Every finding on record at Christian Care Nursing Center

Based on observations, interviews, and a review of facility records, the facility failed to ensure dishwashing machines were maintained and operated according to manufacturer specifications to effectively clean and sanitize resident dishes and food. The deficient practice could result in inadequate cleaning and sanitization of resident dishes and food-contact equipment, increasing the risk for transmission of infectious organisms and foodborne illness.Findings include:On August 17, 2026, at 6:30 AM, during the initial tour of the first kitchen with the cook (staff #175), the low temperature (chemical sanitization) dishwashing machine was observed during the wash and rinse cycle. The wash temperature reached 79 degrees Fahrenheit (F) and the rinse temperature reached 80 degrees Fahrenheit (F). However, this did not meet the required manufacturer's instructions of wash and rinse cycles 120 F, and final sanitization rinse 50 ppm (part per million). An immediate second observation in the first kitchen revealed the wash cycle temperature reached 103 degrees F and the rinse cycle temperature reached 107 degrees F. However, the wash and rinse cycles did not meet the manufacturer guidelines. The cook stated that the service technician had evaluated the dishwasher several times because the machine continued to experience temperature and/or sanitizer problems. The cook also stated that the dishwasher would be taken out of service and dirty dishes would be washed in the second kitchen.On August 17, 2026, at 12:12 PM, the facility reported that the first kitchen had been primed for the sanitization and was functioning again. Another observation of the dishwashing machine during the wash and rinse cycles revealed a wash temperature of 123 degrees F and rinse temperature of 83 degrees F. The rinse cycle did not meet the manufacturer guidelines. The sanitization was tested and read 100 ppm (parts per million). At 12:17 PM, another cycle of the first-kitchen dishwasher was observed. The wash temperature reached 115-degree F, the rinse temperature reached 95-degree F and the sanitizer concentration measured 95 ppm. The wash and rinse temperatures did not meet the manufacturer's required minimum of 120-degree F. On August 18, 2026, at 11:00 AM, facility staff reported that the first-kitchen dishwasher had been taken out of service and that all resident dishes were being washed in the second kitchen. An observation of the second kitchen dishwasher was conducted with a Registered Dietician (RD/staff #165). The wash cycle revealed a temperature of 120 degrees F and the rinse cycle temperature reached 123 degrees F. However, the sanitizer concentration measured only 10 ppm, below the manufacturer's required 50 ppm.On August 18, 2026, at 11:48 AM, an observation of the dishwashing machine in the second kitchen was conducted with the RD (staff #165) and the Kitchen Manager (staff #151). The wash cycle revealed a temperature of 111 degrees F, which was below the manufacturer's required 120-degree F. The rinse cycle temperature reached 120 degrees F and the sanitization was tested and read 50 ppm. Review of the dishwasher temperature logs for the second kitchen, dated June 2026, revealed the following:-Wash cycle temperatures reached 115 degrees F on 39 shifts in the AM and PM. -Wash cycle temperatures reached 116 degrees F on 28 shifts in the AM and PM.-Rinse cycle temperature reached between 116 - 118 on 31 shifts in the AM and PM.An Ecolab Service Visit Report dated June 16, 2026, revealed that a call was placed by the Kitchen Manger (staff #151), requesting a service tech from Ecolab to assess the dishwashing machine in the second kitchen because it was not pulling chlorine through the rinse cycle. The Ecolab service comments stated replaced missing wintertime gasket as well as added 5-gallon pro buckets to chemical lines.Review of the dishwasher temperature logs for the second kitchen dated July 2026, revealed:- AM/PM wash cycle temperatures that ranged between 115 to 118 degrees F on 62 shifts-AM/PM rinse cycle temperatures that ranged between 117 to 118 degrees F on 62 shifts.An Ecolab Service Visit Report dated July 28, 2026, revealed a call was placed by the Kitchen Manager (staff #151), requesting a service tech from Ecolab due to the first kitchen dishwashing machine was not dispensing sanitizer properly. The report stated after priming the dishwashing machine, the sanitizer was dispensing too strong, however, if the dishwasher was not primed, the sanitizer dispensed too low. The Ecolab service comments stated fixed problem (not dispensing sanitizer) found that the detergent wasn't dispensing, fixed both problems did not need to replace PRV (pressure reducing valve), ran asset 4 washes to make sure sanitizer was at 100.Review of the August 1 through August 18, 2026 dishwasher temperature logs for the second kitchen with RD (staff # 165) and the Kitchen Manager (staff #151) was conducted on August 19, 2026 which revealed the following dishwasher temperatures:-Wash cycle reached 115 once, all others met the manufacturer guidelines. -rinse cycle temperatures ranged between 116 to 118 degrees F on 35 shifts.An interview was conducted on August 19, 2026, at 8:40 AM with the RD (Staff #165). She stated that the dishwashing machines did not reach the required temperature of 120 degrees for the wash and rinse cycles and this would have to be addressed by Ecolab service. She stated the kitchen could switch to Styrofoam containers in the interim until the dishwasher was serviced by Ecolab.An interview was conducted on August 19, 2026, at 9:30 AM with the Director of Nursing (DON, Staff #199) and the Administrator, Staff #126. The Administrator and the DON stated they understood the dishwashers were not reaching the 120-degree F for both the wash and rinse cycles per the recommended manufacturers guidelines and that it would be addressed by Ecolab service to determine the solution to the problem.A Energy Star Certified Low Temperature Undercounter Dish Machine Manual (second kitchen) dated 2020, and the E-ULT Dish Machine (first kitchen) dated 2026, revealed the manufacturers required minimum operating temperature for the wash cycle of 120 degrees F, and the operating temperature for the rinse cycle should be 120 degrees F, and sanitization cycle at 50 ppm.A facility policy and procedure manual titled, cleaning dishes/dish machine, dated 2021 stated the dish machines will be checked prior to meals to assure functioning and appropriate temperatures for cleaning and sanitizing. Low temperature dishwasher, wash temperature-120 degrees F.

Based on documentation, staff interview, and the facility policy and procedures, the facility failed to report accurate PBJ (Payroll Based Journal) data as per requirements.Findings included: Review of the PBJ (Payroll Based Journal) FY (fiscal year) Quarter 2 2024 (January 1 to March 31) revealed:no registered nurse (RN) hours on January 1, 2, 3, 9, 13, 14 2024 or March 20 and 31, 2024. no licensed nursing coverage twenty-four hours a day on January 9, 13, 14, 21, 28, 2024, February 4, 11, 17, 25, 2024, and March 2, 3, and 31, 2024. Review of the employee time cards revealed that during the PBJ FY Quarter 2 2024 (January 1 to March 31): there was a registered nurse (RN) coverage for 12 hours on January 1, 2, 3, 9, 13, 14 2024. there was RN coverage for 12 hours on March 20 and 31, 2024. there was licensed nursing coverage twenty-four hours a day on January 9, 13, 14, 21, 28, 2024there was licensed nursing coverage twenty-four hours a day on February 4, 11, 17, 25, 2024.there was licensed nursing coverage twenty-four hours a day on March 2, 3, and 31, 2024. Review of the PBJ FY Quarter 1 2025 (October 1 to December 31) revealed:no registered nurse (RN) hours on October 2, November 15, 18, 20, and December 29, 2024. no licensed nursing coverage twenty-four hours a day on October 2m 7, 13, 27, November 23, and December 14, 22, 26, and 29, 2024.Review of the employee time cards revealed that during the PBJ FY Quarter 1 2025 (October 1 to December 31):there was RN coverage for 12 hours on October 2, November 15, 18, 20, and December 29, 2024.there was licensed nursing coverage twenty-four hours a day on October 2, November 15, 18, 20, and December 29, 2024.Review of the PBJ FY Quarter 2 2025 (January 1 to March 31) revealed no licensed nursing coverage twenty-four hours a day on January 1, 11, 18, February 16, and March 16, and 30, 2025. Review of the employee time cards revealed that during the PBJ FY Quarter 2 2025 (January 1 to March 31):there was RN coverage for 12 hours on January 1, 11, 18, 2024.there was RN coverage for 12 hours on February 16, 2024.there was RN coverage for 12 hours on March 16 and 30, 2024.An interview was conducted on August 27, 2025 at 7:06 a.m. with the Administrator (staff #3) who stated that he started working at the facility on March 31, 2025. During the interview, review of the:PBJ FY Quarter 2, 2024 (January 1 to March 31) revealed eight dates that no registered nurse (RN) hours were reported to CMS and twelve dates that the facility failed to report 24-hour nursing coverage. PBJ FY Quarter 2, 2025 (January 1, 2024 through March 31) revealed six dates that the facility failed to report 24-hour nursing coverage.The Administrator stated that the facility census was under 60, so the Director of Nursing (DON) was a floor nurse staff; he was going to review the census and provide time cards showing that nursing staff were present and RN coverage provided. An interview was conducted on August 27, 2025 at 8:15 a.m. with the Administrator (staff #3), who stated that after the PBJ is submitted, he receives a letter or an email identifying any problems with the data submitted and the last quarter he received an email stating that the hours for some of the staff was not accurate, but the issue was too many hours worked and there was nothing stating that there was no RN coverage on specific dates and no licensed nursing coverage for 24 hours/day on specific dates. He stated that he has no information regarding data submitted or CMS response to the facility data submitted prior to this last quarter because he was not the Administrator at that time, but would look for the information. During an interview conducted on August 27/2025 at 10:30 a.m. with the Administrator (staff #3), he stated that there were errors in the staffing data submitted because the facility did not include agency staff, but there was RN coverage. The facility, Payroll-Based Journaling (PBJ) Standard Operating Procedure policy states that facilities are required to submit PBJ data quarterly, within 45 days of the end of each quarter. The data must be submitted electronically and follow specific CMS submission guidelines. Request files from agency staffing agencies and contractors for hours worked in the SNF for the prior calendar year.

