Every finding on record at Daleville Health and Rehabilitation

Based on observation, staff interview, and facility document review, the facility staff failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility kitchen and 2 of 2 nourishment rooms. The findings included: 1. In the facility kitchen, staff failed to maintain the correct concentration of sanitizing solution in the low temperature sanitizing dish machine and stacked (nested) wet pans together. On [DATE] at 12:40 PM, during the initial kitchen tour, surveyor observed dietary staff washing pans in the dish machine. The Dietary Manager (DM) stated the dish machine was a low temperature machine using a chemical sanitizer. The DM tested the dish machine final rinse chemical sanitizer concentration using a chlorine test strip; however, the test strip did not change color to indicate the presence of sanitizing solution. The DM retested the solution with another dish machine cycle, however, the test strip failed to change color. The DM stated they would contact the dish machine service provider and staff would use Styrofoam serving trays and all other items would be sanitized using the three-dip sink until corrected. At 12:55 PM, surveyor notified the Administrator of the concern regarding the dish machine. On [DATE] at 2:59 PM, the Memory Care Administrator approached the surveyor and stated a new container of sanitizing solution had been installed and the dish machine was now working properly. At 3:01 PM, surveyor observed the DM test the dish machine again using a chlorine test strip which indicated the presence of 50 ppm (parts per million) with the final rinse. Surveyor observed a form titled Dish Machine Log located outside the dish room which indicated the dish machine was tested at Breakfast on [DATE] and staff documented a checkmark in the column titled PPM*. The Dish Machine Log included the statement Manufacturer Recommended PPM: ____, however the line to record the recommended PPM was left blank. On [DATE] at 10:46 AM, surveyor spoke with the Dietary Aide (DA) who stated they tested the dish machine on the morning of [DATE] and the sanitizing solution was okay, and the test strip had changed color. Surveyor then spoke with the DM who stated staff record a checkmark on the Dish Machine Log if the sanitizer tested okay. The DM stated they would add the recommended PPM on the log in the designated area. Surveyor requested and received the facility policy titled Dishwashing Machine Use which read in part .4. Dishwashing machine chemical sanitizer concentrations and contact times will be as follows: Type of Solution Chlorine Minimum Concentration ,d+[DATE] ppm . On [DATE] at 10:43 AM, surveyor observed a wire shelving unit with multiple stacks of stacked (nested) pans. At the surveyor's request, the DM separated individual pans from three separate stacks and found water droplets between five pans. The DM stated staff would re-wash the pans and allow them to dry. On [DATE] at 3:40 PM, the survey team met with the Administrator, Memory Care Administrator, and the Director of Nursing and discussed the concern of the dish machine failing to have the correct concentration of sanitizing solution and the presence of wet stacked pans in the facility kitchen. No further information regarding these concerns were presented to the survey team prior to the exit conference on [DATE]. 2. Nourishment room refrigerators located on the Blue Ridge and Alleghany nursing units contained multiple unlabeled and/or undated food items. On [DATE] at 10:25 AM, surveyor observed the following items in the Alleghany Nourishment Room refrigerator: an open, undated package of sliced deli turkey, three undated plastic grocery bags tied closed, an undated pizza box, and an undated Styrofoam take-out tray. On [DATE] at 10:31 AM, surveyor observed the following items in the Blue Ridge Nourishment Room refrigerator: an unlabeled/undated take-out container with a meat and bean mixture and two additional undated take-out containers. The freezer contained a half full cup of ice cream with a spoon sticking out of the lid without a label or date, a cup with a frozen brown substance without a label or date, and an unlabeled open cup of ice. On [DATE] at 10:35 AM, surveyor informed the Dietary Manager (DM) of the above observations. The DM stated the kitchen staff checks the temperature of the nourishment room refrigerators daily and discards expired items. Surveyor requested and received the facility policy titled Foods Brought by Family/Visitors which read in part .Food brought by family/visitors that is left with the resident to consume later will [sic] labeled and stored in a manner that is clearly distinguishable from facility-prepared food . On [DATE] at 3:40 PM, the survey team met with the Administrator, Memory Care Administrator, and the Director of Nursing and discussed the concern of the multiple unlabeled and/or undated food items in the Nourishment Room refrigerators. No further information regarding this concern was presented to the survey team prior to the exit conference on [DATE].

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the correct code status was in place for 1 of 19 residents in the survey sample, Resident #46. The findings included: For Resident #46, the current code status order was full code, however the comprehensive person-centered care plan and the clinical record Advanced Directive information tab documented the resident as having a DNR (do not resuscitate) decision in place. The resident's clinical record also included a completed Durable Do Not Resuscitate [DDNR] Order. Resident #46's diagnosis list indicated diagnoses, which included, but not limited to Acute Follicular Conjunctivitis, Chronic Pain Syndrome, Open-Angle Glaucoma, Type 2 Diabetes Mellitus, Schizophrenia, and Congestive Heart Failure. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/12/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #46's current provider orders included an order dated 3/15/24 for Full Code. The resident's comprehensive person-centered care plan included a care plan dated 3/15/24 stating Resident has the following Advanced Directive on record: DNR. Resident #46's clinical record documented the resident as having an active DNR status in the section of Advanced Directives. The resident's clinical record also included a completed DDNR dated 3/03/23 signed by the resident. On 4/09/24 at 3:06 PM, the survey team met with the Administrator and Director of Nursing (DON) and discussed the concern of Resident #46 having conflicting documentation regarding their code status. On 4/10/24 at 5:05 PM, surveyor spoke with the DON who stated when Resident #46 was readmitted from a hospital stay, the resident had rescinded their decision to have a DNR status, but they talked with the resident yesterday and Resident #46 wanted to remain a DNR at this time. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/10/24.

Based on observation, Resident interview and staff interview the facility staff failed to provide a clean, comfortable, and homelike environment for 1 of 19 residents, Resident #63. The findings included: For Resident #63 the facility staff failed to ensure the resident's room was free from odors. Resident #63's face sheet listed diagnoses which included but not limited to Parkinsonism, hypertension, and encounter for palliative care. Resident #63's most recent minimum data set with an assessment reference date of 03/11/24 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that that the resident is cognitively intact. On 04/08/24 at 1:30 pm, while speaking with Resident #63, surveyor observed a strong odor of urine in the resident's room. Surveyor spoke with Resident #63 again on 04/09/24 at 11am. There was again a strong odor of urine in the resident's room. Surveyor spoke with certified nurse's aide (CNA) #2 outside of resident's room at this time. Surveyor asked CNA #2 if they could identify the odor in Resident #63's room, and CNA #2 stated, Oh, it's urine. CNA #2 stated that it was from the resident's roommate, who refuses showers. CNA #2 stated they were attempting to get roommate to shower. Surveyor observed licensed practical nurse (LPN) #4 standing in hallway outside Resident #63's room at 12:20 pm. When surveyor walked by, LPN #4 stated, I can't breathe in there, referring to Resident #63's room. Surveyor asked LPN #4 why they couldn't breathe in the room and LPN #4 stated, The smell. Surveyor asked LPN #4 what the smell was, and LPN #4 stated, I don't know, I've only been a nurse for a year but I have never smelled anything like that. Surveyor spoke with Resident #63 on 04/09/24 at 2:25 pm. Surveyor asked Resident #63 if the odor in the room bothers them, and Resident #63 stated they have sinus problems, and can't smell. The concern of the strong odor of urine in Resident #63's room was discussed with the administrator and director of nursing on 04/09/24 at 3:15 pm. Surveyor observed housekeeping staff cleaning Resident #63's room on 04/09/24 at 4:10 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to implement a comprehensive person-centered care plan to meet the needs of the resident for 1 of 19 residents in the survey sample, Resident #2. The findings included: For Resident #2, the facility staff failed to implement the comprehensive person-centered care plan (CPCCP) intervention and registered dietitian's (RD) recommendation to weigh the resident weekly. Resident #2's diagnosis list indicated diagnoses, which included, but not limited to Multiple Sclerosis, Vascular Dementia, Epilepsy, Hemiplegia Affecting Right Dominant Side, Dysphagia Following Cerebral Infarction, and Atrial Fibrillation. