Every finding on record at Covenant Woods Nursing Home

Based on observations, resident interview, staff interview, and facility document review, it was determined the facility staff failed to implement the comprehensive care plan for one of 28 residents in the survey sample, Resident #34. The findings include: The facility staff failed to implement the comprehensive care plan for oxygen as ordered for Resident #34. Resident #34 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure). The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 2/5/24, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 2/21/24, which revealed, FOCUS: Respiratory Status-altered respiratory status. Status post respiratory failure with risks for complications increased by CHF. INTERVENTIONS: Administer oxygen as ordered to keep sats above 90% as directed by physician. A review of the physician's orders dated 1/30/24, revealed, Oxygen 1-2 liters per minute to keep stats at 90% or greater. On 3/11/24 at 1:40 PM, during initial observation of Resident #34, oxygen was observed to be in use at 3 liters per minute via nasal cannula, and again on 3/12/24 at 8:21 AM. An interview was conducted on 3/11/24 at 1:40 PM with Resident #34, when asked what oxygen settings she was on, Resident #34 stated, it is on two liters. On 3/12/24 at 1:20 PM an interview was conducted with LPN (licensed practical nurse) #1. When asked to observe Resident #34's oxygen setting, LPN #1 came to room and stated it is on 3 liters. LPN #1 obtained oxygen saturation during this period which was 97%. LPN #1 then went back to EMR (electronic medical record) and reviewed Resident #34's order and stated, it should only be 1-2 liters per nasal cannula to keep sats 90% or greater. When asked the purpose of the care plan, LPN #1 stated, it is to provide the guide for the care of the resident. When asked if the care plan had been implemented, LPN #1 stated, no, it is not. On 3/12/24 at 4:15 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the AIT (administrator in training) was informed of the finding. A review of the facility's Comprehensive Care Planning policy revealed, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. No further information was provided prior to exit.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to meet professional standards of quality for one of 28 residents in the survey sample, Resident #259. The findings include: For Resident #259 (R259), the facility staff changed an indwelling urinary Foley catheter size from 16 fr (French) to 24 fr without a physician order. (Note: a catheter French size of 24 is larger than the physician ordered 16 French size. According to Urinary catheters: history, current status, adverse events and research agenda - PMC (nih.gov), Catheter size is usually expressed in French gauge. The normal practice is to use the smallest catheter compatible with good drainage: 12-16 Fr is usually adequate and only rarely is a catheter larger than 18 Fr necessary.) Review of the clinical record revealed the following nurse's notes: A nurses note dated, 9/11/2023, revealed, Resident had urologist appointment new order to change foley cath, collect urine for UA/CS and increase Eliquis [an anticoagulant medication] to 5 mg BID, RP made aware. A nurse's note dated 9/11/23 documented, Resident foley changed out this shift, 24 fr, resident requested smaller size due to irritation. Resident is not in any pain or distress from this. The nurse who changed the Foley catheter no longer worked at the facility and therefore could not be interviewed. A nurse's note dated 9/13/23 documented, Resident c/o (complains of) pain, urinary discomfort, and a burning sensation since foley was placed 9/11/23. Resident informed writer that he had no urine output since morning time on day shift. Informed resident that I would reach out to the Dr. (doctor) and inform him of complaints and concerns pertaining to his foley cath. Per Dr. orders; to change foley. Removed a 24 fr size foley. Resident had 800 ml (milliliters) of urine residual. Noted some blood on the foley and blood in the tubing. Foley was changed during shift. 16 french 10cc (cubic centimeters) . Reassess resident, resident stated that he feels better, and he feels big relief since foley was changed. Reassess pain, discomfort, and burning sensation and all complaints subsides. Rechecked, and flushed 100 cc (cubic centimeters) per orders, 250 ml with amber color urine. On 3/13/24 at 9:31 a.m., an interview was conducted with RN (Registered Nurse) #1. She stated notifying the physician is required to change the size of a Foley catheter. She stated the staff should have reached out to the doctor if there was a need to change the catheter size. On 3/13/24 at 11:41 a.m., an interview was conducted with ASM (Administrative Staff Member) #2, the Director of Nursing. She stated that the resident faced a negative outcome due to the nurse using the wrong catheter size and the resident developed burning and other complications. She stated that they called the doctor to remove it. She also stated that the nurse should have looked in the supply room or contacted her instead of taking it upon herself to change the size without a physician's notification and order. The facility policy, Change in Condition was reviewed. The policy documented, (Name of facility) will immediately inform the resident and consult with the resident's physician, if appropriate, when changes occur .Notification of changes shall include: .3. A need to alter treatment significantly. On 3/13/24 at 1:51 p.m., ASM #1 (Administrative Staff Member) the Administrator, and ASM # 2 the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interviews, clinical record review, and facility document review, it was determined that the facility staff failed to provide urinary catheter care and services in accordance with the physician's order for one of 28 residents in the survey sample, Resident #259. The findings include: For Resident #259 (R259), the facility staff failed to utilize the correct catheter size when changing the Foley catheter on 9/11/23. The physician ordered the catheter size to be 16 fr (French size), however the facility used 24 fr. (Note: a catheter French size of 24 is larger than the physician ordered 16 French size. According to Urinary catheters: history, current status, adverse events and research agenda - PMC (nih.gov), Catheter size is usually expressed in French gauge. The normal practice is to use the smallest catheter compatible with good drainage: 12-16 Fr is usually adequate and only rarely is a catheter larger than 18 Fr necessary.) A review of the clinical record revealed a physician's order dated 7/28/23 for the use of an Indwelling Catheter 16 fr. Further review of the clinical record revealed the following nurse's notes: A nurses note dated, 9/11/2023, revealed, Resident had urologist appointment new order to change foley cath, collect urine for UA/CS and increase Eliquis to 5 mg (1) BID, RP made aware. A nurse's note dated 9/11/23 that documented, Resident foley changed out this shift, 24 fr, resident requested smaller size due to irritation. Resident is not in any pain or distress from this. A nurse's note dated 9/13/23 documented, Resident c/o (complains of) pain, urinary discomfort, and a burning sensation since foley was placed 9/11/23. Resident informed writer that he had no urine output since morning time on day shift. Informed resident that I would reach out to the Dr. (doctor) and inform him of complaints and concerns pertaining to his foley cath. Per Dr. orders; to change foley. Removed a 24 fr size foley. Resident had 800 ml (milliliters) of urine residual. Noted some blood on the foley and blood in the tubing. Foley was changed during shift. 16 french 10cc (cubic centimeters) . Reassess resident, resident stated that he feels better, and he feels big relief since foley was changed. Reassess pain, discomfort, and burning sensation and all complaints subsides. Rechecked, and flushed 100 cc per orders, 250 ml with amber color urine. On 3/13/24 at 9:31 a.m., an interview was conducted with RN (Registered Nurse) #1. She stated that a physician's order is required to change the size of a foley catheter. She stated the staff should have reached out to the doctor if there was a need to change the order for the size. She also stated, if the wrong size catheter is applied it could cause issues like splitting the penis. On 3/13/24 at 11:41 a.m., an interview was conducted with ASM (Administrative Staff Member) #2, the Director of Nursing. She stated that the resident faced a negative outcome due to the nurse using the wrong catheter size and the resident developed burning and other complications. She stated that they called the doctor to remove it. She also stated that the nurse should have looked in the supply room or contacted her instead of taking it upon herself to change the size without a physician's notification and order. The facility policy Foley Catheter Insertion, Male Resident was reviewed. This policy documented, Verify that there is a physician's order for this procedure The following equipment and supplies will be necessary when performing the procedure. 1. Foley catheter tray (size specified in the order) . On 3/13/24 at 1:51 p.m., ASM#1 (Administrative Staff Member) the Administrator, and ASM# 2 the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. Reference: (1) Apixaban (brand name Eliquis) is used to help prevent strokes or blood clots in people who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease. Apixaban is also used to prevent deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in people who are having hip replacement or knee replacement surgery. Apixaban is also used to treat DVT and PE and may be continued to prevent DVT and PE from happening again after the initial treatment is completed. Apixaban is in a class of medications called factor Xa inhibitors. It works by blocking the action of a certain natural substance that helps blood clots to form. https://medlineplus.gov/druginfo/meds/a613032.html

Based on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide respiratory care per physician orders for one of 28 residents in the survey sample, Resident #34. The findings include: The facility staff failed to provide oxygen as ordered for Resident #34. The physician's order was for 1-2 liters per minute, however the oxygen was set to 3 liters per minute. Resident #34 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure). The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 2/5/24, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 2/21/24, which revealed, FOCUS: Respiratory Status-altered respiratory status. Status post respiratory failure with risks for complications increased by CHF. INTERVENTIONS: Administer oxygen as ordered to keep sats above 90% as directed by physician. A review of the physician's orders dated 1/30/24, revealed, Oxygen 1-2 liters per minute to keep stats at 90% or greater. On 3/11/24 at 1:40 PM, during initial observation of Resident #34, oxygen was observed to be in use at 3 liters per nasal cannula, and again on 3/12/24 at 8:21 AM. An interview was conducted on 3/11/24 at 1:40 PM with Resident #34, and when asked what oxygen settings she was on, Resident #34 stated, it is on two liters. On 3/12/24 at 1:20 PM an interview was conducted with LPN (licensed practical nurse) #1. When asked to observe Resident #34's oxygen setting, LPN #1 came to room and stated it is on 3 liters. LPN #1 obtained oxygen saturation during this period which was 97%. LPN #1 then went back to EMR (electronic medical record) and reviewed Resident #34's order and stated, it should only be 1-2 liters per nasal cannula to keep sats 90% or greater, and that they will correct it. On 3/12/24 at 4:15 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the AIT (administrator in training) was informed of the finding. A review of the facility's Oxygen Administration policy revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to implement bed rail requirements for two of 28 residents in the survey sample, Residents #36 and #212. The findings include: 1. For Resident #36, the facility staff failed to assess the risks/benefits and obtain informed consent for the use of side rails. Resident #36 was observed in bed with quarter bed rails on 3/11/24 at 1:20 PM, 3/12/24 at 10:53 AM, and 3/13/24 at 9:40 AM. Resident #36 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: hemiplegia following cerebral vascular accident and dementia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/19/24, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring maximal assistance for bathing, bed mobility, transfer, dressing and hygiene. A review of the comprehensive care plan dated 12/21/23 revealed, FOCUS: Self care deficit-extensive assistance required for bathing, hygiene, dressing and grooming. INTERVENTIONS: .Siderails for turning/positioning. There was no evidence of assessment of risks/benefits or consent obtained for bed rail use for Resident #36. An interview was conducted on 3/11/24 at 1:20 PM with Resident #36. When asked if he used the side rails, Resident #36 stated, yes, to turn in bed. On 3/13/24 at 9:25 AM, ASM (administrative staff member) #1, the administrator, stated they do not have evidence of assessments of the risks/benefits or consents for this resident. On 3/13/24 at 1:30 PM, ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the AIT (administrator in training) was made aware of the concerns. A review of the facility's Bed Rail/Side Rail Entrapment and Consent policy, revealed, Answer the questions below using the Yes / No column. The answers to questions 1-21 will provide information regarding the resident's functional and medical needs, request for side rails, as well as associated risks related to injury against or over the rails. No responses to any question requires further assessment of the resident's, risk of side rail use and evaluation of bed and side rail gaps; if rails are to be used, the resident requires care planning and monitoring by staff to reduce risk of entrapment and injury. The resident has the right to be free from use of side rails when imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms / need. The consent is to be fully executed prior to the installation of any siderail. No further information was provided prior to exit. 2. For Resident #212, the facility staff failed to assess the risks/benefits and obtain informed consent for the use of side rails. Resident #212 was observed in bed with quarter bed rails on 3/11/24 at 2:10 PM, 3/12/24 at 8:35 AM, and 3/13/24 at 9:15 AM. Resident #212 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: right hip replacement and osteoarthritis. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 3/13/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the baseline care plan dated 3/6/24 revealed, FOCUS: Activities of Daily Living. INTERVENTIONS: Assist with turning, positioning, transfers, bed rails. A review of the physician orders revealed Siderail quarter length to assist resident in turning/positioning while in bed. There was no evidence of assessment of risks/benefits or consent obtained for bed rail use for Resident #212. An interview was conducted on 3/11/24 at 2:10 PM with Resident #212. When asked if she used the side rails, Resident #212 stated, yes, I use them to reposition myself in bed. On 3/13/24 at 9:25 AM, ASM (administrative staff member) #1, the administrator, stated they do not have evidence of assessments of the risks/benefits or consents for this resident. On 3/13/24 at 1:30 PM, ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the AIT (administrator in training) was made aware of the concerns. No further information was provided prior to exit.

