Every finding on record at Chatsworth at Pga National

Based on observations, interviews and record review, the facility failed to maintain acceptable parameters of nutritional status and failed to provide nutritional interventions in a timely manner for 1 of 2 sampled residents reviewed for nutrition (Resident #23). The findings included: Review of the facility's policy titled, Weight Management, dated 06/2021, included the following: Residents will have their weight obtained on admission, re-admission and monthly or at a frequent determined by the interdisciplinary team or provider. Definitions: Significant weight change- As defined in RAI Manual is any unplanned weight change of 5% change over 1 month, 7.5% over 3 months or 10% change over the past 6 months. Procedure: 4.The case associate and or Medication Aide obtains the weight and documents the weight into Touchscreen and or in myUnity. 5. Once weights have been entered into the EMR (Electronic Medical Record), the licensed nurse reviews myUnity's Resident Weight Report/and or Weight Changes +Report for residents obtained on the last day of the Month for any of the following weight changes: a.5 percent (5%) change over 1 month b.7.5 percent (7.5%) change over 3 months or c. 10 percent (10%) change over the past 6 months. 7.When a significant weight change is identified the following will occur: a. PA/CS: The licensed nurse or designee notifies the Dietitian of any resident with a weight change of 5 pounds from the previous weight or a significant weight change. 11. Guest/residents with significant weight change should be discussed in High Risk Rounds/Utilization Review. 12. When a significant weight change is identified, the guest/resident plan of care will be reviewed, evaluated and revised, as applicable, to reflect interventions to support the guest/resident goals and preferences after medical consideration and interdisciplinary discussion. Record review for Resident #23 revealed that the resident was admitted to the facility on [DATE] with diagnoses to include: Alzheimer's Disease, Major Depressive Disorder, Atrial Fibrillation, and Dementia. Review of Section C of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 had a Brief Interview for Mental Status (BIMS) of 00, which indicated that he was severely cognitive impaired. Review of Section GG of the same MDS revealed Resident #23 was dependent on staff assistance for eating/nutrition and all his Activities of Daily Living (ADLs). In addition, review section O revealed Resident #23 was not on the Hospice care program. Review of the Physician's Orders showed Resident #23 had orders dated 10/24/24 for ascorbic acid (vitamin C) 500 mg tablet daily, Vitamin B-12 500 mcg tablet daily, diet: Pureed, Nectar Thick Liquid, continuous; Barrier Cream, apply barrier cream to buttocks 3 times daily and as needed. Review of the Physician's Orders showed Resident #23 had orders dated 12/03/24 for Calcium 600 + Minerals 600 mg (as carbonate) 200-unit tablet daily and on 12/30/24 for cholecalciferol (vitamin D3) 1,250 mcg (50,000 unit) tablet Every 1 Week. Review of the Holistic Care Plan dated 01/29/25 under Nutritional Status documented Resident #23 enjoys eating in the dining room and requires Puree diet with double portions. Care Plan approaches were to provide prescribed diet at every meal; honor food preferences as able; staff to assist with meals as needed; offer fluids throughout the day; encourage oral intake; weigh as prescribed and monitor weights. During an observation conducted on 04/15/25 at 12:09 PM Resident #23 was in the dining room, lunch tray was set on the table and the MDS coordinator assisted the resident, however, the consistency of the food was not pureed and was not the correct lunch tray for Resident #23. At 12:18 PM an observation of Resident 23's tray with correct consistency and appeared to have double portions. Resident #23 was observed opening his mouth wide and eating 100% of his lunch. At this time an interview was conducted with the MDS coordinator, who stated Resident #23 has a good appetite and eats 100% of his meals most of the time. During a second dining observation on 04/16/25 at 12:24 PM, Resident #23 was in the dining room for lunch and was assisted by a Certified Nursing Assistant (CNA) and was eating well. The meal ticket was reviewed and stated double portions. A review of Resident #23's weight log showed that the following weights were recorded: on 10/28/24 upon admission he was at 134.90 pounds, on 02/04/25 he was at 127.00 pounds (7.9 pounds weight loss), and on 04/01/25 he had an additional 6-pound weight loss. This showed a 10.30 percent weight loss from 10/28/24 to 04/01/25. During an interview conducted on 04/16/25 at 10:58 AM with Staff A, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 4 years. She stated the facility does not have a restorative CNA and the CNA assigned to the resident would do the monthly weights. Staff A stated the CNA then would document the weights in the computer and the nurses and the dietitian have access to see the residents' weights. She also stated that weights are done monthly at the beginning of the month unless there's a physician's order for a specific timeline to obtain the resident's weight. Staff A stated she would report any weight changes to the Assisting Director of Nursing (ADON) and then the dietitian will come in and follow up with the resident. Record review of the dietitian nutrition note dated 10/29/24 showed Resident #23's Ideal Body Weight (IBW) was 69 kg (152.1 pounds) and current body weight (BW) was 61 kg (134.90 pounds) with recommendation to continue to follow up per protocol. At this time, no Body Mass Index (BMI) was calculated and no documentation that Resident #23 was at risk for weight loss. Record review of the dietitian nutrition follow up note dated 01/23/25 stated Resident #23 is tolerating puree diet well and staff has reported about 100 percent intake of meals. In addition, she reviewed the weights from 10/28/24 to 01/04/25, however, the dietitian only looked at the weight for 12/04/24 and 01/03/25 and noted Resident #23 has had a small weight decline (2.3 percent weight loss x 1 month), which is not significant. The interventions were to continue to monitor oral intake, body weight and skin integrity, with a goal for weight stabilization. Further review of the chart revealed no nutritional interventions or supplements were ordered at this time. Record review of the dietitian note dated 04/13/25 for Resident #23 evaluation due to recent weight loss of 3.4 percent in a month. She reviewed the last 3 months of Resident #23's weight history and noted the weight loss as not significant. She mentioned Resident #23 is currently on supplements including Vitamin E, Vitamin D3, Calcium with minerals, Vitamin C, and Vitamin B12. She also noted that Resident #23 is considered at risk for weight loss and overall decline due to current medical status. The interventions were to continue monitoring closely, weight trends, and skin integrity. No additional interventions were ordered to address the weight loss. In addition, the dietitian did not review the complete weight history (10/28/24 to 04/01/25). At this time Resident #23 had a weight loss trend of 13.9 pounds since admission which indicated a 10.30 percent weight loss from 10/28/24 to 04/01/25. An interview conducted on 04/16/25 at 12:35 PM with the General Manager for Dining, who stated staff members such as nursing, dietitian and even herself can add a food preference to the residents' chart. She stated these preferences are part of the meal ticket and printed on the Dining Details report daily. She reviewed Resident #23's preferences and noted the double portions preference was entered by the ADON on 11/12/24. During an interview conducted on 04/16/25 at 12:59 PM with the Clinical Dietitian, who stated she has been at the facility since September 2024 and works Part-time at least 20 hours a week. She stated she would receive an email with new admissions, and she usually completes the nutritional assessment within 3 days. For the Long-Term Care (LTC) residents, she conducts assessments quarterly, unless she is requested by family, or if the resident is losing weight. She noted that weight loss is considered if the resident has lost 5 percent in a month, 7.5 percent in 3 months and 10 percent in 6 months. She stated that during her assessments she utilizes her clinical knowledge, low BMI, any wounds the resident may have or if poor intake to assess the resident for risk of weight loss. She noted that a normal BMI is 18.5-25 and under 18.5 is considered excessive weight loss. She stated the facility does offer fortified foods, for breakfast is oatmeal, and the other meal is mashed potatoes to add more calories for the residents who are underweight. She then stated that the residents in this community are usually underweight. She also stated if a resident is losing weight, she would immediately put interventions in place such as Ensure or Glucerna (for diabetic residents) supplements, then fortified foods, the last resort is an appetite stimulant (with a physician's order) and continue evaluation. In addition, she stated she receives the monthly weight changes report via email. The report will include residents that are losing weight and percentage change in 30 days, 90 days and 180 days. At this time, the dietitian was asked to review Resident #23's weight history from admitted and was asked to calculate the weight loss and if it is significant. The dietitian stated, yes it looks significant, let me look at the weights again. She then stated, I missed that. I did not look back to 6 months, only until 02/01/25. She then stated that she was not aware Resident #23 was getting double portions for his meals. A side-by-side review of the clinical monthly weight changes report she received revealed that Resident #23 has a significant weight loss and again she stated, I missed that. Furthermore, the Clinical Dietitian also acknowledged that the current BMI for Resident #23 is 18.4 which indicates that Resident #23 is underweight by 0.1. An interview was conducted on 04/016/25 at 3:00 PM with the ADON and the Director of Nursing (DON). The ADON stated she spoke with Resident #23's son on 11/12/24 and she added double portions as preferences as per the son. In addition, the care plan would note this food preference change and the dietitian was notified. They both stated that the interdisciplinary team (ADON, DON, Social Services, MDS, Activity Manager) holds weekly high-risk rounds, the dietitian does not attend these meetings however, she receives email updates with the monthly weight changes report. ADON also stated that they identified a weight loss for Resident #23 and immediately notified the Clinical Dietitian by email on 04/08/25. Then the High-Risk meeting was conducted on 04/10/25. She acknowledged that the dietitian documentation was done on 04/14/25 and she did not address the significant weight loss. ADON also stated she is the one to update the care plans, however, the dietitian did not advise any recommendations for her to update the nutrition care plan. At this time both ADON and DON acknowledged all findings.

