Every finding on record at Chapel Woods Health and Rehabilitation

Based on record review, interview, and facility policy review, the facility failed to ensure a cognitively impaired resident was not left outside alone, unsupervised, and after hours for 1 (Resident #1) of 1 sampled resident reviewed for neglect. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of J. The IJ began on 05/04/2025 around 5:45 PM when Resident #1 was left outside, alone and unsupervised, in the courtyard of the secured unit. The Administrator, Director of Nursing, and Nurse Consultant were notified of the IJ on 05/09/2025 at 8:54 AM. A plan of removal was requested. The removal plan was accepted by the State Survey Agency on 05/09/2025 at 6:36 PM. The immediacy of the IJ was removed on 05/09/2025 at 6:36 PM. The findings are: Review of an Office of Long-Term Care (OLTC) Incident and Accident [I&A] report with a discovery date of 05/5/2025 indicated that on 05/04/2025 at approximately 5:15 PM, Resident #1 requested to sit in the courtyard, located outside of the dining room on the secured unit, to get some sun. The resident was noticed missing on 05/05/2025 at 4:19 AM and was located on 05/05/2025 at 5:21 AM sitting outside in the courtyard. On 05/05/2025 at 10:45 PM, Resident #1 was interviewed and reported going outside after supper to sit. Resident #1 reported trying to come back in but could not because the door was locked. Resident #1 reported knocking hard on the door all night long and sitting wherever possible to stay warm because it was cold that night. A nursing general note dated 05/05/2025 at 5:21 AM indicated the Director of Nursing (DON) located Resident #1 sitting in a chair outside of the dining room on the patio with jacket zipped up and head covered. Review of an online weather service ' s historical data revealed the low temperature the morning of the incident, 5/5/2025, was 47 degrees Fahrenheit. Review of the Medical Diagnosis portion of Resident #1 ' s electronic health record revealed the resident was admitted to the facility on [DATE] with diagnoses of schizophrenia and psychotic disorder with hallucinations. Review of an annual Minimum Data Set with an Assessment Reference Date of 04/30/2025 revealed a brief interview for mental status score of 12, which indicates moderate cognitive impairment. The MDS also indicated Resident #1 required supervision/touch assistance with toileting and personal hygiene, shower/bathe self, chair/bed-to-chair transfer, toilet and tub/shower transfer. Review of the Care Plan Report, dated as revised 04/30/2025, revealed Resident #1 could benefit from placement in the secured neighborhood due to the need for a safe environment and special programming with an intervention of providing opportunity for the resident to experience growth, connectedness, meaning, and joy by participating in the life of the neighborhood. Resident #1 was an elopement risk/wanderer with an intervention of supervision in courtyard. On 05/05/2025 at 11:04 AM, Certified Nursing Assistant (CNA) #1 was interviewed over the telephone and stated that on the evening of 05/04/025, she opened the door to the courtyard so the residents could go outside after supper. She stated between 5:00 PM and 5:30 PM, the residents came back inside, and she did not see Resident #1 seated in the resident's usual seating area and she assumed Resident #1 had come back inside so she closed the door. CNA #1 stated she did not check the resident's room or anywhere else on the secured unit for the resident because the resident was in and out of the bathroom frequently and she thought the resident was in the bathroom when she made rounds. CNA #1 stated staff were supposed to round every two hours but that does not always happen. She stated she did not realize the resident was not in the room prior to leaving her shift at 11:00 PM because the resident frequently used the bathroom and when the resident was not seen in the room, she usually assumed the resident was in the bathroom. On 05/08/2025 at 1:32 PM, CNA #3 was interviewed by telephone and stated she came to work on 05/04/2025 around 10:50 PM and made rounds a little after 12 AM but could not give an exact time. CNA #3 stated when she looked in Resident #1 ' s room, she saw the bathroom light on and assumed the resident was in the bathroom but did not go in and check. She stated around 4:20 AM, she went to Resident #1's room to get the resident up and realized the resident was not there when she turned the light on. CNA #3 stated she notified the nurse [LPN #4], and staff began looking for the resident. She stated the DON was working that night up front and LPN #4 called and requested the DON come back to the secured unit. CNA #3 stated the DON located Resident #1 outside in the courtyard and brought the resident inside. CNA #3 stated she was sure the resident was cold but was unsure of what the temperature was the night of 05/04/2025. She stated staff were supposed to make rounds on the residents every 2 hours, but sometimes staff do not do that. On 05/08/2025 at 2:51 PM, the DON was interviewed and stated she was working the front of the facility, halls A and B, the night of the incident. At around 5:15 AM she was passing medications, and CNA #6 asked if the DON knew a resident was missing and she stated no. The DON immediately locked her cart and went to the unit. When she got to the unit she was told Resident #1 was missing. The DON stated she immediately started looking room to room while talking to the staff asking questions and asked when the last time Resident #1 was seen. Both the 7 AM to 7 PM nurse and 11 PM to 7 AM aide stated they had not seen Resident #1 during their shift. She stated she immediately called the day nurse [LPN #5] to see when the last time she saw the resident. LPN #5 stated it was around 5:30 PM after she had given the resident's medications and sat in the courtyard with the resident. The DON stated that while she was on the phone with LPN #5, she went to the dining room and courtyard door. The DON opened the door, and the resident was sitting on the bench to the left of the door with a jacket on, zipped all the way up and face covered. The immediate jeopardy was removed on 05/09/2025 at 6:36 PM when the following plan of removal was implemented by the facility: Immediate interventions: 1. Resident was immediately brought into building and taken to his room where he was toileted, and clothing changed. 2. APN was contacted. She stated she would not be in the facility today so requested that facility schedule a tele-med visit. 3. Body Audit was completed on [Resident #1] with no negative findings. 4. Family notified, 5. Tele-med visit completed with new orders received_. 6. Abuse in-service began on Abuse and Neglect. 7. Body Audits completed on all residents on the secured unit with no negative findings. 8. The nurse [LPN #4] and CNA's [CNA #1, #2 and #3] were all placed on administrative leave. 9. Administrator/DON/designee will round the secure neighborhood 3 times per day, at least 1 time on each shift, to ensure that all residents are present in the confines of the building and safe. These rounds will begin on 5/9/25 and will be documented on a facility designed rounding calendar. 10. Beginning 3:00 p.m., 5/9/25, Administrator/designee will round the smoking area courtyard at least 1 time every 2 hours to ensure that wandering residents have not made their way outside, until security system with Wanderguard sensor automatic magnetic locks are installed. Action to Prevent Similar Incident: 1. Facility will ensure residents residing on the secure neighborhood will not be allowed to be in either facility courtyard unattended. D.O.N/Designee will train secured unit staff on this change beginning 5/5/25. No employee will be allowed to work the neighborhood until training is completed by 05-09-2025. 2. DON/Designee will train all nursing staff on the importance of making rounds at shift change to make sure all residents are accounted for. Trainings were begun on 5/5/25. Beginning at 12 noon on 5/9/25, no nursing staff will be allowed to work before being trained by DON/Designee and training will be completed by 05-09-25. 3. DON/Designee will train all LPNs/RNs [Registered Nurses] on the importance of completing midnight census with visual check of each and every resident. Training began on 5/5/25. Beginning at 12 noon on 5/9/25, no nurses will be allowed to work before being trained by DON/Designee on 05-09-25. 4. Train all CNAS on the importance of completing 2-hour rounds and visualizing every resident even if they toilet independently. Training was begun on 5/5/25 by the DON. Beginning noon on 5/9/25, no aides will be allowed to work before being trained by DON/Designee and training will be completed by 05-09-25. By 1:00 p.m. on 5/9/25, a task was set up in the EMR (electronic medical record) system for aides to document 2-hour rounds. CNAs and nurses were trained by the DON/designee on the completion of this task on 5/9/25. The completion of this task will be verified by the charge nurse assigned to each work area at the end of the shift, starting at the end of evening shift on 5/9/25. 5. DON/Designee will train all staff on the elopement policy, including when resident is not located immediately within the facility, check the courtyards. Training began on 5/5/25 and training will be completed by 05-09-25. Beginning 12 noon on 519125, no employees will be allowed to work who have not been trained by 05-09-25. 6. From the time this QAA document was established on 5/5/2025, no employee has been allowed to work on the secure neighborhood until trained on the points above, with special emphasis on point #1. And no employee will be allowed to work on the secure neighborhood until they have been trained. All corrections were completed on 05/09/2025. Onsite Verification: The IJ was removed on 05/12/2025 at 2:30 PM after this surveyor performed an onsite verification that the removal plan had been implemented as follows: Immediate interventions: 1. Review of the reportable dated 05/05/2025 revealed Resident #1 was located outside the building at 5:21 AM and was brought inside, toileted and clothing changed. 2. Review of the progress notes revealed a nursing general note dated 05/05/2025 at 5:21 AM which indicated APN notified with no new orders. Plan for tele-med later in the morning. 3. Review of body audit dated 05/05/2025 indicated no negative findings. 4. This surveyor spoke with Resident #1's responsible party by telephone on 05/12/25 at 9:43 AM and she stated she was notified the morning of 05/05/2025. 5. Review of an Access Medical Note dated 05/05/2025 at 10:57 AM by APRN, revealed visit was conducted via tele-med with interactive audio and visual capabilities and was necessary due to resident was outside last night. 6. Review of the reportable dated 05/05/2025 included a training dated 5/5/25 conducted by the DON with a topic of abuse/neglect. 7. Review of the reportable revealed body audits on residents on the secured unit with no negative findings. 8. Review of the reportable dated 05/05/2025 revealed in the steps taken four staff members were suspended pending the outcome of investigation: [LPN#4, CNA #2, CNA #1, CNA #3]. 9. Review of sheets provided by the DON revealed a licensed nurse (LPN or RN) signed a document indicating 2-hour rounding was completed on the secured units for 5/9/25, 5/10/25, and 5/11/25, and all residents were safe and accounted for. 10. Review of a smoking area courtyard security rounds sheet revealed 2-hour rounds started on 05/09/2025 at 3:00 PM and the sheet was current up to 05/12/2025 at 11:00 AM when the document was provided to this surveyor.

