Every finding on record at Carroll Lutheran Village

Based on observations of the facility's kitchen, review of kitchen records, and interview of dietary staff, it was determined that the facility failed to store food items to maintain the integrity of the specific item, and prevent ice from building up on the floor in the walk-in freezer. These deficient practices have the potential to affect all residents served food out of the facility's kitchen identified during the recertification survey. The findings include: Surveyor's initial observation of the kitchen, accompanied by dietary shift supervisor #23 on 05/29/25 at 08:36 AM, revealed that: - Caramel topping, artificially flavored, was dated as 04/24 without labeling the year. - Black mission figs from Jeppe Nut Company were labeled as 04/21, without mentioning the year. - The bread rolls' expiration date was noted as 05/26/25, and the hot dog bread expired on 05/20/25. - Noted open container of Orange natural flavor extract, without an open date. Noted the label received on 4/24. On 05/29/25 at 08:36 AM, the surveyor interviewed Dietary staff # 24 who stated that the labels should have a complete date, including the year, or it should have a label of best use by; their labeling gun cannot add the year for the label. They will come up with a different process, including the complete date. Staff # 24 also added that their culinary team, whoever is at work, checks the expiration of bread every day except Sundays. On 05/29/25 at 09:20 AM, surveyor observation of the cold storage revealed that small pieces of ice were noted on the floor, making the floor wet and slippery. On 06/02/25 at 11:30 AM, in cold storage, two of the storage shelves had boxes stacked up to the ceiling, leaving less than an inch of clearance from the ceiling. On 06/02/25 at 11:45 AM, findings were reviewed with Dietary staff #24 and reviewed with the Nursing home administrator.

Based on medical record review, and staff interviews, it was determined that the facility failed to review and revise care plans by Interdisciplinary team (IDT) members, when quarterly, annual, and significant change assessments were completed. This was evident for one resident (#44) of the 29 Residents reviewed for the care plan participation during the recertification survey. The findings include: The interdisciplinary team meets and develops care plans once the facility staff completes a comprehensive resident assessment. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and ensuring the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment of the resident to ensure the interventions on the care plan are accurate and appropriate for the resident. Review of the medical record on 06/05/25 at 09:57 AM revealed that Resident # 44 had been a resident at the facility for more than a year, receiving long-term care. Comprehensive assessments for Resident #44 were completed on 2/22/24, 08/20/24, 11/19/24, and 2/13/25. IDT care plan attendance did not reflect the signatures of the GNA and the physician. On 06/06/25 at 11:49 AM, the surveyor reviewed care plan attendance and participation of required members with Director of Nursing (DON) and Nursing Home Administrator (NHA) who acknowledged that the Geriatric Nursing Assistant and the Physician did not participate in care plan meetings on the four above-mentioned dates and stated that they will develop a system to include them. Both agreed that they will develop a system that will involve all required members to attend.

Based on observation, medical record review, and interview, it was determined the facility staff failed to follow physician orders and label oxygen tubing and humidifier bottle when changed. This was evident for 1 (Resident #20) of 29 residents reviewed during a recertification/complaint survey. The findings include: Oxygen (O2) therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from your health care provider. On 5/29/2025 at 9:35 AM during initial pool screening, surveyor observed Resident #20 in bed. The resident was wearing a nasal cannula (a device that delivers extra oxygen through a tube and into your nose) that was connected to a humidifier (water) bottle connected to an oxygen concentrator set at 4LPM (liters per minute). The LPM oxygen flow rate of 4 indicates that 4 liters of oxygen should flow into the resident's nose in 1 minute. There was no date/time and/or staff initials noted on both the oxygen tubing and humidifier bottle. When asked the resident stated the oxygen tubing was changed last week but s/he could not remember the exact date/day the oxygen tubing and/or humidifier bottle were changed. On 5/29/2025 at 9:45 AM, Registered Nurse (RN #2) verified and confirmed that Resident #20's oxygen tubing and humidifier bottle were not labelled with the date/time they were hung. She stated that both the oxygen tubing and humidifier bottle should be changed at least once a week and should be dated. RN #2 further stated she was going to change both the oxygen tubing and humidifier bottle right away so as to label them. On 5/29/2025 at 10:25 AM, in an interview with the Director of Nursing (DON), surveyor reviewed the above observations regarding Resident #20's oxygen tubing and humidifier bottle not labeled as per physician orders. DON stated she was aware of surveyor's observation and they were in the process of doing an audit of all the residents on oxygen to make sure the tubing and humidifier bottles were dated. During a review of Resident #20's medical record conducted on 6/2/2025 at 8:54 AM, surveyor noted an active physician order dated 4/29/2025 for: Oxygen at 4L/min via nasal cannula continuous to maintain SPO2 > greater than 90% every shift. There were additional orders dated 5/5/2025 for Change Oxygen tubing and humidifier bottle weekly. Date and initial, every night shift every Mon. On 6/2/2025 at 9:03 AM, review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) for May 2025 revealed staff documentation that the oxygen tubing and humidifier bottle were changed on Monday 5/26/2025. However, when surveyor observed the Oxygen tubing and humidifier bottle on 5/29/2025, there was no date/time and/or initial to indicate that the oxygen tubing and humidifier bottle had been changed as per physician orders.

Based on medical record review and interview, it was determined the facility staff failed to ensure that a resident was given pain medication consistent with professional standards of practice. This was evident for 1 (Resident #20) of 29 residents reviewed during a recertification/complaint survey. The findings include: Review of Resident #20's clinical records on 6/2/2025 at 8:40 AM revealed the resident was admitted to the facility in April 2025 with medical diagnoses that include but not limited to unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing, unspecified atrial fibrillation, chronic obstructive pulmonary disease with (acute) exacerbation, acute and chronic respiratory failure with hypoxia. On 6/2/2025 at 8:54 AM, a review of physician orders for Resident #20 revealed the following orders: - Tylenol Oral Tablet 325 MG (Acetaminophen), Give 2 tablets by mouth every 4 hours as needed for pain/fever Do not exceed 3000mg/day, start date 4/29/2025. [Of note: this PRN (as needed) order has no parameters for administration] There were also discontinued orders for: - Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl), Give 1 tablet by mouth every 6 hours as needed for pain management 6-10, start date 4/29/2025 and discontinued on 5/14/2025, and - Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl), Give 1 tablet by mouth every 6 hours as needed for Pain 6-10 for 1 Week, start date 5/14/2025 and completed on 5/21/2025. On 6/2/2025 at 9:03 AM, record review revealed that Resident # 20's pain was not managed consistently: A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for May 2025 was completed. Staff documentation revealed that the resident was given: - Oxycodone 5 mg (1 tab) for pain outside ordered parameters (pain 6-10) on the following dates: On 5/1/2025 at 1938 (7:38 PM) for pain score of 5, 5/4/2025 at 2058 (8:58 PM) for pain score of 5, 5/10/2025 at 0936 (9:36 AM) for pain score of 4, 5/10/2025 at 1536 (3:36 PM) for pain score of 5, 5/11/2025 at 1007(10:07 AM) for pain score of 5, 5/16/2025 at 0940 (9:40 AM) for pain score of 5, 5/18/2025 at 2238 (10:38 PM) for pain score of 5, and 5/19/2025 at 0402 (4:02 AM) for pain score of 5. - PRN Tylenol 325 mg (2 tabs) ordered without parameters for pain management was given multiple times (17 times) for pain scores ranging from 3 to 8: pain score 5 on 5/8/25 at 2024 (8:24 PM), pain score of 4 on 5/19/2025 at 2349 (11:49 PM), pain score of 6 on 5/20/2025 at 1358 (1:58 PM), pain score of 7 on 5/21/2025 at 2131 (9:31 PM), pain score of 8 on 5/22/2025 at 1409 (2:09 PM), pain score of 5 on 5/23/2025 at 0757 (7:57 AM), pain score of 3 on 5/24/2025 at 0801 (8:01 AM) etc. On 6/2/2025 at 10:45 AM, an interview was conducted with Registered Nurse (RN #3), who has worked in the facility for about 2 years. Regarding administration of PRN pain medications, RN #3 stated that prior to giving any pain medication, he will assess the resident's pain and choice of pain med to be given will be based on physician orders/ordered parameters. He stated that Oxycodone was usually given for a pain score of 6 or greater. RN #3 added that for a pain score of below 6, he would give Tylenol and monitor resident for pain relief. If pain was not relieved by Tylenol, he (RN #3) will call the doctor and get an order to administer something else. RN #3 further stated that ordered parameters for PRN pain meds should always be followed. On 6/3/2025 at 9:35 AM, in an interview with the Director of Nursing (DON), surveyor reviewed Resident #20's MAR and TAR for May 2025 regarding pain management and staff not following ordered parameters for PRN pain med administration. DON reviewed and verified that the ordered PRN Tylenol did not have parameters for administration. She further verified that PRN Oxycodone was given outside ordered parameters on the dates noted above. DON stated that the PRN Oxycodone appeared to have been given by the same nurses and she (DON) was going to find out if they documented in the progress notes why the Oxycodone was given outside ordered parameters. On 6/3/2025 at 10:16 AM, in a follow up interview with the DON, she stated that she (DON) reviewed the nurses' progress notes and could not find any documentation why the nurses gave the PRN Oxycodone outside ordered parameters. She added that she will educate the nurses.

