Every finding on record at Covenant Living at Inverness

Based on observation and interview, the facility failed to maintain a clean ice machine and service meals in a manner which limited the risk of cross contamination. The DON identified 39 residents ate meals prepared in the kitchen and served from the satellite kitchen. Findings: On 07/06/26 at 2:15 p.m., the ice machine in the kitchen was observed with the kitchen manager and Maintenance #1. The front panel was removed, and the front panel and the mechanical area of the ice machine was observed. There was a grey tube which ran downward and into the water reservoir. A green substance, speckled with brown and with brown and green edges, was observed under the water line and in the bend of the grey tube. There were green and black spots observed on the walls of the water reservoir and on the front covering. On 07/07/26 at 11:40 a.m., in the satellite kitchen, Dining Services Associate #1 and the dining manager were observed to use gloved hands to retrieve and plate the hamburger buns for the residents who ordered the sloppy joes. Dining Services Associate #1 and the dining manager were observed to touch multiple surfaces, utensils, plates, trays, and their own person/clothing with the same gloved hands they used to plate the hamburger buns for the sloppy joes. On 07/06/26 at 2:16 p.m., the kitchen manager stated they could see the green substance observed under the water line and in the bend of the grey tube and the green and black spots on the walls of the water reservoir and on the front covering. The kitchen manager stated they would have the ice machine cleaned. On 07/10/26 at 3:18 p.m., Dining Services Associate #1 stated they utilized a dedicated utensil for each item they served, used clean tablecloths for each meal, made sure their hands were washed or used hand sanitizer, and utilized gloves to maintain infection control when plating meals. On 07/10/26 at 3:25 p.m., the dining manager stated they assisted with serving most meals from the satellite kitchen. The dining manager stated they did use their gloved hands to handle the bread when plating the sloppy joes as well as touching other surfaces. The dining manager stated they washed their hands before and after each task.

Based on observation, record review, and interview, the facility failed to ensure informed consent was obtained prior to the utilization of bed rails for two (#13 and #25) of two sampled residents reviewed for bed rails. The administrator identified 40 residents whose beds were equipped with a bed rail of any type. Findings: 1. Res #13 had diagnoses which included dementia, abnormalities of gait and mobility, and muscle weakness. A physician order, dated 07/07/23, documented the resident could use assist handle to assist with turning or repositioning. An admission assessment, dated 07/13/23, documented the resident was severely impaired in cognition, required extensive assistance with bed mobility, and had one fall with injury. On 09/24/24 at 10:08 a.m., Res #13 was observed in their room with a family member present. Bilateral half bed rails were observed on the upper half of the bed in the up position. Res #13's family member stated the bed rails were used to aide in the turning and repositioning of Res #13. There was no documentation of informed consent for bed rails found in the medical record. There was no documentation of the utilization of bed rails found in the care plan. 2. Res #25 had diagnoses which included dementia, adult failure to thrive, and muscle weakness. A quarterly assessment, dated 07/04/23, documented the resident was moderately impaired in cognition, required extensive assistance with bed mobility, and had no falls. A physician order, dated 07/18/23, documented the resident could use assist handle to assist with bed mobility. On 09/24/24 at 10:00 a.m., Res #25 was observed lying in bed. Bilateral half bed rails were observed on the upper half of the bed in the up position. Res #25 stated the bed rails were used for turning from side to side in the bed. There was no documentation of informed consent for bed rails found in the medical record. There was no documentation of the utilization of bed rails found in the care plan. On 09/25/24 at 8:46 a.m., the DON stated informed consents had not been documented for Res #13 and Res #25 prior to the implementation of bed rails. They stated the utilization of bed rails as an assistive device had not been documented in the residents' care plan. The DON stated the facility did not have a policy specific to bed rails. On 09/25/24 at 9:39 a.m., the administrator stated informed consent had not been obtained prior to the implementation of bed rails. They stated the facility had no specific policy regarding bed rails at this time.

Based on record review and interview, the facility failed to ensure a resident's right to privacy during care for one (#1) of three sampled residents reviewed for privacy. The administrator identified 42 residents resided in the facility. Findings: An Abuse Prevention Program policy, revised 07/12/23, read in parts, .Unauthorized Photographs or Recording .taking recordings of a resident and/or his/her private space without a resident's, or designated representative's, written consent, is a violation of the resident's right to privacy and confidentiality . Res #1 had diagnoses which included hemiplegia, hemiparesis, vascular dementia, and anxiety. A quarterly resident assessment, dated 11/14/23, documented the resident's cognition was moderately impaired and they required substantial/maximal assistance with bed to chair transfers. A state incident report, dated 12/13/23, documented CNA #1 reported to the administrator they had seen an online video CNA #2 posted of Res #1. It was documented the video showed CNA #2 transferring Res #1 from their bed to their powered wheelchair with CNA #2 looking at the camera during the transfer. It was documented you could hear in the video Res #1 telling CNA #2 they did a good job and CNA #2 thanking the resident. It was documented CNA #2 was interviewed and admitted they recorded Res #1. It was documented CNA #2 was aware they violated the resident's privacy and they did not ask for permission. It was documented the allegation was substantiated and CNA #2 was terminated. On 01/08/24 at 11:19 a.m., CNA #1 was asked about the online video CNA #2 posted of Res #1. They stated the video was of CNA #2 transferring Res #1. They stated CNA #2 was trying to show off. They stated the resident was dressed and not exposed. They stated they had concerns Res #1's rights were violated. On 01/08/24 at 12:04 p.m., the administrator was asked about the online video CNA #2 posted of Res #1. They stated Res #1 was recorded being transferred from their bed to their electric wheelchair without consent. They stated CNA #2 was not malicious and the resident's rights were violated.

Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan related to insulin and [CONDITION(S)] medications for two (#18 and #79) of five sampled residents whose care plans were reviewed for medications. The Resident Census and Conditions Report identified 17 residents on [CONDITION(S)] medications. The administrator identified two residents who received insulin. Findings: The undated Care Plans, Comprehensive Person-Centered policy, read in parts, .The comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Care plan interventions are chosen only after careful data gathering .careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making .The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment .The Interdisciplinary Team must review and update the care plan at least quarterly, in conjunction with the required quarterly MDS assessment . 1. Resident #18 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission MDS assessment (a resident assessment tool used to identify resident care needs), dated 08/03/21, documented the resident was severely impaired in cognition and received an anticoagulant medication six days of the seven day look back period. The resident's quarterly MDS assessment, dated 10/27/21, documented the resident was severely impaired in cognition, and received a hypnotic medication and opioid medication seven days of the seven day look back period. The resident's Care Plan, dated 12/01/21, read in parts, .Problems .Antianxiety: [name withheld] is receiving antianxiety drugs on a regular basis .Goals .Symptoms of anxiety will be controlled with minimal side effects over the next 90 days. Status: Active (Current) .Interventions .administer .as ordered .Monitor for side effects of medications . A review of resident #18's physician orders and medication administration records did not reveal an antianxiety medication had been ordered or administered. During the survey, the DON reported resident #18 had no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/16/21 at 1:10 p.m., the MDS coordinator/nurse manager stated she was currently responsible for development and revision of resident care plans. The MDS coordinator/nurse manager was asked why the resident's care plan would include antianxiety medication when the resident had not been prescribed or administered antianxiety medications. She stated the MDS nurse must have entered it incorrectly. The MDS coordinator/nurse manager was asked if the care plan would be accurate for this resident. She stated no, it would not. On 12/16/21 at 3:00 p.m., the DON stated was asked if resident #18's care plan which included antianxiety medication was accurate. She stated No. 2. Resident #79 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's initial MDS assessment, dated 11/28/21, documented the resident was severely impaired in cognition, and received an insulin injection, antidepressant medication, and hypnotic medication seven days of the seven day look back period. The Physician Order sheet, dated December 2021, read in parts, .insulin [MEDICATION(S)] (U-100) 100 unit/ml (3ml) subcutaneous pen .sliding scale insulin .Order Date: 11/22/21 .Four Times Daily . Levimir [MEDICATION(S)] 100 unit/ml (3ml) solution subcutaneous insulin pen (10 units) .Order Date: 11/22/21 .Two Times Daily . [MEDICATION(S)] 8 mg tablet (1) tablet oral .Order Date .11/22/21 .Hour of Sleep . [MEDICATION(S)] 100 mg tablet (1) tablet oral .Order Date: 11/22/21 .Hour of Sleep . Resident #79's Care Plan, dated 11/23/21, and updated 11/29/21 and 12/2/21, did not address diabetes, insulin, or the use of the [CONDITION(S)] medications [MEDICATION(S)] and [MEDICATION(S)]. On 12/16/21 at 1:10 p.m., the MDS coordinator/nurse manager stated she was currently responsible for development and revision of resident care plans. The MDS coordinator/nurse manager was asked why resident #79's care plan did not address diabetes, insulin, or the use of hypnotics/sedatives. She stated she was actively working on resident #79's care plan. The MDS coordinator/nurse manager stated resident #79's care plan should have included these identified areas. On 12/16/21 at 3:00 p.m., the DON stated resident #79's care plan should have included these identified areas. The DON was asked if resident #79's care plan would be a comprehensive care plan. She stated there were issues not addressed on the care plan. The DON was asked how staff would be aware of the resident's plan of care for insulin, diabetes, and [CONDITION(S)] medications if they were not addressed on the care plan. She stated they would not be aware.

Based on observation, record review, and interview, the facility failed to ensure the care plan was revised to include antibiotic therapy and contact isolation precautions for one (#19) of one sampled residents whose care plans were reviewed for antibiotic therapy and contact isolation precautions. The Resident Census and Conditions Report identified five residents on antibiotics. The DON identified two residents on contact isolation precautions. Findings: Resident #19 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's quarterly MDS assessment (a resident assessment tool used to identify resident care needs), dated 10/27/21, documented the resident was cognitively intact, required extensive assist with toileting, and was occasionally incontinent of urine. Record review revealed the resident had received laboratory services, dated 11/18/21, which included a urinalysis with culture and sensitivity. A notation on the laboratory results documented the resident was to receive an antibiotic and have contact isolation precautions. On 11/30/21, during an initial tour of the facility, signage was observed on resident #19's door indicating contact precautions. A PPE cart was observed in the hallway. The DON reported the resident was on contact isolation precautions due to multi-resistant organism in the urine. A review of the resident's care plan did not reveal the care plan had been revised to include the resident's urinary tract infection, antibiotic therapy, or contact isolation precautions. On 12/16/21 at 1:10 p.m., the MDS coordinator/nurse manager stated she was currently responsible for development and revision of resident care plans. She stated a resident's care plan would be revised following a significant change, completion of a quarterly assessment, and when new or revised physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The MDS coordinator/nurse manager stated a copy of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated some orders, such as [CONDITION(S)] medication or antibiotic therapy would automatically indicate a care plan revision was needed. The MDS coordinator/nurse manager was asked why resident #19's care plan had not been revised to include the November 2021 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated maybe the revision had not been saved correctly in the electronic system. The MDS coordinator/nurse manager stated resident #19's care plan should have been revised to include [CONDITION(S)], antibiotic therapy, and contact isolation precautions. On 12/16/21 at 3:00 p.m., the DON stated resident #19's care plan should have been revised to include [CONDITION(S)], antibiotic therapy, and contact isolation precautions.

Based on observation and interview, it was determined the facility failed to maintain an infection control program and implement measures to provide a safe environment to help prevent the development and transmission of COVID-19 and/or other infections. The facility failed to ensure staff: ~ donned appropriate PPE before providing care to a resident on contact precautions; and ~ performed hand hygiene and/or washed hands when exiting a resident room who was on contact precautions. The Resident Census and Conditions Report identified 29 residents who resided in the facility. The DON identified three residents who were on contact precautions/quarantined due to being a new admission and not vaccinated for COVID-19. Findings: On 12/13/21 at 5:04 a.m., CNA #1 was observed to approach a resident room that had signage on the door indicating contact precautions and a PPE cart in the hallway. The CNA was observed to wear a mask. CNA #1 entered the room, donned gloves, retrieved the resident's urinal from the bedside table, entered bathroom, and then placed the empty urinal back on the bedside table. CNA #1 removed her gloves, and exited the room. CNA #1 was then observed to enter another resident room where she donned gloves, and performed incontinent care. CNA #1 was not observed to perform hand hygiene between resident rooms. At 6:50 a.m., CNA #1 stated she did not know how many residents were on contact precautions. She stated she had not noticed any, but usually there were signs on the door. CNA #1 was asked what the sign on the doors indicated. She stated What signs? CNA #1 stated the procedure for contact precautions was to wear gown and gloves, remove them when leaving the room, and wash hands. CNA #1 was asked why she did not wash hands or perform hand hygiene when exiting room with contact precautions earlier. She stated she usually washed her hands when she left the room. CNA #1 was asked how she ensured infection control. She stated she washed/sanitized hands. On 12/13/21 at 7:00 a.m., LPN #1 stated to ensure infection control staff were to follow the contact precautions signs posted and remove the biohazard boxes from the resident room after each shift. On 12/14/21 at 9:15 a.m., the DON was asked what PPE was to be utilized by staff entering a resident room on contact precautions. She stated staff were to wear gown, gloves, mask, wash/sanitize hands, remove all PPE and place in biohazard box in room.