Based on observation, record review, interview and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%) during the medication administration observation of 1 (Resident #7) of 2 (Residents #1 and #7) sampled residents, and one (Resident #8) non-sampled resident who received medications from 1 Registered Nurse (RN) and 2 Certified Med Techs (CMT). Observed 25 opportunities of medication administration and 2 of the 25 medications were not administered in accordance with the physician's orders, resulting in a medication error rate of 8.00%. The findings are: 1. On 03/11/2025 at 9:06 AM, CMT #2 entered Resident #7's room to administer the medication she had prepared. CMT #2 gave the resident a cup of pills with a cup of water. Once the resident took the pills, CMT #2 administered one drop of [Name brand - Polyethylene Glycol 440 / Propylene Glycol] ophthalmic (eye) drops in each of the resident's eyes. CMT #2 did not take [brand name] laxative to the resident with the other medications. Resident #7's Order Summary Report was reviewed and indicated the resident was to receive [brand name] Powder (Polyethylene Glycol 3350) 17 grams by mouth one time a day for constipation and [brand name - carboxymethylcellulose sodium] Solution instill 1 drop in both eyes in the morning related to dry eye syndrome of unspecified lacrimal gland (a small organ that produces tears). There was no active order for [brand name - Polyethylene Glycol 440 / Propylene Glycol] eye drops. The electronic Medication Administration Record (eMAR) was reviewed and indicated the [brand name] laxative powder was last administered at 0800 (8:00 AM) on 03/11/2025 by CMT #2. The eMAR indicated [brand name - carboxymethylcellulose sodium] solution was last administered at 0800 (8:00 AM) by CMT #2. On 03/11/2025 at 9:53 AM, CMT #2 was interviewed and stated she did not give [brand name] laxative powder to Resident #7 with the other medication this morning. She stated the resident refuses this medication and would ask for this medication when the resident feels constipated. She stated she signed the [brand name] laxative medication as being administered this morning in error. On 03/11/2025 at 10:04 AM, Resident #7 was interviewed and stated [brand name] laxative powder was not taken this morning. The resident stated [pronoun] asks for the laxative medication when constipated. On 03/11/2025 at 3:40 PM, the Unit Manager was in the medication stock room restocking medication. There was a box of [carboxymethylcellulose sodium] Lubricant eye drops on the top shelf. The Unit Manager was interviewed and stated she ordered the medication, and the delivery came today. On 03/11/2025 at 3:59 PM, the Advanced Practice Nurse (APN) was interviewed by telephone and stated she was not made aware by staff that Resident #7 was not taking the [name brand] laxative medication. She stated [brand name - Polyethylene Glycol 440 / Propylene Glycol] eye drops, and [brand name - carboxymethylcellulose sodium] Tears were different but worked the same. She stated what the practitioner ordered needed to be sent to the pharmacy because [brand name - carboxymethylcellulose sodium] Tears was ordered for a reason. On 03/12/2025 at 10:14 AM, CMT #2 was interviewed and stated she looked for [brand name - carboxymethylcellulose sodium] eye drops, and the facility did not have any. She stated it was on a Saturday, and the LPN who was working that day told her it was ok to use the [brand name - Polyethylene Glycol 440 / Propylene Glycol] eye drops. The LPN she asked is no longer an employee at the facility. On 03/12/2025 at 10:26 AM, the Director of Nursing (DON) was interviewed and stated nurses and med techs were placed on orientation with a nurse who has been at the facility for a while to train with until they were comfortable passing medications at the facility. She stated if a resident was refusing to take a scheduled medication, the doctor should be notified of the refusal and the reason should be charted. She stated if a medication was not available, the nurse/med tech should mark the medication as not given and call the provider. She stated the nurse/med tech should not substitute a medication order without notifying the provider. An Adverse Consequences and Medication Errors policy, dated as revised April 2014, was reviewed and indicated a medication error was defined as the preparation or administration of drugs or biological which was not in accordance with the physician's orders, manufacture's specifications, or accepted professional standards of the professional providing services. Examples of medication errors included: a drug ordered but not administered, wrong drug, and wrong time. An Administering Oral Medications policy with a revision date of October 2010, was reviewed and indicated for preparation, a physician's medication order should be verified. Steps in the procedure indicated check the label on the medication and confirm the medication name and dose with the MAR (Medication Administration Record).