Based on observation, interview and record review, it was determined that the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents. This was evident for 1 (Resident #12) of 29 residents observed during the recertification/complaint survey. The findings include: On 5/30/25 at 8.49 AM during the initial tour of the facility, a round pink medication was found in a medication cup at Resident #12's bedside table with a half-empty cup of water. The resident was not in the room at the time. Staff #22 a Registered Nurse (RN), was called to the resident's room on 5/30/25 at 8: 55 AM and was shown the medication. She identified it as TUMs (Calcium Carbonate) prescribed for acid reflux and stated that it must have been left there by the night shift nurse. She stated that she has not given the resident her morning medications yet because the resident was in the dining room having breakfast. Staff #22 took the medication, discarded it with the half empty cup of water. A review of Resident #12's May 2025 Medication Administration Records (MAR) on 5/30/25 at 9:15 AM revealed that s/he was prescribed tums-calcium carbonate 600mg twice a day (BID), it was signed off as given on 5/29/25 by the night nurse. On 5/30/25 at 10:00 AM-the surveyor went back to interview the resident. S/he was asked about the medication left at the bedside. The resident stated that s/he was unable to swallow the medication because it was too big and would normally request to have it crushed. On 5/30/25 at 10:15AM, the Director of Nursing (DON) was made aware of the findings, she stated that she will follow up.

Based on a review of the medical record and staff interview, it was determined that the facility failed to ensure accurate documentation of staff communication with the Resident. This was evident for 1 (Resident # 64) out of 29 Residents reviewed for accurate medical records during the recertification survey. The findings include: The medical record must contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatments and/or services, and changes in his/her condition, plan of care goals, objectives and/or interventions. On 06/04/25 at 10:22 AM, Medical record review revealed that Resident #64 was admitted on [DATE], for short-term rehab, and his/her roommate was admitted during the weekend. Further review of documentation revealed that the Resident# 64 left the facility against medical advice on 03/23/25. On 06/04/25 at 10:59 AM, an Interview with the unit manager staff #14 revealed that the admission coordinator communicates with staff and residents regarding the new roommate. No documentation was provided on staff communication with the Resident, regarding upcoming, new roommate admission. On 06/04/25 at 11:31 AM, an interview with staff #11 revealed that, when he/she went to inform resident #64 regarding the new roommate, the Resident #64 told staff #11 that he/she does not like to have a roommate. Staff #11 told the Resident that the facility will review alternative arrangements. Staff #11 was unable to provide documentation to reflect the communication between the staff member #11 and Resident #64. On 06/04/25 at 11:39 AM, an Interview with the Director of Nursing (D.O.N) revealed that weekend Supervisor staff (#25) reported that the resident was offered alternatives, including a private room, but the Resident insisted on leaving along with a family member, against medical advice (AMA). DON was unable to provide any documentation that the supervisor spoke to the resident, offering alternatives. On 06/04/25 at 02:51 PM the surveyor reviewed with the D.O.N. and the Nursing Home Administrator (N.H.A) regarding the Resident's discharge against medical advice and staff not documenting the communication with the Resident, about the new roommate. Both of them acknowledged the concern.

Based on medical record and employee file review and interviews, it was determined that the facility failed to have an effective system in place to ensure that newly hired geriatric nursing assistants (GNA) demonstrated skills competency prior to being allowed to independently care for residents. This was found to be evident for two out of the two recently hired GNAs selected for review (GNA #28 and #32) and had the potential to affect all of the residents. The findings include: On 8/30/21, review of Resident #66's medical record revealed the resident had resided at the facility for several years and whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment, with an assessment reference date of 5/12/21, revealed that the resident required extensive assistance of one person physical assist for bed mobility, toilet use and personal hygiene, the resident was totally dependent on two person physical assist for transfers from bed to chair, and totally dependent on one person support for bathing. Further review of the medical record revealed that the resident had fallen out of bed on 5/19/21 while receiving care from a geriatric nursing assistant (GNA) who was an orientee. Review of the fall investigation documentation provided by the facility revealed the orientee that was providing care to the resident at the time of the 5/19/21 fall was GNA #28. Review of the statement written by the preceptor, GNA #29, revealed that GNA #29 was in the room at the time of the fall, but was providing care to the resident in the other bed, with the curtain pulled, so she was not witness to the fall. Review of GNA #28's employee file revealed that the GNA had a hire date of 5/11/21, had received general orientation training on 5/12, clinical training on 5/13 and dementia training on 5/14. GNA #28 was terminated from employment with the facility on 6/3/21. On 9/02/21 at 8:46 AM, the staffing coordinator (Staff #31) reported that she was a geriatric nursing assistant/certified medication aide who had worked at the facility for several years but only recently became the staffing coordinator. She reported that newly hired GNAs would have two days of orientation prior to 5 days of orientation with another GNA on the hall. The staffing coordinator reported that there was a new employee skills checklist sheet and that they have to give that sheet to him/her before the new GNA can be scheduled. She/he indicated that this checklist sheet would be reviewed by nursing. Review of a list of current employees provided by the facility revealed that GNA #32 had a hire date of 6/8/21. On 9/2/21 at 9:19 AM, the staff development nurse (Staff #30) reported that newly hired GNAs have 3 days of orientation prior to working on the floor with a preceptor for several days. The third day of orientation includes some skills competencies with her. The staff development nurse confirmed that there is a skill checklist sheet. Surveyor requested the completed skills checklist for GNA #28 and GNA #32. The staff development nurse reported the previous scheduler kept this documentation but that she would look for it. On 9/2/21 at 9:34 AM, the staff development nurse provided a blank copy of the Orientation Checklist for GNAs. She went on to report that she signs off for what she covers with the employee and was not sure if the form was reviewed by the Director of Nursing (DON). She also reported that she was not sure they would be able to provide the checklist for the two GNAs as requested . Review of the Orientation Checklist for GNAs revealed areas for the preceptor to date and initial for various resident care tasks and procedures. These tasks included, but were not limited to: bathing residents, repositioning and turning residents, bed operations and use of mechanical lifts. On 9/2/21 at approximately 10:00 AM, the DON reported that the Orientation Checklist for GNAs are supposed to go to the staff development nurse because it is supposed to go to the employee file. DON reported that she does not review these forms. Surveyor reviewed the concern that no documentation has been provided to indicate that the newly hired GNAs had demonstrated competency in basic skills and that there was no process in place to ensure that the Orientation Checklist for GNAs was being reviewed by a nurse. The DON reported she would find out if the unit nurse managers review the checklists. As of time of exit on 9/2/21 at 3:00 PM, no additional documentation or information had been provided regarding this concern.