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/23/24 assigned the resident a brief interview for mental status (BIMS) summary score of 5 out of 15 indicating the resident was severely cognitively impaired. The resident was coded for the presence of a feeding tube in which they received 51% or more of total calories during the previous seven (7) days. A review of Resident #2's CPCCP revealed a care plan goal of Tolerates tube feeding as ordered with interventions dated 5/02/22 to Weigh weekly and Refer to Dietician for evaluation of current nutritional status and determine formula options. A review of Resident #2's clinical record on 4/08/24, revealed the following: Resident #2 was reviewed by the RD on 1/30/24, the progress note read in part .Recommend weekly weight on TF [tube feeding] . An additional RD progress note dated 2/26/24 read in part .Recommend weekly weight on TF . The most recent RD progress note dated 4/02/24 read in part .2/08/24 112.3 # [pounds] .Would benefit from updated weight measurement for serial assessment .Recommended updated wt [weight] measurement and weekly weights on TF. On 4/08/24, surveyor reviewed Resident #2's clinical record and was unable to locate evidence of weekly weights. On 4/09/24 at 3:48 PM, surveyor spoke with the Director of Nursing (DON) and requested documentation of the resident's weekly weights. On 4/09/24 at 1:37 PM, the DON provided a document titled Weight Change History for Resident #2 with the following weights documented: 11/15/23 116.90, 12/07/23 128.00, 12/28/23 130.40, 1/30/24 132.40, 2/08/24 112.30, 3/06/24 114.20, 4/09/24 116.20. Surveyor requested evidence of weekly weights being obtained for Resident #2, DON stated they would look for weekly weights. On 4/10/24 at 3:26 PM, surveyor spoke with the DON who stated they could only locate monthly weights for Resident #2. Surveyor requested and received the facility policy titled Weight Assessment and Intervention which read in part .Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record .Individual care plans shall address, to the extend possible .Time frames and parameters for monitoring and reassessment . On 4/10/24 at 3:40 PM, the survey team met with the Administrators and DON and discussed the concern of the facility staff failing to follow the care plan intervention and RD recommendations to weigh Resident #2 weekly. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/10/24.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for 2 of 19 residents, Resident #31 and #63. The findings included: 1. For Resident #31, the facility staff failed to provide ADL care. Resident #31's fingernails were observed to be long with debris present. Resident #31's diagnoses included, hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side. Section C (cognitive patterns) of Resident #31's annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/08/24 included a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 points. Section GG (functional abilities and goals) was coded to indicate Resident #31 was dependent (1) in the area of personal hygiene. On 04/08/24, during initial tour of the facility Resident #31's fingernails on both hands were observed to be long with debris present. On 04/09/24 at 8:58 a.m., during an observation of Resident #31 with the Director of Nursing (DON). The DON acknowledged Resident #31's fingernails were long and had debris present. The DON stated they would get someone to cut the residents nails. On 04/09/24 at 3:00 p.m., during an end of the day meeting with the Administrator and DON the issue with Resident #31's fingernails was reviewed. On 04/10/24 at 12:34 p.m., the Administrator provided the survey team with documentation indicating an in-service was provided to the facility staff regarding nail care. Sixteen employees had signed this form. No further information regarding this issue was provided to the survey team prior to the exit conference. 34307 2. For Resident #63, the facility staff failed to provide nail care. Resident #63's face sheet listed diagnoses which included but not limited to Parkinsonism, hypertension, and encounter for palliative care. Resident #63's most recent minimum data set with an assessment reference date of 03/11/24 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that that the resident is cognitively intact. Resident #63's comprehensive care plan was reviewed and contained a care plan for Resident will have assistance as needed to complete toileting, bathing, dressing, grooming, to maintain dignity. Interventions for this care plan included Assist resident with grooming: brush teeth, denture care, comb hair, glasses, dentures, hearing aids . Surveyor spoke with Resident #63 on 04/09/24 at 10:55 am. Surveyor observed resident's fingernails to be long and discolored. Surveyor asked Resident #63 if nails being long bothers them and Resident #63 stated, Yes, and I have asked where or when I can get them cut. I also asked where I can get my hair cut. Surveyor spoke with Resident #63 on 04/10/24 at 8:30 am and resident showed surveyor his hands, and stated, they finally cut my nails. The concern of Resident #63's nails being long and discolored was discussed with the administrator and director of nursing on 04/09/24 at 3:15 pm. Administrator provided the surveyor with an in-service education form regarding nail care dated 04/10/24 on 04/10/24 at 11:00 am. No further information provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to follow the medical provider orders for 1 of 19 residents in the survey sample, Resident #62. The findings included: For Resident #62, the facility staff failed to administer the medication, Questran on two separate occasions. Resident #62's diagnosis list indicated diagnoses, which included, but not limited to Adult Failure to Thrive, Fecal Abnormalities, Dementia, Paroxysmal Atrial Fibrillation, and Chronic Pain. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/31/24 assigned the resident brief interview for mental status (BIMS) summary score of 13 out of 15 indicating the resident was cognitively intact. Resident #62's clinical records included a 3/26/24 hospice nurse progress note which read in part Upon entering patient's room I noted that patient, clothing and bed linens were covered in a brown substance. The patient stated it was a mixture of Boost and diarrhea .Staff report that patient has multiple episodes of diarrhea each day and that Imodium was ineffective. MD notified and order received for antidiarrheal, see medication order this date . Resident #62's medical provider orders included an order dated 3/26/24 for Questran 4-gram oral powder mix in 8 ounces fluid and administer by mouth every Monday, Wednesday, and Friday for diarrhea. A review of Resident #62's March 2024 and April 2024 Medication Administration Records (MARs) revealed the Questran was not administered on 3/29/24 due to awaiting pharmacy and 4/03/24 due to not available pending pharmacy. On 4/09/24 at 4:31 PM, surveyor spoke with the pharmacy representative (PR) regarding Resident #62's Questran delivery. PR stated the order was received by the pharmacy on 3/26/24 at 5:43 PM and a 22-day supply was delivered to the facility the same day between 10:00 PM to 11:00 PM. PR stated the medication was delivered in powder form in a tin container. PR stated the facility sent in an order on 4/04/24 requesting a refill in packet form. On 4/09/24 at 4:55 PM, surveyor observed Resident #62's Questran packets located in the medication cart with a pharmacy delivery date of 4/04/24. On 4/10/24 at 2:31 PM, surveyor spoke with Registered Nurse (RN) #1 who stated they did not administer the Questran on 3/29/24 because it was not in the facility. The survey team met with the Administrators and Director of Nursing (DON) on 4/10/24 at 3:40 PM and discussed the concern of Resident #62 not receiving Questran as ordered on 3/29/24 and 4/03/24. The DON returned to the surveyor on 4/10/24 at 5:31 PM with an unopened tin container of Questran powder and stated they had located it on the wrong medication cart. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/10/24.

Based on staff interview and clinical record review, facility staff failed to provide treatment as ordered for pressure ulcers for 2 of 19 residents in the survey sample (Residents #68 and #35). Resident #68 was admitted to the facility with diagnoses including, but not limited to, hypertension, seizures, pressure ulcers, pain, anxiety, and depression. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the brief interview for for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The electronic clinical record contained orders for daily dressing changes to a sacral wound. The Treatment Administration Record was blank for 4/4/2024. The nursing progress note dated 4/4/2024 at 2:10 AM documented the resident refused a shower at that time but agreed to a bed bath. There were no wound care notes on that date. The surveyor asked to speak with the wound care nurse about missed treatments on 4/8/2024, but was not able to speak with the nurse. The administrator and director of nursing were made aware of the concern on 4/10/2024. Resident #35 was admitted to the facility with diagnoses including but not limited to amputation above the knee, hypertension, pressure ulcers of right and left hip and sacrum, and malignant neoplasm of liver and colon. On the most recent Minimum Data Set assessment the resident scored 0/15 on the Brief Interview for Mental Status and was assessed with continuous signs of delirium including inattention and disorganized thinking. The electronic clinical record contained orders for daily dressing changes to a stage 3 sacral wound. The Treatment administration records for March and April 2024 contained multiple blanks, which the Director of Nursing told surveyors was generally an indication that treatments were not completed. The surveyor was able to establish that the majority of the blanks were on days the treatment nurse had assessed or completed treatments. The surveyor was unable to find evidence of treatments completed on 4/5 and 3/15/2024. The administrator and director of nursing were notified of the remaining concern during a summary meeting on 4/10/2024.