Based on record review, interview, and facility policy review, the facility failed to ensure allegations of abuse and neglect were thoroughly investigated for 3 (Residents #1, #4 and #5) of 6 sampled residents reviewed for abuse and 1 (Resident #6) of 1 sampled resident reviewed for neglect. The findings are: 1)The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/26/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident was not cognitively intact. Diagnoses on the MDS included end-stage renal disease (kidney disease), bipolar disorder (depression/mania), dementia, and heart failure. The resident's Incident Report (I&A) and corresponding action plan were reviewed for completeness. A review of Resident #1's I&A revealed the following: a. On 10/31/2024 the resident made allegations of abuse. b. The I&A Report dated 10/31/2024 stated Admin interviewed cognitive residents on C Hall with no negative findings. Residents unable to be interviewed were assessed for any signs of abuse with no negative findings. c. On 01/22/2025 at 12:55PM the Nurse Consultant was unable to provide the documents referenced above, to reflect the resident interviews or the resident assessments (body audits) completed on 10/31/2024. 2) The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/15/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident was not cognitively intact. Diagnoses on the MDS included dementia, atrial fibrillation (abnormal heart rhythm), and high blood pressure. The resident's I&A and corresponding action plan were reviewed for completeness. A review of Resident #4's I&A revealed the following: a. On 11/13/2024 the resident was noted by staff to have a bruise of unknow origin. b. The I&A Report dated 11/13/2024 mentioned the Licensed Practical Nurse (LPN) assessed the resident for signs of abuse. The report also stated, LPN then assessed all other residents on the unit for any signs of abuse; there were no negative findings. c. On 01/22/2025 at 12:55PM the Nurse Consultant was unable to provide the documents referenced above, to reflect the resident assessments (body audits) completed for 11/13/2024. 3) On 11/05/2024 at 12:40 PM, the facility submitted an OLTC [office of long-term care] Incident and Accident Report (I&A) to the state agency for an allegation of physical and verbal abuse for Resident #5. The report indicated on 11/05/2024 at 11:00 AM, Resident #5 reported to the social worker and the unit manager a certified nursing assistant (CNA) was being rough with the resident during care and snatched a call light from the resident's hand. The report indicated CNA #1 was assigned to the resident's hall the day of the incident. CNA #1 was suspended while the incident was investigated. The I&A report indicated the residents on Halls A and B who were unable to be interviewed were assessed for any signs/symptoms of abuse. There were no assessments provided for any non-interviewable residents in the report. On 01/21/2025 at 3:18 PM, Resident #5 was sitting up in a recliner in the room and was interviewed. The resident was unable to recall what happened the day of the incident but stated the CNA thought she knew it all and was helping the resident after the resident was in the bed. The resident was unable to give the name of the CNA and did not provide any other specific information about the alleged incident. Resident #5's medical diagnosis screen was reviewed and indicated diagnoses of unusual patterns of movement or changes in the way an individual walks or moves (abnormalities of gait and mobility) and generalized muscle weakness. A quarterly MDS with an ARD of 12/17/2024 was reviewed and indicated Resident #5 had a BIMS of 13 which indicated cognitively intact and was dependent on staff for toileting and personal hygiene and chair/bed-to-chair transfers. 4) The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/26/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident was not cognitively intact. Diagnoses on the MDS included dementia, anxiety, depression, and dysphagia (trouble swallowing). The resident's Incident Report and corresponding action plan were reviewed for completeness. A review of Resident #6's I&A revealed the following: a. On 11/14/2024 the resident had a fall, and the case was reviewed by the facility for neglect. b. The I&A Report dated 11/15/2024 stated Interview residents on C Hall to see if they felt neglected. If they can't be interviewed a body audit will be completed. c. On 01/22/2025 at 12:55PM the Nurse Consultant was unable to provide the documents referenced above, to reflect the resident interviews or the resident assessments/body audits completed for 11/15/2024. 5) On 01/23/2025 at 01:15 PM the Director of Nursing (DON) was interviewed regarding the I&A reports with missing documents for resident interviews and/or resident assessments/body audits. The DON stated that the responsibility of ensuring that resident interviews and/or resident assessments/body audits were completed after an allegation of abuse or neglect was up to the DON and the Administrator. In addition, the DON stated it was important to ensure resident interviews and resident assessments/body audits were completed to make sure the same situations had not happened to other residents. The DON was not able to provide the documentation requested (referenced above) with the resident I&As for #1, #4 and #6 to reflect that the resident interviews and resident assessments/body audits were done. 6) On 01/23/2025 at 2:00 PM the Administrator was interviewed regarding the I&A reports with missing documents for resident interviews and/or resident assessments/body audits. The DON stated that the responsibility of ensuring that resident interviews and/or resident assessments/body audits were completed after an allegation of abuse or neglect was up to the Administrator. In addition, the Administrator stated it was important to ensure resident interviews and resident assessments/body audits were completed to make sure the same situations have not happened to other residents. The Administrator was not able to provide the documentation requested (referenced above) with the I&As for residents #1, #4, #5, and #6 to reflect that the resident interviews and Resident assessments/body audits were done. 7) On 01/24/2025, the Administrator was asked to provide the assessments completed on the non-interviewable residents. The Administrator returned to the room and stated no assessments were located for the non-interviewable residents on Halls A and B. 8) An Abuse Prevention policy, dated as revised 11/16/2017, was reviewed and indicated all reports of resident abuse, neglect, injuries of an unknown source, resident-to-resident abuse and resident-to-staff abuse are promptly and thoroughly investigated by facility management. 37925

Based on observation, interview, record review, and facility policy review, the facility failed to ensure dietary staff thoroughly washed their hands and changed gloves when contaminated; expired food items were promptly removed/discarded on or before the expiration or use by date; foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated; and hot food item was maintained at the required temperature on the tray above the steam table for one meal observed. The findings are. 1. During a concurrent observation and interview on [DATE] at 10:02 AM, Dietary Aide (DA) #1 removed bananas from the original box and placed them on the counter, contaminating her hands. DA #1 then peeled off the skin layers from the bananas and placed them on the cutting board and held it with her hands while she sliced them with a knife. DA #1 then transferred the slices of bananas into a bowl on the counter to be used in preparing dessert to be served to the residents for lunch. DA #1 stated she should have washed her hands. 2. On [DATE] at 10:05 AM, an opened box of bread sticks were on a shelf in the freezer with no opened date. 3. During a concurrent observation and interview on [DATE] at 10:09 AM, one pan with 34 thawed biscuits, covered with clear wrap dated [DATE] was on a shelf in the glass refrigerator. When asked about it, Dietary [NAME] (DC) #2 stated they had put it out to thaw in the refrigerator at 8:30 AM, this morning, as it takes time to thaw completely by the next morning. The Dietary Manager confirmed they prepared it this morning at 8:30 AM for the breakfast meal tomorrow, emphasizing the need for adequate thawing time. When asked about the instructions on the box. The Dietary Manager checked and said it indicated that the item should be baked while frozen. The Dietary Manager confirmed it was thawed and they will throw them away. 4. During a concurrent observation and interview on [DATE] at 10:57 AM, DA #1 wore gloves when she picked up the water hose with her bare hands and used it to spray leftover food from inside of the blender. DA #1 placed the blender, a blade, and the lid in the dirty racks and pushed the rack into the dish washing machine to wash. After the dishes stopped washing, DA #1 moved to the clean side of the dishwasher area and picked up a clean blade and attached it to the base of the blender to be used in pureeing foods to be served to the residents who received pureed diets for lunch. DA #1 stated she should have washed her hands. 5. On [DATE] at 11:21 AM, the Station 2 freezer temperature was -10 degrees Fahrenheit, and refrigerator temperature was 39 degrees Fahrenheit. The following observations were made on a shelf in the refrigerator at the nurse's station in Station #2: a. One carton of whole milk with an expiration date of [DATE]. b. One carton of 2% milk with an expiration date of [DATE]. c. An opened carton of discolored pudding. There was no opened or received date on the carton. The Dietary Manage stated it looked old. d. A bowl of leftover chili with chips. There was no received date and no name to indicate who it belongs to. The Dietary manager stated it looked like it's been there for more than 3 days. It is supposed to be there for 3 days. 6. On [DATE] at 11:36 AM, the following observations were made on the tray on top of the freezer at the nurses' station in Station #2. a. An opened box of vanilla wafers had a best when used by date of [DATE]. b. A bottle of pizza sauce with no name and no received date on it. c. Two bags of smoking crackers with no name and no received date on the bags. d. One box of pizza crust with no name or received date on the box. 7. During a concurrent observation and interview on [DATE] at 11:41 AM, DA #1 wore gloves on her hands when she picked up a pan of cheesy biscuit from the counter in the food preparation room and placed it on the counter by the mixer. DA #1 opened the refrigerator, took out a gallon of milk from the refrigerator and poured some on top of the cheesy biscuits inside the blender. After placing the gallon back in the refrigerator, DA #1 then, attempted to cover the blender bowl with its lid to puree the cheesy biscuits. However, the lid wouldn't fit because the blade wasn't fully attached to the base. DA #1 then used her contaminated gloved hand to adjust the blade at the base of the blender. DA #1 stated she should have washed her hands. She pureed the cheesy biscuits, used #8 scoop to portion the pureed mixture into 10 individual bowls on the tray and placed it in the refrigerator. DA #1 stated she should have washed her hands. 8. During a concurrent observation and interview on [DATE] at 12:24 PM, DA #1 removed the pan with individual bowls of pureed cheesy garlic biscuits from the refrigerator and placed it on top of the steam table. The Dietary Manager was asked if she could check the temperature of cheesy garlic biscuit, she did and stated it was 84 degrees Fahrenheit. DC # 2 stated they were to serve it hot. 9. On [DATE] at 12:29 PM, the following observations were made on a shelf in the refrigerator in Station #1's medication room: a. Two packages of honey buns with an expiration date of [DATE]. b. An opened box of pudding. The box was not covered and there was no open date or received date on the box. The freezer temperature was 0 degrees Fahrenheit. On [DATE] at 12:38 PM, the following observations were made in the freezer: a. One box of salisbury steak with no name or received date on it. b. One box of chocolate chip cookies with no name or received date on it. 10. During a concurrent observation and interview on [DATE] at 4:45 PM, Dietary Aide (DA) #3 was wearing gloves on his hands when he picked up a bread bag from the rack and placed it on the counter. After that, he opened the refrigerator, removed 2 cartons of milk and placed them in the preparation sink, near the blender machine. He then united the bread bag and used his contaminated gloved hands to remove slices of bread from the bag, preparing to put them into a blender to puree. DA #3 stated he should have removed the gloves, washed his hands, and used a tong to pick up the bread. 11. The undated facility policy titled, Employee Cleanliness and Handwashing Technique provided by the Dietary Manager, indicated hands should be washed before beginning a shift and after picking up anything from the floor.