Based on observations and interviews of the facility's kitchen, dietary staff and nursing staff, it was determined that 1) the facility failed to ensure food was stored and dated properly, 2) the facility failed to ensure food was stored and maintained in a safe manner to reduce the risk of foodborne illness, and 3) the facility failed to ensure sanitary practices were followed in accordance with professional standards for food service safety. This deficient practice has the potential to affect all residents. The findings include: 1. During a tour of the facility's dry food storage room conducted on [DATE] at approximately 10:56 AM, the Surveyor, Operations Manager of Dietary (Staff #6) and Executive Chef (Staff #7) observed 3 opened bags of peanuts undated, 2 opened bags of pecans undated, 1 bag of almonds opened to air with a label that had a written open date of ,d+[DATE], no date written for use by date, and 1 opened bag of sliced almonds that had a label with a written open date of ,d+[DATE] and no date written for use by date. During an interview conducted on [DATE] at approximately 11:02 AM, the Executive Chef #7 confirmed the policy was to securely close packages/bags once opened, write an open date, use by date, and use a date format of month and day. 2. During a tour of the facility's walk in refrigerator on [DATE] at approximately 11:19 AM, the Surveyor and Executive Chef #7 observed four 5 pound tubs of expired sour cream with an expiration date of [DATE], 1 opened package of undated grated Parmesan cheese, 1 opened package of undated blue cheese chunks, 1 opened package of undated Cotija cheese, 1 opened package of undated pepper jack cheese, and 1 carton of eggs with the top opened. The Surveyor and Executive Chef #7 observed several eggs cracked in the opened carton. During the continued tour, the Executive Chef #7 discarded the expired sour cream, the opened and undated cheeses and the carton of eggs that contained cracked eggs. During an interview conducted on [DATE] at approximately 11:25 AM, the Executive Chef #7 stated the policy is to immediately discard all food on the expiration date and write an open date, use by date, and use a date format of month and day once the food had been opened. 3. During a tour of the kitchen conducted on [DATE] at approximately 11:33 AM, the Surveyor observed Dietary Aid (Staff #8) carry milk cartons in his/her apron and placed the milk cartons on a cart. During an interview on [DATE] at approximately 11:35 AM, the Surveyor advised the Operations Manager of Dietary #6 of the Surveyor observation. The Operations Manager of Dietary educated the Dietary Aid #8 and requested that the milk cartons be discarded immediately. During a tour conducted of the nursing unit on [DATE] at approximately 9:35 AM, the Surveyor observed nurse #20 carry 3 milk cartons up against his/her chest and placed the milk cartons on top of the medication cart. During an interview conducted on [DATE] at approximately 9:36 AM, the nurse #20 confirmed he/she did not follow the expectation of the facility. The nurse #20 stated the facility's expectation was to handle all food and beverages in a sanitary manner. During an interview conducted on [DATE] at approximately 9:45 AM, the Surveyor advised the Assistant Director of Nursing (ADON) #16 of the Surveyor's observation. 4. On [DATE] at 9:24 AM, a tour of the facility's kitchen was conducted. The janitor's closet at the entrance of the kitchen was observed with multiple fruit flies in the air and on the walls above the floor sink. The floor sink drain was observed with food and debris in the drain. At 9:33 AM, multiple hotel pans were observed wet-stacked on the drying rack of the dish room. The Director of Dining Services was made aware of these findings at the time of observation.

Based on review of previous annual surveys and deficient practices identified during this survey, it was determined that the facility failed to have an effective Quality Assurance program as evidenced by the identification of deficiencies related to food safety requirements for the past 3 annual surveys and again during the current survey; and the identification of deficiencies related to Infection Prevention and Control on three surveys since the start of the COVID pandemic. The failure to identify and develop appropriate plans of corrections to correct quality deficiencies places all residents at risk. The findings include: 1. On 9/2/21 review of the deficiencies identified during the last 3 annual surveys revealed F371/F812 (Store, prepare, distribute and serve food in accordance with professional standards for food service safety.) had been cited during each of these surveys. Deficiencies related to this regulation have been identified on this annual survey as well. Cross reference to F 812. 2. Review of surveys conducted during the current COVID pandemic revealed deficiencies related to F 880 Infection Control and Prevention have been identified in June 2020, March 2021 and again during this annual survey. Review of the statement of deficiencies for the survey that ended on March 18, 2021 revealed F 880 included multiple examples of staff's failure to wear masks correctly. This failure was identified again during this annual survey. Review of the plan of correction for the March 2021 survey revealed the following plan had been put in place to ensure the deficient practice did not re-occur: Formal audits will be conducted by the Nursing Home Administrator, across all work shifts. The results will be presented to the QA [Quality Assurrance] Committee each month. Any noncompliance will be addressed immediately and on an ongoing basis. The results of the audit will be presented starting with the April QA meeting. On 9/2/21 at 1:59 PM, surveyor reviewed the concern with the QA nurse (Staff #18) and the Administrator regarding QA concern related to the repeat deficiencies related to the kitchen and infection control. The Administrator reported there has been a lot of staff turnover in the kitchen.

Based on observation, medical record review and staff interview, it was determined that the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 6 of 36 residents (#20, #11, #53, #60, #120, #4) reviewed during the annual survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) Review of Resident #20's medical record on 8/29/21 at 12:27 PM revealed the resident had a fall with no injuries on 5/16/21. Review of Resident #20's quarterly MDS with an assessment reference date (ARD) of 6/29/21 failed to capture the fall in section J1900 during the lookback period. Discussed with the MDS Coordinator, Staff #12 on 9/2/21 at 11:25 AM who confirmed the error. 2) Review of Resident #11's medical record, on 8/30/21 at 1:03 PM, for unnecessary medication review revealed that Resident #11 took the medication [MEDICATION(S)] Tablet, 1 GM (gram) twice per day for urinary health. [MEDICATION(S)], an antibiotic, eliminates bacteria that cause urinary tract infections. It usually is used on a long-term basis to treat chronic infections and to prevent recurrence of infections. Review of Resident #11's quarterly MDS assessment, with an ARD of 6/14/21, Section N revealed documentation that Resident #11 received the medication 4 days during the 7 day lookback period. Review of Resident #11's June 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 3) Review of Resident #53's medical record, on 8/30/21 at 2:57 PM, revealed a quarterly MDS with an ARD of 8/5/21, Section M0150 Skin, which documented the resident was not at risk for pressure ulcers. Review of an 8/4/21 at 6:51 AM nurse's note revealed the following documentation, reeducated on the importance of offloading d/t (due to) sacrum wound, incontinence, and [CONDITION(S)]. A 7/12/21 weight change note revealed documentation that the wound on the sacrum had resolved. A 7/9/21 nurse's note revealed the following, Resident seen by wound MD. Pressure wound to sacrum and wounds to BLE are closed. A 6/21/21 at 10:55 AM nurse's note revealed, Resident c/o pain to sacrum related to pressure wound. Resident #53 was at risk for pressure wounds due to history of sacral wound and other contributing factors. The MDS Coordinator (Staff #12) was interviewed on 9/2/21 at 11:25 AM and confirmed that it was an error. 4) Review of Resident #60's medical record, on 8/31/21 at 9:50 AM, revealed that the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record revealed that Resident #60 was taking [MEDICATION(S)] 20 mg. every day for GERD. [MEDICATION(S)] can treat heartburn, a damaged esophagus, stomach ulcers, and [CONDITION(S)]. Continued review of the medical record revealed that Resident #60 received [MEDICATION(S)] opth. 0.5%, 1 drop in each eye twice per day for [CONDITION(S)]. [MEDICATION(S)] is a beta-blocker that also reduces pressure inside the eye. It is used to treat open-angle [CONDITION(S)] and other causes of high pressure inside the eye. Review of Resident #60's quarterly MDS with an ARD of 8/8/21, Section I, diagnoses, failed to include [CONDITION(S)] and GERD , but included difficulty walking and Tinea Unguium, both which had been resolved. Interview of the MDS Coordinator on 9/2/21 at 11:25 AM revealed that he/she should have included those active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 5) Review of Resident #120's medical record on 8/30/21 at 9:53 AM revealed a 6/26/20 and 6/27/20 Respiratory Screener Evaluation that documented the resident was receiving oxygen due to [CONDITION(S)] (Chronic Obstructive Pulmonary Disease). Review of Resident #120's quarterly MDS, with an ARD of 6/29/20, Section O, coded that the resident did not receive oxygen. Discussed with Staff #12, on 9/2/21 at 11:25 AM, who confirmed the error. 6. The facility staff failed to accurately assess Resident #4's dental assessment. Observation of Resident #4 on 8/29/21 at 11:58 AM revealed the resident to have an upper denture that did not fit, broken lower teeth and lower teeth with likely decay. Review of Resident #4's medical record on 8/30/21 revealed the resident was admitted to the facility on [DATE] from the hospital. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the dentist treatment notes revealed the dentist documented, Teeth are hopeless due to extensive decay, root tips, fractures and periodontitis. Patient has an acrylic ill-fitting upper partial denture with missing teeth. Further review of Resident #4's medical record revealed the facility staff had completed an annual MDS assessment on 10/1/20 and coded the resident in Section L Oral/Dental Status as A. No for Broken or loosely fitting full or partial denture and D. No for Obvious or likely cavity or broken natural teeth. The Surveyor reviewed the MDS Section L with the MDS Coordinator on 8/31/21 at 10:18 AM. At that time, the MDS Coordinator confirmed the facility staff had inaccurately coded the resident's MDS Section L Oral/Dental Status assessment. Interview with the Director of Nursing on 8/31/21 at 11:00 AM confirmed that the facility staff failed to accurately document a dental assessment for a resident on the MDS.

