Every finding on record at East Cobb Center for Nursing and Healing LLC

Based on observations, resident and staff interviews, and review of the facility's policies titled, Food Receiving and Storage, Refrigerators and Freezers, and Food Brought by Family/Visitors, the facility failed to remove expired food items from the refrigerator and dry storage, failed to label and date an opened package of frozen food, failed to maintain cleanliness of the kitchen's ice machine, failed to remove expired items from a resident's personal refrigerator, failed to maintain cleanliness of a resident's personal refrigerator, and failed to serve cold and hot food at an appropriate temperature. The deficient practices had the potential to cause foodborne illness and to affect 107 residents who received food from the kitchen. The facility census was 109.Findings include:Review of the undated facility policy titled Food Receiving and Storage documented under Policy Interpretation and Implementation: .7. All food stored in the refrigerator or freezer will be covered, labeled and dated.Review of the undated facility policy titled Refrigerators and Freezers documented under Policy Interpretation and Implementation: 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates.Review of the facility policy titled Food Brought by Family/Visitors issued April 2024 documented under Guidelines: 8. The Nursing and/or Nutrition Services staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due packaging expiration dates).An initial tour observation of the facility kitchen was conducted on 8/19/2025 at 8:51 am and revealed two containers of thickened lemon-flavored water, each with a net weight of 46 fl oz (fluid ounces) and expiration dates of 7/14/2025 were observed in the dry storage area, a bag of what appeared to be chicken tenders in the freezer, opened and unlabeled, and a container of thickened lemon-flavored water with an expiration date of 7/14/2025 in the refrigerator, opened and used.An observation on 8/19/2025 at 9:14 am revealed the kitchen ice machine with a black substance build up under the cover of the ice dispenser. The Food Service Director (FSD) confirmed at this time that it should be cleaned and stated that it was the responsibility of Maintenance to clean the ice machine.In an interview with the FSD on 8/19/2025 at 9:01 am, she confirmed the opened and unlabeled bag of chicken in the freezer and three expired containers of thickened lemon-flavored water. She stated that whenever the delivery truck came to the facility, which was twice a week, she expected staff to rotate the food items with a first in, first out approach. When asked her expectations with expired food items, she stated that she thought that staff had checked them but acknowledged that it was also her responsibility to double-check the food items.An interview with the Director of Maintenance on 8/19/2025 at 4:52 pm revealed he was responsible for cleaning the kitchen ice machines and performed the cleaning quarterly by flushing the ice machine out with hot water and using disinfecting wipes. When shown the build up of black substance on the ice machine, he stated he never cleaned that area.An interview with the Administrator on 8/21/2025 at 11:45 am revealed her expectation was that part of the day-to-day supervision in the kitchen was to ensure everything was labeled and dated appropriately. Regarding the cleanliness of the ice machines, she stated that she expected the ice machine to be wiped down by maintenance, but going forward, kitchen staff would be checking off on cleaning the ice machines.An observation on 8/19/2025 at 10:33 am revealed R91's personal refrigerator with items including three tubs of cream cheese with expiration dates of 7/31/2025, 8/9/2025, and 8/14/2025. A foul smell was noted upon opening the refrigerator. Further observation revealed a buildup of a black substance on the tray of freezer as well as a buildup of ice-like growth surrounding items in the freezer. In an interview with R91 at this time, she stated that staff cleaned her refrigerator once a week. R91 further stated that she was bedridden and could not go to her refrigerator to look at the cleanliness of it so she relied on staff to maintain it.In an interview on 8/19/2025 at 10:45 am, the Director of Nursing (DON) stated that cleaning resident's personal refrigerators was the responsibility of housekeeping. The staff checked temperatures, expired foods, and cleaned the refrigerators. The DON stated that cleaning should be done once a week, but they also looked at it daily to check the temperatures. The DON confirmed the three containers of cream cheese were expired and removed them. The DON further confirmed the presence of black substance buildup on the tray of the freezer portion as well as the buildup of ice in the freezer.An interview on 8/19/2025 at 2:43 pm with Dietary Aide MM revealed she took the food carts and tea carts to and from the kitchen and halls. She stated she never checked the refrigerators in resident rooms and did not think kitchen staff checked them. She further stated she thought it was the responsibility of nursing.An interview on 8/19/2025 at 2:45 pm with Certified Nursing Assistant (CNA) NN revealed that CNAs had the responsibility to check for expiration dates in resident personal refrigerators, remove expired items, and clean them out if needed once a week. She further stated that housekeeping also cleaned.An interview on 8/19/2025 at 2:48 pm with the Housekeeping Supervisor revealed when asked whose responsibility it was to maintain resident refrigerators, she stated it was a team effort between CNAs and housekeeping. She expected her housekeeping staff to check for expired items twice a week as well as checking for cleanliness of the refrigerators.An interview with the Administrator on 8/21/2025 at 11:45 am revealed regarding the cleanliness and supervision of food items in resident personal refrigerators, that the facility had previously educated resident families and staff about labeling, dating and cleanliness of personal refrigerators, and they were looking to possibly get rid of the personal refrigerators.Observations of a test tray were conducted on 8/21/2025. On 12:49 pm, the food delivery cart left the kitchen which included the test tray to be served last. On 12:51 pm, the cart reached the last hallway to be served. It was observed that staff from housekeeping, therapy, and administrative staff passed out the trays to the residents in the hall. At 1:00 pm, the food delivery cart was emptied, and the test tray was retrieved by the Food Service Director (FSD). The tray consisted of fried chicken, tater tots, green beans, and a cold fruit parfait. The internal temperatures of the food were taken by the FSD prior to consuming and measured 141degrees Fahrenheit (F) for the fried chicken, 123 degrees F for the tater tots, 145 degrees F for the green beans, and 43 degrees F for the fruit parfait.In an interview with the Food Service Director on 8/21/2025 at 1:20 pm, she stated that cold foods should be served with an internal temperature between 32 degrees F and 41 degrees F and hot foods should be served at an internal temperature of at least 135 degrees F. She confirmed that cold food should not be served at 43 degrees F and hot food should not be served at 123 degrees F.

Based on observation, staff interviews, and record review, the facility failed to ensure safe medication administration practices for one of nine residents (R) (R3) receiving insulin. Specifically, the facility failed to ensure R3 did not receive Humalog insulin from a vial that was not intended for R3.Findings include:Review of the Electronic Medical Record (EMR) for R3 revealed that she was admitted to the with diagnoses that included but not limited to acute kidney failure, and type 2 diabetes mellitus.Review of the Modification of Significant Change Minimum Data Set (MDS) dated [DATE] revealed in Section C (Cognitive Patterns) R3 had a Brief Interview for Mental Status (BIMS) score of 15, indicating little to no cognitive impairment.Review of the EMR care plan section for R3 revealed that she had a diagnosis of diabetes mellitus and current orders for insulin therapy.Review of the physician's order dated 7/2/2025 revealed an order for Humalog injection solution 100 units/Milliliter (ml), inject as per sliding scale.If 0-59 (sic), or below 60 (sic), call the physician.60-200 (sic): do not give any insulin. 201-250 (sic): give 4 units. 251-300 (sic): give 8 units. 301-350 (sic): give 10 units. If above 400 (sic), call the physician.(Sic) subcutaneously (injection given just below the skin) before meals and at bedtime for diabetes mellitus.Observation of medication administration on 8/20/2025 at 11:10 am with Registered Nurse (RN) HH revealed RN HH administered 4 units of Humalog insulin to R3 from a medication box/vial labeled with another resident's name. Interview on 8/20/2025 at 11:15 am with RN HH confirmed that she did administer the Humalog insulin from a vial that was not prescribed for R3.Interview on 8/20/2025 at 1:25 pm with the Director of Nursing (DON) revealed that it was her expectation that insulin was administered from a box/vial labeled for that specific resident.