Based on staff interview, clinical record review and facility document review the facility staff failed to complete a safe smoking assessment for 1 of 19 residents, Resident #20. The findings included: For Resident #20, the facility staff failed to complete a safe smoking assessment when resident was admitted to the facility. Resident #20's face sheet listed diagnoses which included but not limited to hemiplegia and hemiparesis following cerebral infarction, dementia, Alzheimer's disease, and nicotine dependence. Resident #20's most recent minimum data set with an assessment reference date of 02/09/24 assigned the resident a brief interview for mental status score of 5 out of 15 in section C, cognitive patterns. This indicates that that the resident is severely cognitively impaired. Resident #20's comprehensive care plan was reviewed and contained a care plan for Resident will smoke safely at designated areas at scheduled times through next review. Interventions for this care plan include Safe smoking screen completed on admission and as needed. During entrance conference, survey team requested a list of residents in the facility that currently smoke. Resident #20 was included on this list. Resident #20's clinical record contained a nurse's progress note dated 02/02/24 which read in part, Resident arrived at the facility at approximately 12PM in private vehicle from home accompanied by two family members .Resident does smoke and will need to be evaluated for smoking safety . Resident #20's clinical record was reviewed, and surveyor could not locate a safe smoking assessment. On 04/09/24 at 3:15 pm, surveyor informed administrator and director of nursing (DON) that a safe smoking assessment for Resident #20 could not located be in clinical record. On 04/10/24 at 9:20 am, DON provided surveyor with a copy of a safe smoking assessment for Resident #20 dated 02/02/24 and stated, We did a late entry for the assessment. Surveyor requested and was provided with a facility document entitled Smoking Policy-Residents which read in part, 1. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. The concern of completing a safe smoking assessment upon admission was discussed with the administrator and director of nursing on 04/10/24 at 3:50 pm. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide the health care provider ordered therapeutic diet for 2 of 19 residents, Resident #54 and #25. The findings included: 1. For Resident #54, the facility staff failed to provide the health care provider ordered Magic Cup. Resident #54's diagnoses included, but were not limited to, Parkinson's disease and dysphagia. Section C (cognitive patterns) of Resident #54's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/07/24 included a Brief Interview for Mental Status (BIMS) summary score of 14 out of a possible 15 points. Resident #54's comprehensive care plan included the area of nutrition. Goals included diet as ordered. Resident #54's clinical record included a provider order for a Magic Cup three times a day with trays. Order date 03/11/24. On 04/09/24 at 8:30 a.m., the surveyor observed Resident #54's breakfast meal. Resident #54 was observed with chocolate ice cream on their meal tray. The surveyor did not observe a Magic Cup on this meal tray. 04/09/24 at 9:31 a.m., the Dietary Manager stated they had been out of Magic Cups for the last 2 weeks and they were substituting with Magic Shakes. The surveyor did not observe a Magic Cup or a Mighty Shake with Resident #54's breakfast meal on 04/09/24. On 04/09/24 at 1:45 p.m., Resident #54 was asked if they received a Magic Cup with meals, they were unable to answer this question. On 04/09/24 at 1:48 p.m., during an interview with Certified Nursing Assistant (C.N.A.) #1 this staff stated they had not seen a Magic Cup on the residents meal trays for a while. A review of Resident #54's Medication Administration Records (MARs) revealed that for the month of April 2024 the facility nursing staff were documenting the Magic Cup had been provided and were documenting the percentage the resident consumed. For 04/03/24 for the breakfast meal there was no documentation on the MAR to indicate the Magic Cup had been provided the administration block was blank. On 04/09/24 at 2:10 p.m., Licensed Practical Nurse (LPN) #4 was asked about the Magic Cup and stated they saw what they thought was a Magic Cup. LPN #4 stated it was in a clear container and there was a small amount of chocolate around the cup. On 04/07/24 for the evening meal LPN #4 documented Resident #54 had consumed 100% of their Magic Cup. The resident's tray ticket that accompanied the lunch meal on 04/09/24 indicated this Resident received ice cream and a Magic Cup with each meal. On 04/09/24 at 3:00 p.m., during a meeting with the Administrator and Director of Nursing (DON) the issue with the Magic Cup not being on the residents meal tray and the nursing staff documenting that it had been provided was reviewed. The Administrator stated Magic Cups were backordered and they were substituting with Mighty Shakes. On 04/10/24 at 4:57 p.m., the DON provided the surveyor with a copy of a progress note timed and dated after the breakfast meal on 04/09/24 indicating the provider had been notified the Magic Cups were on back order and a new order was obtained to supplement with Mighty Shakes. The DON was asked if the MAR had a hole in an administration block what would this mean. The DON stated it could mean various things and gave examples of the nursing staff may have forgotten to document, item not available, not administered, or an omission. No further information regarding this issue was provided to the survey team prior to the exit conference. 34307 2. For Resident #25 the facility staff failed to ensure the provider ordered supplement Magic cup was available. Resident #25's face sheet listed diagnoses which included but not limited to type 2 diabetes mellitus, dysphagia, and dementia. Resident #25's most recent minimum data set with an assessment reference date of 03/22/24 assigned the resident a brief interview for mental status score of 6 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Resident #25's comprehensive care plan was reviewed and contained a care plan for Maintain adequate nutritional status. Interventions for this care plan include Diet as ordered, encourage compliance with ordered diet. Resident #25's clinical record was reviewed and contained a physician's order summary which read in part, Magic cup with meals. Resident #25's electronic medication administration record for the month of April 2024 was reviewed and contained an entry which read in part, Magic cup with meals. This entry was initialed as being administered as ordered. On 04/09/24 at 8:35 am, surveyor observed licensed practical nurse (LPN) #3 checking Resident #25's breakfast meal tray. LPN #3 stated, I need to go get her a magic cup. LPN #3 stopped a kitchen staff in the hallway and asked them to get a magic cup for Resident #25. Kitchen staff stated We don't have magic cups. I'll have to go next door to get one. On 04/09/24 at 9:30 am during an interview with the dietary manager, they stated that the facility food vendor has been out of magic cup for the last two weeks, and they have been substituting mighty shakes. Surveyor observed Resident #25's breakfast meal tray and it did not contain a mighty shake. Surveyor spoke with Resident #25 on 04/09/24 at 10 am regarding magic cups and mighty shakes. Surveyor asked resident if they had been getting either a magic cup or a mighty shake on their meal tray, and Resident #25 stated, I don't think so. Resident #25's clinical record was reviewed and contained a Nutrition Quarterly form dated 04/02/24 which read in part, Quarterly Progress Summary: . with quarterly f/u (follow up). Wt. (weight) trending down; 4.6# (pounds) in 3 months, not significant at this time. Receiving magic cup with meals, Glucerna BID (twice daily) provided by family per orders . The concern of not providing magic cup with meals was discussed with the administrator and director of nursing on 04/09/24 at 3:30 pm. On 04/10/24 the director of nursing provided the surveyor with a nurse's progress note which read in part, 4/9/2024 10:38 AM NP (nurse practitioner) . (name omitted) gave order that states may hold magic cups and supplement with mighty shakes until off back order. Rp (responsible party) made aware. No further information was provided prior to exit.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to obtain a provider ordered medication for 1 of 19 residents in the survey sample, Resident #46. The findings included: For Resident #46, the facility staff failed to obtain Alaway eye drops (antihistamine eye drops used to provide temporary relief for itchy eyes due to ragweed, pollen, grass, animal hair and dander) as ordered by the provider. Resident #46's diagnosis list indicated diagnoses, which included, but not limited to Acute Follicular Conjunctivitis, Chronic Pain Syndrome, Open-Angle Glaucoma, Type 2 Diabetes Mellitus, Schizophrenia, and Congestive Heart Failure. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/12/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. On 4/08/24 at 1:11 PM, while speaking with Resident #46, surveyor noted redness of the right eye and underneath the eye. When asked the cause of the redness, Resident #46 stated their eye was itchy and they had been waiting 18 days for the medication to arrive. Resident #46's clinical record included a 3/25/24 family nurse practitioner (FNP) progress note which read in part .Patient presents today with right eye redness and itching .Allergic conjunctivitis of both eyes .Redness of right eye .Itch of right eye .Plan: Alaway with drops in each eye daily x 2 weeks . According to Resident #46's March 2024 and April 2024 Medication Administration Records (MARs), the Alaway was only signed as being administered once (4/01/24) between 3/26/24 through 4/05/24 due to being unavailable/awaiting pharmacy. On 4/09/24 at 4:33 PM, surveyor spoke with the pharmacy representative (PR) who stated Alaway was an over the counter (OTC) medication and the facility had chosen to have the pharmacy send OTC medications only if pre-approved by the facility Director of Nursing (DON). PR stated the order was received by the pharmacy on 3/25/24 at 4:30 PM but was never sent by the pharmacy. PR stated a facility nurse contacted the pharmacy on 3/29/24 inquiring why the Alaway had not been delivered and was informed it was due to the medication being an OTC medication requiring DON approval. DON approval was never received by the pharmacy and the order was for a limited duration and automatically discontinued on 4/05/24 per the provider order. PR stated when an OTC medication was ordered, the nurses need to know to notify the DON because the pharmacy does not automatically notify the facility for DON approval. On 4/09/24 at 4:38 PM, surveyor spoke with the DON and requested evidence indicating the facility provided Alaway for Resident #46. DON stated they would check the shipping manifest. On 4/10/24 at 1:10 PM, surveyor spoke with licensed practical nurse (LPN) #7 who signed the MAR indicating administration of the Alaway on 4/1/24. LPN #7 stated they did not administer the Alaway on 4/01/24 due to it not being available and had signed the MAR in error. According to the clinical record, Resident #46 received a new order for Ketotifen 0.025% one drop in both eyes once daily for irritation on 4/05/24 and received the first administration on 4/06/24. On 4/10/24 at 3:40 PM, the survey team met with the Administrators and DON and discussed the concern of staff failing to obtain Resident #46's Alaway eye drops. The DON returned to the surveyor on 4/10/24 at 5:08 PM and stated they had not been able to find where Alaway had been purchased by the facility. Surveyor then spoke with the Administrator who agreed there had been a delay in receiving the ordered Alaway for Resident #46. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/10/24.

