Every finding on record at Coosa Valley Health and Rehab

Based on interviews, record reviews and a review of facility policies titled, Abuse, Neglect and Exploitation, Controlled Substances, Inventory Control of Controlled Substances and Online Incident Report, the facility failed to ensure licensed staff members were following the facility policy on conducting counts with the exchanging of the cart keys, which resulted in missing medications for Resident Identifier (RI) #4. This deficient practice affected RI #4, one of one resident's who were investigated for missing narcotic medication. Findings Include: A review of a facility policy titled, Abuse, Neglect and Exploitation, with a date of 12/19/2022, revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions . Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. A review of a facility policy titled, Controlled Substances with a revised date of December 2012 revealed: Policy Statement 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. Policy Interpretation and Implementation . 9. 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. A review of a facility policy titled, Inventory Control of Controlled Substances with a revised date of 01/01/2013 revealed: . Procedure: . 1.2 Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift . A review of a pharmacy delivery sheet revealed, (RI #4's name) . 5/17/22 . Quantity Description . 90 EA (each) Lorazepam 1 MG (Milligram) tablet . received by Employee Identifier (EI) #7 dated 5/17/22 at 10:50 PM. A review of RI #4's Physician Orders revealed, . 5/17/22 Lorazepam 1 MG. One tablet TID (three times a day) . for nerves . A review of a copy of a medication card for RI #4 revealed, Lorazepam 1 mg tablet . 5/17/22 .1 of 3 . RI #4 was admitted to the facility on [DATE] with a diagnosis of Unspecified Dementia with behavioral disturbance. A review of an online Incident Report revealed: . On June 6, 2022, at 3:30 p.m., EI #6, (Registered Nurse) RN and EI #5, (Licensed Practical Nurse), LPN were counting the 100 hall medication cart. While counting the cart EI #6 realized there were two cards of Lorazepam 1 mg that belonged to RI #4 that did not have a sheet. Furthermore, the two cards were labeled 2 and 3 but there was not another one which should have been labeled 1. This meant that there was a card containing 30 pills of Lorazepam that was missing. On June 7, 2022, EI #3, RN was interviewed. On June 6, 2022, EI #3 said that she did not count her cart that morning. On June 9, 2022, EI #4, LPN was interviewed. She said she came in at 6:45 a.m. (June 6th). She said she counted the 100 hall cart with EI #8, LPN. She said the count was correct. EI #4 said she locked the cart and put the keys in her left pocket. She said she went straight to the 400 hall to help start feeding. EI #4 said she never opened the 100 hall cart back up. She went on to say . EI #3 came to the room. EI #4 said at that time, she handed EI #3 her cart keys. She said she did not count the cart with EI #3. On July 14, 2022 EI #7 was interviewed. She said that she received the 90 pills of Lorazepam 1mg pills for RI #4 on May 17, 2022 at 10:50 pm from Omnicare Pharmacy. She said that she counted all three blister packs and noted that 90 pills were there. EI #7 said that she recorded in the narcotic book and that she added all three cards and record of controlled substance paper to 100 hall narcotic box and placed the sign off sheet in the narcotic book. On 01/04/2023 at 11:25 AM, an interview was conducted with EI #3. EI #3 was asked what was the practice at shift change. She said count the cards and each medication verifying the number on the control sheet. It was to be done at the beginning of the shift, at the end and if they hand off the keys to someone. EI #3 was asked who counted the narcotics with shift change. She said the oncoming nurse and the off going nurse. When asked what could she tell about RI #4's Lorazepam; she said she came in late, she had asked another nurse to hold the keys until she got there. When asked who was holding the keys she said EI #4, and she did not count the cart when she got there and she should have. EI #3 was asked why did she not count when she took the keys. She said she was not sure why, she was late and it was unfortunate on her part. EI #3 was asked when was the narcotic count done. She said it was not done by her and EI #4. EI #3 was asked what form of abuse would missing Lorazepam be. She said misappropriation. On 01/04/2023 at 2:30 PM, an interview was conducted with EI #4, LPN. She was asked who she counted with on 06/06/2022; she said EI #8. EI #4 was asked who was supposed to get the keys. She said EI #3, she was late. EI #4 was asked what should have been done when she gave the keys to EI #3. She said they should have counted the cart, but they did not. EI #4 was asked why the count was not verified when she gave the keys to EI #3. She said EI #3 came to the resident's room she was in and got the keys. EI #4 was asked how the empty Lorazepam card was found. She said it was in the shred box with no pills in it and she was not sure when it was found. EI #4 was asked what it was when resident medication was missing. She said misappropriation of property, EI #4 was asked when should nurses count controlled medications. She said the beginning and end of shift and anytime they switch keys. EI #4 was asked what was done before a nurse accepted cart keys. She said the oncoming and off going nurses count together. EI #4 was asked what the procedure facility nurses use to ensure narcotic medications were accounted for. She said oncoming and off going nurses count together and then sign the shift change sheet. EI #4 was asked what should have been done when EI #3 came in. She said they should have counted the narcotic box together then she should have given the keys to EI #3, but that was not done. EI #4 was asked what was the harm of the nurses not counting. She said diversion or misappropriation of resident's medication. On 01/05/2023 at 9:15 AM, an interview was conducted with EI #2, the Director of Nursing. EI #2 was asked how often RI #4 was out of the Lorazepam an. She said it was three times a day and RI #4 was never out of the medication as there were three cards and card one was missing. EI #2 was asked how many Lorazepam were delivered to the facility and when. She said they were delivered on 05/17/2022 according to the delivery sheet 90 pills also 3 cards and EI #7 signed for them. EI #2 was asked how did she determine how many Lorazepam were missing. She said she did not, other than the card said 30, therefore, the facility replaced that many. EI #2 was asked what was the policy for nurses at shift change regarding the narcotic keys. She said both nurses, oncoming and off going, count and sign the log before exchanging keys. She was asked if EI #3 and EI #4 did that; she said no. EI #2 was asked how the policy was followed if EI #3 did not count when she got the keys from EI #4. She said it was not. EI #2 was asked what it was when a resident's medication was diverted. She said misappropriation of property. EI #2 was asked what should have been done to prevent the misappropriation of RI #4's Lorazepam. She said both EI #3 and EI #4 should have counted. EI #2 was asked what would the harm be in nurses not counting the controlled medication when handing off the keys. She said a risk for misappropriation. EI #2 was asked to review the pharmacy delivery sheet then asked how many Lorazepam were delivered. She said 90 pills, three cards and two cards were in the cart. EI #2 was asked where was card one of the Lorazepam found. She said in the shred box no pills in it had 30 on the card. On 01/05/2023 at 9:50 AM an interview was conducted with EI #1, the Administrator. He was asked what should occur at shift change related to controlled medications. He said oncoming and off going nurses should count controlled medications after the count, the oncoming nurse accepts the keys if the count was correct. EI #1 was asked according to the investigation, did the nurses count before exchanging the keys. He said no, EI #4 was providing care when EI #3 went to that room and got the keys. EI #1 was asked what was it when a resident's medication was diverted. He said misappropriation of property. EI #1 was asked what led staff to look in the shred box during the investigation. He said they looked everywhere, that box was emptied at 9:45 AM so it had to have been placed in it after then.