Based on observation, interview, record review, and policy review, the facility failed to ensure care and services for the prevention of Urinary Tract Infections (UTIs) or other complications for 3 of 3 sampled residents who had an indwelling urinary catheter. Nursing staff failed to maintain proper positioning and securing of the catheter tubing for Residents #24 and #45, and failed to educate Resident #38 of the risks of refusing to follow-up with a urology consult and discontinue use of the indwelling urinary catheter. The findings included: Review of the policy Urinary Catheters dated 06/2021 documented, Procedure: 1. Catheter Care . c. Use of proper infection control practices regarding hand washing, catheter care, tubing and the collection bag will be followed at all times. h. Maintain unobstructed urine flow. i. Catheter tubing, bag or spigot cannot touch the floor. 1) Review of the record revealed Resident #24 was admitted to the facility on [DATE] and was ordered an indwelling urinary catheter on 11/14/23 for urinary retention with obstruction. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 1, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. This MDS also documented the resident was dependent upon staff for all Activities of Daily Living (ADLs). During an observation on 01/17/24 at 11:13 AM, the collection bag for the resident's indwelling urinary catheter was noted in a dignity bag hooked to the low bed, with the tubing lying directly on the floor. Sediment was noted in the tubing leading to the drainage bag (Photographic Evidence Obtained). Observation of the resident's thigh revealed the catheter was stretched tightly from the resident's adult brief. A second observation on 01/17/24 at 4:52 PM revealed the indwelling urinary catheter tubing directly on the floor again (Photographic Evidence Obtained). On 01/17/24 at 5:15 PM, Staff B, Certified Nursing Assistant (CNA), was asked about the tubing on the floor and agreed it should not be there. Upon further observation of the resident, the CNA identified an anchor on the innermost aspect of the resident's right thigh, but the catheter was not in the clamp of the anchor. The CNA confirmed the anchor was for the catheter tubing, but when the CNA placed the catheter into the clamp, she failed to do so at the Y connection (a place on the catheter for obtaining a urine sample and used for proper securing) that would keep the catheter from pulling. The CNA was asked if the catheter was secure, and the CNA demonstrated how it moved freely in the clamp on the anchor. At 5:33 PM, the Clinical Manager was asked to assist the CNA, and the catheter was properly placed into the anchor and urinary drainage bag was replaced. An observation of care for Resident #24 was made on 01/18/24 at 10:35 AM with Staff C, CNA, assisted by Staff A, CNA, for positioning of the resident. Proper indwelling catheter and peri-care (personal care) was observed. Upon completion of the care, the CNA covered the resident and stated she was done. The surveyor asked the CNA to observe the catheter at the anchor. When asked what was wrong, the CNA did not know. The catheter was hooked in the anchor in such a way that the catheter was kinked so that urine would not be able to flow freely into the collection bag. The indwelling catheter bag was noted on the floor. When asked what happened, the CNA stated it fell . When asked what she needed to do, the CNA stated she needed to clean it off. The Assistant Director of Nursing (ADON) was brought into the room and notified of the findings. The ADON provided education to the CNA, assisted the CNA on proper catheter positioning, and changed out the indwelling catheter collection bag. 2) Review of the record revealed Resident #45 was admitted to the facility on [DATE] and had an indwelling urinary catheter upon admission. The resident had the indwelling urinary catheter placed prior to admission for inability to void. Review of the current MDS assessment dated [DATE] documented the resident had a BIMS score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented the use of an indwelling urinary catheter. A progress note dated 01/12/24 documented Resident #45 went to the urologist, who placed him on an antibiotic for three days. During an interview with Resident #45 on 01/16/24 at 3:34 PM, Staff B, CNA entered the resident's room and proceeded to empty the indwelling urinary catheter leg bag. The CNA donned gloves but failed to don a gown as per their Enhanced Barrier Precautions (EBP), utilized by the facility to protect the resident from infection. The catheter was not anchored in any way and was noted to be stretched tightly down the resident's leg. After the CNA left the room, when asked about the anchor, Resident #45 stated when he first got it (the catheter), they were careful about putting the tube in the anchor, but it comes out. A cloth/Velcro type anchor secure device was noted on the resident's thigh, but not being used. When asked if the urinary catheter was pulling, the resident stated, Now that you mention it . yes. When asked if staff routinely clean the catheter each shift or daily, the resident stated, sometimes they clean it, but would not specify. During an observation on 01/17/24 at 11:57 AM, Resident #45 had just returned from therapy. The resident's urinary catheter leg bag was noted, the tubing was not anchored, and the tubing was taunt (Photographic Evidence Obtained). The urinary catheter tubing was visible to all staff as the resident was wearing shorts. A washcloth was noted over the collection bag as per the resident's request, but part of the catheter was visible along with the unused anchor. On 01/18/24 at about 11:30 AM, the ADON was shown the photo of the lack of catheter anchor for Resident #45 and agreed with the concern. On 01/19/24 at 10:58 AM, when asked who was responsible for ensuring the urinary catheters were properly secured, the Clinical Manager stated it was the nursing teams responsibility, which included the CNAs, nurses, and managers. 3) During an interview on 01/16/24 at 10:51 AM, when asked why she had an urinary catheter, Resident #38 stated, I couldn't walk to the bathroom. They wanted to take it out last week, I think, but I told them no. Think I will ask them to take it out this week or next. When asked if she was aware of the risks of long-term catheter use, the resident stated she knew she could get an infection, but was unaware of any other risks such as difficulty returning back to a normal urinary function, damage to the bladder or urinary tract, or any other possible complication. Review of the record revealed Resident #38 was admitted to the facility on [DATE], transferred back to the hospital on 10/31/23 related to surgical complications, and returned to the facility on [DATE]. Review of the physician orders revealed an order dated 11/28/23 for a urology consult related to urinary retention. Further review of the record lacked any evidence of this consult. During an interview on 01/17/24 at 4:04 PM, Staff F, Registered Nurse (RN) and usual day shift direct care nurse for Resident #38, stated she was unaware of a urology consult. The Infection Preventionist (IP), who was at the nurses' station at the time of the interview, stated Resident #38 has canceled two urology appointments. When asked if they had attempted to discontinue the catheter, the IP stated they had, but was unable to locate any documentation in the medical record as to when and the outcome. When asked why Resident #38 still had the indwelling catheter, the IP stated, Because the resident chooses not to have the Foley cath (catheter) discontinued. The IP volunteered that at one point the urinary catheter came out, and when asked what happened, the IP stated the resident wanted it back, so they did, but again was unable to provide any supporting documentation of this or the urology consult. During an interview on 01/17/24 at 4:22 PM, when asked about the urology consult for Resident #38, the Central Supply/Transportation/Scheduling person stated she made an appointment with a urologist when the 11/28/23 order came through. The Scheduler stated the appointment was made, but at that time the resident was not able to walk yet, and refused to go to the appointment or have the urinary catheter taken out. The Scheduler, who was also a Licensed Practical Nurse (LPN), stated she educated the resident, who stated she didn't care. When asked if she documented anything anywhere, the Scheduler stated she doesn't do clinical anymore, so she doesn't document in the record, but that she told the nurse. The Scheduler was unable to locate and provide any information about the first appointment at that time. The Scheduler stated that again this month, when she noted the resident was now up and about, she made a second urology appointment for 01/11/24, and provided an Appointment form that documented the appointment for 01/11/24 at 10 AM. The Scheduler stated when she went to remind the resident the day before the appointment, Resident #38 stated she had called and canceled the appointment herself. When asked what she did at that point, the Scheduler stated she spoke with the nurse again. Review of the working nursing schedule for 01/10/24 and 01/11/24 revealed Staff F, RN, was again the resident's direct care nurse. During an interview on 01/17/24 at 4:38 PM, the RN stated she was not made aware that Resident #38 canceled her second urology appointment. The RN stated if she had known she would have educated the resident, called the family if appropriate, notify the physician, and make a note in the record. On 01/19/24 at 11:05 AM, when asked if they had any further information related to the urology consult for Resident #38, the Director of Nursing (DON), stated she reached out to the physician who stated she knew about the canceled urology visit. A side-by-side review of a physician note dated 01/12/24 documented, Urinary retention - Foley catheter medically necessary. Encouraged resident to follow up with urology - Pt (patient) refused. This note, along with the medical record, lacked any documented evidence of education to Resident #38 of the risks of prolonged use of an indwelling urinary catheter.