Based on record review and interview, the facility failed to ensure a claim for outpatient hospital services was submitted /paid as Medicare Part A, consolidated billing for one (#131) of one sampled residents whose records were reviewed for Medicare Part A, consolidated billing. The administrator identified five residents who received Medicare Part A services. Findings: The Skilled Nursing Facility Agreement, dated December 2019, read in part, .Medicare/Medicare Supplemental Polices. If Facility is certified to provide services under the Medicare Act, it will accept Medicare payment as full payment for covered services . Record review revealed the resident was admitted to the facility in May 2020 for Medicare Part A services and received outpatient hospital services on 06/06/20 during her Medicare Part A stay at the facility. On 12/16/21 at 2:24 p.m., the business office specialist was asked what the payment procedure was when residents received outpatient hospital services. She stated the resident would be responsible for payment unless they were under a Medicare Part A stay. The business office specialist stated resident #131 was under a Medicare Part A stay and the invoice for hospital outpatient services, dated 06/06/20, should have been paid. At 4:10 p.m., the business office specialist informed the surveyors that she contacted the hospital and was informed resident #131's invoice for outpatient hospital services, dated 06/06/20, had not been paid and had been turned over to the collection department. On 12/16/21 at 4:47 p.m., the associate executive director stated based on the coding on the hospital outpatient claim form, the facility would be responsible for payment of the bill. The associate executive director stated he had checked their electronic system and the claim was not in their system for payment. At 5:15 p.m., the surveyors were provided with correspondence dated 05/20/21, 05/21/21, 06/03/21, and 06/10/21 supporting the resident's inquiry and potential Medicare Part A consolidated billing situation. No additional documentation or correspondence, dated between 06/10/21 and 12/16/21, was provided to support resolution/payment of the resident's claim for outpatient hospital services that occurred during a Medicare Part A stay at the facility.

Based on interview and record review, it was determined the facility failed to ensure resident and/or resident representative was notified of a room change for one (#28) of 17 sampled residents who were reviewed for resident rights. This had the potential to affect all 38 residents who resided in the facility. Findings: An undated policy titled, Room Change or Transfer Notification, documented, .Purpose .To preserve each resident's right to be notified prior to a room change or transfer .Social services will notify the residents and or responsible parties whenever possible prior to room changes or transfers . Resident #28 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 04/11/19, documented the resident was moderately impaired in cognition for daily decision making. On 05/15/19 at 5:18 p.m., a staff member in the memory unit stated resident #28 was moved from long term care to the memory unit on 05/14/19. She stated the resident was not happy about being moved. The resident was not interviewable regarding the room change. An activity note, dated 05/16/19, documented, (Resident #28) is not happy with her move to Memory care. We have been visiting and trying to continue to bring her to events but she has been mad/depressed and doesn't want to participate. She was coming sporadically to exercise and she has declined to come since the move. She tended to self-propel around which has done a little of but spend most of the first day in her room. She would not engage with activities specially for the Memory unit community yet. She will watch television in her room. Review of the clinical record did not reveal when the resident had changed rooms or that the resident and/or resident representative had been given advanced notification of the room change. On 05/20/19 at 1:53 p.m., the ADON (assistant director of nursing) was asked to provide documentation of the resident's recent room change. On 05/20/19 at 2:47 p.m., the ADON and DON (director of nursing) stated the resident was moved to the memory unit on 05/14/19. They stated she had been exit seeking and interventions implemented on the long term care unit had not been successful. The ADON stated the interdisciplinary team had discussed moving the resident to the memory unit. She stated the administrator was going to place a phone call to the resident's daughter to discuss the treatment plan. She stated the daughter wanted to wait to move the resident until 05/20/19 to enable herself to be present and assist with the move and the transition. She was asked who was responsible to communicate the resident's daughter's wishes. She stated the administrator had contacted the daughter but neglected to communicate to staff the daughter's request to wait and move the resident on 05/20/19. She stated it was everyone's lack of communication which led to the resident being transferred to the memory unit on 05/14/19. She was asked when the resident's daughter was made aware her mother had been transferred to the memory unit. She stated she did not know. She stated the resident's daughter had called this past weekend and spoke to the nurse. She was asked what the resident had stated about moving to the memory unit. She stated due to the resident's cognitive deficit she was confused and knew her new room was not her previous room and was trying to adjust. A progress note, documented, .Effective Date/Time 05/13/2019 .03:26 PM .Author (administrators name withheld) .Entered Date/Time 05/20/2019 3:30 PM .I called (resident's daughter's name withheld) today about moving (resident #28) to memory. I shared incidents and concerns the team had with (resident #28) recently and our concern. She had been notified of incidents and concerns by staff in separate call and agreed that memory might be a good idea. She asked that I talk to (physician name withheld) first and that she would be here on the 20th to visit and help with the move. The progress note was signed by the administrator. A progress note, dated 05/20/19 at 3:17 p.m., documented, .I met with (resident's daughter's name withheld) and Husband today .They asked if she would stay in memory or need to move to another room .Moving to memory had been confusing and they did not know day it happened .I let them know we thought it would be best if (resident #28) stayed in memory and they agreed . The progress note was signed by the administrator.