Based on record review, interview, and facility policy review, the facility failed to ensure a pharmacist medication regimen review recommendations were addressed for 3 (Residents #2, #3 and #69) of 5 (Residents #2, #3, #53, #69 and #77) sampled residents who were reviewed for unnecessary and psychotropic medications, and medication regimen reviews (MRRs). The findings are: Resident #3's medical diagnosis screen was reviewed and indicated the resident was diagnosed with a condition which caused loss of thinking and decision-making skills which interfered with daily life (dementia) and a change in the mental status (altered mental status). A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/27/2024, was reviewed and indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact and was taking the following high-risk drugs: an antipsychotic, an antidepressant, an antibiotic, a diuretic (removes excess fluid) and antiplatelet. Resident #3's Order Summary Report was reviewed and indicated the resident had an order for Quetiapine Fumarate (Seroquel-antipsychotic) 25 mg and give 12.5 mg by mouth four times a day for anxiety and was ordered on 09/22/2024. A Pharmacy MRR-Antipsychotic form, dated 09/24/2024, was reviewed and indicated Resident #3 was receiving Quetiapine Fumarate (Seroquel) 12.5 mg by mouth four times a day since 09/22/2024 and recommended a gradual dose reduction or tapering the dose to determine either the most favorable (optimal) dose or if the medication was necessary for the resident as the resident had a documented fall. On 10/15/2024, the Advanced Practice Registered Nurse (APRN) documented on the form to make the changes per pharmacy recommendations. As of 10/25/2024, the medication had not been adjusted. 48390 2. Resident #69's medical diagnosis screen was reviewed and indicated the resident had a condition which caused loss of thinking and decision-making skills which interfered with daily life (dementia) and depression. A quarterly MDS with an ARD of 10/03/2024, was reviewed and indicated Resident #69 had a BIMS of 6, which indicated severely cognitively impaired and was receiving antianxiety and antidepressant medications. Resident #69's Order Summary Report was reviewed and indicated Mirtazapine 7.5 milligrams (mg) every night at bedtime and was ordered on 06/24/2024 for depression and Buspirone 7.5 mg three times a day for anxiety and was ordered on 10/26/2023. A care plan, dated 10/04/2024, was reviewed and indicated Resident #69 was taking an antidepressant and antianxiety medication and listed signs and symptoms to monitor the resident for. A Pharmacy MRR-Anxiolytic form, dated 05/30/2024, was reviewed and indicated Resident #69 was receiving Buspirone 7.5 mg by mouth three times a day since 03/10/2024 and recommended a gradual dose reduction or tapering the medication dose to determine the optimal dose or if the medication was necessary for the resident. There was no response from the attending physician/prescribing practitioner on the form. As of 10/25/2024, the resident was yet receiving the dose indicated above. 3. A review of Admission Record indicated Resident #2 had diagnoses of dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. A review of the care plan initiated on 10/07/24 indicated Resident #2 was on antianxiety therapy related to an antianxiety medication. The facility developed interventions to include to monitor the resident's condition based on clinical practice guidelines or clinical standards of practice related to the use of the antianxiety medication. A review of Order Summary Report indicated Resident #2 had a physician order dated 08/07/2024 for an antianxiety medication and to give 1 tablet via PEG-Tube every 8 hours as needed for anxiety. A review of Medication Administration Records (MARs) from August through October 2024 (08/08/24 through 10/24/2024) were reviewed with the following findings: - August 2024: Nurses' initials documented the antianxiety medication was administered 11 out of the 24 remaining dates of the month (08/08/24 through 08/31/24). - September 2024: Nurses' initials documented the antianxiety medication was administered 17 times, on 14 out of 30 days, - October 2024: Nurses' initials documented the antianxiety medication was administered 4 times on 3 out of 24 days. A review of Medication Regimen Review dated and signed by the Pharmacist on 08/22/2024 showed no discrepancies. During an interview on 10/25/24 at 10:50 AM the Assistant Director of Nursing (ADON) was asked, a PRN (as needed) anxiety medication is supposed to be for how long? The ADON indicated 30 days. The ADON was asked when a PRN antianxiety medication that was ordered on 08/07/24 be reassessed? The ADON indicated it should have already been reassessed by the physician.

Based on record review, interview, and facility policy review, the facility failed to ensure the process for dispensing controlled substances was consistently implemented to decrease the potential for diversion of medications from one of four medication carts from which a random narcotic count was performed. The findings are: On 10/24/2024 at 1:19 PM, this surveyor and Licensed Practical Nurse (LPN) #3 performed a random narcotic count of the contents of the controlled substance box on the medication cart for halls E and F. During the count, the following were observed: 1. Page 74 indicated Resident #75 had Diazepam 5 milligrams (mg), last signed out on 10/24/2024 at 0900 (9:00 AM) by LPN #3 and 39 tablets (tabs) remaining for the balance. Upon review of the medication card, there were 38 tabs remaining. LPN #3 stated the medication was sent out of the facility at 11:30 AM with Resident #75's family member. (Diazepam is used to treat anxiety, muscle spasms, and seizures.) 2. Page 77 indicated Resident #25 had Hydro-APAP (Hydrocodone-Acetaminophen) 5/325 (5 milligrams per 325 milligrams) tabs with 17 tabs for the balance. The last dose was signed out on 10/24 (10/24/2024) at 0545 (5:45 AM), and the name was illegible. Upon review of the medication card, there were only 16 tablets remaining. The nurse stated she had administered the medication to the resident at 12 noon but had not signed the pill out of the narcotic log. 3. Page 79 indicated a non-sampled resident had Hydro-APAP 7/325 and 9 tabs remaining for the balance and the last dose was signed out on 10/24/24 at 0800 (8:00 AM) by LPN #3. Upon review of the medication card, there were only 8 tablets remaining. LPN #3 stated she had administered the medication to the resident at 12 noon but had not signed the medication out of the narcotic log. On 10/24/2024 at 1:35 PM, LPN #3 was interviewed and stated Resident #75's family member was taking the resident out of the facility for a while and the resident would not be back in time for the 2:00 PM dose of Diazepam. LPN #3 stated around 11:30 AM, she removed a pill, placed it in a clear plastic bag and gave the medication to the Administrator, who was standing at the doorway of the medication room, to take the medication to Resident #75's family member. LPN #4 was sitting in a chair in the medication room and stated she witnessed LPN #3 pass the pill to the Administrator. LPN #3 stated she did not sign the medication out of the narcotic log after it was removed. LPN #3 stated that medication removed from the narcotic box was supposed to be signed out after the medication was removed. She stated the family member who received the medication for the resident leaving the facility was supposed to sign the narcotic book with the nurse. On 10/24/2024 at 4:11 PM, the Director of Nursing (DON) was interviewed and stated two nurses performed the narcotic count at shift change. She stated the nurses were required to sign the count sheet as soon as the count was finished. She stated the narcotic log was audited and she was ultimately responsible for this task, but she assigned the task to her nurse manager. She stated she liked to review the narcotic log at least weekly. She stated when a nurse removes a narcotic from the medication cart, the nurse is supposed to sign the medication out immediately. She stated two nurses normally sign the narcotic medication out together in the book (narcotic log). She stated once the medication was signed out of the narcotic log, the medication should be given to the direct family member taking the medication from the facility. She stated the family member receiving the medication for the resident was supposed to sign the narcotic log to indicate the medication was issued. At 4:25 PM, the DON was informed about the concern regarding Resident #75's Diazepam count. The DON was informed about the other controlled medications whose remaining balance on the card did not match the balance in the controlled substance book. A Controlled Substances policy, dated as revised November 2022, was reviewed and indicated controlled substance inventory was monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. The policy indicated the nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count and the on-coming and off-going nurse made the count together, documented and reported any discrepancies to the DON. The policy also indicated the controlled substance was not surrendered to anyone except for a resident on pass or therapeutic leave, to a resident or responsible party upon discharge from the facility.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. The findings are: 1. On 10/21/24 at 11:41 AM, during the noon meal preparation Dietary Aide (DA) #1 placed 10 servings of cheesy biscuits into a blender added milk, pureed, and used a #8 scoop to portion it into 10 individual bowls, covered the bowls with lids and placed them in the refrigerator. a. On 10/21/24 at 12:46 PM, 7 of 8 residents did not receive pureed cheesy biscuits. b. On 10/21/24 at 12:56 PM, during an interview DA #1 stated she forgot to serve pureed cheesy biscuit to the remaining 7 residents.