Based on staff interview and facility document review it was determined the facility staff failed to evidence COVID-19 testing of staff, during an outbreak of active COVID-19 cases confirmed in the facility 12/23/2022-1/17/2023 for 2 of 3 staff sampled, CNA (certified nursing assistant) #1 and OSM (other staff member) #1. The findings include: The facility staff failed to evidence COVID-19 testing of staff following confirmed resident and staff infections of COVID-19 (1) on 12/23/2022, 12/27/2022, 12/28/2022, 12/29/2022, 12/30/2022, 12/31/2022, 1/3/2023, 1/4/2023, 1/6/2023, 1/7/2023, 1/15/2023 and 1/17/2023. On 1/23/2023 at approximately 10:00 a.m., during an entrance meeting with RN (registered nurse) #1, unit manager, RN #1 stated that they currently had two residents positive for COVID-19 in isolation in the facility and were not aware of any active staff cases. RN #1 stated that the last outbreak had began in December of 2022. On 1/23/2023 at approximately 11:45 a.m., RN #1 provided a list of residents and staff who were confirmed with COVID-19 over the past four weeks. The list documented 13 resident names, one resident was confirmed positive on 12/23/2022, three on 12/29/2022, one on 12/30/2022, two on 12/31/2022, four on 1/4/2023, one on 1/15/2023 and one on 1/17/2023. The list also documented one staff confirmed positive on 12/27/2022, one on 12/28/2022, one on 1/3/2023, two on 1/6/2023 and one on 1/7/2023. On 1/23/2023 at approximately 2:45 p.m., RN #1 provided a resident vaccination roster documenting 100% resident COVID-19 primary series vaccination as well as a staff vaccination roster documenting 100% eligible staff COVID-19 primary series vaccination with four staff having approved vaccine exemptions. On 1/23/2023 at approximately 1:00 p.m., a request was made to RN #1 for evidence of staff testing for a sample of three current staff members who worked on the skilled nursing unit. On 1/23/2023 at 2:34 p.m., RN #1 stated that OSM #1 had tested positive with a home test on 1/7/2023 and they did not have any prior testing to provide. RN #1 stated that they did not have any testing to provide for CNA #1. RN #1 stated that LPN #1 had transferred to assisted living and was not currently working on the skilled nursing unit. RN #1 stated that if a resident tested positive for COVID-19, they performed contact tracing identifying any staff who worked with the resident or residents exposed. RN #1 stated that the staff were informed that they were to monitor themselves for any symptoms and to report any symptoms and be tested immediately. RN #1 stated that they were not testing staff unless they developed symptoms and staff were educated to report any signs or symptoms. On 1/23/2023 at 3:38 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that they had not been testing asymptomatic staff members during their outbreak cases. ASM #2 stated that they had been following guidance provided by their local health department for contact tracing and identifying staff who worked with positive residents for the past 72 hours and having all staff wear N95 masks and monitor for signs and symptoms. ASM #2 stated that they were not testing any staff unless they displayed symptoms of COVID-19. ASM #2 stated that their outbreak began in December of 2022. The facility policy, Coronavirus (COVID-19): Emergent Infectious Disease (EIDS) revised 10/22 documented in part, .If a quarantine is in place, the following additional steps should be followed: .All regulatory guidance regarding visitation and testing requirements can be found in the policy appendix under Facility Protocol. Facility protocol will be developed in response to regulatory guidance, health department recommendations, and best practices . The attached policy, A. Facility Specific Protocol updated 10/31/2022 documented in part, .Staff Testing: All staff as identified by regulatory guidance will be tested as outlined in the regulatory guidance. Facility reserves the right to require all staff, regardless of vaccination status, to be tested . According to CMS- QSO-20-38-NH revised 9/23/2022, .Testing of Staff and Residents During an Outbreak Investigation. An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed. An outbreak investigation would not be triggered when a resident with known COVID-19 is admitted directly into TBP (transmission based precautions), or when a resident known to have close contact with someone with COVID-19 is admitted directly into TBP and develops COVID-19 before TBP are discontinued. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further viral transmission. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately (but not earlier than 24 hours after the exposure, if known). Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility-wide) testing . On 1/23/2023 at approximately 3:45 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit. Reference: (1) COVID-19 COVID-19 is caused by a coronavirus called SARS-CoV-2. Coronaviruses are a large family of viruses that are common in people and may different species of animals, including camels, cattle, cats, and bats. Rarely, animal coronaviruses can infect people and then spread between people. This occurred with MERS-CoV and SARS-CoV, and now with the virus that causes COVID-19. The SARS-CoV-2 virus is a betacoronavirus, like MERS-CoV and SARS-CoV. All three of these viruses have their origins in bats. The sequences from U.S. patients are similar to the one that China initially posted, suggesting a likely single, recent emergence of this virus from an animal reservoir. However, the exact source of this virus is unknown. This information was obtained from the website: https://www.cdc.gov/coronavirus/2019-ncov/faq.html#How-COVID-19-Spreads

Based on staff interview and facility document review, it was determined the facility staff failed to assess the risks and benefits of side rails for one of 20 residents in the survey sample, Resident #52. The findings include The facility staff failed to evidence that Resident #52 had the risks / benefits reviewed for her use of side rails. Resident #52 was observed in bed with bilateral half side rails on 4/19/22 at 1:10 PM, 2:48 PM, 4:15 PM and on 4/20/22 at 8:30 AM. Resident #52 was admitted to the facility on [DATE]. Resident #52's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #52's most recent MDS (minimum data set) assessment, a Medicare 5 day assessment, with an assessment reference date of 4/8/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. MDS Section G- Functional Status: coded the resident as requiring extensive assistance for bed mobility, transfers, walking/locomotion, and dressing; personal hygiene/bathing Resident #52 is totally dependent and the resident is independent for eating. A review of Resident #52's comprehensive care plan dated 4/8/22, documents in part, PROBLEMS-Turning/positioning in bed requires extensive assistance. INTERVENTIONS-Half side rails when in bed for repositioning and independence. A review of the physician orders dated 4/4/22, which revealed, One-half side rails up when in bed to assist with repositioning and independence. An interview was conducted on 4/19/21 at 2:48 PM with Resident #52. When asked if she used the side rails, Resident #52 stated, yes, I use them to turn and move around in the bed. A request was made on 4/20/22 at approximately 10:00 AM for the bed rail assessment and consent for Resident #52. On 4/20/22 at 3:45 PM, an interview was conducted with OSM (other staff member) #1, the social worker stated, we do not have any assessment, consent of bed inspection for the rails for Resident #52. On 4/20/22 at 4:25 PM, an interview was conducted with LPN (licensed practical nurse) #2. When asked who assesses the resident and obtains consent for use of bed rails, LPN #2 stated, nursing does the initial assessment and obtains consent. I believe that therapy comes after that and does another assessment. When asked who and when the bed with the rails is inspected, LPN #2 stated, we have a computerized system for work orders for maintenance to come and do the rail checks. On 4/21/22 at 8:00 AM, ASM (administrative staff member) #2, the director of nursing brought in the requested information for Resident #52 and stated, we grabbed a screen shot of the work order for the bed rails for Resident #52 and here is the assessment and consent we obtained yesterday (4/20/22) for the resident. The facility's Restraints (Including Side Rails) policy dated 4/22, which reveals, A pre-restraining assessment will be done: If the resident has a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/20/22 at 5:00 PM, ASM #1, the administrator and ASM #2, the director of nursing were informed of the above concern. No further information was provided prior to exit.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to dispose of refuse properly. The facility staff failed to maintain clean dumpster area during the facility task- kitchen observation 4/19/22 at 12:40 PM, for one of one dumpster. The findings include: On 4/19/22 at 12:40 PM, an observation was conducted in the dumpster area outside of the main kitchen, with OSM (other staff member) #3, the executive chef. Three plastic bags with garbage, two disposable gloves, paper trash and approximately one half cup of food debris were found around the dumpster. There were no other dumpsters. An interview was conducted on 4/19/22 at 12:40 PM with OSM #3, the executive chef. When shown the trash and food debris outside of the dumpster, and asked who is responsible for maintaining the area, OSM #3 stated, maintenance is responsible for cleaning up any debris around the dumpster. When asked how frequently the area is cleaned, OSM #3 stated, I believe they round daily out here. An interview was conducted on 4/20/22 at 12:50 PM with OSM #6, the environmental services and transportation manager, who stated, I am here to talk with you about the dumpster as the maintenance director is at a meeting. When asked who is responsible for maintaining a clean area around the dumpster, OSM #6 stated, maintenance has a staff person assigned to this area. There is a daily work order generated for ensure this area is kept clean. On 4/20/22 at 5:00 PM a request was made for any policy related to the dumpster. On 4/21/22 at 8:40 AM, ASM (administrative staff member) #1, the administrator, brought a draft policy titled Grounds Maintenance Protocol dated 4/22 and stated, the maintenance department thought it would be better to have a policy to outline what is expected, so they drafted this policy. Usually they have this area clean in the morning. Here are some work order examples. ASM #1 provided work orders for the following dates of examples of the work order being in the system: 12/16/21, 1/14/22, 2/14/22, 3/10/22, 3/20/22, 4/15/22, 4/18/22, 4/19/22 and 4/20/22. The work order with the date of 4/19/22, had a completion time of 11:29 AM. The facility's Ground Maintenance Policy dated 4/22, Maintain cleanliness of compactor and loading dock areas. Scheduled work order should be in place for the grounds man to maintain cleanliness of the compactor and recycling containers as well as the surrounding areas daily during the weekday. On the weekend, the janitor on duty will maintain these areas as part of his daily routine. Removal of trash and debris from compactor area/recycle/grease/smoking area/concrete pads. On 4/20/22 at 5:00 PM, ASM #1, the administrator and ASM #2, the director of nursing were informed of the above concern. