient pneumococcal vaccine tracking log will be maintained by the infection preventionist New patients names will be placed on the log at the time of admission and offered the pneumococcal vaccination if not received as indicated. On 10/21/2021 at approximately 11:40 AM, during an end of day meeting the facility Administrator, Director of Nursing and Corporate Clinical Director were made aware of the facility staff's failure to determine vaccine status and offer the influenza and pneumococcal vaccines and education to Residents and document such in Resident records. No further information was provided.

Based on resident medical record reviews, facility policy review, and resident and staff interviews, it was determined the facility failed to ensure four of four sampled residents reviewed for Advance Directives and resuscitation status (Resident (R) 34, R31, R43, and R32) were offered the opportunity to formulate an Advance Directive or make decisions regarding their code status. Findings include: 1. Review of R34's Clinical Patient Profile located under the Profile tab in the electronic medical record (EMR) revealed the resident was admitted to the facility from an acute care hospital on [DATE] and was documented to be a full code resuscitation status. Review of the Miscellaneous tab in R 34's EMR revealed no documentation of the full code resuscitation status. Review of the hospital Discharge Record dated [DATE], revealed a copy of the Code Status assigned during admission to the acute care hospital, which indicated he was a full code while hospitalized . Review of R34's Admission Minimum Data Set (MDS), located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of [DATE] indicated R34 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact for decision making. Review of R34's Progress Notes located under the Progress Notes tab in the EMR, from the date of admission through [DATE], revealed no documentation of codes status or advance directives were discussed with the resident at the time of admission or at any time after admission. Review of R34's MFA Policies Governing the Implementation of Self-Determination Rights provided by the facility's Director of Admissions, revealed, .2. At the time of admission and as part of the admission process the admission designee will ask the Resident if he or she has an advance directive or if he or she wants more information regarding advance directives . Further review of this document revealed R34 did not have an advance directive and did not want more information regarding advance directives but was no signed upon admission but signed on [DATE]. The resident signed the document on [DATE], after it was requested from the Director of Admissions. 2. Review of R31's Clinical Patient Profile located under the Profile tab in the EMR revealed the resident was admitted to the facility on [DATE] and had a do not resuscitate code status. Review of the Miscellaneous tab in R31's EMR revealed the resident and a physician had signed a Do Not Resuscitate (DNR) form on [DATE]. Review of R31's Admission MDS, located under the MDS tab in the EMR, with an ARD of [DATE] indicated R31 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact for decision making. Review of the Progress Notes located under the Progress Notes tab in the EMR revealed a Physician's Progress Note dated, [DATE] which indicated the resident was a Full code. Review of R31's MFA Policies Governing the Implementation of Self-Determination Rights provided by the facility's Director of Admissions and dated [DATE], from a previous admission to the facility, was signed by the resident as her own responsible party. Review of the document revealed no documentation by the resident or the Admission Representative to indicate responses to the following statements on the form: I have been provided written information regarding my rights to make medical decisions under Virginia state law which includes my right to accept or refuse treatment and my right to formulate advance directives. Neither Yes nor No were marked on the form. I have been provided with written Health & Rehabilitation Center policies governing the implementation of self-determination rights. Neither Yes nor No were marked on the form. I understand that I will not be discriminated against based on my decision to execute or not execute an advance directive. Neither Yes nor No were marked on the form. The Advance Directives Acknowledgement section of this form was also blank of responses as to whether R31 had or had not executed an Advance Medical Directive or if the resident did or did not want more information regarding advance directives. 3. Review of R43's Clinical Patient Profile located under the Profile tab in the EMR revealed the resident was admitted to the facility on [DATE] and had a full code resuscitation status. Review of the Miscellaneous tab in R43's EMR revealed no documentation of the full code resuscitation status. Review of R43's Admission MDS, located under the MDS tab in the EMR, with an ARD of [DATE] indicated R43 had a BIMS score of six out of 15, which indicated the resident was severely cognitively impaired. Review of the quarterly MDS with an ARD of [DATE] and the quarterly MDS with an ARD of [DATE] indicated R43 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of R43's Progress Notes located under the Progress Notes tab in the EMR, from the date of admission through [DATE], revealed no documentation of codes status or advance directives were discussed with the resident at the time of admission or at any time after admission. Review of R43's MFA Policies Governing the Implementation of Self-Determination Rights provided by the facility's Director of Admissions and dated [DATE], was signed by the resident as her own responsible party. Review of the document revealed no documentation by the resident