Every finding on record at Freedom Plaza Care Center

Based on observation, interviews, clinical record review and review of facility policy and procedures, the facility failed to ensure one out of two sampled residents (Resident #26) received meal consistent with the prescribed diet order. The deficient practice resulted in the resident consuming food that was not consistent with the prescribed diet and placed the resident at risk for complications associated with receiving food that did not meet the resident's individual dietary needs.Findings Include:Resident #26 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of cardia, aftercare following surgery for neoplasm, encounter for surgical aftercare following surgery on the digestive system, encounter for attention to other artificial openings of digestive tract, adult hypertrophic pyloric stenosis, acquired absence of other specified parts of digestive tract, and mild cognitive impairment of uncertain or unknown etiology.The Minimum Data Set (MDS) assessment Section C - Cognition dated November 21, 2023 revealed that the resident had a Brief Interview for Mental Status (BIMS) of 08, indicating that the resident had moderately impaired cognition.The resident's hospital visit summary, with an entered date of November 14, 2023, revealed that the resident was on a full liquid diet only until seen by the physician at the first post-surgical appointment. Review of the patient discharge instructions, dated [DATE], revealed in the follow up care information that the surgical follow up appointment was scheduled for November 21, 2023.The order summary dated November 15, 2023 revealed an order for a Liquidized diet, Liquidized texture, Thin consistency, with no more that 4 ounces every hour.A nursing progress note dated November 15, 2023 at 1:17 p.m. revealed that the resident was to receive a full liquid diet.Review of Summary for Providers Change in Condition note dated November 15, 2023 at 2:00 p.m. revealed that the resident was on a full liquid diet and was only allowed 4 Oz every 1 hour. The note later revealed that the resident was given a regular diet inadvertently and he ate all the mashed potato and a big portion of the pot roast. After eating, the resident had increased coughing and also had a large amount of emesis x1 of undigested food.An interview was conducted on August 27, 2026 at 1:06 p.m. with the Director of Quality Management (Staff #33). Staff #33 stated that the risk of giving a resident who is on tube feed solid food would be that they could choke, aspirate, or get pneumonia and that dietary would not be able to give that person food. Further, Staff #33 stated that eating the provided meal had caused Resident #26 to have a negative outcome, which was dysphasia, and that it did not meet facility expectation.An interview was conducted on August 27, 2026 at 11:26 a.m. with the Director of Nursing (DON/Staff#48). Staff #48 stated that the facility expectation is that whatever the tube feed directions are, they are followed per doctor's orders. Additionally, Staff #48 stated that a risk of dietary or tube feed orders not being followed is that there could be a choking hazard if the resident is given a solid and does not have the ability to swallow correctly.Review of the facility policy titled, FPCC Enteral Nutrition, with a revision date of August 15, 2023 stated that adequate nutritional support through enteral nutrition is provided to residents as ordered.Review of the facility policy titled International Dysphagia Diet Standardization Initiative (IDDSI) revised September 26, 2025 states One of the following Texture-Modified Diets are prepared and served as prescribed by the physician or appropriate personnel at the community when a resident has difficulty chewing and/or swallowing. The resident's acceptance and tolerance of the diet determines the extent of texture modification. Meals need to be modified to suit individual resident preferences.