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review it was determined that the facility staff failed to ensure one of 20 sampled residents, (Resident #6), was free from unnecessary medications. The facility failed to act in a timely manner on the on 1/17/21 pharmacy medication regimen review, with recommendations for a gradual dose reduction of the antidepressant and hypnotic medications prescribed and administered to Resident #6. The 1/17/21, pharmacy gradual dose reduction recommendation was not discovered by the facility in their email or presented to the physician for action until 2/24/21, a period of 39 days. The findings include: Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #6's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/27/2020, coded Resident #6, as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Section N documented Resident #6 receiving antidepressant and hypnotic medications. The comprehensive care plan for Resident #6 dated 11/20/20 documented, (Name of Resident #6) is at risk for side effects related to use of psychoactive medication: -sedatives/hypnotics -antidepressants. Psychoactive medications are being used to treat/manage following behaviors/symptoms: [MEDICAL CONDITION], depressed mood. Status: Active (Current) . Under Interventions, it documented in part, Conduct medication regiment review no less than monthly. Status: Active (Current) . The physician's orders [REDACTED]. - Order Date: 11/20/2020, Status: Active (Current), Description: Duloxetine (antidepressant) 60 mg (milligram) capsule, delayed release 1 (one) time daily. Start Date: 11/21/2020 . - Order Date: 11/22/2020, Status Active (Current), Description:[MEDICATION NAME](hypnotic) 10 mg tablet 1 time daily. Start Date: 11/22/2020 . - Order Date: 2/25/2021, Status: Active (Current), Description: Duloxetine 30 mg capsule, delayed release 1 time daily. Start Date: 2/25/2021 . - Order Date: 2/25/2021, Status Active (Current), Description:[MEDICATION NAME] mg tablet 1 time daily. Start Date: 2/25/2021 . The eMAR (electronic medication administration record) for Resident #6 dated January 2021 Medications documented Resident #6 receiving the Duloxetine 60mg daily [MEDICATION NAME] daily each day as documented above. The eMAR (electronic medication administration record) for Resident #6 dated February 2021 Medications documented Resident #6 received the Duloxetine 60mg each day in February from 2/1/21 through 2/25/21 and [MEDICATION NAME] each day in February from 2/1/21 through 2/24/21. The eMAR further documented the new orders dated 2/25/2021 for the reduced dosages of the Duloxetine and Ambien. The progress notes for Resident #6 documented in part, 1/17/2021 15:51 (3:51 p.m.) Pharmacy. This patient's medical record/medication regimen has been reviewed. MD (medical doctor) notes- GDR (gradual dose reduction) requests . On 2/24/21 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #2, the director of nursing for evidence of pharmacy medication regimen reviews and any recommendations for gradual dose reductions for Resident #6. On 2/25/21 at approximately 8:00 a.m., ASM #2 provided lists of residents having pharmacy medication regimen reviews completed in January and February containing Resident #6. ASM #2 also provided two documents titled Note to Attending Physician/Prescriber with a MRR (medication regimen review) date of 1/17/2021 for Resident #6. The documents requested the physician evaluate the duloxetine [MEDICATION NAME] a potential gradual dose reduction. The documents were observed to be signed and dated by the physician 2/24/21, 39 days after the MRR date of 1/17/2021. The Physician/Prescriber Response for the document referencing the medication Duloxetine 60mg once daily documented a physician response of Agree and further documented, .1) Reduce dose to the following Duloxetine 30mg PO (by mouth) QD (every day) . The Physician/Prescriber Response for the document referencing the [MEDICATION NAME] once daily documented a physician response of Agree and further documented, .1) Reduce dose to the [MEDICATION NAME] PO QD . On 2/25/21 at 9:40 a.m., an interview was conducted with ASM #2. ASM #2 stated that the pharmacist came in monthly and sent the medication reviews to them by email. ASM #2 stated that they print out the reviews and place them in the doctor's book for them to review and sign. ASM #2 stated that after the physician reviewed them the nurses would fax their response to the pharmacy and make any changes to medication orders as needed. When asked about the length of time between the date of the MRR and the date of the physician review, ASM #2 stated that the medication reviews sent from the pharmacy were normally reviewed the next day. When asked about the facility policy for review within thirty days, ASM #2 stated that they were having problems getting the emails and that their IT department was working to resolve the issue of the pharmacy emails going to their junk mail folder. ASM #2 stated that they had found these documents in their junk folder yesterday after this surveyor had requested them and printed them out for review. ASM #2 stated that the pharmacist had observed that their reviews were not on the residents charts back in January and had resent them a bulk of pharmacy reviews in January of 2021. ASM #2 stated that was when they initially discovered the email problem, and they had received the reviews for September through December 2020 in January of 2021. The facility policy Drug Regimen Review/Medication Regime Review, Developed: 6/19 documented in part, .Specific Procedures/Requirement: .a) The consulting pharmacist will provide copy of recommendations to the attending physician, medical director, and director of nursing within five (5) working days of completion of the review .b) The director of nursing or designee will review the recommendations and the attending physicians will be contacted for review and response. c) If the attending physician does not respond within thirty (30) days, the medical director will be asked to review the recommendations and/or contact the attending physician . On 2/25/21 at approximately 11:10 a.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: 1. [MEDICAL CONDITION] A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. 2. [MEDICAL CONDITION] A common sleep disorder. If you have it, you may have trouble falling asleep, staying asleep, or both. As a result, you may get too little sleep or have poor-quality sleep. You may not feel refreshed when you wake up. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. 3. Major [MEDICAL CONDITION] [MEDICAL CONDITION] is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works. This information was obtained from the website: https://medlineplus.gov/ency/article/ 5.htm.

Based on staff interview and clinical record review, it was determined that the facility staff failed to label medications in one of three medication carts and dispose of biologicals upon expiration date in one of two medication rooms. The facility staff failed to label medications; two white pills were observed in a medication cup in second medication drawer on the Unit C Wing 1. The facility staff failed to dispose of biologicals upon expiration date. Eight bottles of expired tube feeding formula and three medication wound dressings were observed in the Unit C Wing 1medication storage room. The findings include: On 2/24/21 at 8:30 AM, an inspection of Unit C Wing 2 medication cart was conducted. The medication cart was unlocked and in the second medication drawer, two white round pills were observed in a 30-milliliter clear medication cup. There was no labeling of medication, dose, resident name or date on the cup. An interview was conducted on 2/24/21 at 8:30 AM, with LPN (licensed practical nurse) #1. When asked if the medications were stored properly, LPN #1 stated, No, they are not. I am not sure why they would be in the cup like that. They look like Tylenol (pain reliever) (1) pills. When asked what labeling the cup should have, LPN #1 stated, It should have the resident name, drug, dose at a minimum. On 2/24/21 at 10:07 AM, an inspection of Unit C Wing 2 medication cart and medication storage room was conducted. The medication storage room was unlocked and observation of the first cabinet revealed eight 1.1 quart bottles of [MEDICATION NAME] (tube feeding nutrition) (2) that expired on 2/1/21. Observation of the wound care cart, revealed in the second and fourth drawers, three expired dressings. One Dermaginate calcium alginate (3) dressing 4.25 x 4.25 inches that had expired on 9/2020 and two [MEDICATION NAME] One (4) 3x4 inch dressings that had expired on 1/28/21. An interview was conducted on 2/24/21 at 10:07 AM with LPN #2. When shown the expired [MEDICATION NAME] bottles, LPN #2 stated, We hardly ever use them. I don't know why we have so many. When asked who was responsible for checking the tube feeding dates, LPN #2 stated, It is nursing's responsibility to check the dates. When shown the expiration dates for the three dressings in the wound care cart, LPN #2 stated, Those should have been disposed of. When asked who was responsible for checking the expiration dates of the wound care dressings, LPN #2 stated, Nursing is responsible to check the dates and dispose of any expired dressings. An interview was conducted on 2/24/21 at 2:52 PM with RN (registered nurse) #1, the unit manager. When asked about the process staff follows for labeling medications and removing expired medications, RN #1 stated, It is the nursing responsibility to label medications with the drug name, dose, resident name and time to be administered. Pharmacy delivers the tube feedings and central supply delivers the dressings. Central supply checks their stock to make sure there is no expired supplies prior to delivery. Nursing is responsible for checking the wound care cart and the tube feedings to make sure they aren't expired. ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were informed of the unlabeled medications, expired wound dressings and expired tube feedings on 2/24/21 at 3:50 PM. According to the facility's policy, Storage of Medications revised 4/2007, which documents in part, The facility shall store all drugs and biologicals in a safe, secure and orderly manner. The nursing staff shall be responsible for maintaining medication storage in a clean, safe and sanitary manner. The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. No further information was provided prior to exit. References: (1) 2019 Lippincott Pocket Drug Guide for Nurses, Wolters, Kluwer, page 4. (2) American College of [MEDICATION NAME] GI.org: enteral and parental nutrition (3) 2019 Lippincott Pocket Drug Guide for Nurses, Wolters, Kluwer, page 438. (4) 2019 Lippincott Pocket Drug Guide for Nurses, Wolters, Kluwer, page 438.

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined, that the facility staff failed to provide care for respiratory equipment in a sanitary manner for one of 20 residents in the survey sample, Resident #30. The facility staff failed to store Resident #30's [MEDICAL CONDITION] facemask in a sanitary manner when not in use. Multiple observations revealed Resident #30's [MEDICAL CONDITION] facemask in a basket uncovered wrapped in the [MEDICAL CONDITION] tubing and head strap. The findings include: Resident #30 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #30's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/27/2021, coded Resident #30 as scoring a 11 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 11- being moderately impaired for making daily decisions. Resident #30 was documented as receiving oxygen while a resident at the facility, in Section O of the assessment. On 2/23/21 at approximately 12:40 p.m. an interview was conducted with Resident #30 in their room. Observation of Resident #30's room revealed a rolling stand with attached basket housing a [MEDICAL CONDITION] (positive airway pressure) machine (4). Tubing was observed attached to the machine connecting a facemask with head strap in the basket. The facemask was observed uncovered in the basket wrapped in the tubing and head strap. When asked about the machine, Resident #30 stated that they used it at night when sleeping for their [MEDICAL CONDITION]. When asked how the mask was cared for, Resident #30 stated that the nursing staff applied the mask at night and took it off in the morning and placed it back in the basket. Resident #30 stated that they did not recall seeing staff clean the mask and or put it in a bag. Resident #30 stated that it was stored in the basket of the machine as observed. Additional observations made on 2/23/21 at 3:10 p.m., 2/24/21 at 8:35 a.m. and 2/25/21 at 9:15 a.m. revealed the same findings as above. The physician's orders [REDACTED]. - Home trilogy (brand of [MEDICAL CONDITION] machine) settings. Do not touch home trilogy machine. Settings are already in place. Home trilogy used at night only. Order Date: 2/17/2021. - Clean trilogy water tank. Refill water tank. Order Date: 2/17/2021. Frequency: Two Times Weekly . The comprehensive care plan for Resident #30 dated 11/22/2019 documented in part, (Name of Resident #30) has potential for difficulty in breathing related to: [MEDICAL CONDITION], H/O (history of) pneumonia, [MEDICAL CONDITION] exacerbation, Status: Active (Current). Effective Date: 11/22/2019-Present. Under Interventions, it documented in part, .Trilogy machine at HS (hour of sleep) as ordered . On 2/25/21 at approximately 9:30 a.m., an interview was conducted with LPN (licensed practical nurse) #6. LPN #6 stated that any respiratory equipment was stored in a plastic bag when not in use, and the bag was dated and changed weekly. When asked about the mask for Resident #30's trilogy machine, LPN #6 stated that the night shift cared for the mask but they thought that it was cleaned once a week and stored in a bag. LPN #6 stated that the night shift nurses normally handled the application and removal of Resident #30's trilogy machine because they only wore it during the night. LPN #6 stated that the purpose of storing the mask in the bag was to prevent dust from getting on it and to keep it clean. LPN #6 made an observation of Resident #30's trilogy machine with the mask uncovered in the basket at 9:35 a.m. and stated that the mask should have been stored in a bag when not in use. LPN #6 stated that they were going to clean the mask or replace it and place it in a bag with the date when not in use and report it to the unit manager. The facility policy Departmental (Respiratory Therapy) - Prevention of Infection, Level 1 (one), documented in part, Purpose, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff . The policy failed to evidence guidance on the storage of masks used for [MEDICAL CONDITION] ventilation, however it documented in part, .Keep oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use . On 2/25/21 at approximately 9:30 a.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. References: 1. [MEDICAL CONDITIONS] Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. 2. Chronic [MEDICAL CONDITION] When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. 3. Pneumonia An infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia. You can also get pneumonia by inhaling a liquid or chemical. This information was obtained from the website: https://medlineplus.gov/pneumonia.html. 4. [MEDICAL CONDITION] Positive airway pressure (PAP) treatment uses a machine to pump air under pressure into the airway of the lungs. This helps keep the windpipe open during sleep. The forced air delivered by [MEDICAL CONDITION] (continuous positive airway pressure) prevents episodes of airway collapse that block the breathing in people with obstructive sleep apnea and other breathing problems. This information was obtained from the website: https://medlineplus.gov/ency/article/ 6.htm