Based on observation, interview, and record review, the facility failed to provide timely assistance with meals for two (#2, #3) of eight residents observed eating their noon meal at the memory unit dining table. The facility identified 10 residents requiring assistance with meals on the memory unit. Findings: A facility policy, dated (MONTH) 2013 and titled, Care of the Disoriented Resident, documented, .Purpose: To prevent the deterioration of the disoriented resident .Procedure/Process: ~ Provide cuing and prompting for personal care . ~ Use gestures. Attempt to have the resident imitate the activity you want them to perform. (Example, put a fork in your mouth) (sic) If ineffective, use hand over hand technique . ~ Use eye contact and use commands such as do and let's. Avoid words such as Don't.' (sic) . ~ Observe for signs of frustration and anxiety and change activity if observed. If the resident is having an episode of anxiety or agitation, gently attempt to calm resident and refocus attention . ~ Involve in low stress (low expectation) activities such as small group Activities (sic) . ~ Monitor weights and appetite as confused residents sometimes forget to eat . Behavior Interventions: ~ Pleasant interaction which reassures resident when confused . ~ Plan frequent rest periods but assure there aren't long periods of inactivity . 1. Resident #2 had [DIAGNOSES REDACTED]. The care plan, dated 11/03/17, documented, Problems: Nutrition: (Resident #2) has potential for alteration in nutritional status r/t theraputic (sic) diet, fair po intake of meal and fluids, Hospice care, and general clinical status . Goals: (Resident #2) will consume 50-75% of meals and have adequate nutrition maintained for the next 90 days as shown by no significant weight loss &/or gain . Interventions: Assist with menus and meals as needed . The quarterly assessment, dated 07/24/18, documented the resident was severely impaired in cognition and required set up to one person assistance with meals. A registered dietician's note, dated 07/26/18, documented resident #2 had lost seven pounds in 28 days. The note recommended the resident receive assistance with menus and meal set up and encouragement with meals and fluids. The note also recommended a supplement be ordered twice daily. On 08/29/18, at 5:05 p.m., residents of the memory unit were observed seated around the dining table eating the evening meal. Private sitters, friends/family, and staff were present to assist the residents with their meal intake. On 08/29/18 at 5:00 p.m., a family member of a resident on the memory unit stated they were had observed residents not receive timely assistance with their meals and was concerned. On 08/29/18 at 5:05 p.m., LPN #1 was asked if there was enough staff to provide timely assistance with activities of daily living. She stated the staff was able to provide timely assistance throughout the day but did need more assistance at mealtimes due to so many residents requiring assistance with meals and only two staff members assigned to the unit. On 09/10/18 at 08:50 a.m., a private sitter was observed assisting one resident with breakfast. The private sitter was asked if there were enough staff on the memory unit to provide timely assistance to the residents. The private sitter shook their head and stated the staff needed help assisting residents during mealtimes. On 09/10/18 at 11:35 a.m., five resident were observed seated around the dining table and one person was in the dining room was seated in a recliner. The hot box and cold cart containing the noon meal was delivered. No staff were present in the dining room. At 11:37 a.m., a private sitter was observed to exit a resident room, retrieve a hot plate of food from the hot box, cold items from the refrigerator, and return to the resident's room, closing the door. No staff were observed. At 11:43 a.m., CNA #1 was observed to exit a resident's room with a trash bag in hand, place the bag in a closet, enter another resident's room and exit the unit pushing a resident in a wheelchair. No other staff were observed. At 11:45 a.m., CNA #1 was observed to return to the unit, hand out silverware, and begin pouring/delivering drinks for the residents. At 11:49 a.m., CMA #1 was observed to escort a resident via wheelchair to the dining table. At 11:50 a.m., CMA #1 and CNA #1 were observed to transfer the resident in the recliner to a wheelchair and escort her to the dining table. At 11:55 a.m., a family member was observed retrieving a hot plate of food from the hot box and cold items from the refrigerator. CMA #1 and CNA #1 were observed to begin passing hot plates of food to the eight residents seated at the dining table. At 12:00 p.m., RN #1 was observed to enter the unit and walk back to the dining area. The RN spoke with CMA #1 and CNA#1 before exiting the unit. CMA #1 was observed to enter a resident's room with a meal tray and assist the resident with their meal. CNA #1 sat at the dining table and assisted two residents with their meals. Two residents were observed eating independently. One resident was assisted by a private sitter. Resident #2, #3, and a third resident were observed to not eat. On 09/10/18 at 12:07 p.m., a family member was asked if there were enough staff to assist residents in a timely manner. The family member stated there was enough staff at the dining table but if any resident needed assistance in their room, they were not sure how the staff were to accommodate the need. On 09/10/18 at 12:10 p.m., a private sitter was asked if there were enough staff to assist residents in a timely manner. The private sitter stated the residents used to be more independent with meals but now need more assistance. The sitter stated there was not enough staff to assist residents during meal times and no other staff ever came back to assist the residents with meals unless they were on light duty. At 12:20 p.m., a hospice nurse was observed to obtain drinks from the refrigerator and refill drinks for the three residents not eating. The hospice nurse then sat and visited with another resident. At 12:25, CMA #1 was observed to return to the dining area and was asked by CNA #1 to assist resident #2 with their meal. On 09/10/18 at 12:28 p.m., CMA #1 spooned a bite of mashed potatoes from the plate in front of resident #2. The CMA was asked to stop and temperatures were taken of the hot food items. Temperatures were measured as follows: ~ Cheese Tortellini 87F degrees ~ Mashed Potatoes 79F degrees ~ Green Beans 78F degrees. The CMA was asked to obtain another plate for resident #2. 12:33 p.m., CMA #1 was observed to return to the dining table with a hot plate of food, stand to the right side of the resident and attempt to feed the resident. She prompted the resident approximately three to four times to take a bite of food. The CMA appeared rushed. The CMA placed the spoon of food down, retrieved a small drink cup from the refrigerator and stated she was giving the resident a shake. The CMA then left the resident and did not return to assist her with her meal. On 09/10/18 at 12:47 p.m., CMA #1 was asked if there was enough staff on the memory unit to provide timely assistance to all the residents. She stated they needed more help during meal times. On 09/10/18 at 1:05 p.m., CNA #1 was asked if there was enough staff on the memory unit to provide timely assistance to all the residents. She stated when everything ran smoothly there was enough staff for most needs but at mealtimes the residents needed more help. She stated resident #2 used to eat independently but now needed more assistance, especially when she was sleepy at mealtime. On 09/10/18 at 4:30 p.m., CNA #2 was asked if there was enough staff on the memory unit to provide timely assistance to all the residents. She stated the residents needed more help during mealtimes but otherwise she felt the assigned staff were able to meet the residents needs in a timely manner. On 09/10/18 at 4:35 p.m., CMA #2 was asked if there was enough staff on the memory unit to provide timely assistance to all the residents. She stated more help was needed during mealtimes. She stated more residents required assistance with meals then what they could provide in a timely manner. She stated sometimes the private sitter for a resident may not show up and they would have to assist a resident with the meal in their room, or a resident may need bathroom assistance during mealtime. On 09/11/18 at 11:10 a.m., seven residents, including resident #2 and resident #3, were observed seated around the memory unit dining table. A private sitter was present at the table. There were no facility staff present. At 11:20 a.m., CMA #1 and CNA #1 were observed in the dining area. At 11:28 a.m., CNA #3 entered the memory unit with the hot box and cold cart. She stocked the refrigerator from the cold cart and distributed silverware. She stated she had been pulled from main dining today to help during dining in the memory unit. On 09/11/18 at 11:35 a.m., no food had been passed to residents. CNA #1 was observed to exit a resident's room. The CNA was asked how the facility ensured residents received timely assistance with activities of daily living. She stated they usually tried to have all the residents up and ready for lunch by 11:30 a.m. but today one resident was trying to have a bowel movement. She stated by now they normally tried to have the food served and her seated at the dining table assisting two residents with their meals. She stated she would cue resident #2 and #3 while assisting the others with their meal. On 09/11/18 at 11:45 a.m., CMA #1 was observed to exit a resident's room. She was asked how the facility ensured residents received timely assistance with activities of daily living. She stated they sometimes received extra help during mealtime, relied on private sitters to help the resident during mealtime, and kept plates in the hot box until someone was available to assist with their meals. On 09/11/18 at 12:45 p.m., the ADON was asked how the facility ensured residents on the memory unit were provided timely assistance with activities of daily living. She stated the staff provided personal care a minimum of every two hours and staffed the unit with either an LPN or CMA and a CNA or two CMA's. She was asked how they met the resident's needs during mealtime. She stated they usually have two staff present to assist the residents but they could call for another CNA/CMA to assist from the front. She stated light duty staff were also assigned to help in the memory unit but today they were assigned to a field trip. On 09/11/18 at 12:52 p.m., LPN #2 was asked how the facility ensured residents on the memory unit were provided timely assistance with activities of daily living. She stated nurse went back to the memory unit throughout the day to provide treatments. She stated if the two staff assigned to the unit needed further help, they usually called for assistance. On 09/11/18 at 12:55 p.m., the DON was asked how the facility ensured residents on the memory unit were provided timely assistance with activities of daily living. She stated the careplan informed the staff of how to care for the resident. She was asked if the needs of the residents on the memory unit changed from day to day. She stated yes and the staff would need to adjust as needed based on the care plan. 2. Resident #3 had [DIAGNOSES REDACTED]. The care plan, dated 12/01/17, documented, .Problems: Nutrition: (Resident #3) has potential for alteration in nutritional status r/t fair po intake of meals, theraputic (sic) diet and general clinical status . Goals: (Resident #3) will consume at least 50% of meals and have adequate nutrition maintained as shown by no significant weight loss &/or gain through review date . Interventions: Offer supplements or alternates if east (sic) less than 50% of meals served, or refuses a meal .Assist with menus and meals. Staff to encourage fluids .Give verbal encouragement to consume as much as possible at each meal . The quarterly assessment, dated 08/09/18, documented the resident was severely impaired in cognition, and required one person extensive assistance with meals. On 09/10/18 at 11:35 a.m., five resident were observed seated around the dining table and resident #3 was seated in a recliner. The hot box and cold cart containing the noon meal was delivered. No staff were present in the dining room. At 11:50 a.m., CMA #1 and CNA #1 were observed to transfer resident #3 from the recliner to a wheelchair and escort her to the dining table. At 12:00 p.m., CNA #1 and CMA #1 were observed to serve the noon meal to the eight residents seated at the dining table. CNA #1 sat at the dining table and assisted two residents with their meals. Two residents were observed eating independently. One resident was assisted by a private sitter. Resident #2, #3, and a third resident were observed to not eat. On 09/10/18 at 12:07 p.m., a family member was asked if there were usually enough staff to assist residents in a timely manner. The family member stated there was enough staff at the dining table but if any resident needed assistance in their room, they were not sure how the staff were to accommodate the need. At 12:10 p.m., resident #3 was observed to have drank fluids but not eaten. The CNA was heard to provide infrequent cueing to resident #3 while assisting the two other residents with their meals. At 12:20 p.m., resident #3 was observed to have drank fluids but not eaten. The CNA was heard to provide infrequent cueing to resident #3 while assisting the two other residents with their meals. A hospice nurse, visiting another resident, pulled a thickened drink from the refrigerator for resident #3. At 12:30 p.m., resident #3 was observed to have drank fluids but not eaten. The CNA was heard to provide infrequent cueing to resident #3 while assisting the two other residents with their meals. At 12:40 p.m., resident #3 was observed to have drank fluids but not eaten. The CNA was heard to provide infrequent cueing to resident #3 while assisting the two other residents with their meals. The resident's meal was removed. No physical assistance with meal intake had been provided to the resident. On 09/10/18 at 12:47 p.m., CMA #1 was asked if there was enough staff on the memory unit to provide timely assistance to all the residents. She stated they needed more help during meal times. On 09/10/18 at 1:05 p.m., CNA #1 was asked if there was enough staff on the memory unit to provide timely assistance to all the residents. She stated when everything ran smoothly there was enough staff for most needs but at mealtimes the residents needed more help. She stated resident #3 used to feed herself but since the consistency of her diet had changed, she would only take a few bites. On 09/10/18 at 4:30 p.m., CNA #2 was asked if there was enough staff on the memory unit to provide timely assistance to all the residents. She stated the residents needed more help during mealtimes but otherwise she felt the assigned staff were able to meet the residents needs in a timely manner. On 09/10/18 at 4:35 p.m., CMA #2 was asked if there was enough staff on the memory unit to provide timely assistance to all the residents. She stated more help was needed during mealtimes. She stated more residents required assistance with meals then what they could provide in a timely manner. She stated sometimes the private sitter for a resident may not show up and they would have to assist a resident with the meal in their room, or a resident may need bathroom assistance during mealtime. On 09/11/18 at 11:10 a.m., seven residents, including resident #2 and resident #3, were observed seated around the memory unit dining table. A private sitter was present at the table. There were no facility staff present. At 11:20 a.m., CMA #1 and CNA #1 were observed in the dining area. At 11:28 a.m., CNA #3 entered the memory unit with the hot box and cold cart. She stocked the refrigerator from the cold cart and distributed silverware. She stated she had been pulled from main dining today to help during dining in the memory unit. On 09/11/18 at 11:35 a.m., no food had been passed to residents. CNA #1 was observed to exit a resident's room. The CNA was asked how the facility ensured residents received timely assistance with activities of daily living. She stated they usually tried to have all the residents up and ready for lunch by 11:30 a.m. but today one resident was trying to have a bowel movement. She stated by now they normally tried to have the food served and her seated at the dining table assisting two residents with their meals. She stated she would cue resident #2 and #3 while assisting the others with their meal. On 09/11/18 at 11:45 a.m., CMA #1 was observed to exit a resident's room. She was asked how the facility ensured residents received timely assistance with activities of daily living. She stated they sometimes received extra help during mealtime, relied on private sitters to help the resident during mealtime, and kept plates in the hot box until someone was available to assist with their meals. On 09/11/18 at 12:45 p.m., the ADON was asked how the facility ensured residents on the memory unit were provided timely assistance with activities of daily living. She stated the staff provided personal care a minimum of every two hours and staffed the unit with either an LPN/CMA and a CNA or two CMA's. She was asked how they met the resident's needs during mealtime. She stated they usually have two staff present to assist the residents but they could call for another CNA/CMA to assist from the front. She stated light duty staff were also assigned to help in the memory unit but today they were assigned to a field trip. On 09/11/18 at 12:52 p.m., LPN #2 was asked how the facility ensured residents on the memory unit were provided timely assistance with activities of daily living. She stated nurse went back to the memory unit throughout the day to provide treatments. She stated if the two staff assigned to the unit needed further help, they usually called for assistance. On 09/11/18 at 12:55 p.m., the DON was asked how the facility ensured residents on the memory unit were provided timely assistance with activities of daily living. She stated the careplan informed the staff of how to care for the resident. She was asked if the needs of the residents on the memory unit changed from day to day. She stated yes and the staff would need to adjust as needed based on the care plan.

Based on interview and record review, it was determined the facility failed to develop a comprehensive care plan for activities for two (#13 and #21) of 19 sampled residents whose care plans were reviewed. Findings: A policy titled, Care Plans, documented, .Purpose: To assure that all disciplines coordinate the care of each resident .After the Resident Assessment Protocol is completed, the care plan will be updated to include additional or new information obtained during MDS completion .Add changes to the resident's status as they occur . 1. Resident #13 had [DIAGNOSES REDACTED]. A significant change assessment, dated 01/24/18, documented the resident was moderately impaired in cognition for daily decision making. The assessment documented the following daily and activity preferences: choosing what clothes to wear, caring for personal belongings, receiving showers, snacks between meals, family or significant other involvement in care discussions, and participating in religious activities or practices. Review of the resident's care plan did not reveal a care plan had been developed for activities. On 06/26/18 at 11:45 a.m., the resident was in her room with the TV on. She stated she enjoyed listening to TV programs at times. 2. Resident #21 had [DIAGNOSES REDACTED]. A significant change assessment, dated 02/09/18, documented the resident was moderately impaired in cognition for daily decision making. The assessment documented listening to music and participating in religious services were very important to the resident. Review of the care plan did not reveal a care plan had been developed for activities. On 06/27/18 at 4:44 p.m., the activity director was asked who was responsible to develop activity care plans. She stated for the past two weeks she had been responsible for developing activity care plans. She was asked why resident #13 and resident #21 did not have a care plan for activities. She stated if the resident had not had an MDS due in the past two weeks then she had not updated their care plan. On 06/27/18 at 5:12 p.m., the ADON was asked who was responsible to develop care plans. She stated it was a team effort. She was asked why an activity care plan was not developed for resident #13 and resident #21. She stated, I can't answer that.

Based on observation, interview, and record review, it was determined the facility failed to ensure: ~ humidifier bottles were changed on oxygen concentrators; ~ oxygen tubing was dated and labeled; and ~ filters on oxygen concentrators were kept clean and free of debris for one (#7) of one sampled resident who was reviewed for respiratory services. The facility identified one resident who utilized oxygen on a continuous basis. Findings: A policy titled, Oxygen Concentrator Procedure, dated (MONTH) (YEAR), documented, .Clean filter weekly (11-7 nursing staff) with soap and water, squeeze water out using a towel .Change humidifier bottle weekly and as needed when in use (11-7 nursing staff). Label bottle with date, time, and initial . Resident #7 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 02/27/18, documented the resident was moderately impaired in cognition for daily decision making, and received oxygen therapy while a resident. A care plan, dated 03/26/18, documented, .has a Dx of [MEDICAL CONDITION] .change o2 tubing and humidifier as applicable .has a Dx of [MEDICAL CONDITION] and requires oxygen at 2.5_L/min via nasal cannula to maintain adequate oxygen saturation rate .Rinse out air filter (sponge) at least once a week. This is located on the top, side or back of the oxygen machine .Change oxygen tubing weekly as per protocol . The monthly physician orders, dated (MONTH) (YEAR), documented, .change out oxygen tubing and humidifier if applicable .initial and date tubing .one time weekly . The treatment record, dated (MONTH) (YEAR), documented, .change out oxygen tubing and humidifier if applicable initial and date tubing . The treatment record, dated (MONTH) (YEAR), documented the oxygen tubing and humidifier had been changed on 06/02, 06/09, 06/16, and 06/23. On 06/19/18 at 11:19 a.m., the oxygen concentrator was observed to be in use by the resident. The filter was observed to be covered in light gray debris. The oxygen humidifier bottle was dated 05/21/18. The tubing was not dated. On 06/21/18 at 3:28 p.m., the oxygen concentrator was observed to be in use by the resident. The filter was observed to be covered in light gray debris. The oxygen humidifier bottle was dated 05/21/18. The tubing was not dated. On 06/26/18 at 8:51 a.m., the oxygen concentrator was observed to be in use by the resident. The filter was observed to be covered in light gray debris. The oxygen humidifier bottle was dated 05/21/18. The tubing was not dated. On 06/27/18 at 9:56 a.m., the oxygen concentrator was observed to be in use by the resident. The filter was observed to be covered in light gray debris. The oxygen humidifier bottle was dated 05/21/18. The tubing was not dated. On 06/27/18 at 4:02 p.m., LPN #1 was asked who was responsible to change/date oxygen tubing and humidifier bottles and clean the filters on oxygen concentrators. She stated she thought the weekend nurse changed them. She was asked how often the tubing and humidifier bottle was to be changed and the filter to be cleaned. She stated weekly. On 06/27/18 at 4:16 p.m., the ADON was asked who was responsible to change oxygen tubing and humidifier bottles, and clean the filters on oxygen concentrators. She stated the night shift nurse. She was asked how often they were to be changed/cleaned. She stated weekly. She was asked who was responsible to monitor the charge nurses to ensure the oxygen tubing and humidifier bottles were changed and the filter was clean on the oxygen concentrators. She stated it was a team effort. She stated if tubing was in use it was to be dated and initialed. She was asked where changing of the tubing and humidifier bottles and cleaning the filter on the oxygen concentrator was documented. She stated on the treatment record. She was asked to review the (MONTH) (YEAR) treatment record. She was asked why the oxygen tubing was not dated, the humidifier bottle was dated 05/21/18, and why the filter was covered in light gray debris. She stated, I couldn't answer that.