Based on observation, interviews, clinical record review and review of facility policy and procedures, the facility failed to ensure pureed foods were prepared in accordance with established recipes and preparation procedures to achieve the prescribed consistency. This deficient practice had the potential to affect residents requiring therapeutic and/or texture-modified diets by increasing the risk of receiving food inconsistent with their prescribed diet and increasing the risk of choking and/or aspiration.Findings include: An interview was conducted with the complainant on August 26, 2026, at 9:03 a.m. The complainant stated the facility was not following the approved menus, designated scoop sizes, or recipes. The complainant further stated the facility was not serving sufficient amounts of food to residents. The complainant stated that kitchen staff were combining assorted leftover foods and pureeing them together for residents requiring pureed diets. The complainant further stated that kitchen staff prepared pureed foods in large quantities and either froze the food or stored it in the refrigerator for later use. According to the complainant, kitchen staff were not following the recipes for pureed foods and instead were adding varying amounts of thickener and/or fluids without following the specified measurements. The complainant stated that, at times, the amount of thickener added was greater than the amount of food, resulting in an inappropriate consistency and insufficient food volume. An observation was conducted on August 27, 2026, at 10:56 a.m., of the preparation of pureed chicken breast. The preparation was conducted by the Sous Chef (Staff #36). Staff #36 stated she was preparing two servings of pureed chicken breast. Staff #36 stated the remainder of the meal, consisting of zucchini and rice, had been pre-made by US Foods. Staff #36 placed two cooked chicken breasts into a blender and added an unmeasured ladle of chicken broth. Staff #36 blended the chicken and broth and assessed the consistency. Staff #36 stated the mixture contained too much liquid and added an unmeasured ladle of thickener. Staff #36 blended the mixture and reassessed the consistency. Staff #36 stated the mixture remained too thin and obtained a set of measuring spoons. Staff #36 used a measured tablespoon to add two additional tablespoons of thickener and blended the mixture. Staff #36 then stated the pureed chicken mixture was ready to be served. When asked how she ensured the pureed food was prepared to the appropriate consistency for residents, Staff #36 stated she had prepared pureed foods for a long time. Staff #36 did not taste the flavor of the pureed food to ensure the same desirable flavor as the menu item. The Dietary Manager (Staff #42) and Registered Dietitian (Staff #12) joined the observation. Staff #36 added two additional tablespoons of thickener to the mixture and blended the mixture again. The resulting product was observed to have a paste-like texture with clumps of an unidentified substance when placed on a spoon for observation by Staff #36 and Staff #42. Staff #42 and Staff #12 advised Staff #36 that the preparation should be restarted. Staff #36 did not have the recipe for pureed grilled chicken breast available during the preparation and did not follow the facility's established recipe. The recipe provided by Staff #12 specified that two servings required 6 ounces of grilled chicken breast, 6 tablespoons plus 1 teaspoon of water, and 1/2 teaspoon of chicken base. The recipe further directed that, if thinning was needed, liquid was to be gradually added to achieve a smooth, pudding-soft, or soft-mashed-potato consistency. If thickening was needed, a commercial or natural food thickener was to be gradually added to achieve a smooth, pudding-soft, or soft-mashed-potato consistency. The observed preparation included multiple unmeasured additions of chicken broth and thickener, followed by additional measured additions of thickener, and resulted in a paste-like product with clumps. The preparation was not completed according to the facility's established recipe or the recipe's specified method for achieving the required consistency. An interview was conducted on August 27, 2026, at 2:46 p.m. with the Dietary Manager (Staff #42). Staff #42 stated that many of the facility's pureed diets were pre-packaged by the facility's food distributor, US Foods. Staff #42 stated that he would like the kitchen to resume preparing its own texture-modified diets. He further stated that when the menu calls for a protein, the protein is prepared in the facility's kitchen. Staff #42 stated that facility recipes should be followed when preparing meals for residents. When asked about the risks associated with not following recipes when preparing pureed diets, Staff #42 stated the risk was extremely dangerous because a resident could choke. Staff #42 was present during the observation of Staff #36 preparing pureed chicken breast on August 27, 2026. Staff #42 stated he believed Staff #36 had become flustered during the preparation. Staff #42 further stated he was confident that if the pureed chicken had been sent to the dining room, the platter and server would have recognized that the consistency was incorrect, would not have served the food, and would have returned it to the kitchen. Review of the facility policy titled, FPCC Enteral Nutrition, with a revision date of August 15, 2023 stated that adequate nutritional support through enteral nutrition is provided to residents as ordered. Review of the facility policy titled International Dysphagia Diet Standardization Initiative (IDDSI) revised September 26, 2025 states One of the following Texture-Modified Diets are prepared and served as prescribed by the physician or appropriate personnel at the community when a resident has difficulty chewing and/or swallowing. The resident's acceptance and tolerance of the diet determines the extent of texture modification. Meals need to be modified to suit individual resident preferences. The following texture-modified diets are based on the International Dysphagia Diet Standardization Initiative (IDDSI) framework: Easy to Chew (EC7) Soft & Bite-Sized (5B6) Minced & Moist (MMS) Pureed (PU4)Pureed Food PreparationGuideline: Pureed foods will be prepared using standardized recipes to ensure quality, flavor, palatability, and maximum nutritive value.2. Standardized recipes will be used to prepare all pureed foods. The recipes will be adjusted according to the number of pureed diets needed, indicating seasoning and technique to ensure the highest quality.4. Food thickener will be used only in accordance with a specific recipe or product instructions. Measure and add commercial thickener, stabilizer, or shaping/enhancing product as directed in the recipe and process until blended.6. Pureed foods will be the consistency of applesauce or smooth, mashed potatoes. A food processor is preferred; however, a blender may be used to make pureed foods.7. The flavor of pureed foods will be assessed. The pureed food should have the same desirable flavor as the menu item.