Based on staff interview, clinical record review and facility document review the facility staff failed to review and act upon a monthly medication regimen review for 1 of 19 residents, Resident #234. The findings included: For Resident #234 the facility staff failed to follow-up on pharmacy recommendation from the monthly medication regimen review. Resident #234's face sheet listed diagnoses which included but not limited to type 2 diabetes mellitus. Resident #234's most recent minimum data set with an assessment reference date of 02/17/24 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #234's comprehensive care plan was reviewed and contained a care plan for Resident is as risk for complications associated with hyper or hypoglycemia related to: diabetes on insulin therapy. The director of nursing (DON) provided the survey team with a list of residents who had a medication regimen review with recommendations for the month of February 2024. Resident #234 was on this list. Resident #234's clinical record was reviewed on 02/09/24. Surveyor could not locate a medication regimen review/recommendation form in the clinical record. Surveyor informed the DON on 04/10/24 that they could not locate a pharmacy recommendation form in the clinical record. On 04/10/24 at 3:15 pm, the DON provided the surveyor with copy of a Note to Attending Physician/Prescriber form from the pharmacy, dated 02/21/24, which read in part, This resident is currently receiving: 1) Lantus 30 units BID (twice daily). 2) Jardiance 25 mg QD (every day). 3) Humalog SSI (sliding scale insulin) QID (four times daily). Recent blood glucose levels have been elevated. Please consider increasing Lantus to a total dose of 32 units BID. This form had not been signed by the physician/provider. Resident #234's clinical record contained a physician's order summary for the month of March 2024 which read in part, insulin glargine (Lantus) (U-100) 100 unit/ml (3 ml) subcutaneous pen: subcutaneous twice daily. give 30 units in the morning and 30 units before bedtime. Resident #234's blood glucose levels were reviewed and indicated that blood glucose levels continue to be elevated with an average of 300. Surveyor requested and was provided with a facility policy entitled Medication Regimen Reviews which read in part, 1. The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. 8. Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity. 11. If the Physician does not provide a timely or adequate response, or the Consultant Pharmacist identifies that no action has been taken, he/she contacts the Medical Director or (if the Medical Director is the physician of record) the Administrator. 15. Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record. The concern of not reviewing and/or acting upon a pharmacist recommendation was discussed with the administrator and DON on 04/10/24 at 3:40 pm. No further information provided prior to exit.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a complete and accurate clinical record for 2 of 19 residents in the survey sample, Resident #46 and #21. The findings included: For Resident #46, the facility staff failed to document a change in the resident's condition resulting in an acute care hospital admission. Resident #46's diagnosis list indicated diagnoses, which included, but not limited to Acute Follicular Conjunctivitis, Chronic Pain Syndrome, Open-Angle Glaucoma, Type 2 Diabetes Mellitus, Schizophrenia, and Congestive Heart Failure. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/12/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. On 4/08/24 at 1:11 PM, surveyor spoke with Resident #46 who stated they were sent to the hospital in December after being sick for three to four days. The resident stated upon arrival at the hospital their temperature was 104.5 and they were positive for flu, RSV (Respiratory Syncytial Virus), COVID, and pneumonia. Resident #46's was seen by the family nurse practitioner (FNP) on 12/29/23, the progress note read in part .Patient seen today due to staff reporting patient is noted with cough, congestion, vomiting, and has complaints of nausea .Plan: 2 view chest x-ray due to cough and congestion. Mucinex 600 mg twice daily x 1 week for cough and congestion. Albuterol nebulizer twice daily x 3 days . A nursing progress note dated 12/29/23 at 2:14 PM read in part New orders noted per [name omitted] NP to obtain 2 view chest x-ray, start Mucinex bid [twice a day] x 1 week, albuterol nebulizer treatment x 3 days for c/o [complaints of] cough . The next progress note was dated 1/06/24 at 3:51 AM and read in part Rsd [resident] readmitted after being treated at hospital for Flu . Surveyor was unable to locate facility documentation following the 12/29/23 2:14 PM nursing progress note indicating the change in the resident's condition and resulting transfer to the hospital. On 4/09/24 at 3:06 PM, the survey team met with the Administrator and Director of Nursing (DON) and requested any additional documentation related to Resident #46's change in condition and hospital discharge in December. However, no additional documentation was provided. Surveyor requested and received the facility policy titled Charting and Documentation which read in part All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition shall be documented in the resident's medical record . No further information regarding this concern was presented to the survey team prior to the exit conference on 4/10/24. 22218 2. For Resident #21, facility staff failed to monitor the resident's weight as ordered. Resident #21 was admitted to the facility with diagnoses including, but not limited to, congestive heart failure (CHF), hypertension, gastroesophageal reflux disease, and fall with fracture. On the most recent Minimum Data Set assessment the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The the electronic clinical record contained an order dated 3/12/24 for weights 3 times per week to monitor CHF status. The electronic medical record (EMR) did not contain three weights per week. The surveyor asked the administrator and director of nursing (DON) about weights during a summary meeting on 4/9/2024. On 4/10, the director of nursing offered a print-out from the EMR titled Vital Signs Grid which listed weights recorded between 3/12 and 4/8. On 4/10/2024 at 9 AM the surveyor noted the resident's EMR weights/vitals section documented 2 weights on 4/10/24. The surveyor asked the resident if she had been weighed that morning. The resident stated she had not. The surveyor asked if she had been weighed the day before or the day before that. The resident said no, they weighed her about once per week. The surveyor spoke with LPN #3, who showed the surveyor the weights and vitals binder with a page for each day. There were weights on 4/3, 4/4, and 4/8. None were recorded on 4/10/2024 page. From the date of the order, there were weights in the EMR on 3/12, 3/13, 3/20, 3/25, 3/29, 4/1, 4/2, 4/3, 4/5, 4/8, and 4/10. The binder where staff documented weights and vital signs daily had weights on 4/3, 4/4, and 4/8. There was a 7 day gap without weight from 3/13 through 3/20; The next 7 day period had 1 recorded weight on 3/25. The surveyor discussed the reliability of the weights recorded in the EMR. The DON stated the nurses explained documenting weights on 4/10 when the resident had not been weighed filling in holes in the EMR.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a Quality Assurance and Performance Improvement (QAPI) Program to meet the needs of the facility and failed to monitor and revise as needed the plan of correction for the standard recertification surveys dated 4/11/19, 5/27/21, and 2/16/23 in order to maintain compliance as evidenced by repeated deficiencies in the area of Pharmacy Services. The findings included: The area of Pharmacy Services was previously cited with the 4/11/19, 5/27/21, and 2/16/23 standard surveys due to failure to provide evidence of the attending medical provider reviewing and acting upon monthly drug regimen reviews completed by the pharmacist. This deficiency was cited again on the current standard survey dated 4/10/24 due to failure to provide evidence of the attending medical provider review and action taken upon monthly drug regimen reviews completed by the pharmacist for 1 of 5 residents reviewed. On 4/10/24 at 2:45 PM, surveyor met with the Administrator to review the facility QAPI Program. The Administrator stated QAPI meetings were held at least quarterly where facility statistics were reviewed for trending and action plans were developed as indicated. Surveyor discussed the concern of drug regimen reviews being cited on the previous three standard surveys. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/10/24.