Based on record review, observations, and interviews, the facility failed to honor the resident's choice regarding the name that the resident preferred to be called by, as conveyed on the day of admission, and as documented in the resident's records, for 1 of 2 sampled residents (Resident #10), reviewed for choices. The findings included: A review of Resident #10's records revealed that the resident was admitted to the facility on [DATE] with diagnoses of Major depressive disorder, Dementia, unspecified severity with other behavior disorders, and Generalized anxiety disorder. Record review of Resident #10's care plan, dated 01/04/24, related to Engagement and Socialization, documented that the resident had a preferred first name that was different than her legal name. The care plan specified that the resident should be called by her preferred name. The preferred name was entered incorrectly on this care plan. Record review of Resident #10's Initial Physical Therapy Evaluation and Care Plan, dated 12/30/23, documented Resident #10's preferred name in the Precautions Section. An interview was conducted on 01/17/24 at 5:15 PM with Staff B, Certified Nursing Assistant (CNA), in D Hall. When asked what she called Resident #10, Staff B answered, I call her Ms. (legal first name). An observation on 01/18/24 at 9:39 AM revealed Resident #10 being assisted at the sink in her room by Staff G, Physical Therapy Assistant (PTA). While talking to Resident #10, Staff G consistently used the resident's legal first name instead of her preferred name. A phone call interview was conducted with the representative of Resident #10 on 01/19/24 at 10:05 AM. Resident #10's representative stated that, She's never been called (legal first name). Not even as a child. Resident #10's representative reported that on the day of admission she personally informed the facility's physician, the Director of Nursing (DON), the resident's CNA and the Director of Rehabilitation, that they should call Resident #10 (preferred name). She stated, I wanted them to know that it could help them in her care. The representative for Resident #10 also informed the interviewer that she wrote and placed the sign seen in Resident #10's room that says, Call Me (preferred name), on the day of admission. Photographic Evidence Obtained An interview was conducted on 01/19/24 at 10:28 AM, with Staff C, CNA, in Resident #10's room, regarding the sign beside the resident's bed with written instructions. The sign said, Call Me (preferred name). Staff C reported that, We use both names. Her daughter wrote that, because saying (preferred name) calms her. We use (preferred name) to calm her down. An interview was conducted on 01/19/24 at 10:34 AM, in the Rehabilitation Gym with Staff D, Certified Occupational Therapy Assistant (COTA). Staff D reported, She (Resident #10) prefers to be called by (preferred name) Staff D added that the preferred name was, .established in her initial evaluation. An observation on 01/19/24 at 10:45 AM in the dining room, revealed Resident #10 seated with a group led by Staff E, Activity Assistant. Staff E introduced Resident #10 by her surname, rather than her documented preferred name. An interview was conducted on 01/19/24 at 11:12 AM, in D Hall, with Staff F, Registered Nurse (RN). Staff F was asked how she called Resident #10. Staff F replied that she calls Resident #10, Miss (surname), or (nickname), which is the resident's legal first name shortened. An interview was conducted on 01/19/24 at 2:15 PM, in the Rehabilitation Gym with Staff G, PTA. When asked about Resident 10's name, Staff G reported that, Her preference is (preferred name), but I call her (legal first name). I forget. An observation on 01/19/24 at 2:24 PM revealed Staff E, Activity Assistant, entering Resident 10's room. Staff E knocked on Resident #10's door and said, Hi, Ms. (surname). During an interview with the Director of Nursing (DON) in the conference room, on 01/19/24 at 3:03 PM, the DON was asked how she called Resident #10. The DON replied, How do I refer to her? Ms. (surname)?

Based on record review and interview, the facility failed to ensure accurate documentation for 4 of 22 sampled residents. Medication physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Discharge Report for Resident #51 documented an incorrect discharge location. The findings included: 1) Review of the record revealed Resident #18 was admitted to the facility on [DATE]. Review of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] An order dated 08/04/22 for the medication [MEDICATION(S)], used for [CONDITION(S)] (sleeping issues), documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 08/30/22 for the medication [MEDICATION(S)] sulfate (an iron supplement), used to treat low iron blood levels, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Review of the record revealed Resident #20 was admitted to the facility on [DATE]. Review of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] An order dated 05/01/22 for Milk of Magnesia, used for constipation, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 05/01/22 for [MEDICATION(S)], used to treat very low blood sugar levels, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 05/01/22 for [MEDICATION(S)], used for muscle spasms, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 05/01/22 for Acetaminophen (Tylenol) used for pain or fever, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 05/01/22 for Calcium-Vitamin D, a mineral supplement used for bone formation and maintenance, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 05/01/22 for [MEDICATION(S)] Sulfate, used to treat low blood levels, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 05/01/22 for Loperamide, used to treat diarrhea, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 05/01/22 for [MEDICATION(S)], used to treat high blood pressure, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 05/01/22 for Omeprazole, used to treat stomach acid, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 05/01/22 for [MEDICATION(S)], used to decrease inflammation, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 05/01/22 for Vitamin D3, used as a supplement to help absorb calcium, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 05/01/22 for [MEDICATION(S)]-Antioxidant (a multivitamin with minerals), documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 05/01/22 for [MEDICATION(S)] sodium, used for constipation, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 05/01/22 for [MEDICATION(S)], used to prevent blood clots, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 05/01/22 for baby Aspirin, used to prevent heart attacks, strokes or chest pain, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 05/01/22 for [MEDICATION(S)] suppository, used to treat constipation, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 05/07/22 for [MEDICATION(S)], used to treat inflammation and pain, documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 09/06/22 in the afternoon, the Risk Manager/Staff Developer, who was at the nurse's station assisting with the survey process, explained they started using an electronic medical record system in April or May of this year. When asked in general about the same diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 3) Review of Resident#36 medical records revealed Resident#36 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -[MEDICATION(S)] 5 mg one time a day for Altered Mental Status, order date 08/22/22 -Xeroform [MEDICATION(S)] Dressing 4 X 4 every 2 days (to skin tear left elbow) for Essential Hypertension, order date 08/21/22 -[MEDICATION(S)] 2.5 mg twice daily for [CONDITION(S)], order date 08/16/22 -Potassium Chloride Extended Release 10 MEQ one time daily Pleural Effusion, order date 08/13/22 -[MEDICATION(S)] 20 mg one time daily for Pleural Effusion, order date 08/13/22 -[MEDICATION(S)] 1% Topical three times daily for [CONDITION(S)], order date 08/08/22 -Losartan 50 mg 1 tab daily for [CONDITION(S)], order date 08/01/22 -Omeprazole 20 mg capsule delayed release for [CONDITION(S)], order date 08/04/22 -[MEDICATION(S)] 2.5 mg 1 capsule daily for [CONDITION(S)], order date 08/16/22 -Xeroform [MEDICATION(S)] Dressing 4 X4 (to skin tear left lower arm) for [CONDITION(S)], order date 09/07/22 During an interview on 09/08/22 at 12:55 PM, with Staff A, Licensed Practical Nurse (LPN), she was asked about the diagnosis listed for the medications on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . We have to click on something so we can order the medication. She stated she believes the MDS Coordinator will update it the next day. During an interview on 09/08/22 at 1:02 PM with the Director of Nursing (DON), she stated, We have to use whatever diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS coordinator puts in the right diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 09/08/22 at 1:41 PM with the MDS Coordinator, she stated. The process is that our Admission Director emails an admission document to our leadership staff, which includes me on it. It shows the primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I don't get the total record or medication reconciliation. For example, right now I am working on a new admission that will arrive in a couple of hours. I received 8 pages for her. From this information, I assign the diagnoses. I do it prior to them coming in so the nurses have something to go by. I am inputting into computer. Then my job is done until patient comes in. I do not review the chart the next day. The ADON and the DON take it into morning meeting and review medication list and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor asked the MDS Coordinator to pull up Resident #36 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When she reviewed his orders, she stated, It is the nurse that is putting in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . If there is no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nobody is trained to put ICD codes except myself, DON, ADON, and my back up in training. We just started in May with new electronic record. If not in drop box, I have to add it but have to know the ICD code. She acknowledged that there are many medications for Resident #36 that do not have the right diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 4) Resident #51 was admitted on [DATE] with diagnoses which included malignant neoplasm of intestinal tract, Chronic Kidney Disease Stage 4, [CONDITION(S)], Enterocolitis due to [CONDITION(S)], [CONDITION(S)], Hypertension, and presence of Cardiac Defibrillator. Per Progress Notes, Resident #51 was admitted to Hospice on 07/31/22. At 8:00 PM on 07/31/22, medical transport company arrived to the facility to transport resident to a Hospice facility. Discharge MDS (Minimum Data Set) report dated 07/31/22 documents resident was discharged to hospital instead of Hospice. This error triggered resident to be reviewed for hospitalization during the survey process. On 09/08/22 at approximately 4:30 PM, the Director of Nursing was notified of the documentation error.

Based on observation and interview, the facility failed to serve food with professional standards in accordance with food service safety, with the potential to affect 39 of 41 residents. The findings included: On 08/02/21 at 9:24 AM, conducted an initial brief tour of the Main kitchen accompanied by the Culinary Director. The following was observed. (1)The oven was dirty with grease. (2)Stove very dirty, with grease and spills. (3) The can opener insert needs to be clean, very greasy and sticky. On 08/04/21 at 12:23 PM, conducted an interview with the Sous Chef to inform him of the findings. On 08/04/21 at 12:23 PM, during an interview with the Sous Chef he was informed of the opened cups of applesauce that were sitting on the nurses' Medication carts not refrigerated. An observation of all 3 Medication carts revealed that the applesauce container were not refrigerated after opening and sat on the medication cart for three days. The Sous Chef agreed that applesauce must be refrigerated after opening. 2) On 08/03/21 at 10:10 AM, while observing medication administration from the North Medication Cart, 3 small opened applesauce containers were noted on top of the Medication Cart. Further observation showed that the 3 containers were dated 08/2/21 but were not on ice or a cool pack. During this observation, Staff A, Licensed Practical Nurse, reported that the apple sauce containers were good for 3 days, do not need refrigeration and are used for medication administration. On 08/03/21 at 10:30 AM, an additional observation of the South Medication Cart, 3 small applesauce containers were noted on top of the Medication Cart. Further observation showed that the 3 containers were dated 08/2/21 but were not on ice or a cool pack. During this observation, Staff B, Registered Nurse, said the apple sauce containers were good for 3 days, do not need refrigeration and are used for medication administration. An additional observation of the South Medication Cart on 08/04/21 at 1:45 PM again revealed opened individual dated cups of applesauce for medication administration being stored on top of the medication cart not being refrigerated (photographic evidence obtained).