Based on observation, medical record review and interview, it was determined that the facility staff failed to maintain a medical record in the most accurate form. This was evident for 4 of 22 residents(Resident #13, #11, #120, #121) with care area investigations completed during the survey. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1. Observation was made of Resident #13, on 8/29/21 at 12:50 PM, in the dining area eating lunch. Resident #13 was wearing a short sleeved shirt. Resident #13's bare arms were exposed with nothing covering the arms. Review of Resident #13's medical record on 8/29/21 at 1:37 PM revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's Treatment Administration Record (TAR) on 8/29/21 at 3:10 PM revealed that the nurse's initials indicated that the resident wore geri-sleeves during the day shift. Resident #13 was observed multiple times on 8/30/21 during the 7:00 AM to 3:00 PM shift and was not wearing geri-sleeves, however, the TAR was signed off at the end of the shift indicating that the resident wore the geri-sleeves. On 8/31/21 at 11:37 AM, Resident #13 was observed sitting in dining area with his/her daughter wearing a long sleeve shirt. The daughter pulled up the resident's sleeves and confirmed there were no geri-sleeves on the resident. Review of the TAR revealed the nurse had already signed off that geri sleeves were worn by 11:37 AM. On 8/31/21 at 2:48 PM, during an observation with the Unit Nurse Manager (Staff #18) the resident was observed lying in bed. Staff #18 confirmed at that time that Resident #13 did not have geri-sleeves on his/her arms. The surveyor showed Staff #18 the TAR that had already been signed off that the geri-sleeves were on the resident. Discussed with Staff #18 how the nurse, on 3 consecutive days, falsely signed off that the geri-sleeves were placed on the resident. 2. Review of Resident #11's medical record on 8/30/21 at 7:55 AM revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . TED ([CONDITION(S)]-[CONDITION(S)] Deterrent) stockings are also known as compression stockings or anti-embolism stockings. They help reduce the risk of developing a [CONDITION(S)] (DVT) or blood clot and help reduce the risk of swelling ([CONDITION(S)]). Observation was made on 8/30/21 at 1:13 PM, of Resident #11 sitting in the dining room wearing slipper socks with gray tennis shoes. A second observation was made on 8/31/21 at 11:34 AM, of Resident #11 sitting in the common area wearing beige slipper socks with black tennis shoes. The resident did not have TED stockings on, however, review of Resident #11's August 2021 TAR revealed the nurse had already signed off that the TEDS were being worn. On 8/31/21 at 2:50 PM, during an observation with Unit Nurse Manager (Staff #18) the resident was observed with slipper socks and tennis shoes. Staff #18 confirmed at that time that Resident #11 did not have TED stockings on his/her legs. The surveyor showed Staff #18 the TAR that had already been signed off that the TEDS were on the resident. 3. A review of facility reported incident MD 830 was conducted on 8/30/21 at 9:53 AM. The incident documented that on 5/26/20 at 7:00 PM a geriatric nursing assistant (GNA) noticed bruising on Reisident #120's right forearm measuring 3 cm. by 5 cm. The GNA reported the bruising to the nurse and an investigation was started. The first documentation found in the resident's medical record about the bruising was on 5/27/21 at 6:15 PM and that documentation was a follow-up note. There was no initial documentation found in Resident #120's medical record about the bruising and no measurements of the bruising. 4. A review of facility reported incident MD 708 was conducted on 8/30/21 at 12:52 PM. The facility report investigation documented that Resident #121 was found by the nurse on 4/23/20 at 5:50 PM with blood on the left side of the geri chair, on the floor and on Resident #121's gown. The facility documented that an open area 6 cm by 3 cm was found on the resident's left forearm. The incident was substantiated as an injury of unknown origin, however there was no documentation anywhere in the medical record that the incident occurred. On 9/22/21 at 9:10 AM, the surveyor informed the Director of Nursing (DON) that there was no documentation in Resident #121's medical record about the open area (skin tear). The DON provided the surveyor with an incident audit report. When the surveyor stated about the incident audit report not being part of the medical record the DON stated, if it was asked for it would be provided. On 9/2/21 at 9:49 AM, the DON gave the surveyor an investigation into the skin tear. The DON confirmed that there was no nursing note in the medical record. Discussed all concerns with the DON and Nursing Home Administrator on 9/2/21 at 3:00 PM