Based on observation, staff interview, and facility document review, the facility staff failed to distribute and serve food in accordance with professional standards for food service safety as evidenced by a final rinse temperature below 180 degrees Fahrenheit (F) for a high temperature (heat sanitization) dishwasher in the facility kitchen. The findings included: The facility staff failed to consistently maintain a final rinse temperature at the manufacturer recommended minimum temperature of 180 degrees F for the facility high temperature dishwasher. On 2/13/23 at 2:10 pm, the surveyor observed the facility dishwasher in use. The dietary manager (DM) stated the machine was a high temperature dishwasher. Dishwasher wash and rinse temperature gauges were located on the front of the machine. The wash temperature reached a maximum of 150 degrees F, and the rinse temperature reached a maximum temperature of 170 degrees F. The DM stated the rinse temperature should be 180 degrees F and proceeded to empty and drain the machine and ran another cycle. At that time the wash temperature reached a maximum of 164 degrees F, and the rinse temperature again reached a maximum temperature of 170 degrees F. The DM stated the facility has a new heat booster waiting to be installed for the dishwasher. Surveyor asked the DM if they had any other temperature measuring methods such as a temperature disc for the dishmachine and they stated no. Therefore, surveyor was unable to measure the ware surface temperature of the dishmachine. A data plate affixed to the side of the dishwasher identified the machine as Model: ES-2000HT with a minimum wash temperature of 150 degrees F and a minimum rinse temperature of 180 degrees F. On 2/13/23 at 2:35 pm, surveyor notified the administrator of the dishwasher only reaching a maximum rinse temperature of 170 degrees F. On 2/13/23 at 5:35 pm, surveyor met with the administrator in training (AIT) and the (company name omitted) service technician in the facility kitchen. The heat booster had been installed, however, the rinse temperature continued to reach only 170 degrees F. The service technician stated they could convert the dishwasher to a low temperature machine with chemical sanitizer tomorrow. At 5:45 pm, the administrator, AIT, and the service technician approached the surveyor and stated the dishwasher would be converted to a low temperature machine in the morning and the evening meal dishes would be washed to remove debris only and paper products would be used until the machine was repaired. Surveyor requested and received the dish machine temperature logs for the past three months. The December 2022 Dishmachine Temperature Log (High Temperature) log was designed to document the wash and rinse temperatures three times a day labeled as breakfast, lunch, and dinner. In each rinse column heading 180 degrees F was documented. An additional column was labeled Action Taken if Out of Range. From 12/07/22 through 12/31/22, the rinse temperature was recorded below 180 degrees F on 48 of 60 occasions with the recorded range being between 168 degrees F to 178 degrees F. On each day of December when the rinse temperature was below 180 degrees F, the action taken column was blank. The January 2023 dishwasher log was labeled High Temperature Dishwasher Log, the log included the statement acceptable temperatures: wash min [minimum] 150 [degrees] & final rinse min [minimum] 180 [degrees]. Rinse temperatures were recorded from 1/01/23 through 1/26/23 breakfast with 75 of 76 readings documenting a rinse temperature below 180 degrees F. The documented rinse temperatures ranged from a minimum of 168 to a maximum of 178 degrees F. The dishwasher was documented as not working from 1/26/23 lunch though 1/31/23 dinner. On 1/05/23 and 1/12/23 fixed was documented in the Action taken column. The February 2023 log documented the machine as not working 2/01/23 through 2/02/23. All rinse temperatures from 2/03/23 through 2/13/23 lunch was documented between the range of 170 degrees F to 175 degrees F. On 2/15/23 at 11:40 am, surveyor spoke with the AIT who stated the dishwasher manufacturer stated the machine should be performing at 180 degrees F and recently had the company come in and check the internal temperature of the machine. The AIT provided information from the service company and the most recent local Food Establishment Inspection Report dated 1/13/23. A letter from the dishwasher service provider dated 1/19/23 read in part This letter is written to verify the proper method to ensure proper Dishmachine water temperatures for hot water sanitation. There are multiple water temperature requirements for water utilized in a commercial dishmachine. For hot water sanitation, these water temperature requirements are found on the data plate affixed in a visible location on the Dishmachine of interest. The dataplate will state required minimum wash temperature and rinse temperatures for proper sanitation among other requirements for proper operation. The FDA food code has requirements for hot water sanitation stating that the Dishmachine must achieve at least the desirable minimum temperatures on the Dishmachine data plate as well as a ware temperature of 160 degrees F .To validate the Dishmachine temperatures either the gauges on the Dishmachine, if they exist, or a manual method may be used to determine proper operating temperatures for proper sanitation. This performed in combination with the ware surface indicator strip with a minimum ware surface temperature of 160 [degrees] F validate proper ware sanitation. A (company name omitted) Regular Service Call report dated 1/11/23 documented in part a rinse temperature of 170 degrees F and included the comment Incoming water temp low temp and low pressure. Booster heater needed to achieve required rinse temp of 180. The facility provided 1/13/23 Food Establishment Inspection Report completed by the local health district read in part Warewashing Info: Machine Name: Sanitization Method: High Temperature Thermo Label: PPM: Sanitizer Name: Sanitizer Type: Temperature: 170 [degrees] F. Surveyor requested and received the facility policy entitled Dishwashing Machine Use which read in part: 3. Dishwashing machine hot water sanitation rinse temperatures may not be more than 194 [degrees] F, or less than: a. 165 [degrees] F for stationary rack, single temperature machines. b. 170 [degrees] F for all other machines. On 2/15/23 at 4:11 pm, the survey team met with the administrator, director of nursing, and the nurse consultant and discussed the concern of the facility dishwasher not consistently reaching the required minimum rinse temperature of 180 degrees F on multiple occasions since December 2022. On 2/16/23 at 5:55 pm, the AIT provided an email exchange dated 2/15/23 between the AIT and the local health district inspector in which the AIT questioned Based off this information, an internal rinse temperature of 160 or above means that we are in compliance, correct?. The response from the inspector read in part That is correct . On 2/14/23, the facility dishwasher was converted to a low temperature dishwasher using chemical sanitation. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/16/23.