Based on staff interview, facility document review and clinical record review it was determined that the facility staff failed to act in a timely manner on the pharmacy medication regimen review for two of 20 residents in the survey sample, Residents #6 and #30. 1. Resident #6's medication regimen review was completed on 1/17/21 with recommendations for a gradual dose reduction of the antidepressant and hypnotic medications which were not discovered by the facility in their email or presented to the physician for action until 39 days later. 2. The facility staff failed to act in a timely manner on a medication regimen review for Resident #30. Resident #30's medication regimen review was completed on 9/17/2020 with recommendations to evaluate the as needed order for Klonopin (sedative medication) which was not reviewed by the physician until January of 2021. The findings include: 1. Resident #6's medication regimen review was completed on 1/17/21 with recommendations for a gradual dose reduction of the antidepressant and hypnotic medications which were not discovered by the facility in their email or presented to the physician for action until 39 days later. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #6's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/27/2020, coded Resident #6, as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Section N documented Resident #6 as receiving antidepressant and hypnotic medications. The physician's orders [REDACTED]. - Order Date: 11/20/2020, Status: Active (Current), Description: Duloxetine (antidepressant) 60 mg (milligram) capsule, delayed release 1 (one) time daily. Start Date: 11/21/2020 . - Order Date: 11/22/2020, Status Active (Current), Description:[MEDICATION NAME](hypnotic) 10 mg tablet 1 time daily. Start Date: 11/22/2020 . - Order Date: 2/25/2021, Status: Active (Current), Description: Duloxetine 30 mg capsule, delayed release 1 time daily. Start Date: 2/25/2021 . - Order Date: 2/25/2021, Status Active (Current), Description:[MEDICATION NAME] mg tablet 1 time daily. Start Date: 2/25/2021 . The eMAR (electronic medication administration record) for Resident #6 dated January 2021 Medications documented Resident #6 received the Duloxetine 60mg daily [MEDICATION NAME] daily each day as ordered above. The eMAR (electronic medication administration record) for Resident #6 dated February 2021 Medications documented Resident #6 received the Duloxetine 60mg each day in February from 2/1/21 through 2/25/21 and [MEDICATION NAME] each day in February from 2/1/21 through 2/24/21. The eMAR further documented the new orders dated 2/25/2021 for the reduced dosages of the Duloxetine and Ambien. The progress notes for Resident #6 documented in part, 1/17/2021 15:51 (3:51 p.m.) Pharmacy. This patient's medical record/medication regimen has been reviewed. MD (medical doctor) notes- GDR (gradual dose reduction) requests . The comprehensive care plan for Resident #6 dated 11/20/20 documented, (Name of Resident #6) is at risk for side effects related to use of psychoactive medication: -sedatives/hypnotics -antidepressants. Psychoactive medications are being used to treat/manage following behaviors/symptoms: [MEDICAL CONDITION], depressed mood. Status: Active (Current) . Under Interventions, it documented in part, Conduct medication regiment review no less than monthly. Status: Active (Current) . On 2/24/21 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #2, the director of nursing for evidence of pharmacy medication regimen reviews and any recommendations for gradual dose reductions for Resident #6. On 2/25/21 at approximately 8:00 a.m., ASM #2 provided lists of residents having pharmacy medication regimen reviews completed in January and February containing Resident #6. ASM #2 also provided two documents titled Note to Attending Physician/Prescriber with a MRR (medication regimen review) date of 1/17/2021 for Resident #6. The documents requested the physician evaluate the duloxetine [MEDICATION NAME] a potential gradual dose reduction. The documents were not signed and dated by the physician until 2/24/21, 39 days after the MRR date of 1/17/2021. The Physician/Prescriber Response for the document referencing the medication Duloxetine 60mg once daily documented a physician response of Agree and further documented, .1) Reduce dose to the following Duloxetine 30mg PO (by mouth) QD (every day) . The Physician/Prescriber Response for the document referencing the [MEDICATION NAME] once daily documented a physician response of Agree and further documented, .1) Reduce dose to the [MEDICATION NAME] PO QD . On 2/25/21 at 9:40 a.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that the pharmacist comes in monthly and sends the medication reviews to them by email. ASM #2 stated that they print out the reviews and place them in the doctor's book for them to review and sign. ASM #2 stated that after the physician reviews them the nurses fax the physician's response to the pharmacy and make any changes to medication orders as needed. When asked about the length of time between the date of the MRR and the date of the physician review, ASM #2 stated that the medication reviews sent from the pharmacy were normally reviewed the next day. When asked about the facility policy for review within thirty days, ASM #2 stated that they were having problems getting the emails and that their IT department was working to resolve the issue of the pharmacy emails going to their junk mail folder. ASM #2 stated that they had found these documents for Resident #6 in their junk folder yesterday after this surveyor had requested them and printed them out for review. ASM #2 stated that the pharmacist had observed that their reviews were not on the residents charts back in January and had resent them a bulk of pharmacy reviews in January of 2021. ASM #2 stated that was when they initially discovered the email problem, and they had received the reviews for September through December 2020 in January of 2021. The facility policy Drug Regimen Review/Medication Regime Review, Developed: 6/19 documented in part, .Specific Procedures/Requirement: .a) The consulting pharmacist will provide copy of recommendations to the attending physician, medical director, and director of nursing within five (5) working days of completion of the review .b) The director of nursing or designee will review the recommendations and the attending physicians will be contacted for review and response. c) If the attending physician does not respond within thirty (30) days, the medical director will be asked to review the recommendations and/or contact the attending physician . On 2/25/21 at approximately 11:10 a.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. References: 1. [MEDICAL CONDITION] A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. 2. [MEDICAL CONDITION] A common sleep disorder. If you have it, you may have trouble falling asleep, staying asleep, or both. As a result, you may get too little sleep or have poor-quality sleep. You may not feel refreshed when you wake up. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. 3. Major [MEDICAL CONDITION] [MEDICAL CONDITION] is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works. This information was obtained from the website: https://medlineplus.gov/ency/article/ 5.htm. 2. The facility staff failed to act in a timely manner on a medication regimen review for Resident #30. Resident #30's medication regimen review was completed on 9/17/2020 with recommendations to evaluate the as needed order for Klonopin (sedative medication) which was not reviewed by the physician until January of 2021. Resident #30 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #30's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/27/2021, coded Resident #30 as scoring a 11 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 11- being moderately impaired for making daily decisions. Section N documented Resident #30 receiving antipsychotic, antidepressant and antianxiety medications while a resident at the facility. The physician's orders [REDACTED]. - .Oder Date: 8/10/202. Discontinued 11/27/2020. Klonopin 0.5 mg (milligram) tablet PRN (as needed) .Give 0.25mg 1 (one) time daily as needed in addition to scheduled dose . - .Order Date: 11/27/2020. Discontinued 2/7/2021. Klonopin 0.5mg tablet PRN (Max (maximum) 1(one) doses), . Give 0.25 mg 1 time daily at (bedtime) as needed in addition to scheduled dose . - [MEDICATION NAME] (generic name for Klonopin) 0.5 mg (milligram) tablet (0.25 mg) Tablet Oral. Give 0.25 mg nightly as needed for anxiety .Order Date: 2/7/2021 . The eMAR (electronic medication administration record) for Resident #30 dated January 2021 Medications and February 2021 Medications failed to evidence any as needed [MEDICATION NAME] administrations 1/1/21 through 1/31/21. The progress notes for Resident #30 documented in part, - 8/20/2020 14:25 (2:25 p.m.) Pharmacy. Clarify duration for prn (as needed) [MEDICATION NAME]- rec (recommendation) to provider. Medications and chart reviewed. This DRR (drug regimen review) was conducted within the limitations imposed by the COVID-19 outbreak . - 9/17/2020 18:26 (6:26 p.m.) Pharmacy. Medication regimen has been reviewed. MD (medical doctor) note- PRN (as needed) order . - 10/21/2020 11:28 (11:28 a.m.) Pharmacy. This patient's medical record/medication regimen has been reviewed. NN (nursing notes) - clinical monitoring . - 11/17/2020 12:12 (12:12 p.m.) Pharmacy. This patient's medical record/medication regimen has been reviewed. NN- order clarification . The comprehensive care plan for Resident #30 dated 11/22/2019 documented in part, (Name of Resident #30) is at risk for side effects related to use of psychoactive mediation (sic): -antipsychotics -antidepressants -antianxiety, Psychoactive medications are being used to treat/manage following behaviors/symptoms: Status: Active (Current), Effective: 11/22/2019 . Under Interventions it documented in part, .Conduct medication regimen review no less than monthly. Effective: 1/22/2019 . On 2/24/21 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #2, the director of nursing for evidence of pharmacy medication regimen reviews and any recommendations for gradual dose reductions for Resident #30. On 2/25/21 at approximately 8:00 a.m., ASM #2 provided lists of residents having pharmacy medication regimen reviews completed in January and February containing Resident #30. ASM #2 also provided a document titled Note to Attending Physician/Prescriber with a MRR (medication regimen review) date of 9/17/2020 for Resident #30. The Note to Attending Physician/Prescriber for Resident #30 dated 9/17/2020 documented in part, .Please evaluate the order for PRN: Klonopin and select one of the following: 1) Continue for 14 days, 2) Continue for 60 days due to the following:, 3) Continue for __ days due to the following: . The note further documented in the Physician/Prescriber response section, .Continue standing order, (Signature of Physician/Prescriber), 1/21 (January 2021) . On 2/25/21 at 9:40 a.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that the pharmacist comes in monthly and sends the medication reviews to them by email. ASM #2 stated that they print out the reviews and place them in the doctor's book for them to review and sign. ASM #2 stated that after the physician reviews them the nurses fax the physician's response to the pharmacy and make any changes to medication orders as needed. When asked about the length of time between the date of the MRR and the date of the physician review, ASM #2 stated that the medication reviews sent from the pharmacy were normally reviewed the next day. When asked about the facility policy for review within thirty days, ASM #2 stated that they were having problems getting the emails and that their IT department was working to resolve the issue of the pharmacy emails going to their junk mail folder. ASM #2 stated that they had received the Note to Attending Physician/Prescriber dated 9/17/2020 from the pharmacy in January after the pharmacist had resent it to them. ASM #2 stated that the pharmacist had observed that their reviews were not on the residents charts back in January and had resent them a bulk of pharmacy reviews in January of 2021. ASM #2 stated that was when they initially discovered the email problem, and they had received the reviews for September through December 2020 in January of 2021. On 2/25/21 at approximately 11:10 a.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. References: 1. [MEDICAL CONDITIONS] Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. 2. Dementia A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/ 9.htm. 3. Major [MEDICAL CONDITION] [MEDICAL CONDITION] is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works. This information was obtained from the website: https://medlineplus.gov/ency/article/ 5.htm.