Based on observation, staff interview and record review, it was determined the facility failed to ensure an effective infection prevention and control program by failing to ensure that staff performed hand hygeine when indicated, failed to utilize personal protective equipment (PPE) in a manner that met minimum standards and minimize risk for infectious spread, and failed to ensure proper handling of a resident's Foley Catheter urine bag. This was found to be evident during observations of 9 residents (Resident #37, #54, #30, #53, #41, #20, #25, #60 and #61) but this noncompliant practice within the facility's infection prevention and control program left all residents, staff, and visitors at increased risk for infection during an active COVID-19 outbreak in the facility. The findings include: 1) Hand Hygiene The surveyor made multiple observations where facility staff members were not performing hand hygiene as necessary. On 5/8/2020, the Centers for Disease Control and Prevention (CDC) released updated guidance on Hand Hygiene noting that hand hygiene should be performed in the following situations: before resident contact, even if PPE is worn; after contact with the resident; after contact with blood, body fluids, or contaminated surfaces or equipment; before performing aseptic tasks; and after removing PPE. 1a. Observation was made on 8/29/21 at 1:25 PM of activity staff (Staff #33) doing hand massages in the Good Shepherd Way unit. Staff #33 put lotion on Resident #37's hands. She massaged the lotion into both hands of Resident #37 and then proceeded to put lotion on Resident #54's hands. Staff #33 massaged the lotion into Resident #54's hands and went to Resident #30 and massaged her hands with lotion. Staff #33 did not sanitize her hands in between touching other resident's hands. 1b. Observation was made on 8/30/21 at 1:37 PM of activities staff (Staff #15) walking into the Good Shepherd Way unit. Staff #15 picked up the remote control to turn the television on. Staff #15 then proceeded to walk over to a resident in the sitting area and rub the resident's hair. Staff #15 then walked over to Resident #53 and rubbed his/her hair and took a clothing protector off Resident #53 from lunch and put it in the soiled basket, picked up a stuffed giraffe and gave the giraffe to another resident. Staff #15 then walked over to Resident #41 and helped him/her walk from the table to the sitting area. Staff #15 held Resident #41's hand the entire time. Staff #15 leaned up against a table in the sitting area and put her hands in her pocket and then threw a soiled napkin away. Staff #15 pulled her pants up, walked over to the kitchen area then walked back and removed a paper schedule from the plexiglass that was sitting on a table and threw the schedule away. Staff #15 grabbed a cup from a resident and filled it with a beverage and gave it back to the resident after touching a cabinet and beverage machine. Staff #15 then went to Resident #20 and rubbed his/her hair before sanitizing her hands. After Staff #15 sanitized her hands, she touched a resident's w/c arm rests and then rubbed the back of another resident. Staff #15 went over to open the bathroom door for a resident and then walked back to the sitting area and rubbed the head/hair of Resident #20. Staff #15 then got an activities crate out of the closet and walked over and rubbed the head/hair of Resident #57 and then walked back and rubbed Resident #20's head/hair and back to rubbing the head/hair of Resident #57. Staff #15 then sanitized her hands. Staff #15 did not sanitize her hands in between touching residents. Staff #15 stood for a minute and then went back to Resident #20 and rubbed her hair and walked over and scratched Resident #57's back, rubbed his/her neck and then picked up a stuffed giraffe to hold and gave the giraffe back to the resident. Staff #15 then wheeled Resident #20 into the kitchen area by touching the wheelchair handles. Staff #15 walked over to the kitchen counter and got plastic gloves out of a box. Staff #15 proceeded to put the plastic gloves on Resident #54, Resident #20, and Resident #60 as they were preparing to do a food craft with cookies, icing and Hershey kisses. While putting the gloves on the 3 residents, Staff #15 was using her bare hands and massaging the gloves down over the resident's hands and fingers, touching the entire outside of the gloves. Staff #15 then grabbed a chair for a resident and moved the resident's walker. Staff #15 opened a cabinet door over the refrigerator and got paper plates, napkins, and utensils. She then placed plastic gloves on her hands to handle the food items. Staff #15 did not sanitize her hands prior to putting the gloves on. Staff #15 then got up from the table to look for scissors, opened the door to the activity room, opened the closet and cut the tip off the decorative icing container and then came back to the table and proceeded to put the icing on the cookies. The residents spread the icing on the top of a cookie and then Staff #15 picked up a fudge stripe cookie out of the cookie packaging and put icing on top of each cookie. Staff #15 grabbed each cookie for the resident with the soiled gloved hand. Staff #15 then unwrapped Hershey kisses and placed on top of the cookies, touching the Hershey kisses with her soiled gloved hand. 2. Facility staff failed to properly wear face masks. Consistent with the 4/2/2020 CMS guidance, on 4/27/2021, the Centers for Disease Control and Prevention (CDC) published updated guidance which stated, In general, fully vaccinated HCP (health care provider) should continue to wear source control while at work. However, fully vaccinated HCP could dine and socialize together in break rooms and conduct in-person meetings without source control or physical distancing. On 5/4/2021, The Maryland Department of Health (MDH) Secretary issued an amended Directive and Order Regarding Nursing Home Matters. The 5/4/21 Directive and Order, finding it necessary for the prevention and control of 2019 Novel Coronavirus (SARS-CoV-2 or 2019-NCoV or COVID-19), and for the protection of the health and safety of patients, staff, and other individuals in Maryland, hereby authorize and order the following actions for the prevention and control of this infectious and contagious disease under the Governor's Declaration of Catastrophic Health Emergency. This Amended Directive and Order replaces and supersedes the Directives and Orders Regarding Nursing Home Matters, dated February 8, 2021, November 17, October 1, July 24, June 19, April 29, April 24, April 9, and April 5, 2020. 1C. documented, All staff, volunteers, vendors, visitors, and residents, shall follow CDC and CMS guidance on face covering usage when in the facility. 2a. Observation was made on 8/30/21 at 7:45 AM on the Good Shepherd Way unit of the nurse (Staff #14) getting something out of the closet at the nurse's station. Staff #14's mask was resting below her nose. There was a resident sitting in a chair in front of the nurse's station. When the surveyor walked up to the station, Staff #14 placed her mask above her nose. 2b. Observation was made on 8/31/21 at 3:00 PM, while in the Good Shepherd Way unit, of the geriatric nursing assistant (Staff #17) walking into the unit from the door that came directly from the outside without her facemask up around her nose. The unit nurse manager (Staff #18) was with the surveyor at the time of the observation and confirmed that Staff #17's mask was not worn properly. Review of sign-in sheets related to infection prevention revealed that Staff #17 was educated on the use of PPE on 6/25/21. 2c. Observation was made on 9/1/21 at 9:58 AM of the kitchen. Staff #21 was observed in the kitchen removing soiled trays from the cart with her mask below her nose. 2d. Observation was made, on 9/2/21 at 1:53 PM, of the receptionist with her mask not covering her nose or mouth. The mask was hanging down from one ear. The surveyor motioned for the receptionist to cover her face and the receptionist asked what the surveyor meant. The surveyor verbalized the concern regarding the mask and the receptionist then placed the mask over her mouth and nose. At approximately 2:00 PM, the Nursing Home Administrator (NHA) was made aware of the observation. On 9/1/21 at 10:40 AM, an interview was conducted with the Infection Control Preventionist (ICP). The ICP stated that staff are in-serviced at least yearly and when needed on infection control and that competencies are done for each staff member which included hand hygiene and PPE. The ICP was told of the infection control concerns. The facility was previously cited for infection control concerns related to mask wearing in March 2021. The Nursing Home Administrator (NHA) did a root cause analysis from the last survey about face masks not being worn properly and an in-service was done with staff. The Director of Nursing (DON) and NHA were made aware of infection control concerns on 9/1/21 at 12:00 PM. 2e. On 8/31/2021 at 9:35 AM, during a tour of the facility's laundry room, Staff #24 was observed with their mask pulled down under their chin while placing dirty laundry into a washing machine. On 9/1/2021 at 8:15 AM Staff #24 was observed in the laundry room with no mask. Staff #24 correctly donned a surgical mask after seeing that the surveyor was present. The Administrator and Director of Nursing were made aware of these findings on 9/1/2021 at 12:45 PM. 3. Failed to ensure proper handling of a resident's Foley Catheter urine bag in accordance with the standards of practice for infection control (Resident #61). A Foley Catheter is a flexible plastic tube that is used to drain urine from your bladder when you are unable to urinate on your own. The Foley Catheter allows urine to drain from the bladder into a bag. During a tour conducted on 08/29/21 at 09:36 AM, the Surveyor observed Resident # 61's Foley Catheter urine bag on the floor and the urine tube empty. During an interview conducted on 08/29/21 at 9:43 AM with Resident #61, the Surveyor observed GNA #4 remove the Foley Catheter urine bag from off of the floor, move the Foley Catheter tube to the left side of the resident and hung the Foley Catheter urine bag to the left side of the bed. The Surveyor observed urine flow through the tube and into the urine bag. The GNA # 4 stated the facility's policy is to never allow the catheter urine bag to touch the floor. During an interview on 08/29/21 at 10:12 AM, the Surveyor advised nurse # 3 of Resident #61's urine bag observed on the floor. Nurse #3 stated the facility's policy expects the Foley Catheter urine bag to never lay on the floor. During an interview on 08/29/21 at 1:30 PM, the Surveyor advised the Administrator of the Surveyor's findings.

Based on observation and medical record review, it was determined facility staff that failed to treat a resident with dignity as evidence by standing to feed the resident while in a dining room with other residents. This was evident for 1 of 16 residents (Resident #13) observed for dining in the Good Shepherd Way Unit. The findings include: Observation was made, on 8/29/21 at 12:50 PM, of Geriatric Nursing Assistant (GNA) #13 feeding Resident #13. GNA #13 stood to feed Resident #13 from 12:50 PM to 12:54 PM. There were other staff in the dining room that sat while feeding other residents. Review of Resident #13's medical record on 8/29/21 at 1:37 PM revealed the resident required supervision and cues with meals and the resident also suffered from major depressive disorder with occasional tearfulness. The observation was discussed with the Assistant Director of Nursing on 9/1/21.