Based on interviews and document reviews, the facility staff failed to maintain complete and accurate clinical records for five (5) of 24 residents, Resident #50, Resident #68, Resident #70, Resident #125, and Resident #176. The findings include: 1. Resident #50's Medication Regimen Review (MRR) dated 12/30/22 failed to include documentation of the medical provider's reason for not attempting a Gradual Dose Reduction (GDR). Resident #50's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/9/23, was signed as completed on 2/3/23. Resident #50 was assessed as able to make self understood and able to understand others. Resident #50's Brief Interview for Mental Status summary score was documented as an 8 out of 15; this indicated moderate cognitive impairment. Resident #50 was assessed as being independent with bed mobility and eating. Resident #50 was assessed as requiring assistance with personal hygiene and bathing. The following information was found in a facility document titled Charting and Documentation (dated as revised July 2017): - All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. - Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Resident #50's Consultant Pharmacist Recommendation to Physician dated 12/30/22 included the following request: Federal guidelines state antipsychotic drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with at least 1 month between attempts, then annually thereafter. This resident has been taking Quetiapine 100 mg since 6/20/2022 without a GDR. Could we attempt a dose reduction at this time to perhaps Quetiapine 75 mg to verify this resident is on the lowest possible dose? If not, please indicate response below . This Consultant Pharmacist Recommendation to Physician document indicated the medical provider marked the following option: The drug, dose, duration and indications are clinically appropriate; further reductions are contraindicated due to . The medical provider failed to provide a reason for not attempting the GDR. On 2/16/23 at 12:20 p.m., Nurse Practitioner (NP) #6 was interviewed about the aforementioned MRR. NP #6 confirmed they did not want to attempt the GDR. NP #6 stated they would document the reason for not attempting the GDR. The surveyor was provided a copy of the aforementioned Consultant Pharmacist Recommendation to Physician document what included the following note dated 2/16/23: condition would likely decline as result of med reduction. On 2/16/23 at 5:23 p.m., the survey team conducted a meeting with the facility's Administrator, Director of Nursing, and a Nurse Consultant. The surveyor discussed the failure of facility staff members to ensure the medical provider documented the reason for declining to attempt a GDR for Resident #50's quetiapine order. 2. Resident #68's Medication Regimen Review (MRR) dated 12/30/22 failed to include documentation of the medical provider's reason for not attempting a Gradual Dose Reduction (GDR). Resident #68's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/11/23, was signed as completed on 1/11/23. Modification to this MDS assessment were documented on 2/14/23 and 2/16/23. Resident #68 was assessed as rarely or never able to make self understood and as rarely or never able to understand others. Resident #68 was assessed as the Brief Interview for Mental Status should not be completed due to the resident being rarely/never understood. Resident #68 was documented a being dependent on others for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #68's Consultant Pharmacist Recommendation to Physician dated 12/30/22 included the following request: Federal guidelines state antipsychotic drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with at least 1 month between attempts, then annually thereafter. This resident has been taking Quetiapine 12.5 mg since 7/1/2022 without a GDR. Could we attempt a dose reduction at this time to perhaps Quetiapine 12.5 mg (every other day) to verify this resident is on the lowest possible dose? If not, please indicate response below . This Consultant Pharmacist Recommendation to Physician document indicated the medical provider marked the following option: The drug, dose, duration and indications are clinically appropriate; further reductions are contraindicated due to . The medical provider failed to document provide a reason for not attempting the GDR. On 2/16/23 at 12:20 p.m., Nurse Practitioner (NP) #6 was interviewed about the aforementioned MRR. NP #6 confirmed they did not want to attempt the GDR. NP #6 stated they would document the reason for not attempting the GDR. The surveyor was provided a copy of the aforementioned Consultant Pharmacist Recommendation to Physician document what included the following note dated 2/16/23: condition would likely decline as result of med reduction. On 2/16/23 at 5:23 p.m., the survey team conducted a meeting with the facility's Administrator, Director of Nursing, and a Nurse Consultant. The surveyor discussed the failure of facility staff members to ensure the medical provider documented the reason for declining to attempt a GDR for Resident #50's quetiapine order. 3. The facility staff failed to document the results of flushing Resident #70's right ear. Resident #70's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/25/22, was signed as completed on 12/7/22. Resident #70 was assessed as able to make self understood and as able to understand others. Resident #70 was assessed to not have the Brief Interview for Mental Status completed due to the resident being rarely/never understood. Resident #70 was assessed as being independent with transfers, dressing, and toilet use. The following information was found in a facility document titled Ear Irrigation (with a revised date of February 2018): The following information should be recorded in the resident's medical record: 1. The date and time the ear was irrigated. 2. The name and title of the individual(s) who irrigated the ear. 3. The type of solution used to irrigate the ear. 4. All assessment data obtained concerning the resident's ear. 5. How the resident tolerated the procedure. 6. If the resident refused the treatment, the reason(s) why and the intervention taken. 7. The signature and title of the person recording the data. This Administrator provided the aforementioned document to the surveyor on 2/15/23 at 9:25 a.m. Resident #70's medical provider orders included two (2) separate orders for the resident's right ear to be flushed after receiving ear wax removal drops. Documentation on Resident #70's medication administration record (MAR) included a nurse's initial indicating these orders were followed. Resident #70's clinical documentation failed to include details and/or results of the ear being flushed. On 2/16/23 at 5:23 p.m., the survey team conducted a meeting with the facility's Administrator, Director of Nursing, and a Nurse Consultant. The surveyor discussed the failure of facility staff members to document details and/or results of flushing Resident #70's ear. 4. The facility staff failed to document admission notes for Resident #125. Resident #125's Minimum Data Set (MDS) assessment had yet to be completed at the time of the survey. The following information was found in a facility document titled Admission Notes (with a revised date of September 2021): - Preliminary resident information shall be documented upon a resident's admission to the facility. - When a resident is admitted to the nursing unit, the admitting Nurse must document the following information (as each may apply) in the nurses' notes, admission form, or other appropriate place, as designated by facility protocol: a. The date and time of the resident's admission; b. The resident's age, sex, race, and marital status; c. From where the resident was admitted (i.e., hospital, home, other facility); d. Reason for the admission; e. The admitting diagnosis; f. The general condition of the resident upon admission; g. The time the Attending Physician was notified of the resident's admission; h. The time the physician's orders were received and verified . Review of Resident #125's clinical record indicated the resident was admitted to the facility at least 38 hours prior to the documentation of the Admission Data Collection information. On 2/13/23 at 3:17 p.m., the surveyor interviewed the facility's Director of Nursing (DON) about Resident #125's admission documentation. The DON reported a progress note should have been written, for the time of the resident's arrival, to include: vital signs, how the resident arrived, general information about the resident, general condition of the resident, and the time of the resident's arrival. On 2/16/23 at 5:23 p.m., the survey team conducted a meeting with the facility's Administrator, Director of Nursing, and a Nurse Consultant. The surveyor discussed the failure of facility staff members to document Resident #125's admission assessment/information for the time of the resident's arrival. 22218 For Resident #176, facility staff failed to document reasons for not administering multiple medications and treatments. Based on facility document review and clinical record review, and staff interview facility staff failed to provide treatment as ordered for one of 24 current residents in the survey sample (Resident # 176). Resident #176 was admitted to the facility on [DATE]. The resident's diagnoses included primary adrenocortical insufficiency, ployneuropathy, chronic obstructive pulmonary disease, polymyalgia rheumatica, common variable immunodeficiency, morbid obesity type 2 diabetes mellitus, chronic pancreatitis, depression, anxiety, muscle spasms, nausea, allergies, edema, primary adrenocortical insufficiency, hypertension, and insomnia. At the time of the survey, the resident did not yet have a minimum data set assessment. The surveyor interviewed the resident on 2/13/2023 and found the resident knowledgeable about diagnoses and treatment and able to answer questions about the time in the facility. The resident expressed no concerns other than lack of medication availability and not having received a fentanyl patch (due every third day) since admission on 2/9. The surveyor reviewed the clinical record on 2/13/2023 and discovered that fentanyl 75mcg transdermal patch apply 1 patch every 72 hours at 10 AM was ordered on admission on 2/9/23. Staff documented fentanyl N= not administered- other on 2/10 and 2/13/2023. Review of the Medication Administration Record (MAR) on 2/15/2023 revealed the following additional medications documented as N=not administered without explanation on 2/12-2/14: 2/12 8AM- Golytely, incruse ellipta 9AM- Gabapentin 9PM- methacarbamol 2/13 5AM- methacarbamol 8AM- [NAME] discus, Golytely 11AM- venlafaxine 8PM-topiramate, ursodiol, Lunesta 9 PM- methacarbamol 2/14 1AM- methacarbamol 5AM- methacarbamol 8AM-Golytely 12PM-diclofenac gel 6PM-diclofenac gel 9PM-methacarbamol There was no evidence that the physician/physician surrogate had been notified of any of the medications not being administered. During a brief interview on 2/16/2023 at 9:40 AM, the nurse caring for the resident, Licensed Practical Nurse (LPN) #5, stated that nurses were expected to document reasons for not administering ordered medications and treatments. During a summary meeting on 2/16/2023, the surveyor reported the medications that were documented as not administered without explanation.