Based on observations, staff interviews, and record reviews, the facility failed to ensure the incentive spirometer (device to improve lung function) was properly stored in a manner to prevent contamination for one of 14 residents (R) (R60) using respiratory equipment. The deficient practice had the potential to increase the risk of respiratory infection for R60.Findings include: Review of the electronic medical record (EMR) revealed R60 was admitted to the facility with diagnosis of but not limited to chronic obstructive pulmonary disease (COPD) unspecified. Review of R60's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. During an observation on 8/19/2025 at 11:10 am and 4:55 pm revealed R60's incentive spirometer was not properly bagged while not in use. During an observation on 8/20/2025 at 9:07 am revealed R60's incentive spirometer was not properly bagged while not in use. During an observation and interview on 8/20/2025 at 9:10 am with the Unit Manager (UM) GG, they stated the incentive spirometer does not need to be properly bagged and it was okay to be on the nightstand, and they had orders for it. UM GG was asked if there were any concerns associated with the incentive spirometer being exposed regarding infection control, she stated she would have to check on that. During an interview on 8/20/2025 at 9:14 am with UM GG, she revealed she spoke with the Respiratory Therapist and confirmed the incentive spirometer was supposed to be properly bagged when not in use. Interview on 8/20/2025 at 2:43 pm with the Director of Nursing (DON) confirmed any respiratory equipment was supposed to be bagged for infection control purposes. The DON continued to state that respiratory items were supposed to be checked on by the Certified Nursing Assistant (CNA) when they conducted their rounds.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Resident Self-Administration of Medication, the facility failed to adequately assess two of 59 sampled Residents (R) (R60, R75) for self-administration of medication. The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents.Findings include:Review of the facility's policy titled Resident Self-Administration of Medication with a review date of March 2024 documented under the section Policy Explanation and Compliance Guidelines: .3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team (IDT) should at a minimum consider the following: a. the medication appropriate and safe for self-administration; b. the resident's physical capacity to swallow without difficulty, open medication bottles administer injections; c. the resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for; d. the resident's capability to follow directions and tell time to know when medications need to be taken; e. the resident's comprehension of instructions for the medication they are taking, including the dose, timing, and signs of side effects, and when to report to facility staff; e. the resident's ability to understand what refusal of medication is, and appropriate steps taken by staff to educate when this occurs; and f. the resident's ability to ensure that medications is stored safely and securely. 4. The results of the IDT assessment are recorded on the Medication Self-Administration Form, which is placed in the resident's medical record .7. bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's room or to confuse roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur; a. the manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage in ineffective .b. the medications provided to the resident for bedside storage are kept in the containers dispense by the provider pharmacy. 1. Review of the electronic medical record (EMR) revealed R60 was admitted to the facility with a diagnosis of but limited to Chronic obstructive pulmonary disease (COPD) unspecified.Review of R60's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment.Review of the care plan for R60 revealed no documentation for self-administration of medication.Review of the Physician's Orders for R60 revealed there were no orders found for nasal mist.Review of R60's EMR revealed no assessment for self-administration of medication.During an observation and interview on 8/19/2025 at 11:08 am with R60 in his room revealed there was a bottle of nasal mist on R60's nightstand. He stated he used the nasal mist when he got congested, but he had not used it in a while. During an observation and interview on 8/19/2025 at 11:30 am with Licensed Practical Nurse (LPN) OO confirmed R60 was not assessed for self-administration for medication. LPN OO further stated she did not notice R60's nasal mist on his dresser that morning when she was giving him medication, but he was not supposed to have it.2. Review of the EMR for R75 revealed admission to the facility with a diagnosis of but limited to displaced comminuted fracture of shaft of right femur subsequent encounter for closed fracture with routine healing. Review of R75's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating R75 was cognitively intact.Review of the care plan for R75 revealed no documentation for self-administration of medication.Review of R75's EMR revealed no assessment for self-administration of medication.Observation on 8/19/2025 at 10:57 am revealed R75 had traid hydrophilic wound dressing (a paste that adheres to wet skin, absorbs fluid, moisturizes, and protects wounds) on the nightstand.Observation and interview on 8/19/2025 at 11:40 am with LPN OO confirmed R75 was not assessed for self-administration for medication. However, the wound care ointment was left in R75's nightstand drawer and not on top of the nightstand.Interview on 8/20/2025 at 2:26 pm with the Director of Nursing (DON) stated the wound care ointment and nasal mist should not be in the resident's room. The DON continued to state nurses, unit managers, and department heads were responsible for doing rounds and were assigned certain rooms to ensure these items were not present.

Based on observations, resident and staff interviews, and record review, the facility failed to provide oxygen (O2) tubing extensions for one of 15 residents (R) (R68) who received O2 therapy. The deficient practice had the potential to cause issues with mobility and independence.Findings Include:Review of the electronic medical record for R68 revealed admission to the facility with diagnoses of coronavirus disease (Covid-19), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and shortness of breath (SOB).Review of the quarterly Minimum Data Set (MDS) dated [DATE] documented that R68 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. Further review of MDS section E (Behaviors) revealed R68 had no behaviors, section GG (Functional Abilities and Goals) required supervision for personal hygiene, dependent on showers, supervision with upper body dressing and moderate assistance for lower body dressing.Review of the care plan for R68 revealed a care plan dated 8/1/2025 documenting the resident was to receive three (3) (liters) L of oxygen (O2) continuously with a revision date of 8/20/2025 documenting the resident was to receive two (2) L of O2 via nasal every shift.During interview and observation on 8/19/2025 with R68 at 3:21pm in the residents' room revealed that the resident was being administered O2. She stated that the O2 tubing was too short, which caused her to take it off when going to the bathroom or maneuvering throughout her room. She stated that she put in a request for a longer tube 12 days ago but had not received it.During interview and observation on 8/20/2025 with R68 at 9:43 am, it was revealed that R68 had not received the extended O2 tubing that was requested. She continued to take O2 off when going to the bathroom as the tubing was not long enough for the resident to take to the bathroom. R68 revealed that she was out of breath after using the bathroom and returned to her wheelchair. R68 stated she had a physician order for O2 continuously.Interview with the Assistant Director of Nursing (ADON) on 8/21/2025 at 11:54 am in her office revealed that the Central Supply Coordinator completed the ordering of medical supplies for the facility. She stated that she was unaware that R68 requested extended O2 tubing.