Based on observations, record review, interviews, and review of a facility policy titled Perineal Care, the facility failed to provide incontinence care to RI (Resident Identifier) #43 in a timely manner. This deficient practice had the potential to affect RI #43, one of one resident sampled for incontinence care. Findings included: A review of the facility's policy titled Perineal Care, last revised in February of 2018, indicated Purpose The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. RI #43 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a quarterly Minimum Data Set (MDS), dated [DATE], indicated RI #43 had severely impaired cognitive function. Per the MDS, the resident required extensive assistance of one person for dressing and toileting, Further review of the MDS indicated RI #43 was always incontinent of bowel and bladder. A review of RI #43's Care Plan, reviewed 03/30/2022, revealed the facility developed a care plan related to RI #43's bowel and bladder incontinence. Care plan interventions included providing incontinence care as needed and providing incontinence briefs as appropriate. Continuous observations of RI #43 on 04/27/2022 from 9:16 AM until 2:03 PM revealed staff did not provide incontinence care for approximately five hours, from 9:16 AM until 2:03 PM. The observations were as follows: Observation at 9:16 AM revealed RI #43 was sitting cross-legged in bed with his/her back against the bed rail. RI #43 was wearing only an adult incontinence brief. At 9:48 AM, Employee Identifier (EI) #5, Certified Nurse Aide (CNA), walked by the resident's room and called out the resident's name, but continued walking down the hallway. Continued observation at 10:05 AM revealed EI #13, Licensed Practical Nurse (LPN) walked into RI #43's room, asked the resident if he/she wanted the radio on, turned on the radio, then walked out of the room. At 11:25 AM, observation revealed EI #5 entered RI #43's room with a lunch tray, turned the radio down, set down the tray, assisted the resident into a chair, and walked out of the room. The resident then started eating. At 11:33 AM, RI #43 got out of the chair and returned to the bed. Observation at 12:02 PM, revealed EI #5 entered the room, picked up the lunch tray, and walked out after documenting the percentage of the meal eaten on a clipboard. Observation at 2:03 PM revealed EI #14, CNA, entered RI #43's room to provide incontinence care for the resident. RI #43 would not allow incontinence care to be provided with the surveyor in the room. At 2:05 PM, EI #14 came out of RI #43's room carrying a bag of trash. RI #43 was sitting cross-legged in the middle of the bed and leaning over, with his/her head on the bed and covered with a sheet. During an interview on 04/27/2022 at 2:05 PM, EI #14 stated RI #43 was totally dependent on staff for personal hygiene. An interview on 04/28/2022 at 2:39 PM with EI #9, Restorative Aide (RA), indicated that, except for transfers, RI #43 required total care with ADLs. EI #9 stated RI #43 should be checked for incontinence every two hours. During an interview on 04/29/2022 at 10:35 AM, EI #13, Licensed Practical Nurse (LPN), indicated RI #43 was not able to use the bathroom and should be checked every two hours for incontinence and changed if needed.

Based on observations, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #31, had documented medical justification for the use of an indwelling urinary catheter. This deficient practice affected RI #31; one of seven residents reviewed for catheter use. Findings included: A review of RI #31's Face Sheet revealed no diagnoses related to the use of an indwelling urinary catheter. A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order lacked information regarding the catheter size to be used or any diagnoses related to the use of the catheter. Review of RI #31's record revealed no documented valid medical justification for the indwelling urinary catheter placement and no indications for its continued use. On 04/26/2022 at 12:44 PM, a urinary drainage collection bag containing urine that was orange in color was observed to be hanging on the side of RI #31's bed. The tubing contained a great deal of sediment. On 04/27/2022 at 12:19 PM, the urinary drainage collection bag containing dark orange-yellow urine was observed hanging on the side of RI #31's bed. The associated tubing contained sediment. The size of the urinary catheter was illegible. During an interview on 04/29/2022 at 9:30 AM, Employee Identifier (EI) #2, Director of Nursing, stated orders for an indwelling urinary catheter should include the size of the catheter and the reason for the catheter. EI #2 stated the physician should provide a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 04/29/2022 at 10:35 AM, EI #13, Licensed Practical Nurse, stated a resident with a catheter should have orders that included a related diagnosis, the size of the catheter/bulb to be used, and how often to change the catheter.

Based on interview, medical record review, and review of a facility policy titled, Change in a Resident's Condition or Status, the facility failed to ensure Resident Identifier (RI) #1's resident representative was notified of a change in condition requiring a new treatment order on 12/14/2020. This deficient practice affected RI #1, one of five sampled residents reviewed for notifications. Findings include: Review of the facility policy titled, Change in a Resident's Condition or Status, revised May 2017, revealed the following: .4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: .b. There is a significant change in the resident's physical, mental, or psychosocial status . 6. Regardless of the resident's current mental or physical condition, a nurse or health care provider will inform the resident of any changes in his/her medical care or nursing treatments . RI #1 was admitted to the facility on [DATE]. Review of RI #1's Departmental Notes revealed the following note made on 12/8/2020 by Employee Identifier (EI) #1, Licensed Practical Nurse (LPN): .SKIN WARM AND DRY. THREE PINPOINT OPEN AREAS NOTED TO BUTTOCK. TOP LAYER OF SKIN ONLY MISSING. ZINC APPLIED . SPONSOR AWARE OF AREAS. NO OTHER OPEN AREAS NOTED . Further review of RI #1's Departmental Notes revealed the following note made on 12/14/2020 by EI #2, LPN: .Excoriated areas noted to bilateral buttocks with small pea sized blister not (noted) to upper right buttocks. Applied [MEDICATION NAME] to all excoriated areas and covered. Dressing to be changed and [MEDICATION NAME] reapplied daily . Review of RI #1's December 2020 Physician Orders revealed a new order dated 12/14/2020 to Clean and pat dry excoriated areas to bilateral buttocks. Apply [MEDICATION NAME] with q-tip and cover with adhesive dressing daily until recovered. On 2/12/2021 at 2:13 p.m., EI #2, LPN, was asked about the note she made on 12/14/2020 regarding RI #1's wounds and an order for [REDACTED].#2 was asked why she should have notified RI #1's responsible party. EI #2 said it was standard protocol, but she made a mistake and failed to do it. RI #1's responsible party was interviewed on 2/16/2021 at 12:40 p.m When asked if she could recall when she was first informed of the areas to RI #1's buttocks, the responsible party said she called the facility each Monday to get an update. On 12/7/2020 it was reported to the sponsor that RI #1's skin was good. According to RI #1's responsible party, she called the facility again on 12/14/2020 to inquire about the resident's skin and was told there were a few pinpoint areas; however, RI #1's responsible party said she was not informed of the new orders for [MEDICATION NAME] at that time. This deficiency was cited as a result of complaint/report number AL 144.