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide care in a manner to maintain and promote resident dignity for one of 20 residents in the survey sample, Resident #1. The facility staff failed to ensure Resident #1 was covered during the residents bath on 2/24/21, to promote and maintain Resident #1's, dignity. The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/19/20, Resident #1 was coded as moderately cognitively impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). She was coded as requiring the extensive assistance of staff for bed mobility, transfers between surfaces, eating, toileting, and personal hygiene. She was coded as totally dependent on staff for bathing. On 2/23/21 at 3:05 p.m., Resident #1 was observed lying on her back in bed. Her bed was in the lowest position, approximately six inches above the floor. Fall mats were visible on both sides of her bed. An attempt was made to interview Resident #1, however Resident #1's voice was very soft and hoarse, and her words were unintelligible. On 2/24/21 10:04 a.m., Resident #1 was observed in her private bathroom. She was seated in a shower chair, and the back of the chair was reclined. The resident was elevated to waist-height of CNA (certified nursing assistant) #2 in the shower chair. CNA #2 was observed bathing the resident. Observation revealed Resident #1 was leaning to the right in the chair, and was completely uncovered. At 10:06 a.m., CNA #2 left Resident #1's room and closed the door behind her. Observation revealed CNA #2 returned to Resident #1's room in approximately 60-90 seconds. As she was entering the room, CNA #2 was asked if anyone was with Resident #1 while the CNA had been gone. CNA #2 stated, No. CNA #2 stated no one was assisting her to bathe Resident #1, and that no one was supervising Resident #1 while she was alone in the bathroom in the shower chair. CNA #2 stated, I'm getting ready to brush her teeth. I needed to get a cup for water. CNA #2 was accompanied back into Resident #1's private bathroom. Resident #1 was still in the elevated shower chair, leaning over to the right, with her back reclined. Resident #1 was totally uncovered. On 2/24/21 at 10:29 a.m., CNA #2 was interviewed. When asked why she had left Resident #1 alone in the shower chair, CNA #2stated, She was having a bowel movement so she asked me to step out for a minute. When asked if she had considered covering Resident #1 up during her bath or when she left the room, she stated she did not. CNA #2 stated, She (Resident #1) has a private bathroom. CNA #2 stated she did not see a need for Resident #1 to be covered. When asked if being left completely exposed for any length of time added to Resident #1's experience of being treated with dignity, CNA #2 stated she could not speak for the resident. On 2/24/21 at 2:13 p.m., LPN (licensed practical nurse) #2 was interviewed. She stated she had already been informed of the questions the surveyor had asked CNA #2. LPN #2 stated, From my understanding, (Resident #1) wanted to have privacy to have a bowel movement. When asked if Resident #1 should have been covered either during the bath, or while CNA #2 left her completely alone in the room, LPN #2 stated she could not say for sure. LPN #2 was asked if Resident #1 had been treated in a dignified manner when CNA #2 left the room and left Resident #1 completely uncovered. LPN #2 stated she could not say for sure because different people want different things. On 2/24/21 at 2:46 p.m., RN (registered nurse) #1, the unit manager, was interviewed. When asked if Resident #1 should have been covered either during her bath or when CNA #2 left her completely alone in the bathroom, RN #1 stated, Yes. She (Resident #1) should have been covered. She stated basic nursing practice is to cover the part of the body not being bathed. RN #1 stated, That is (nursing) 101. That is a basic thing to do. She should have been covered up. There is nothing else I can say. RN #1 stated Resident #1's dignity was not preserved when she was left totally uncovered by CNA #2. A review of Resident #1's care plan dated 4/11/19 revealed no information related to treating the resident with dignity. On 2/24/21 at 4:00 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Preservation of Resident Dignity, revealed, in part: (Name of Facility) ensures that each resident is treated with dignity and respect, and that each resident is assisted in maintaining and enhancing his or her well-being and self-esteem. No further information was provided prior to exit. (1) [MEDICAL CONDITION] (PD) is a type of movement disorder. It happens when nerve cells in the brain don't produce enough of a brain chemical called [MEDICATION NAME]. Sometimes it is genetic, but most cases do not seem to run in families. This information is taken from the website https://medlineplus.gov/[MEDICAL CONDITION].html. (2) Dementia is a gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information is taken from the website https://medlineplus.gov/ency/article/ 6.htm.

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility failed to provide care in a safe manner for one of 20 residents in the survey sample, Resident #1. The facility staff failed to ensure Resident #1 was provide supervision during bathing on 2/24/21. Resident #1, who was assessed as at risk for falls, was left in the bathroom unattended, while seated and reclined in an elevated shower chair. The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/19/20, Resident #1 was coded as being moderately cognitively impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). She was coded as requiring the extensive assistance of staff for bed mobility, transfers between surfaces, eating, toileting, and personal hygiene. She was coded as being totally dependent on staff for bathing. On 2/23/21 at 3:05 p.m., Resident #1 was observed lying on her back in bed. Her bed was in the lowest position, just approximately six inches above the floor. On either side of her bed, fall mats were visible. An attempt was made to interview Resident #1. However, Resident #1's voice was very soft and hoarse, and her words were unintelligible. On 2/24/21 10:04 a.m., Resident #1 was observed in her private bathroom. She was seated in a shower chair, and the back of the chair was reclined. The resident was elevated to waist-height of CNA (certified nursing assistant) #2 in the shower chair. CNA #2 was observed bathing the resident. The resident was leaning to the right in the chair, and was completely uncovered. The surveyor exited the room. At 10:06 a.m., CNA #2 left Resident #1's room and closed the door behind her. In approximately 60-90 seconds, CNA #2 returned to Resident #1's room. As she was entering the room, CNA #2 was asked if anyone was with Resident #1 while the CNA had been gone. CNA #2 stated: No. CNA #2 stated no one was assisting her to bathe Resident #1, and that no one was supervising Resident #1 while she was alone in the bathroom in the shower chair. She stated: I'm getting ready to brush her teeth. I needed to get a cup for water. The surveyor accompanied CNA #2 back into Resident #1's private bathroom. Resident #1 was still in the elevated shower chair, leaning over to the right, with her back reclined. Resident #1 was totally uncovered. A review of Resident #1's clinical record revealed a physician's order dated 12/20/20. The order documented: Floor mats .check three times daily. A review of Resident #1's care plan dated 4/11/19, and updated 12/16 20, revealed: At risk for falls R/T (related to) [MEDICAL CONDITION]. Fall mats beside bed when in bed. On 2/24/21 at 10:29 a.m., CNA #2 was interviewed. When asked why she had left Resident #1 alone in the shower chair, CNA #2 stated, She was having a bowel movement so she asked me to step out for a minute. When asked if Resident #1 was able to support herself in the chair, CNA #2 stated, No. She can't support herself. That's why it's good the chair leans back. When asked if Resident #1 was safe to be left alone in an elevated shower chair without a staff member within sight or sound range, CNA # 2 stated she thought so. On 2/24/21 at 2:13 p.m., LPN (licensed practical nurse) #2 was interviewed. She stated she had already been informed of the questions the surveyor had asked CNA #2. LPN #2 stated, From my understanding, (Resident #1) wanted to have privacy to have a bowel movement. When asked if it was a safe practice to leave Resident #1 completely alone while she was in an elevated shower chair, LPN #2 stated, I probably would have stayed by the bathroom door. I feel like that chair is safe enough for her. That chair has arms. It is safe enough for her to be left alone. When asked why Resident #1's bed is kept at the lowest position and why the resident's floor has fall mats on both sides of the bed, LPN #2 stated, In case she (Resident #1) falls. On 2/24/21 at 2:46 p.m., RN (registered nurse) #1, the unit manager, was interviewed. When asked if Resident #1 was safe to be left alone in an elevated shower chair, she stated the resident was not safe. RN #1 stated, That was a safety issue. She should have been within eyesight. It was not safe. On 2/24/21 at 4:00 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Safety and Supervision of Residents, revealed, in part: Our resident-oriented approach to safety addresses safety and accident hazards for individual residents .Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. No further information was provided prior to exit. (1) [MEDICAL CONDITION] (PD) is a type of movement disorder. It happens when nerve cells in the brain don't produce enough of a brain chemical called [MEDICATION NAME]. Sometimes it is genetic, but most cases do not seem to run in families. This information is taken from the website https://medlineplus.gov/[MEDICAL CONDITION].html. (2) Dementia is a gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information is taken from the website https://medlineplus.gov/ency/article/ 6.htm.

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to maintain an infection control program, as evidenced by no infection control tracking, trending, and surveillance logs for (MONTH) 2019 through (MONTH) 2019. The facility staff failed to maintain tracking, trending, and surveillance logs for facility infections. There were no infection control tracking, trending, and surveillance logs for (MONTH) 2019 through (MONTH) 2019 The findings include: The facility staff failed to maintain tracking, trending, and surveillance logs for facility infections. There were no infection control tracking, trending, and surveillance logs for (MONTH) 2019 through (MONTH) 2019 On 6/26/19 at 4:00 PM, the infection control tracking logs was requested from ASM #2 (Administrative Staff Member, the Director of Nursing DON). On 6/27/19 at 8:15 AM, a review of the logs was conducted. The logs were for the current month of (MONTH) 2019 only. On 6/27/19 at 8:21 AM, in an interview with ASM #2, she stated that she had started employment at the facility in the middle of (MONTH) 2019, and started the tracking logs. She stated that there were no tracking, trending, and surveillance logs prior to (MONTH) 2019. On 6/27/19 at 8:55 AM, ASM #2 provided an infection control logbook for the calendar year of (YEAR). However, she was still not able to provide evidence of infection control tracking, trending, and surveillance for (MONTH) 2019 through (MONTH) 2019, a 5 month time period with no tracking, trending and surveillance. A review of the facility policy, Infection Control documented, Policy: The primary purpose of (facility) infection control policies and procedures are to establish guidelines for providing a safe and sanitary environment and to help prevent the development and transmission of disease and infection, while maintaining the residents' comfort, dignity and rights. Procedures: 2. The objectives of our infection control policies and procedures are to: *Identify, investigate, control and prevent infections in the facility. *Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; *Establish guidelines for the implementation of isolation precautions; *Maintain records of incidents and corrective actions related to infections. *Establish guidelines to follow in implementing Standard Precautions for the handling of blood, body fluids, secretions, excretions, mucous membranes and nonintact skin. 3. It shall be the responsibility of the Quality Assurance Committee, through the Infection Control Sub-Committee; to approve infection control policies and procedures and to ensure that they are implemented and followed 5. The Governing Board, through the Quality Assurance and the Infection Control Sub-Committees, has adopted our infection control policies and procedures, as those that best reflect the needs and operational requirements of this facility in the prevention of transmission of infections and communicable diseases as set forth in current (multiple agencies listed) guidelines and recommendations On 6/27/19 at 9:07 AM, ASM #1 (the Administrator) was made aware of the findings. No further information was provided by the end of the survey.