Number of residents sampled:Number of residents cited:TFFT explain in a form and manner including a language that the resident or his/her representative understood Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure the binding arbitration agreement provided for the selection of a neutral arbitrator agreed upon by both parties and a venue agreed upon by both parties. Findings included: Resident (#12) was admitted to the facility on [DATE] with diagnoses that included a seizure disorder, vascular dementia, and cirrhosis of the liver.The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 9 indicating the resident had a moderate cognitive impairment. An arbitration agreement dated August 11, 2027 was signed by resident (#2) and the Administrative Assistant (staff #31). An interview was conducted on August 27, 2025 at 1:47 p.m. with the Administrative Assistant (staff #31), who stated that she reviews the binding arbitration agreement with each resident by reading through each section of the agreement and asking the resident questions to ensure the resident understands the agreement. The arbitration agreement was reviewed during the interview and she stated that she did not know that the arbitrator needed to be a neutral party agreed upon by the resident and the facility and could not find an explanation of the neutral party in the agreement. She stated that the agreement identified the National Arbitration Forum and thought this was the arbitration party that listens to the disagreement between the resident and the facility, but was not sure. She also stated that she doesn't tell the resident that both parties are to agree upon a venue for meeting. An interview was conducted on August 27, 2025 at 2:11 p.m. with the Administrator (#3), who stated that he supervises the Administrative Assistant (staff #31) and she has had some training about arbitration. During the interview, (staff #3), reviewed resident (#2's) arbitration agreement and stated that he did not know of the National Arbitration Forum and was not sure if the forum was an individual arbitrator or some type of forum that has multiple arbitrators. He stated that the HUD Department Manager (staff #100) was in charge of Arbitration. An interview was conducted on August 27, 2025 at 2:20 p.m. with the HUD Department Manager (staff #100), who stated that she was the Admissions Coordinator up to July 1 2025 and that she trained the previous person who had staff #31's position. She also stated that she gave staff #31 a few pointers about arbitration yesterday, such as the resident has to sign the form and date the form. During the interview, she reviewed resident (#2's) arbitration form and could not explain the National Arbitration Forum's role in the arbitration process, but thought it might be an organization that the facility uses. The HUD Department Manager stated that she thought that the arbitration agreement used to say that a neutral party (arbitrator) will be agreed upon by the facility and the resident. She further stated that she didn't know how a venue was chosen and acknowledged that the venue was not mentioned in the agreement. Review of the facility Pre-Dispute Voluntary binding Arbitration Agreement, did not reveal that the resident and facility are to agree upon a neutral arbitrator or venue. It did include a signature page which included the signature and title of the staff member who explained the meaning of the agreement to the resident.

Number of residents sampled:Number of residents cited:TFFT ensure that food handling processes were properly implemented. Based on observations, staff interviews, and policy review, the facility failed to ensure that food items were not expired. The deficient practice could increase the risk of cross-contamination and foodborne illness.Finding includes:During an initial kitchen observation conducted on August 26, 2025 at 7:19 a.m., with the Kitchen Manager (staff # 101), the following food items were found to be expired:-In the dry food storage, 2 bags of Sysco Classic Peanuts with an expiration date of July 31, 2025.-In the walk-in refrigerator, red tomato sauce was stored in a metal container with used-by date of August 21, 2025; a white colored dessert stored in a metal container with used-by date August 22, 2025; dry oats stored in a metal container with used-by date August 10, 2025; and teriyaki sauce stored in a metal container with used-by date August 13, 2025.An interview was conducted on August 26, 2025, at 7:56 a.m., with a Kitchen Manager (staff # 101) who stated that foods were prepared in the same kitchen for both skilled and assisted living residents. The Kitchen Manager stated that leftover prepared foods are dated, labelled, and used by 7 days. The kitchen manger further stated that the expired leftover food found in the refrigerator and dry storage should have been previously discarded.An interview was conducted on August 26, 2025 at 10:40 a.m., with the Executive Chef Director (staff #10), who stated that the nursing center's food storage inventory and kitchen are shared by assisted living, skilled, and short-term memory care units. Staff #10 then stated that leftover food should be clearly labeled, dated, and used within 7 days. Staff #10 also stated that the risk of not discarding food at the expiration dates could result in residents becoming sick, if they ingest the food.An interview was conducted on August 26, 2025, at 11:51 a.m., with a cook (staff #41), who stated that leftover foods are labelled, dated, and stored in a walk-in refrigerator and used within 5 days. The cook also stated that if food were not thrown after its expiration date the risk could result in salmonella and food poisoning.A follow-up interview was conducted on August 26, 2025 at 12:09 p.m., with Executive Chef Director (staff #10), who stated that leftover foods should be stored in covered containers or wrapped carefully and securely. He further stated that each item should be clearly labeled, dated, and cooled at 41 F (Fahrenheit) within 7 days. He further stated that his expectation included for staff to inspect the food items daily in dry storage and the refrigerator, discard food that had expired. He stated the risk could result in residents becoming sick with food-borne illness.An interview was conducted on August 27, 2025 at 1:22 p.m., with a Certified Nursing Assistant (CNA, staff #37), who stated that she would not eat outdated, expired, or old food because food may be tasteless, cause digestive issues, and could make you sick.An interview was conducted on August 27, 2025 at 2:40 p.m., with the Director of Nursing (DON, staff # 68), who stated that she expects food to be prepared according to food safety guidelines.A facility policy entitled, Food Storage, revised September 5, 2025, revealed that leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2017 Federal Food Code. The policy also stated that all foods should be covered, labeled, and dated and routinely monitored to ensure that foods (including leftovers) will be consumed by their safe use-by dates, or frozen (where applicable), or discarded.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure that there were no expired food items readily available for resident use in the dining room refrigerator. The deficient practice could result in potential foodborne illness. Findings include: On [DATE] at 10:02 a.m. an interview was conducted with the administrator (staff #10)who stated that the kitchen had not been in-use since [DATE]; and that, food was brought from the neighboring assisted living facility which was considered their satellite kitchen. The administrator stated that whenever drinks or snacks were requested outside of regular meal times, the items in the dining room refrigerator were available to the residents. An observation of the refrigerator located in the dining room was conducted administrator immediately following the interview. There were five cartons of orange juice with expiration date of [DATE] found inside the refrigerator. In the cabinet beside the refrigerator were twelve peanut butter sandwich crackers without any expiration date on packaging or any dates that would indicate if the crackers were old or newly opened or used by dates. The administrator stated that the dietary aides had not removed the expired juices; and that, the peanut butter sandwich cracker snacks had no used by dates. Further, the administrator said that there was a risk of residents becoming ill if they eat or drink expired items; having expired food items readily available for resident use did not meet the facility's expectations. Review of the facility's Policy titled, Food Storage (revised [DATE]) revealed all foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.

Based on observations, interviews, and record review, the facility failed to ensure that food was properly stored, labeled and dated sanitary conditions. The census was 9. The deficient practice could result in residents acquiring a foodborne illness. Findings include: During a brief kitchen inspection conducted on [DATE] at 8:29 a.m. with the Food Service Director (staff #7), the following were identified in the refrigerator and freezer: -Sweet Street Chocolate Peanut Butter Pie with a received date of [DATE], was notably exposed to air and had no use by date. -Brand Villa Frizzoni pepperoni slices was open and exposed to air, with no use by date. -1 large box of blueberries with received date of [DATE] was open and exposed to air and did not include an open or use by date. The blueberries were withered and wrinkled in appearance. -Oatmeal Raisin English Bay cookies dated [DATE] had no open or use by date. -1 large pepperoni pizza opened and exposed to air, with no open or use by date. -Cooked Meatloaf sealed in aluminum foil dated [DATE]. -Great Value Vanilla and Chocolate Containers of ice cream with no open or use by date. -6 large fresh zucchini were noted with mold, and appeared soft and wrinkled. -Macaroni salad 3-pound container with no open or use by dates, was open and exposed to air. An interview was conducted with the Food Service Director (staff #7) during the inspection. He stated that the food products should be dated with opened and use by dates. He stated that there could be possible contamination or spoilage of the oatmeal cookies. Staff #7 stated that the meatloaf was left over and expired from a previous meal and should have been tossed. He stated that the Activities Department should not be storing food items (ice cream) without permission or his knowledge. Review of the facility policy titled Food Storage included that sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination.