Based on interview and record review, it was determined the facility failed to ensure; ~ residents did not receive an anticoagulant medication without adequate monitoring for one (#4) of five sampled residents who were reviewed for unnecessary medications. The facility identified eight residents who received anticoagulant therapy; and ~ residents were given an antianxiety medication as ordered by the physician for one (#21) of five sampled residents who were reviewed for unnecessary medication. The facility identified 12 residents who received antianxiety medication. Findings: A facility policy titled, Medication Regimen Review, dated 04/23/15, documented, .Purpose .to provide routine oversight of each resident's medication regimen .The consultant Pharmacist will provide the Director of Nursing Services and Medical director with a written, signed, and dated copy of the report, listing the irregularities found and recommendations for their solutions . 1. Resident #4 had [DIAGNOSES REDACTED]. A care plan dated 10/01/17, documented, .Problems .Medication: (name withheld) has potential for bleeding related to anticoagulant therapy secondary to: Hx of embolis (sic) .Goals .Will receive anticoagulant therapy at therapeutic level and without adverse effects through the service plan period .Interventions .Administer anticoagulant ([MEDICATION NAME]) 2 mg daily as ordered .Encourage resident to maintain consistent diet of food with Vitamin K meaning do not increase or decrease excessively .Obtain INRs as ordered and report results to MD promptly . A quarterly assessment, dated 05/01/18, documented the resident was severely impaired in cognition for daily decision making and received anticoagulant medication seven days of the seven day look back period. A coagulation lab result, dated 05/03/18, documented, .PT 13.0 .reference range (10.5-15.7) .INR 1.1 .reference range (0.7-1.3) . The physician responded with a handwritten note which ordered no changes and to recheck the INR on 05/08/18. The lab result was signed and dated 05/07/18. A pharmacist consultation report, dated 05/30/18, documented, .(name withheld) receives a magnesium supplement but does not have a current serum magnesium concentration documented in the last six months . The monthly physician orders, dated 06/01/18, documented, .medications: [REDACTED].Magnesium oxide 400mg (1) tablet oral .every one day .9:00 am . On 06/04/18 the physician responded to the (MONTH) pharmacist consultation report accepting the recommendation for a magnesium level on the next lab day. A pharmacist consultation report, dated 06/20/18, documented, .(name withheld) has order to recheck an INR on 05/08/18, but at the time of this review they were not available in the resident record . A clinical review revealed no lab results for PT/INR or Magnesium levels. On 06/27/18 at 3:52 p.m., LPN #1 was asked how lab orders were processed. She stated any lab order would be placed in the facility's computer program, a requisition would be completed, and a verbal report given to the night shift. She stated the lab would pick up anything drawn that day. She was asked what days were scheduled lab days. She stated Tuesdays and Thursdays unless it was a stat order. She was asked if she was familiar with resident #4. She stated yes. LPN #1 was asked if the resident was currently on a long term anticoagulant and had an order for [REDACTED]. She was asked how the pharmacist recommendations were processed. She stated usually the ADON would review them, complete whatever she needed to do with them, then the ADON would paperclip them together and return them to the night shift nurse. She was asked to review resident #4's PT/INR result of 05/03/18. She was asked what the handwritten note had instructed. She stated it was to have the INR rechecked. She was asked if a PT/INR was completed on 05/08/18 as ordered. She stated she was not sure as there were reports that had not been filed, but she could call the lab to verify if the lab had been completed. On 06/27/18 at 4:08 p.m., the ADON was asked what the process was for processing the pharmacist recommendations. She stated the process was the night shift would be the one to follow up, since evening shift typically was busy with admissions. She stated all the recommendations would go through the shifts until each recommendation had been completed. She stated the process changed a couple of months ago. She stated the recommendations now come to her first. She was asked if a magnesium level had been collected for resident #4. She stated it was recently collected and should be in the basket to be filed. She was asked if the magnesium level had been collected following the pharmacist's second recommendation. She stated yes. She was asked why the magnesium level was not collected in (MONTH) when it was ordered. She stated two physicians would make rounds on the same day and the amount of orders to be processed became overwhelming. She was asked if the ordered PT/INR was collected in May. She stated she did not know if it had been completed, but if it had been it possibly had been misfiled. On 06/27/18 at 4:31 p.m., LPN #1 returned and stated she had contacted the lab and the 05/08/18 ordered PT/INR had not been completed. On 06/27/18 at 4:41 p.m., the ADON was asked if not having a timely PT/INR and magnesium level could have a detrimental outcome for the resident. She stated she thought anything could be detrimental for the resident. On 06/28/18 at 4:32 p.m., the facility provided copies of coagulation lab results dated 06/21/18 and a magnesium level dated 06/26/18. 2. Resident #21 was admitted with [DIAGNOSES REDACTED]. A physician telephone order, dated 04/18/18, documented, .[MEDICATION NAME] 1.5mg give 1 (1 mg) tab and 1/2 (1 mg) to equal 1.5mg at HS routine .[MEDICATION NAME] 1 mg/ml 0.5ml q 6 hours prn anxiety/agitation . On 04/25/18 at 12:20 a.m., the facility narcotic record for resident #21 documented the resident received [MEDICATION NAME] 1mg tablet and [MEDICATION NAME] 0.5mg tablet for a total dose of 1.5mg. On 04/26/18 at 3:47 a.m., the facility narcotic record for resident #21 documented the resident received [MEDICATION NAME] 1mg tablet and [MEDICATION NAME] 0.5mg tablet for a total dose of 1.5mg. On 04/27/18 at 2:40 a.m., the facility narcotic record for resident #21 documented the resident received [MEDICATION NAME] 1mg tablet and [MEDICATION NAME] 0.5mg tablet for a total dose of 1.5mg. The monthly physician orders, dated (MONTH) (YEAR), documented, .Medications .[MEDICATION NAME] 1mg tablet (1.5) tablet oral .9:00 p.m .[MEDICATION NAME] 0.5mg tablet (1) .as needed every six hours . On 05/02/18 at 1:00 a.m., the facility narcotic record for resident #21 documented the resident received [MEDICATION NAME] 1mg tablet and [MEDICATION NAME] 0.5mg tablet for a total dose of 1.5mg. On 05/03/18 at 12:15 a.m., the facility narcotic record for resident #21 documented the resident received [MEDICATION NAME] 1mg tablet and [MEDICATION NAME] 0.5mg tablet for a total dose of 1.5mg. On 05/03/18 at 3:32 p.m., the facility narcotic record for resident #21 documented the resident received [MEDICATION NAME] 1mg tablet and [MEDICATION NAME] 0.5mg tablet for a total dose of 1.5mg. A quarterly assessment, dated 05/04/18, documented the resident was severely impaired in cognition for daily decision making, minimal depression, and received an antianxiety medication seven days of the seven day look back period. A Medication Error Report, dated 05/04/18, documented, .[MEDICATION NAME] prn order changed on 4/18/18 to [MEDICATION NAME] 0.5mg q 6 hours prn, medication put into electronic system to read [MEDICATION NAME] 1.5mg q 6 hrs .no changes, give what was ordered . On 05/08/18 at 11:30 a.m., the facility narcotic record for resident #21 documented the resident received [MEDICATION NAME] 1mg. On 05/09/18 at 12:15 p.m., the facility narcotic record for resident #21 documented the resident received [MEDICATION NAME] 1mg. On 05/10/18 at 12:45 p.m., the facility narcotic record for resident #21 documented the resident received [MEDICATION NAME] 1mg. On 05/15/18 at 1:00 p.m., the facility narcotic record for resident #21 documented the resident received [MEDICATION NAME] 1mg. On 05/16/18 at 9:24 a.m., the facility narcotic record for resident #21 documented the resident received [MEDICATION NAME] 1mg. A physician telephone order, dated 05/22/18, documented, .Discontinue [MEDICATION NAME] 1mg/ml 0.5ml q 6 hr prn . On 06/27/18 at 4:18 p.m., the ADON was asked about the medication error incident report for resident #21. She stated the medication had been changed and put into the electronic medical record incorrectly. She was asked what interventions were implemented to prevent recurrence. She stated they now write the order on top of the narcotic record so they can compare them with the MAR.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free from significant medication errors for one (#183) of one resident observed to receive an anticoagulant medication during medication administration. The facility identified eight residents who received anticoagulant medications. Findings: A facility policy, dated 10/30/17, titled, Medication Management, documented, .Nursing shall follow the directions of the prescriber . Resident #183 had [DIAGNOSES REDACTED]. The care plan, dated 06/19/18, documented, .(resident name) is on anticoagulant therapy for: Hip Replacement and [MEDICAL CONDITION] .Give [MEDICATION NAME] 40 mg/0.4ml daily for 30 days injections as per orders . The physician order, dated 06/19/18, documented, .[MEDICATION NAME] 40 mg/0.4 mL subcutaneous syringe (40mg) SYRINGE (ML) Subcutaneous .ENCOUNTER FOR OTHER ORTHOPEDIC AFTERCARE .Frequency: Every One Day for Thirty Days Starting 06/19/2018 .Schedule: 9:00 am . On 06/21/18 at 12:00 p.m., LPN #2 was observed during medication administration observation. She was observed to administer [MEDICATION NAME] 40mg subcutaneously to resident #183. On 06/27/18 at 3:50 p.m., LPN #1 was asked what timeframe a medication, ordered to be given at 9:00 a.m., could be administered. She stated one hour before to one hour after the ordered time. On 06/27/18 at 4:10 p.m., the ADON was asked what timeframe a medication, ordered to be given at 9:00 a.m., could be administered. She stated between 8:00 a.m. and 10:00 a.m. On 06/28/18 at 9:40 a.m., LPN #2 was asked to review the physician's orders [REDACTED]. She stated between 8:00 a.m. and 10:00 a.m. She was asked why the [MEDICATION NAME] injection was administered at 12:00 p.m. on 06/21/18. She stated she was late giving the injection. She stated she was unable to give the injection until 12:00 p.m. due to other duties. On 06/28/18 at 12:15 p.m., the DON was asked who monitored staff to ensure medications were given on time. She stated they would need to check the electronic clinical record to see if actual times of medication administration were documented.