Based on observation resident interview, staff interview facility document review and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for six of 26 residents in the survey sample, Residents #10, #35, #22, #17, #41 and Resident #14. The findings include: 1. The facility staff failed to review and revise Resident #10's comprehensive care plan to include the use of side rails. Resident #10 was admitted to the facility on [DATE]. Resident #10's [DIAGNOSES REDACTED]. Resident #10's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/20/19, coded Resident #10 with no cognitive impairment. Section G coded Resident #10 as requiring extensive assistance of one staff member with bed mobility. Review of Resident #10's clinical record revealed a physician order dated 06/20/18 which documented, Side rails to be on both sides of bed at all times and a facility document titled, Side Rail & Entrapment Risk Evaluation, completed 5/06/19. Further review of Resident #10's clinical record failed to reveal a review and revision of the comprehensive care plan to include the use of side rails for Resident #10. On 6/25/19 at 11:45 a.m., Resident #10 was observed sitting in her wheelchair watching television. Both quarter rails were in a raised position. Resident #10 was asked if she used the half rails at any time. Resident #10 stated, I use them to move around sometimes. On 6/26/19 at 12:30 p.m., an interview was conducted with LPN #6. LPN #6 was asked about the process staff follow for ensuring interventions are added to the care plan. LPN #6 stated, You add interventions to the care plan after reviewing physician orders or during the care plan meeting while the interdisciplinary team is reviewing them. LPN #6 was asked if side rails should be care planned. LPN #6 stated, Yes, they should be. On 6/28/19 at 12:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. A review of the facility policy, Care Planning, documented, 8) The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a) When there has been a significant change in resident's condition; b) When the desired outcome is not met; c) When the resident has been readmitted to the facility from a hospital stay; and i) At least quarterly. No further information was presented prior to the end of the survey. 2. The facility staff failed to review and revise Resident #35's comprehensive care plan to include the use of side rails. Resident #35 was admitted to the facility on [DATE]. Resident #35's [DIAGNOSES REDACTED]. Resident #35's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 5/17/19, coded Resident #35 with no cognitive impairment. Section G coded Resident #35 as requiring limited assistance of one staff member with bed mobility. Review of Resident #35's clinical record revealed a facility document titled, Side Rail & Entrapment Risk Evaluation, completed 5/06/19. Further review of Resident #35's clinical record failed to reveal a review and revision of the comprehensive care plan to include the use of side rails for Resident #35. On 6/25/19 at 11:50 a.m., Resident #35 was observed sitting on her bed in the room. Both quarter rails were in a raised position. Resident #35 was asked if she used the half rails at any time. Resident #35 stated, I use the rails sometimes because I am blind. My bed remote hangs from it. On 6/26/19 at 12:30 p.m., an interview was conducted with LPN #6. LPN #6 was asked what the process is for ensuring interventions are added to the care plan. LPN #6 stated, You add interventions to the care plan after reviewing physician orders or during the care plan meeting while the interdisciplinary team is reviewing them. LPN #6 was asked if side rails should be care planned. LPN #6 stated, Yes, they should be. On 6/28/19 at 12:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to the end of the survey. 3. a. The facility staff failed to review and revise Resident #22's comprehensive care plan after the resident fell on [DATE], 2/1/19, 2/11/19 and 2/17/19. Resident #22 was admitted to the facility on [DATE]. Resident #22's [DIAGNOSES REDACTED]. Resident #22's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/22/19, coded the resident's cognitive skills for daily decision-making as moderately impaired. Section G coded Resident #22 as requiring extensive assistance of one staff with bed mobility and transfers. Section J coded the resident as sustaining two or more falls with no injury. Review of Resident #22's clinical record and fall investigations revealed the following falls: 1/28/19- Resident #22 was observed on the floor beside the bed. 2/1/19- Resident #22 was observed on the floor beside the bed. 2/11/19- Resident #22 was observed on the floor in the living room area. 2/17/19- Resident #22 sustained a fall from the bed. Review of fall investigations dated 1/28/19, 2/1/19, 2/11/19 and 2/17/19, and Resident #22's comprehensive care plan dated 10/6/17 failed to reveal evidence that the resident's comprehensive care plan was reviewed and/or revised after each fall. On 6/26/19 at 11:02 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked the facility process regarding resident falls. LPN #1 stated a different intervention is implemented after each fall and the type of intervention depends on the cause of the fall; what has occurred with the fall and what facility staff can do to prevent future falls. LPN #1 stated the fall and interventions are then discussed with the resident and/or family and the resident's care plan is updated. On 6/26/19 at 3:36 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 3. b. The facility staff failed to review and revise Resident #22's comprehensive care plan for the use of bed rails. A side rail (bed rail) evaluation dated 1/7/19 documented Resident #22 used side rails for positioning and support. The evaluation further documented no risk to the resident if side rails are used. Review of Resident #22's clinical record failed to reveal a physician's order for bed rails. Resident #22's comprehensive care plans dated 10/6/17 and 6/3/19 failed to document information regarding bed rails. On 6/26/19 at 2:55 p.m., Resident #22 was observed lying in bed. Both quarter bed rails were up. On 6/26/19 at 11:02 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked if residents' comprehensive care plans should be reviewed and revised to include the use of bed rails. LPN #1 stated, Yes. LPN #1 stated residents' care plans should be updated every so often to see if the resident is still using bed rails and if continued use is safe. On 6/26/19 at 3:36 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 4. a. The facility staff failed to review and revise Resident #17's comprehensive care plan for the use of bed rails. Resident #17 was admitted to the facility on [DATE]. Resident #17's [DIAGNOSES REDACTED]. Resident #17's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 4/11/19, coded the resident's cognition as severely impaired. Section G coded Resident #17 as requiring extensive assistance of one staff with bed mobility and as requiring extensive assistance of two or more staff with transfers. Review of Resident #17's clinical record revealed a side rail (bed rail) evaluation dated 6/10/17. The evaluation documented there was no risk to the resident if side rails are used. A physician's order dated 7/5/18 documented an order for [REDACTED].#17's comprehensive care plan with an effective date of 5/16/19 failed to document information regarding bed rails. On 6/25/19 at 9:38 a.m., the bed rails on Resident #17's bed were observed in an upright position. On 6/26/19 at 11:02 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked if residents' comprehensive care plans should be reviewed and revised to include the use of bed rails. LPN #1 stated, Yes. LPN #1 stated residents' care plans should be updated every so often to see if the resident is still using bed rails and if continued use is safe. On 6/26/19 at 2:00 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 was asked if Resident #17 uses his bed rails. LPN #2 stated the resident uses his bed rails for turning and positioning. On 6/26/19 at 3:36 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 4. b. The facility staff failed to review and revise Resident #17's comprehensive care plan for the use of antidepressant medication. Resident #17 was admitted to the facility on [DATE]. Resident #17's [DIAGNOSES REDACTED]. Resident #17's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 4/11/19, coded the resident's cognition as severely impaired. Section N coded Resident #17 as having received antidepressant medication seven out of the last seven days. Review of Resident #17's clinical record revealed a physician's order dated 11/2/18 for [MEDICATION NAME] (1) 10 milligrams one time daily for major [MEDICAL CONDITION]. Resident #17's comprehensive care plan with an effective date of 5/16/19 failed to document information regarding antidepressant medication. The MDS coordinator was not available for interview during the survey. On 6/26/19 at 2:47 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated the MDS nurse was responsible for reviewing and revising care plans for [MEDICAL CONDITION] medications but that responsibility was now transitioning to all of the nurses. LPN #3 was asked if a resident's care plan should be reviewed and revised to include antidepressant medication use. LPN #3 stated, Yes. When asked why, LPN #3 stated, Because for any [MEDICAL CONDITION] meds you want to do reductions, and also well, because we need to know what they are on, look for side effects and things like that and what our goal is for it. On 6/26/19 at 3:36 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. (1) [MEDICATION NAME] is used to treat depression. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 5.html 5. The facility staff failed to review and revise Resident #41's comprehensive care plan for the use of bed rails. Resident #41 was admitted to the facility on [DATE]. Resident #41's [DIAGNOSES REDACTED]. Resident #41's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/5/19, coded the resident's cognitive skills for daily decision making as independent. Section G coded Resident #41 as requiring extensive assistance of two or more staff with bed mobility and transfers. Review of Resident #41's clinical record revealed a side rail (bed rail) evaluation dated 9/12/18 that documented the resident was not at risk if side rails are used. A physician's order dated 5/29/19 documented an order for [REDACTED].#41's comprehensive care plan with an effective date of 6/1/19 failed to document information regarding bed rails. On 6/26/19 at 7:54 a.m., Resident #41's quarter bed rails were observed in an upright position. On 6/26/19 at 11:02 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked if residents' comprehensive care plans should be reviewed and revised to include the use of bed rails. LPN #1 stated, Yes. LPN #1 stated residents' care plans should be updated every so often to see if the resident is still using bed rails and if continued use is safe. On 6/26/19 at 2:00 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 was asked if Resident #41 uses her bed rails. LPN #2 stated the resident uses her bed rails for turning and positioning. On 6/26/19 at 3:36 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 6. The facility staff failed to review and revise the Resident #14's comprehensive care plan to address the residents use of be rails. Resident #14 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The significant change MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 4/3/19 coded the resident as being moderately impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing and transfers; extensive assistance for dressing, toileting, and hygiene; supervision for eating; and was incontinent of bladder and had an ostomy for bowel. Observations conducted on 6/25/19 at 10:47 AM, and 6/26/19 at 8:55 AM revealed the resident in her room in her wheelchair. The bed was noted to have approximate quarter-length sized side rails on in the up position. Review of the clinical record revealed a physician's order, dated 8/18/16 that documented, 1/2 side rails up when in bed to assist with repositioning and independence. A review of the comprehensive care plan, with an Effective Date of 5/16/19, revealed one, undated, for Turning/positioning in bed (bed mobility) - (Resident #14) requires extensive assistance. This care plan included the goal, undated, for While in bed, assist (Resident #14) to turn/reposition self. Use pillows and foam wedges to maintain position. The care plan did not address or include any interventions for the use of side rails. On 6/26/19 at 10:37 AM, in an interview with LPN #3 (Licensed Practical Nurse), when asked if the side rails should be care planned, LPN #3 stated that they should be. On 6/26/19 at 11:02 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked if the side rails should be care planned, she stated that they should be. On 6/28/19 at 4:00 PM, ASM #1 (Administrative Staff Member - the Administrator) and ASM #2 (the Director of Nursing) made aware of the findings. No further information was provided by the end of the survey.