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for 3 of 19 sampled residents (Resident #48, Resident #28, and Resident #3), related to discharge location (Resident #48) and medication use (Resident #28 and Resident #3). The findings include: 1) Resident #48 was admitted to the facility for short term rehabilitation on 5/21/21. Review of Resident #48's Discharge MDS assessment dated [DATE] showed she discharged to an acute hospital. Review of Resident #48's clinical record showed she was discharged home and was not hospitalized . An interview was conducted with the Assistant Director of Nursing (ADON) on 08/04/21 at 03:23 PM. The ADON confirmed Resident #48 was discharged home and was not hospitalized . The ADON spoke with the MDS Coordinator and stated it was a coding error. 2) Review of the current MDS assessment dated [DATE] documented Resident #28 received an anticoagulant seven of seven days during the assessment look back period. During a side-by-side review of the medical record on 08/05/21 at 3:23 PM, Staff C, a Registered Nurse (RN) and Clinical Manager, reviewed all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Clinical Manager agreed the MDS was not accurate as the baby aspirin should not be coded as an anticoagulant. 3) Review of the current MDS assessment dated [DATE] documented Resident #3 received an opioid (a narcotic/medication for pain) one of seven days during the assessment look back period. Review of the corresponding Medication Administration Records (MARs) for 04/26/21 through 05/02/21 revealed Resident #3 received both Roxinol (Morphine/an opioid) and [MEDICATION(S)] (a narcotic/opioid) seven of seven days. This was confirmed by the Clinical Manager during a side-by-side review of the record on 05/04/21. Resident #3 was on Hospice services and receiving both medications routinely for pain management.

Based on observation, interview and record review, the facility failed to change a suprapubic catheter per physician's order for 1 of 1 sampled residents reviewed for urinary catheters (Resident #16). The findings included: An interview was conducted on 08/02/21 at 1:57 PM with Resident #16 during the initial pool process. Resident #16 was able to verbalize that he had a catheter but due to limited hearing a full interview could not be conducted. A review of the medical chart for Resident #16 revealed the resident has a suprapubic catheter. A suprapubic catheter is a hollow flexible tube that is inserted into the bladder directly and used to drain urine from the bladder. He was admitted to the facility with the catheter from an assisted living facility on 05/31/21. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #16 has a Brief Interview for Mental Status (BIMS) of 8 per admission assessment, indicating he is mildly cognitively impaired. Physician's orders for the care of the suprapubic catheter reveal orders to change the suprapubic catheter monthly and as needed. An interview was conducted with Staff C, Registered Nurse (RN), on 08/03/21 at 2:49 PM. Staff C was asked if Resident #16 saw a Urologist. Staff C stated that the resident has not been out of the facility since he was admitted on [DATE]. Staff C was then asked if nurses at the facility are able to change suprapubic catheters. Staff C stated that he changed the suprapubic catheter for Resident #16 on 06/09/21. Staff C was then asked when the catheter was changed in July, 2021. A review of the Treatment Administration Record (TAR) for Resident #16 for July, 2021 revealed the catheter was due to be changed on 07/05/21 on the 11-7 shift. There was no signature in the box which would have indicated that the nurse changed the catheter or nurse's note stating why the catheter was not changed. This was reviewed with Staff C, who confirmed that there was no evidence that the suprapubic catheter was changed in July, 2021.

Based on record review and interview, the facility failed to ensure the provision of medications for 1 of 1 newly admitted sampled resident. Resident #248 was admitted to the facility on [DATE] at 5:30 PM and had physician signed orders for ten medications to be administered as of 5 PM or after on that evening. Four of the ten medications were available in the facility's Omnicell (the medication storage device available at the facility), but not provided. One of the ten medications was an antibiotic, that was not available in the Omnicell, was not ordered STAT as per management's voiced procedure, and was not provided to Resident #248 that evening. The findings included: Review of the record revealed Resident #248 was admitted to the facility on [DATE] at 5:30 PM, as per the resident's face sheet. This face sheet documented diagnoses to include urinary tract infection (UTI), [CONDITION(S)], and hypertension (high blood pressure). Review of the hospital Discharge Document with the resident's discharge medications documented the following medications were due the evening of 07/17/21: [MEDICATION(S)] (an antibiotic) 300 milligrams (mg) every 12 hours, due at 6 PM. [MEDICATION(S)] (an antihypertensive/medication for elevated blood pressure) 5 mg twice daily, due at 10 PM. ASA (aspirin) 81 mg, due at 6 PM. [MEDICATION(S)] (a medication for elevated cholesterol) 20 mg, due at 6 PM. Vitamin B12, 1000 micrograms, due at bedtime. [MEDICATION(S)]/calcium carb/Hg ([MEDICATION(S)] Complete/a medication for acid reflux), due at bedtime. [MEDICATION(S)] 50 micrograms (mcg) inhaler, due at bedtime. [MEDICATION(S)] (an antihypertensive medication) 50 mg, due at bedtime. [MEDICATION(S)] (an antihypertensive) 10 mg, scheduled three times daily. [MEDICATION(S)] (an antidepressant) 50 mg, due at bedtime. Review of the Admission Data Collection signed by Staff D, a Registered Nurse (RN) on 07/17/21 at 7 PM, documented the nurse verified all medications with the physician and faxed the physician order sheet (POS) to the pharmacy. Review of this physician signed POS revealed the medications were scheduled as follows: [MEDICATION(S)] was scheduled for 9 AM and 9 PM. [MEDICATION(S)] was scheduled for 9 AM and 5 PM. Aspirin was scheduled for 5 PM. [MEDICATION(S)] was scheduled for 5 PM. Vitamin B12 was scheduled for 9 PM. [MEDICATION(S)]/calcium carb/Hg ([MEDICATION(S)] Complete) was scheduled for 9 PM. [MEDICATION(S)] 50 mcg inhaler was scheduled for 9 PM. [MEDICATION(S)] was scheduled for 9 PM. [MEDICATION(S)] was scheduled for 6 AM, 2 PM, and 10 PM. [MEDICATION(S)] was scheduled for 9 PM. On 08/04/21 at approximately 5:00 PM, the Director of Nursing (DON) was asked to provide the Omnicell Inventory. Upon receipt of the list on 08/05/21 at approximately 9:00 AM, the DON explained the provided inventory included all medications that are routinely available to nursing staff for resident use. Review of the Omnicell Inventory revealed the following medications were available: [MEDICATION(S)] 5 mg ASA (aspirin) 81 mg [MEDICATION(S)] 10 mg [MEDICATION(S)] 20 mg [MEDICATION(S)] 25 mg Review of the Medication Administration Record (MAR) for Resident #248 revealed all medications documented on the hospital discharge record were transcribed onto the POS and MAR. Further review of this MAR revealed no medications were provided to Resident #248 on 07/17/21. The record lacked any notification to the physician related to the inability of the facility to obtain the evening medications not available in the Omnicell, or notification of the lack of administration of the available medications. The record lacked notification to the physician that the antibiotic was neither available or provided. During an interview on 08/05/21 at 9:52 AM, Staff D, an RN explained the process for obtaining medications for a newly admitted resident would be to verify the medications with the physician and fax the POS to the pharmacy. The nurse explained if the resident needed to start a medication the same day, they would obtain the medication from the Omnicell. The RN further explained that part of the admission process would be to verify the pharmacy received the faxed POS and to ask the expected delivery time. During an interview on 08/05/21 at 11:35 AM, a grievance filed from the family of Resident #248 was reviewed with the Social Services Director (SSD) and the Assistant Director of Nursing (ADON), who worked together on the concerns voiced by the family that the resident did not receive any evening medications (on 07/17/21). The grievance documented that three of the resident's evening medications were available in the Omnicell, but the nurse did not remove them (for administration). The ADON was made aware that review of the Omnicell Inventory revealed four of the evening medications were available for administration, along with the [MEDICATION(S)] ([MEDICATION(S)], although not the [MEDICATION(S)] Complete). When asked if there was a process for obtaining ordered antibiotics that were not in the Omnicell, the ADON stated she would have to defer to the DON or Administrator. During a subsequent interview on 08/05/21 at 12:27 PM, Staff D, who was identified as the admitting RN, confirmed she did the admission, further stating the resident was admitted at 7 PM, at shift change, and that really wasn't even supposed to be her admission. Staff D was shown the admission time of 5:30 PM and the assessment for Resident #248, and agreed she signed the assessment at 7 PM. The RN also agreed the assessment note documented she had faxed the medications to the pharmacy. When asked if the physician was made aware of the delay of the antibiotic, the nurse stated she reviewed the medications with the physician but did not specifically make her aware of any delay. On 08/05/21 at 12:26 PM the DON (in the accompaniment of the Administrator) was asked about antibiotics that were not available in the Omnicell. The DON stated antibiotics should automatically be a STAT order from pharmacy and available. The DON was asked to provide any policy or process related to the STAT antibiotic orders and as of the exit conference on 08/05/21 at approximately 4:30 PM none had been provided. During this interview a side-by-side review of the physician orders for Resident #248 was made. The DON agreed the evening antibiotic and medications that were available via the Omnicell should have been provided on 07/17/21. During a phone interview on 08/05/21 at 1:07 PM, Staff E, a Licensed Practical Nurse (LPN), was asked the process related to obtaining medications for a newly admitted resident. The LPN stated the medication list from the hospital is reviewed with the physician, and then faxed to the pharmacy. When asked if she remembered Resident #248, the LPN confirmed she did. When asked if she was aware the resident had not receive the 6 PM antibiotic ([MEDICATION(S)]), Staff E stated she was not aware as the day nurse did not let her know, and she was scheduled to work 7 PM to 7 AM on 07/17/21. When asked about the evening medications, like her blood pressure medications, due during her shift that were available in the Omnicell but not provided, the LPN stated maybe her blood pressure was low and the medications were held. The LPN confirmed she would have documented in the clinical record if a medication was held. When asked again if she remembered that particular resident as to why the medications were not provided, the LPN stated she was just waiting for the medications to come from the pharmacy and they did not arrive. Staff E then stated she was a new nurse and was not sure if she was allowed to go into the Omnicell or not. The LPN again stated she thought she had to just wait for the delivery. When asked if there was someone else available during her evening shift to assist her, the LPN stated there was another nurse who she could have asked to help. After the phone interview with Staff E, the ADON was asked about training for new nurses. The ADON explained they shadow a nurse for a couple of weeks. The ADON was asked to provide evidence Staff E had the training, to include any documented evidence of education on use of the Omnicell and or medication administration. The ADON provided evidence of the LPN's training by shadowing another nurse and a Pharmacy and Math Knowledge Test - Nurses test completed by the LPN. This test lacked any information related to obtaining medications and or use of the Omnicell.