Based on resident representative interview, staff interview, clinical record review, and facility document review, the facility staff failed to notify the resident representative of significant changes in the resident's physical condition for 1 of 24 residents in the survey sample, Resident #61. The findings included: For Resident #61, the facility staff failed to notify the resident representative of significant weight loss in a timely manner and failed to notify of an episode of rectal bleeding. Resident #61's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Chronic Atrial Fibrillation, Chronic Respiratory Failure with Hypoxia, Chronic Conjunctivitis, Unspecified Blepharitis, and Repeated Falls. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 1/19/23 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. Resident #61 was coded as requiring limited assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Resident #61 was coded for a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months while not on a physician-prescribed weight-loss regimen. On 2/14/23 at 3:51 pm, surveyor spoke with Resident #61's adult child who stated they were not being notified with all health changes, medication changes or when the doctor comes in. A review of Resident #61's clinical record revealed the following resident weights: 10/06/22 - 113.0 1/23/23 - 104.5 2/03/23 - 99.4 Resident #61's clinical record included a 1/25/23 quarterly nutrition assessment by the RD (registered dietitian) which documented in part .Wt [weight] 3 months ago 113# with a 7% wt loss in 3 months and 6 months ago wt 124# with a 15% wt loss in 6 months. Ubw [usual body weight] 124# Currently on Ensure plus 240 ml BID [twice a day] which provided 350 kcals and 20 grams protein for each. Encourage intakes at meals and snacks and description of foods and location for vision. Recommend increase to Ensure Plus TID [three times a day] for added Kcals and protein and monthly wts. Resident #61's clinical record included a Nutrition Risk Note dated 2/09/23 stating Res [resident] on Regular diet and Ensure BID BMI [body mass index] has decreased in past month to 19.4. Wt on 2/03 99.4# Wt 2 weeks ago 104.5# which is a significant wt loss of 5%. Wt 6 months ago 125# and significant 21% wt loss in 6 months. Recommended increasing ensure nutrition supplement to TID [three times a day] or keep Ensure BID and add magic cup daily - resident preference. Monitor wts and encourage intakes at meals and snacks. Surveyor reviewed the resident's clinical record and was unable to locate documentation of Resident #61's resident representative being notified of the weight losses identified on 1/23/23 or 2/03/23 until 2/15/23. A 2/15/23 5:53 am late entry nursing note for 2/14/23 stated in part [family nurse practitioner (FNP)] notified of recent weight loss, RD recommendations. New orders noted to obtain CMP [complete metabolic panel], CBC [complete blood count] now, obtain weekly weights and document for review. Attempt made to notify Rp [responsible party], will retry in AM. A 2/15/23 1:39 pm nursing note stated Late entry - approx. 0900 2/15/23 - Notified RP of new orders, recent weight loss and condition. RP states [he/she] would like an update when lab results returned and MD review. Resident #61 was seen by the FNP on 12/22/22 for rectal bleeding with plans to hold the anticoagulant Eliquis for 5 days, check stools for occult blood on two occasions, obtain CBC level, iron saturation level, ferritin level, and total iron binding capacity level, and start the medication Protonix. Surveyor reviewed Resident #61's clinical record and was unable to locate documentation of the resident representative being notified of the rectal bleeding or subsequent orders. Surveyor requested and received the facility policy entitled Change in a Resident's Condition or Status which read in part Our facility shall notify the resident, his or her Attending Physician, and/or resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). On 2/16/23 at 5:22 pm, the survey team met with the administrator, DON, and nurse consultant and discussed the concern of Resident #61's resident representative not being notified timely of weight loss or an episode of rectal bleeding with subsequent orders. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/16/23.

Based on interviews and document review, the facility staff failed to complete a Significant Change Minimum Data Set (MDS) assessment for one (1) of 24 residents, Resident #68. The findings include: The facility staff failed to complete a Significant Change Minimum Data Set (MDS) assessment when Resident #68 started receiving hospice care. Resident #68's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/11/23, was signed as completed on 1/11/23. Modifications to this MDS assessment were documented on 2/14/23 and 2/16/23. Resident #68 was assessed as rarely or never able to make self understood and as rarely or never able to understand others. Resident #68 was assessed as the Brief Interview for Mental Status should not be completed due to the resident being rarely/never understood. Resident #68 was documented a being dependent on others for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #68 had an order for consult for hospice care and to treat if approved dated 11/29/22. Documentation indicated the hospice admission was delayed until 12/7/22 at the request of one of the resident's family members. On 2/15/23 at 2:10 p.m., Registered Nurse (RN) #1 was interviewed about Resident #68's MDS assessments. RN #1 reported a significant change MDS assessment had not been completed when Resident #68 started receiving hospice services. On 2/15/23 at 2:52 p.m., RN #1 stated a significant change MDS had been started with an Assessment Reference Date (ARD) of 2/15/23. On 2/16/23 at 5:23 p.m., the survey team conducted a meeting with the facility's Administrator, Director of Nursing, and a Nurse Consultant. The surveyor discussed the failure of facility staff members to complete a significant change MDS assessment when Resident #68 started receiving hospice care.

Based on interviews and document reviews, the facility staff failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents' conditions for two (2) of 24 residents, Resident #68 and Resident #70. The findings include: 1. Resident #68's Minimum Data Set (MDS) assessment (with an Assessment Reference Date (ARD) of 1/11/23) had the resident assessed as both able to make self understood and as being rarely/never understood. Resident #68's MDS assessment, with an ARD of 1/11/23, was signed as completed on 1/11/23. Resident #68 was assessed as able to make self understood and as able to understand others. Resident #68 was also assessed not to have the Brief Interview for Mental Status completed due to the resident being rarely/never understood. Resident #68 was documented a being dependent on others for bed mobility, transfers, dressing, toilet use, and personal hygiene. On 2/14/23 at 4:04 p.m., the surveyor discussed Resident #68's conflicting MDS data with the facility's Administer. On 2/16/23, the survey team was provided with a modified MDS assessment that had Resident #68's assessment modified to change (a) able to make self understood and able to understand others to (b) rarely/never able to make self understood and rarely/never able to understand others. On 2/16/23 at 5:23 p.m., the survey team conducted a meeting with the facility's Administrator, Director of Nursing, and a Nurse Consultant. The surveyor discussed the Resident #68's MDS assessment including conflicting information related to the resident's ability to be understood. 2. Resident #70's Minimum Data Set (MDS) assessment (with an Assessment Reference Date (ARD) of 11/25/22) had the resident assessed as both able to make self understood and as being rarely/never understood. Resident #70's MDS assessment, with an ARD of 11/25/22, was signed as completed on 12/7/22. Resident #70 was assessed as able to make self understood and as able to understand others. Resident #70 was assessed not to have the Brief Interview for Mental Status completed due to the resident being rarely/never understood. Resident #70 was assessed as being independent with transfers, dressing, and toilet use. On 2/14/23 at 4:04 p.m., the surveyor discussed Resident #70's conflicting MDS data with the facility's Administer. The surveyor was provided a copy of a modified MDS assessment (with an ARD of 11/25/22) that had Section C modified to remove the information indicating the Brief Interview for Mental Status should not be completed, for Resident #70, due to the resident being rarely/never understood. This was modified on 2/14/23. On 2/16/23 at 5:23 p.m., the survey team conducted a meeting with the facility's Administrator, Director of Nursing, and a Nurse Consultant. The surveyor discussed the Resident #70's MDS assessment including conflicting information related to the resident's ability to be understood.