Based on observations, record review, the facility policy entitled, Blood Sampling - Capillary (Finger Sticks), and staff interviews, the facility failed to follow the manufacturer's instructions for cleaning blood glucose monitoring devices (glucometer). Specifically, five (5) of five (5) facility staff cleaned resident shared glucometers with a hand-sanitizer antiseptic solution which had the potential to affect 40 of 99 residents. This practice increased the risk of transmission of bloodborne illness to residents. The failures occurred during a COVID-19 pandemic. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The Immediate Jeopardy was related to 483.80 Infection Control for failure to follow the manufacturer's instructions for cleaning shared resident glucometers. The Director of Nursing was made aware, via phone, that Immediate Jeopardy existed on July 22, 2020 at 5:00 p.m. Immediate Jeopardy was removed on July 23, 2020 at 11:00 a.m., after an acceptable removal action plan was received, and surveyor validation that included further glucometer cleaning observations, staff interviews, policy review, and review of training's to verify the immediate corrective action had been implemented. The facility remained out of compliance at a lower scope and severity of E, (no actual harm with the potential for more than minimum harm that is not Immediate Jeopardy) for deficiencies at F880. In addition, the facility failed to screen one (1) of (1) visitor allowed entry into the facility, and failed to ensure that three (3) of three (3) nursing staff were not expected to perform environmental cleaning services. These findings did not rise to Immediate Jeopardy level. The findings include: 1. During a concurrent observation and interview on 07/21/2020 at 6:20 p.m., Licensed Practical Nurse (LPN) #1 demonstrated she used 80% hand-sanitizer antiseptic solution to clean the glucometer. LPN #1 confirmed the glucometer was shared by residents, and this had been her practice at least one week. LPN #1 revealed, that one week prior to using the hand-sanitizer, she used a germicidal Sani-cloth to clean the glucometers. LPN #1 stated usually there were two (2) glucometers on the 400 hall medication cart; however, she only had one (1) when observed. 2. During a concurrent observation and interview on 07/22/2020 at 3:52 p.m., LPN #2 confirmed there were two (2) glucometers on the 100 hall medication cart, that were shared by residents. She said that she used the glucometers on any resident that showed signs and symptoms of [DIAGNOSES REDACTED] (blood sugar or glucose lower than normal). LPN #2 demonstrated she used 80% hand-sanitizer antiseptic solution to clean the glucometers. She stated that she had cleaned the glucometers with hand-sanitizer one week and a half. 3. During a concurrent observation and interview on 07/22/2020 at 4:04 p.m., LPN #3 confirmed there was one (1) glucometer on the 200 medication cart, that was shared by residents. She demonstrated that she had cleaned the glucometer at least one week and a half, with 80% hand-sanitizer antiseptic solution. 4. During a concurrent observation and interview on 07/22/2020 at 4:05 p.m., LPN #4 confirmed two (2) glucometers on the 300 hall medication cart, that were shared by residents. He demonstrated that he had cleaned the glucometers, for a couple of weeks, with 80% hand-sanitizer antiseptic solution. 5. During an interview on 07/22/2020 at 4:09 p.m., LPN #5 stated she was the Minimum Data Set Coordinator. LPN #5 stated, she would use 80% hand-sanitizer antiseptic solution to clean the glucometers, that were shared by residents. She confirmed the hand-sanitizer solution was located on the medication cart. Review of the directions on the 80% hand-sanitizer antiseptic solution bottle, used by the LPNs as aforementioned to clean glucometers read, .Place enough product on hands to cover all surfaces. Rub hands together until dry . Further review of the labeling did not reveal, the product was an EPA-registered disinfectant product against bloodborne pathogens. The glucometer device observed used by the aforementioned LPNs was the EVENCARE ProView (blood glucose monitoring system). During a phone interview on 07/22/2020 at 4:23 p.m., the Director of Nursing (DON) stated, she was unaware that nursing staff were using 80% hand-sanitizer antiseptic solution, to clean glucometers shared by residents. The DON indicated, she was aware that the nurses were provided a disinfectant for use, but had not self-identified it was hand-sanitizer. The DON said she expected the nurses to have notified her, if they no longer had germicidal wipes Sani-cloth. The DON directed Registered Nurse (RN) #6 to get a container of Sani-cloth wipes from her office, and ensure nurses cleaned the glucometers, with an EPA-registered disinfectant product. RN #6 retrieved the Sani-cloth container as instructed, and updated the nurses on the proper agent to use to clean the glucometers. On 07/23/2020 at 9:50 a.m., the DON shared that each medication cart now had an approved EPA-registered disinfectant container of Sani-cloth. The DON further stated the hand-sanitizer antiseptic solution, was to be used on hands, and non-invasive procedure; but not for cleaning the glucometers. The DON confirmed that a blood glucose monitoring test, could be completed on any resident that exhibited signs and symptoms of [DIAGNOSES REDACTED], [MEDICAL CONDITION] (elevated levels of sugar or glucose in the blood), or any resident with a change in condition. Review of the diabetic resident list provided by the facility revealed, there were 40 diabetic residents in the facility. The list confirmed there was a diabetic resident on each hall. Further review of the list revealed, there were two (2) residents with a bloodborne pathogen, [MEDICAL CONDITION] (virus spread by contact with contaminated blood). Review of the facility undated policy, revealed, .Always ensure blood glucose meters intended for reuse are cleaned and disinfected with Sani-Cloth, placing on paper towel, allowing 5 minutes of air dried time before use between residents . Review of the manufacturer's instructions for the glucometer device, provided by the facility, revealed, .The meter must be disinfected between patient uses by wiping it with a CaviWipe towelette or EPA-registered disinfecting wipe in between tests and be cleaned prior to disinfecting. The Disinfection process reduces the risk of transmitting infectious diseases if it is performed properly . The facility provided an acceptable removal action plan on July 22, 2020, that read: Facility failed to ensure proper cleaning and disinfecting of glucometers. Facility was using hand sanitizer of 80% alcohol base (Ginesis Alcohol Antiseptic Topical Solution) instead of the approved cleansing agent Sani-Cloth to kill bloodborne pathogens. - RN Supervisor removed the product from the nurse's medication carts and educated all nurses in the facility on July 22, 2020 on only using the approved cleansing agent of Sani-Cloths to clean and disinfect the glucometers. All 40 diabetic residents were assessed by RN Supervisor along with that resident's charge nurse and no harm was noted. Residents will continue to be monitored by the charge nurse for any signs and symptoms of infection. - Director of Nursing instructed RN Supervisor via telephone to divide up a container of the approved cleansing agent Sani-Cloths between the nurses to use for cleansing glucometers. At this time, RN Supervisor witnessed charge nurses on each medication cart clean and disinfect their glucometers with the Sani-Clothes before any further use. - All nurses educated verbally via telephone by the Director of Nursing on July 22, 2020 and by RN Supervisor upon entering the facility before providing care to any resident, on using only the approved cleansing agent, Sani-Cloths for cleaning and disinfecting glucometers and the importance to do so as to kill bloodborne pathogens and prevent the spread of infection to other residents. - Completion date for the immediate removal plan July 22, 2020 at 7:30 PM. This deficiency will be followed in QAPI to ensure deficient practice does not occur again. Education and QAPI meeting documentation will be kept in a binder in the NHA office. Additional findings that did not rise to the level of Immediate Jeopardy include: 1. On 07/21/2020 at 4:15 p.m., LPN #1 allowed visitor entry into the building without completing a screening. LPN #1 acknowledged, awareness of the current COVID-19 pandemic, and further verified the screening station setup, located in the main lobby, upon entry. 2. On 07/22/2020 at 3:35 p.m., the Maintenance Director (MD) allowed visitor entry into the building without completing a screening. The MD acknowledged, that he was aware of the current COVID-19 pandemic, and should have completed the screening, prior to the visitor passing the screening station, located in the main lobby. During an interview on 07/22/2020 at 4:23 p.m., the Director of Nursing stated, she expected the required COVID-19 screening, to be completed immediately, upon entry into the main lobby. Review of the facility protocol entitled, COVID-19: Screening Checklist - for Visitors and Staff, revealed, several screening questions were to be completed by the screener. The form also was to be signed and dated by the visitor or staff, as part of the screening process. 3. On 07/21/2020 at 4:30 p.m., the Housekeeping Director (HD) acknowledged, that he was aware of the current COVID-19 pandemic. The HD stated that licensed nurses and Certified Nursing Assistants (CNAs) were responsible for cleaning and disinfecting residents' rooms, on second and third shift, if a situation required. He stated that staff could call him; however, the said staff were expected to complete the task, including sanitation, and deep cleaning. The HD indicated to date, he had not provided environmental cleaning training, to the licensed nurses and CNAs, but assumed the staff knew how to perform the tasks. On 07/21/2020 at 5:30 p.m., accompanied by the HD, RN #6 confirmed, she did not know what solutions to use if a resident's room required sanitation, disinfecting or deep cleaning. At 5:46 p.m., CNA #1 confirmed, she did not know what solutions to use if a resident's room required sanitation, disinfecting or deep cleaning. At 5:48 p.m., CNA #2 confirmed, she did not know what solutions to use if a resident's room required sanitation, disinfecting or deep cleaning. During an interview on 07/23/2020 at 9:50 a.m., the DON stated, environmental staff was expected to stagger their work schedule, to allow environmental staff presence in the facility, if a resident's room, required the aforementioned cleaning services. The DON stated nursing staff were not expected to performed the aforementioned cleaning services, nor were environmental cleaning services to be delegated to the nursing staff. She stated that nursing staff are only required to put a Do Not Enter sign on the door, if a resident exhibited signs and symptoms of COVID-19, or exposed, and had to be sent to the hospital.