Based on observation, interview, record review and facility policy review, the facility failed to ensure toenail care was consistently provided during resident care for 1 (Resident #22) sampled resident reviewed for nail care. The findings are: On 10/21/2024 at 11:57 AM, Resident #22 was leaned back in a recliner and the left shoe was off. The toenails were observed to be discolored, thick and had jagged edges. The resident stated the staff used to trim the toenails on bath days, which the resident thought were Tuesdays and Fridays. Resident #22's medical diagnosis screen was reviewed and indicated the resident had a condition which affected the airflow in the lungs and breathing (chronic obstructive pulmonary disease) and a condition in which the heart could not pump blood as efficiently (heart failure). An annual Minimum Data Set with an Assessment Reference Date of 08/04/2024, was reviewed and indicated Resident #22 had a Brief Interview for Mental Status score of 12, which indicated moderately cognitively impaired and required partial/moderate assistance with the bathing activity and supervision/touch assistance with personal hygiene. A care plan, dated 09/25/2024, was reviewed and indicated Resident #22 had an activity of daily living (ADL) self-care performance deficit. The care plan indicated the resident's nail length was to be checked, trimmed and cleaned on bath days and as necessary and required one-person assistance with bathing/showers. An ADL task for bathing document was reviewed and indicated Resident #22's bath days were Tuesday, Thursday and Saturday. The ADL bathing document indicated the resident received a whirlpool bath on 10/11/2024, 10/17/2024 and 10/19/2024; a bed bath on 10/12/2024 and 10/15/2024; refused a bath on 10/18/2024 and received a shower on 10/22/2024. On 10/23/2024 at 9:18 AM, Resident #22 was reclined in a recliner in the room, awake with black house slippers on. Certified Nursing Assistant (CNA) #11 was interviewed with concurrent observations and was asked to take off the resident's left shoe. The resident's toenails on the left foot were thick, the great toenail was jagged, discolored and long. CNA #11 was asked to describe the resident's toenails on the left foot, and she stated the toenails were thick, long, yellowish and sharp. She stated the 11 to 7 CNAs were responsible for providing nail care and nail care was to be provided when the residents were showered. She stated Resident #22's shower days were Tuesday, Thursday and Saturday. On 10/24/2024 at 3:00 PM, CNA #5 was interviewed and stated she did give Resident #22 whirlpool baths and provides nail care to all the residents. She stated she believed Resident #22's nail care was provided last week but did not give a date. She stated she did not give the resident a whirlpool on Tuesday, 10/22/2024, as another staff member, CNA #6, assisted the resident with a shower. On 10/24/2024 at 3:39 PM, CNA #6 was interviewed and she stated she started working at the facility on October 5th [2024] and was instructed on what to do when a resident was showered. She stated she did not recall if she gave Resident #22 a shower on 10/22/2024. A Fingernails, Toenails, Care of policy, dated as revised February 2018 and provided by the Administrator, was reviewed and indicated nail care included daily cleaning and regular trimming and trimmed, and smooth nails prevented the resident from accidently scratching and injuring the skin. The policy indicated evidence of ingrown nails, infections, pain, or if nails were too hard or too thick to cut with ease should be reported to the nurse supervisor.

Based on observation, interviews, record reviews, and facility policy review the facility failed to ensure staff donned the proper Personal Protective Equipment (PPE) while performing high contact resident activities for 1 (Resident #76) sampled resident on Enhanced Barrier Precautions (EBP). The findings include: A review of the admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 8/18/2024 revealed Resident #76 had memory problems and a history of coughing/choking during meals or when swallowing medications. A plan of care (revision date: 9/17/2024) revealed Resident #76 required Enhanced Barrier Precautions related to Percutaneous Endoscopic Gastrostomy (PEG) tube. On 10/23/24 at 7:50 AM, the Surveyor observed Licensed Practical Nurse (LPN) #2 administer medication to Resident #76 via PEG tube wearing only gloves, with no additional PPE. On 10/23/24 at 8:00 AM, during an interview LPN #1 stated, I messed up, I did not wear a gown. On 10/23/24 at 2:18 PM, during an interview the Director of Nursing (DON) stated staff should wear a gown and gloves when administering medication through a PEG tube, to protect the resident from potential infections. A policy titled, Enhanced Barrier Precautions, noted that high contact resident care activities requiring the use of gown and gloves include device care or use (central line, urinary catheter, feeding tubes) to prevent the spread of multi-drug resistant organism (MDRO).