3. The facility staff failed to develop a care plan to address Resident #68's hospice needs. Resident #68's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/11/23, was signed as completed on 1/11/23. Modification to this MDS assessment were documented on 2/14/23 and 2/16/23. Resident #68 was assessed as rarely or never able to make self understood and as rarely or never able to understand others. Resident #68 was assessed as the Brief Interview for Mental Status should not be completed due to the resident being rarely/never understood. Resident #68 was documented a being dependent on others for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #68 had an order for consult for hospice care and to treat if approved dated 11/29/22. Documentation indicated the hospice admission was delayed until 12/7/22 at the request of one of the resident's family members. On 2/15/23 at 2:10 p.m., Registered Nurse (RN) #1 was interviewed about Resident #68's care plan. RN #1 reported Resident #68's comprehensive care plan did not address the resident's hospice care. On 2/15/23 at 2:20 p.m., RN #1 provided the surveyor a copy of Resident #68's Hospice Care Plan which had a start date of 2/15/23. On 2/16/23 at 5:23 p.m., the survey team conducted a meeting with the facility's Administrator, Director of Nursing, and a Nurse Consultant. The surveyor discussed Resident #68's not having a hospice care plan developed when the resident started receiving hospice care. 42353 Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to implement a comprehensive person-centered care plan to meet the needs of the resident for 3 of 24 residents in the survey sample, Resident #61, #59, and #68. The findings included: 1. For Resident #61, the facility staff failed to implement the comprehensive person-centered care plan intervention of bilateral mats placed to both sides of the bed. Resident #61's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Chronic Atrial Fibrillation, Chronic Respiratory Failure with Hypoxia, Chronic Conjunctivitis, Unspecified Blepharitis, and Repeated Falls. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 1/19/23 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. Resident #61 was coded as requiring limited assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. A review of Resident #61's comprehensive person-centered care plan revealed a care plan description documenting in part at risk for falls, bilateral mats placed to both sides of bed. Throughout the course of the survey, surveyor made eight visual observations of Resident #61, on each observation, the resident was in bed. On four of the eight observations, the floor mats were not in place per the care plan. On 2/14/23 at 2:19 pm and 5:01 pm, Resident #61 was in bed and the bilateral floor mats were folded up and located on each side near the head of the bed. At 5:02 pm, surveyor requested licensed practical nurse (LPN) #4 accompany the surveyor into the resident's room. Surveyor asked LPN #4 if the floor mats should be in place on each side of the bed and LPN #4 stated yes and placed the floor mats in position on each side of the bed. On 2/15/23 at 8:25 am and 12:04 pm, surveyor observed Resident #61 in bed with the right floor mat in place and the left floor mat folded up and placed on top of the resident's chest of drawers near the foot of the bed. Surveyor requested and received the facility policy entitled Care Plans, Comprehensive Person-Centered which read in part A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. On 2/16/23 at 5:22 pm, the survey team met with the administrator, director of nursing, and the nurse consultant and discussed the concern of Resident #61's bilateral floor mats not being in place per the resident's plan of care. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/16/23. 47299 2. For resident #59 the facility staff failed to implement a comprehensive person-centered care plan. The findings include: Resident #59's diagnoses included, but were not limited to, Alzheimer's disease, chronic kidney disease, anxiety disorder, and major depressive disorder. The admission minimum data set (MDS) with an assessment reference date (ARD) of 1/18/23, assigned the resident a brief interview for mental status (BIMS) score of 3, indicating severe cognitive impairment. Under Section G for functional status, resident #59 is coded as dependent on staff for all activities of daily living (ADL's). Section H reveals resident is always incontinent of bowel and bladder. 2/15/23 at 10:15 A.M. Surveyor observed resident with an anxious, pained facial expression while interviewing their spouse. Resident was fidgeting with the bed covers, grimacing and would repeatedly point to the bathroom. Resident asked surveyor, Is it busy? Is somebody in there? Spouse stated that resident thinks they need to use the restroom and won't settle down. Surveyor went to locate a staff member to assist resident with toileting. RN #2 informed surveyor that spouse had said the son was coming to assist. Surveyor approached the facility administrator in the hall, explained the situation and asked that they check on resident. Administrator reported to surveyor at 10:43 A.M. that resident had been toileted and given a laxative. Surveyor noted at 1:20 P.M. resident was resting quietly with his eyes closed. 2/15/23 2:44 P.M. Surveyor requested a copy of the comprehensive care plan for resident #59. The regional nurse consultant brought the baseline care plan, and a care plan for advanced directives. There was no other care plan available in the medical record that addressed toileting, anxiety, or incontinence. 2/16/23 9:20 A.M. Surveyor interviewed RN #1. Surveyor asked if resident should have a comprehensive care plan completed in the medical record as they were admitted [DATE] and the admission MDS was signed as complete on 1/23/23. RN #1 confirmed that the care plan should be complete, and that it would be done by the end of day. On 2/16/23 at 5:09 P.M. Surveyor reviewed this concern with the Administrator, Director of Nursing the regional nurse consultant. No further information was received prior to exit.

Based on interviews and document review, the facility staff failed to ensure clinical documentation supported new diagnoses for two (2) of 24 residents, Resident #68 and Resident #50. The findings include: 1. Resident #68's clinical documentation included the diagnosis of Schizoaffective disorder, unspecified dated 12/21/22. Resident #68's clinical documentation failed to include assessment information to support the addition if this diagnosis. Resident #68's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/11/23, was signed as completed on 1/11/23. Modification to this MDS assessment were documented on 2/14/23 and 2/16/23. Resident #68 was assessed as rarely or never able to make self understood and as rarely or never able to understand others. Resident #68 was assessed as the Brief Interview for Mental Status should not be completed due to the resident being rarely/never understood. Resident #68 was documented a being dependent on others for bed mobility, transfers, dressing, toilet use, and personal hygiene. The following information was found in a document titled DIAGNOSIS CLARIFICATION REQUEST which addressed Resident #68's diagnoses: Can we utilize (diagnosis) . schizoaffective disorder due to (resident) being on Seroquel? This document was signed by a medical provider on 12/21/22 but the medical provider did not document whether or not the diagnosis of schizoaffective disorder should be used. On 2/15/23 at 1:15 p.m., the surveyor interviewed the facility's Medical Director about Resident #68's Schizoaffective Disorder diagnosis. The Medical Director reported they would contact the psychiatric nurse practitioner for information related to this diagnosis. On 2/16/23 at 9:22 a.m., the surveyor interviewed the facility's Medical Director via telephone. The Medical Director reported the diagnosis of Schizoaffective Disorder should be removed due to the lack of supporting documentation. On 2/16/23 at 3:48 p.m., the facility's Director of Nursing (DON) provided documentation which indicated Resident #68's diagnosis of Schizoaffective disorder, unspecified had been retracted. On 2/16/23 at 5:23 p.m., the survey team conducted a meeting with the facility's Administrator, Director of Nursing, gand a Nurse Consultant. The surveyor discussed the failure of facility staff members to have supporting documentation for Resident #68's diagnosis of Schizoaffective Disorder resulting in a medical provider removing the diagnosis. 2. Resident #50's clinical documentation included the diagnosis of Schizoaffective disorder, unspecified dated 12/21/22. Resident #50's clinical documentation failed to include assessment information to support the addition if this diagnosis. Resident #50's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/9/23, was signed as completed on 2/3/23. Resident #50 was assessed as able to make self understood and able to understand others. Resident #50's Brief Interview for Mental Status summary score was documented as an 8 out of 15; this indicated moderate cognitive impairment. Resident #50 was assessed as being independent with bed mobility and eating. Resident #50 was assessed as requiring assistance with personal hygiene and bathing. On 2/16/23 at 9:22 a.m., the surveyor interviewed the facility's Medical Director via telephone. The Medical Director was asked about Resident #50's diagnosis of Schizoaffective Disorder. No documentation supporting the addition of Resident #50's Schizoaffective Disorder diagnosis was provided to the surveyor. On 2/16/23 at 3:48 p.m., the facility's Director of Nursing (DON) provided documentation which indicated Resident #50's diagnosis of Schizoaffective disorder, unspecified had been retracted. On 2/16/23 at 5:23 p.m., the survey team conducted a meeting with the facility's Administrator, Director of Nursing, and a Nurse Consultant. The surveyor discussed the failure of facility staff members to have supporting documentation for Resident #50's diagnosis of Schizoaffective Disorder resulting in a medical provider removing the diagnosis.