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for seven of 26 residents in the survey sample; Residents #46, #249, #22, #41, #17, #10 and #35. The findings include: 1. The facility staff failed to ensure, risks versus benefits were explained to Resident #46 and/or the resident representative, and failed to ensure a risk for entrapment assessment was conducted, and a signed consent was obtained prior to the installation/use of side rails for Resident #46. Resident #46 was readmitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 6/6/19, coded Resident #46 as being cognitively intact in ability to make daily life decisions. The resident was coded as requiring extensive assistance for bathing, hygiene, toileting, dressing, and transfers; limited assistance for eating; and was frequently incontinent of bowel and bladder. On 6/25/19 at 1:45 PM and 6/26/19 at 8:55 AM, observations were made of Resident #46's room. The resident was not in the room. The bed was noted with quarter-length sized side rails on the bed in the up position. Review of the clinical record revealed a physician's order, dated 5/30/19, for 1/2 siderails (Sic.) up when in bed to assist with repositioning and independence. A review of the clinical record revealed a Side Rail Evaluation dated 6/1/19, which documented 15 questions and resident responses regarding the use of side rails. The Recommendations section documented, Recommendations: Side Rails Half Rails Bilateral. This form did not include documentation regarding the risks versus benefits of the use of side rails or specify if there was any entrapment risk. Further review of the clinical record failed to reveal any signed consents for the use of the side rails for Resident #46. A review of the baseline care plan dated 5/30/19 included a section for Restraints/Alarms/Side Rails: ___No restraints, alarms, or side rails used .___Restraint(s) used .___Alarm(s) used . ___Side rail(s) used . Each line item contained a box to the left of the type of restraint, to check if that type was required, and three lines after each line item for writing in specific details. The box next to No restrains, alarms, or side rails used was checked. A review of the comprehensive care plan, with an Effective Date of 6/11/19, revealed one, undated, for Turning/positioning in bed (bed mobility). (Resident #46) requires extensive assistance. This care plan included the intervention, undated, While in bed, assist (Resident #46) to turn/reposition self. Use pillows and foam wedges to maintain position. This care plan did not document that the use of bedrails was appropriate for this resident. A second care plan, undated, for Impaired Bed Mobility also did not document the use of bedrails was appropriate for this resident. The resident was not care planned for the use of side rails. On 6/26/19 at 10:33 AM, in an interview with LPN #3 (Licensed Practical Nurse), when asked if the side rails were on the bed, was there the potential that the staff or family may utilize them and put them in the up position with the resident in bed. She stated that there is a potential if it is on the bed. On 6/26/19 at 11:02 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked about the facility process regarding bed rails. LPN #1 stated bed rails are usually used for a resident that needs more help with pulling up and who is a little more independent, but needs assistance with getting in and out of bed. LPN #1 stated that prior to bed rail use, a physician's order is obtained, the facility staff makes sure the bed rails are safe for the resident and discusses the use of bed rails with the resident or family. LPN #1 stated the resident and/or family is made aware of the dangers of bed rails and consent is obtained and the use of side rails should be care planned. LPN #1 was asked if there was a risk of bed rails being used if they were on a resident's bed, even if the resident does not have a physician's order for bed rails. LPN #1 stated, Yes. On 6/28/19 at 4:00 PM, ASM #1 (Administrative Staff Member - the Administrator) and ASM #2 (the Director of Nursing) made aware of the findings. They were asked that if the side rails were present on the beds, then was there the potential that staff or family may utilize them and put them in the up position with the resident in bed. They stated that there was a potential. A review of the facility document Pivoting Assist Device documented, An optimal bed system assessment should be conducted on each resident by a qualified clinician or medical provider to ensure maximum safety of the resident. The assessment should be conducted within the context of, and in compliance with, the state and federal guidelines related to the use of restraints and bed's system entrapment guidance, including the clinical guidance for the assessment and implementation of side rails The assist device is intended for use as an aid in entering or exiting the bed sleep area, as well as a stable handhold during self-positioning within the bed sleep area .The assist device is only one part of your healthcare bed system. Proper combinations of bed, mattress, head/foot panels and assist rails are needed to minimize the risk of entrapment A review of the facility policy, Restraints (Including Side Rails) was conducted. The policy referred to the use of full side rails in the context of being a restraint and did not address the criteria for half or quarter sized side rails for the purposes of aiding residents' independence with moment in the bed. No further information was provided by the end of the survey. 2. The facility staff failed to review the risks and benefits and obtain informed consent, prior to the presence of and use of bed rails for Resident #249. Resident #249 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set), an initial admission assessment, with no ARD (Assessment reference date), no BIMS (Brief Interview for Mental Status) score indicating the Resident's ability for daily decision-making. On 6/24/19 at 7:010 PM and 6/25/19 at 1:54 PM, an observation was made of Resident #249's room. The resident was observed in the bed. His bed was noted to have 2 quarter-length side rails (one on each side) and the side rails were up at each observation. The side rails were present, in the up position, and available for use by the resident while he was in bed. A review of the clinical record revealed a undated Side Rail Evaluation form that documented in part, Instructions: Check YES or NO, as appropriate, to answer each question. Provide additional information where requested. This form contained a series of questions. Has the resident expressed a desire to have side rails raised while in bed for their own safety? Yes response was entered. Resident states the side rails help with changing positions. Does the resident have fluctuations in levels of consciousness or a cognitive defect? Yes response was entered. Periods of forgetfulness. Does the resident have any visual defects? If yes, explain. Yes response was entered. Wears glasses daily. Is the resident able to get in / out of bed? No response was entered. Is the resident able to get in / out of bed safely? No response was entered. Does the resident have a history of falls? Yes response was entered. Is the resident having problems with balance or poor trunk control? No response was entered. Does the resident use the side rail for positioning or support? Yes response was entered. Does the side rail help the resident rise from a supine position to a sitting / standing position? Yes response was entered. Does the resident have a history of postural [MEDICAL CONDITION]? No response was entered. Is there a possibility the resident will climb over the side rail? No response was entered. Is there evidence (reason to believe) the resident has (or may have) a desire or reason to get out of bed? If yes, explain. No response was entered. Does the resident receive any medications that would require safety precautions? If yes, explain. No response was entered. Is there a risk to the resident if side rails are used? If yes, explain. No response was entered. Do the side rail alternatives / interventions create more risk that side rail use? If yes, explain. No response was entered. This form contained a section identified as Interventions, dated 6/16/19. This section contained the following: Reminder to use call light. This form contained a section identified as Recommendations. This section contained the following documentation: This resident has requested Side Rails while in bed. A review of the clinical recorded revealed a physician's order dated 6/16/19, documented in part, 1/2 side rails up when in bed to assist with repositioning and independence. A review of the clinical record revealed a baseline care plan, dated 6/14/19. The base line care plan included a section for Restraints/Alarms/Side Rails: ___No restraints, alarms, or side rails used .___Restraint(s) used .____Alarm(s) used .___Side Rail(s) used . Each line item contained in a box to the left of the type of restraint, to check if that type was required, and three lines after each item for writing in specific details. The box next to Side Rail(s) used was checked. Further review of the clinical record failed to reveal the risks and benefits for the use of side rails were reviewed with Resident #249 and or the residents responsible party and failed to evidence a signed informed consent for the use of bed rails was obtained prior to the use of bed rails for the resident. On 6/26/19 at 4:15 PM, ASM (Administrative Staff Member) #1, the Administrator and ASM #2, the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey. (1) Suprapubic: A suprapubic catheter (tube) drains urine from your bladder. It is inserted into your bladder through a small hole in your belly. This information was obtained from the following website: https://medlineplus.gov/ency/patientinstructions/ 5.htm (2) An indwelling catheter is a tube that drains urine from the bladder to a bag outside of the body. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/ 0.htm 3. The facility staff failed to review risks and benefits, and obtain informed consent for Resident #22's use of bed rails. Resident #22 was admitted to the facility on [DATE]. Resident #22's [DIAGNOSES REDACTED]. Resident #22's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/22/19, coded the resident's cognitive skills for daily decision making as moderately impaired. Section G coded Resident #22 as requiring extensive assistance of one staff with bed mobility and transfers. A side rail (bed rail) evaluation dated 1/7/19 documented Resident #22 used side rails for positioning and support. The evaluation further documented no risk to the resident if side rails are used. Review of Resident #22's clinical record failed to reveal a physician's order for bed rails. Further review of Resident #22's clinical record failed to reveal the risks and benefits of bed rails was explained to Resident #22 and/or the resident's representative or evidence that informed consent was obtained for the use of bed rails. Resident #22's comprehensive care plans dated 10/6/17 and 6/3/19 failed to document information regarding bed rails. On 6/26/29 at 2:55 p.m., Resident #22 was observed lying in bed. Both quarter bed rails were up. On 6/26/19 at 11:02 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked about the facility process regarding bed rails. LPN #1 stated bed rails are usually used for a resident that needs more help with pulling up and who is a little more independent but needs assistance with getting in and out of bed. LPN #1 stated that prior to bed rail use, a physician's order is obtained, the facility staff makes sure the bed rails are safe for the resident and discusses the use of bed rails with the resident or family. LPN #1 stated the resident and/or family is made aware of the dangers of bed rails and consent is obtained. LPN #1 was asked if there was a risk of bed rails being used if they were on a resident's bed, even if the resident does not have a physician's order for bed rails. LPN #1 stated, Yes. On 6/26/19 at 3:36 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 4. The facility staff failed to review risks and benefits, and obtain informed consent for Resident #41's use of bed rails. Resident #41 was admitted to the facility on [DATE]. Resident #41's [DIAGNOSES REDACTED]. Resident #41's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/5/19, coded the resident's cognitive skills for daily decision making as independent. Section G coded Resident #41 as requiring extensive assistance of two or more staff with bed mobility and transfers. Review of Resident #41's clinical record revealed a side rail (bed rail) evaluation dated 9/12/18 that documented the resident was not at risk if side rails are used. A physician's order dated 5/29/19 documented an order for [REDACTED].#41's comprehensive care plan with an effective date of 6/1/19 failed to document information regarding the resident's use of bed rails. Further review of Resident #41's clinical record failed to reveal the risks and benefits of bed rails was explained to Resident #41 and/or the resident's representative or evidence that informed consent was obtained. On 6/26/19 at 7:54 a.m., Resident #41's quarter bed rails were observed in an upright position. On 6/26/19 at 11:02 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked the facility process regarding bed rails. LPN #1 stated bed rails are usually used for a resident that needs more help with pulling up and who is a little more independent but needs assistance with getting in and out of bed. LPN #1 stated that prior to bed rail use, a physician's order is obtained, the facility staff makes sure the bed rails are safe for the resident and discusses the use of bed rails with the resident or family. LPN #1 stated the resident and/or family is made aware of the dangers of bed rails and consent is obtained. On 6/26/19 at 2:00 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 was asked if Resident #41 uses her bed rails. LPN #2 stated the resident uses her bed rails for turning and positioning. On 6/26/19 at 3:36 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 5.a. The facility staff failed to ensure Resident #17's right, quarter bed rail was maintained in a safe manner. Resident #17 was admitted to the facility on [DATE]. Resident #17's [DIAGNOSES REDACTED]. Resident #17's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 4/11/19, coded the resident's cognition as severely impaired. Section G coded Resident #17 as requiring extensive assistance of one staff with bed mobility and as requiring extensive assistance of two or more staff with transfers. Review of Resident #17's clinical record revealed a physician's order dated 7/5/18 for 1/2 side rails (bed rails) up when in bed to assist with repositioning and independence. Resident #17's comprehensive care plan with an effective date of 5/16/19 failed to document information regarding the resident's use of bed rails. On 6/24/19 at approximately 7:45 p.m., Resident #17 was observed in his room voicing concern to an unidentified staff member about a loose bed rail. On 6/25/19 at 9:38 a.m., an interview was conducted with Resident #17. The resident voiced concern regarding his right bed rail. Resident #17 stated the bed rail was loose and dangerous and stated it may make him fall. At this time, observation of the right, quarter bed rail was conducted. The bed rail was up and in a locked position. The bed rail moved approximately one inch to the left (facing the bed) and approximately one inch out from the bed when pulled. On 6/26/19 at 7:50 a.m., observation of Resident #17's right bed rail revealed the rail remained loose when up and in the locked position. On 6/26/19 at 10:38 a.m., an interview was conducted with OSM (other staff member) #2 (the maintenance manager). OSM #2 was asked to describe the role the maintenance department plays regarding the maintenance of bed rails. OSM #2 stated, We get work orders when something goes wrong. We will immediately dispatch a maintenance person to make a repair or order a part. OSM #2 was asked if he had received any work orders regarding Resident #17's bed rail. OSM #2 stated he would look. On 6/26/19 at 11:22 a.m., OSM #2 presented a work order dated 6/25/19 at 8:35 a.m. The work order documented Resident #17's right grab bar on the bed was loose and hanging down on the side of the bed. OSM #2 stated this was the only work order regarding Resident #17's bed rail. OSM #2 stated the work order was received on the previous day at 8:35 a.m. OSM #2 stated a maintenance employee had tightened the bed rail. OSM #2 was made aware that at 7:50 a.m. on this date the bed rail was not repaired. OSM #2 was asked why the bed rail had not been repaired if the work order was received on 6/25/19. OSM #2 stated the assigned maintenance employee did not get to the bed rail for repair until this morning. On 6/26/19 at 1:52 p.m., another interview was conducted with OSM #2. OSM #2 was asked if Resident #17's loose bed rail posed a safety risk. OSM #2 stated he did not physically see the bed rail and that the employee who repaired the bed rail stated it was loose and was tightened with three to four turns of a screwdriver. OSM #2 stated he could not say if the bed rail posed a risk because he did not see the bed rail. On 6/26/19 at 2:00 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 was asked if Resident #17 uses his bed rails. LPN #2 stated the resident uses his bed rails for turning and positioning. LPN #2 was asked if a loose bed rail posed a safety risk. LPN #2 stated, Yes, because it's supposed to be for mobility and they may use for transfers. If loose, possibly not tight enough, it could give and drop on them and cause them to fall. On 6/26/19 at 3:36 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy regarding side rails (bed rails) failed to document information regarding the maintenance of bed rails. No further information was presented prior to exit. 5. b. The facility staff failed to review risks and benefits, and obtain informed consent for Resident #17's use of bed rails. Review of Resident #17's clinical record revealed a side rail (bed rail) evaluation dated 6/10/17. The evaluation documented there was no risk to the resident if side rails are used. A physician's order dated 7/5/18 documented an order for [REDACTED].