Based on observation, interview, and record review, it was determined the facility failed to maintain infection control and prevent cross-contamination related to placement of indwelling urinary catheter bags and tubing for two (#42 and #56) of two sampled residents whose urinary catheters were observed. The facility identified two residents who had indwelling urinary catheters. Findings: A policy titled, Catheter Care, documented, .Be sure the catheter tubing and drainage bag are kept off the floor . 1. Resident #42 had [DIAGNOSES REDACTED]. On 04/03/17 at 11:05 a.m., the resident was observed in his recliner with the urinary catheter drainage bag, in a pillow case, and the catheter tubing observed laying on the floor. On 04/03/17 at 11:23 a.m., the urinary catheter drainage bag, in a pillow case, and catheter tubing was observed to remain on the floor. On 04/03/17 at 1:51 p.m., the resident was observed in his room sitting in his wheel chair working with a physical therapist. The resident's catheter drainage bag, in a pillow case, was observed touching the floor. On 04/03/17 at 2:52 p.m., the resident was observed in bed. The catheter bag was observed hanging off the bed laying on the frame of the bedside table. On 04/04/17 at 8:20 a.m. the resident was observed in the main dining room sitting in his wheelchair. The catheter drainage bag, in a pillow case, was observed touching the dining room floor. On 04/04/17 at 9:21 a.m., the resident was observed being transported in his wheelchair by physical therapy down the hall. The resident's catheter drainage bag, in a pillow case, was observed with the bottom of the pillow case dragging under the wheel chair. On 04/04/17 at 10:52 a.m., the resident was in his room, sitting in his wheelchair. The catheter drainage bag, in a pillow case, was observed laying on the floor. On 04/04/17 at 1:15 p.m., CNA #1 was asked where indwelling urinary catheter bags and tubing were to be placed. She stated they were to be attached to the bed or wheel chair frame and off the floor. She was asked who was responsible to ensure indwelling urinary catheter bags and tubing were placed in a manner to maintain infection control and prevent cross-contamination. She stated the nurses and CNA's. On 04/04/17 at 2:54 p.m., the DON was asked where indwelling catheter bags and tubing would be placed in order to maintain infection control and prevent cross-contamination. She stated it was to be attached to the side of the bed and placed in a dignity bag or pillow case. She was asked if a catheter bag, in a pillow case or dignity bag, and/or catheter tubing was on the floor or on the frames of bedside tables would it be considered a potential breach in infection control. She stated yeah. 2. Resident #56 had [DIAGNOSES REDACTED]. The care plan, dated 01/23/17, documented, .Interventions: Attach catheter to bedside drain, ensure closed drainage system intact and not touching floor . On 03/28/17 at 10:35 a.m., the resident was in bed with the urinary catheter bag resting on the floor. At 3:25 p.m., the resident was observed in bed with his urinary catheter bag attached to the left side of the bedframe. The urinary catheter bag was observed on the floor. On 04/03/17 at 11:25 a.m., the resident was observed in bed with the urinary catheter bag laying on the floor. On 04/03/17 at 11:35 a.m., CNA #2 was asked what the facility policy was for placement of a urinary catheter bag and catheter tubing. She stated if the resident was in bed, it would be attached to the bedframe. At 1:50 p.m., the resident was observed in bed with the urinary catheter bag attached to the bedframe and resting on floor. At 4:10 p.m., the resident was observed in bed with the urinary catheter bag laying on the floor. On 04/04/17 at 11:10 a.m., the resident's urinary catheter bag was observed hanging upside down. The urinary catheter bag and tubing was in contact with the floor. At 1:50 p.m., the resident's urinary catheter bag was observed attached to the bedframe and laying on the floor. On 04/04/17 at 2:50 p.m., the DON was asked the proper placement of a urinary catheter bag and catheter tubing. She stated it should be attached to the side of the bed and in a privacy bag or covered with a pillow case but never on the floor. The DON was asked if a catheter bag and/or catheter tubing was observed on the floor would it be considered an infection control issue. She stated, Yes.

Based on observation, interview, and record review, it was determined the facility failed to develop a comprehensive care plan for one (#3) of one sampled residents whose comprehensive care plans were reviewed for pressure ulcers. This had the potential to effect all 40 residents. Findings: An undated policy titled, Care Plans, documented, .To assure that all disciplines coordinate the care of each resident. Procedure: After the Resident Assessment Protocol is completed, the care plan will be updated to include additional or new information obtained during MDS completion. Add changes to the resident's status as they occur . Resident #3 had [DIAGNOSES REDACTED]. A progress note, dated 08/29/16, documented, .Deep Tissue Injury observed to Rt. heel during skin assessment. Site measuring 2.7cm x 3.4cm area intact has Eschar noted and is firm to touch. Skin prep applied. Padded cushion placed to soft cast for comfort . A quarterly assessment, dated 11/10/16, documented the resident was moderately impaired in cognition. The assessment documented the resident had three unstageable pressure ulcers, two with slough and/or eschar and one suspected of evolving from a deep tissue injury. A quarterly assessment, dated 02/08/17, documented the resident was moderately impaired in cognition, had one stage II pressure ulcer, and two unstageable pressure ulcers. The care plan, dated 02/15/17, documented, .Skin: (Resident #3) has potential for impaired skin integrity related to incontinence and being at risk for pressure ulcer. Goals: Skin will remain intact without sign or symptoms of impaired skin through review date. Interventions: Apply barrier cream to peri area as needed; Encourage toileting upon rising, before and after meals, at bedtime and as needed; (Resident #3) wears pullups, check with each toileting and change as needed; Report any redness or break in skin to nursing with each shower and as needed . The resident's care plan did not include a problem related to pressure ulcers, measurable goals, or interventions. The dietary progress note, dated 03/29/17, documented, .Foot/heel wound care continues .[MEDICATION NAME] ordered - to help promote healing .Wound/skin care per physician order [REDACTED]. On 04/03/17 at 09:45 a.m., LPN #1 was observed while completing a dressing change for resident #3. The right heel was observed to have a large open wound with necrotic tissue along the back edge of the heel and pink through the center and forward. There was also an open wound to the right inner ankle. On 04/04/17 at 11:15 a.m., the ADON was asked who was responsible for developing resident care plans. She stated she was. She was asked how she determined what care areas to care plan. She stated she developed her care plan from what triggered on the comprehensive and quarterly assessments, nursing staff, resident families, clinical records, and whatever was pertinent to the resident. She was asked how she received her information to care plan. She stated she received a copy of any new physician's orders [REDACTED]. She was asked to review the resident's care plan for the presence of pressure ulcers. She stated she had not developed a care plan related to the presence of pressure ulcers. She was asked if pressure ulcers would be an area of concern to suggest the need for a plan of care. She stated, Yes.

Based on observation, interview, and record review, it was determined the facility failed to ensure staff maintained privacy and confidentiality of residents' clinical information for two (#2 and #12) of 10 residents who resided in the memory unit. This had the potential to affect all 39 residents who resided in the facility. Findings: On 01/27/16 at 5:31 p.m., the evening meal was observed in the common area of the memory unit. Three residents and two visitors were seated at one of the dining tables. Next to the dining table was the medication cart which was unattended. On top of the medication cart was a facility computer used to document medication administration. The screen was visible with resident #12's picture, personal information, and medications to be administered. At 5:34 p.m., LPN #1 approached the unattended cart. She was asked what the facility's policy was regarding resident information left exposed and unattended. She stated, We're not supposed to. I'm sorry. At 5:40 p.m., a notebook was observed on a table next to the medication cart. On top of the notebook was the facility's resident room roster which contained the names of all the residents in the facility and room numbers. On the other side of the medication cart was a counter top. A visual check form was observed laying on the counter top with timed documentation for resident #2. No staff members were observed monitoring the visualization of confidential resident information. At 5:45 p.m., CNA #1 approached the table next to the medication cart. She was shown the exposed resident information left unattended. She was asked what the facility's policy was regarding resident information left exposed and unattended. She stated, Your not suppose to leave it out where people can see it. She was asked if resident information was left exposed and visible would it be considered a breach of confidentiality. She stated, Yea, I would say it's a HIPAA violation. When the surveyor left the memory unit at 5:55 p.m., the resident information continued to remain on the table and counter top. On 01/28/16 at 10:20 a.m., the DON was asked what the facility's policy was regarding resident information. She stated only the people needed to do a particular job should have access to the information. She stated when the information is not needed it should not be visible. She was asked if it was ever appropriate to leave resident information exposed and unattended. She stated, No.