Based on record review and interview, the facility failed to ensure a resident's insulin was provided per physician's ordered sliding scale for 1 of 5 residents (Resident #43) whose medication regimens were reviewed. The findings included: 1) Resident #43 was admitted to the facility on [DATE] for short term rehabilitation with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #43's Physician Orders for July 2021 showed: Insulin [MEDICATION(S)] 100 unit/ml vial. Inject unit(s) Sub-Q Sliding Scale: 180-200=2units; 201-230=3units; 231-260=4units; 261-290=5units; 291-320=6units; 321-350=7units; Blood Sugar greater than 350=8units and call MD. Review of Resident #43's July 2021 Medication Administration Record (MAR) showed his blood sugar (BS) was checked four times daily (6:30am, 11:30am, 4:30pm, and 9:30pm) and insulin was administered or not administered depending on BS readings. The information was handwritten onto the paper MAR. Further review showed: -7/9/21 4:30pm showed BS reading was 194 and 0 units were provided -7/10/21 6:30am showed BS reading was 195 and 0 units were provided -7/10/21 11:30am showed BS was illegible -7/12/21 6:30am showed BS reading was 200 and 0 units were provided -7/12/21 4:30pm showed BS reading was 198 and 0 units were provided -7/17/21 11:30am showed BS reading was 186 and 0 units were provided -7/19/21 4:30pm showed BS reading was 185 and 0 units were provided -7/26/21 11:30am showed BS reading was 196 and 0 units were provided -7/30/21 9:30pm showed BS reading was 189 and 0 units were provided An interview and record review was conducted with the Assistant Director of Nursing (ADON) on 08/05/21 at 10:16 AM. The ADON reviewed Resident #43's MAR and stated he should have received two units for the BS readings of 180-200 on 7/10, 7/12, 7/17, 7/19, 7/26, and 7/30. She was also unable to read the documented information for 7/10/21 at 11:30am. Review of Resident #43's comprehensive care plans showed: [Resident #43] has potential for hyper/[CONDITION(S)] related to diabetes. Goal: minimize diabetic complications through next review date. Approaches include: Administer SSI [sliding scale insulin] as ordered. 2) During a medication pass observation on 08/04/21 at 11:43 AM, Staff A, a Licensed Practical Nurse (LPN), obtained a blood sugar level for Resident #43. The blood sugar reading was 180. Staff A returned to the medication cart and stated, Because the blood sugar (level) is 180, the resident does not get any (insulin) coverage. As the LPN was signing the Medication Administration Record (MAR), she stated, Oh, let me correct myself. The sliding scale (an order that documents the amount of insulin to give depending upon the blood sugar result) says for a blood sugar of 180 the resident gets 2 units. During an interview after the LPN administered the insulin, Resident #43 was asked if the staff were checking his blood sugars routinely, and he confirmed they were. Resident #43 stated he understood his sliding scale insulin. When asked when are the nurses providing the sliding scale insulin Resident #43 stated, All of the nurses give me insulin when I'm over 200 (the blood sugar level), and some of the nurses give me insulin when it's in the 180s or 190s.

Based on the observation and interview the facility failed to ensure that the resident meals were served in a sanitary condition in accordance with professional standards for food service safety. Findings included: On 12/02/19 at 09:15 AM during the initial brief tour in the main kitchen, accompanied by the Dietary General Manager and the Registered Dietitian, the following was observed. (1) The interior of the oven was encrusted with residue. (2) There was an uncovered garbage can in the Kitchen fill with garbage, that was not in use. (3) The walk-in refrigerator that was Labeled #1, door gasket was soiled and black in some areas. (4) A bin was observed in the walk-in refrigerator that contained twenty (20), 8 oz cartons of 2% milk that was dated 11/23/19. (5) A tray in the reach in refrigerator by the trayline had 6 egg salad sandwiches, and there was no date on the sandwiches. On 12/04/19 at 1:00 PM, in an interview with the Registered Dietitian and the Dietary General Manager they were informed of the findings, which they acknowledged. 2) An observation of the lunch meal in the Memory Care Unit was made on 12/02/19 beginning at 12:30 PM. A total of 8 residents were in the dining room. Sitting at the first table were Residents #35, #7, and #13. Resident #7 was not centered on her side of the table, but was sitting toward the corner, closer to Resident #35. Staff offered a lunch tray to Resident #35 who stated she didn't want it, so it was returned to the cart. Resident #35 then reached over and took a cookie and the glass of milk from Resident #7. Staff D, a Registered Nurse (RN), who was assisting Resident #13, started to return the glass of milk to Resident #7, when the surveyor had to intervene to prevent cross contamination. Continued observation on 12/02/19 at 12:44 PM revealed Staff D, the RN, assisted Resident #35 and had touched the resident's silverware and glass. The RN went to another table, without any type of hand hygiene, and moved a coke bottle and glass of Resident #23. Resident #23 was eating independently. This Memory Care Unit dining room did not have any hand sanitizer available, although there was a bathroom in the room, as it was a converted bedroom. A second dining observation was made on 12/03/19 beginning at 08:22 AM. There were 6 residents in the dining room. Staff B, a facility Registered Nurse (RN) was distributing breakfast trays, overseeing the dining room, and assisted Resident #6 who was sitting at the back table. The RN was positioned in a manner that she could oversee the dining room. At 08:37 AM, Staff C, a private caregiver for Resident #13, assisted Resident #35 and touched her glass and silverware. The private caregiver then assisted Resident #13 with her breakfast meal, touching the resident's silverware and glasses without any type of hand hygiene. It was noted that both residents were able to feed themselves at times, with cueing assistance. The surveyor asked the private caregiver about the meal ticket of Resident #13. The private caregiver reached into the half full garbage can, obtained the menu ticket, and proceded back to the table to assist Resident #13. The surveyor intervened and asked the private caregiver to wash her hands before assisting any resident. During this observation, Staff B, the RN was feeding Resident #6, got up and assisted Resident #23 by guiding his hand to his oranges and bacon. The RN then returned to the back table to assist Resident #6 without doing any type of hand hygiene. During an interview on 12/03/19 at approximately 8:45 AM, the private caregiver stated she did not have any hand sanitizer with her, but stated she could get it from facility staff or down the hall. The private caregiver agreed she should do some type of hand hygiene between residents. Staff B, the RN was informed of the concerns related to lack of hand hygiene between assisting residents. 3) During an interview, on 12/02/19 at 11:56 AM, with Resident #46, he stated he goes to [MEDICAL TREATMENT] 3 times a week on Monday, Wednesday, and Friday. When asked who provides meals and snacks for him when at [MEDICAL TREATMENT], he replied, They (the NH) give me a sandwich, but I can't eat bread. They send me with juices and drinks. They give me Nepro that I drink for the protein. I eat about half way through [MEDICAL TREATMENT]. An observation of the resident's meal/snack cooler bag on 12/02/19 at 1:21 PM, provided by the facility consisted of 2 four-ounce containers of egg salad, 1 four-ounce prepackaged container of fruit salad in syrup, one can of ginger ale and three packages of crackers. It was noted that the snacks were in a soft sided cooler with no cooling medium and no other means to keep the egg salad and fruit salad below 41 degrees Fahrenheit. During an interview with the Registered Dietitian, on 12/02/19 at 1:28 PM, she acknowledged that there was no ice pack in in the resident's cooler bag. She stated that the staff were going to replace the containers of egg salad and put an ice pack in the cooler bag. During an interview, on 12/02/19 at 4:28 PM, with Staff A, Dietary, when asked about the availability of ice packs for packed lunches/snacks, he replied, We've never had ice packs until this morning. During an interview, on 12/04/19 at 10:07 AM, with the Dietary General Manager, when asked about the process for preparing a meal/snack bag for a [MEDICAL TREATMENT] resident, he replied, we usually get it ready in the morning and then we put it in the cooler until it is time to go. We have cooling packs/ice packs that we implemented. We did inservices so that staff are made aware and will make sure that the coolers have ice packs. The Dietary General Manager acknowledged that the facility did not have any cooling mediums for [MEDICAL TREATMENT] bags before this survey team arrived and it was brought to their attention. At the conclusion of the interview, this surveyor requested to see the cooling mediums/ice packs that were being used. The Dietary General Manager showed this surveyor gel packs that are used for pain relief that were labeled, not recommended for use on pain affected area for more than 20 minutes.