Based on observations, staff interviews, facility documentation, and review of policies and procedures, the facility failed to ensure that two staff members (#22 and #73) completed COVID-19 screening prior to or at the beginning of their shift, and the facility failed to ensure that staff performed appropriate hand hygiene during meal service. The census was 39. The deficient practice could result in the spread of infection. Findings include: Regarding staff COVID-19 screening: -Review of the time sheet for staff #22, a server, from October 25, 2021 through November 7, 2021 revealed that the staff member worked October 25, 26, 27, and 31, 2021; and November 1, 2, 3, 4, and 7, 2021. Review of the COVID-19 screening forms provided by the facility revealed COVID-19 screening by the staff member on October 27, 2021. On request, the facility was able to provide COVID-19 screening forms for staff #22 for November 2 and 7, 2021. However, there was no evidence that the staff member was screened for COVID-19 prior to or at the beginning of the shift worked on October 25, 26, or 31, 2021; or on November 1, 3, or 4, 2021. -Review of the time sheet for staff #73, housekeeper, from October 25, 2021 through November 7, 2021 revealed that the staff member worked October 25, 26, 29 and 30, 2021; and November 5, 6, and 7, 2021. Review of the COVID-19 screening forms provided by the facility revealed COVID-19 screening by the staff member on October 25, 26, and 30, 2021. On request, the facility was able to provide COVID-19 screening forms for staff #73 for November 5-7, 2021. However, there was no evidence that the staff member was screened for COVID-19 prior to or at the beginning of the shift worked on October 29, 2021. An interview was conducted on November 10, 2021 at 10:31 a.m. with a Certified Nursing Assistant (CNA/staff #9). She stated that when she reports for work she reads the screening form, check's off the questions and signs the form which means she understood the information. She stated that she checks her temperature, goes to the nurse station, tells the nurse her temperature, and gives the nurse the screening form. The CNA stated that if she had an elevated temperature and/or signs or symptoms of COVID-19, she must not report to work and immediately leave the facility and would need to get tested for COVID-19. An interview was conducted on November 10, 2021 at 11:04 a.m. with a Registered Nurse (RN/staff #35). She stated that staff fill out a screening form and get their temperature checked before entering the facility for work. The RN stated that the form is given to the night supervisor for review and if the staff member has an elevated temperature or any signs/symptoms indicated on the form, they would be sent home. An interview was conducted on November 12, 2021 at 8:26 a.m. with a staff #73, who stated that before working, she would be screened for COVID-19 at the facility entrance. She stated that if her temperature was elevated she would be sent home and would have to get a COVID-19 test. An interview was conducted on November 12, 2021 at 2:51 p.m. with the Director of Nursing (DON/staff #86). She stated that all staff had to enter for work at the main/emergency entrance and had to be screened for COVID-19 and get their temperature taken before they enter further into the building. She stated that she was unable to provide evidence of screening for staff #22 and staff #73 for all of the days requested. She stated that staff did not meet her expectation and should not be working in the building if they were not first screened. The DON stated that the risk of not being screened for COVID-19, is that staff may have an elevated temperature and/or signs and symptoms of infection and would be working with/around residents and staff. Review of the facility policy for Prevention and Control of COVID-19 dated July 17, 2020 revealed: The facility follows current Centers for Disease Control and Prevention (CDC) guidelines and recommendations for the prevention and control of COVID-19. Under Healthcare Workers, upon entering the facility, included: The Director of Clinical Services/or Nursing designee will perform taking temperature, observe handwashing, and will conduct COVID-19: Screening checklist form. Review of the facility policy on Long Term Care facility testing requirements for staff and residents dated September 13, 2021 included: It is the goal to prevent COVID-19 from entering the facility, detecting cases quickly and stopping transmission. Swift identification of confirmed COVID-19 cases allows the facility to take immediate action to remove exposure risks to the facility staff and residents. Under Testing Frequency: The facility will continue to screen all staff, residents, and other visitors. Regardless of the frequency of testing being performed or the facility's COVID-19 status, the facility will continue to screen staff each shift with temperature taking daily on all persons entering the facility. Review of the facility COVID-19 screening checklist for visitors and staff revealed: All individuals (staff, other health care workers, family, visitors, government officials etc.) entering this building must be asked the following questions and have their temperature taken. The form included 6 question: 1. Have you washed your hands or used alcohol-based hand rub (ABHR) on entry? 2. Have you have any of the following respirator symptoms? (list provided) If yes to any, restrict them from entering the building. 3A. Check temperature and enter results/fever present? 