Based on interview and record review, it was determined the facility failed to perform assessments which accurately reflected the resident's status for two (#4, #6) of eight sampled residents whose assessments were reviewed. This had the potential to effect all 39 residents who resided in the facility. Findings: An undated facility policy, titled Resident Assessment Instrument (RAI) Completion, documented, .Purpose .It is the policy of this facility to complete an RAI on each resident as required by regulations .Procedure .The facility will follow the guidelines as set forth in the CMS's RAI User's Manual or as published by the federal or state government .Responsibility for completing sections of the MDS will be assigned to staff who have clinical knowledge about the resident . 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment, dated 02/24/15, documented the resident was able to understand others and make herself understood. The assessment question, .Should Brief Interview for Mental Status (C0200-C0500) be Conducted? was marked with a dash (-). The assessment questions for the Brief Interview for Mental Status were marked with a dash (-) instead of a numerical score. The assessment summary score documented, .Add score for question C0200-C0400 and fill in total score (00-15). Enter 99 if the resident was unable to complete the interview . The summary score was indicated with a zero and a dash (0-). The assessment question titled, .Staff Assessment for Mental Status , documented the resident's short and long term memory were ok and the resident was able to recall the current season, location of own room, and that she was in a nursing home. The assessment question, .Should Resident Mood Interview be Conducted? , was marked with a dash (-). The Resident Mood Interview documented, .Say to resident: 'Over the last 2 weeks, have you been bothered by any of the following problems?' . Questions A through J were each documented with a dash (-). The total severity score documented, .Add score for all frequency responses in Column 2. Symptom Frequency. Total score must be between 00 and 27. Enter 99 if unable to complete interview (i.e. Symptom Frequency is blank for 3 or more items.) . The total severity score was indicated with a zero and a dash (0-). The assessment question, .Should Interview for Daily and Activity Preferences be Conducted? - Attempt to interview all residents able to communicate. If resident is unable to complete, attempt to complete interview with family member or significant other . The answer was marked yes. The interview for daily preferences, questions A through H, were answered based on a scripted coding system. The interview for activity preferences, questions A through H, were answered based on a scripted coding system. The assessment question, .How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair); Code for most dependent in serlf-performance and support. A. Self-performance ~ 0. Independent - no help provided. ~ 1. Supervision - oversight help only. ~ 2. Physical help limited to transfer only. ~ 3. Physical help in part of bathing activity. ~ 4. Total dependence. ~ 8. Activity itself did not occur or family and/or non-faciility staff provided care 100% of the time for that activity over the entire 7-day period. B. Support provided (Bathing support codes are as define in item G0110 column 2, ADL Support Provided above) . Both questions regarding resident bathing were marked with a dash (-). The assessment documented the resident received scheduled pain medication. The assessment question, .Should Pain Assessment Interview be Conducted? Attempt to conduct interview with all residents. If resident is comatose, skip . The answer was marked with a dash (-). The assessment question regarding presence of pain, documented, .Ask resident: 'Have you had pain or hurting at any time in the last 5 days?' . ~ 0 No - Skip to J1100 . ~ 1 Yes - Continue to J0400, Pain Frequency . ~ 9 Unable to answer - Skip to J0800, Indicators of Pain or Possible Pain . The question was answered with a dash (-). The assessment question regarding frequency of pain, documented, .Ask resident: 'How much of the time have you expereinced pain or hurting over the last 5 days?' . ~ 1. Almost constantly ~ 2. Frequently ~ 3. Occasionally ~ 4. Rarely ~ 9. Unable to answer . The question was answered with a dash (-). The assessment question regarding the effect of pain on function documented, .A. Ask resident: 'Over the past 5 days, has pain made it hard for you to sleep at night?' . ~ 0. No ~ 1. Yes ~ 9. Unable to answer . B. Ask resident: 'Over the past 5 days, have you limited your day-to-day activities because of pain?' . ~ 0. No ~ 1. Yes ~ 9. Unable to answer . Both questions were each answered with a dash (-). The assessment question regarding the intensity of pain, documented, .Administer ONLY ONE of the following pain intensity questions (A or B) .A. Numeric Rating Scale (00-10) Ask resident: 'Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine.' .Enter two-digit response. Enter 99 if unable to answer .B. Verbal Descriptor Scale. Ask resident: 'Please rate the intensity of your worst pain over the last 5 days.' . ~ 1. Mild ~ 2. Moderate ~ 3. Severe ~ 4. very severe, horrible ~ 9. Unable to answer . Both questions were each answered with a dash (-). A clinical note, dated 02/24/15, documented, .I met with (resident #4) to complete her assessment. Her responses are recorded in MDS Section F (preferences). Faith and family are very important to (resident #4) and the two main things that keep her going . On 01/26/16 at 4:30 p.m., the MDS coordinator was asked what the dashes (-) indicated for the resident interview sections of the comprehensive assessment. She stated the areas which were marked with dashes (-) were to be completed by social services. The MDS coordinator was asked if social services was responsible for performing the pain assessment. She stated, They did for a time period. The MDS coordinator was asked why the staff interview for resident cognition was performed instead of the resident interview for cognition. She stated, When cognitive was documented with a zero and a dash (0-), you have to dash the staff interview too. The MDS coordinator was asked if the resident was out of the facility. She stated, No, she just came off hospice. The MDS coordinator was asked why the staff interview for resident mood was performed instead of the resident interview for mood. She stated, mood was documented as a zero and a dash (0-). Staff (interview) was a 03 but should not have been done because the resident interview was dashed (-). I moved the ARD (assessment reference date) from the 23rd to the 24th to capture the resident interview on preferences done by (activities director) in activities. The MDS coordinator was asked why the resident's bathing was not assessed in the seven day look back period provided. She stated, I even pushed past the 14 day assessement to count days. I could have put eights (activity did not occur) but without all the documentation, I could not say for certain. When I spoke with the nurse aides, they were accustomed to the resident receiving her bath from hospice and did not know she was no longer on hospice. Now, looking back at the documentation from a year ago, I should have marked it as an eight. On 01/28/16 at 9:35 a.m., the social service director was asked if she was responsible for the resident interview sections of the resident assessments. She stated she was responsible for performing the interviews for a time a few years ago but not currently. The social service director was asked if she performed the interviews for the comprehensive assessment for resident #4. She stated, To my recollection, I had stopped doing interviews. I will have to look. There was all these discrepancies with my doing a portion of the assessment and (MDS coordinator) doing a portion. The social service director was asked if the sections of the resident assessment which required a resident interview should have been completed. She stated, Well, yes. The social service director was asked if the resident assessment was available for interview for the assessment dated [DATE]. She stated, Well, yes. On 01/28/15 at 1:40 p.m., the DON was shown the assessment dated [DATE] for resident #4 and asked who was responsible for ensuring the accuracy of the assessment. She stated the MDS coordinator was responsible for the accuracy of the assessment. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment, dated 09/10/15, documented the resident was able to understand others and make herself understood. The Brief Interview for Mental Status was scored at a 15 which indicated the resident was cognitively intact. The quarterly assessment, dated 12/11/15, documented the resident was able to understand others and could make herself understood. The assessment question, .Should Brief Interview for Mental Status (C0200-C0500) be Conducted? was marked yes. The assessment questions for the Brief Interview for Mental Status were marked with a dash (-) instead of a numerical score. The assessment summary score documented, .Add score for question C0200-C0400 and fill in total score (00-15). Enter 99 if the resident was unable to complete the interview . The summary score was indicated with a zero and a dash (0-). The assessment question .Should Resident Mood Interview be Conducted? was marked yes. The Resident Mood Interview documented, .Say to resident: 'Over the last 2 weeks, have you been bothered by any of the following problems?' . Questions A through J were each documented with a dash (-). The total severity score documented, .Add score for all frequency responses in Column 2. Symptom Frequency. Total score must be between 00 and 27. Enter 99 if unable to complete interview (i.e. Symptom Frequency is blank for 3 or more items.) . The total severity score was indicated with a zero and a dash (0-). The assessment question .Should Interview for Daily and Activity Preferences be Conducted? - Attempt to interview all residents able to communicate. If resident is unable to complete, attempt to complete interview with family member or significant other . The answer was left blank. The interview for daily preferences, questions A through H, were left blank. The interview for activity preferences, questions A through H, were left blank. The assessment question, .Should Pain Assessment Interview be Conducted? Attempt to conduct interview with all residents. If resident is comatose, skip . The answer was marked yes. The assessment question regarding presence of pain, documented, .Ask resident: 'Have you had pain or hurting at any time in the last 5 days?' . ~ 0 No - Skip to J1100 . ~ 1 Yes - Continue to J0400, Pain Frequency . ~ 9 Unable to answer - Skip to J0800, Indicators of Pain or Possible Pain . The question was answered with a dash (-). The assessment question regarding frequency of pain, documented, .Ask resident: 'How much of the time have you expereinced pain or hurting over the last 5 days?' . ~ 1. Almost constantly ~ 2. Frequently ~ 3. Occasionally ~ 4. Rarely ~ 9. Unable to answer . The question was answered with a dash (-). The assessment question regarding the effect of pain on function documented, .A. Ask resident: 'Over the past 5 days, has pain made it hard for you to sleep at night?' . ~ 0. No ~ 1. Yes ~ 9. Unable to answer . B. Ask resident: 'Over the past 5 days, have you limited your day-to-day activities because of pain?' . ~ 0. No ~ 1. Yes ~ 9. Unable to answer . Both questions were each answered with a dash (-). The assessment question regarding the intensity of pain, documented, .Administer ONLY ONE of the following pain intensity questions (A or B) .A. Numeric Rating Scale (00-10) Ask resident: 'Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine.' .Enter two-digit response. Enter 99 if unable to answer .B. Verbal Descriptor Scale. Ask resident: 'Please rate the intensity of your worst pain over the last 5 days.' . ~ 1. Mild ~ 2. Moderate ~ 3. Severe ~ 4. very severe, horrible ~ 9. Unable to answer . Both questions were each answered with a dash (-). The assessment question, .Participation in assessment .resident participated in assessment . was marked yes. On 01/28/15 at 1:10 p.m., the MDS coordinator was asked why the resident assessment questions requiring a resident interview were answered with a (-). She stated an alternate nurse was responsible for performing the resident interview assessments and when they were not completed within the specified timeframe, she could only document dashes (-) for each interview question. On 01/28/15 at 1:40 p.m., the DON was shown the assessment dated [DATE] for resident #6 and asked who was responsible for ensuring the accuracy of the assessment. She stated each person involved with the resident assessment had their own electronic signature and the MDS coordinator was responsible for the accuracy of the assessment.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision of an unlocked medication cart for one (#7) of one sampled resident who wandered in the memory unit. The facility identified one resident who wandered in the memory unit. Findings: An undated facility policy, titled Storage and expiration dating of medications, biologicals, syringes and needles, documented, .The Community should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room, inaccessible by residents and visitors . Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/11/16, documented the resident was moderately impaired in cognition for daily decision making, had disorganized thinking, inattention, had trouble concentrating on things, and used a wheelchair for mobility. An undated care plan, documented, .Problems .COGNITIVE DEFICIT .has impaired cognitive deficit as shown by impaired decisional abilities due to short term memory loss r/t Dementia .demonstrates poor decision making and impaired safety awareness. She needs cues and supervision from staff daily . Interventions .Coach through process when decisions are poor .Give directions, cues, reminders or orientation as needed to situation or event as needed . On 01/26/16 at 10:45 a.m., the memory unit was observed with an unlocked medication cart in the living room. Resident #7 was observed as she moved about the living room in her wheel chair. No staff was observed in the living room. At 10:49 a.m., resident #7 was observed as she sat in her wheelchair beside the unlocked medication cart. At 10:54 a.m., housekeeper #1 and #2 entered the living room and went to room 312 where housekeeper #3 was located. From 10:45 a.m. until 10:54 (nine minutes), resident #7 was observed unsupervised in the living room with the medication cart unlocked. At 10:56 a.m., housekeeper #1 and #2 left the memory unit and housekeeper #3 went back into room 312 where she had no view of the medication cart. At 10:56 a.m., CNA #2 wheeled resident #2 to a table in the living room and then exited the memory unit. At 11:01 a.m., CMA #1 entered the living room and answered the telephone exited the living room resident #7's room. From 10:56 a.m. through 11:01 a.m., (five minutes) resident #7 was observed unsupervised in the living room with an unlocked med cart, as she propelled herself around the living area. On 01/28/16 at 9:29 a.m., CMA #1 was observed as she retrieved a medication from the medication cart and went into room 315. The medication cart was unlocked and CMA #1 did not have the cart within her sight. CNA #3 was in the living room at the time. On 01/28/16 at 9:39 a.m., CMA #1 was asked what the facility's policy was regarding locking the medication cart. She stated the medication cart was to be locked every time you walk away from it. She was asked why was the medication cart unlocked for approximately 20 minutes on 01/26/16. She stated she must have thought she had locked it. She was asked how she ensured residents are provided supervision and not have access to unlocked medication carts. She stated, I don't have any resident who can walk and I keep it locked and no medications are left on the cart. She was asked who was responsible to ensure medication carts are locked. She did not respond. On 01/28/16 at 9:41 a.m., CMA #2 was asked what the facility's policy was regarding locking the medication cart. She stated when you are away from the cart it was to be locked. On 01/28/16 at 9:43 a.m., the ADON was asked what the facility's policy was regarding providing supervision of residents from accessing the medication cart. She stated, The med cart should be locked when no one is there. She was asked what the consequences were of an unlocked medication cart. She stated, Anything can be taken out of the cart except narcotics. She was asked what the consequences were of an unlocked medication cart in the memory unit. She stated, Same. She was asked why the medication in the memory unit was unlocked. She stated, They should all know the policy. If no one at the med cart, it was to be locked. On 01/28/16 at 10:08 a.m., the DON was asked what the facility's policy was regarding locked medication carts. She stated, Locked all the time if not working at the cart. She was asked why was a medication cart unlocked for 20 minutes in the memory unit. She stated it should never be unlocked. She was asked what the consequences were of an unlocked medication cart in the memory unit. She stated the residents were exposed to medications. She was asked who was responsible to ensure medication carts are locked. She stated, The person who has the keys. CMAs.