Based on record review and interview, the facility failed to maintain accurate records for 2 of 15 sampled residents. The facility failed to ensure a verbal order was documented in the record for Resident #35; failed to maintain a consent to administer the flu vaccine in the record for Resident #13; and failed to ensure the correct date on the flu vaccine consent for Resident #35. The findings included: 1) Review of the most current pharmacy consultant review dated 11/22/19, documented the recommendation to obtain a blood level for the medication [MEDICATION NAME] ([MEDICATION NAME], an anticonvulsant) on the next convenient lab day for Resident #35. The physician agreed with the recommendation. At the bottom of the recommendation was a hand written note that the medication had been discontinued on 09/29/19. Review of the record lacked any written order for the discontinuation of the [MEDICATION NAME]. During an interview on 12/05/19 at approximately 10:00 AM, the Clinical Manager of the Memory Care Unit was shown the pharmacy recommendation. The Clinical Manager reviewed the record, which revealed the Physician order [REDACTED]. An Interdisciplinary Progress Notes dated 09/29/19 documented, New (verbal) order received to D/C (discontinue) [MEDICATION NAME] . The Clinical Manager was unable to locate a written order. Further review of the record revealed each month following (November and (MONTH) 2019), the [MEDICATION NAME] remained on the POS, indicating the pharmacy had not received any written verbal order, and the nurse's were marking through the [MEDICATION NAME] as discontinued. 2) Review of the (MONTH) 2019 Medication Administration Record, [REDACTED]. Further review of the record for the same resident revealed a lack of consent for the flu vaccine for the 2019-2020 flu season. During an interview on 12/04/19 at 10:52 AM, the Clinical Manager of the Memory Care Unit acknowledged that the consent for the 2019-2020 flu season was missing for Resident #13, and that he had obtained a verbal order from the family. 3) In a review of the record for Resident #35, the flu consent for the 2019-2020 season was signed by the power of attorney and dated for 10/11/12. During the continued interview with the Clinical Manager of the Memory Care Unit on 12/04/19 at 10:52 AM, he acknowledged that the consent was dated incorrectly.

Based on observation, record review, interview, and policy review, the facility failed to ensure the nurse followed standards of practices and policy for medication administration for 1 of 6 sampled residents, resulting in a significant medication error (Resident #39). The findings included: During a medication pass observation on 12/04/19 at 09:20 AM, Staff B, a Registered Nurse (RN), administered a nebulizer treatment of [REDACTED].#39. Review of the current Physician Order's for the month of (MONTH) 2019, lacked an order for [REDACTED].>During an interview on 12/04/19 at approximately 1:00 PM, Staff B was asked to obtain the nebulizer medication from her medication cart, that was provided to Resident #39 that same morning. The RN provided the [MEDICATION NAME] in the labeled box, and confirmed this was the only nebulizer medication for Resident #39 in the medication cart. Review of the Medication Administration Record [REDACTED]. This MAR indicated [REDACTED]. When asked, the RN confirmed the [MEDICATION NAME] was the only nebulizer medication she had ever given to Resident #39. Review of the policy Medication Administration, Receipt, Storage & Disposal revised 11/2019 documented, 2. Medications are administered in accordance with Nursing Standards of practice . a. Staff designated to administer medications will verify that he/she is administering medications using the 5 Rights of Medication Administration. The 5 Rights of Medication Administration include the right medication and right dose.

Based on interview, observation and record review, the facility failed to coordinate scheduling of meals for a resident receiving [MEDICAL TREATMENT] for 1 of 1 resident receiving [MEDICAL TREATMENT] (Resident #46). The findings included: During an interview with Resident #46, on 12/02/19 at 11:56 AM, when asked about his [MEDICAL TREATMENT] schedule, he replied, I go Monday, Wednesday and Friday. My chair time is 2:20 PM, I think. When asked about the meals provided and taken to [MEDICAL TREATMENT], he replied, They (the NH) give me a sandwich, but I can't eat bread. They send me with juices and drinks. They give me Nepro that I drink for the protein. I eat about half way through [MEDICAL TREATMENT]. During an interview, on 12/02/19 at 12:15 PM interview with the Dietary General Manager (GM), when asked by this surveyor to see the meal that was packaged for Resient #46 to take to [MEDICAL TREATMENT] with him, he stated that there were no residents going to [MEDICAL TREATMENT] today. The Dietary Manager was informed by this surveyor that Resident 46's [MEDICAL TREATMENT] was changed from Tuesday, Thursday and Saturday to Monday, Wednesday, Friday on 11/22/19. The DM was not aware of the change and did not have a meal ready. He stated, I'll have to get with the Dietitian. During an interview, on 12/02/19 at 12:19 PM with the Registered Dietitian, when asked about the change in the [MEDICAL TREATMENT] order, she replied, he changed his chair dates on 11/22/19. When asked how the resident received the cooler to take to [MEDICAL TREATMENT], she replied, On those days, nursing would have called down for his meals. I am updating his care plan now. I wasn't here when they changed his schedule. The Registered Dietitian showed this surveyor a note that she stated was left on her door, dated 11/30/19, which stated, Can you please request late tray (dinner) for (resident) on [MEDICAL TREATMENT] days M-W-F. She also showed a document reflecting the request, dated 12/02/19 (Day one of the recertification survey). During a follow up interview, on 12/04/19 at 10:07 AM, with the DM, when asked how diet orders are communicated to the kitchen, he replied, Nursing fills out a diet slip and it goes to the menu clerk. The Dietician is the one who puts it in the computer and generates the orders for us to follow up on in the kitchen. They would call down and say they needed a [MEDICAL TREATMENT] bag for the resident. I spoke with him this morning and he is going to let me know what he wants. The nurses do a lot of follow up with us to get him his [MEDICAL TREATMENT] bag. He will be here for lunch and then take the bag with him.

Based on observation, record review, interview and policy review the facility failed to ensure 1 of 6 residents were free of a significant medication error. The nurses failed to ensure the correct nebulizer medication and dosage was being administered to Resident #39 since 07/10/19. The findings included: During a medication pass observation on 12/04/19 at 09:20 AM, Staff B, a Registered Nurse (RN), administered a nebulizer medication of [MEDICATION NAME] inhalation 0.5 milligrams (mg)/2 milliliters (ml) to Resident #39. Review of the current Physician order [REDACTED]. During a phone interview with the Consultant Pharmacist on 12/04/19 at 12:42 PM, he agreed that the [MEDICATION NAME] and Duo-Neb would not be used interchangeably. During an interview on 12/04/19 at approximately 1:00 PM, Staff B was asked to obtain the nebulizer medication from her medication cart, that was provided to Resident #39 that same morning. The RN provided the [MEDICATION NAME] in the labeled box from a local Pharmacy, and confirmed this was the only nebulizer medication for Resident #39 in the medication cart. Review of the Medication Administration Record [REDACTED]. This MAR indicated [REDACTED] The Clinical Manager of the Memory Care Unit confirmed the nebulizer medication that was administered to Resident #39 (the [MEDICATION NAME]) was not the nebulizer medication documented on the current Physician order [REDACTED]. When asked, the RN confirmed the [MEDICATION NAME] was the only nebulizer medication she had ever given to Resident #39. During this interview, the Clinical Manager of the Memory Care Unit was asked to determine how the [MEDICATION NAME] ended up at the facility. During an interview on 12/04/19 at 4:10 PM, the Clinical Manager provided a fax from Walgreens Pharmacy that documented the original order the physician for Resident #39 had called into the pharmacy. This order was for the [MEDICATION NAME] nebulizer and was dated 07/10/19. During the interview, the Clinical Manager confirmed the [MEDICATION NAME] had been the only nebulizer medication sent to the facility for Resident #39. Review of the MARs for the months of (MONTH) 2019 through (MONTH) 2019 all documented the administration of Duo-Neb ([MEDICATION NAME]-[MEDICATION NAME]), and never documented any administration of [MEDICATION NAME]. Review of the policy Medication Administration, Receipt, Storage & Disposal revised 11/2019 documented, 2. Medications are administered in accordance with Nursing Standards of practice . a. Staff designated to administer medications will verify that he/she is administering medications using the 5 Rights of Medication Administration. The 5 Rights of Medication Administration include the right medication and right dose.

Based on record review and interview, the facility failed to maintain written documentation for 2 of 5 sampled residents, of their declining the flu vaccine for the 2019-2020 season (Resident #33 and #202). The findings included: During record review for Resident #33 and Resident #202, they both had signed consents accepting the flu vaccine for the 2019-2020 season. During further investigation neither resident received the flu vaccine according to the medication administration record. During an interview on 12/05/19 at 10:25 AM, the Clinical Manager of Long Term Care explained that if the resident declines the flu vaccine, they usually write declined on the consent form. She stated Resident #33 and Resident #202 both declined the vaccine, and the nurse just forgot to write the word declined on the consents. In an interview with Resident #33 on 12/05/19 at 2:30 PM she stated she did not want the flu vaccine this year and that she had signed the form. In an interview with Resident #202 on 12/05/19 at 2:35 PM, she stated she did not want the flu vaccine this year because she already had it, and confirmed she had signed the form.