Based on observations, resident and staff interviews and review of the facility's policy titled Medication Storage, the facility failed to discard expired biologicals prior to the expiration date printed on the medication in one of two medication storage rooms and one of seven medication carts. Findings include: Review of the facility policy titled Medication Storage revealed under Policy Explanation and Guidelines: 8. Unused Medications: The Pharmacy and all medication rooms are routinely inspected by the consultant Pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, ineligible or missing labels. Observation and interview on [DATE] at 3:00 pm of the Long-Term Care (LTC) Magnolia Station (nurses' station) revealed one vial of Tuberculin Purified Protein Derivative with an open seal that was not labeled with an open date. Information on the box indicated to discard 30 days after opening. Interview with Licensed Practical Nurse (LPN) AA verified the vial, or the box was not labeled with an open date and should be discarded after 30 days according to the box directions. Observation on [DATE] at 3:36 pm of the 300 Magnolia Hall medication cart revealed a vial of Lantus insulin with an open seal that had an open date of [DATE]. Information on the box indicated to discard 28 days after opening. Interview with LPN BB verified the vial should be discarded 28 days after opening according to the box directions. Interview on [DATE] at 10:45 with the Director of Nursing (DON) revealed the medication room and the medication carts are checked two times a week and as needed. Each Unit Manager (UM) and the nurses on each shift are responsible for checking the dates and labeling during each medication administered. The DON revealed when a medicine is expired it is supposed to be removed from the medication cart or medication room immediately and sent to be destroyed.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Oxygen Administration, the facility failed to maintain respiratory equipment consistent with professional standards for three of 50 sampled residents (R) (R91, R74, and R271). Specifically, the facility failed to bag a CPAP (continuous positive airway pressure) mask when not in use, clean/change/install filters on oxygen (O2) concentrators (machine that administers O2). The deficient practice had the potential to cause infection. Findings include: Review of the facility policy titled Oxygen Administration revised date December 2022 revealed under Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans and the resident goals and preferences. Under Policy Explanation and Compliance Guidelines: 5. Staff shall perform hand hygiene, and don gloves when administrating oxygen or when in contact with oxygen equipment, other infection control measures include: e. Keep delivery devices covered in plastic bags when not in use. 7. Cleaning and care of equipment should be in accordance with facility policies for such equipment. 8. Storage of oxygen should be in accordance with the facility's oxygen safety policy. 1. Review of R91's quarterly Minimum Data Set (MDS) dated [DATE] in the electronic health record (EHR) revealed in Section C - Cognitive Patterns- a Brief Interview for Mental Status (BIMS) score of 13, indicating little or no cognitive impairment, in Section GG - Functional Abilities and Goals-Independent, and in Section O - Special Treatments, Procedures, and Programs- CPAP. Review of Physician's orders for R91 dated 12/30/2023 CPAP: Monitor placement of mask-at bedtime for Sleep Apnea and as needed for sleep. Clean CPAP/BiPAP (bilevel positive airway pressure) Reservoir (clean CPAP/BiPAP Reservoir in the morning) Review of the Care plan dated 12/30/2023 for R91 included Focus Area-The resident has altered respiratory status/difficulty breathing r/t [related to] Sleep Apnea. Goal-The resident will have no complications related to SOB [shortness of breath] though the review date. Intervention-BIPAP/CPAP/VPAP [variable positive airway pressure] SETTINGS: as per medical director / nurse practitioner orders. Observation on 3/12/2024 at 10:12 am revealed that R91's CPAP mask was not bagged. Observation on 3/14/2024 at 8:52 am revealed that R91's CPAP mask was not bagged. Interview on 3/14/2024 at 8:52 am revealed R91 sitting in the bed eating breakfast. R91 stated that he had minor surgery on his toe yesterday. R91's CPAP mask was not bagged. R91 stated that he was not able to bag his CPAP mask due to the bag being out of his reach. R91 stated that it takes him about 15 minutes to reach the plastic bag as staff was always busy around mealtime. Interview on 3/14/2024 at 9:09 am with LPN DD revealed that R91's CPAP mask should be cleaned and bagged after every use. Staff are supposed to assist with bagging. LPN DD confirmed that R91's CPAP mask was not bagged. Interview on 3/14/2024 12:50 pm with the DON confirmed that when CPAP mask/machines are stored they should be clean and bagged. 47146 2. Review of the EHR revealed R74 was admitted to the facility with diagnoses listed but not limited to chronic obstructive pulmonary disease (COPD). Review of R74's significant change MDS assessment with an ARD of 12/14/2023 revealed in Section C-Cognitive Patterns-a BIMS score of 12, which indicated moderate cognitive impairment. Section O-Special Treatments, Procedures, and Programs revealed R74 received oxygen therapy while a resident. Review of R74's care plan indicated a focus of respiratory impairment related to COPD/pulmonary embolus (PE)/diagnosis of acute respiratory failure (date initiated 4/12/2022). Goals included but not limited to: will have no acute respiratory distress (date initiated 4/12/2022). Interventions included but not limited to: administer O2 two liters via nasal cannula (NC) (date initiated 4/12/2022). Review of the EHR revealed physician's orders for R74 included but not limited to oxygen at two liters per minute via nasal cannula (12/8/2022), monitor oxygen saturation, notify physician if saturation drops below 90 percent (12/8/2022), and oxygen tubing change weekly, label each component with date and initials every Sunday morning (12/24/2023). Observation on 3/12/2023 at 3:54 pm of R74 in bed wearing O2 via NC, the O2 concentrator was set of two liters per minute (LPM), the dark gray/black filter located on the back of the O2 concentrator appeared to have a light gray, fuzzy substance covering it. Observation on 3/13/2024 at 9:30 am of R74 in bed wearing O2 via NC, the concentrator was set at two LPM, the dark gray/black filter located on the back of the concentrator was noted to have a light gray, fuzzy substance around the edges and across the filter. Observation and interview on 3/13/2024 at 2:18 pm with the ADON, she confirmed and verified the O2 concentrator used by R74 had a filter on the back of the concentrator and was covered with a light gray, fuzzy substance. She stated the Central Supply Clerk is responsible for changing the filters on the O2 concentrators, but she did not know how often. 3. Review of the EHR revealed R271 was admitted to the with diagnoses listed but not limited to acute and chronic respiratory failure with hypoxia. Review of R271's admission MDS assessment with an ARD of 3/8/2024 revealed the assessment was in progress and not completed. Review of R271's care plan indicated a focus of care on shortness of breath (SOB) (date initiated 3/12/2024). Goals included but not limited to R271 will have no complications related to SOB through the next review date (date initiated 3/12/2024). Interventions included but not limited to administer oxygen as ordered by the physician/nurse practitioner (dated initiated 3/12/2024). Review of R271 baseline care plan dated 3/9/2024 revealed under section three titled Health Conditions/Special Treatments 1a was marked oxygen therapy. No staff signature as on the document. Review of the EHR revealed physician's orders for R271 included but not limited to oxygen saturation every shift, notify physician if saturation less than 90%, Oxygen at four liters per minute via nasal cannula, oxygen tubing: change weekly, label each component with date and initials. Observations on 3/12/2023 at 2:54 pm of R271 sitting up in a wheelchair, wearing O2 via NC set at 3.5 liters per minute. The O2 concentrator was clean, but the filter was missing from the compartment on the back of the O2 concentrator. Observations on 3/13/2024 at 10:30 am of R271 sitting up in a wheelchair wearing her O2 via NC. The O2 concentrator was set at 3.5 liters per minute and the back of the O2 concentrator had an area for a filter, but there was no filter placed on the O2 concentrator. Observation and interview on 3/13/2024 at 2:18 pm with the ADON of R271's O2 concentrator revealed it had an area on the back of the machine intended for the filter but there was no filter located on the O2 concentrator. The ADON verified and confirmed the filter was missing from the O2 concentrator. She stated the Central Supply Clerk was responsible for changing the filters on the O2 concentrators, but she did not know how often. Review of Oxygen Audit forms dated 2/28/2024 revealed R74 was listed as part of the audit, the tubing was dated 2/28/2024, the filter and concentrator clean was marked yes. R271 was not listed as part of the audit. Interview on 3/13/2024 at 2:20 pm with the DON revealed that the O2 concentrator filters are checked weekly on Thursday night (11:00 pm to 7:00 am shift) and the Central Supply Clerk performs a weekly audit every Friday. She stated her expectation was that staff follow up after checking the filters on the O2 concentrators and clean/replace them as needed and weekly. She stated she expected the Central Supply Clerk to replace filters found to be dirty during her audit.

Based on observations, staff interviews, record review, and review of the facility policy titled, Care Plans - Baseline, the facility failed to add anticoagulant (blood clotting medication) use to the baseline care plan for one of 50 sampled residents (R) (R267). The deficient practice had the potential for lack of interventions to monitor anticoagulant treatment that could lead to blood clotting issues. Findings include: Review of the facility policy titled Care Plans - Baseline updated December of 2022 revealed the Policy Statement was A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Under the section titled Policy Interpretation and Implementation number two revealed the interdisciplinary team will review the health care practitioner's orders to implement a baseline care plan to meet the residents immediate care needs. Review of the electronic health record (EHR) revealed R267 was who was admitted to the facility with diagnoses listed but not limited to encounter for other orthopedic aftercare. Review of R267's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/6/2024 revealed admitted was 3/6/2024 from a short-term general hospital. Review of R267's baseline care plan initiated on 3/6/2024 revealed there was no focus, goal, or interventions related to anticoagulant use. Review of the comprehensive nursing admission assessment dated [DATE] revealed under section R subtitle Physician Orders/Medication Review number two - current medications, the nurse marked, number one - insulin, number six - anticoagulant, and number eight - narcotics/opioids. Review of the EHR revealed physician's orders for R267 included but was not limited to Lovenox injection solution prefilled syringe 40 milligrams (mg)/0.4 milliliters (ml), inject 40 mg subcutaneously one time a day for deep vein thrombosis (DVT) prophylaxis until 3/28/2024. Start date 3/8/2024. The medication monitoring order - Anticoagulant medication monitoring. Monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle, joint pain, lethargy, bruising, sudden changes in metal status and or vital signs, shortness of breath, nose bleeds - document Y if monitored and not of the above observed, N if monitored and any of the above was observed. Select chart code other/see nurses notes and progress note findings. Review of the EHR revealed medication orders for R 267 included but was not limited to: Lovenox 40 mg/0.4 mg, inject 40 mg subcutaneously one time a day for DVT (deep vein thrombosis-blood clots) prophylaxis until 3/28/2024 and the nursing staff documented R267 received the Lovenox every day starting on 3/8/2024. Review of education / In-Service Attendance Records revealed on 6/23/2023 an in-service was presented by the Director of Nursing (DON) to staff related to Baseline Care Plan. The discussion covered how to access the baseline care plan in the EHR and the use of four focuses on all residents admitted (falls, pain, skin, and diagnoses). 22 Nursing staff signed the attendance in attestation of attendance. On 7/13/2023 an in-service was presented by the DON related to Baseline Care Plans and Alert Charting with two nursing staff signatures in attestation of attendance. Interview on 3/13/2024 at 10:14 am with LPN HH revealed residents who receive anticoagulants are monitored for increased bruising, prolonged bleeding, s/s of GI bleed. She stated any symptoms of suspected abnormal bleeding/ increased bruising is reported to the physician. She reported the care plan interventions flow into the E-MAR (electronic medication administration record) but she stated the care plan should include interventions for each high risk medication class. She stated all nurses can update the care plan. She revealed that on admission the nurse will create a basic care plan (baseline care plan) based upon the admission assessment which becomes part of the comprehensive care plan. She stated the MDS Coordinator builds the care plan based upon the MDS assessment. Interview on 3/13/2024 at 11:38 am with LPN MDS Coordinator CC revealed that the comprehensive care plan is due 45 days after admission. She stated R267 was admitted on [DATE]. She verified and confirmed the care plan for R267 did not address the use of anticoagulants for prophylaxis. She stated the use of anticoagulant or special care needs should be addressed on the baseline care plan. She stated the baseline care plan does become part of the comprehensive care plan. She stated nursing is responsible for completing the baseline care plan. Interview on 3/13/2024 at 11:41 am with the DON, she confirmed and verified the care plan for R267 did not include anticoagulant use. She stated it should have been captured on the baseline care plan by the admission nurse. She stated her expectation was for the anticoagulant to be captured on admission or during the managers 24 to 48-hour chart review. She stated the managers complete a chart review for all new admissions within 24 to 48 hours of the admission. Interview on 3/13/2024 at 3:10 pm with the Assistant Director of Nursing (ADON), she revealed regarding in-service training that one of the items covered in June 2023 was baseline care plans and assessments, she revealed that baseline care plans had been identified by the QAPI (quality assurance performance improvement) group as a potential area of improvement. She stated it was a result of the QAPI recommendation that she chose to educate on this topic.