Based on observation, record review, and facility policy review, the facility failed to ensure a care plan was revised to reflect the resident's most recent care needs for 1 (Resident #3) sampled resident whose care plan was reviewed. The findings are: Resident #3's medical diagnosis screen was reviewed and indicated the resident was diagnosed with a condition which caused loss of thinking and decision-making skills which interfered with daily life (dementia) and a change in the mental status (altered mental status). A quarterly Minimum Data Set with an Assessment Reference Date of 09/27/2024, was reviewed and indicated Resident #3 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact and was taking the following high-risk drugs: an antipsychotic, an antidepressant, an antibiotic, a diuretic (removes excess fluid) and antiplatelet. Resident #3's Order Summary Report was reviewed and indicated the following orders: a. Bumex (removes excess fluid) 2 milligrams (mg) and give 1 tablet by mouth one time a day and was ordered on 09/22/2024; b. Fluoxetine (antidepressant) 20 mg give 1 tablet by mouth one time a day and was ordered on 07/25/2022; Quetiapine Fumarate (Seroquel- antipsychotic) 25 mg and give 12.5 mg by mouth four times a day for anxiety and was ordered on 09/22/2024 and Tramadol 50 mg and give 50 mg by mouth every 8 hours as needed (PRN) for pain and was ordered on 07/11/2023. The care plan, dated 09/24/2024, was reviewed and indicated Resident #3 was using an antidepressant, a diuretic, and Tramadol for pain but did not indicate which side effects or signs and symptoms to monitor the resident for while taking these high-risk medications. On 10/25/2024 at 1:25 PM, the MDS Coordinator was interviewed by another surveyor and stated she was familiar with the Resident Assessment Instrument (RAI) manual and had an active icon on her desktop which keeps the information up to date and accurate at all times. She stated when gathering information for the MDS, she visits and talks with new residents, speaks to staff and reviews the residents' charts. She stated high-risk medications should be care planned, so staff can monitor the residents, the residents' symptoms and positive or negative changes/reactions the residents may have. She stated the nurses and certified nursing assistants know how to care for the residents by their care plan information. She stated she updated the care plans quarterly and when new orders or gradual dose reductions were received. A Care Plans, Comprehensive Person-Centered policy, dated as revised December 2016 and provided by the Administrator, was reviewed and indicated the care plan interventions came from a thorough analysis of information collected from the comprehensive assessment. The care plan policy indicated the assessments of residents were ongoing and care plans were revised as information about the residents and the residents' conditions change. The care plan policy indicated that the care plan must be updated with certain conditions, one being at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, record review and interview, the facility failed to ensure food items stored in the freezer and refrigerator were covered or sealed to decrease the potential for cross contamination; expired food items were promptly removed/discard by the expiration or use by dates as when it was delivered, door frames, ceiling tiles, ceiling vent floor tiles were free of stains, debris, rust and chipped; 1 of 2 ice machines was maintained in clean and sanitary condition, staff washed their hands, and dietary staff washed their hands and between clean tasks to decrease the potential for food borne illness dirty and clean, before handing food items. The failed practices had the potential to 80 affect residents who received meals from the kitchen. The findings are: 1. On [DATE] at 10:12 AM, Dietary Employee (DE) #1 pulled her mask up. Without washing her hands, she picked up glasses and placed them on the counter, with her fingers touching the rims. She then poured beverages in the glasses to be served to the residents with their lunch meal. 2. On [DATE] at 10:19 AM, DE #2 turned on the 3- compartment sink faucet and obtained water. She then turned off the faucet, without washing her hands, she removed gloves from the glove box and placed them on her hands. At 10:20 AM, DE #2 then used her gloved hand to remove chicken fried steaks from the bag and placed them in a deep fryer basked to be fried served to the residents for lunch. 3. On [DATE] at 10:23 AM, the following observations were made in the walk-in freezer. a. An open box of biscuits on a shelf in the walk-in freezer. The box was not covered or sealed. b. An open box of cookies on a shelf in the walk-in freezer. The box was not covered or sealed. 4. On [DATE] at 10:24 AM, Dietary Employee (DE) #3 was wearing gloves on her hands when she picked up a pan from the bottom shelf of the food preparation counter and placed it on the counter. Without changing gloves and washing her hands. She picked plates to be used portioning dessert to be served to the residents for lunch and placed them on the trays on the counter with her gloved fingers inside the plates. 5. On [DATE] at 10:50 AM, the right and the back inside panels of the ice machine had wet black residue on them. The Surveyor asked the Dietary Employee to wipe the area where wet black residue was noted. She did so and stated it was black residue. The Surveyor asked how often they cleaned the ice machine. She stated, We clean it every week The Surveyor asked, Who uses the ice from the ice machine? She stated, The Certified Nursing Assistant (CAN)s used it to fill water pitchers in the residents' room. 6. On [DATE] at 10:54 AM, the following observations were made in the kitchen area. a. The flat panels on the wall by the dirty dish washing machine were chipped, exposing the metal and paper insulation. The exposed areas had rust stains on them. The door frames leading to the dish washing machine were chipped, exposing the metal. The floor in front of the dish machine had a mixture of brown and black stains on it. b. The ceiling tiles above the food preparation counter have brown, rust, and lint stains on them. c. The ceiling tiles above the food preparation sink in the food preparation area had a buildup of yellow lint on it. d. The ceiling vent in the dish washing room had rust stains on it. 7. On [DATE] at 12:15 PM, DE #1 pulled her pants up, picked up condiments and placed them on the trays. Without washing her hands, she picked glasses that contained beverages to be served to the residents for lunch and placed them on the trays with fingers touching the rims. 8. On [DATE] at 12:19 PM, the following observations were made in the unit refrigerator in the nourishment room at the nurses' station. a. There was a bowl of chef salad with turkey and ham on a shelf in the refrigerator with an expiration date of [DATE]. There was no name to whom it belongs or date when received on the bowl. b. An opened bottle of miracle whip was on a shelf in the refrigerator and there was no name to whom it belongs to, no date when stored and no date when received on the bag. c. A plastic bag of forest ham was on a shelf in the refrigerator with an expiration date of [DATE]. There was no name, no date when it was stored or received on the bag. 9. On [DATE] at 12:34 PM in the refrigerator medication room leading to the D-Hall, there was a bottle of tropical orange juice on a shelf in the refrigerator in the medication room leading to the D-Hall with an expiration date of [DATE]. 10. A facility policy titled .Employee cleanliness and handwashing technique documented, Dietary department employees are required to wash their hands on the occasions listed below . Before beginning shift and any other time deemed necessary.

Based on observation during medication administration, record review and interview, the facility failed to ensure physician's orders were followed to maintain a medication error rate of less than 5% to prevent potential complications for one Resident #64. Medication errors were made by 1 Licensed Practical Nurses (LPN) (LPN #2) of 2 LPNs and 1 Medication Assistant Certified (MAC) who administered medications in the facility. The medication error rate was 7.32%. The failed practice had the potential to affect 84 residents who received medications. The findings are: a. A Physician's Order dated 11/10/2023 Slow Magnesium/Calcium Oral Tablet Delayed Release 70-117 MG (Milligram) (Magnesium Chloride-Calcium Carbonate) Give 2 tablets by mouth two times a day related to Hypomagnesemia. b. On 12/13/23 at 08:14 AM, MAC #1 administered medications and failed to give the Slow Magnesium/Calcium Oral Tablets. c. On 12/14/23 at 10:44 AM the MAC was asked if she remembered how many medications, she gave Resident #64. MAC #1 stated, 8. The MAC was asked to look at the electronic record and count. The MAC stated, There should have been 9, I missed the Magnesium 2 tabs. The MAC stated, I will double check my MAR (Medication Administration Record) from now on. By her not getting her Magnesium, her labs can be low in that area, and she can get sick. d. On 12/14/23 at 1:25 AM, The Surveyor asked the Director of Nurses (DON) was asked if she expected the nurses to follow the Medication Administration Record (MAR). The DON stated, yes. The DON was asked to explain her understanding of how medications are supposed to be administered. The DON stated, By looking at the MAR and card and match them together. You make sure it's the correct dose, med time and resident and make sure they match. e. On 12/13/23 at 2:52 PM, the Administrator provided a form titled, Administering Oral Medications The purpose of this procedure is to provide guidelines for the safe administration of oral medications .Verify that there is a physician ' s order .6. Check the label on the medication and confirm the medication name and dose with the MAR .8. Check the medication dose. Recheck to confirm the proper dose . 46868