Based on observations, staff interviews, and policy review, the facility failed to ensure their system of prompt identification of loss or potential diversion of controlled medications was implemented. The resident census was 9. The deficient practice could result in misappropriation of residents' medications. Findings include: -Regarding misappropriation of a medication: Review of the Controlled Count Record revealed no evidence of two nurse reconciliation: -January 29, 2023: 6AM - 6PM - no evidence of off-going nurse verification -January 29, 2023: 6PM - 6 AM - no evidence of on-coming nurse verification. According to a facility investigation, dated January 30, 2023 at approximately 6:30 AM the Director of Nursing (DON/staff #2) was informed that there were missing narcotics by an on-coming registry Registered Nurse (Rn/staff #100). The investigation revealed that a vial of liquid Ativan (lorazepam/anxiolytic) for oral administration ordered for a hospice patient, was missing from the medication refrigerator. The investigation also revealed that the off-going RN (staff #27) had thoroughly examined the medication cart, medication refrigerator, sharps containers and outside garbage receptacles, without recovery of the medication. The report/investigation revealed that the DON was unable to definitively determine who took the medication or what happened to the medication. Per the Controlled Count Record dated the January 30, 2023, the 6AM - 6PM shift documentation revealed no evidence of off-going nurse verification. Written statements from 5 nurses were obtained on January 30, 2023 and included the following: - Licensed Practical Nurse (LPN/staff #103) who stated she worked January 28, 2023, 6:00 AM - 6:00 PM, relayed that she viewed the contents in the medication refrigerator during the on-going reconciliation, but did not look at the individual medications. She also indicated that when completing the off-going shift narcotic reconciliation with staff #27, they did not check the contents of the fridge at all. The Investigation revealed that the LPN cancelled her shift for January 29, 2023 and called off a scheduled shift on January 31, 2023. -RN (staff #27) furnished a written statement indicating that January 29, 2023 he confirmed the vial of Ativan (lorazepam/anxiolytic) was there at 6:00 PM when his shift started, and at approximately 7:00 PM. The report included that staff #27 stated that he always checks the medication refrigerator when reconciling narcotics. Per the report RN (staff #27) was removed from the scheduled and submitted to a drug screen that was negative. The investigation included that RN (staff #27) had received previous counselling regarding medication errors. -Registry Licensed Practical Nurse (LPN/staff #104's), written statement revealed that she was scheduled on January 29, 2023, 6:00 PM - 6:00 AM and that she became aware of the situation at shift change. She further revealed that she was not assigned to the unit, and did not open the medication refrigerator. -Registry RN (staff #102), who worked on January 29, 2023, 6:00 Am - 6:00 PM, stated that she did not pass medications or count narcotics, but did open the medication refrigerator to retrieve tuberculosis solution, and did not notice if the Ativan was present. -Registry LPN (staff #101) worked January 29, 2023, 6:00 AM - 6:00 PM and stated that she did not administer Ativan or open the medication refrigerator. An interview was conducted on July 20, 2023 at 08:27 AM with a registry LPN (staff #105), who stated that narcotics are counted each shift by the on-going and off-going nurses. She further stated that it is the facility policy for both nurses to sign the Controlled Count Record. The LPN reviewed the July 2023, Controlled Count Record form, and stated that there were multiple missing signatures for the two-person sign off. She further revealed that on July 1 and July 2, 2023, there was 1 shift each day that did not have evidence of two nurse sign off. She also stated that this did not follow the facility policy. As the form was initially being reviewed with the nurse, she stated that she forgot to sign the form this morning, and then quickly signed/corrected the form. The LPN further stated that this did not follow the facility process. An interview was conducted on July 20, 2023 at 9:46 AM with the Director of Nursing (DON/staff #2), who stated that she expected that the on-coming/off-going shifts sign the reconciliation form as they complete the narcotic count. She stated the risk of not conducting the narcotic reconciliation per policy could result in a medication being diverted. The DON also stated that the nurses have been educated regarding medication reconciliation. An interview conducted on July 20, 2023 at 9:46 AM with a Clinical Resource (staff #41) who stated that they were notified regarding the missing Ativan on January 30, 2023. She also stated that staff interviews were conducted, and a room to room check including the medication carts and storage room. She stated that the facility process was not followed, that narcotic not been located. Review of a facility policy titled, Controlled Substances, revealed that the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. The must document and report any discrepancies to the Director of Nursing Services. 47911 -A review of the narcotic logs was conducted on July 20, 2023 at 9:05 a.m. The review revealed that there were multiple missing signatures for the narcotic count log for the months of January 2023, February 2023, March 2023, April 2023, May 2023, and June 2023. The total count of missing signatures was 139. The breakdown by month, revealed the following: January: north medication cart: missing 15 signatures January: south medication cart: missing 14 signatures February: north medication cart: missing 2 signatures February: south medication cart: missing 13 signatures March: north medication cart: missing 21 signatures March: south medication cart: missing 9 signatures April: north medication cart: missing 20 signatures April: south medication cart: missing 12 signatures May: north medication cart: missing 15 signatures May: south medication cart: missing 3 signatures June: north medication cart: missing 7 signatures June: south medication cart: missing 8 signatures An observation of the medication storage room on July 20, 2023 at 9:21 a.m. was conducted with a Licensed Practical Nurse (LPN/staff #105) revealed no narcotics housed in the medication storage room. Staff #105 stated all narcotics are currently on the medication cart. She stated that as the resident census was so low, that there was only a north medication cart at that time, as there was no longer a need for a south medication cart. An observation of the north medication cart conducted on July 20, 2023 at 9:30 a.m. with an LPN (staff #105) revealed a total of 8 controlled medication cards present, which were reviewed and the counts were confirmed. Staff #105 stated that when medication counts are conducted that one nurse would count the medications, while another nurse would log the count. She stated that medication counts must be conducted every shift, per policy, and must always be signed off on the medication log. An interview was conducted on July 20, 2023 at 1:18 p.m. with the Director of Nursing (DON/staff #2). The DON stated that the expectation for medication storage is that scheduled drugs are kept under lock and key and that storage locations are temperature controlled. She stated that the medication control logs are expected to be counted properly at the beginning and end of each shift, and at the same time every day. She stated that she had scheduled nursing shifts to overlap in an effort to facilitate the medication counts. She stated that missing signatures on the narcotic control logs did not meet her expectations. She stated that she had implemented an additional audit program on the 13th of July, 2023 and noted that 7 of the missing signatures for that month were registry nurses. An interview was conducted on July 20, 2023 at 1:29 p.m. with the administrator (staff #106). She stated that she knew at the beginning of the year that logs were not being signed consistently. She stated that she was focused on performance improvement and had put spot checks in place, but the staff member in charge of the spot checks had left as well as the previous DON. She stated that under the new DON, daily audits have been put into place, since July 13, 2023 and would continue for 4 weeks. She stated that the facility had also identified those registry nurses who are not following the medication count policy and reported them to the agency. The facility was addressing the issues with in-house nurses directly on an individual basis. The administrator stated that if the medication counts and subsequent signatures on the log are not occurring then it was not meeting her expectations. She stated that the risk was that narcotics could be diverted and patient care could be affected. A review of the Medication Storage policy with revise date of February 4, 2023 included that staff must resolve discrepancies and report any discrepancies that cannot be resolved immediately. It further stated staff may not leave the area until discrepancies are resolved. A Controlled Substances policy with a revise date of February 2, 2023 included that nursing staff must count controlled medications at the end of each shift and that the nurse coming on duty in conjunction with the nurse going off duty must make the count together. It further revealed that nursing staff must document and report any discrepancies to the director of nursing services.

Based on observations, clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to ensure that the resident environment remained free of accident hazards, by failing to ensure that a shower chair was inspected for safety before use, and that one resident received appropriate transfer assistance (#113). The deficient practice increased the risk for preventable accidents. Findings include: Resident #113 was admitted on [DATE], with diagnoses that included wedge compression fracture of vertebra, fracture of shaft of right arm humerus, difficulty walking and muscle weakness. Review of the admission MDS (minimum data set) dated October 25, 2022 revealed a BIMS (brief interview of mental status) score of 9, indicating moderate cognitive impairment. The assessment revealed that resident required extensive two-plus person physical assistance with transfers. A nurse's notes dated October 27, 2022 at 2:36 p.m. revealed while resident #113 was being transferred from wheelchair to bed the resident began slipping off the side of the bed. Further, the notes revealed the staff noticed the resident was bleeding and discovered a large laceration approximately 12 millimeters long to the right lower extremity. The notes indicated that the resident had edema on both lower extremities and fragile skin. Per the nursing notes, the resident was sent out to an acute care hospital for further evaluation. A physician order written on October 31, 2022 revealed the following order: -Clean right lower extremity laceration with wound cleanser, pat dry, apply Xeroform dressing and wrap with kerlix every other day for laceration. Review of the facility's 5-day investigation report submitted to the State Agency on November 1, 2022 at 9:45 a.m. included the following narrative notes: [The] resident was sitting up in a shower chair following the shower. [A] CNA (certified nursing assistant) performed a transfer from shower to bed. During transfer, the resident was unable to fully sustain her weight. After transfer, the resident was sitting on the mattress but not fully. The CNA called for lifting assistance. When the CNAs looked down, the resident had a skin tear on her right lower leg. Resident was found to have a large leg laceration to the right leg that was not able to be steri-stripped. Further record review revealed the resident was transferred from the shower chair to the bed and that her right lower leg was caught on the shower chair which had protruding capped bolts causing her right leg to rub and the skin to tear. However, record review revealed the resident was transferred only by one CNA from shower chair to bed, and there was no evidence of the shower chair examination prior to use. Review of a care plan problem that was initiated on November 17, 2022 revealed the resident has a skin tear on right lateral lower extremity due to injury during transfer. The interventions included using caution during transfers to prevent striking arms, legs, and hands against any sharp or hard surface. An interview was conducted on July 21, 2023 at 10:29 a.m. with certified nursing assistant (CNA/staff #11). She stated that she gets reports from another CNA she is relieving, and that the report would include how many staff's assistance is needed for transferring the residents under her care. She stated that if a resident required two-person physical assistance for transfers, she could use a mechanical lift or she would ask another CNA or a charge nurse for help. She stated that the same process applies for a resident requiring two-person assistance when transferring from shower chair to bed. An interview was conducted on July 21, 2023 at 10:42 a.m. with a licensed practical nurse (LPN/ staff #17). She said when CNAs arrive to work on the floor, she gives them a report including whether a resident is independent or total care. She stated for residents who required extensive assistance of two-persons, the CNA would call her to help with transfer with the use of gait belts which are located in all resident rooms. Following the interview at 10:57 a.m., staff #17 inspected the shower chair located in the resident's room. She touched the two large knobs located in the front of the shower chair and she immediately pulled back her hand. She stated the knobs were sharp and could cut the skin, especially if the skin was frail. An interview was conducted with the executive director (ED/ staff #6) on July 21, 2023 at 11:13 a.m. She stated that it was her expectation that all DME (durable medical equipment), including shower chairs, must be examined by the maintenance or staff for safety prior to use. Following the interview with staff #6 at 11:22 a.m., she walked into the resident's room and examined the shower chair. She immediately removed the shower chair from the resident's room after touching the knobs located on the front of the shower chair. She stated that the facility owned the shower chair and that the knobs located on the front of the chair, located where the resident's legs would be resting, were sharp. The facility policy, Provision of Quality Care, revised on February 4, 2022 included that each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.