3B. For staff and health care providers/Have you worked in any facilities or locations with recognized COVID-19 cases? If yes and have worked with a person(s) with confirmed COVID-19, required to wear PPE including mask, gloves, gown before any contact with residents. 4. You are allowed entry to this building and remember to wash your hands or use ABHR throughout your time in the building, and do not shake hands, touch, or hug individuals during your visit. 5. Have you traveled internationally or to any other areas identified by CDC as hot spots/cluster with in the last 14 days? and 6. Have you been around or exposed to anyone else or within your family or community with signs or symptoms of respiratory illness or provided care for anyone with respiratory illness? If you answered yes to question 5 and/or 6, see the Director of Nursing for further instruction. Observations conducted of the dining room for hall 400: -On November 8, 2021 at 12:25 p.m., the Licensed Practical Nurse (LPN/staff #43) from hall 400 brought a resident into the dining room, placed the resident at the table and locked the wheelchair. Staff #43 then went to assist another resident. The LPN touched the resident on the shoulder, sat down at that residents table, touched the table cloth and one resident's silverware. The LPN was not observed to perform hand hygiene. -On November 9, 2021 at 1:15 p.m. during the lunch service, a Certified Nursing Assistant (CNA/staff #71) was observed to move from table to table delivering plates and beverages in the dining room. The CNA assisted residents in cutting food, touched silverware for several residents including two residents who subsequently used the same utensils. The CNA was not observed to perform hand hygiene. Following these observations, staff #71 left the dining room to deliver room trays. Staff #71 was observed to deliver a room meal tray from the dining room to a resident on hall 400, returned to the dining room, retrieved another room meal tray from the dining room and leave the dining room again without performing hand hygiene. -On November 10, 2021 at 7:52 a.m., staff #71 was observed to stir oatmeal for a resident and immediately afterwards stir the oatmeal served to another resident. Each time staff #71 used the spoon belonging to the resident which was then used by the resident. There was no hand hygiene observed. Staff #71 also handed both residents their coffee cups immediately afterwards with no observed hand hygiene. At 7:54 a.m., staff #71 got up from the table where she was assisting the two residents, turned on the light switch across the room, immediately came back to the residents' table and touched both residents' coffee cups without having performed any hand hygiene. At 8:26 a.m., staff #71 was observed to cut food for both residents using the individual resident silverware. The residents then used their respective silverware. No hand hygiene was observed before or between cutting the two residents' food. -On November 10, 2021 at 8:05 a.m., the Registered Nurse (RN/staff #35) from hall 400 was assisting a resident with eating, the RN got up, left the table and went to assist another resident. Staff #35 touched this resident on the back while talking and then returned to further assist the first resident with eating. Staff #35 touched the silverware of the first resident and assisted the resident in wiping her mouth. The RN was not observed to perform hand hygiene during these interactions. On November 10, 2021 at 9:02 a.m., an interview was conducted with the director of nursing (DON/ staff #86) and the administrator (staff #31) The DON stated that the expectation of their staff was to perform hand hygiene as appropriate. The DON stated that there is alcohol-based gel in the dining room for their use and staff are expected to use it between residents, even when cutting food for different residents at the same table. She stated that the staff have been taught often about appropriate hand hygiene, as there are many in-services on the topic. The administrator stated that anytime a staff members hands are contaminated the staff is to perform hand hygiene. On November 10, 2021 at 9:20 a.m., an interview was conducted with the CNA (staff #71), who stated that the process for serving food and helping in the dining room included using hand sanitizer. She stated that there is no sink to wash their hands within that area. The CNA stated that the process for serving food is that staff use hand sanitizer and then pick up the tray and take it to a resident's room. She stated that if a tray is brought to a resident room, staff should perform hand hygiene when coming out of the room. Staff #71 stated that there is also hand sanitizer at the entry to the dining room that can be used if the sanitizer outside the resident's room is not used. Staff #71 went on to state that if the resident eats in the dining room, after hand sanitizing, staff would bring a plate from the kitchen area and place it in front of resident in on the table, staff would then cut up the resident's food if needed. She stated that hand sanitizing between residents was supposed to be done. She stated hand sanitizer is on the wall in a dispenser and she has some in her pocket. The CNA stated that hand sanitizer is used if they touch a resident or mask. Staff #71 stated that she thought she used the hand sanitizer outside the dining after the room trays were delivered at lunch on November 9, 2021 but really did not clearly remember. Staff #71 stated that she had not been using hand sanitizing between residents