Based on medical record review, interview and observations, it was determined that the facility failed to ensure that care interventions were carried out by facility staff as indicated in the care plans, and failed to ensure care plans were developed to address the use of [CONDITION(S)] medications. This was found to be evident for 4 out of 22 residents (Residents #64, #66, #17 and #61) who had care area investigations completed during the survey. The findings include: 1) Review of Resident #64's medical record revealed that the resident was originally admitted to the facility in 2020 and whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had received occupational therapy (OT) in January 2021. Review of the OT discharge summary, dated 1/28/21, revealed one of the focuses of the therapy had been wheelchair positioning. The discharge recommendations included: .left arm rest support in addition to left lateral torso support with staff to reposition and monitor for safety . Surveyor had observed the resident, on 8/30/21 at 2:14 PM, sitting in the wheelchair, but no arm rest or torso support was noted at that time. On 9/1/21, review of the resident's current care plan for activities of daily living revealed that the left arm rest support in addition to left lateral torso support had been added to the interventions on 1/29/21. This care plan had a revision date of 7/23/21. On 9/02/21 at 10:50 AM surveyor observed the resident seated in the wheelchair, no left arm rest support or left torso support observed. This observation was confirmed by nurse manager #26. Surveyor reviewed the concern with nurse #26 regarding the failure to follow the care plan for the arm support. Nurse #26 indicated she would follow up with the other unit manager and indicated that this may be an old intervention that should be discontinued. On 9/02/21 at 11:00 AM, surveyor reviewed the observation with the Director of Nursing as well as the concern regarding the facility's failure to follow the current care plan for arm support. On 9/02/21 01:10 PM, therapy director (Staff #9) reported the left armrest support is a device placed over the armrest of the wheelchair and that the torso support would have been obvious if it was in place. As of time of exit at 3:00 PM, no additional documentation had been provided to indicate these interventions should have been discontinued. 2) On 8/30/21, review of Resident #66's medical record revealed that the resident had resided at the facility for several years and whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment, with an assessment reference date of 5/12/21, revealed the resident required extensive assistance of one person physical assist for bed mobility, toilet use and personal hygiene, the resident was totally dependent on two person physical assist for transfers from bed to chair, and totally dependent on one person support for bathing. Further review of the medical record revealed the resident had fallen out of bed on 5/19/21 while receiving care from a geriatric nursing assistant (GNA). The resident did not sustain an injury as a result of this fall. Further review of the medical record revealed a care plan addressing the resident's risk for falls. The care plan had been updated after the fall to include the following intervention: 5/20/21 Assist resident towards nursing staff if turning and repositioning resident independently, or turn and reposition resident with 2 staff members assistance. This intervention had an initiation date of 6/7/21. Further review of the medical record revealed the resident had fallen out of bed on 7/25/21 while receiving care from a GNA. Further review of the medical record and the fall investigation report revealed that only one GNA was caring for the resident at the time and that the resident rolled away from the GNA and continued to roll off the bed. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/02/21 at 9:55 AM, surveyor reviewed the concern with the Director of Nursing regarding the failure to follow the care plan intervention in regard to turning and repositioning this resident. As of time of exit at 3:00 PM on 9/2/21 no additional documentation or information had been provided by the facility staff regarding this concern. Cross reference to F 689. 3. [CONDITION(S)] medications are used to treat mental health disorders. There are five main types of [CONDITION(S)] medications, and each type has its own specific uses, benefits, and side effects. The five main types are anti-anxiety agents, antidepressants, antipsychotics, mood stabilizers, and stimulants. On 09/01/21 at 08:32 AM review of Resident #17's medical record revealed the resident was diagnosed with Major Depressive Disorder and Anxiety Disorder. On 09/01/21 at 08:40 AM, a record review of Resident #17's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] ([MEDICATION(S)]) is an antidepressant medicine. It's used to treat depression and sometimes obsessive compulsive disorder and anxiety disorders. [MEDICATION(S)] HCL is an Antidepressant and Nerve pain medication. It can treat depression, anxiety, diabetic peripheral [CONDITION(S)] (nerve pain), [CONDITION(S)], and chronic muscle or bone pain. On 09/01/21 at 08:43 AM, a record review of Resident #17's most recent care plan did not show a care plan for [CONDITION(S)] medications. 4. On 09/01/21 at 08:44 AM, a review of Resident #61's medical record revealed the resident was diagnosed with Major Depressive Disorder. On 09/01/21 at 08:46 AM, a record review of Resident #61's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] XR is an extended-release capsules used to treat adults diagnosed with Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), Social Anxiety Disorder (SAD), and Panic Disorder (PD) with or without agoraphobia (a fear of being in situations where escape might be difficult or that help wouldn't be available if things go wrong). On 09/01/21 at 08:52 AM, a record review of Resident #61's most recent care plan did not show a care plan for [CONDITION(S)] medications. During an interview, conducted on 09/01/2021 at approximately 11:25 AM, Nurse #18 advised that [CONDITION(S)] medication care plans were first included in the fall care plan and later were changed to a separate care plan for [CONDITION(S)] medications.

Based on medical record review and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions for a Resident (#13) with a history of skin tears. This was evident for 1 of 2 residents (Resident #13) reviewed for skin conditions during the annual survey. The findings include: Review of Resident #13's medical record on 8/29/21 at 1:37 PM revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a 6/18/21 nursing note revealed documentation, sitting in new wheelchair hospice purchased in dining room when skin tear noted to right elbow with surround skin discolored. When observing resident after cleansing wound, noticed resident use arm to help position in chair. [physician name] updated and new orders to apply geri-sleeves. Review of Resident #13's June, July and August 2021 Treatment Administration Records (TAR) revealed the nurse's initialing every day that the resident was wearing geri-sleeves. Review of Resident #13's care plan, resident has the potential for pressure ulcer development and skin breakdown r/t impaired mobility, AEB (as evidenced by) bowel and bladder incontinence, dependent with toileting and peri care, poor nutrition, weight loss which was initiated on 2/3/21 and revised on 4/22/21, failed to have geri-sleeves as an intervention. On 8/31/21 at 2:48 PM, an interview was conducted with Unit Nurse Manager (Staff #18). Staff #18 stated that the resident used to get a lot of skin tears and she confirmed that the care plan had not been updated to reflect the use of geri-sleeves. Discussed with the Director of Nursing and the Nursing Home Administrator on 9/2/21 at 3:00 PM.

Based on observation, medical record review, and interviews, it was determined that the facility staff failed to meet professional standards by 1) documenting that a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This was evident for 1 of 2 residents (Resident #13) reviewed for skin conditions and 1of 5 residents (Resident #11) reviewed for unnecessary medications during the annual survey. The findings include: 1) Observation was made of Resident #13 on 8/29/21 at 12:50 PM in the dining area eating lunch. Resident #13 was wearing a short sleeved shirt. Resident #13's arms were exposed with nothing covering the arms. Review of Resident #13's medical record on 8/29/21 at 1:37 PM revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's Treatment Administration Record (TAR) on 8/29/21 at 3:10 PM revealed the nurse's initials indicating that the resident wore geri-sleeves during the day shift. Resident #13 was observed multiple times on 8/30/21 during the 7:00 AM to 3:00 PM shift and was not wearing geri-sleeves, however, the TAR was signed off at the end of the shift indicating that the resident wore the geri-sleeves. On 8/31/21 at 11:37 AM, Resident #13 was observed sitting in dining area with his/her daughter wearing a long sleeve shirt. The daughter pulled up the resident's sleeves and confirmed there were no geri-sleeves on the resident. Review of the TAR revealed that the nurse had already signed off that geri sleeves were worn by 11:37 AM. On 8/31/21 at 2:48 PM, during an observation with the Unit Nurse Manager (Staff #18) the resident was observed lying in bed. Staff #18 confirmed at that time that Resident #13 did not have geri-sleeves on his/her arms. The surveyor showed Staff #18 the TAR that had already been signed off that the geri-sleeves were on the resident. Staff #18 stated that the resident used to get a lot of skin tears. 2) Review of Resident #11's medical record on 8/30/21 at 7:55 AM revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . TED ([CONDITION(S)]-[CONDITION(S)] Deterrent) stockings are also known as compression stockings or anti-embolism stockings. They help reduce the risk of developing a [CONDITION(S)] (DVT) or blood clot and help reduce the risk of swelling ([CONDITION(S)]). Observation was made on 8/30/21 at 1:13 PM of Resident #11 sitting in the dining room wearing slipper socks with gray tennis shoes. A second observation was made, on 8/31/21 at 11:34 AM, of Resident #11 sitting in the common area wearing beige slipper socks with black tennis shoes. The resident did not have TED stockings on; however, review of Resident #11's August 2021 TAR revealed the nurse had already signed off that the TEDS were being worn. On 8/31/21 at 2:50 PM, with Unit Nurse Manager (Staff #18) the resident was observed with slipper socks and tennis shoes. Staff #18 confirmed at that time that Resident #11 did not have TED stockings on his/her legs. The surveyor showed Staff #18 the TAR that had already been signed off that the TEDS were on the resident. Discussed with the Director of Nursing and the Nursing Home Administrator on 9/2/21 at 3:00 PM.