Based on concerns identified during the survey, the narcotic log review, and staff interviews, the Quality Assurance and Performance Improvement (QAPI) committee failed to implement and review an appropriate plan of action to correct the deficiency of incomplete narcotic count documentation. The deficient practice could result in narcotic medications not being accurately accounted for. Findings include: A review of the narcotic logs was conducted on July 20, 2023 at 9:05 a.m. The review revealed that there were multiple missing signatures for the narcotic count log for the months of January 2023, February 2023, March 2023, April 2023, May 2023, and June 2023. The total count of missing signatures was 139. The breakdown by month, revealed the following: January: north medication cart: missing 15 signatures January: south medication cart: missing 14 signatures February: north medication cart: missing 2 signatures February: south medication cart: missing 13 signatures March: north medication cart: missing 21 signatures March: south medication cart: missing 9 signatures April: north medication cart: missing 20 signatures April: south medication cart: missing 12 signatures May: north medication cart: missing 15 signatures May: south medication cart: missing 3 signatures June: north medication cart: missing 7 signatures June: south medication cart: missing 8 signatures An interview was conducted on July 20, 2023 at 1:18 p.m. with the Director of Nursing (DON/staff #2). The DON stated that the expectation for medication storage is that scheduled drugs are kept under lock and key and that storage locations are temperature controlled. She stated that the medication control logs are expected to be counted properly during at the beginning and end of each shift and at the same time every day. She stated that she had scheduled nursing shifts to overlap in an effort to facilitate the medication counts. She stated that missing signatures on the narcotic control logs did not meet her expectations. She stated that she had implemented an additional audit program on the 13th of July, 2023 and noted that 7 of the missing signatures for that month were registry nurses. An interview was conducted on July 20, 2023 at 1:29 p.m. with the Administrator (staff #106). She stated that QAPI meetings are held monthly; however with the relocation process occurring within the facility, meetings are now held every other month. She stated that an area identified by QAPI was the lack of consistent documentation for the narcotic log counts. Staff #106 stated that she knew at the beginning of the year that the narcotic logs were not being signed consistently and had created a PIP (performance improvement plan). She stated that she was focused on performance improvement and had put spot checks in place, but the staff member in charge of the spot checks had left as well as the previous DON. She stated that under the new DON, daily audits have been put in place effective July 13, 2023 and would continue for 4 weeks. She stated that the facility had also identified those registry nurses who are not following the medication count policy and reported them to the agency. The facility was addressing the issues with in-house nurses directly on an individual basis. The administrator stated that some of the tools utilized to correct and monitor identified issues included audits, observations and training. However, staff #106 stated that with changes in staffing and change in facility focus to include the relocation of residents, tracking the effectiveness of the PIP for the narcotic log documentation had not been consistent, which did not meet her expectations. She stated that the lack of review could impact the resolution of the identified concern.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to document treatment and care in accordance with professional standards of practice regarding implementation of compression stockings for one resident #263. The deficient practice could result in residents not receiving treatment and care based on their needs. Findings Include: Resident #263 was admitted on [DATE] with diagnosis including unspecified dementia, Alzheimer's disease and essential hypertension. The MDS (minimum data set) dated April 20, 2020 revealed a BIMS (brief interview for mental status) score of 4, suggesting severe cognitive impairment. The dashboard in the electronic health record revealed that resident #263 required one-person physical assistance with dressing. A review of the physician's orders dated January 28, 2020 included an order for compression stockings for edema. Review of the care plan initiated February 5, 2020 included that resident #263 was to have compression stockings applied in the morning and taken off at bed time. A review of the physician progress notes dated March 5, 2020 revealed that compression stockings (TED hose/thrombo-embolic deterrent) were in use for resident #263. However, on March 7, 2020 a new order was generated, due to the absence of compression stockings in the facility, to read compression stockings or CE wraps to be put on the morning and taken off at night. A review of the progress notes revealed an entry on March 7, 2020, noting a concern expressed by the son that resident #263 was not wearing TED hose. The note further indicated that the floor nurse checked the resident's room and was unable to locate the stockings and that no stockings were located in the supply room. A review of the TAR (Treatment Administration Record) for March 2020 revealed no evidence of a nurse initial or administration check-mark noting compression stocking application on the morning of March 1, 2020. A further review of the TAR revealed the following: -March 10, 2020: no evidence that compression stockings were applied. -March 11, 2020: no evidence that compression stockings were removed. -March 15, 2020: no evidence that compression stockings were applied. Additional review of the care plan further revealed that resident #263 had ADL (activities of daily living) self-care performance deficits due to confusion, dementia and impaired mobility. An interview was conducted on July 21, 2023 with staff #17 (LPN). Staff #17 stated that nurses check to ensure compression stockings are put on and taken off as ordered via visual confirmation. Staff #17 stated that there should always be an entry in the electronic health record indicating application or removal of compression stockings. When staff #17 was asked to review the record for resident #263, she stated that it appeared that no one signed off on March 1, 10, 11, and 15th. She stated that the risk of not wearing compression stockings, as ordered, could include the resident being at risk for an embolism. An interview was conducted on July 21, 2023 at 8:57 a.m. with the Director of Nursing (DON/staff #2) and MDS Nurse, (staff #41). Staff #2 stated that if there were blank signature areas in the MAR (medication administration record) or TAR, it indicated that the task was not completed. Both staff #2 and staff #41 reviewed the electronic health record for resident #263 and stated that based on the observation of the MAR/ TAR, the compression stockings were either not administered or taken off on March 1, 10, 11 and 15 of 2020. Staff #2 stated that the risk to the resident would be that the edema for resident #263 would not be addressed. A review of the Charting Documentation policy, revised date of February 4, 2022, included that treatments or services performed are to be documented in the resident's medical record and that documentation in the medical record will be objective, complete and accurate. The Provision of Physician Ordered Services policy, reviewed/revised February 4, 2022, included the purpose was to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. Professional Standards of Quality means that care and services are provided according to accepted standards of clinical practice.

Based on clinical record review, observations, staff interviews, and facility policy, and CDC guidance the facility failed to ensure one staff (#22) was tested for COVID-19 prior to working in the facility with residents. The census was 35. The deficient practice could result in staff infecting residents with the virus. Findings include: Staff #22 was hired as a certified nursing assistant on October 2, 2012. Review of the COVID-19 Staff Vaccination Status for Providers revealed that staff #22 was granted a non-medical exemption for the vaccine. Review of the staffing schedules for May 2021 revealed that staff #22 worked in the facility on May 18, May 21, May 23, May 24, 2022. Review of the staffing schedules for July 2021 revealed that staff #22 worked in the facility on July 2, July 4, July 5, Review of the staffing schedules for July 2022 revealed that staff #22 worked in the facility on July 17, July 24, July 31, 2022. Review of the COVID-19 test results for July 2022 did not include test results for staff #22. An interview was conducted on August 3, 2022 at 10:49 a.m. with a licensed practical nurse, who identified herself as the Infection Control Preventionist (LPN/staff #2). She stated that she was not able to find the COVID-19 test results for staff for 2021. On August 4, 2022 at 12:48 p.m., an interview with the Director of Nursing (DON/staff #1), who stated that staff #22 may have been here more than once in the last two weeks and did not test for the COVID-19 virus. She said, staff #22 arrives earlier than the receptionist who would have had her test. Staff #22's shift starts at 7 a.m. and the receptionist doesn't come in until 7:30 a.m. During a second interview conducted on August 4, 2022 at 2:16 p.m. with (LPN/staff #2), she stated that staff #22 begins her shift at 7:00 am, is not vaccinated, and has not been testing for COVID-19. Staff #2 stated that any of the nurses can do the testing with the residents and staff and the front desk if keeping track of all the testing for staff and residents. She said that she has posted signs at the nurses' station and at the Time Clock stating that if you are not vaccinated, you have to test twice a week. She said, if staff do not test, there is a risk that COVID can get into the building and affect the other staff and residents. The facility policy, Coronavirus Surveillance, revised February 4, 2022 states all staff are required to receive the COVID-19 vaccination series (one-dose or two-dose) as per CMS guidelines or be up to date with recommended doses (CDC guidance) unless exempted for religious or medical reasons, or the vaccine needs to be delayed due to clinical considerations as outlined by the CDC. The Infection Preventionist, or designee, will track the the number of residents and staff who have been tested for COVID-19 (testing in accordance with current CDC guidelines and priorities). The CDC guidance updated February 2, 2022 includes in nursing homes, HCP (health care providers) who are not up to date with all recommended COVID-19 vaccine doses should continue expanded screening testing based on the level of community transmission as follows: In nursing homes located in counties with substantial to high community transmission, these HCP should have a [CONDITION(S)] test twice a week. If these HCP work infrequently at these facilities, they should ideally be tested within the 3 days before their shift (including the day of the shift).

Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure one resident (#34) who was receiving a [CONDITION(S)] medication was monitored for behaviors and side effects, and that one resident (#11) receiving an antipsychotic medication had adequate indication for its use. The sample size was 5 residents. The deficient practice could result in residents receiving [CONDITION(S)] medications not being monitored for behaviors, side effects and effectiveness, and not having indication for its use. Findings include: -Resident #34 was originally admitted to the facility on [DATE] and later readmitted on [DATE] after a brief discharge. The resident had diagnoses that included urinary tract infection, recurrent major depressive disorder, anxiety disorder, and multiple pressure ulcers. A physician's order dated July 12, 2021 stated [MEDICATION(S)] 25 Milligram (MG) give 1 tablet by mouth at bedtime for depression as evidenced by (AEB) [CONDITION(S)]. The order was discontinued on August 10, 2021 A physician's order dated July 12, 2021 stated to monitor specific behavior of depression related to neuropathic pain and document the number of episodes every shift. The order was discontinued on August 10, 2021 Further review of the physician orders revealed a physician's order dated August 19, 2021, discontinued on August 20, 2021 for antidepressant medication- monitor for common-sedation, drowsiness, dry mouth, blurred vision, urinary retention, [CONDITION(S)], muscle tremor, agitation, headache, skin rash, photosensitivity, and excess weight gain. every shift for [CONDITION(S)] med use. Document: 'N' if monitored and none of the above observed. 'Y' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and document in a progress note findings. A physician's order dated December 4, 2021 stated [MEDICATION(S)] ([MEDICATION(S)]) 10 MG by mouth at bedtime for depression. The care plan initiated on December 9, 2021 revealed a Focus that stated mood related to depression AEB sadness, decreased interest, self-isolation. The resident has been prescribed [MEDICATION(S)] which is classified as an antidepressant. The goal was to improve quality of life and for the resident's mood to improve and for symptoms to become less frequent. Interventions included notifying the physician for any and all changes in the resident condition, monitoring for medication effectiveness and potential for decrease in medications, and monitoring for adverse reactions and side effects to medication usage like dry mouth, constipation, [CONDITION(S)], unrelieved depression, nausea, vomiting and diarrhea. The 10 MG [MEDICATION(S)] order was discontinued on March 10, 2022 and a new order dated March 10, 2022 stated [MEDICATION(S)] 20 MG, give 1 tablet by mouth at bedtime for depression. However, further review of the orders revealed no physician orders for behavior monitoring or side effect monitoring for this antidepressant medication. Review of the Medication Administration Records (MAR) revealed that resident #34 received [MEDICATION(S)] as ordered from March 2022 through May 31, 2022. A quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, which indicated that the resident did not have cognitive deficits. Further, the assessment revealed that resident #34 had received antidepressant medications on 7 days of the 7-day lookback period. An interview was conducted with a Licensed Practical Nurse (LPN/staff #37) on June 1, 2022 at 1:00 PM. The nurse stated that [CONDITION(S)] medications orders are entered in the resident's record once the nurse receives an order from the physician. She also stated that if a resident was receiving any [CONDITION(S)] medication such as an antidepressant, there should be a consent, and a physician's order for the nurse to monitor the resident for behaviors or side effects. Further, she explained that the nurses do not have to complete monitoring with every administration, but there should be documentation in the resident's record once every shift. Additionally, the nurse stated that it is important to document every shift if the resident is or is not experiencing behaviors or side effects. Staff #37 stated that [CONDITION(S)] medications have many side effects and nurses have to check and be sure that the medication is needed and is treating the resident's symptoms effectively. The nurse reviewed the orders for resident #34 and stated the resident is currently on [MEDICATION(S)] and the staff are not currently monitoring this resident for behaviors or side effects because there is no order. However, the LPN stated the order should have been there and both day shift and night shift nursing staff should have been documenting it in the resident's record. The nurse stated that historically the facility does monitor every shift for residents' behaviors because it is important to see if the resident's medications are working and are effective. On June 1, 2022 at 1:30 PM, an interview was conducted with the Director of Nursing (DON/staff #33). The DON stated that when the nurse obtains an order for any [CONDITION(S)] medication such as an antidepressant, then there should be an appropriate diagnosis and the nurses should be documenting any signs or symptoms of depression or side effects that the resident is or is not experiencing. The DON stated that it is important so when they review the resident's record they can assess and decide if the resident needs more or less medication because the physician should be giving the least amount of medication to the resident. Further, she stated that she believes there should be a physician's order for both behavior and side effect monitoring in the residents' clinical record. The DON stated that upon review of resident #34 clinical record, there was not any monitoring for the behaviors. Further, she stated that this resident does have depression and has symptoms of depression due to the disease process. She stated that since it was not done that does not meet her expectations. The facility policy titled [CONDITION(S)] medication revised on February 4, 2022 stated the facility will monitor [CONDITION(S)] medications for proper dose, including duplicate therapy, duration, evidence of adequate monitoring for efficacy and adverse consequences and to prevent, identify and respond to adverse consequences. The goal is to monitor the resident's use of [CONDITION(S)] drugs in an effort to assist with stabilizing or improving the resident's outcome, quality of life and functional capacity, while using [CONDITION(S)] medications only when needed to treat a specific condition that is diagnosed and documented. Identified target behaviors will be monitored each shift along with individualized interventions as well as supporting documentation in the clinical record. The goals of [CONDITION(S)] medication and non-pharmacologic approaches will be addressed in the resident's care plan. The care plan will also include the type of [CONDITION(S)] drug(s) to be monitored for side effects daily, such as gait disorders, movement disorders, cognitive or behavior changes, discomfort (pain, constipation etc.), signs of [CONDITION(S)], dry mouth (cholinergic effects). -Resident #11 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia Without Behavioral Disturbances, Major Depressive Disorder, recurrent, unspecified, Anxiety Disorder, unspecified. A physician's order dated March 11, 2022 included [MEDICATION(S)] ([MEDICATION(S)]) ER (extended release) 150 MG tablet by mouth in the morning for anxiety AEB yelling out related to unspecified dementia without behavioral disturbance. Another physician's order dated March 11, 2022 included [MEDICATION(S)] 300 MG tablet by mouth at bedtime for anxiety AEB restlessness related to unspecified dementia without behavioral disturbance. Review of the care plan initiated on March 18, 2022 revealed the resident used the [CONDITION(S)] medication [MEDICATION(S)] related to dementia as evidence by yelling out, visual hallucinations, often about a dog. The goal was for the resident to remain free from [CONDITION(S)] drug related complications including movement disorder, discomfort, hypertension, gait disturbance, constipation/impaction or cognitive/behavioral impairment. Interventions included administering the [CONDITION(S)] medication as ordered by the physician, monitoring for side effects and effectiveness every shift, and consulting with pharmacy, the medical doctor to consider dosage reduction when clinically appropriate. A monthly Pharmacy review for March 2022 stated the resident is receiving the [CONDITION(S)] medication [MEDICATION(S)] but lacks an allowable diagnosis to support its use. It also stated Antipsychotics have a black box warning that they can increase the mortality rate in dementia patients. The pharmacist recommendation was for the psychiatric physician to assess the resident. Review of the April 2022 and May 2022 MARs revealed the resident received the medications as ordered. In an interview conducted on June 1, 2022 at 1:05 pm with the Director of Nursing (DON/staff #33), she stated that she reviewed the pharmacy medication recommendation review for March 2022 that indicated [MEDICATION(S)] was being administered to the resident without a proper diagnosis. The DON stated the review revealed psychiatry was supposed to follow up with an acceptable diagnosis for the resident to continue taking [MEDICATION(S)]. The DON then provided psychiatry notes from two psychiatry providers but neither notes revealed an addition or change of a diagnosis that would support a rationale for the administration of [MEDICATION(S)]. The facility policy related to [CONDITION(S)] Medication revised on February 4, 2022 stated based upon each resident's comprehensive care assessment, the facility will ensure residents who have not received [CONDITION(S)] drugs are not given them unless the medication is necessary to treat a specific condition that is diagnosed and documented in the clinical record. The indication for any [CONDITION(S)] medication will be thoroughly documented in the clinical record to include an appropriate supporting diagnosis and identification of behavioral symptom(s) being treated. The medical record must show documentation of adequate indication and diagnosed condition. Residents will not receive [CONDITION(S)] medications unless behavioral programming and or environmental changes or non-pharmacological interventions have failed to sufficiently address the resident's target behavioral goals.

Based on clinical record review, staff interview, and policy review, the facility failed to act upon a pharmacy recommendation timely for one resident (#11). The sample size was 5 residents. The deficient practice could result in other pharmacy recommendations not being acted upon timely. Findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia Without Behavioral Disturbances, Major Depressive Disorder, recurrent, unspecified, Anxiety Disorder, unspecified. A physician's order dated March 11, 2022 included [MEDICATION(S)] ([MEDICATION(S)]) ER (extended release) 150 MG (milligram) tablet by mouth in the morning for anxiety AEB (as evidenced by) yelling out related to unspecified dementia without behavioral disturbance. Another physician's order dated March 11, 2022 included [MEDICATION(S)] 300 MG tablet by mouth at bedtime for anxiety AEB restlessness related to unspecified dementia without behavioral disturbance. A monthly Pharmacy review for March 2022 stated the resident is receiving the [CONDITION(S)] medication [MEDICATION(S)] but lacks an allowable diagnosis to support its use. It also stated Antipsychotics have a black box warning that they can increase the mortality rate in dementia patients. The pharmacist recommendation was for the psychiatric physician to assess the resident. Review of the Medication Administration Records for April 2022 and May 2022 revealed the resident received the medication as ordered. However, further review of the clinical record did not reveal evidence that the pharmacist recommendation had been acted upon. In an interview conducted on June 1, 2022 at 1:05 pm with the Director of Nursing (DON/staff #33), the DON stated that she reviewed the pharmacy medication recommendation review for March 2022 that indicated [MEDICATION(S)] was being administered to the resident without a proper diagnosis. The DON stated the review revealed psychiatry was supposed to follow up with an acceptable diagnosis for the resident to continue taking [MEDICATION(S)]. The DON then provided psychiatry notes from two psychiatry providers but neither notes revealed an addition or change of a diagnosis that would support a rationale for the administration of [MEDICATION(S)]. The facility policy related to [CONDITION(S)] Medication revised on February 4, 2022 stated the pharmacist performing the monthly medication regimen review will also review the resident's medical record to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. The pharmacist will alert the facility immediately for any hazards related to FDA boxed warning and provide directions for monitoring and additions to the plan of care.