regularly as was her normal process. In regards to the last two lunches and the breakfast today, she stated that she knew that she did not perform hand hygiene as taught, that she had forgotten to hand sanitize the last few meal services between assisting different residents and after turning on the light switch that morning. She stated that forgetting to perform hand hygiene could result in passing germs between residents and her germs to the residents as well. Review of the facility policy titled Handwashing/Hand Hygiene (April 4, 2018) revealed that all associates shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other associates, residents and visitors. The policy further stated that use of an alcohol-based hand rub containing at least 62% alcohol or soap should be used before and after direct contact with residents, before and after handling food, and before and after assisting a resident with meals. Review of the facility policy prevention and control of COVID-19 (revised July 2020) revealed that standard precautions are used during the care of any resident. The standard precautions included performing hand hygiene. Hand hygiene is performed by washing with soap and water or using alcohol-based hand rubs. Supplies for hand hygiene are to be available throughout the building.

Based on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure a scheduled blood pressure medication was consistently administered to one resident (#5). The sample size was 5. The deficient practice could result in medications not being administered to residents. Findings include: Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a medication administration observation conducted on November 10, 2021 at 8:53 a.m. with a Registered Nurse (RN/staff #35), the RN stated that she had not received [MEDICATION(S)] (antihypertensive) ER (extended release) tablet from the pharmacy for resident #5. At 8:56 a.m., staff #35 asked a Licensed Practical Nurse (LPN/staff #3) to look for the medication in the Omnicell Pyxis. On November 10, 2021 around 9:12 a.m., staff #3 informed staff #35 that the Omnicell pyxis did not carry the medication [MEDICATION(S)] ER and he informed the physician. He stated the physician gave an order to hold the medication and give the medication once it arrives from the pharmacy. He stated he called the pharmacy to send the medication STAT (immediately). He informed staff #35 that he would add the orders to hold the medication and give the medication once it arrived. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the November 2021 MAR (Medication Administration Record) revealed [MEDICATION(S)] ER 60 mg was not given on November 2, 6, 7, 8 and 10, 2021. The MAR and was marked 9 for November 2, 6, 7, and 8, 2021 which meant other/see nurses notes and marked 5 which meant hold/see nurses notes for November 10, 2021. The MAR revealed the medication was on hold on November 11, 2021. The MAR also revealed the medication was administered on November 1, 3, 4, 5, and 9, 2021. Review of the corresponding e-MAR (electronic MAR) notes revealed the following; - November 2, 2021 stated waiting for delivery - November 6, 2021 stated out of stock, reordering - November 7, 2021 stated awaiting for delivery - November 8, 2021 stated Still not available. Will follow up with pharmacy - November 10, 2021 stated hold, see progress note. A review of the resident blood pressure (BP) for November 2021 revealed the following on the days the resident was not administered [MEDICATION(S)]: November 2, 2021 at 9:08 a.m. BP was 164/62 November 6, 2021 at 6:21 a.m. BP was 140/74 November 7, 2021 at 6:55 a.m. BP was 150/60 November 8, 2021 at 7:03 a.m. BP was 132/68 November 10, 2021 at 7:07 a.m. BP was 150/78 November 11, 2021 at 7:09 a.m. BP was 164/60 The progress notes were reviewed and did not reveal the medication was given on November 2, 6, 7 and 8, 2021. The progress note dated November 10, 2021 stated resident's #5 medication [MEDICATION(S)] was not available, the physician was notified and gave an order to hold the medication until available. Review of the medication delivery shipment summary sheet from the pharmacy for October 2021 and November 2021 for [MEDICATION(S)] ER 60 mg for resident #5 revealed the facility received thirty tablets of [MEDICATION(S)] ER 60 mg for resident #5 on October 22, 2021. The summary also included the facility received seven tablets of [MEDICATION(S)] ER 60 mg for resident #5 on November 10, 2021. Further review of the progress notes did not reveal that the medication was given on November 10 and 11 after the medication became available. An interview was conducted with staff #35 on November 10, 2021 at 2:00 p.m. The RN stated that she believed she gave resident #5 last tablet of [MEDICATION(S)] ER the day before and forgot to reorder it from the pharmacy. She stated she remembered there was one last tablet left the day before. The RN stated when a medication is not available, the process is to check the Omnicell Pyxis, call pharmacy and request the medication STAT, and notify the physician. The RN stated that she was unaware the medication was not available and not given on November 2, 6, 7, and 8, 2021. Staff #35 stated that was a long time without the medication and that the medication should have been given. In an interview conducted with an LPN (staff #43) on November 10, 2021 at 2:06 p.m., the LPN stated when a medication is not available, the process is to click on number '9' in the MAR, enter a note in the MAR that the medication was not given as the medication was not