Based on interview and record review, it was determined the facility failed to ensure residents did not receive unnecessary medications without adequate monitoring for two (#4, #6) of four residents whose clinical records were reviewed for psychoactive medications. The facility identified 23 residents on psychoactive medications. Findings: An undated facility policy, titled Monitoring the Side Effects for Psychotherapeutic Medications, documented, .Purpose .To assess for early signs of possible side effects from psychotherapeutic medications .Procedure .Monitor the resident for possible side effects . 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The behavior monitoring psychoactive flow record, dated January 2015, documented the resident was monitored for paranoia, pacing, and crying out related to the administration of [MEDICATION NAME] and [MEDICATION NAME]. ~ First shift documented the resident had no behaviors nor displayed any side effects for 22 of 31 days. There were nine dates with no documentation of the number of behavioral episodes nor side effects the resident displayed. ~ Second shift documented the resident had no behaviors nor displayed any side effects for 31 of 31 days. ~ Third shift documented the resident had no behaviors nor displayed any side effects for 19 of 31 days. There were 12 dates with no documentation of the number of behavioral episodes nor side effects the resident displayed. Review of the clinical record revealed no documentation for behavior monitoring for February 2015. The comprehensive assessment, dated 02/24/15, documented no behaviors were present. The assessment also documented the resident received an antidepressant and an antianxiety medication for seven out of the last seven days of the look back period. The behavior monitoring psychoactive flow record, dated March 2015, documented the resident was monitored for delusions and restlessness related to the administration of Tylenol PM, [MEDICATION NAME], and [MEDICATION NAME]. ~ First shift documented the resident had no behaviors nor displayed any side effects for 22 of 31 days. There were nine dates with no documentation of the number of behavioral episodes nor side effects the resident displayed. ~ Second shift documented the resident had no behaviors nor displayed any side effects for 14 of 31 days. There were 17 dates with no documentation of the number of behavioral episodes nor side effects the resident displayed. ~ Third shift documented the resident displayed a behavior for 18 of 31 days. There were 13 dates with no documentation of the number of behavioral episodes the resident displayed. The third shift documented there were 18 of 31 days the resident displayed no side effects to the psychoactive medications. There was no documentation if the resident displayed side effects to the psychoactive medication for 13 of 31 days. The care plan, dated 03/06/15, documented, .Problems: [MEDICAL CONDITION]-Anti depressant: (Resident) is prescribed [MEDICATION NAME] for depression .Goals: (resident) will continue to be free of distress related to depression, aand (sic) will be free from adverse reactions to [MEDICATION NAME] for the next 90 days .Interventions: Notify MD if side effects are observed .Monitor for effectiveness .Assess for continued need. If need continues, maintain on lowest possible effective dosage .Monitor for GI side effects, dry mouth, nausea, diarrhea, anorexia, dyspepsia, vomiting, abnormal pain, taste perversion, increased saliva, flatulence, decreased and increased weight gain, increased appetite .Monitor for other side effects, diaphoresis, asthenia, weight loss, rash yawning (sic), chills, infection . Problem: [MEDICAL CONDITION] - [MEDICATION NAME] - (Resident#4) has Dx of anxiety and has active s/s of anxiety at times and need her [MEDICATION NAME] to help reduce the anxiety .Goals: (resident) will continue to have no drug related side effects and will remain content and free of S/S of distress for the next 90 days .Interventions: Notify physician if side effects are observed .Monitor for effectiveness and continued need .If need continues, maintain on lowest possible effective dosage .Monitor for side effects of medication dizziness, drowsiness, confusion, headache, anxiety, tremors, stimulation, fatigue, depression, [MEDICAL CONDITION], hallucinations, constipation, dry mouth, nausea, vomiting, anorexia, diarrhea, rash, [MEDICAL CONDITION], itching, orthostatic,(sic) [MEDICAL CONDITION], ECG changes, [MEDICAL CONDITION] huptenison (sic), blurred vision, tinnitus, mydriasis .record behavior on Behavior Tracking Form. Observe for episodes of anxiety . The behavior monitoring psychoactive flow record, dated April 2015, documented the resident was monitored for delusions and restlessness related to the administration of [MEDICATION NAME] and [MEDICATION NAME]. ~ First shift documented the resident had no behaviors nor displayed any side effects for 30 of 30 days. ~ Second shift documented the resident had no behaviors nor displayed any side effects for 28 of 30 days. There were two dates with no documentation of the number of behavioral episodes nor side effects the resident displayed. ~ Third shift documented the resident displayed a behavior for 10 of 30 days. There were two dates which documented the resident had no behaviors. There were 18 dates with no documentation of the number of behavioral episodes the resident displayed. Third shift documented there were 12 of 30 days the resident displayed no side effects to the psychoactive medications. There was no documentation if the resident displayed side effects to the psychoactive medication for 18 of 30 days. Review of the clinical record revealed no documentation for behavior monitoring for May 2015. The pharmacy consultation report, dated 05/19/15, documented, .(resident #4) behavior monitoring documentation appears not to be maintained completely. Only side effects are being monitored for [MEDICATION NAME] for anxiety. Recommendation: Please update behavior monitoring . The behavior monitoring psychoactive flow record, dated June 2015, documented the resident was monitored for paranoia and delusions related to the administration of [MEDICATION NAME], melantonin, and [MEDICATION NAME]. ~ First shift documented the resident had no behaviors nor displayed any side effects for 26 of 30 days. There were four dates with no documentation of the number of behavioral episodes nor side effects the resident displayed. ~ Second shift documented the resident had no behaviors nor displayed any side effects for 28 of 30 days. There were two dates with no documentation of the number of behavioral episodes nor side effects the resident displayed. ~ Third shift documented the resident had no behaviors nor displayed any side effects for 12 of 30 days. There were 18 dates with no documentation of the number of behavioral episodes nor side effects the resident displayed. Review of the clinical record revealed no documentation for behavior monitoring for July 2015. Review of the clinical record revealed no documentation for behavior monitoring for August 2015. The pharmacy consultation report, dated 08/18/15, documented, .(Resident #4) behavior monitoring record appears not to be maintained completely; that is, it is missing the following items: Behavior modifications on section L-O of behavior sheet. Recommendation: Please update behavior sheet . The Medication Administration Record [REDACTED] ~ .[MEDICATION NAME] 10 mg (1) Tablet Oral Every One Day Starting 11/13/2014 .Order Date: 11/12/2014 Notes: Depression . ~[MEDICATION NAME] 5 mg (1) Tablet Oral Hour of Sleep Starting 04/27/2015 .Notes: [MEDICAL CONDITION] . ~[MEDICATION NAME] 0.5 mg (1 tab) Tablet Oral Two Times Daily Starting 05/20/2015 .Anxiety State . Review of the clinical record revealed no documentation for behavior monitoring for September 2015. The Medication Administration Record [REDACTED] ~ .[MEDICATION NAME] 10 mg (1) Tablet Oral Every One Day Starting 11/13/2014 .Notes: Depression . ~[MEDICATION NAME] 5 mg (1) Tablet Oral Hour of Sleep Starting 04/27/2015 .Notes: [MEDICAL CONDITION] . ~[MEDICATION NAME] 0.5 mg (1 tab) Tablet Oral Two Times Daily Starting 05/20/2015 .Anxiety State . Review of the clinical record revealed no documentation for behavior monitoring for October 2015. The Medication Administration Record [REDACTED] ~ .[MEDICATION NAME] 10 mg (1) Tablet Oral Every One Day Starting 11/13/2014 .Notes: Depression . ~[MEDICATION NAME] 5 mg (1) Tablet Oral Hour of Sleep Starting 04/27/2015 .Notes: [MEDICAL CONDITION] . ~[MEDICATION NAME] 0.5 mg (1 tab) Tablet Oral Two Times Daily Starting 05/20/2015 .Anxiety State . Review of the clinical record revealed no documentation for behavior monitoring for November 2015. The quarterly assessment, dated 11/22/15, documented there were no behaviors present. The assessment also documented the resident received an antidepressant and an antianxiety for seven of the last seven days during the look back period. The pharmacy consultation report, dated 11/30/15, documented, .Comment: (Resident #4) has been taking [MEDICATION NAME] 0.5 mg BID for anxiety since 5/20/15. Recommendation: Please consider a gradual dose reduction, perhaps decreasing to [MEDICATION NAME] 0.25 mg BID for anxiety . The pharmacy consultation report was marked with an (X) beside .I decline the recommendation(s) above because GDR is CLINICALLY CONTRAINDICATED for this individual as indicated below .(X) The resident's target symptoms returned or worsened after the most recent GDR attempt within the facility and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder AS DOCUMENTED BELOW . The pharmacy consultation report rationale describing why a GDR attempt was likely to impair function or cause psychiatric instability was documented as, .Resident anxiety has increased d/t increase stimulation from the holidays. Will consider in the next 90 days. (signed as a telephone order from the resident's physician to the DON on 01/05/16) . The behavior monitoring psychoactive flow record, dated December 2015, documented the resident was monitored for paranoia and crying out related to the administration of [MEDICATION NAME], and [MEDICATION NAME]. ~ First shift documented the resident had no behaviors nor displayed any side effects for 30 of 31 days. There was one date with no documentation of the number of behavioral episodes nor side effects the resident displayed. ~Second shift documented the resident had no behaviors nor displayed any side effects for 23 of 31 days. There were eight dates with no documentation of the number of behavioral episodes nor side effects the resident displayed. ~Third shift documented the resident had no behaviors nor displayed any side effects for 15 of 31 days. There were sixteen dates with no documentation of the number of behavioral episodes nor side effects the resident displayed. The pharmacy consultation report, dated 12/28/15, documented, .Comment: (Resident #4) has been taking [MEDICATION NAME] 10 mg q d since 11/12/14. Recommendation: Please consider a gradual dose reduction, perhaps decreasing to [MEDICATION NAME] 5 mg q d for depression . The pharmacy consultation report was marked with an (X) beside .I decline the recommendation(s) above because GDR is CLINICALLY CONTRAINDICATED for this individual as indicated below .(X) Continued use is in accordance with the current standard of practice and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder AS DOCUMENTED BELOW . The pharmacy consultation report rationale describing why a GDR attempt was likely to impair function or cause psychiatric instability was documented as, .Reduction unwarranted due to recent increase agitation, resident needs time to adjust to stable environment. (signed as a telephone order from the resident's physician to the DON on 01/15/16) . The behavior monitoring psychoactive flow record, dated January 2016, documented the resident was monitored for paranoia and crying out related to the administration of [MEDICATION NAME], and [MEDICATION NAME]. ~ First shift documented the resident had no behaviors nor displayed any side effects for 27 of 27 days. ~Second shift documented the resident had no behaviors nor displayed any side effects for 26 of 27 days. There was one date with no documentation of the number of behavioral episodes nor side effects the resident displayed. ~Third shift documented the resident had no behaviors nor displayed any side effects for 24 of 28 days. There were four dates with no documentation of the number of behavioral episodes nor side effects the resident displayed. On 01/28/16 at 9:35 a.m., the medical records person was asked for the behavior logs for the months of February, May, July, August, September, October, and November for resident #4 for the year 2015. No documentation was provided. On 01/28/16 at 11:15 a.m., the medical records person was asked again for the behavior logs for resident #4. She stated she had been unable to find any of the requested behavior logs. She said, Medicare (records) comes to me and long term care goes to (alternate staff member) to put in the resident's chart. We have decided it should all go to one person. It should have been in their medical record or here in their thinned chart. On 01/28/16 at 2:50 p.m., the DON was asked for the behavior logs for resident #6. The DON stated the facility staff had looked for the missing behavior logs for resident #6 and she was aware the documentation had not been located. The DON was asked what was the facility policy for medication monitoring. She stated the facility staff monitored [MEDICAL CONDITION] medications. The DON was asked what was the facility monitoring for with the [MEDICAL CONDITION] medications. She stated the staff monitored side effects of the medications and what particular behavior the medication was to reduce. She was asked who was responsible to ensure documentation was complete. The DON stated she was ultimately responsible for the completeness of the documentation. The DON was shown the available behavior logs for resident #6 and asked if the clinical record for resident #6 was complete and accurate related to the behavior monitoring psychoactive flow record. She reviewed the documentation and stated, No. There is some missing documentation there. The DON was asked how she monitored the use of [MEDICAL CONDITION] medications. She stated staff normally performed a sight check weekly. She also stated new [MEDICAL CONDITION] medication orders were reviewed each month and the contracted pharmacist reviewed the charts and requested medication monitoring if none were found. The DON was asked how the facility monitored for unnecessary medications. She stated the pharmacist checked monthly during his medication review. The DON was asked what the facility policy was for monitoring [MEDICAL CONDITION] medications. She stated, We should do daily charting on all shifts for those residents on [MEDICAL CONDITION]'s. On 01/28/16 at 3:25 p.m., the pharmacist was asked who was responsible for monitoring for the use of unnecessary medications. He stated, I review the behavior sheets each month. Usually only issue is when medication is started or a new resident enters on medication which requires monitoring and the monitoring is not started. The pharmacist was asked how often he checked the residents for unnecessary medications. He stated he checked the residents monthly for unnecessary medications. He stated he was aware there were behavior monitoring sheets missing but he had reviewed the behavior monitoring sheets monthly. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The behavior monitoring psychoactive flow record, dated February 2015, documented the resident was monitored for side effects only with no medications documented on the form to monitor for side effects. The resident was admitted on [DATE]. ~ First shift documented the resident had no side effects for 15 of 20 days. There were five dates with no documentation of the number of side effects the resident displayed. ~ Second shift documented the resident had no side effects for 20 of 20 days. ~ Third shift documented the resident had no side effects for 11 of 20 days. There were nine dates with no documentation of the number of side effects the resident displayed. Review of the clinical record revealed no documentation for behavior monitoring for March 2015. Review of the clinical record revealed no documentation for behavior monitoring for April 2015. Review of the clinical record revealed no documentation for behavior monitoring for May 2015. The behavior monitoring psychoactive flow record, dated June 2015, documented the resident was monitored for side effects only related to the administration of [MEDICATION NAME], and [MEDICATION NAME]. ~ First shift documented the resident had no side effects for 27 of 30 days. There were three dates with no documentation of the number of side effects the resident displayed. ~ Second shift documented the resident had no side effects for 28 of 30 days. There were two dates with no documentation of the number of side effects the resident displayed. ~ Third shift documented the resident had no side effects for 17 of 30 days. There were 13 dates with no documentation of the number of side effects the resident displayed. Review of the clinical record revealed no documentation for behavior monitoring for July 2015. Review of the clinical record revealed no documentation for behavior monitoring for August 2015. The pharmacy consultation report, dated 08/18/15, documented, .(Resident #6) receives an anxiolytic, [MEDICATION NAME] for anxiety. Only side effects are being monitored on the behavior sheet. Recommendation: Please consider updating behavior monitoring for this medication to include 'acceptable' target behavior . There was no documentation of behavior monitoring psychoactive flow record for the month of September 2015. The Medication Administration Record [REDACTED] ~[MEDICATION NAME]-[MEDICATION NAME] 25-100 mg (1) Tablet Oral Three Times Daily starting 02/09/2015 . ~[MEDICATION NAME] 10 mg (1) Tablet Oral Hour Of Sleep Starting 05/06/2015 . ~[MEDICATION NAME] 25 mg (1 tab) tablet Oral Hour of Sleep Starting 05/14/2015 . ~[MEDICATION NAME] 10 mg (1) Capsule Oral Hour Of Sleep Starting 05/20/2015 . The comprehensive assessment, dated 09/10/15, documented there were no behavior symptoms present. The assessment also documented the resident received an antidepressant and an antianxiety for seven out of the last seven days. Review of the clinical record revealed no documentation for behavior monitoring for October 2015. The Medication Administration Record [REDACTED] ~[MEDICATION NAME]-[MEDICATION NAME] 25-100 mg (1) Tablet Oral Three Times Daily starting 02/09/2015 . ~[MEDICATION NAME] 10 mg (1) Tablet Oral Hour Of Sleep Starting 05/06/2015 . ~[MEDICATION NAME] 25 mg (1 tab) tablet Oral Hour of Sleep Starting 05/14/2015 . ~[MEDICATION NAME] 10 mg (1) Capsule Oral Hour Of Sleep Starting 05/20/2015 . Review of the clinical record revealed no documentation for behavior monitoring for November 2015. The Medication Administration Record [REDACTED] ~[MEDICATION NAME]-[MEDICATION NAME] 25-100 mg (1) Tablet Oral Three Times Daily starting 02/09/2015 . ~[MEDICATION NAME] 10 mg (1) Tablet Oral Hour Of Sleep Starting 05/06/2015 .Discontinued 11/11/2015 ~[MEDICATION NAME] 25 mg (1 tab) tablet Oral Hour of Sleep Starting 05/14/2015 . ~[MEDICATION NAME] 10 mg (1) Capsule Oral Hour Of Sleep Starting 05/20/2015 . ~[MEDICATION NAME] 5 mg (1) Tablet, Sublingual Oral Hour Of Sleep Starting 11/12/2015 . December 2015, documented the resident was monitored for paranoia, crying out, and screaming related to the administration of [MEDICATION NAME], Trazadone, and [MEDICATION NAME]. ~ First shift documented the resident had no behaviors nor displayed any side effects for 31 of 31 days. ~Second shift documented the resident had no behaviors nor displayed any side effects for 22 of 31 days. There were nine dates with no documentation of the number of behavioral episodes nor side effects the resident displayed. ~Third shift documented the resident had no behaviors nor displayed any side effects for 15 of 31 days. There were 16 dates with no documentation of the number of behavioral episodes nor side effects the resident displayed. The care plan, updated 12/02/15, documented, .[MEDICAL CONDITION] drug - Anti-Depressant: (Resident #6) is taking Trazadone ([MEDICATION NAME]) on a routine basis to manage the Dx. of [MEDICAL CONDITION] .Goals: (resident #6) will be free of distress R/T [MEDICAL CONDITION]; and will be free of adverse side effects r/t Trazadone for the next 90 days .Interventions: Observe for other side effects, such as: [MEDICAL CONDITION], acute [MEDICAL CONDITION], rash, urticaria, sweating, pruritis, photosensitivity, orthostatic [MEDICAL CONDITION], RCG changes (sic), [MEDICAL CONDITION] hypertension, palpitations, blurred vision, tinnitus, mydriasis .Observe for side effects, such as: dizziness, drowsiness, confusion, headache, anxiety, tremors, stimulation, weakness, [MEDICAL CONDITION], nightmares, EPS (elderly), increase in psychiatric symptoms, diarrhea, dry mouth, nausea, vomiting, paralytic ileus, increased appetite, cramps, epigastric distress, [MEDICAL CONDITION], stomatitis . The quarterly assessment, dated 12/11/15, documented there were no behavior symptoms present. The assessment also documented the resident received an antidepressant for seven out of the last seven days during the look back period. The Medication Administration Record [REDACTED] ~[MEDICATION NAME]-[MEDICATION NAME] 25-100 mg (1) Tablet Oral Three Times Daily starting 02/09/2015 . ~[MEDICATION NAME] 25 mg (1 tab) tablet Oral Hour of Sleep Starting 05/14/2015 (On hold from 01/15/16) . ~[MEDICATION NAME] 5 mg (1) Tablet, Sublingual Oral Hour Of Sleep Starting 11/12/2015 .Discontinued 01/05/2016 . ~Trazadone HCL 50 mg (1) tablet Oral Hour Of Sleep Starting 12/02/2015 . ~[MEDICATION NAME] 5 mg (1) Tablet, Sublingual Oral Hour Of Sleep Starting 01/05/2016 . The behavior monitoring psychoactive flow record, dated January 2016, documented the resident was monitored for paranoia, crying out, and screaming related to the administration of [MEDICATION NAME]-[MEDICATION NAME], ([MEDICATION NAME] discontinued), Trazadone, and [MEDICATION NAME]. ~ First shift documented the resident had no behaviors nor displayed any side effects for 27 of 27 days. ~Second shift documented the resident had no behaviors nor displayed any side effects for 25 of 27 days. There were two dates with no documentation of the number of behavioral episodes nor side effects the resident displayed. ~Third shift documented the resident had no behaviors nor displayed any side effects for 23 of 28 days. There were five dates with no documentation of the number of behavioral episodes nor side effects the resident displayed. The January 2016 monthly physician's orders [REDACTED]. ~[MEDICATION NAME]-[MEDICATION NAME] 25-100 mg (1) TABLET Oral .Order Date: 2/9/2015 ~ .[MEDICATION NAME] 25 mg (1 tab) Tablet Oral Notes: depression .Order Date: 5/13/2015 . ~[MEDICATION NAME] 5 mg (1) TABLET, SUBLINGUAL Oral .Order Date: 11/11/2015 . ~Trazadone HCL 50 mg (1) TABLET Oral Notes: [MEDICAL CONDITION] .Order Date: 12/2/2015 . On 01/28/16 at 9:35 a.m., the medical records person was asked for the behavior logs for the months of March, April, May, July, August, September, October, and November for resident #6 for the year 2015. No documentation was provided. On 01/28/16 at 11:15 a.m., the medical records person was asked again for the behavior logs for resident #6. She stated she had been unable to find any of the requested behavior logs. She said, Medicare (records) comes to me and long term care goes to (alternate staff member) to put in the resident's chart. We have decided it should all go to one person. It should have been in their medical record or here in their thinned chart. On 01/28/16 at 2:50 p.m., the DON was asked for the behavior logs for resident #6. The DON stated the facility staff had looked for the missing behavior logs for resident #6 and she was aware the documentation had not been located. The DON was asked what was the facility policy for medication monitoring. She stated the facility staff monitored [MEDICAL CONDITION] medications. The DON was asked what was the facility monitoring for with the [MEDICAL CONDITION] medications. She stated the staff monitored side effects of the medications and what particular behavior the medication was to reduce. She was asked who was responsible for the completeness of the documentation. The DON stated she was ultimately responsible for the completeness of the documentation. The DON was shown the available behavior logs for resident #6 and asked if the clinical record for resident #6 was complete and accurate related to the behavior monitoring psychoactive flow record. She reviewed the documentation and stated, No. There is some missing documentation there. The DON was asked how she monitored the use of [MEDICAL CONDITION] medications. She stated staff normally performed a sight check weekly. She also stated new [MEDICAL CONDITION] medication orders were reviewed each month and the contracted pharmacist reviewed the charts and requested medication monitoring if none were found. The DON was asked how the facility monitored for unnecessary medications. She stated the pharmacist checked monthly during his medication review. The DON was asked what the facility policy was for monitoring [MEDICAL CONDITION] medications. She stated, We should do daily charting on all shifts for those residents on [MEDICAL CONDITION]. On 01/28/16 at 3:25 p.m., the pharmacist was asked who was responsible for monitoring for the use of unnecessary medications. He stated, I review the behavior sheets each month. Usually only issue is when medication is started or a new resident enters on medication which requires monitoring and the monitoring is not started. The pharmacist was asked how often he checked the facility residents for unnecessary medications. He stated he checked the facility residents monthly for unnecessary medications. He stated he was aware there were behavior monitoring sheets missing but he had reviewed the behavior monitoring sheets monthly.