Based on clinical record review, staff interviews, and policy review, the facility failed to provide a speech therapy evaluation and treatment as ordered by the physician for one sampled resident (#4). The deficient practice could result in the resident not maintaining their communication capabilities. Findings include: Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan initiated on December 1, 2021 revealed the resident presented with an alteration in the ability to communicate due to a [CONDITION(S)] with [CONDITION(S)]. The goal was that the resident would communicate through verbal/non-verbal means. Interventions included assessing the resident's communication strengths and deficits, and emphasizing abilities. A social service progress note dated December 2, 2021 revealed social services spoke with resident #4's spouse to better assess the resident's communication abilities. The spouse indicated that the resident's world has shrunk as a result of declined ability to communicate. Review of the Social Service Initial Psychosocial History Evaluation dated December 2, 2021, indicated that resident #4 had difficulty communicating and could become agitated/irritated as a result. It also noted that the resident was unable to consistently make needs known and would become frustrated. A care plan initiated on December 22, 2021 revealed the resident has a potential for a psychosocial well-being problem related to cognitive communication deficit. Interventions included providing the resident time to respond to questions and verbalizing feelings, perceptions, and fear. A Social Service Psychosocial Quarterly Evaluation dated March 3, 2022, revealed the resident can be unhappy when unable to express feelings, needs or words. It also indicated that resident #4 has difficulty communicating and becomes sad and frustrated when unable to get the meaning across. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had unclear speech, slurred or mumbled words. The nursing progress note dated May 9, 2022, revealed an incident occurred in which the resident was agitated, pointed to the foot of the bed and yelled for help. A Certified Nursing Assistant (CNA) had to be called to assist in communicating with resident #4. Continued review of resident #4's clinical record did not reveal any speech therapy evaluation or treatments. An interview was conducted with the MDS Coordinator (staff #8) on June 1, 2022 at 10:45 a.m. Staff #8 stated that residents normally have orders from the hospital if they need communication intervention. She stated swallowing, cognition, respiratory, coughing or spitting are indicators of speech deficit and are reported to the physician to determine if an evaluation order is appropriate. She said orders are reviewed every morning. She said that the expectation is that once an evaluation is completed, it is annotated in the progress report. Staff #8 stated that if the evaluation found that treatment is not required, then it should be indicated in the progress report as such and the order discontinued. During the interview, clinical records for resident #4 were reviewed with staff #8. Regarding the order for speech therapy to evaluate and treat, staff #8 stated that there was no documentation regarding the status or outcome of the order. An interview conducted with the Director of Nursing (DON/staff #33) on June 1, 2022 at 10:59 a.m. The DON stated the expectation is that if an order to evaluate is given, then it is to be completed. During the interview, clinical records for resident #4 were reviewed with staff #33, who stated that there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that she was not sure what happened in the case of resident #4 since she was not employed at the facility during that time. A policy regarding Provision of Quality of Care dated February 4, 2022, indicated that based on comprehensive assessment the facility will ensure residents receive treatment and care by qualified persons.

Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure that the ordering provider was notified of lab results in a timely manner for one resident (#136). The sample size was 12 residents. The deficient practice could result in delayed treatment. Findings include: Resident #136 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the care plan initiated on May 26, 2017 revealed the resident was incontinent of bladder and/or bowel related to poor cognitive skills, inability to communicate the need for toileting, and [CONDITION(S)] stage 3. Interventions included administering appropriate cleansing and peri-care after each incontinent episode, toileting at regular intervals, and providing fluids according to schedule. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The MDS assessment further revealed the resident experienced frequent incontinence. A bi-annual history and physical (H&P) dated January 7, 2020 revealed the resident was experiencing dysuria. The plan included collecting a urinalysis (UA) with culture and sensitivity (C&S) and to start an antibiotic if the urine culture was positive. The bi-annual H&P was signed by a healthcare group company Nurse Practitioner (NP/staff #51) on January 9, 2020. A nurse's note dated January 7, 2020 at 3:44 p.m. revealed the NP was in for a visit and new orders were received for a UA with C&S. Review of physician orders revealed an order dated January 7, 2020 for a UA with C&S. Review of the lab report for the UA with C&S revealed the collection date was January 8, 2020 at 3:30 p.m. and the received date was January 9, 2020 at 11:07 AM. The report also revealed the documentation across from the UA with C&S run by . on 1/9/2020 1:01:37 PM, and across from urine culture run by . on 1/11/2020 2:42:57 PM. The culture and sensitivity revealed that Escherichia coli (E-coli) was present and the colony count was 50,000 to 100,000 cfu/ml (colony forming units per milliliter). A hand-written note on the lab report revealed the results were texted to the NP (staff #51) on January 11, 2020. However, a review of the nursing communication with physician note dated January 11, 2020 at 6:38 p.m. revealed the lab results dated January 8, 2020 were faxed to the facility physician (staff #52). The note also revealed tiger texted the results from recent UA and C&S, resident may have E.coli. A nurse's note dated January 15, 2020 at 2:00 p.m. stated the NP (staff #51) was texted the CBC (complete blood count) and prior lab results and that there were no new orders. A nurse's note dated January 17, 2020 at 7:14 a.m. revealed the resident was sent to the hospital. An interview with a Licensed Practical Nurse (LPN/staff #21) was conducted on June 1, 2022 at 9:39 a.m. She stated that if there is a concern with a resident such as a urinary tract infection ([CONDITION(S)]), the nurse would let the provider know and the provider may order labs and other tests as needed. The LPN stated labs are done in the facility. She stated lab orders that are stat (immediate) are done in 4 to 6 hours. The LPN stated that if it is not indicated as stat, the lab draw would be some time later that day. She stated the lab results may be in the results section of the resident's electronic health record. The LPN stated lab results that are faxed to the facility are immediately uploaded into the system. She stated that if she does not see results after 4 hours she would call the lab to inquire about the status. She stated results take no longer than 24 hours. The LPN stated the provider is called as soon as possible with all lab results, usually within an hour of results being sent. The nurse stated that informing the provider should not take longer than 4 hours. Staff #21 stated if there were any orders, they would be put into the system by the nurse after being advised by the provider via phone. She stated a progress note is to be entered as well indicating the call to the provider, any orders, and follow up notes needed. The LPN stated this can be one or multiple notes depending on the conversation and follow up needed. An interview with the Director of Nursing (DON/staff #33) was conducted on June 1, 2022 at 11:18 a.m. She stated that if labs are ordered for a resident, the lab comes to the facility and the results are generally available the same day. The DON stated that however, the current lab seems to take longer at times. She said UA results are typically available within a couple hours but the C&S may take a day or two. The DON stated if the results are not seen in a timely manner, she expects that the nurse would call the lab to follow up on the results. She stated that the provider is to be contacted immediately via email and/or phone and told the results of the UA and contacted again with C&S results. She said that antibiotics are prescribed once the C&S results have been obtained. The DON stated it is not good practice to prescribe an antibiotic without a C&S being completed. She stated the C&S result determines the appropriate antibiotic to be prescribed based on the organism involved. She said that the recommendation was that an antibiotic would be prescribed for bacteria count over 100,000 cfu/ml and 3 other symptoms based on McGeer's criteria (a diagnostic tool used to identify true infections) that is used in the facility. The DON stated that a wait of 2 or 3 days to notify the provider of lab results was not acceptable and does not meet her expectation. She stated labs and lab results are considered an order and should be forwarded to the provider as soon as the results are available. The DON said that waiting 2 or 3 days was bad nursing practice as waiting to advise the provider of results can be detrimental to the resident. Review of the facility policy change in resident condition or status (February 2022) revealed that the facility shall promptly notify the resident, his or her attending physician and any representative of changes in the residents medical/mental condition and or status. The nurse will notify the resident's attending physician when there is a significant change that will not resolve itself without intervention. No facility policy for notification of lab results to the provider or notification to provider was provided as these were covered by the change of condition policy per the DON.

Based on clinical record review, staff interviews, and policy review, the facility failed to provide evidence that the Notice of Medicare Non-Coverage (NOMNC) was issued to one (#86) of three sampled residents when there was an ending of Medicare services. The deficient practice could result in residents not being informed of their potential liability for payment. Findings include: Resident #86 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the face sheet revealed that a family member of resident #86 was the responsible party. A skilled nursing note dated November 11, 2021 revealed the resident was alert and oriented to person, place, time, and situation. Review of the clinical record revealed the last day of Medicare coverage was on November 11, 2021. Review of a progress note dated November 11, 2021 revealed the resident was discharged to independent living with the family member, transport via car. The note also revealed the resident was discharged due to completing skilled services. However, no evidence was revealed in the medical record that the NOMNC informing resident #86 and/or the resident's family member that Medicare may not pay for services beginning on November 11, 2021 was issued to the resident. An interview was conducted on June 1, 2022 at 1:48 PM with the Social Services Director (staff #35), who stated she was not able to locate a NOMNC for the resident. An interview was conducted on June 1, 2022 at 1:57 PM with the Director of Nursing (DON/staff #33). The DON stated the process is to notify residents or family members of discharge from Medicare services by delivering a NOMNC normally within seventy-two hours of the discharge date . The DON stated the expectation is that a NOMNC be delivered and explained to the resident and/or the resident's representative prior to discharge. Staff #33 stated the resident's representative can sign the NOMNC on behalf of the resident. Review of the facility policy titled, Advance Beneficiary Notice of Non-Coverage (ABN) Policy, revealed that it is the policy to inform any Medicare beneficiary of the termination of their part A/Skilled stay via a NOMNC letter and follow up with notice of skilled nursing facility advance beneficiary notice of non-coverage (SNFABN) verbally with the resident and or representative when the NOMNC is delivered. This information is documented in the progress notes in the electronic medical record.