Based on staff interviews and record review, the facility failed to complete a significant change Minimum Data Set (MDS) after a significant change occurred for one of 50 sampled residents (R) (R44). The facility census was 107 residents. Findings include: Review of Minimum Data Set (MDS) revealed that there was no significant change MDS for R44 completed in the electronic health record (EHR) after a significant change occurred. Record review of SBAR Communication Form and Progress Notes dated 10/19/2023 revealed: The Change in Condition/s reported on this CIC (change in condition) evaluation are/were Pain (uncontrolled) as a change in R44's condition did occur. Interview on 3/14/2024 at 12:43 pm with MDS Coordinator CC revealed that a Significant Change MDS assessment should have been completed, but it was not. MDS Coordinator CC confirmed that a Significant Change MDS assessment was not in the EHR. Interview on 3/14/2024 at 12:50 pm with the Director of Nursing (DON) confirmed that there should have been a significant change MDS completed on R44. Interview on 3/14/2024 at 1:09 pm with MDS Coordinator CC confirmed that the Significant Change was missed. MDS Coordinator CC stated that all preventative care was being implemented, however the Significant Change was missed.

Based on record review and staff interviews, the facility failed to follow the comprehensive, person-centered care plan for one resident (R) (R#58) related to activities. Sample size was 34. Finding include: The facility did not provide a care plan policy upon request. Review of the medical record for R#58 revealed that she was admitted to the facility with diagnoses that included but not limited to: paraplegia, peripheral vascular disease, and spinal stenosis, lumbar region without neurogenic claudication. The quarterly Minimum Data Set (MDS) dated [DATE] for Section C: Cognitive Patterns revealed that R#58 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact and able to make her own decisions. Section F - Preferences for Customary Routine and Activities- How important is it to you to have books, newspapers, and magazines to read? Very important How important is it to you to do things with groups of people? Very important How important is it to you to do your favorite activities? Very important How important is it to you to go outside to get fresh air when the weather is good? Important, but can't do or no choice. Section G - Functional Status revealed R#58 required extensive assistance Two+ person physical assistance with Activities of Daily Living (ADL). Care plan reviewed and revealed that R#58: Enjoys/Enjoyed activities such as reading, watching TV/movies, socializing, and religious activities. Interventions: Find, offer, and make use of newspapers, magazines, or books about the patient's culture. Offer activities consistent with patient's known interest, physical and intellectual capabilities. Offer activity program directed toward specific interests/needs. Provide adaptations of activities/environment specify what adaptations used) to accommodate participation in activities of choice. Provide supplies/materials for leisure activities as needed/requested. Desires to participate in outdoor hot/cold weather activities. Interventions: Avoid extended amount of time outdoors. Observe for and report signs and symptoms of over exposure to heat such as reddening of skin, faintness, blurred vision, dry mucous membranes, muscle cramps, flushed or pale clammy skin, nausea, heavy sweating, headache, elevated pulse, or respiratory rate, etc. Bring patient inside and hydrate. Observe for and report signs and symptoms of over exposure to cold such as shivering, slurred speech, sleepiness, change in consciousness, cool, pale skin, burning sensation, numbness, etc. Offer & assist to put on protective garb such as gloves, hat, coat, etc. as needed. Offer and assist to apply sunscreen prior to exposure. Offer warm or cold beverages. Provide with lightweight loose-fitting garments. Interview on 1/25/2023 at 1:45 p.m. with the Activities Director (AD) revealed R#58 does independent activities, reads newspapers daily, participates in bingo weekly, and makes cards for people. The AD stated with COVID-19 they wanted to do a bridge group with R#58 but as of right now R#58 does not receive any one-on-one activities. The AD could not provide documentation to prove that one-on-one room visits were provided to R#58. The AD further stated that she does not have any written documentation of one-on-one room visits with R#58. When asked, what assistance does she provide in the activities that are part of R#58's care plan, AD stated that she offers several independent activities such as books, games, trivia packets, coloring, arts, and crafts. The AD stated that R#58 reads every day, but she refuses individual packets most of the time. When asked, how do you make sure that R#58 is informed and transported to group activities of choice, the AD stated that R#58 does not come out of her room. The AD stated that R#58 gets socialization when the CNAs comes in to care for her. Interview on 1/25/2023 at 2:24 p.m. with the MDS coordinator revealed she updates the care plans quarterly, annually, and at each completed assessment. She stated that recreations (the AD) created the care plan about the outside activities. She stated that episodically care plans should reflect the residents' current needs and concerns. She further stated that she has never seen R#58 outside for activities.