Based on record review and staff interview, the facility failed to reflect the Hospice services on the three most recent quarterly Minimum Data Set (MDS) assessments, for 1 of 15 residents (Resident #17). The findings included: Review of the record revealed Resident #17 was admitted to the skilled nursing facility on 09/18/15 and was currently receiving Hospice services. Review of the current MDS dated [DATE] lacked the hospice services in Section O (Special Treatments, Procedures, and Programs). Further review revealed the lack of documented Hospice services on the Quarterly MDSs dated 04/16/19 and 07/16/19. In an interview with the Assistant Director of Nursing on 12/05/19 at 1:13 PM she stated the hospice [DIAGNOSES REDACTED].

Based on interview, record review, and policy review the facility failed to ensure the baseline care plans for 6 of 14 sampled residents were kept current and provided to the resident, and or representative if applicable (Residents #21, #48, #151, #49, #301, and #99). The findings included: Review of the policy Care / Service Plans revised 07/24/18 documented, The interim care plan will reflect resident's goals and include interventions that address his or her current needs in a language and format that the resident and/or representative, if applicable, understand. The interim care plan will include healthcare information necessary to care for a resident including, but not limited to initial goals based on admission orders [REDACTED]. An interim care plan will be provided to the resident and responsible party, if applicable. Documentation that the interim care plan was provided to the resident and/or responsible party, if applicable will be documented in the medical record. 1) Review of the record revealed Resident #21 was admitted to the facility on [DATE]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #21 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating she was alert and oriented. Review of the Interim (Admission) baseline care plan revealed it was initiated and developed on the day of admission, 09/19/18. This baseline care plan and the record lacked any documented evidence the resident received a copy of the care plan. The comprehensive care plans were initiated as of 10/09/18. 2) Review of the record revealed Resident #48 was admitted to the facility on [DATE], and was discharged to the hospital on [DATE]. Review of the Interim (Admission) baseline care plan revealed it was initiated and developed on the day of admission, 07/24/18. This baseline care plan and the record lacked any documented evidence the resident, or representative as applicable, received a copy of the care plan. 3) An interview with Resident #151 was conducted on 10/30/18 beginning at 11:43 AM. The resident mentioned that she needed to speak to the nurse to ensure she received her [MEDICATION NAME]. Review of the record revealed Resident #151 was admitted to the facility on [DATE]. Review of the admission orders [REDACTED]. Review of the Interim (Admission) baseline care plan revealed it was initiated and developed on the day of admission, 10/29/18 and included the intervention for contact precautions. The resident's signature was noted on the last page of this care plan, next to the nurses signature, on the line for Signature of Nurse Completing the care plan. The care plan or record lacked documentation that Resident #151 received a copy. The comprehensive care plans had not been initiated as of yet. Further review of the record revealed a physician's orders [REDACTED]. The baseline care plan did not reflect that order. The physician's orders [REDACTED].#151 was on a blood thinner, a medication for her heart, and a [MEDICATION NAME] since the time of admission. The baseline care plan did not reflect those medications. During an interview on 10/31/18 at 11:30 AM, the Assistant Director of Nursing (ADON) explained the resident's signature on the Interim (Admission) Care Plan indicated the resident received a copy of the care plan. When asked if the resident gets anything else, the ADON stated, I don't think so. The ADON agreed that the CP was not accurate or kept up to date as the resident was no longer on isolation. The ADON was informed the regulation also includes that the resident be given information about their medications and treatments, and the ADON stated, Oh really? The ADON stated, We really just started this new process a couple of weeks ago, the giving a copy to the resident part. During an interview on 10/31/18 at 11:51 AM Resident #151 stated she did get a copy of the baseline care plan, and it was noted on her bedside table. When asked if she received information as to her ordered medications and treatments, the resident stated, I know my medications. Resident #151 had not received a list of her medications or treatments. 4) The facility failed to provide Resident #301 and her representative (daughter) a written summary of the baseline care plan, that included the specific diet and medications to be provided by the facility. Resident #301 was admitted to the facility on [DATE]. During an interview on 10/29/18 at 9:45 AM, Resident #301's daughter stated that she was unclear as to what her mother was receiving for pain medication and had asked for clarity multiple times since her mother's admission. The daughter stated that Resident #301 was on a gluten free diet and was not sure she was always receiving appropriate food, she had spoken to the staff but had not received anything in writing. During an interview on 11/01/18 at 1:36 PM, Resident #301's daughter stated that she was present on admission to the facility and did not recall Resident #301 signing and/or receiving anything that explained her immediate health and safety needs or Physician and dietary orders. 5) Resident #49 was admitted to the facility on [DATE] after a fall at home. Resident #49s daughter had repeatedly been to the nurses station on 10/28/18 and on 10/29/18 asking for Resident #49's pain medication schedule and what could be done to keep Resident #49 safe from falls. Resident #49's daughter stated that no one has gone over anything with her, and she had never received any information about her mother's care. During an interview on 10/30/18 at 4:03 PM, the Assistant Director of Nursing (ADON) stated that the facility's practice is to have the resident sign the Interim Care Plan, which is the baseline care plan, and that serves as verification that resident or family received a copy. The ADON stated that this is a new practice that just started a couple of weeks ago. Resident #49's Interim Care Plan was in the record dated 10/26/18, and was not signed by the resident and or representative 6) During interview and interim care plan review conducted with the DON (Director of Nursing), on 11/01/18 beginning at 1:35 PM, she stated if this interim (baseline) care plan had been reviewed with Resident #99 and their representative it would have been signed. She stated it is the facility's current policy to obtain the signatures as evidence of receipt of the interim (baseline) care plan. She acknowledged it was not signed by the resident or their representative. The DON also acknowledged that Resident #99's interim (baseline) care plan, initiated on 10/25/18, did not reflect the use of [MEDICATION NAME] 0.5mg daily or that this resident has a [DIAGNOSES REDACTED]. Resident #99's MAR (Medication Administration Record) reflected the facility has been providing [MEDICATION NAME] daily for [MEDICAL CONDITION].

Based on observation, interview and review of policy, the facility failed to maintain an infection prevention program for 7 of 8 sampled residents. The nurse failed to clean the IV port prior to administration of an IV medication for Resident #151. Five of 5 nurses failed to properly wash their hands during the medication observation and/or provision of accuchecks for Residents #149, #201, #12, #100, #37, and #148. The findings included: 1) A medication pass observation was made on 10/31/18 at 9:20 AM with Staff C, a Registered Nurse (RN), for Resident #151. Staff C prepared medication to include Linezolid, an intravenous (IV) antibiotic. The RN spiked the IV medication with the new IV tubing set and primed the line. Staff C then took the end of the IV tubing, removed the cap and hooked it to a port in the middle of the tubing, without cleaning the end of the line or that port. The RN cleaned the residents IV access line and flushed it with normal saline. The RN then took the IV line, removed the end from the port, and connected it to the resident's IV access line without cleaning the access line again. During an interview on 10/31/18 at 9:50 AM, Staff C stated she did not clean the port that she hooked the end of the tubing to because it came from a clean package and had never been used. Reviewed IV line instructions Clearlink System Continu-Flo Solution Set revealed the nurse is to swab the luer activated surface (the ports or lines to be used) with preferred antiseptic prior to the first use and before every subsequent connection. Review of the facility policy, 3.6 Administration of an Intermittent Infusion revised 05/01/16 documented, 15. Vigorously cleanse needleless connector with alcohol. Allow to air dry. 16. Maintaining asepsis, attach flush syringe to needleless connector. Flush . Remove syringe. 17. Vigorously cleanse needleless connector with alcohol. Allow to air dry. Attach administration set to needleless connector. Begin infusion. 2) Review of the policy Infection Prevention and Control Program revised 10/04/17 documented, Policies and procedures reflect current CDC practice and support an effective Infection Prevention and Control program. Current CDC standards dictate to scrub your hands for 20 seconds after applying soap, then rinse. A medication pass observation was made on 10/31/18 at 12:03 PM with Staff C, an RN, for Resident #201. Staff C obtained the blood sugar level, removed her gloves and hand washed for 5 seconds. The RN cleaned the glucometer and again washed her hands for less than 5 seconds. Staff C drew up insulin for Resident #201, gave the insulin, and then hand washed again for just a few seconds. During the continued medication pass observation, Staff C again washed her hands for 5 to 6 seconds each time, before and after obtaining the blood sugar level for Resident #149. Each time Staff C washed her hands, she would wet her hands, apply soap, lather for about 5 seconds, then put her hands under the running water to rinse off. 3) A medication pass observation was made on 10/31/18 at 4:36 PM with Staff B, an RN, for Resident #12. Staff B pulled medications to include 4 pills and one eye drop. Before administering the eye drops, Staff B applied soap to wash her hands and immediately rinsed for about 10 seconds under running water. 4) A medication pass observation was made on 10/31/18 at 4:54 PM with Staff A, an RN, for Resident #100. Before and after administration of a pill, Staff A washed her hands for 3 to 5 seconds total. During the continued medication pass observation, Staff A obtained and administered medications for Resident #37. Staff A again washed her hands for about 3 to 5 seconds. During an interview on 11/01/18 at 10:13 AM, the Assistant Director of Nursing (ADON) stated staff receives education related to hand hygiene upon orientation and as needed. The ADON stated the Staff Educator would do further education and hands on training as needed. During an interview on 11/01/18 at 10:49 AM, the Staff Educator also stated staff receive education related to hand hygiene upon orientation. When asked if he ever watches staff wash their hands or do any kind of demonstration or return demonstration, the Staff Educator stated he would do that as needed. When asked the last time he did any type of hand hygiene audit, the Staff Education stated that he could not, recall any time that a trend was identified that was directly related to hand washing. 5) During Medication Administration observation of Unit D on 10/31/18 at 9:56AM Staff D, a Registered Nurse (RN) was observed washing her hands for less than 10 seconds prior to administering [MEDICATION NAME] PF eye drops to Resident #37. 6) During Medication Administration observation of Unit D on 10/31/18 at 4:26PM Staff E, a Licensed Practical Nurse (LPN) was observed: a) Washing her hands for 10 seconds prior to administering 3 oral medications and preforming an Accu-Check (Blood glucose monitor) for Resident #149. b) After preforming the Accu-Check Staff E washed her hands for 8 seconds in Resident #149's room. c) Prior to administering an injection of [MEDICATION NAME]for Resident #149 Staff E washed her hands for 7 seconds. d) Prior to administering 2 oral medications to Resident #148 Staff E washed her hands for 7 seconds. e) After medicating Resident #148 Staff E washed her hands for 10 seconds.