Based on observation interview and record review the facility failed to assure that staff followed infection control and prevention techniques to prevent the potential spread of infections including [DIAGNOSES REDACTED]-CoV-2 [MEDICAL CONDITION] that causes COVID 19 for residents and staff who are exposed to staff who have not followed infection control and prevention techniques. Findings: The director of nursing (DON) accompanied the surveyor on the tour of the facility. The facility was temporarily without an infection preventionist (IP). The DON was acting IP. 1. On 7/9/2020 at 10:10 AM during observation of the hallway that included room [ROOM NUMBER] and 116, HK Staff 32 did not change her gloves or sanitize her hands between cleaning room [ROOM NUMBER] and room [ROOM NUMBER]. When asked about this, HK Staff 32 stated she was supposed to change gloves and sanitize her hands between each room. 2. On 7/9/2020 at approximately 10:20 AM, Staff 15 put on a gown to enter room [ROOM NUMBER]; however did not tie the waist ties. When asked about this, the DON stated the waist ties were to tie securely to prevent the gown from pulling away from the body exposing the staff to potentially infectious material during resident care. The resident (R4) in that room was on transmission based precaution (TBP) for presumed positive COVID19 infection and was a person under investigation (PUI). 3. On 7/9/2020 at approximately 10:40 AM, observations of the laundry process revealed the following: HK Staff 38 had entered the laundry room to begin sorting soiled laundry. She went to the sink and washed her hands by placing liquid soap on her hands then putting them under the running water for 3 seconds. She then dried her hands and shut off the water with a dry towel. When asked how long they were to wash their hands, HK Staff 38 stated 20 seconds. She again went to the sink and washed her hands by placing liquid soap on her hands placing her hands under water and washed them for 10 seconds. After letting her know she had washed them for less than 10 seconds. She stated she would count to 20 when washing her hands. There was a hand washing poster near the sink. She read the poster and acknowledged that she should wash with the soap for 20 seconds and then rinse her hands. Before beginning to sort the laundry HK Staff 38 placed a thin plastic apron on and attempted to tie the waist ties; however she said she was not able to tie it securely because her gloves were too large. She continued to sort laundry with the gown pulling away from her uniform potentially exposing her uniform to contaminated wet linen. When pointed out, HK Staff 38 tried again to tie the gown; however the ties then broke. She removed her gloves, sanitized her hands and then put on another gown. She again attempted to tie the gown now with bare hands; however she still had difficulty and the ties broke again. She was finally able to get an apron to stay tied at the waist. When asked about the aprons, HK Staff 38 stated the ties come loose or break all the time. After she completed sorting the laundry during the interview she touched her mask several time with soiled gloves. When pointed out she stated she was not aware that she had touched her mask. She stated she would have to throw her mask away, remove her gloves and sanitize her hands again. 4. During a tour of the COVID 19 Unit on 7/9/2020 beginning at 11:20 AM, accompanied by the DON and the ADON was present as well, the DON stated people entering the unit had to wear full PPE, which included mask, eye covering, gloves and gowns. Staff 12 was observed entering R1's room without eye covering other than her glasses. When asked about this, Staff 12 stated the goggles and face shield got fogged up so that she could not see when she took care of the residents. I could see that she was sweating and her glasses were fogged up without any eye covering. Her N95 mask was tightly pinched at the nose. She stated she had informed the ADON however there was nothing they could do. In addition the gown Staff 12 wore was not tied at the waist. When asked about this she said it didn't have any ties. They were short on gowns so reused them. When asked the ADON about Staff 12 not wearing eye covering or not having a gown that tied at the waist. The ADON stated Staff 12 should be wearing eye covering and tie the gown at the waist. However she stated the facility is having a hard time retaining staff who will work this unit. They had many staff who contracted COVID 19 in May and they were afraid to work at this facility. Staff 12 had recently been tested for COVID and tested negative. 5. At approximately 11:30 AM, still in the COVID 19 unit, C-Staff 26 was observed getting ready to go into R1's room to provide therapy services to the resident. C-Staff 26 was wearing a N95 mask with an exhalation valve. When asked if he used that mask while caring for other residents outside the COVID 19 unit, C-Staff 26 stated yes. He stated the therapy company provided the masks. When asked if he got close to the residents during therapy, he stated yes sometimes he did. When asked the DON if staff caring for residents could use the N95 mask with an exhalation valve, she stated yes. She stated she was not aware of any concerns with these types of masks. At 11:55 AM, during an interview with C-Staff 84 when asked about providing the N95 mask with exhalation valve to therapy staff, stated these were the masks the company provided. Provided reference to them for the CDC and NIOSH website for more information: https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirator-use-faq.html. https://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/resp[DIAGNOSES REDACTED].html .The valve opens to release exhaled breath and closes during inhalation so that inhaled air comes through the filter. Health care workers may wear respirators with exhalation valves unless the patient has a medical condition (such as an open wound) for which a health care worker would normally wear a surgical mask to protect the patient. Similarly, respirators with exhalation valves should not be placed on a patient to contain droplets and prevent spread of infectious particles; surgical masks are adequate for this purpose. On 7/10/2020 record review was conducted. The following policy and procedures (P&Ps) read in pertinent part as follows: Preventing Transmission/Novel [MEDICAL CONDITION]-19 revised date 4/15/2020 included directions from the CDC website: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. The following is the pertinent part: .Eye Protection . Put on eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) upon entry to the patient room or care area .Personal eyeglasses .are NOT considered adequate eye protection . Handwashing/Novel [MEDICAL CONDITION]-19 dated 3/4/2020 read in pertinent part as follows: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility .15. Hand hygiene technique when using soap and water; A. Wet hand with water .b. Apply to hands the amount of soap recommended .c. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. D. Rinse hands with water .