Based on observation, record review and staff interview, it was determined facility staff failed to provide care and treatment in accordance with the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] the facility staff documentation that a treatment was performed when it was observed not performed, and failed to ensure physical and occupational therapy screening was completed as ordered by the physician. This was found to be evident for 3 out of 22 residents (Resident #13, #11 and #64) with care area investigations completed during the survey. The findings include: 1) Observation was made of Resident #13 on 8/29/21 at 12:50 PM in the dining area eating lunch. Resident #13 was wearing a short sleeved shirt. Resident #13's bare arms were exposed with nothing covering the arms. Review of Resident #13's medical record on 8/29/21 at 1:37 PM revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's Treatment Administration Record (TAR) on 8/29/21 at 3:10 PM revealed the nurse's initials indicating that the resident wore geri-sleeves during the day shift. Resident #13 was observed multiple times on 8/30/21 during the 7:00 AM to 3:00 PM shift and was not wearing geri-sleeves, however, the TAR was signed off at the end of the shift indicating that the resident wore the geri-sleeves. On 8/31/21 at 11:37 AM, Resident #13 was observed sitting in dining area with his/her daughter wearing a long sleeve shirt. The daughter pulled up the resident's sleeves and confirmed there were no geri-sleeves on the resident. Review of the TAR revealed the nurse had already signed off that geri sleeves were worn by 11:37 AM. On 8/31/21 at 2:48 PM, during an observation with the Unit Manager Staff #18, the resident was observed lying in bed. Staff #18 confirmed at that time that Resident #13 did not have geri-sleeves on his/her arms. The surveyor showed Staff #18 the TAR that had already been signed off that the geri-sleeves were on the resident. Staff #18 stated that the resident used to get a lot of skin tears. Facility staff failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2) Review of Resident #11's medical record on 8/30/21 at 7:55 AM revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . TED ([CONDITION(S)]-[CONDITION(S)] Deterrent) stockings are also known as compression stockings or anti-embolism stockings. They help reduce the risk of developing a [CONDITION(S)] (DVT) or blood clot and help reduce the risk of swelling ([CONDITION(S)]). Observation was made, on 8/30/21 at 1:13 PM, of Resident #11 sitting in the dining room wearing slipper socks with gray tennis shoes. A second observation was made on 8/31/21 at 11:34 AM of Resident #11 sitting in the common area wearing beige slipper socks with black tennis shoes. The resident did not have TED stockings on, however, review of Resident #11's August 2021 TAR revealed the nurse had already signed off that the TEDS were being worn. On 8/31/21 at 2:50 PM, during an observation with Staff #18 the resident was observed with slipper socks and tennis shoes. Staff #18 confirmed at that time that Resident #11 did not have TED stockings on his/her legs. The surveyor showed Staff #18 the TAR that had already been signed off that the TEDS were on the resident. Facility staff failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Discussed with the Director of Nursing and the Nursing Home Administrator on 9/2/21 at 3:00 PM. 3. Review of Resident #64's medical record revealed the resident was originally admitted to the facility in 2020 and whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had orders for PT (physical therapy) and OT (occupational therapy) 3 times per week starting on 7/13/21. This order was discontinued on 7/22/21. On 8/31/21, further review of the medical record revealed a brief hospitalization in late July, and an order upon re-admission, also dated 7/22/21, for PT/OT evaluation and treatment as indicated one time only for 30 days. No documentation was found to indicate that the resident had been re-evaluated as ordered after the re-admission from the hospital. On 8/31/21 at 1:12 PM, the therapy director (Staff #9) confirmed that the resident had been on therapy service on 7/15/21 and confirmed the resident was not currently receiving services. Surveyor reviewed the concern that there had been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/02/21 at 9:56 AM, surveyor reviewed the concern that the PT/OT evaluation had not been completed as ordered upon re-admission with the Director of Nursing. As of time of exit on 9/2/21 at 3:00 PM, no documentation was provided to indicate the PT or OT evaluations had occurred as ordered.

Based on medical record review and interview, it was determined that the facility failed to prevent a resident from falling out of bed while receiving care. This was found to be evident for one out of eight residents reviewed for accidents (Resident #66) during the survey. The findings include: On 8/30/21, review of Resident #66's medical record revealed the resident resided at the facility for several years and whose diagnoses included but were not limited to end stage dementia, high blood pressure, [CONDITION(S)] and anxiety. Review of the Minimum Data Set assessment, with an assessment reference date of 5/12/21, revealed that the resident required extensive assistance of one person physical assist for bed mobility, toilet use and personal hygiene, the resident was totally dependent on two person physical assist for transfers from bed to chair, and totally dependent on one person support for bathing. Further review of the medical record revealed the following nursing note, dated 5/19/21: Resident was in bed and receiving personal care by GNA [geriatric nursing assistant] orientee. Resident reported to be restless and moving while laying on [his/her] right side. Resident eased [his/her] legs to the edge of the bed and rolled away from the GNA . The GNA tried to roll resident back towards her but instead ended up easing [resident] down feet first until [s/he] eventually came to rest entirely on the floor. GNA stated that resident did not hit [his/her] head during this lowering. Review of the fall investigation documentation provided by the facility revealed the orientee that was providing care to the resident at the time of the 5/19/21 fall was GNA #28. Review of the statement written by the preceptor, GNA #29, revealed, GNA #29 was in the room at the time of the fall, but was providing care to the resident in the other bed, with the curtain pulled, so she was not witness to the fall. Review of GNA #28's employee file revealed the GNA had a hire date of 5/11/21. Further review of the medical record revealed a care plan addressing the resident's risk for falls. The care plan had been updated after this fall to include the following intervention: 5/20/21 Assist resident towards nursing staff if turning and repositioning resident independently, or turn and reposition resident with 2 staff members assistance. This intervention had an initiation date of 6/7/21. Further review of the medical record revealed the following nursing note, dated 7/25/21: While being cared for, resident was restless and agitated when turned sled further away from the GNA. GNA attempted to prevented fall, resident managed to hit the left side of [his/her] head on the oxygen concentrator leaving a lacerations, resident was on floor at 6:05. resident also has a hematoma [bruise] over the left cheek . The laceration was 0.26 cm by 0.86 cm and was monitored until it was completely healed as of 8/10/21. This was confirmed by the Assistant Director of Nursing (Staff #16) on 9/1/21. Review of the fall investigation documentation provided by the facility revealed a witness statement completed by the GNA (Staff #27) who had been providing care at the time of the 7/25/21 fall. This statement included the following: .Resident continued to roll away from writer and was unable to roll resident back towards writer . No documentation was found to indicate a second GNA was present at the time of the July fall. Further review of the fall investigation documentation revealed the immediate intervention placed post fall was to have two person assist during care. On 9/02/21 at 9:55 AM, surveyor reviewed the concern with the Director of Nursing regarding the failure to follow the care plan intervention in regard to turning and repositioning this resident and the failure to prevent the resident from falling out of bed while care was being provided on two occasions. As of time of exit at 3:00 PM on 9/2/21, no additional documentation or information had been provided regarding this concern. Cross reference to F 726.