Based on record review, staff interview, and the facility's policy entitled, Quality Assurance and Performance Improvement (QAPI), the QAPI committee failed to maintain an effective infection control surveillance plan which sustained regulatory compliance, related to infection control practices for two (2) of two (2) past surveys conducted at the facility. The findings include: 1. Cross reference F880. The facility failed to follow the manufacturer's instructions for cleaning blood glucose monitoring devices (glucometer). Review of the facility survey history revealed, the facility was cited for similar issues of cleanliness of resident equipment for the past two (2) survey cycles: 2. On 06/13/2019, during a recertification survey, for failure to place inhaler mouthpieces on a clean surface, prior to storing in the medication cart, and staff wore the same gloves while administering crushed medications and eye drops. 3. On 07/26/2018, during a recertification survey, related to nebulizer treatment administration. Revisit surveys were conducted for each of the aforementioned deficiencies with compliance confirmed. However, the facility remain unable to maintain substantial compliance with infection control issues related to cleaning resident care equipment. During an interview on 07/22/2020 at 4:23 p.m., the Director of Nursing (DON) stated, she was unaware that licensed nurses were using hand-sanitizer antiseptic solution, to clean shared resident glucometers. The DON indicated, she was aware that the nurses were provided a disinfectant for use, but had not self-identified it was hand-sanitizer. On 07/23/2020, at 9:50 a.m., the DON stated, that she was unaware that environmental staff, expected nursing staff, to perform environmental cleaning. The DON acknowledged, an understanding of the facility's responsibility to self-identify concerns, and implement the facility quality assurance program. The DON did not comment on the facility's inability to remain in compliance with infection control, nor did she explain how the QAPI program was utilized to ensure infection control practices were monitored on an ongoing basis to ensure regulatory complaince. Review of the facility's policy, revised on 11/28/17, revealed, .It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data¿driven QAPI program that focuses on indicators of the outcomes of care and quality of life .b. Meet monthly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary .

Based on observation, interview and review of the Food Code United States Public Health Service facility failed to ensure: 1) ice cream cups in the walk-in freezer were frozen solid, 2) opened items in the walk-in freezer were properly resealed, 3) walk-in freezer was maintained at a temperature to ensure food items were frozen solid, and 4) a dietary aide did not continue to serve trays after dropping the handle of the thermometer into the gravy. This deficient practice had the potential to affect 86 residents receiving meals from the kitchen. Findings Include: The Food Code U.S. Public Health Service (YEAR) indicates the following: . Temperature and Time Control 3-501.11 Frozen Food. Stored froze Foods shall be maintained frozen. . 3-202.15 Package Integrity. Food packages shall . protect the integrity of the contents so that the food is not exposed to ADULTERATION or potential contaminates. . Temperature and Time Control 3-501.11 Frozen Food. Stored froze Foods shall be maintained frozen. . 3-302.11 . (A) Food shall be protected from cross contamination . On 06/11/2019 at 11:08 AM, an observation of the walk-in freezer revealed the temperature at 11 degrees Fahrenheit. Seventeen strawberry ice cream cups were noted to not be frozen solid. A box with cinnamon rolls and a box with biscuits were opened and not resealed, with no open or use by dates noted. Employee Identifier (EI) #2, Dietary Manager, was asked if the ice cream cups were frozen solid. EI #2 replied, no they were not solid. On 06/12/19 at 11:28 AM, during lunch tray line observation, Employee Identifier (EI #1), dietary aide, dropped a thermometer into the brown gravy, then continued to plate a regular tray, adding the brown gravy to the beef patty. The plate was placed on the tray covered with a dome lid and placed into the cart for delivery. EI #1 then proceeded to plate another meal. On 06/13/19 at 9:38 AM, an interview was conducted with EI #1, dietary aide. EI #1 was asked what occurred during the lunch tray line service on 06/12/19. EI #1 said she dropped the thermometer in the brown gravy and the handle fell into the gravy. EI #1 was asked what was the concern with the handle of the thermometer not being clean and falling completely in the pan of food. EI #1 replied the handle was not clean by then causing cross contamination. EI #1 was asked what did she do after the thermometer fell in the gravy. EI #1 stated she kept serving. EI #1 was asked what should she have done. EI #1 said she should have pulled the gravy immediately. EI #1 was asked what was the concern with serving a resident food that was potentially contaminated. EI #1 answered it could make them sick. On 06/13/19 at 9:43 AM, an interview was conducted with EI #2, Dietary Manager. EI #2 was asked what happened during the lunch tray line on 06/12/19. EI #2 stated EI #1 dropped the thermometer in the gravy. EI #2 was asked what was the concern with the handle of the thermometer falling completely into a food item. EI #2 replied the germs that would be on the handle would cause cross contamination. EI #2 was asked did EI #1 continue to plate the contaminated gravy. EI #1 replied yes. EI #2 was asked what should EI #1 have done. EI #2 answered as soon as the thermometer fell she should have stopped and removed the gravy and made more gravy. EI #2 was asked what was the concern with serving a resident a food item that was potentially contaminated. EI #2 said could cause illness. EI #2 was asked what was the concern with the two boxes being opened in the walk-in freezer. EI #2 replied freezer burn that would diminish the product affecting the quality of the food. EI #2 was asked what should have been done. EI #2 stated they should have been tied properly, sealed and the tops closed. EI #2 was asked what was the concern with the 17 cups of strawberry ice cream. EI #2 said they were soft. EI #2 was asked should they have been. EI #2 replied per policy they should have been frozen solid.