Based on observation, interview, and record review, it was determined the facility failed to serve food in a sanitary manner for two (noon meal on 01/26/16 and evening meal on 01/27/16) of two meals observed. This had the potential to affect 29 of 29 residents were served food in the main dining room. Ten residents resided in the memory care unit and were served food in the dining room in the memory care unit. Findings: A facility policy, titled Food safety standards and requirements, dated 03/13/15, documented, .Ready-to-eat food must not be touched with bare hands. Disposable gloves or cleaned, sanitized utensils must be used properly to handle food . Gloves must be changed before starting another job and when they are torn, dirty or contaminated . On 01/26/16 at 12:06 p.m., the following was observed when dietary aide #1 served the noon meal from the kitchenette to the residents in the main dining room: ~With gloved hands the dietary aide went into the refrigerator and obtained a pea salad, placed it on the counter, and with the same gloves placed a roll on a resident's plate; ~With the same contaminated gloves, she placed a roll on a plate, placed noodles on the plate with a ladle, and touched noodles which were hanging off the side of the plate and placed them back onto the plate; ~With the same contaminated gloves, she continued to go obtain food from the refrigerator and steam oven and plate rolls. On 01/26/16 at 12:15 p.m., the dietary aide was asked when she changed gloves during a meal service. She stated, If I go out of the kitchen or wash dishes. She was asked if the facility had a policy regarding touching bread with gloved hands. She stated, I haven't touched any thing dirty. She was asked how many times she had obtained food from the refrigerator. She stated, Many times. She was asked if it was sanitary to touch rolls with the same gloves she had went into the refrigerator on multiple occasions then place the roll on the residents' plates. She stated, I guess I could use a utensil. On 01/27/16 at 4:10 p.m., cook #1 was asked when would you change gloves when you were serving residents from the kitchenette. He stated every time I changed a task. He was asked how would you expect the server to serve rolls. He stated, Use gloves when serve everything. He was asked what he meant when he stated change a task. He stated, when I go to the refrigerator or warmer, I would change gloves. He was asked if it was acceptable to obtain food from the refrigerator and warmer multiple times and then plate a roll with the same gloves. He stated we are not to do that. On 01/27/16 at 5:02 p.m., cook #1 and #2 were observed serving the evening meal from the kitchenette. Cook #2 obtained food from the refrigerator one time and the warmer two times then with the same contaminated gloves. She then placed two slices of bread on a plate and opened a package of lunch meat and proceeded to make a sandwich. On 01/27/16 at 5:13 p.m., cook #2 was asked when she was to change gloves and wash her hands. No response was given. Cook #1 instructed cook #2 to change gloves whenever she touched any thing including the refrigerator and warmer. On 01/28/16 at 10:50 a.m., the director of dining services was asked what the facility's policy was regarding when to change gloves when serving a meal. He stated, Every time you change tasks. He was asked how he ensured staff served meals in a sanitary manner. He stated, I have observed them and conducted in-services.

On 12/16/14, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to prepare non-pasteurized eggs to the proper temperature for safe consumption. The Oklahoma State Department of Health verified the existence of the IJ related to the facility's failure to prepare non-pasteurized eggs to the proper temperature for safe consumption. At 8:25 a.m., the administrator and the second chef were informed of the IJ related to the facility's failure to prepare non-pasteurized eggs to the proper temperature for safe consumption. At 9:51 a.m., an acceptable plan of removal was provided. The plan of removal documented, "...Plan of Removal - RE: Non-pasteurized eggs. At approximately 820, I was notified by the Oklahoma State Department of Health Survey team of an immediate Jeopardy concern for the use of non-pasteurized eggs at the breakfast meal. All non-pasteurized eggs were removed from the facility by 845a by the Health Center Dining Manager and the Executive Chef. All dining staff on-site received inservice education, conducted by the Health Center Dining Manager, at approximately 9a. This education included reviewing the policy of only pasteurized eggs are to be used in the facility as well as the proper temperature and cooking techniques for eggs. All dining staff who were not on-site at the time of the inservice education received the same education via telephone. This education was conducted by the Health Center Dining Manager and was completed by 950a. The Health Center Dining Manager, or designee, will conduct daily audits of all facility kitchens to ensure that only pasteurized eggs are being used. These audits will be completed utilizing an audit spreadsheet and will be conducted daily for one month, then weekly for two months. The Quality Assurance Committee will monitor the effectiveness of the plan of removal monthly for three months, then quarterly for one quarter." On 12/16/14 at 9:51 a.m., the administrator provided the documentation to show the plan of removal had been implemented as described. On 12/16/14, staff were interviewed in regards to their knowledge of the inservice; to ensure their understanding of all aspects of the plan of removal. The IJ was removed, effective 12/16/14 at 9:51 a.m., when all components of the plan of removal had been completed. The practice remained at a level for more than potential for harm at a pattern. Based on observation and interview, it was determined the facility failed to prepare non-pasteurized eggs to the proper temperature for safe consumption for two (#5 and #14) of two residents who received eggs cooked over easy for breakfast. This had the potential to affect 24 residents who ate in the dining room. Findings: On 12/15/14 at 9:10 a.m., an opened case of non-pasteurized eggs was observed in the main kitchen walk-in refrigerator. The dietary manager was asked if the eggs were pasteurized. He stated, "No." The dietary manager immediately removed the eggs from the walk-in refrigerator. The dietary manager was asked if any of the food items in the main kitchen supplied the long term care kitchenette. He stated, "Yes." At 9:35 a.m., 17 non-pasteurized eggs were observed in the Heather Hall kitchenette refrigerator. On 12/16/14 at 7:35 a.m., 17 non-pasteurized eggs were observed in the Heather Hall kitchenette refrigerator. At 8:16 a.m., resident #5 and resident #14's dietary tray cards were observed to be marked for over easy egg. At 8:18 a.m., Cook #1 prepared an egg for resident #5. At 8:20 a.m., a dietary aide delivered the plate to resident #5's table. The egg temperature was measured at 119 degrees Fahrenheit and observed to have a yellow runny yolk. The plate was removed from the table. At 8:21 a.m., cook #1 prepared an egg and a dietary aide delivered it to resident #14. The plate was removed and the resident did not consume the egg. On 12/16/14 at 8:27 a.m., cook #1 was asked if the eggs were pasteurized. He stated, "No." He was asked what temperature the non-pasteurized eggs were to be cooked. No comment was made. On 12/16/14 the infection control log was reviewed for November and December 2014. No food born illnesses were documented.