Based on medical record review and staff interview, it was determined that the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to monitor the blood pressure and heart rate prior to administering a blood pressure medication per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of Resident #53's medical record on 8/30/21 at 2:57 PM revealed the resident was admitted to the facility in January 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #53's medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . ER (extended release), one tablet daily, hold for sbp (systolic blood pressure (which is the top number of a blood pressure reading) less than 90, Pulse HR (heart rate) less than 60 (beats per minute). Review of Resident #53's Medication Administration Records (MAR) for July and August 2021 revealed no documentation of the blood pressure or heart rate where the [MEDICATION(S)] was listed for sign off as given by the nursing staff. Review of the vital sign section of the medical record revealed blood pressures and heart rates that did not correspond with the 8:00 AM medication administration time. On 8/6/21, there were no vital signs in the medical record. On 8/31/21 at 2:34 PM, an interview was conducted with Unit Nurse Manager (Staff #18). Staff #18 stated that staff should be documenting the vital signs where the order was in the MAR. Staff #18 then stated, I guess they are putting them in the vital sign section. Typically it would be in with the order under supplementary documentation. Staff #18 looked in the medical record and stated, it appears the nurses are not monitoring and documenting the blood pressure and heart rate. Staff #18 confirmed that the times in the vital sign section did not correspond to the time when the medication was administered and she confirmed that there were no vital signs in the medical record for 8/6/21. The Director of Nursing and the Nursing Home Administrator were informed on 9/2/21 at 3:00 PM.

Based on medical record review and staff interview, it was determined that the facility staff failed to ensure a resident receiving antipsychotic medication had an attempted gradual dose reduction (GDR). This was evident for 1 out 5 residents (Resident #11) reviewed for unnecessary medications during the annual survey. The findings include: [MEDICATION(S)] is an antipsychotic medication that can treat [CONDITION(S)], [CONDITION(S)], and depression. A [CONDITION(S)] drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to anti-psychotic, anti-depressant, anti-anxiety, and hypnotic medications. Review of Resident #11's medical record, on 8/30/21 at 1:03 PM, revealed that Resident #11 was admitted from the assisted living unit in March 2021 due to advanced dementia per the physician's history and physical note, dated 3/9/21. The note documented, Resident is suffering from dementia of advanced degree (Alzheimer type) without associated behavioral disturbance. The note documented, on [MEDICATION(S)] 25 mg daily - for agitation r/t dementia. Review of August 2021 physician's orders revealed, [MEDICATION(S)] 25 mg. every morning for behavioral disturbance and agitation. Further review of the medical record failed to reveal that a gradual dose reduction (GDR) had been attempted for the resident who had no documented behaviors on the Medication Administration Records, Treatment Administration Records or in nurse's notes. An interview was conducted with Resident #11's physician and medical director (Staff #22) on 8/31/21 at 2:57 PM. Staff #22 stated that the resident had recently had behaviors and dementia is progressing and more aggressive and we keep on medications. I have seen progressive decline in [his/her] cognition and that is the reason we did not try. The surveyor asked if that was justification to keep Resident #11 on an antipsychotic medication when there were no documented behaviors for 5 months. Staff #22 replied that he agreed that the GDR should have been tried. Staff #22 stated, [he/she] deserves at least a trial. The Director of Nursing and Nursing Home Administrator were informed on 9/2/21 at 3:00 PM.

Based on review of the medical record, administrative records, and staff interview, it was determined that the facility staff failed to adequately supervise and protect a resident from an accident with injury. This was evident for 1 of 3 residents (#5) reviewed for falls during a complaint survey. The findings include: Resident #5 was diagnosed with [REDACTED]. The resident required extensive assistance from the nursing staff for all aspects of her care, except eating. The resident had a history of [REDACTED]. Review of the facility incident report for Resident #5, dated 5/17/14, revealed that resident "got up out of the bed and the alarm was sounding. Geriatric Nursing Assistant #1, who was not the resident's assigned aide, put her on the toilet and returned to the shower room, where she had been assisting another resident. She said she told resident #5 to call for help when she was finished using the bathroom, and positioned the walker within reach of the resident. Resident #5 was then noted on the floor at the doorway of her room." The injury was "bloody open area to right side of head. Resident complained of back pain at the time of fall. Abrasion to the upper center of the back." Review of Resident #5's care plan for "Falls," which was initiated on 12/5/13, stated "pressure alarms on bed and in chair and functioning at all times" and "Alarming seat belt when in w/c (wheelchair), " which was initiated on 3/11/14. Pressure alarms on the bed and chair alerted the staff when the resident attempted to get up from the chair or bed. Review of the Resident ADL (activities of daily living) Care List that the GNAs use as a guide to care stated "Fall precautions, wanderguard, low bed with mats, pressure alarm in bed and chair. Alarming seat belt in w/c (wheelchair)." Interview of GNA #1 on 8/6/14 at 2:05 PM revealed the following: " I worked with her (Resident #5) on a Saturday (5/17/14) and I was on the hall with 2 other people, and I was in the shower with another resident (name) and we were in the process of him getting washed up and I heard the alarm going off and I let it go off a little bit because there were 2 other people on the hall. I went in (Resident #5's) room and she had to go to the bathroom and she is pretty alert and I put her in the bathroom and I told her to ring and I would be right back and she never rung and when I came back out she apparently walked out of the bathroom without her walker and fell and that is when I saw 2 nurses with her and a GNA. We were assessing her and getting her in her chair. The nurse said she hit her head and was bleeding a little. There was blood on the carpet. The resident said her head hurt. " GNA #2 (the GNA assigned to Resident #5 that morning) on 8/6/14 at 5:20 PM was interviewed and stated " I had resident the day of Saturday, May 17th. It happened early in the morning. The last time I saw the resident she was in bed. I was in another room with a resident when I heard the commotion. I went and saw Resident #5 on the floor. The nurses were taking care of her at that point. " When asked if she would leave the resident alone when taking her to the bathroom and give her a call light she said " no because she is a fall risk and she is confused. If she wanted privacy I would just turn around but I would never leave her alone. " Interview of Licensed Practical Nurse (LPN) #1 on 8/6/14 at 3:20 PM revealed "the resident is not the type of resident you can leave alone in the bathroom and tell to call when finished. You have to stay with her". GNA #3 on 8/6/14 at 4:00 PM stated during an interview "she fell a few times when I worked with her". When asked if Resident #5 wore a seatbelt on her wheelchair GNA #3 stated "I want to say she had a seat belt, I remember her having it at one point, yes she had it on because you had to remove it to go to the bathroom. I always stayed with her because she didn't take that long and you don't leave a resident with an alarm". LPN #2 was interviewed on 8/6/14 at 4:05 PM and stated "she (Resident #5) was a big fall risk. She would just want to stand up every second. We walk her sometimes with a contact guard and she stands up again, sets the alarm off a lot. She cannot be left alone in the bathroom. " An interview was conducted with the Director of Nursing (DON) on 8/6/14 at 12:59, and the DON stated "she should not be leaving residents unattended in the bathroom when they have alarms. It was not her (GNA) assigned section. She heard the alarm, responded to that and put her (the resident) in the bathroom with her walker and told her to call and left the resident to go back to another resident that she had left in the bathroom. This was for the fall on 5/17/14. She had a laceration to the back of the head, was sent to the ER and got 3 staples" . When the surveyor asked what happened to the GNA that left the resident unattended, the DON stated " the unit manager met with her and let her know that it was unacceptable, that residents with monitors could not be left unattended". When asked by the surveyor if any further education was done the DON stated "No" . When asked if any other education was done with the rest of the nursing staff the DON stated "no." On 8/7/14 at 12:20 PM, the DON and the Nursing Home Administrator handed the surveyor a typed statement from the Way of Love Unit Manager for date 5/21/14 that stated an inservice was done on that unit for leaving a resident unattended when the resident had safety alarms. At 12:25 PM, the DON was asked for the education sign in sheets showing staff that had been educated about this issue. The DON stated "we don't have any sign in sheets." Review of the "Employee Communication/Counseling Memo " dated 5/19/14 for GNA #1 had the " Description of Current Issue - Safety Violation and Performance" checked off. The written statement by the supervisor stated "Resident left unattended in restroom with walker. Resident high risk of falls with personal bed/chair alarms. Fall resulted from incident with injury requiring hospital transfer for laceration." Failure of the facility staff to supervise a resident that was left unattended and was assessed to be a high falls risk, resulted in the resident falling and sustaining an injury. This [AGE] year old resident was transferred to the hospital for treatment of [REDACTED].