Based on clinical record review, facility documentation, hospital records, staff interviews, review of the Center for Disease Control (CDC) recommendations and policies and procedures, the facility failed to ensure infection control standards were followed including for resident #3. The deficient practice could result in the spread of infections, including COVID-19. Findings include: -Resident #3 was readmitted [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was being assessed daily for COVID -19. Questions on the assessment included Are you experiencing any of the following symptoms? and if the physician was notified of any abnormal findings. Symptoms listed included fever. Review of the weights and vital exception form revealed the following temperatures: May 1, 2020 at 10:56 p.m. - 102.3 degrees Fahrenheit (F) May 1, 2020 at 11:10 p.m. - 102.6 degrees F May 2, 2020 at 9:36 a.m. - 100.0 degrees F May 4, 2020 at 11:58 p.m. - 101.4 degrees F May 5, 2020 at 12:18 a.m. - 101.4 degrees F May 7, 2020 at 5:59 a.m. - 100.8 degrees F May 7, 2020 at 11:04 p.m. - 100.1 degrees F The Medication Administration Record [REDACTED] May 1 at 10:56 p.m. for temperature 102.3 degrees F May 2 at 9:36 a.m. for temperature 100.0 degrees F May 4 at 11:58 p.m. for temperature 101.4 degrees F Per the COVID-19 assessment dated [DATE], Tylenol was administered for the 101.4 degrees F temperature. Review the nurses' notes dated May 5, 2020 revealed the resident was on a change of condition for monitoring fevers. Per the COVID-19 assessment dated [DATE], the physician was informed of the resident's temperature on May 5, 2020. Additional review of the clinical record revealed no evidence the resident was placed on precautions. Review of the nursing note dated May 9, 2020 revealed the resident had minimal verbal response, oxygen saturation on room air was 88%, and that there was no change in oxygen saturation after the resident was encouraged to deep breath. Oxygen at 2 liters via nasal cannula was applied and the oxygen saturation increased to 93%. The physician was notified at 8:00 a.m. and orders were given for a stat chest x-ray, blood work, and a urinalysis. The family was notified at 8:10 a.m. and voiced concerned regarding COVID-19 and requested the resident be sent to the hospital. The physician was contacted and an order to send the resident to the hospital was obtained at 9:20 a.m. The note included the resident was released for transport to the hospital at 10:30 a.m. Review of the facility's documentation revealed the resident's COVID-19 test sample collected May 9, 2020 was positive for COVID-19. The documentation also revealed the resident's onset date of symptom was May 1, 2020 and that the symptom observed was a temperature of 102.3 degrees F. The documentation did not reveal any evidence the resident was placed on precautions for infection control. Review of the hospital records revealed an emergency room provider notes dated May 9, 2020 that a rapid COVID-19 test was obtained and that the resident tested positive for COVID-19 which is indicative of an active infection. The physician's discharge summary dated May 13, 2020, revealed the resident's hospital course included fever and acute hypoxic [MEDICAL CONDITION] secondary to COVID-19. An interview was conducted at 2:20 p.m. on 5/18/2020 with the Administrator (staff #18), the Director of Nursing (DON/staff #17), and the Infection Preventionist (staff #27). The DON stated that their policy is to notify the physician, the DON, the administrator and the family when a resident has signs and symptoms of COVID-19 and complete a change of condition. In an interview conducted with the Assistant Director of Nursing (ADON/staff #20) on 5/19/2020 at 12:45 p.m., the ADON stated that for residents displaying symptoms of COVID-19, the physician, DON and ADON are notified, isolation precautions are implemented, and a change of condition is completed. Staff #20 stated resident #3 had intermittent fevers from 5/1/2020 - 5/6/2020 and no action was taken for 5 days. The ADON stated the physician was not notified until 5/6/2020 and that the physician should have been notified sooner of the elevated temperatures. Staff #20 said she did not know why this resident was not moved to the COVID-19 unit. An interview was conducted with a Certified Nursing Assistant (CNA/staff #37) on 5/19/2020 at 9:56 a.m. The CNA stated that she is to notify the nurse immediately if a resident has a cough, a temperature over 100 degrees F, body aches, or loss of taste and or smell. Staff #37 stated that approximately 2 weeks ago resident #3 had an elevated temperature and that she immediately reported the elevated temperature to the Registered Nurse (RN/staff #28). The CNA stated the RN told her to remove some of the resident's clothing and that he would administer Tylenol. Staff #37 stated that she provided care for the resident several more shifts and that no precautions were implemented for the resident. A telephone interview was conducted with a CNA (staff #12) on 5/20/2020 at 1:12 p.m. The CNA stated that she did not recall any formal in-services regarding COVID-19. She said their policy states that if a resident has even one symptom related to COVID-19, it should be reported immediately to the nurse on duty. The CNA stated the expectation is that the nurse would assess the resident, quarantine the room, and precautions would be implemented for the resident and the roommate. The CNA stated that she took resident #3's temperature and that it was about 100 degrees F (she could not recall the date). She said the resident said her mouth was on fire and that she had lost her sense of taste and was weak. The CNA said she reported this information to the Registered Nurse (RN/staff # 32). She said staff #32 told her the resident was doing it to herself, remove some of the resident's clothing, and do not chart the first temperature reading. The CNA also stated staff #32 told her to recheck resident #3's temperature one hour after the resident was given Tylenol. She stated she was off for 2 days and that when she returned, she was told the resident had been taken to the hospital. During a telephone interview conducted with the RN (staff #28) on 5/20/2020 at 2:29 p.m., the RN stated the nurses are expected to conduct COVID-19 assessments on every resident on the night shift. Staff#28 stated that having a febrile resident or one with a cough is common, and giving them Tylenol or cough medicine is normally enough to resolve the symptom. The RN stated that he was unaware of what the policy was regarding signs or symptoms of COVID-19. Staff #32 was interviewed via telephone on 5/20/2020 at 3:33 pm and stated that she has attended 2 or 3 COVID-19 in-services at the facility. She said that residents' elevated temperatures are often due to bundling up and having the heat on in their room. Staff #32 stated that if a resident has an elevated temperature and it is not due to the resident bundling up, she would contact the provider. The RN stated that resident #3 had on several blankets and the heat was on in her room, so the provider was not contacted regarding the elevated temperature. The RN also stated that she was unsure if the first temperature was documented but the resident's temperature did decrease and that was documented. She said she could not recall if she gave the resident Tylenol. She stated resident #3 did have intermittent temperature spikes. Review of the facility's policy regarding Resident Quarantine/Novel [MEDICAL CONDITION]-19 dated March 12, 2020 revealed any resident who is ill, running a fever, or who has signs and symptoms of a respiratory illness, will be quarantined for 14 days. The policy also included it is the facility's policy to follow all recommendations provided by the CDC. The facility's policy COVID-19 Preparedness Planning: Identification, Management & Surveillance of Ill residents revised March 20, 2020 revealed residents will be monitored each shift for signs and symptoms of respiratory infections. Vital signs will be taken and documented every shift. All symptomatic residents will be isolated to their rooms. If possible, the exposed and symptomatic residents will be moved to the dedicated hall to further isolate and prevent the spread of COVID-19. Review of the CDC guidance Preparing for COVID-19 in Nursing Homes included monitoring all residents at least daily for fever (temperature greater than 100.0 degrees F) and symptoms consistent with COVID-19. If residents have fever or symptoms consistent with COVID-19, implement Transmission-Based Precautions. More than two temperatures greater than 99.0 degrees F in this population might be a sign of fever and should prompt isolation and further evaluation for COVID-19. Regarding multiple residents observed in the hallway. -On May 18, 2020 at 2:17 p.m., an observation was conducted on the north hallway of the facility. Four residents were observed sitting and/or talking to one another in the hall and three other residents were observed propelling themselves in wheelchairs along the hallway. Two were wearing facemasks, however the other five residents were not observed to be wearing them. The residents were within a two to four foot proximity from each other. At 3:00 p.m. on May 18, 2020, two residents were observed in the north hallway playing BINGO and were sitting approximately 2 feet apart from each other. Both of the residents were wearing a facemask. On May 18, 2020 at approximately 3:10 p.m., an interview was conducted with the Infection Preventionist (staff #27). She stated that most activities were being conducted in the residents' rooms, but that cards and BINGO games were taking place, with her expectation being that residents were kept at a 6 foot distance from each other. On May 18, 2020 at 3:15 p.m. a Certified Nursing Assistant (CNA/staff #33) was observed taking three residents' vitals on the north hallway. The three residents were sitting approximately 1-2 feet from each other and were not wearing face masks. The CNA stated that she did not know what the facility policies were for residents to be out of their rooms, regarding social distancing, or the wearing of masks. The policy titled Activities & Events stated the facility recognizes the threat posed by the Novel [MEDICAL CONDITION]-19. It is our policy to follow all recommendations provided by the Centers for Disease Control (CDC), Arizona Department of Health Services (AZDHS), and local health departments. To further protect our residents, the following procedures have been implemented to minimize the risk and spread of Covid-19 including social distancing must be practiced (6 feet or more between residents, staff, and individuals). Review of the CDC Key Strategies for Long-term Care Facilities included actions to take now to prevent the spread of COVID-19 including to enforce social distancing among residents, and to all residents wear a cloth face covering for source control whenever they leave their room or around others. The CDC Infection Prevention and Control (IPC) Guidance for Memory Care Units guidance includes to limit the number of residents or space residents at least 6 feet apart as much as feasible when in a common area, and gently redirect residents who are ambulatory and are in close proximity to other residents or personnel.

Based on clinical record reviews, interviews, and facility policy, the facility failed to conduct monthly Medication Regimen Reviews (MRRs) for three residents (#14, #25, and #39) and failed to respond to pharmacy recommendations for one resident (#39). The sample size was five residents. The deficient practice could result in medication irregularities that go unnoticed or are not acted upon. Findings include: -Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the monthly MRRs revealed no evidence that the reviews were completed for February 2019, March 2019, May 2019, August 2019, September 2019, and November 2019. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 15 on the Brief Interview for Mental Status (BI[CONDITION]) indicating that she was cognitively intact. -Resident #25 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE], included a BI[CONDITION] score of 14, indicating the resident was cognitively intact. Review of the clinical record revealed no evidence that monthly MMRs were completed for February 2019, March 2019, May 2019, August 2019, September 2019, and November 2019. In an interview with the Director of Nursing (DON/staff #66) on [DATE] at 11:25 a.m., she stated she has no documentation of the MRRs for the resident during the missing timeframes. -Resident #39 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed that the resident scored 11 on the BI[CONDITION]. This score indicated moderate cognitive impairment. Regarding monthly MRRs: Review of the clinical record indicated no evidence that the monthly MRRs were completed in June 2019 or August 2019. Regarding pharmacy recommendations: Review of the pharmacy recommendations included that the pharmacist had several recommendations for medication changes for the resident. This included the same recommendation in March 2019, April 2019, and May 2019 regarding the drug [MEDICATION NAME] (used to treat [MEDICAL CONDITION] issues). The recommendation included to monitor certain laboratory findings, such as Complete Blood Counts (CBC) and [MEDICAL CONDITION] hormones to determine if the medication was being effective. The recommendation included that no laboratory findings were noted in the clinical record. There was no evidence on the recommendation forms to show that they had been acted upon or that the physician had responded to the recommendation. The clinical record revealed no evidence that the physician had responded to the recommendations or that the recommended labs were being monitored or completed. On February 13, 2020 at 9:08 a.m., an interview was conducted with the Director of Nursing (DON/staff #66), who stated that she was unable to find the MRRs for the missing dates. She stated that the problem is that there is no process in place at this time. She said that the staff don't know that the pharmacist is supposed to complete the MMRs on a monthly basis and no one has ensured they were completed, kept, or that the physician was contacted about recommendations if needed. Review of the policy, Pharmacy Consultant Expectations, revealed that the pharmacy consultant will conduct a monthly MRR and document and report the results of the review.

Based on interviews, an observation, and facility policy, the facility failed to ensure several residents received necessary care and services to attain their highest practicable wellbeing by not answering call lights timely. The facility census was 45 residents. The deficient practice could result in resident safety concerns and residents not being able to attain or maintain their highest practicable physical, mental and psychosocial well-being. Findings include: Multiple resident interviews and an observation were conducted on 2/10/20 regarding facility staffing. These included the following: -At 11:20 a.m., a resident stated that it takes a long time to get assistance from staff. The resident said that it could take up to 30 minutes at times. -At 2:09 p.m., a resident stated that the wait to get assistance can be up to 45 minutes. She said that this just happened last Saturday (2/8/20) -At 2:26 p.m., a resident stated that she needs help going to the bathroom. At the time of the interview, observation of the resident revealed that she was grimacing and she said she did not know if she could wait. The resident's call light was in her hand and the call light had been activated. After about five minutes of waiting, a Certified Nursing Assistant (CNA) came in and turned off the call light. The CNA told the resident she could not take her to the toilet until she found another person because the resident required a mechanical lift for transfers. She stated that she had come to take the resident for a shower. The CNA left the room to get a second CNA to assist her. The resident stated that she had already been waiting for at least an hour. She stated that this is not the first time that this happened. During a meeting with resident council members (there were 7 residents in attendance) on 2/10/20 at 3:11 p.m., the residents complained that call light response times were delayed. One resident waited over 2 hours to get a response from staff. In an interview with a resident on 2/12/20 at 12:42 p.m., he said that the call light response time was very lengthy the night prior. He said he waited almost 2 hours and had pressed the call light several times. He expressed concerns that if there was an emergency, there could have been a detrimental outcome. During an interview with a resident on [DATE] at 2:00 p.m., he stated that he had to wait between half and hour to an hour to be changed. He said that sometimes the CNAs will turn off the light and say that they will be back, but then it can take another half and hour before they return. He stated this is usually an issue between 5:00 and 7:00 p.m. An interview was conducted with a CNA on [DATE] at 2:08 p.m. She stated she answers lights timely for residents but that there are times when she turns off the call light and goes back to the resident later. She said this occurs when the resident refuses care, but she does not document this. Review of the facility's staffing policy revealed that the facility is to provide sufficient numbers of staff with the skill and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. The policy included that concerns relative to the facility's staffing should be directed at the administrator or his designee.