Based on inspection of the medication room and medication carts on 12/12/2023, the facility failed to ensure medications in 1 of 2 medication rooms were labeled and stored in accordance with State law and accepted standards of pharmacy practice, the facility failed to ensure discontinued or expired medications were removed and placed into an area for destruction to prevent potential administration to residents for 2 of 4 medication carts, and the facility failed to ensure all medications and biologicals were stored in locked compartments with only authorized personnel to have access. These failed practices had the potential to affect all 84 residents who resided in the facility and would receive any physician-ordered medications from the medications room, or the medication carts and 47 residents who are mobile and self-propel around the facility. The findings are: 1. On 12/12/2023 at 2:01 PM, The E/F hall medication cart was checked with Licensed Practical Nurse (LPN) #3. The PRN (as needed) medications check for the medication cart contained the following results: a. 30 Tizanidine 2 mg (milligrams) -- expired 10/17/2023. b. 13 Levothyroxine 150 mcg (micrograms)-- expired 08/21/2023. c. 15 ondansetron 4 mg-- expired 08/27/2023. d. 28 ondansetron 4 mg-- expired 11/15/2023. e. 2 clonidine 0.1 mg-- expired 05/10/2023. f. 12 clonidine 0.1 mg-- expired 09/13/2023. g. 15 ondansetron 4 mg-- expired 09/15/2023. 2. On 12/12/2023 at 2:28 PM, the G/H hall medication cart was checked with the Director of Nurses (DON). The PRN (as needed) medications check for the medication cart contained the following results: a. 4 ondansetron 4 mg-- expired 03/03/2023. 3. On 12/12/2023 at 2:38 PM, the medication room was checked with the DON. The check for the Medication room contained the following results: a. An open Influenza Vaccine 5 ml multi dose vial with no open date was in the medication refrigerator. 4. On 12/12/2023 at 2:20 PM, LPN #3 was asked, What is the process for expired drugs? LPN stated, If they have an order for it I will reorder it. If not, I will put the medication in the discontinue bin. The Surveyor asked, What is the importance of checking for expired medications? LPN #3 replied, So that you do not give an expired drug. 5. On 12/12/2023 at 2:31 PM, the Surveyor asked the DON, What is the process for expired medications? The DON stated, replied, When the medication expires remove the card and write in book and place in barrel. The Surveyor asked, How often is the medication carts checked for expired medications? DON replied, Usually daily or 2 times a week. The Surveyor asked, What should the nurses do immediately after opening a medication vial? The DON stated, replied, Open date and initials. The Surveyor asked, What is the reason for placing an open date? The DON replied, To know how many days the medication is good for. 6. On 12/12/2023 at 2:45 PM., the Surveyor asked LPN #3 What should you do after opening a medication vial? LPN #3 stated, replied, date it. 7. a On 12/13/23 at 8:08 AM, the Surveyor observed the Hall C cart unlocked and unattended. The Surveyor opened the cart and the Medication Assistant Certified #2 (MAC) came to the cart at 8:13 AM. The Surveyor asked MAC #2 if she had the keys to the unlocked cart. MAC #2 stated No mam [named nurse] does. At 8:16 AM, Licensed Practical Nurse (LPN) #1 came to the medication cart. b. On 12/13/23 at 8:17 AM, the Surveyor asked LPN #1, what is wrong with the medication cart? LPN #1 stated, I guess I left it unlocked. LPN #1 was asked to explain the reason a medication cart should be locked. LPN#1 stated, Because anyone can get into it and overdose; It is super serious. c. On 12/14/2023, the Director of Nursing [DON] was asked by the Surveyor why the medication cart needs to be locked. The DON stated To keep residents from any risk of ingesting medications that are not for them. It could be disastrously fatal. d. On 12/13/2023 at 2:52 PM, the Administrator provided the policy titled Storage of Medications, The facility shall store all drugs and biologicals in a safe secure and orderly manner . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals . 7. Compartments containing drugs and biologicals shall be locked when not in use. Trays or carts used to transport such items are not left unattended and available to others .10. Only authorized personnel will have access to the keys .

Based on observation, record review and interview, the facility failed to ensure enough food items were prepared and served according to planned written menu for 1 of 1 meal observed. The failed practice had the potential to affect 13 residents who received their meal trays in the unit dining room, 8 residents who received their meal trays in the room on E- Hall, 4 residents who received their meal trays in their room on B-Hall, and 5 residents who received their meal trays in their room on G- Hall from 1 of 1 kitchen. The findings are: 1. Resident #51 had a diagnosis of Diabetes Mellitus. The Quarterly Minimum Data Set [MDS] with an assessment reference date [ARD] of 12/06/2023 documented a Brief interview for mental status [BIMS] of 13 (13-15 cognitive). On 12/11/23 at 11:17 AM Resident #51 stated the portions of food here are small and they don't get enough to eat. He went on to say the facility frequently runs out of food. 2. 1. On 12/11/2023, the menu for noon meal documented all residents were to receive 1/2 cup of squash casserole. 3. On 12/11/23 at 12:39 PM, all residents who received noon meal in the unit were served small portions of squash casserole. 4. On 12/11/23 at 12:43 PM, Dietary Employee used a 4- ounce spoon (1/2 cup) to serve half a portion (1/4 cup) of baked squash casserole to 8 residents who received meal trays in their room on E-Hall, instead of 1/2 cup. 5. On 12/11/23 at 12:54 PM, the following observations were made during the noon meal service in the kitchen. a. The kitchen ran out of baked squash casserole. b. Four residents were served broccoli/cauliflower and carrots, instead of baked squash casserole. c. Five residents were served cream corn with boiled squash, instead of baked squash casserole. d. On 12/11/23 at 1:02 PM, the surveyor asked Dietary Employee (DE) #2 the reason some residents were served small portions of baked squash casserole and the reason some residents did not get baked squash casserole. DE #2 stated, I ran out. I didn't make enough.

Based on observation, interview and record review, the facility failed to update the resident care plan to reflect the needs of 1 Resident (Resident #10) sampled resident. Resident #10 had a past diagnosis of Osteomyelitis of lower extremities. On 12/11/2023 at 10:45 AM, Resident #10 was sitting in a wheelchair with bilateral lower extremities with 2+ pitting edema. When questioned about her lower leg swelling, Resident #10 stated she had this problem for years off and on. Progress note dated 10/06/2023 at 10:30 AM documented resident had 2+ pitting edema of lower extremities. At 2:16 it documented to start Lasix 40 mg daily. The Physician's order dated 10/07/2023 documented .Lasix oral tablet 40 mg (milligrams) give one tablet by mouth one time a day for fluid retention. On 12/12/2023 review of Resident #10's plan of care did not address nor document the pitting edema or the diuretic use. On 12/13/2023 at 2:50 PM, the (Minimum Data Set) MDS Coordinator was asked, should the edema of Resident #10's lower extremities be care planned? The MDS Coordinator stated, I mostly try to care plan problems, but she does have lower leg issues. On 12/13/2023 at 2:52 PM, the MDS Coordinator was asked how they were made aware of changes in the resident's condition or medications. The MDS coordinator stated, The floor nurse documents in the progress note, any significant change and we go from there. I wasn't aware [Resident #10] had the swelling until just now. On 12/14/2023 at 1:45 PM, the Surveyor asked the Director of Nursing why is it important to care plan medications, the DON stated, It could help prevent a medication error, so the staff know what side effects to look for and better care for our residents.

Based on observation, record review and interview the facility failed to invite resident and family to attend care plan meetings for one (Resident #10) sampled residents. Resident #10 had a diagnosis of muscle weakness. The Quarterly Minimum Data Set [MDS] with an assessment reference date [ARD] of 10/12/2023 documented a brief interview of mental status [BIMS] of 14 which indicated resident cognitive. On 12/11/23 at 10:40 AM, Resident #10 was asked if she attended care plan meetings and participated in developing her plan of care, Resident #10 stated she would like to attend care plan meetings but was unaware of when they are and had not been invited to attend. Review of Resident #10's clinical record did not document an invitation to resident or resident's representative to attend the care plan meeting. On 12/13/2023 at 1:20 PM during an interview, the Social Director was unable to provide documentation of Resident #10 and Resident #10's representative being invited to care plan meeting and confirmed neither party was invited. The Social Director went on to say she calls family members to invite them to care plan meetings according to list in charting system-[Facility Computer Software] populated by the MDS Coordinator. Review of the list confirmed Resident #10 was not listed prior to the last care plan meeting. On 12/14/2023 at 1:45 PM, the DON was asked why it is important to include the resident and family in care planning? The DON said it helps to better care for the residents and to keep the resident and family informed of what is going on with the resident and to plan with the residents wants and needs in mind, family can voice concerns. On 12/14/2023 at 1:53 PM, the MDS coordinator was questioned why it is important to include the resident and family in the care plan, they responded, So they can keep informed of the residents generalized care. The facility Care Planning policy documented, .the resident and residents family and/or the residents legal representative are encouraged to participate in the development of and revisions to the residents care plan .every effort will be made to schedule care plan meetings at the best time of day for the resident and family .