or the Admission Representative to indicate responses to the following statements on the form: I have been provided written information regarding my rights to make medical decisions under Virginia state law which includes my right to accept or refuse treatment and my right to formulate advance directives. Neither Yes nor No were marked on the form. I have been provided with written Health & Rehabilitation Center policies governing the implementation of self-determination rights. Neither Yes nor No were marked on the form. I understand that I will not be discriminated against based on my decision to execute or not execute an advance directive. Neither Yes nor No were marked on the form. The Advance Directives Acknowledgement section of this form was also blank of responses as to whether R31 had or had not executed an Advance Medical Directive or if the resident did or did not want more information regarding advance directives. 4. Review of R32's Admission MDS assessment with an ARD of [DATE] revealed he was admitted to the facility on [DATE] and had a BIMS score of 15, indicating he was cognitively intact. Review of R32's Clinical Patient Profile located under the Profile tab of his electronic health record, revealed R32 was a full code resuscitation status. Review of R32's Interdisciplinary Team (IDT) notes, located under the Progress Notes tab of his electronic health record for [DATE] at 11:35 AM revealed the IDT offered R32 information on advanced directives, but the resident did not want them. Review of R32's Admission Agreement, dated [DATE] and obtained from the facility's Director of Admissions, revealed an MFA Policies Governing the Implementation of Self-Determination Rights. Further review of the document revealed, . It is the policy of this Health and Rehabilitation Center to initiate cardiopulmonary resuscitation (CPR) as a resuscitation procedure . except when the resident's physician has specifically and appropriately documented a valid Do Not Resuscitate (DNR) order in the resident's permanent medical record . An interview with Registered Nurse (RN) 4 on [DATE] at 9:18 AM revealed she was the charge nurse for R32 that day, worked most days in the facility, and was responsible for completing admission assessments when residents were admitted to the facility. She stated she would have to review R32's record to see what his code status was, but the facility used whatever code status the hospital nurse gave in a verbal report when the resident was admitted to the facility. RN4 stated her duties when admitting a resident did not include review of their code status. On [DATE] at 10:33 AM and interview with R32 revealed he was not aware the facility considered him a full code resuscitation status and had not been educated as to his options or asked to make a choice. R32 stated he recalled being offered to formulate a living will but did not think he needed one because his wife was available for decisions if needed. R32 stated, That's one of the troubles around here. They don't make things clear all the time. There is nothing wrong with my mind, but they really do treat me like an invalid that way. I'm perfectly capable of understanding these things and making a choice. On [DATE] at 11:41 AM an interview with the Assistant Director of Nursing (ADON) revealed the facility did not typically have a discussion with a resident regarding their code status and did not have them sign a document indicating their choice. The ADON stated the facility typically accepted verbal report from the hospital and entered that information as the resident's code status. The ADON stated the Director of Nursing (DON) would know more about how the facility included the resident in their code status options. On [DATE] at 11:43 AM and interview with the DON revealed he did not consider determination of code status to be a nursing function, but perhaps the facility's discharge planners would know more about it. On [DATE] at 11:45 AM an interview with the Director of Discharge Planning (DDP) revealed the facility's Interdisciplinary Team (IDT) met with R32, as with all residents after admission, and offered them the opportunity to formulate a living will, designate a surrogate health care decision maker, or make an anatomical gift, but did not discuss a resident's code status. The DDP stated such a discussion would be had with the nurse who admitted the resident to the facility. The DDP reviewed R32's clinical record but could not find documentation from either the nursing staff or the resident's physician that his code status had been discussed with him. On [DATE] at 1:45 PM an interview with the Director of Admissions revealed a resident's code status was not something discussed with them on admission, and there would be no documentation residents had been offered a choice on their code status. An interview with the Administrator on [DATE] at 1:55 PM revealed the facility receives a verbal report from the hospital regarding a resident's code status prior to admission, which is not necessarily documented anywhere from either the hospital or the facility. The Administrator stated when a resident arrived in the facility, the nurse was supposed to verbally inform them of their code status, but there was not a designated time, person, or procedure to ensure the resident was able to make their own choice. Review of the facility's Patient Self Determination Act policy, number 502, dated [DATE], revealed, . Explain to the patient the right to make advanced directives about his/her care. There are three (3) types of decisions about health care in an advanced directive that can be made by the patient. Living Will . Appointment of an Agent to Make Health Care Decisions . Appointment of an Agent to Make an Anatomical Gift . The policy did not address the resident's right to determine their code status.