available, that pharmacy was called and the physician was notified. She stated pharmacy should be called to find out when the medication will be delivered. She stated if the delivery was late then the physician should be notified and the physician direction should be followed. The LPN stated sometimes they have to request the medication STAT so that the medication is delivered within 2 hours. She stated if the medication did not arrive during her shift then she would pass it on to the oncoming shift. The LPN stated she remembered that the medication was unavailable on November 6, 7 and 8, 2021. She stated she notified the physician on November 6, 2021 and called the pharmacy. She stated the pharmacy told her they needed to track down the order and the pharmacy asked to be called back. Staff #43 stated that she did not get a chance to call the pharmacy back and the physician stated to make sure the resident received the medication. She stated she had passed it on to the evening shift and the evening shift had stated they would pass it on to the morning shift so that the regular nurse on the unit could take care of it. The LPN stated she did not usually work on the unit and she waited for the regular nurse on the unit to communicate with the pharmacy. An interview was conducted with another LPN (staff #3) on November 12, 2021 at 10:44 a.m., who stated that he did wound care and assisted the nurses on the unit. He stated the pyxis did not have [MEDICATION(S)] ER so he spoke with the physician and requested the medication STAT from the pharmacy. He stated depending on the pharmacy the medication should be available within 4 hours when the medication is ordered STAT. He stated he assumed the nurses gave the medication once the medication was available. He stated when a medication is not available, it is important the resident receive the medication even if the facility has to pay for the medication. The LPN stated the medication should have been given on November 10 and 11, 2021 if the medication arrived November 10, 2021. The LPN stated if the pharmacy was not able to deliver the medication then the process is to let the DON (Director of Nursing) know so that the residents received the medication they need. He stated if the pharmacy did not deliver the medication, the nurses should follow up to see what happened. An interview was conducted with an Omnicell Pharmacy representative (staff #129) on November 12, 2021 at 11:04 a.m. She stated that the medication [MEDICATION(S)] ER for resident #5 was ordered on November 10, 2021 and a seven-day supply was filled on November 10, 2021. She stated the medication was sent out on the noon run. Staff #129 stated that before the November 10, 2021 order, the medication was ordered on October 22, 2021 and a thirty-day supply was filled. She stated there was no information that the medication was reordered between October 22, 2021 to November 10, 2021. An interview was conducted with a RN (staff #10) on November 12, 2021 at 11:48 a.m. She checked the medication [MEDICATION(S)] on the cart and stated 7 pills were dispensed on November 10, 2021. She stated medications are ordered through PCC (Point Click Care). She stated if a medication is not available then the Omnicell Pyxis is checked, pharmacy is called immediately, and the physician is notified. She stated she will then follow the physician direction regarding holding the medication or skipping the dose. The RN stated if the pharmacy is late to deliver the medication then the staff should call the pharmacy and follow up and if the medication did not arrive till next day, staff should notify the physician. An interview was conducted with the Director of Nursing (DON/staff #86) on November 12, 2021 at 2:04 p.m. She stated if a medication is not available, her expectation from the staff is to go to Omnicell pyxis as many of the medications are stored in Omnicell. She stated if the medication is not in the Omnicell then her expectation is for the staff to call the physician. She stated the physician usually gives an order to put the medication on hold until available. She stated the nurses should call the pharmacy as soon as possible. She stated sometimes the pharmacy states the resident have an insurance issue. In that case she stated the nurses should notify her even if it is on a weekend. The DON stated she usually tells the nurses to tell the pharmacy that the facility will pay and the pharmacy usually sends a seven-day supply. The DON stated the facility do not want the resident to go without their scheduled medications so the facility will pay for the medication. Staff #86 stated if a nurse failed to give a medication, she expects the nurses to document it in the e-MAR. Staff #86 stated the facility randomly check the MAR to make sure the medications were given. She stated she and staff #3 does random checks, that the MAR is audited randomly. The facility policy titled Following Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy further stated the order establishes the medical necessity for the services provided. The policy stated that if medication has not been received from the pharmacy, the licensed nurse will check the Omnicell for available medications. The policy stated if not available in the Omnicell, the Healthcare Provider will be notified for further directions and the pharmacy will also be notified for medication availability. The policy stated the licensed nurses should document on the e-MAR/TAR in PCC (Point Click Care) after administration of medication or rendering of treatment.