Based on observations, record review, and resident and staff interviews, the facility failed to provide an individualized, person-centered activities program to meet the needs for one resident (R)(R#58) of 34 sampled residents who needed extensive assistance by staff for provision of all care. Specifically, R#58 was not provided with person-centered activities that would meet their individual needs. Findings include: The facility did not have a current activity policy in place at the time of the survey. Review of the medical record for R#58 revealed that he was admitted to the facility with diagnoses that included but not limited to: paraplegia, peripheral vascular disease, and spinal stenosis, lumbar region without neurogenic claudication. The quarterly Minimum Data Set (MDS) dated [DATE] for Section C: Cognitive Patterns revealed that R#58 has a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact and able to make her own decisions. Section F - Preferences for Customary Routine and Activities- How important is it to you to have books, newspapers, and magazines to read? Very important How important is it to you to do things with groups of people? Very important How important is it to you to do your favorite activities? Very important How important is it to you to go outside to get fresh air when the weather is good? Important, but can't do or no choice. Section G - Functional Status-Bed mobility- Extensive assistance Two+ person physical assist. Transfer- Extensive assistance Two+ person physical assist. Toilet use- Extensive assistance Two+ person physical assist. Review of the care plan revealed: Enjoys/Enjoyed activities such as reading, watching TV/movies, socializing, and religious activities. Interventions: Find, offer, and make use of newspapers, magazines, or books about the patient's culture. Offer activities consistent with patient's known interest, physical and intellectual capabilities. Offer activity program directed toward specific interests/needs. Provide adaptations of activities/environment (specify what adaptations used) to accommodate participation in activities of choice. Provide supplies/materials for leisure activities as needed/requested. Desires to participate in outdoor hot/cold weather activities. Interventions: Avoid extended amount of time outdoors. Observe for and report signs & symptoms of over exposure to heat such as reddening of skin, faintness, blurred vision, dry mucous membranes, muscle cramps, flushed or pale clammy skin, nausea, heavy sweating, headache, elevated pulse, or respiratory rate, etc. Bring patient inside and hydrate. Observe for and report signs and symptoms of over exposure to cold such as shivering, slurred speech, sleepiness, change in consciousness, cool, pale skin, burning sensation, numbness, etc. Offer and assist to put on protective garb such as gloves, hat, coat, etc. as needed. Offer and assist to apply sunscreen prior to exposure. Offer warm or cold beverages. Provide with lightweight loose-fitting garments. Further review of the medical record did not reveal any documentation of one-one on activities offered or provided to R#58. Observation and interview on 1/24/2023 at 9:53 a.m. revealed R#58 was observed lying in bed with eyes open. R#58 stated that she is paralyzed from the waist down. She stated that she cannot sit up in a wheelchair. R#58 stated that she is transported to appointments via stretcher. She stated that she participates in bingo from her bed. R#58 stated that bingo is called on Mondays by the Activity Director (AD) over the intercom. R#58 stated that the AD does not offer her any one-on-one room activities. She stated that she would like to have activities offered to her in her room because she cannot sit up in a wheelchair to participate in activities outside of her room. R#58 stated that she watches as her roommate leaves their room to attend activities. Observation on 1/25/2023 at 2:40 p.m. revealed R#58 lying in bed with a visitor noted sitting at bed side. Observation on 1/26/2023 at 9:31 a.m. revealed R#58 lying in bed with eyes open. During an interview with R#58 at this time she stated that she had a visit from the psychologist yesterday. R#58 stated that she does not receive any activities other than bingo on Mondays. She stated that she would love to have someone come in and play games with her. R#58 stated that she has a personal iPad that she uses. She also reads and watches television. She stated that all of that is great, but she would like some socialization with people. R#58 stated that the only socialization that she receives is from anyone that comes into her room. She stated that no one has offered to provide her with one-on-one activities. R#58 stated that she, along with her roommate and two other residents, formed a group together where they meet in her room occasionally and have discussions. Interview on 1/25/2023 at 1:45 p.m. with the AD revealed R#58 does independent activities, reads newspapers daily, participates in bingo weekly, and makes cards for people. The AD stated with COVID, they wanted to do a bridge group with R#58, but as of right now R#58 does not receive any one-on-one activities. The AD could not provide documentation to prove that one-on-one room visits was provided to R#58. The AD further stated that she does not have any written documentation of one-on-one room visits with R#58. When the AD was asked what assistance does she provide in the activities that are part of R#58's care plan, the AD stated that she offers several independent activities such as books, games, trivia packets, coloring, arts, and crafts. The AD stated that R#58 reads every day, but she refuses individual packets most of the time. When asked, how do you make sure that R#58 is informed and transported to group activities of choice, the AD stated that R#58 does not come out of her room. The AD stated that R#58 gets socialization when the CNAs comes in to care for her. Interview on 1/25/2023 at 2:24 p.m. with the MDS Coordinator revealed she updates the care plans quarterly, annually, and at each completed assessment. She stated that recreations (AD) created the care plan about the outside activities. She stated that episodically care plans should reflect the residents' current needs and concerns. She further stated that she has never seen R#58 outside for activities. Interview on 1/26/2023 at 11:00 a.m. with Charge Nurse Licensed Practical Nurse (LPN) AA revealed she is familiar with R#58 and her care. LPN AA stated that R#58 does not get out of bed. She stated that when R#58 goes out on appointments she is transported by stretcher. LPN AA stated that she has not witnessed R#58 participate in any other activities other than bingo. LPN AA also stated that she has not witnessed the AD conducting one-on-one activities with R#58. Interview on 1/26/2023 at 11:56 a.m. with the Rehab Manager (RM) revealed R#58 is currently not receiving therapy. The RM stated that when R#58 was on the therapy case load in May of 2020, she was capable of sitting up in a wheelchair. She stated that R#58 did not like to sit up in the wheelchair. Interview on 1/26/2023 at 12:35 p.m. with the Director of Nursing (DON) revealed that R#58's name comes up a lot in their interdisciplinary team (IDT) meetings. She stated that the current AD is new, and she has only been at the facility for a month. The DON stated that the former AD offered R#58 one-on-one activities and that R#58 refused, however the DON nor the AD could provide documentation that R#58 refused one-on-one activities.

Based on observation, resident, family, and staff interviews, the facility failed to ensure R#54 choice to eat in the residents room was honored. The sample size was 26. Findings: During an interview with R#54 on 8/27/19 at 2:49 p.m. States that she did not receive a lunch tray today. License Practical Nurse ( LPN) AA came around to give meds and she told her that she had not received her lunch yet. LPN AA came back after some time to see if she received a tray, but she had not. Stated that LPN AA offered her a sandwich, but she turned it down due to it being close to dinner time. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] Section C Brief Interview for Mental Status is coded 15/15 which indicates no cognitive impairment. During an interview on 8/27/19 at 3:40 p.m. with LPN AA regarding R#54 lunch she stated that she was going to deliver 1:30 p.m. meds when the resident informed her that she had not received her tray. Stated that she then went to the two aids who were responsible for delivering trays on the hall. One aid stated that she did not deliver trays on R#54's hall today and the other believes that her tray was accidentally picked up under the assumption that she was done eating. LPN AA states that resident usually eats in the dining room but today chose to eat in her room. States that there is no real process for communicating if a person eats in their room or the dining room. States that staff would find out if a person eats in their room by going through and checking to see if they received a tray or if a resident vocalizes that they have not ate. States that there are two aids on the hall responsible for delivering trays to the hall based off the trays that are on the cart. During an interview on 8/28/19 at 10:00 a.m. with Unit Manager (UM) BB stated that everybody that shows up to the dining room has a ticket. Once all tickets are served in the dining room the left-over tickets are assumed to be for the hall. Trays are then delivered to the hall based on the left-over tickets. States that there are two hall Certified Nursing Assistants (CNA's) are assigned to deliver trays. States that it was brought to her attention on yesterday by LPN AA that R#54 did not receive her tray. States that she is unsure as to what happened. States that she was not in hall when trays were delivered, because she is assigned to be in the dining room. States that she is unaware if a tray was created in the kitchen and delivered to the hall for the R#54. Once she was made aware that resident did not receive her tray she went to the resident to ask if she would like a sandwich and the resident stated that she was fine. States that the only way to know if a resident did not receive their tray is by them vocalizing or staff checking. States that the resident usually eats in the dining room and so it threw them off by her staying in her room to eat. During an interview on 8/28/19 at 10:40 a.m. with the Dietary Manager (DM) he explained the tray service delivery process. States that he prints meal tickets in dietary for the day. States that the tickets are separated by hall and then organized in alphabetical order. The CNAs who are assigned to dining come get the tickets. States the dining room opens at 12:00 p.m. and closes at 12:30 p.m. As residents enter the dining room and choose a seat a CNA goes over to take their order. The order is taken on the meal ticket and the ticket is given back to the kitchen to prepare the tray. Once the tray is prepared it is placed on a serving plate with the meal ticket, so the CNA knows who to deliver the tray to. After the dining room closes at 12:30 p.m. the left-over tickets are assumed to be for residents who eat on the hall, because they were not present in the dining room. States that CNAs go to the halls to ask the resident what they would like to eat. Dietary delivers trays to the halls and CNAs serve them. Stated he was not aware of R#54 not receiving her tray on Tuesday because he was absent. The Dietician in room at the time of the interview with the DM states that it was brought to her attention later in the day well after meal service. Both the DM and the Dietician confirmed that the kitchen was not made aware that R#54 did not receive her tray at the time it was identified.