Based on observation, interview and record review, the facility failed to ensure a comfortable environment for 1 of 10 residents able to be interviewed (Resident #148). The resident had made daily requests, for four or five days, for the room to be warmer. The issue was not corrected until 10/30/18, after surveyor intervention. The findings included: An interview was conducted with Resident #148 on 10/29/18 at 12:06 PM. Throughout the interview, the resident said numerous times, If you can get this cold room warmer I will be happy. Resident #148 complained of it being too cold in his room, especially in the morning. The resident stated that every morning since his admission, he had complained that it was too cold, that he would tell staff and everyone just told him, The thermostat says 85 degrees. The resident stated, Maybe the thermostat is wrong. You can feel the cold air coming from the vent. The resident stated he finally talked to a maintenance man today, and he adjusted it. Resident #148 stated, Every morning I'm shaking like a leaf. The room felt cool to the surveyor and observation of the thermostat read 85 degrees. On 10/30/18 at 9:18 AM, upon entering the room, Resident #148 was very upset and stated in a loud stern voice, I'm freezing in here . nobody gives a damn. Resident #148 confirmed he had been complaining about the cold room since admission, 4 or 5 days ago, especially in the morning. Observation revealed the air vent was directly above the bed and it felt cold in the room. Observation of the thermostat on the wall at the entrance of the room documented 85 degrees (photo taken), and it was on the icon for high fan/cool. A state issued thermometer was placed on the bed covers of Resident #148, and it documented 70.3 degrees. The resident was dressed in a heavy sweat suit and covered with a heavy blanket. During an interview on 10/30/18 at 9:23 AM, the Maintenance Supervisor stated he was in Resident #148's room about 45 minutes ago, and turned the thermostat up as Someone had turned it down. The Maintenance Supervisor stated he first heard about the complaint late yesterday. The Maintenance Supervisor did not recall what the thermostat was set at, but stated he turned it up to about 80 degrees. Upon entering the resident's room on 10/30/18 at 9:34 AM, the Maintenance Supervisor immediately changed the thermostat from on (the high fan icon) to auto. The Maintenance Supervisor took room temperatures in various locations in the room, using his laser thermometer. The readings ranged from 61 degrees to 68.3 degrees, depending on where in the room he pointed the laser. The Assistant Director of Nursing (ADON) joined the conversation in the room and agreed it was cold. The ADON stated the first she heard about the concern was yesterday, and that she provided the resident with a blanket and called maintenance. The ADON stated she thought it had been resolved. The Maintenance Supervisor and ADON were asked to provide any appropriate policy or procedure, evidence of any work orders related to the environment, and any preventative audits that had been done. During an interview on 10/31/18 at 9:45 AM the Administrator stated they do not do any routine checks of the room temperatures, but if they have any complaints, they will then look into it and do some room temps, including to have security check them at night. On 10/31/18 at 10:44 AM the room for Resident #148 felt warm and comfortable. The roommate stated it felt comfortable. Resident #148 was not in the room at the time. Earlier while the surveyor was doing a medication pass observation, the wife of Resident #148 walked by with a thumbs up and stated, He said it was the best night he's had here. On 10/31/18 at 1:31 PM the room for Resident #148 felt warm and comfortable. Resident #148 was sleeping soundly. The resident's wife stated, He is elated. The wife confirmed that the first morning she came in to see Resident #148, after he had been readmitted to this semi-private room, He was like an ice cube, and our requests fell on deaf ears. The wife stated that everyone kept telling them that the thermostat was set on 85 degrees. Review of the clinical record revealed Resident #148 was admitted to the facility on [DATE] and was alert and oriented. Review of the Current Activity Report Work Order #: WO- 269 dated 10/30/18 at 8:00 AM as scheduled start time, documented Resident saying that room is freezing. This work order was for room D18, the room of Resident #148.

Based on interview and record review the facility failed to honor choices for 2 of 4 residents reviewed for choices (Resident #15 and #149). Resident #15 was not offered a shower and the facility lacked any documented showers. Resident #149 was not offered a choice of physicians. The findings included: 1) During an interview on 10/29/18 at 10:11 AM, Resident #15 was asked if she had a choice related to showering. Resident #15 stated, I don't know about a shower yet. I haven't been offered one. Resident #15 stated she would like a shower, and feels like the staff are overwhelmed because, A bunch of us had to move over here from the other side. Review of the record revealed Resident #15 was admitted to the facility on [DATE], and resided in room C21A until 10/25/18 when she was moved to room D20B. The C unit was on one side of the building and the D unit was on the opposite side. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] documented Resident #15 had a Brief Interview for Mental Status (BIMS) score of 15, on a scale of 0 to 15, indicating she was alert and oriented. This MDS lacked any documented behaviors and documented it was very important for her to choose between and tub, bath and shower. This MDS assessment documented the resident needed assistance for personal hygiene, showering and dressing. Review of the ADL (Activities of Daily Living) Status Care Plan documented Resident #15 had decreased ADL self care due to muscle weakness and or mobility issues and required extensive assistance for bathing and dressing. Review of the ADL Verification Worksheet for the month of (MONTH) (YEAR) lacked any documented showers. This ADL worksheet lacked any place to document showers, and only documented the general categories of personal hygiene and bathing. During an interview on 11/01/18 at 12:51 PM, the Assistant Director of Nursing (ADON) stated they do not document when showers are given. The ADON stated the aides offer showers all the time, and give them when asked. During an interview on 11/01/18 at approximately 1:00 PM, Staff F, a Certified Nursing Assistant (CNA) stated the residents on this unit are all alert and oriented, and can ask for a shower at anytime. The CNA stated he will provide a shower anytime a resident asks for one or if he sees that they need a shower, he will offer it. When asked specifically if he offers showers routinely, he again stated, The residents tell me when they want one. When asked specifically about Resident #15, Staff F stated that she has not asked for a shower and has been up and dressed prior to his shift. During a subsequent interview on 11/01/18 at 1:02 PM the ADON again stated there is no place for the CNAs to document showers. The ADON stated they used to have a shower schedule, and that was a problem, so they just allow the resident to choose if and when to have a shower. The ADON agreed it was a problem that there was no documentation for showers. 2) During an interview on 10/29/18 at 11:33 AM Resident #149 was asked if she felt included in decisions about her care. Resident #149 stated she does not like the doctor because, He doesn't know me and is making changes. Resident #149 explained she has a complicated history, had worked a long time with her own doctor to find out what works for her related to her medications and oxygen use, and that the doctor at the facility was just making changes. The resident gave the example that she has been on oxygen at 4 liters for years, and the doctor ordered it at 2 liters, to keep my level at 90%. Resident #149 stated she wanted the oxygen at 4 liters to keep her oxygen level at 98%. The resident also stated, He's messing with my pain medications. Resident #149 stated she did not choose the doctor, and did not know how she got him. Resident #149 stated she was not asked about him or any other doctor. The surveyor informed the resident she had a right to choose a physician, and the resident stated, I did not know that. Review of the record revealed Resident #149 was admitted to the facility on [DATE], after a hospital admission. Review of the Admission/Readmission Data Collection assessment dated [DATE] documented Resident #149's cognitive status was intact and oriented to person, place and time. This assessment lacked any documented issues with the resident's mood or behavior. Review of the initial baseline care plan dated 10/25/18, revealed Resident #149 had multiple issues including pain related to migraines, was on anticoagulant medications, anti-infection medications, was at nutritional risk, and had diabetes, cardiac and respiratory problems. During a subsequent interview on 10/31/18 at 1:37 PM, Resident #149 stated she told the head nurse yesterday that she wanted a different doctor, and was told she would look into it. Resident #149 clarified that her assigned physician had been in twice to see her since admission. Resident #149 did not recall being provided a list of physicians. Resident #149 stated she felt 'aggravated' at having to have this doctor. The resident confirmed the Assistant Director of Nursing (ADON) discussed the choice of physicians for the first time yesterday, 10/30/18, after the surveyor informed the resident she had the right to her choice of physicians. During interview and record review for Resident #149 conducted with the Health Care Counselor, who was responsible for admissions to the facility, on 11/01/2018 beginning at approximately 10:00 AM, she confirmed she goes over the admission paperwork with the resident and/or their representative. She was asked how the facility provides each resident with choice of physician upon admission to the facility. She provided a list of physicians with facility privileges. However, she stated depending on the attending physician at the hospital and reviewing the hospital face sheet this is how this facility determines what physician is going to provide services to each resident of this facility. The Health Care Coordinator stated, Residents are not asked or given a choice up front.