Based on observations, interviews and review of a facility policy titled, Resident Rights and a facility document titled, Maintenance Supervisor Job Description, the facility failed to ensure Room Locators (RL)'s #1-63 were free of chipped paint on walls and doors, missing tiles on floors, missing curtains on closets, equipment in disrepair and worn furniture. This was observed three of three days of the survey and affected 63 of 66 rooms on four of four halls of the facility. Findings Include: A review of a facility policy titled, Resident Rights, no date, page 5, revealed: . 9. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, . A review of a facility document titled, Maintenance Supervisor Job Description, no date, revealed: . Ensure the building(s), equipment and utilities are maintained in good working order . are properly maintained in accordance with Company and facility policies and State and Federal Regulations . Essential Job Functions * Perform minor repairs and supervise the day-to-day repair, improvement and preventive maintenance of the building, equipment . and supervise floor care. During the initial tour of the facility on 06/11/2018 the following observations were made: RL #1 - bedside table chipped, A bed head board loose RI #2 - torn armrest on wheelchair, chipped paint closet RL #3 - crack between air conditioner and wall RL #4 - chipped paint bathroom door, geri chair needs torn RL #5 - A bed head and foot board loose and torn, torn blinds, arms worn on green chair, left closet chipped paint RL #6 - chipped paint bathroom door, chipped paint closet on right side RL #7 - A bed head and foot board loose and chipped, B bed bedside table and overbed table chipped, chipped paint bathroom door RL #8 - chipped paint left closet RL #9 - chipped paint closet on left, chipped paint wall behind recliner RL #10 - A bed head board chipped, foot board chipped RL #11 - back of geri chair torn, B bed overbed table torn, chipped paint closet on right RL #12 - chipped paint left closet RL #13 - A bed foot board loose and chipped, chipped paint on wall RL #14 - missing curtain on right closet, chipped paint bathroom door RL #15 - chipped paint bathroom door RL #16 - foot board loose and chipped RL #17 - chipped paint closet and wall behind A bed RL #18 - bedside table chipped, bathroom door sticking, bed on blocks RL #19 - chipped paint wall behind A bed RL #20 - head and foot board loose and chipped, bedside table chipped RL #21 - chipped paint closet on left, floors dirty under bed and TV RL #22 - bedside table chipped, wheelchair armrests worn and torn, arms are worn on chair in room RL #23 - A bed overbed and bedside table chipped, missing curtain on left closet RL #24- closets chipped paint, bed wheels on blocks RL #25 - A bed overbed table chipped, chipped paint closet, cracked air conditioner cover RL #26 - both beds bedside tables chipped, chipped paint on closet RL #27 - B bed overbed table chipped, chipped paint both closets RL #28 - A bed wheelchair in disrepair, chipped paint wall beside bed, chipped paint closet, bed on blocks RL #29 - A bed bedside table chipped, B bed bedside table chipped, chipped paint on closet RL #30 - A bed bedside table chipped RL #31 - chipped paint closet on right side RL #32 - A bed wheelchair armrests worn and torn, B bed overbed table chipped RL #33 - A bed bedside table chipped, B bed overbed table chipped, closet loose board RL #34 - A bed overbed table chipped, armrests on green chair are worn, bathroom door chipped paint RL #35 - bedside table chipped, gap between air conditioner and wall, cracked plastic cover behind bed RL #36 - cracked air conditioner cover, loose cable cover, overbed table with worn edges RL #37 - floor tiles cracked and discolored RL #38 - cracked air conditioner cover RL #39 - chipped paint closets, B bed wheelchair armrests worn and torn RL #40 - cracked air conditioner cover RL #41 - A bed chipped and loose foot board RL #42 - A bed chipped overbed and bedside table, chipped paint wall by B bed RL #43 - missing tile going into bathroom, chipped paint edge of B bed closet, chipped paint door going into room RL #44 - chipped paint door going into room, discolored tile by B bed, chipped paint on wall RL #45 - arms worn on chair in room, closet missing curtain RL #46 - room door chipped, top of closet on left side loose board RL #47 - B bed closet chipped paint, bedside table chipped RL #48 - tan chair has worn arms, overbed table is chipped RL #49 - A bed head board loose and chipped, B bed's overbed table chipped RL #50 - overbed table chipped, closet chipped paint, closet needs curtain RL #51 - bedside table chipped RL #52 - bed needs cleaning, bed wheels in wooden blocks, closet curtain missing RL #53 - A bed bedside table chipped, both closets with chipped paint RL #54 - bed needs foot board loose, closet paint chipped and loose board RL #55 - A bed overbed table and nightstand chipped RL #56 - closets chipped paint, B bed wheelchair armrests worn and torn, armrests on green chair in room are worn RL #57 - both beds overbed tables chipped RL #58 - bathroom trim chipped paint RL #59 - door paint chipped, end of closet chipped paint, A bed overbed table chipped RL #60 - A bed bedside table chipped, air conditioner cover needs replaced RL #61 - closets chipped paint, A bed head and foot board loose and chipped and overbed table chipped RL #62 - closets have chipped paint, A bed needs new head and foot board, B overbed table chipped RL #63 - cable cover is broken, chipped paint on closet, sink in bathroom is leaking, overbed tables chipped. On 06/12/19 02:13 p.m. a facility environment tour with Employee Identifier (EI) #5, Administrator, was made regarding concerns identified by surveyors regarding homelike environment with above concerns acknowledged and agreed upon by EI #5 during the tour. On 06/13/19 at 4:15 p.m., an interview was conducted with EI #5, Administrator. EI #5 was asked what was important in regard to the residents' environment. EI #5 said that it should be homelike, kept clean and in good repair. EI #5 was asked what concerns were identified during the tour of the facility. EI #5 replied, some of the furnishings were in disrepair, closets and walls that needed painting and equipment that was not working or in disrepair, such as overbed tables. EI #5 was asked what was the concern with residents not having equipment in good repair and the environment not being homelike. EI #5 answered, they will not be happy and feel like they are at home.

Based on interview, medical record review and review of Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, the facility failed to ensure Resident Identifier (RI) #65's Minimum Data Set (MDS) assessments did not have [MEDICATION NAME], an anticonvulsant medication, coded as an antipsychotic, which resulted in the assessments being inaccurate for use of antipsychotic medication. This deficient practice affected RI #65, one of 24 sampled residents whose MDS assessments were reviewed. Findings Include: A review of CMS's RAI Version 3.0 Manual, Chapter 3: MDS Items (N), Page N-6, documented: . Coding Tips and Special Populations * Code medications in Item N0410 according to the medication's therapeutic category and/or pharmacological classification, not how it is used. Resident #65 was admitted to the facility on [DATE]. RI #65 [DIAGNOSES REDACTED]. A review of RI #65's medical record revealed no Physician Orders for antipsychotic medications for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) 2019 or (MONTH) 2019. Further review of RI #65's medical record revealed: 1. a Quarterly MDS assessment dated [DATE], was coded for 7 days of antipsychotic use under Section N, 2. a Quarterly MDS assessment dated [DATE], was coded for 7 days of antipsychotic use under Section N, 3. a Quarterly MDS assessment dated [DATE], was coded for 7 days of antipsychotic use under Section N, and 4. a Significant Change in Status MDS assessment dated [DATE], was coded for 7 days of antipsychotic use under Section N. On 06/13/19 at 3:01 p.m., an interview was conducted with Employee Identifier (EI) #3, Licensed Practical Nurse (LPN)/MDS Coordinator. EI #3 was asked was RI #65 coded for antipsychotic use EI #3 said yes, for seven days. EI #3 was asked what medication was coded as an antipsychotic. EI #3 replied [MEDICATION NAME]. EI #3 was asked what classification was [MEDICATION NAME]. EI #3 stated anticonvulsant. EI #3 was asked according to the RAI Manual should [MEDICATION NAME] have been coded as an antipsychotic on the MDS. EI #3 explained that she had been taught to list the medication for the reason it was given and RI #65's [MEDICATION NAME] was given for Dementia with Behaviors. EI #3 was asked to review the RAI Manual. EI #3 then stated, code the classification of the drug. EI #3 was then asked was RI #65's MDS coded accurately for antipsychotics. EI #3 answered no.

Based on interview and medical record review, the facility failed to ensure Resident Identifier (RI) #87's care plan regarding code status was revised to reflect RI# 87's DNR (Do Not Resuscitate) decision. This affected RI # 87, one of twenty-four residents whose care plans were reviewed for code status. Findings Include: RI# 87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 06/13/19 at 01:30 PM, a review of RI #87's medical record revealed a DNR order was written on 05/28/2019, along with an Advance Directive depicting the family's wishes of DNR. Further review revealed a Full Code Care Plan initiated on 04/22/2019 and reviewed by the facility on 05/27/2019, RI #87's Facesheet also depicted Full Code and did not reflect RI #87's decision for DNR. On 06/13/19 at 03:28 PM, an Interview was conducted with Employee Identifier (EI) #3, Licensed Practical Nurse (LPN) / Minimum Data Set (MDS) Coordinator. EI #3 was asked what did the Care Plan for RI #87 depict as Code Status. EI #3 stated the Care Plan depicted Full Code. EI #3 was asked what the physicians orders state for the code status of RI #87. EI #3 replied DNR as of 5/28/19. EI #3 was further asked what did RI #87's Face sheet depict as code status. EI #3 stated that the Face Sheet depicted Full Code. EI #3 was asked, when a code status was documented in multiple places in the medical record, what should she ensure. EI #3 responded that all areas have the same Code status according to the most recent Physician orders. EI #3 was asked what would be the concern with all areas of the medical record not matching and EI #3 replied, the proper code status may not be performed. EI #3 was asked, did RI #87's code status on the face sheet, Physician orders [REDACTED]. EI #3 answered, no, none of it matched.