Based on record review and staff interview the facility failed to thoroughly investigate a Grievance related to Misappropriation of Property for one Resident (R) (R#36). The sample size was 30 Residents. Findings include: Review of the Minimum Data Set Quarterly assessment dated [DATE] for R#36 revealed a (C) Basic Interview for Mental Status (BIMS) score of 14 indicating intact cognition. (E) No Behaviors noted. (G) Extensive one-person physical assistance with Activities of Daily Living (ADL). (I) Active [DIAGNOSES REDACTED]. (N) Receives an antidepressant 7/7 days a week. Review of the Care Plan for R#36 revealed no care plan in place that would indicate memory loss, dementia, or confusion. Review of the Concern Form dated 7/23/19 revealed at 4:56 p.m. R#36 told Licensed Practical Nurse (LPN) AA that she was missing $80.00. She stated she had 5 $20.00 bills and only has 1 remaining. She voiced that the incident would have to occurred between 3:00 p.m. to 7:00 a.m. 7/22/19 to 7/23/19. There was nothing written under Documentation of Facility Follow-Up. Under Resolution of Concern yes or no was not checked to confirm if the concern was resolved but, on the lines provided it stated, Social Worker to get back with family and discuss money as to missing/safe keeping but there is no signature or date on that portion of the form. During an interview on 8/27/19 at 12:33 p.m. with the Administrator/Grievance Coordinator, she stated that she recalls the Social Worker meeting with her last week and discussing R#36 concern about money she had in her room that was missing and that the Social Worker called the son of R#36 but he had not returned the call. Administrator stated when she receives a grievance, she reviews the grievance and based on the area of concern she will pass the grievance on for investigation. She stated, for example, if there was a dining concern, she would send the grievance to dietary and they would investigate and report their findings to the Resident then inform her of the outcome. Administrator stated regarding the concern with R#36 she would have gotten information from the resident as to how much money she had. She stated she would recommend to R#36 that she don't keep money on hand. She stated that she hopes an investigation related to a grievance would be completed within 24 hours. Administrator stated that the grievance outcome is usually given to the resident verbally. During an interview on 8/27/19 at 1:29 p.m. with LPN AA, she stated around the end of (MONTH) R#36 informed her that she had money missing and stated she wrote the concern on a Concern Form and went to the Social Worker with it. She stated the social worker told her to give it to the Administrator. LPN stated that the Administrator was on vacation, so she placed the grievance in her (the Administrators) box. She stated that there has been no follow up that she is aware of. During an interview on 8/27/19 at 2:00 p.m. with the Administrator she stated that R#36 initially filed the grievance regarding missing money with LPN AA, who was her nurse, and she went to the Director of Nursing (DON). She stated last week she and the Social Worker discussed it. She stated that the grievance filed by R#36 dated 7/23/19 was not investigated thoroughly and it was an oversight. Review of the Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention policy dated 11/2016 revealed the Administrator is responsible for the investigating, reporting, and coordinating of the investigation process of any alleged or suspected abuse regardless of the source of the concern.

Based on record review and staff and Resident interview the facility failed to promptly resolve a grievance for one Resident (R) (R#36). The sample size was 27 Residents. Findings include: Review of the Minimum Data Set Quarterly assessment dated [DATE] for R#36 revealed a (C) Basic Interview for Mental Status (BIMS) score of 14 indicating intact cognition. (E) No Behaviors noted. (G) Extensive one person physical assistance with Activities of Daily Living (ADL). (I) Active [DIAGNOSES REDACTED]. (N) Receives an antidepressant 7/7 days a week. Review of the Care Plan for R#36 revealed no care plan in place that would indicate memory loss, dementia, or confusion. During an interview on 8/26/19 at 12:22 p.m. with R#36 she stated a couple of months ago she had 5- twenty dollar bills in her possession. She stated she was keeping the money in her personal folder that she has her social security and debit card in. R#36 stated someone took four of the twenty dollar bills then a couple of days later they took the other twenty. She stated she reported this to the social worker to file a complaint but she hasn't heard anything about it since. R#36 stated it most likely happened during the night and it couldn't have been her roommate because she doesn't have her mind enough to do something like that. She stated that it happened either at night or while she was gone to an activity but she believes it was an employee. Review of the Concern Form dated 7/23/19 revealed at 4:56 p.m. R#36 told Licensed Practical Nurse (LPN) AA that she was missing $80.00. She stated she had 5 $20.00 bills and only has 1 remaining. She voiced that the incident would have to occurred between 3:00 p.m. to 7:00 a.m. 7/22/19 to 7/23/19. There was nothing written under Documentation of Facility Follow-Up. Under Resolution of Concern yes or no was not checked to confirm if the concern was resolved but on the lines provided it stated, Social Worker to get back with family and discuss money as to missing/safe keeping but there is no signature or date. During an interview on 8/27/19 at 12:06 p.m. with the Social Worker, she stated she wrote a grievance last week in regard to a complaint from R#36 that she had money missing. Social Worker stated that she called R#36's son to verify that the resident had the money here in the facility but stated he has not returned her call. She stated she took the grievance to the Administrator. During an interview on 8/27/19 at 12:33 p.m. with the Administrator/Grievance Coordinator, she stated that she recalls the Social Worker meeting with her last week and discussing R#36 concern about money she had in her room that was missing and that the Social Worker called the son but he had not returned the call. Administrator stated when she receives a grievance she reviews the grievance and based on the area of concern she will pass the grievance on for investigation. She stated, for example, if there was a dining concern she would send it to dietary and they would investigate and report their findings to the Resident then inform her of the outcome. Administrator stated in regard to the concern with R#36 she would have gotten information from the resident as to how much money she had. She stated she would recommend to R#36 that she don't keep money on hand. She stated that she hopes an investigation related to a grievance would be completed within 24 hours. Administrator stated that the grievance outcome is usually given to the resident verbally. During an interview on 8/27/19 at 1:29 p.m. with LPN AA, she stated that around the end of (MONTH) R#36 informed her that she had money missing and stated she wrote the concern on a Concern Form and went to the Social Worker with it. She stated the social worker told her to give it to the Administrator. LPN stated that the Administrator was on vacation so she placed the grievance in her (the Administrators) box. She stated that there has been no follow up with R#36 that she is aware of. She stated that Misappropriation of Property should be reported to the State within 24 hours. During an interview on 8/27/19 at 2:00 p.m. with the Administrator she stated that R#36 grievance regarding missing money was not reported to the State Agency. She stated the resident is confused at times and the amount of money she had changed and the son was called to validate the amount of money she had. She stated that Misappropriation of Property should be reported within 24 to 48 hours to the State Agency. Administrator stated she spoke with R#36 today and apologized for the delay in getting back with her regarding the grievance she filed in (MONTH) 2019 about her missing money. She stated during her conversation with R#36 she (R#36) told her the amount missing was one hundred and fifty dollars and that she had a debit card, credit card, and a social security card. Administrator stated she discussed a trust account with the facility and allowing the facility to keep her things locked up for her. She stated that the Business Office Assistant went in and R#36 signed the paper for the trust account with the one hundred dollars to replace what was missing. She stated when the Business Office Assistant ask her about putting the debit card, credit card, and social security card in the safe R#36 told her she didn't have any of those. Administrator stated that R#36 initially filed the grievance with her nurse and the nurse went to the Director of Nursing (DON) and then Social Worker gave the grievance to her (Administrator). She stated that the grievance by R#36 dated 7/23/19 was not investigated thoroughly and it was an oversight. During an interview with R#36 she stated that the Administrator came in and spoke with her about the grievance she filed in July. She stated she told the Administrator when she first reported it she said it was $80.00 dollars missing but then the $20.00 that was left was taken a couple of days later so she told the Administrator that she had a total of $100.00 taken from her. R#36 stated that she now has a personal funds account with the facility so she doesn't have to keep money with her but can ask for it when she needs something. During this time the R#36 pulled out her wallet and with her check book in it along with her social security card and insurance cards. She stated that her debit card is not in there and she believes her son must have it. R#36 stated that she will speak to the Business Office Assistant about putting her wallet in the safe until she needs it. Review of the Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention policy dated 11/2016 revealed, on page 8, that Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Procedures for Reporting, on page 9, revealed the Concern process is the company's grievance process. The administrator is the designated grievance officer for the center. During an interview on 8/27/19 at 2:00 p.m. with the Administrator she stated that the facility Grievance policy, Misappropriation of Property policy, and the Reporting policy is all covered under their Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention policy. Employee files related to the 7/22/19 staffing sheet for 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. shifts were requested and reviewed. All staff files were found to have clear criminal background checks and were vetted appropriately prior to hire. There was no employee warning notices written that would cause concern.