#17's comprehensive care plan with an effective date of 5/16/19 failed to document information regarding bed rails. Further review of Resident #17's clinical record failed to reveal the risks and benefits of bed rails was explained to Resident #17 and/or the resident's representative or evidence that informed consent was obtained. On 6/25/19 at 9:38 a.m., the bed rails on Resident #17's bed were observed in an upright position. On 6/26/19 at 2:00 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 was asked if Resident #17 uses his bed rails. LPN #2 stated the resident uses his bed rails for turning and positioning. On 6/26/19 at 3:36 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 6. The facility staff failed to obtain consent and review risk and benefits prior to the installation/use of bed rails for Resident #10. Resident #10 was admitted to the facility on [DATE]. Resident #10's [DIAGNOSES REDACTED]. Resident #10's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/20/19, coded Resident #10 with no cognitive impairment. Section G coded Resident #10 as requiring extensive assistance of one staff member with bed mobility. Review of Resident #10's clinical record revealed a physician order dated 06/20/18 which documented, Side rails to be on both sides of bed at all times and a facility document titled, Side Rail & Entrapment Risk Evaluation, completed 5/06/19. Further review of Resident #10's clinical record failed to reveal documented consent or documentation that risk and benefits were reviewed with Resident #10 (or the resident's representative) prior to the resident's use of bed rails. On 6/25/19 at 11:45 a.m., Resident #10 was observed sitting in her wheelchair watching television. Both quarter rails were in a raised position. Resident #10 was asked if she used the half rails at any time. Resident #10 stated, I use them to move around sometimes. On 6/26/19 at 11:02 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked the facility process regarding bed rails. LPN #1 stated bed rails are usually used for a resident that needs more help with pulling up and who is a little more independent but needs assistance with getting in and out of bed. LPN #1 stated that prior to bed rail use, a physician's order is obtained, the facility staff makes sure the bed rails are safe for the resident and discusses the use of bed rails with the resident or family. LPN #1 stated the resident and/or family is made aware of the dangers of bed rails and consent is obtained. LPN #1 was asked if there was a risk of bed rails being used if they were on a resident's bed, even if the resident does not have a physician's order for bed rails. LPN #1 stated, Yes. On 6/28/19 at 12:15 p.m., ASM #1 and ASM #2 were made aware of the above concern. No further information was presented prior to the end of the survey. 7. The facility staff failed to obtain consent, a physician order and review risk and benefits prior to the installation/use of bed rails for Resident #35. Resident #35 was admitted to the facility on [DATE]. Resident #35's [DIAGNOSES REDACTED]. Resident #35's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 5/17/19, coded Resident #35 with no cognitive impairment. Section G coded Resident #35 as requiring limited assistance of one staff member with bed mobility. Review of Resident #35's clinical record revealed a facility document titled, Side Rail & Entrapment Risk Evaluation, completed 5/06/19. Further review of Resident #35's clinical record failed to reveal documented consent, a physician order or documentation that risk and benefits were reviewed with Resident #35 (or the resident's representative). On 6/25/19 at 11:50 a.m., Resident #35 was observed sitting on her bed in the room. Both quarter rails were in a raised position. Resident #35 was asked if she used the half rails at any time. Resident #35 stated, I use the rails sometimes because I am blind. My bed remote hangs from it. On 6/26/19 at 11:02 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked the facility process regarding bed rails. LPN #1 stated bed rails are usually used for a resident that needs more help with pulling up and who is a little more independent but needs assistance with getting in and out of bed. LPN #1 stated that prior to bed rail use, a physician's order is obtained, the facility staff makes sure the bed rails are safe for the resident and discusses the use of bed rails with the resident or family. LPN #1 stated the resident and/or family is made aware of the dangers of bed rails and consent is obtained. LPN #1 was asked if there was a risk of bed rails being used if they were on a resident's bed, even if the resident does not have a physician's order for bed rails. LPN #1 stated, Yes. On 6/27/19 at 4:00 p.m., ASM #1 (Administrative Staff Member - the Administrator) and ASM #2 (the Director of Nursing) were asked that if the side rails were present on the beds, then was there the potential that staff or family may utilize them and put them in the up position with the resident in bed. They stated that there was a potential. On 6/28/19 at 12:15 p.m., ASM #1 and ASM #2 were made aware of the above concern. No further information was presented prior to the end of the survey.

Based on staff interview and facility document review, it was determined that the facility staff failed to complete annual CNA (certified nursing aide) performance reviews for three of five CNA record reviews. The facility staff failed to complete annual performance reviews for CNA #2, CNA #3 and CNA #4. The findings include: Review of CNA #2's record revealed the last performance review was completed on 3/25/17. Review of CNA #3's record revealed no performance review. Review of CNA #4's record revealed a performance review with no date. On 6/26/19 at 2:14 p.m., an interview was conducted with OSM (other staff member) #3 (the director of human resources). OSM #3 was asked about the facility process for CNA performance reviews. OSM #3 stated performance reviews were conducted quarterly in (YEAR) and changed to being conducted twice a year in the beginning of 2019. OSM #2 stated the new nursing manager misunderstood the process and thought half of the reviews could be conducted in (MONTH) and the other half of reviews could be conducted in August. OSM #3 was made aware of the above concerns and stated she could not present any further information. On 6/26/19 at 3:36 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. An excerpt from the facility handbook documented, (Name of facility) reviews employee performance on a continuing basis and also periodically on a formal basis to assist the employee in attaining maximum development. The first evaluation is completed in the third month of employment and semi-annually thereafter . No further information was presented prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to notify the physician of a possible need to alter treatment for one of 26 residents in the survey sample, Resident #149. The facility staff failed to notify Resident #149's physician when some of the resident's medications were not available for administration on 6/19/19. The findings include: Resident #149 was admitted to the facility on [DATE]. Resident #149's [DIAGNOSES REDACTED]. Resident #149's MDS (minimum data set) assessment was not complete. An admission nursing assessment dated [DATE] documented the resident was alert and oriented times three (person, place and time). Review of Resident #149's clinical record revealed the following physician's orders [REDACTED].>6/18/19 Aspercreme (1) 4% topical patch- apply one patch to left chest daily. 6/18/19 [MEDICATION NAME] sulfate (2) 90 micrograms/actuation aerosol inhaler- two puffs two times a day. 6/18/19 [MEDICATION NAME] (3) 1% topical gel- two grams four times daily. Review of the (MONTH) 2019 MAR (medication administration record) for Resident #149 revealed the above medications were not administered during the morning medication pass on 6/19/19 because the facility staff was awaiting arrival of the medications from the pharmacy. In addition, the [MEDICATION NAME] was not administered during the lunch medication pass on 6/19/19 because the facility staff was awaiting arrival of the medication from the pharmacy. A nurse's note dated 6/19/19 at 12:00 p.m. documented, Medications given this am awaiting a few from pharmacy due to arrive today . Further review of Resident #149's clinical record (including the (MONTH) 2019 MAR and nurses' notes) failed to reveal documentation that Resident #149's physician was notified and made aware that the above medications were not administered on 6/19/19. Resident #149's baseline care plan dated 6/18/19 documented, MEDICATION/TREATMENT ORDERS. See MAR/TAR (treatment administration record) . On 6/26/19 at 11:02 a.m., an interview was conducted with LPN (licensed practical nurse) #1 (the nurse caring for Resident #149 during the 6/19/19 morning and lunch medication passes). LPN #1 confirmed Resident #149's Aspercreme, [MEDICATION NAME] sulfate and [MEDICATION NAME] did not arrive during her shift on 6/19/19 so the medications were not administered to the resident. When asked if she notified Resident #149's physician and made him aware the medications were not administered, LPN #1 stated, I don't recall. LPN #1 stated she would notify the physician if the resident went the entire day without the medications or if the medications were not going to arrive but in this case, she (LPN #1) had contacted the pharmacy and knew the medications were going to arrive. On 6/26/19 at 3:11 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 was asked if the physician should be notified if a resident misses a dose of medication. ASM #2 stated, Yes. When asked why, ASM #2 stated, It's a missed medication and could be a medication error. On 6/26/19 at 3:36 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. The facility policy titled, CHANGES IN CONDITION documented, (Name of facility) will immediately inform the resident and consult with the resident's physician, if appropriate, when changes occur . No further information was presented prior to exit. (1) Aspercreme is used to treat arthritis pain. This information was obtained from the website: https://www.mayoclinic.org/diseases-conditions/[MEDICAL CONDITION]/in-depth/pain-medications/ART- 899?p=1 (2) [MEDICATION NAME] sulfate is used to treat shortness of breath. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 5.html (3) [MEDICATION NAME] is used to relieve pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 2.html

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to evidence that a periodic review was conducted with the resident and/or resident's responsible party if they wish to make changes to their existing advance directives or maintain them as written for one of 26 residents in the survey sample; Residents #14 The facility staff failed to evidence Resident #14's Advance Directive was reviewed periodically with the resident and/or her responsible party (RP) to ascertain if the resident's wishes and preferences had changed or remained the same. The findings include: Resident #14 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The significant change MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 4/3/19 coded the resident as being moderately impaired in ability to make daily life decisions. On 6/26/19 at 8:55 AM, an interview was attempted with Resident #14. She was not able to recall anything about a review of her Advance Directives. A review of the clinical record revealed an Advance Medical Directive Health Care Instructions form dated 1/20/1997. Further review of the clinical record failed to reveal any evidence that the contents of this form was discussed with the resident and/or RP periodically to ascertain if the information contained within continued to be the resident's wishes or did she wish to make any changes. On 6/25/19 at 4:31 PM, in an interview with OSM #1 (Other Staff Member) the social worker. OSM #1 stated that for periodic review, if a resident has questions, we review it, briefly go over it in care plan meetings, and ask if they want to make any changes to it. When asked how staff evidenced that the Advanced Directive was reviewed with the resident, OSM #1 stated, There is a general note from the care plan meeting and what happened in the meeting. On 6/26/19 at 11:40 AM, OSM #1 provided a copy of the most recent Care Plan meeting invitation provided to the resident. The Care Plan meeting invitation documented, You and your responsible party (RP) are invited to a Care Plan meeting on the morning of Thursday, (MONTH) 4th we will discuss care and services unique to you If you cannot meet on (MONTH) 4th, you can call to schedule an alternate meeting date On 6/26/19 at 11:40 AM, OSM #1 stated that the resident and RP did not attend the above meeting and therefore a review of the Advance Directives were not discussed with her. She stated that she could go to the resident and discuss them at an alternate time but had not. A review of the care plan revealed one, undated, for (Resident #14) has elected an Advance Directive and has defined preferences including: Living Will-Do Not Resuscitate-Do Not. This care plan included the goal of, (Resident #14) and/or responsible party requests will be honored regarding Advance Directives and directions related to care and code status. The interventions, undated, included, The staff will respect (Resident #14) and/or responsible party wishes and preferences and will make all reasonable efforts to carry out their wishes. A review of the facility document, Advance Directives documented, A resident's choice about Advance Directives will be respected 1. Prior to or upon admission of a resident, the Admissions Representative will ask the resident, and/or their family member(s), about the existence of any Advance Directives, and provide information to the resident or their legal representative regarding their right to formulate an Advance Directive if they do not have one and wish to do so. 2. Should the resident indicate that he or she has issued Advanced Directives about his or her care and treatment; the facility will require that a copy of such directives be included in the medical record. 3. Each resident will also be informed that our facility's policies do not condition the provision of care or discriminate against an individual based upon whether or not that person has executed an Advance Directive. 4. Our facility has defined Advance Directives as preferences regarding treatment options which include, but are not limited to: Living Will .Do Not Resuscitate .Do Not Hospitalize Organ Donation Autopsy Request Feeding Restrictions Medication Restrictions Other Treatment Restrictions 5. The Social Services department will review a resident's Advance Directives annually, upon request and/or as needed and incorporate advance decision-making into the interdisciplinary care plan. In (facility unit) changes in Advance Directives will be submitted in writing by the resident or their legal representative to the Nursing department and communicated promptly to the attending physician so that appropriate changes in orders may be obtained 6. Inquiries concerning Advance Directives should be referred to the Social Services personnel, the Administrator, and/or the Director of Nursing services. On 6/26/19 at 4:00 PM, ASM #1 (Administrative Staff Member - the Administrator) and ASM #2 (Director of Nursing) was made aware of the findings. No further information was provided by the end of the survey.