Based on observation, medical record review, interviews, and review of a facility polity titled Enteral Nutrition, the facility failed to ensure Resident Identifier (RI) #9's tube feeding was infusing at 60 ml (milliters) /(an) hr (hour) and tube feeding water flush was infusing at 25 ml (milliliters) /(an) hr( hour) as ordered by the physician. This was observed on 6/12/2019 and affected one of six resident sampled to receive tube feeding and feeding tube water flush. Findings Include: A review of a facility policy titled, Enteral Nutrition, with a revised date of 11/2018, revealed, .Policy Interpretation and Implementation . 11. The nurse confirms .orders for . e. Volume and rate of administration; . RI # 9 was readmitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of RI #9's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/20/2019 revealed RI #9 had severe cognitive impairment for daily decision. The MDS also reflected RI #9 received tube feeding. A review of RI #9's (MONTH) 5, 2019 Physician Order's revealed .Glucerna 1.2 at 60 ml/hr . free water flush at 25 ml/hr . On 6/12/19 at 9:26 a.m. and 4:36 p.m., the surveyor observed Glucerna 1.2 tube feeding at a rate of 50 ml/hr and tube feeding water flush was at a rate of 35 ml/hr. On 6/12/19 at 4:43 p.m, the surveyor observed with Employee Identifier (EI) #6, a LPN (Licensed Practical Nurse), RI # 9's Tube Feeding Pole. The following was observed Glucerna 1.2 tube feeding infusing at a rate of 50 ml/hr and water flush infusing at 35 ml/hr. Surveyor asked EI #6 asked what was the current rate observed for the tube feeding and water flushes for RI #9. EI #6 replied the Glucerna 1.2 50 ml/hr and 35 ml/hr for water flush. Surveyor then asked EI #6 to review the physician orders [REDACTED]. EI #6 said RI #9's order stated the Glucerna 1.2 should be at 60 ml/hr with a water flush at 35 ml/hr. EI #6 was then asked what was the harm with the tube feeding not running at the correct rate. EI #6 stated the resident was not getting enough nutrition, mainly calories. On 6/12/19 at 10:25 a.m. the surveyor asked EI #4, the DON (Director of Nursing) what was the rate of the tube feeding and water flush that was hanging for RI #9 on 6/12/19 at 4:36 p.m. EI #4 stated Glucerna 50 ml/hr and the water flush was 35 ml/hr. EI #4 went on to say the tube feeding Glucerna 1.2 should have been at 60 ml/hr and the water flush should have been at 25 ml/hr. Surveyor asked EI #4 what was the potential harm in the rate not running at the correct rate. EI #4 stated the resident not receiving the amount of calories and the amount of fluids the resident needed.

Based on interviews, medical record review and review of Potter and Perry Fundamentals of Nursing Ninth Edition, Chapter 23 Legal Implications in Nursing Practice, the facility failed to ensure a physician's orders [REDACTED].#87's code status. This affected RI #87, one of 24 sampled residents for whom medical records were reviewed. Findings Include: Review of Potter and Perry Fundamentals of Nursing Ninth Edition, Chapter 23 Legal Implications in Nursing Practice, copyright (YEAR), page 311, revealed the following: . Health Care Providers' Orders . Make sure that all health care provider orders are in writing . and transcribed correctly . RI #87 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of RI #87's medical record revealed a Do Not Resuscitate (DNR) order on 05/28/19. Further review of the medical record revealed RI #87's face sheet and care plan documented full code, making the medical record inaccurate. On 06/13/19 at 3:28 p.m., an interview was conducted with EI #3, Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Coordinator. EI #3 was asked what did RI #87's physician's orders [REDACTED]. EI #3 said, DNR as of 05/28/19. EI #3 was asked what did RI #87's face sheet and care plan document for code status. EI #3 replied full code. EI #3 was asked what was the concern with the physician's orders [REDACTED]. EI #3 stated the proper code status may not be performed. EI #3 was asked was RI #87's physician's orders [REDACTED]. EI #3 answered no, none of it matched.

Based on observations, interviews and review of facility policies titled, Standard Precautions and Instillation of Eye Drops, the facility failed to ensure: 1. a Licensed Practical Nurse (LPN) did not place inhaler mouthpieces on an unclean surface prior to putting them on RI #28's inhalers before storing them in the medication cart, and 2. an LPN did not wear the same gloves she wore while administering RI #1's crushed medication with an ice cream spoon and then administer RI #1's eye drops. These deficient practices affected RI #1 and RI #28, two of four residents and two of four nurses observed during medication pass observations. Findings Include: A review of a facility policy titled, Standard Precautions, Revised (MONTH) (YEAR), documented: Standard precautions include the following practices: . 5. Resident-Care Equipment soiled . are handled in a manner that prevents . transfer of microorganisms to other residents and environments. 1.) RI #28 was readmitted to the facility on [DATE]. A review of RI #28's (MONTH) 2019 physician's orders [REDACTED]. On 06/05/19 at 5:47 p.m., the surveyor observed EI #7, LPN, place caps for RI #28's [MEDICATION NAME] Inhaler and Atrovent Inhaler on the ledge of the bathroom mirror without a barrier and then place them back on the inhalers after she had rinsed them. On 06/05/19 at 5:59 p.m., an interview was conducted with EI #7, LPN. EI #7 was asked what should she do before placing items on an unclean surface. EI #7 said she should put down a barrier. EI #7 was asked where did she put the caps for RI #28's inhaler mouthpieces. EI #7 replied she did not have them on the barrier but beside it. EI #7 was asked what was the concern with placing them on an unclean surface. EI #7 answered, they could get bacteria on them and have germs and cause an infection. 2.) A review of a facility policy titled, Instillation of Eye Drops, Revised (MONTH) 2014, revealed: .Steps in the Procedure 1. Place the equipment on the bedside stand or overbed table.2. Wash and dry your hands thoroughly. 3. Put on gloves. RI #1 was readmitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of RI #1's (MONTH) 2019 Physician order [REDACTED]. On 06/13/19 at 8:28 a.m., the surveyor observed EI #6, LPN, administer RI #1's crushed medications with an ice cream spoon while wearing gloves. EI #6 was then observed administering RI #1's eye drops wearing those same gloves. On 06/13/19 at 9:10 a.m., an interview was conducted with EI #6, LPN. EI #6 was asked what was the concern with not changing gloves when needed. EI #6 said cross-contamination. EI #6 was asked did she change gloves after she administered RI #1's medications by mouth before administering RI #1's eye drops. EI #6 replied no and she should have changed them. EI #6 was asked what was the concern with not changing her gloves before administering RI #1's eye drops. EI #6 answered when giving RI #1's medications with the spoon and helping her drink she touched those items and could have touched RI #1's mouth so she could have cross- contaminated which was an infection control issue. On 06/13/19 at 4:04 p.m., an interview was conducted with EI #4, Registered Nurse/Director of Nursing. EI #4 was asked when should nurses change gloves and wash their hands. EI #4 said every time they do a treatment or if they are doing eye drops, touching skin or any time their hands are potentially contaminated. EI #4 was asked should a nurse change gloves and wash her hands after giving crushed medications with an ice cream spoon while wearing gloves before administering eye drops to a resident. EI #4 replied yes. EI #4 was asked should caps for mouthpieces be placed on a ledge without a barrier and then be placed on inhalers that have been rinsed before storing them in the medication cart. EI #4 responded no. EI #4 was asked what was the concern with not changing gloves and washing hands when potentially contaminated. EI #4 answered possibly causing and infection and infection control.