Based on observation, staff interview, and policy review titled Tray Service and Transport the facility failed to ensure food was served in a sanitary manner, desserts were served open to the residents receiving trays in their rooms. Facility failed to cover food that was distributed to one of two units. This deficient practice had the potential to affect 100 residents receiving an oral diet. Facility census was 102 residents. Findings include: On 6/4/18 at 1:00 p.m. when the staff started to deliver meals trays to residents on Magnolia wing, it was observed the dessert bowls containing strawberry and whipped topping uncovered. There were twelve (12) trays on the lunch cart. Several staff members distributed the trays to different rooms more than 15 feet from the lunch cart. On 6/6/18 at 6:04 p.m. there were eighteen (18) dinner trays on the cart on Magnolia wing and the trays had individual bowl some with marinated tomatoes, sliced peaches and green beans, and each of the bowls were not covered. Interview on 6/07/18 at 9:54 a.m. with the Dietary Manager revealed that the open food items should stay in a closed food cart and the cart should be pushed to the areas that the food is delivered. He stated he was aware of the items that were not covered but he also stated based on infection control all the items should be covered. Interview on 6/7/18 at 1:18 p.m. with the DON regarding food tray delivery, she said that she was not aware that the bowls on the closed cart on Magnolia wing were open. She stated the staff should be moving the cart next to the resident door and that would be equal to the dining room, but if the bowls are open then the kitchen should be covering the bowls for infection control purposes. Review of facility's Tray Service and Transport policy dated (MONTH) 2014 revealed guideline #6: Trays are transported in an enclosed cart whenever possible. Foods, beverages and eating utensils are covered with lids, plastic wrap or other suitable covering if tray are carried through patient care and public areas.

FACILITY Medication Storage and Labeling F761 Based on observation, interviews, and record review, the facility failed to follow the policy titled Storage of Medications and Biological's. Facility failed to ensure disposal of expired medications in one of seven medication carts, and one of three medication storage rooms. Sampled size 23. Findings Include: 6/5/18 9:40 a.m. Facility has seven medication carts, and three medication storage rooms, four medication carts and three medication storage rooms observed. Two bottles of expired medication were observed in one cart, and one expired medication in central medication storage room. 6/5/18 at 10:00 a.m. observation with Licensed Practical Nurse (LPN) BB found expired medications in cart number one of Magnolia Hall. One bottle of Moisturizing Lubricant 0.5% eye drops found in Magnolia hall medication cart one, opened on 1/9/17, expired on 9/9/18. One bottle of Geri-Lanta regular strength Antacid and [MEDICATION NAME] 355 milliliters expired on 11/17. Lot number . 6/5/18 at 10:30 a.m. observation with Registered Nurse (RN) AA found expired medications in one of three medication storage rooms. One bottle of Pink [MEDICATION NAME] regular strength 473 milliliters, lot number SBR001C, expired on 2/18. A record review of the facility's Storage of Medications and Biologicals /Medication Administration policy with an issue date of (MONTH) 20th, 2010 and a review/revision date of (MONTH) 1st, (YEAR) revealed facility will ensure medications and biologicals are stored, labeled, and disposed of properly by expiration date. An interview on 6/5/18 at 10:15 a.m. with the Licensed Practical Nurse (LPN) BB revealed staff are expected to date/label all medications when opened; and check for expired medications in medication carts on daily, prior to administering medication to all residents. An interview on 6/5/18 at 10:30 a.m. with Registered Nurse (RN) AA revealed staff are expected to date all medications when opened and check for expiration date. An interview on 6/5/18 at 11:18 p.m. with the Director of Nursing (DON) revealed staff are in-serviced on medication storage, medication administration, medication expiration date, DON initiates in-services to all Licensed Nurses. 6/6/18 at 12:30 p.m. An interview with(NAME)Bowlers (Pharmacy Consultant) states all License Nursing staff was in-service on medication administration, and medication expiration date. DONE.

Based on observation, review of records, staff interview, and Facility Infection Control Manual, the facility failed to ensure that contact precaution measures were maintained for two residents (#261 and #266) from a sample of 23 residents. The facility census was 102. Finding include: 1. 0n 6/6/18 at 8:30 a. m. housekeeper EE was observed going into the room of R#261 without applying personal protection equipment (PPE) and coming out of the room carrying trash in a plastic bag. The PPE cart was located outside of the room. Review of the Infection Control Manual: Chapter 2 - Practice Guidelines revealed that during contact precaution measures, personal protective equipment (PPE) such as gowns and masks are to be worn when clothing is anticipated to come in contact with residents, their environmental surfaces, or items in the room that are contaminated. The PPE is stored outside of the resident's room and is donned prior to providing care. The PPE should be removed before leaving the resident's room. Transmission-based precautions are discontinued when the infection is resolved or ruled out. Infections are resolved when the patient is free of clinical symptoms of the infection for 48 hours or meet criteria that is specified in the Type and Duration table laid out in the manual. The duration specified for [MEDICAL CONDITIONS] in this table was listed as the duration of the illness. For residents on transmission-based precautions, a sign saying to stop and see nurse for instruction is posted on a resident's room door. 2. Review of clinical records revealed resident (R) #266 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Interview on 6/4/18 at 2:04 p.m. with Registered Nurse (RN) DD revealed R#266 remained on contact precautions for [MEDICAL CONDITION]. Observation on 6/4/18 at 2:44 p.m. revealed Housekeeper CC cleaning the room of R#266. Housekeeper CC was not wearing PPE. A sign on the door of the room warned, Attention Visitors, please report to nurses' station before entering this room Interview on 6/4/18 at 2:50 p.m. with Housekeeper CC revealed she was not wearing PPE because she believed the resident was no longer on contact precaution because the resident was out of the room. The resident was given permission to leave her room and visit with her daughter in the courtyard. Interview on 6/4/18 at 2:55 p.m. with RN DD revealed the resident had not had any loose stools for a while and the Nurse Practitioner (NP) had given the resident permission to leave the room and visit with her family member outside in the courtyard. However, the NP still needed to check with Director of Nursing (DON) to see if the resident was eligible to be taken off of contact precautions. Until the NP give permission, contact precaution measures continued for the resident. Observation on 6/5/18 at 9:07 a.m. revealed the Attention Visitors, please report to nurses' station before entering this room sign remained in place on the resident's door. Interview on 6/7/18 at 10:05 a.m. with the DON/Infection Control Program Manager, if a resident is suspected of a having a transmissible infection such as [MEDICAL CONDITION]; staff will place that resident on contact precautions - the resident is placed in a separate room, the physician is notified, and any necessary laboratory tests are completed. As soon as a resident is placed on contact precautions for one of these transmissible infections, a sign requesting visitors to see the nurse is placed outside door, and a cart containing PPE is placed outside the room. The information regarding the resident's precaution measures is placed on 24-hour report and also passed on to the nurses on the other shifts during nurses' report. The incoming Certified Nursing Assistants (CNAs) receive report from their nurse. They are educated about the type of infection and the types of precautions needed. All department managers receive information about residents that are placed on contact precautions and they are then responsible for disseminating this information to their staff. Staff receive mandatory annual training on transmissible infections, and information such as signs/symptoms, use of PPE, etc. are also given periodically throughout the year. The criteria for removing a resident from contact precaution is dependent on the transmissible infection. For [MEDICAL CONDITION], the resident must be without loose stools for at least 48 hours. Then the physician must give an order for [REDACTED].>Interview on 6/7/18 at 11:37 a.m. with the housekeeping supervisor revealed that the housekeeping supervisor passes along information about which residents are on contact precautions to the housekeeping staff, or they are expected to check with the nurse if they see the do not enter note on the door. Housekeeping staff are expected to use PPE such as gowns and gloves every time they enter the room belong to a resident on contact precautions and they are to discard this equipment before they exit the room. When the housekeeping staff is notified that the resident is no longer on precautions, they are still expected to don PPE to enter the room to perform a final deep clean. This includes cleaning the bed, putting on new linens; basically, everything that the resident could have contaminated is cleaned.

Based on observations, interviews, and record review, facility failed to follow the policy titled Storage of Medications and Biological's. They failed to ensure disposal of expired medications in one of seven medication carts. Sampled size 23. Findings Include: On 6/5/18 at 9:40 a.m. four out of seven medication carts were observed, two expired medications found in one of seven carts. On 6/5/18 at 10:00 a.m. during an observation with Licensed Practical Nurse (LPN) BB expired medications were found in cart number one of the Magnolia Hall used for one resident eight various times in (MONTH) (YEAR). One bottle of Geri-Lanta regular strength Antacid and [MEDICATION NAME] 355 milliliters expired on 11/17. Lot number . A record review of the facility's Storage of Medications and Biologicals /Medication Administration policy with an issue date of (MONTH) 20th, 2010 and a review/revision date of (MONTH) 1, (YEAR) revealed facility will ensure medications and biologicals are stored, labeled, and disposed of properly by expiration date. An interview on 6/5/18 at 10:15 a.m. with the Licensed Practical Nurse (LPN) BB revealed staff are expected to date and label all medications when opened and check for expired medications in the medication carts daily prior to administering medication to all residents. Order was to administer Geri-Lanta 30 milliliters by mouth as needed for indigestion. Geri-Lanta expired 11/17, LPN BB administered the medication to one resident eight various times in (MONTH) (YEAR). LPN BB stated she did not check for expiration date of medications. An interview on 6/5/18 at 10:30 a.m. with Registered Nurse (RN) AA revealed staff are expected to date all medications when opened and check for expiration date. An interview on 6/5/18 at 11:18 p.m. with the Director of Nursing (DON) revealed staff are in-serviced on medication storage, medication administration, medication expiration date, DON initiates in-services to all Licensed Nurses. On 6/6/18 at 12:30 p.m. An interview with the Pharmacy Consultant states all License Nursing staff were in-service on medication administration, and medication expiration date.