Based on observation, interview, and facility policy review the facility failed to ensure medications were secured and outdated medications were discarded. As a result of this deficient practice medications past their effective date may have been administered for two of two medication carts inspected for outdated medications. Findings include: 1. On [DATE] at 4:49 PM, on the second floor in the office area for charge nurses, outside the unit manager's office, the door was open, and medications were sitting on the counter unsecured. The medications were six cards of bubble packed variety of medications, eye drops and two [MEDICATION(S)] injection doses (anticoagulant). On [DATE] at 4:50 PM the Registered Nurse (RN) 1 confirmed the six bubble pack cards of medications, eye drops and two [MEDICATION(S)] doses should not be sitting on the counter in the office and should be secure. The medications should never have been left on the counter in the office. 2. On [DATE] at 3:05 PM, in the medication cart identified as third assignment cart, first floor a bubble pack card with five doses of the medication Mi-Acid (Gas-x) with the expired outdate of [DATE] was in the cart available for administration. The resident no longer had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 3:08 PM, the Licensed Practical Nurse (LPN) 4 verbalized the Mi-Acid medication was outdated and confirmed it should not be on the medication cart because when the medications is given after the expiration date it may not be effective. 3. On [DATE] at 3:35 PM, in the medication cart identified as first cart, second floor a bottle of Nurticia Fiber-STAT, soluble fiber prune flavor with and expired outdate of [DATE] and a bottle of Nurticia [CONDITION(S)]-STAT urinary tract protection cranberry with an expired date of [DATE] were found in the right bottom drawer of the cart. On [DATE] at 3:37 PM, the LPN 2 confirmed the two bottles of Nurticia were outdated and should not have been in the cart and should have been discarded. Review of facility policy titled Storage and Expiration of Medications, Biologicals, Syringes and Needles, revised [DATE], revealed the facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. The facility should ensure that medications and biologicals that have an expired date on the label . are stored separate from other medications until destroyed.

Based on observation, policy review, and interview it was determined the facility failed to protect the dignity of two of 20 Residents (R) (R 211 and R226). This failure created the potential for residents to experience decreased feelings of self-worth. Findings include: 1. Review of R226's Census tab of her electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Review of her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 03/18/21 at 1:11 PM revealed R226 arriving at the facility for admission on a gurney via non-emergent transport. A continuous observation on 03/18/21 from 1:54 PM to 2:39 PM revealed R226 sitting in her room next to her bed with a meal tray with a hot dog on her overbed table, calling out for help in a distressed manner. Certified Nursing Assistant (CNA) 1 approached the doorway to R226's room and asked what she needed. R226, still in a distressed manner, Is this beef? I don't eat pork. I can't have pork. CNA1 stated from the doorway, Yes, it's beef. No pork. Just eat it, closed the door and left the room without waiting for R226 to respond. Continued observation on 03/18/21. At 2:00 PM, through the closed door, R226 could be heard calling out loudly for help. R226's roommate opened the door to the room and called out for someone to help R226. Physical Therapy Assistant (PTA) 2 exited the room across the hall and stated she would get the nurse. R226 was calling out for assistance as PTA2 entered the hallway but the PTA did not respond to R226's requests, PTA2 walked down the hall away from R226, past the nurse and the nurse's station, without speaking to the nurse. Two minutes later the PTA returned to the nurse's station and spoke to Registered Nurse (RN) 4. At 2:05 PM PTA2 approached R226's room with R226 still calling for help. When R226 saw PTA2 approach the doorway she called out, I don't like this! I need catsup referencing her hot dog. PTA2 told R226, I told your nurse. She's going to get you some medication. R226 asked PTA2 if her hot dog had contained pork, to which PTA2 stated, That's a turkey hot dog. R226's roommate (R224) then moved her wheelchair to a position where she was facing R226 and tried to help her eat. Continued observation on 03/18/21. At 2:06 PM, RN4 entered R226's room, stating as she entered the room, Eat your hot dog. You need