Based on record review and interview, the facility failed to ensure residents were provided with knowledge of what an Advance Directive was and provide proof of whether they wanted to formulate one or not. This deficient practice affected Resident Identifiers (RI) #'s 11, 22,33, 36, 41, 45, 46, 50, 55, 57, 60, 62, 67, 68, 73, 76, 77 and 83, 18 of 22 sampled residents reviewed for implementation of Advance Directives. Findings include: The facility's policy regarding, Advance Directives revised (MONTH) (YEAR) was provided to the surveyors. The policy interpretation and implementation included, . 7. Information about whether or not the resident has executed an advance directive shall be displaced prominently in the medical record. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. RI #22 was admitted to the facility on [DATE]. RI #33 was admitted to the facility on [DATE]. RI #36 was admitted to the facility on [DATE]. RI #41 was admitted to the facility on [DATE]. RI #46 was admitted to the facility on [DATE]. RI #50 was admitted to the facility on [DATE]. RI #57 was admitted to the facility on [DATE]. RI #60 was admitted to the facility on [DATE]. RI #62 was admitted to the facility on [DATE]. RI #68 was admitted to the facility on [DATE]. RI #73 was admitted to the facility on [DATE]. RI #76 was admitted to the facility on [DATE]. On 7/24/18 and 7/25/18, chart reviews were conducted regarding advance directives acknowledgement for RI #22, RI #33, RI 36, RI #41, RI #46, RI #50, RI #57, RI #60 RI #62, RI #68, RI #73 and RI #76. No proof of acknowledgement directives could be located on the charts. On 7/25/18 at 4:30 PM, Employee Identifier (EI) #16, (LSBW) Licensed Bachelor Social Worker, was interviewed regarding Advance Directives. When asked about the Advance Directive acknowledgement forms and where they were located on the chart, EI #16 replied the DNR's (Do Not Resuscitate) were on the charts. When asked what she did about finding out whether or not residents wanted to formulate an advance directive, EI #16 reported they put the forms in the admission packet and told the resident and family it was there in case they decided to formulate an advance directive. EI #16 was asked if she explained to the resident and family what an advance directive was and she replied no. There was no evidence in the charts that Advance Directives had been explained to the residents or that they were given an option to formulate one. RI #11 was admitted to the facility on [DATE]. RI #45 was admitted to the facility on [DATE]. RI #55 was admitted to the facility on [DATE]. RI #67 was admitted to the facility on [DATE]. RI #77 was admitted to the facility on [DATE]. RI #83 was admitted to the facility on [DATE]. On 07/26/18 at 5:15 PM, an interview was conducted with EI #16, regarding the lack of Advance Directive Acknowledgement forms on the resident's medical charts. The surveyor and EI #16 reviewed the charts of RI's #11, RI #45, RI #55, RI #67, RI #77, and RI 83. EI #16 said no resident record had an advanced directive, but the facility would be educating on completing the forms. On 07/26/18 at 5:19 PM, an interview was conducted with EI #17, LBSW. EI #17 was asked how were the residents informed of their right to execute an advance directive. EI #17 replied, usually on admission, they asked the resident or the resident's responsible party if they had an advance directive. EI#17 was asked what if the resident did not have an advance directive. EI#17 reported they (residents) were automatically a full code and sometimes they changed to DNR (Do Not Resuscitate) later. EI #17 was asked if she assisted residents in making an advance directive. EI #17 replied, yes, if they wanted to. EI #17 was asked did she have evidence that she discussed advance directives with the family. EI #17 replied, yes there was a form that was in the admission packet. EI #17 said there was an acknowledgement form when they discussed advance directives with families that was kept in the business office. EI #17 was asked if she had evidence that she discussed the resident's right to formulate an advance directive. EI #17 could not provide evidence of acknowledgement of advance directives for 18 sampled residents.

Based on observation, interview, medical record review, and a review of the facility's policy titled, Administering Medications, the facility failed to ensure Resident Identifier (RI) #44 did not self administer a nebulizer treatment after being assessed as not having the ability to self administer medication. The affected one of one resident observed administering a nebulizer treatment. Findings Include: A review of the facility's policy titled, Administering Medications dated (MONTH) 2012, revealed the following: Medications shall be administered in a safe . manner, and as prescribed. Policy Interpretation and Implementation 24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision - making capacity to do so safely. Resident Identifier (RI) #44 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 7/25/18 at 5:57 p.m., the surveyor observed RI #44 self administering his/her nebulizer inhalant medication treatment. A review of RI #44's Assessment for Self-Administration of Medications form dated 05/30/18, revealed RI #44 was unable to administer inhalant medications. On 7/26/18 at 3:58 p.m., an interview was conducted with EI (Employee Identifier) #2, RN (Registered Nurse), MDS (Minimum Data Set) Coordinator. EI #2 was asked if RI #44 was assessed for self-administration of medications. EI #2 said RI #44 was assessed for self-administration of medication and he/she was unable to administer medications. EI #2 was asked if RI #44 was unable to self administer his/her medications, should RI #44 have been doing that (self-administering medications). EI #2 said No. EI #2 was asked what was the potential harm if RI #44 was assessed as not being able to self-administer medications, but was observed self-administering medications. EI #2 said he/she could administer medications inappropriately.

Based on interview, record review and a facility policy titled, .Quality of Life-Accommodation of Needs, the facility failed to ensure Resident Identifier (RI) # 22 was given a choice for method of bathing. This affected one of one sampled resident who expressed a concern regarding baths. Findings include: A review of the facility policy titled, .Quality of Life-Accommodation of Needs with a revised date of 8/09, revealed: .The resident's individual needs and preferences shall be accommodated to the extent possible . RI #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #22's care plans included the plan for requiring extensive assistance with all ADL (activity of daily living) skills due to a right below knee amputation, muscle weakness, and abnormal gait/mobility. Approaches included: . Ask resident is he/she ready to take a bath, shower, etc. On 07/24/18 at 3:39 PM during an interview, RI #22 asked the surveyor why he/she could not have a tub bath. RI #22 commented he/she had only one shower since he/she was admitted to the facility on [DATE]. RI #22 reported he/she had not had a tub bath. RI #22 reported the staff had to bring him/her a pan of water to bathe off while in the bed. RI #22 reported he/she would love to have a tub bath. RI #22 reported he/she did not like the way the staff gave the shower he/she had. When asked why, RI #22 said they laid him/her on a shower table and the water was cold. When asked if he/she would use a shower chair, RI #22 said yes, he/she took showers at home because it was easier. RI #22 reported the staff would ask him/her if he/she wanted to shower, but he/she would refuse. RI #22 reported he/she was told they (the facility) did not have a bath tub. On 07/25/18 at 5:52 PM, Employee Identifier (EI) #11, Maintenance Director, was interviewed. EI #11 reported the facility had four showers but no tubs. EI #11 also reported they had a whirlpool tub, but it had not worked in a longtime. EI #11 said she had been there for two years and the tub was not working when she started, as far as she knew. On 07/26/18 at 7:40 AM, EI #12, the Administrator was interviewed. EI #12 reported he had been the Administrator since (MONTH) 2011. When asked why the facility did not have a tub and why the whirlpool tub had not worked in years, EI #12 replied he had not had any request from anyone for a tub. EI #12 agreed residents should have a choice in a bathing method. On 07/26/18 at 1:48 PM, EI #13, Licensed Practical Nurse/Unit Manager, was interviewed. EI #13 was informed of RI #22 expressing his/her desire for a tub bath. When asked why the resident did not like showers, EI #13 replied she did not know why the resident would not take showers. EI #13 stated the Certified Nursing Assistants just told her RI #22 did not want to take showers. EI #13 confirmed, when asked, that she did not go and speak to RI #22 about the showers.

Based on observation, interview and record review, and a facility's policy titled, . - Confidentiality of Information and Personal Privacy, the facility failed to ensure Resident Identifier (RI) #88's MAR (Medication Administration Record) was not left open to public view. This affected (RI) #88, one of three residents observed during medication administration. Findings Include: The facility's policy titled, . - Confidentiality of Information and Personal Privacy with a revised date of (MONTH) (YEAR), revealed the following information: Policy Statement Our facility will protect and safeguard resident confidentiality and personal privacy. The Policy Interpretation and Implementation revealed, 2. The facility will strive to protect the resident's privacy regarding his or her: .b. medical treatment . 4. Access to resident personal and medical records will be limited to authorized staff . RI #88 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 07/25/18 at 11:05 AM, Employee Identifier (EI) #6, Licensed Practical Nurse (LPN) was observed during medication administration. EI #6 entered RI #88's room with medication and the MAR indicated [REDACTED]. RI #88's MAR indicated [REDACTED]. EI #6 exited the room and opened the medication cart to obtain a gauze. The MAR indicated [REDACTED]. On 07/25/18 at 11:10 AM, during an interview with EI #6, the surveyor asked what was left up and opened for public view. EI #6 stated, The resident's MAR. The surveyor asked what was the policy for leaving MARs up and opened for public view. EI # stated, I should have closed it.