Based on clinical record review and staff interviews, the facility failed to ensure the revision of care plans for non-pharmacological interventions occurred for three of six residents (R#49, R#71, and R#159) reviewed. Findings include: 1. Per the electronic clinical record review, R#159 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A medical record Care Plan most recently revised on 1/26/16 identified R#159 was at risk for adverse effects related to the use of an anxiolytic ([MEDICATION NAME]). There was no mention to offer non-pharmacological interventions prior to the use of the as needed (PRN) anxiolytic. Another most recently revised Care Plan on 11/27/16 identified R#159 enjoyed activities and noted the resident had cognitive and communication impairments related to dementia. Under the interventions it was documented to offer R#159 1:1 visits, participation in group activities of interest, preferred food items, television in bed, and family visits when available. Again, this section of the plan of care in the medical record failed to identify if these activities were attempts to reduce R#159's anxiety prior to the administration of an anxiolytic medication. 2. Per the electronic clinical record review, R#49 was admitted to the facility on [DATE]. A medical record review of the Care Plan dated as revised on 6/8/17 identified R#49 was at risk for adverse effects related to the use of an antipsychotic ([MEDICATION NAME]). There was no mention to offer non-pharmacological interventions prior to the use of the as needed (PRN) antipsychotic. Another reveiw of the Care Plan dated as revised on 9/6/17, identified R#49 enjoyed activities and noted the resident had cognitive and communication impairments related to dementia. Under the interventions it was documented to offer R#49 .redirection and diversion as needed. Again, this section of the care plan failed to identify if the redirection and diversion, were attempts to reduce R#49's anxiety prior to the administration of an antipsychotic medication. 3. Per the electronic clinical record review, R#71 was admitted to the facility on [DATE]. A medical record review of the Care Plan dated as initiated 3/23/17, identified R#71was at risk for adverse effects related to use of a PRN antianxiety medication. There was no mention to offer non-pharmacological interventions prior to the use of the PRN antianxiety. In another Care Plan dated as revised 6/16/17, identified R#71 was not interested in attending activities. The intervention noted was to .redirect the resident as needed due to cognitive impairment. Again, there was no mention if this redirection was to be done prior to the administration of the PRN antianxiety. An interview was conducted with the Minimum Data Set (MDS) Coordinator on 9/20/17 at 11:23 a.m., The MDS Coordinator stated she completes the assessments and revises the care plans. She stated she typically updates and any changes on a resident would be discussed in the morning meetings. The MDS Coordinator further stated the floor nurses have the capability to update resident care plans as well. The facility policy entitled, INTERDISCIPLINARY CARE PLANNING dated 11/16 noted, The patient's care plan is a communication tool that guides members of the interdisciplinary healthcare team in how to meet each individual patient's needs. It also identifies the types and methods .Once the care plan is developed, the staff must implement the interventions identified in the care plan. These may include, but is not limited to: administering treatments and medications .As the care plan is implemented, members of the interdisciplinary team need to evaluate whether the interventions are effective or whether the care plan needs to be revised .

Based on clinical record review and staff interviews, the facility failed to ensure three residents (R#49, R#71, and R#159) of a total of six sampled residents remained free of potentially unnecessary drugs. Specifically, resident #49 was receiving a PRN (as needed) antipsychotic medication and resident #71 and #159 were receiving PRN antianxiolytic medications without attempts to provide non-pharmacological interventions prior to the use of these drugs. Findings include: 1. Per the electronic clinical record review, R#159 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A medical record physician's orders [REDACTED]. The medical record quarterly Minimum Data Set (MDS) assessment dated [DATE], (section C) Cognition identified R#159 had a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated the resident was severely cognitively impaired. The medical record [MEDICAL CONDITION] Medication Use assessment dated [DATE], documented the following effective non-pharmacological interventions being used for R#159: .Music/art/drama therapy, exercise, recreation and activities, relaxation techniques, counseling, toileting program, pain management, sleep hygiene, redirection, and behavioral therapy. The medical record Medication Administration Record [REDACTED]. There was no documentation, such as Nursing Notes or on the MAR, to show R#159 was offered non-pharmacological interventions prior to the administration of the PRN anti-anxiolytic. The MAR for 9/2017 identified R#159 was administered doses of PRN [MEDICATION NAME] on 9/1/17, 9/13/17 (x2), and 9/16/17. There was no documentation, such as nursing notes or on the MAR, to show R#159 was offered non-pharmacological interventions prior to the administration of the PRN anti-anxiolytic. An interview was conducted with Licensed Practical Nurse (LPN) CC on 9/19/17 at 4:15 p.m., She stated staff would try to do non-pharmacological interventions prior to given [MEDICATION NAME] or any other prn psych meds to residents, like diverting their attention, but she was unable to recall any specific interventions for R#159, and she further stated interventions that were tried were not documented anywhere. 2. Per the electronic clinical record review, R#49 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A medical record review of the physician's orders [REDACTED]. The medical record quarterly Minimum Data Set (MDS) assessment dated [DATE], (section C) Cognition identified R#49 had a BIMS score of three out of 15 which indicated the resident was severely cognitively impaired. The medical record MAR for 1/17 identified R#49 was administered a dose of PRN [MEDICATION NAME] on 1/13/17. There was no documentation, such as nursing notes or on the MAR, to show R#49 was offered non-pharmacological interventions prior to the administration of the PRN antipsychotic. The MAR for 5/17 identified R#49 was administered a dose of PRN [MEDICATION NAME] on 5/24/17. There was no documentation, such as nursing notes or on the MAR, to show R#49 was offered non-pharmacological interventions prior to the administration of the PRN antipsychotic. The MAR for 7/17 identified R#49 was administered a dose of PRN [MEDICATION NAME] on 7/8/17. There was no documentation, such as nursing notes or on the MAR, to show R#49 was offered non-pharmacological interventions prior to the administration of the PRN antipsychotic. The MAR for 9/17 identified R#49 was administered a dose of PRN [MEDICATION NAME] on 9/2/17. There was no documentation, such as nursing notes or on the MAR, to show R#49 was offered non-pharmacological interventions prior to the administration of the PRN antipsychotic. 3. Per the electronic clinical record review, R#71 was admitted to the facility on [DATE]. A review of the medical record physician's orders [REDACTED]. The medical record quarterly MDS assessment dated [DATE], (section C) Cognition identified R#71 had a BIMS score of 3 out of 15 which indicated the resident was severely cognitively impaired. The MAR for 7/17 identified R#71 was administered a dose of PRN [MEDICATION NAME] on 7/3/17, 7/4/17, 7/7/17, 7/10/17, 7/13/17, 7/14/17, 7/16/17, 7/18/17, and 7/19/17. There was no documentation, such as nursing notes or on the MAR, to show R#71 was offered non-pharmacological interventions prior to the administration of the PRN antianxiety. An interview was conducted with Licensed Practical Nurse (LPN) AA on 9/9/17 at 1:20 p.m., LPN AA stated before she gives a PRN antipsychotic medication she attempts other interventions, such as one to one visits or to offer the resident something to drink. An interview was conducted with LPN BB on 9/9/17 at 1:21 p.m., LPN BB stated she attempts to redirect a resident, offers coffee prior to the administration of an antianxiety. LPN BB further stated she will document this information in the nursing notes. The Director of Nursing (DON) was interviewed on 9/20/17 at 9:01 a.m. The DON stated clinical staff should evaluate a resident and then provide non-pharmacological interventions. The DON continued stating the nursing staff do a nice job with interventions, but the staff need to document their efforts in the clinical record. The DON further stated she had reached out to her corporate nurse to see if the facility had policies regarding unnecessary medications and stated if the facility does not then they should follow the guidelines under F329. The DON did not provide facility policies by the end of the survey.