to try to eat it, as she closed the door. From inside the room R226 could be heard calling out, I don't like it! I want catsup! Through the closed door, R226's tone became increasingly distressed and pressured, increasing in volume as she asked RN4 repeatedly for assistance. At 2:09 PM, RN4 left the room with R226 continuing to ask for assistance. At 2:11 PM R226 could be heard calling in a distressed tone from inside the room, I can't eat a hot dog! I can't eat a hot dog! Please help me! Please, please help me! Continued observation on 03/18/21. At 2:13 PM CNA1 approached R226's room with a tray containing a sandwich and a beverage. CNA1 knocked on the door, opened it enough for R226 to see the meal, then backed away allowing the door to close behind her. R226 began calling out, No! Don't go! Please leave the sandwich! CNA1 stated quietly towards the closed door, Wait a minute, then carried the meal tray down the hall from R226's room. R226 could be heard inside the room calling out, I can't reach the light! I can't reach the light! At 2:16 PM, CNA1 returned with the tray containing the sandwich and beverage. As she entered R226's room, R226 began to call out, Please come over here! Please come over here with the sandwich! followed by, It's not grilled! I asked for a grilled cheese sandwich! CNA1 responded, We don't have anything else. R226 stated, Can't you grill it? I asked for a grilled cheese! RN1 approached R226's room and stated, What else do you want, so I can let the kitchen know. R226 stated, I don't know what else you have. RN1 responded, OK, then both RN1 and CNA1 left the room. Continued observation on 03/18/21. At 2:21 PM R226 could he heard calling out loudly from inside her room, Please, please help me now! Her cries for help became louder with a more pressured and anxious quality over the next few minutes, with R226 adding, I need to go pee! I need to go pee! At 2:24 PM, with R226 calling out for assistance for the bathroom, CNA1 arrived with a plate with a grilled cheese sandwich, placed it on the overbed table in front of the resident, picked up the previous meal tray, and left the room. Though R226 had been calling out for the bathroom as CNA1 approached the room, the CNA did not inquire or offer to assist with toileting needs. Continued observation on 03/18/21. At 02:33 PM R226 began calling, Nurse! Nurse! At 02:34 PM R226's roommate entered the hallway and called out, Hello! Yeah, she wants to go to the bathroom. Upon hearing that, R226 called out, I don't know where the bathroom is! and even more loudly, Nurse! I gotta go to the bathroom. [R226's name]! At 2:39 PM RN1 and RN4 approached the room to assist R226 to the bathroom. An interview with the Director of Nursing (DON) and Nurse Consultant on 03/18/21 at 4:00 PM revealed, The situation was not handled to our expectation. We don't know the status of the patient at the time. Maybe the food was the catalyst. There was no reprimand acknowledged to the employees related to the staff response to R226 by the facility. 2. An interview and observation with R211 on 03/16/21 at 12:42 PM revealed a commode in the resident's room near the foot of his bed. The receptacle for his waste was a round pink wash basin approximately six inches deep. R211 stated, That's not the right bucket under there and I know it. When I use the commode my own stuff splashes back up on me. And if I have a bowel movement, well, there's no way to clean myself without getting that all over my hands. I was in the Marines and fought in a war, but even in the field I had a more dignified way to relieve myself than here. R211 stated facility management was aware of the basin under his commode but had not acted on it. On 03/18/21 at 11:15 AM, the Administrator and Director of Nursing (DON) were shown the commode in R211's room. R211 was present at the time. The Administrator stated, That's not the right container, that's not deep enough. If someone would have brought it to my attention, I would have fixed it. R211 stated, You have been in this room before when this was here. You sat in a chair right next to it for an hour when I gave you my complaints at least a week ago. I shouldn't have to point it out or complain, you should know just by being another person that isn't deep enough. Review of the facility's Resident Rights section of their Admission Agreement in use at the time of survey revealed, . It is the policy at this Health and Rehabilitation Center . that all residents shall have the following rights . To be treated with consideration, respect, and full recognition of his/her dignity and individuality, including in privacy in treatment and in care for his/her personal needs .