Based on observation, interview, record review and the facility policy titled, . Care Plan, Comprehensive Person - Centered, the facility failed to ensure staff consistently followed Resident Identifier (RI) #85's care plan for self care deficit with eating by not providing a weighted spoon during the breakfast and lunch meal on 07/24/18. This affected one of 23 sampled residents whose care plans were reviewed. Findings include: The facility's policy titled, . Care Plan, Comprehensive Person - Centered , with a revision date of (MONTH) (YEAR), was reviewed. The Policy Statement indicated that, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Policy Interpretation and Implementation included, . 4. g. Receive the services and/or items included in the plan of care: . RI #85 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. RI #85's careplans with a review date of 06/27/18 revealed: . require special equipment during meals times . Approaches .Use appropriate devices, weighted spoon to assist resident to feed self. On 07/24/18 at 8:13 AM, RI #85 was observed sitting up in bed for breakfast. A view of the tray card revealed the following: . weighted spoon, . A weighted spoon was not provided to RI #85. On 07/24/18 at 12:25 PM, an observation was made of the lunch meal. No weighted utensils were provided to RI #85. On 07/26/18 at 11:35 AM, during an interview with EI (Employee Identifier) #2, (Minimum Data Set) MDS Coordinator, RI # 85's care plan was reviewed. EI #2 was asked what was the care plan for the resident's adaptive equipment/utensils. EI #2 stated, Self-care deficit for feeding. The surveyor asked what was the approach. EI #2 stated, Use appropriate device, weighted spoon to assist resident to feed (her/himself). The surveyor asked what was the date on the care plan and intervention. EI #2 stated, Problem onset date was 10/13/17. I reviewed it last 6/27/18, (that) was my last review date. The surveyor asked what was her review outcome related to the weighted spoon. EI #2 stated, The resident still needed the weighted spoon and there was an order and I observed (her/him) use the spoon. (She/he) could use it but with difficulty and required assistance with feeding. The surveyor informed EI #2 that RI #85 was observed on 7/24/18, for breakfast and lunch. For breakfast RI #85 received a weighted fork and for lunch the resident received no weighted utensils. The surveyor asked was the care plan for self care deficit followed. EI #2 stated, No, because (he/she) is care planned for a weighted spoon.

Based on observation, interview, medical record review, and a review Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure staff followed Resident Identifier's (RI) #85's physician's orders [REDACTED]. This affected one of 23 sampled residents whose physician's orders [REDACTED]. Findings Include: A review of Potter and Perry's FUNDAMENTALS OF NURSING Ninth Edition, page 311 revealed the following: . Health Care Providers' Orders.follow health care providers' orders . Resident Identifier (RI) #85 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of RI #85's (MONTH) (YEAR) physician's orders [REDACTED]. On 07/24/18 at 8:13 AM, RI #85 was observed sitting up in bed for breakfast. A weighted spoon was not provided to RI #85. On 07/24/18 at 12:25 PM, an observation was made of the lunch meal. No weighted utensils were provided to RI #85. On 07/24/18 at 12:30 PM, during an interview with Employee Identifier (EI) #3, Certified Nursing Assistant (CNA), the surveyor asked where was RI #85's weighted spoon. EI #3 stated, Dietary did not send it. The surveyor asked if the resident received the weighted spoon for breakfast. EI #3 stated, No ma'am. The surveyor asked should the resident have gotten a weighted spoon with breakfast and his lunch. EI #3 stated, Yes ma'am. The surveyor asked could the resident use the weighted spoon. EI #3 stated, Yes. On 07/26/18 at 7:35 AM, an interview was conducted with EI #4, a Licensed Social Worker. EI #4 was asked when had she observed RI #85 to use a weighted spoon. EI #4 stated, I am actually the one that requested the weighted spoon. The surveyor asked why. EI #4 stated, The resident can actually feed himself/herself and when he/she used the regular spoon he/she would shake really bad, but he/she can use the weighted spoon.

Based on observation, interview, activity participation records, record review and the facility's policy titled, Activities Policies and Procedures Manual, the facility failed to provide Resident Identifier (RI) #55 with activities of choice from (MONTH) (YEAR) to (MONTH) (YEAR). The facility further failed to provide RI #73 with activities of choice on three of three days of the survey. This affected two of 23 sampled residents whose activity records were reviewed. Findings Include: The facility's policy titled, Activities Policies and Procedures Manual, with a revised date of (MONTH) 29,2014 revealed: Procedure: . 2) The department will continuously offer residents a wide range of activities program opportunities so that they may explore any and all potential leisure interests. 5) The department will continue to invite residents to group programs, one-to-one activities contacts, . 1) RI #55 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of RI #55's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had short and long term memory deficits. The MDS also revealed RI #55 required extensive assist of two person for bed mobility and transfers. A review of RI #55's care plans revealed the resident enjoyed being read to, music and visits with family. The care plan was initiated on 09/13/17. A review of RI #55's ACTIVITY INITIAL ASSESSEMENT (ASSESSMENT) SHEET dated 03/05/18, revealed the following resident interests: listening to TV, visits and being read to. A review of RI #55's IN ROOM ACTIVITY PARTICIPATION records from (MONTH) (YEAR) to (MONTH) (YEAR), revealed staff had visited and talked with the resident, however, there was no evidence staff had read to the resident. On 07/24/18 at 12:06 PM, RI #55 reported to the surveyor that she/he liked to listen to the radio and watch TV. On 07/25/18 at 7:58 AM, during an interview with Employee Identifier (EI) #7, Activities Director, the surveyor and EI #7 reviewed RI #55's Activity Initial Assessment Sheet, notes and In Room Activity Participation records. EI #7 was asked what did the resident like to do, as documented on the Activity Initial Assessment Sheet dated 3/5/18. EI #7 stated, Listen to radio, have TV, visit, enjoys being read to and visit with family and staff. The surveyor asked for the month of (MONTH) how many times was RI #55 read to. EI #7 stated, It don't look like any. The surveyor asked for the month of April, how many times was RI #55 read to. EI #7 stated, None. The surveyor asked for the month of May, how many times was RI #55 read to. EI #7 stated, None. The surveyor asked for the month of June, how many times was she/he read to. EI #7 stated, None. The surveyor asked for the month of July, how many times was RI #55 read to. EI #7 stated, None yet. The surveyor asked from (MONTH) to (MONTH) 25, (YEAR), had the resident been provided with activities based on the resident's activity assessment dated [DATE]. EI #7 stated, No, not according to this. 2) RI #73 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of RI #73's Activity Initial Assessment Sheet, dated 01/04/18, revealed the resident's interest included group singing, listening to a band, listening to the radio, parties, visits, church service and that the resident did wish to participate in activities. A review of the (MONTH) (YEAR) activity calendar was conducted. The activity department offered music, coffee club and church service on 07/24/18. On 07/25/18 the activity department offered bible study. On the 07/26/18 TV, bible group and coffee club were offered, among other group activities. A review of RI #73's (MONTH) (YEAR) activity group roster for the days during the survey (07/24/18-07/26/18) were reviewed. The activity staff documented RI #73 participated in group activity by talking and conversing on 07/24/18 and 07/25/18. The activity department also documented on the resident's independent roster that RI #73's independent activities consisted of TV/Movies, conversations/phone and exercise on 07/24/18, 07/25/18 and 07/26/18. On 07/25/18 at 7:50 AM, RI #73 was observed in the hall in the gerichair. At that time, an interview was conducted with Employee Identifier (EI) #14, Certified Nursing Assistant (CNA). EI #14 reported that RI #73 ate meals in the dining room and sometimes was taken to an activity but she/he was mainly placed in the hall so staff could keep an eye on her/him. EI #14 also reported it did not bother RI #73 to be around other residents. On 07/25/18 at 10:30 AM, RI #73 was observed in the hallway next to her/his room. Snack time was the listed activity at that time. On 07/25/18 at 2:31 PM, RI #73 was observed in the hallway in the gerichair. Snack break was the listed activity at that time. On 07/26/18 at 3:23 PM, the Activity Director, EI #7, was interviewed regarding the activities the facility provided to RI #73. EI #7 reported RI #73 did not do well in large groups but could tolerate small group activities. When asked about RI #73's activities, EI #7 reported she considered RI #73 being in the hallway and eating in the dining room as an activity and interacting with others. When asked when was the last time RI #73 attended any activities that week, she reported, not since Monday (07/23/18).