Based on observation, interview and record review, the facility failed to provide activities for, or invite room bound residents to activities for one (Resident #10) of two (Resident #10 and #25) sampled residents who spend most of their time in their room. The findings are: Resident #10 had a diagnosis of muscle weakness. The Quarterly Minimum Data Set [MDS] with an assessment reference date [ARD] of 10/12/2023 documented a brief interview of mental status [BIMS] of 14 which indicated resident cognitive. On 12/11/23 at 10:38 AM Resident #10 was asked if she participated in any activities at the facility, Resident #10 stated they had not but would like to attend activities, especially Bingo. Review of Resident #10's clinical record did not document any activity or participation notes for activities. Review of Resident #10's care plan, with initiated date of 07/07/2023, documented, .Assist the resident in developing /Provide the resident with a program of activities that is meaningful and of interest .Encourage resident to participate in activities of choice. Facilitate attendance as needed . On 12/13/2023 at 12:30 PM, the Activity Director was asked if she kept a record of residents who participated in activities and where activity notes were on Resident #10. Confirmation was made there were not activity notes on Resident #10 and there was a program on (electronic health record program) participation was documented on. When asked for documentation of participation in group or individual activities for Resident #10 since admission on 06/14/2023, the Activity Director gave printed documentation which indicated active participation in a group activity one time in June, no documentation for July, August or September, active participating in a group activity one time in October, actively participating in a group activity one time in November and 2 group and one 1-1 activity in December. On 12/13/23 at 02:35 PM Resident #10 voiced a desire to participate in activities, emphasizing enjoyed playing Bingo and liked to do crafts. On 12/14/2023 at 1:45 PM, the DON was asked why activities are important for the residents. The DON stated, Quality of life, when they come here, I don't want them to feel like it's the end of life, activities help keep their mind active and keeps them happy. That's another reason 1:1 activity is important for room bound residents. On 12/14/23 at 2:00 PM, the Activity Director was asked to explain why it is important for residents to participate in activities, the Activity Director stated, Its important because it helps them be more active and helps prevent them from being depressed, If they spend all their time in their room or in bed, they can be bored and it could affect their health. When asked how often 1:1 activities are held with room bound residents and Activity Director stated, I try to do something with them at least twice a week. The facilities policy on Activity Programs documented, .The Activities Program is provided to support the wellbeing of residents and to encourage both independence and community interaction .Resident's activity participation is documented in the residents individual medical record .

Based on observation, interview and record review, the facility failed to ensure nails were trimmed to maintain good hygiene and prevent potential skin tears and infection. This failed practice had the potential to affect all 49 residents in the facility who were dependent or assisted with nail care. The findings are: 1. On 12/11/2023 at 10:59 AM Resident #3 had jagged fingernails, approximately 1/2 inch long beyond the tip of the fingers. 2. On 12/11/2023 at 2:47 PM, Resident #3 had jagged fingernails, approximately 1/2 inch long beyond the tip of the fingers. 3. On 12/12/2023 at 9:49 AM, Resident #3 had jagged fingernails, approximately 1/2 inch long, a fingernail tore at edge of nail bed with red tinged drainage around the nail and on the fingertip. 4. A care plan with an initiation date of 07/12/2023 stated, Resident #3 has an ADL [activities of daily living] self-care performance deficit r/t [related to] weakness .Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . 5. A Quarterly Minimum Data Set (MDS) with assessment reference date of 08/24/2023 documented Resident #3 is dependent for personal hygiene. 6. On 12/13/2023 at 10:15 AM, the Surveyor asked Nursing Assistant (NA) #1, Who is responsible for nailcare? NA #1 replied, Normally the CNAs [Certified Nursing Assistant] but if the resident is a diabetic then the nurse is responsible. The Surveyor asked, How often is nail care performed? NA #1 replied, Every other day. 7. On 12/13/2023 at 10:20 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, Who is responsible for nailcare? LPN #1 replied, Everybody. The surveyor asked, How often is nail care performed? LPN #1 replied, Weekly. Surveyor asked, What are some negative outcomes for jagged and long length nails? LPN #1 replied, they can get skin tears. 8. On 08/17/23 at 8:46 AM, the Surveyor asked the Director of Nursing (DON), Who is responsible for nailcare? DON replied, Treatment nurse and the nurse on the hall. Surveyor asked, How often is nail care performed? DON replied, Weekly and with body audits. 9. On 12/13/2023 at 2:52 PM the Administrator provided a policy titled, Care of Fingernails/Toenails states, .The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming .proper nail care can aid in the prevention of skin problems around the nail bed .trimmed and smooth nails prevent the resident from accidentally scratching or injuring his or her skin .watch for and report any changes .bleeding .

Based on observation, record review and interview, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the physician, to minimize the potential for respiratory complications for 1 (Residents #230) of 1 sampled resident who had physician's orders for oxygen therapy. The facility also failed to ensure a nasal cannula was dated to ensure regular change out to prevent potential contamination or infection. The failed practice had the potential to affect 9 residents who had physician's orders for oxygen therapy. The findings are: On 12/11/23 at 10:40 AM, during initial rounds Resident # 230 was lying in bed and with oxygen via nasal cannula at 1 liter per minute (lpm) with no date on the tubing. On 12/11/23 at 4:04 PM, Resident #230 was lying in bed with oxygen administered at 1 lpm. On 12/12/23 at 9:06 AM, Resident #230 with oxygen being administered at 1 lpm. On 12/13/23 at 12:10 PM, Resident #230 with oxygen being administered at 1.5 lpm. On 12/13/23 at 12:15 PM, Medication Assistant Certified (MAC) #1 said, Resident #230 ' s oxygen was being administered at 1.5 lpm but should be a 2 lpm which she adjusted to a 2 at this time. MAC #1 checked the electronic record and physician order and stated, It says it's supposed to be at 3 lpm. On 12/13/23 at 1:28 PM, the Surveyor asked the Director of Nurses was asked if she expected the nurses to follow the physician ' s orders when administering oxygen. DON stated, Check them when first come in then every morning to make sure the flow rate is correct. A Physicians order dated 08/28/23 documented Oxygen @ 3L Nasal Cannula (NC). A care plan dated 02/16/23 documented, .oxygen settings: O2 via 3L NC humidified.

Based on interview and record review, the facility failed to ensure that Physician face-to-face visits were conducted, and Physician Progress Notes were documented at least every 60 days identified for 3 (Residents #1, #2, and #3) of 3 residents sampled for the timeliness of Physician Progress Notes. The findings are: 1. Resident #1 was admitted on [DATE] and had diagnoses of Diabetes Mellitus, Thyroid Disorder, and Non-Alzheimer Dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/17/23 documented the resident scored 0 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS). a. The Physician Notes from December 2022 to May 2023 did not document an attending Physician's visit or a Progress Note. The Progress Notes were signed by an Advanced Practice Registered Nurse (APRN). 2. Resident #2 was admitted on [DATE] and had a diagnoses of Diabetes Mellitus, Depression, and Hemiplegia. The MDS with an ARD of 12/05/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS. a. The Physician Notes from December 2022 to May 2023 did not document an attending Physician visit or a Progress Note. The Progress Notes were signed by an APRN. 3. Resident #3 was readmitted on [DATE] and had the diagnoses of Non-Alzheimer Dementia and Thyroid Disorder. The MDS with an ARD of 01/15/23 documented the resident scored 0 (0-7 indicates severe impairment) on a BIMS. a. The Physician Notes from December 2022 to May 2023 did not document an attending Physician visit or Progress Note. The Progress Notes were signed by an APRN. 4. On 05/03/23 at 12:45 PM, the Surveyor asked the Administrator if the APRN was supervised by a Physician. The Administrator stated, Yes. The Surveyor requested the most recent Physician Progress Notes for Residents #1, #2, and #3. The Physician Notes were not produced. 5. On 05/03/23 at 4:00 PM, the Surveyor asked the Administrator for the Physician Progress Notes. The Administrator stated, We have problems with the Physician. The APRN stated, We are discussing plans to become compliant with Physician Services and will implement a plan to ensure the Physician sees the residents, that our notes are timely, and orders are responded to.