Based on clinical record reviews, facility documentation, staff interview, policy review, the Centers for Disease Control and Prevention (CDC) guidance, and the Centers for Medicare and Medicaid Services (CMS) Interim Final Rule, the facility failed to ensure three residents (#2, #9, and #10), their representatives, and families were informed of new COVID-19 cases occurring in the facility within the required time frame. The deficient practice would result in residents, their representatives and families not being aware of new COVID-19 cases and the actions implemented to reduce the risk of transmission. The census was 39. Findings include: Review of documentation provided by the facility included the five most recent confirmed COVID-19 cases in the facility were staff members. Two cases on January 22, 2021, one case on January 26, 2021, one case on February 2, 2021, and one case on February 16, 2021. -Resident #2 was admitted to the facility on [DATE]. Review of the resident's progress notes did not reveal documentation that the resident, resident representative, and/or family were notified of the positive COVID-19 cases identified by the facility in January and February 2021. The facility did not provide further requested documentation of notifications for resident #2 for the months of January and February 2021. -Resident #9 admitted to the facility on [DATE]. Review of the resident's progress notes did not reveal documentation that the resident, resident representative, and/or family were notified of the positive COVID-19 case identified by the facility in January and February 2021. The facility did not provide further requested documentation of notifications for resident #9 for the months of January and February 2021. -Resident #10 had an admission to the facility on [DATE] with a discharge on January 27, 2021. Review of the resident's progress notes for that stay did not reveal documentation that the resident, resident representative, and/or family were notified of the positive COVID-19 case identified by the facility on January 22, 2021. The facility did not provide further requested documentation of notifications for resident #10. An interview was conducted on November 12, 2021 at 2:51 p.m. with the Director of Nursing (DON/staff #86). She stated that the staff notifies residents, families, and representatives of identified COVID-19 cases of residents and/or staff via phone and that the notifications are documented in the residents' clinical record. She acknowledged that she did not provide the requested documentation of notification of COVID-19 cases in the building for residents #2, #9, and #10 for the cases identified in January and February 2021. The DON stated that she understood that, if no further information was provided, the facility did not provide documentation that selected residents/representatives were notified of new COVID-19 cases in the building by 5 p.m. the next day after a case was identified. She stated that her expectation was that notifications would be done as required by CMS. Review of the facility policy for Prevention and Control of COVID-19 dated July 17, 2020 revealed: The facility follows current Centers for Disease Control and Prevention (CDC) guidelines and recommendations for the prevention and control of COVID-19. The CDC Interim Infection Prevention and Control recommendations to prevent [CONDITION(S)]-CoV-2 spread in nursing homes, dated September 10, 2021 stated notify healthcare providers (HCP), residents, and families promptly about identification of [CONDITION(S)]-CoV-2 in the facility. Maintain ongoing, frequent communication with HCP (healthcare personnel), residents, and families with updates on the situation and facility actions. Review of CMS Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes dated May 6, 2020 stated to inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. This information must (i) Not include personally identifiable information; (ii) Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered; and (iii) Include any cumulative updates for residents, their representatives, and families at least weekly or by 5 p.m. the next calendar day following the subsequent occurrence of either: each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other.

Based on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure the physician was consistently notified when a scheduled blood pressure medication was unavailable and not administered to one resident (#5). The sample size was 5. The deficient practice could result in residents not receiving necessary blood pressure medications. Findings include: Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated on March 1, 2021 revealed the resident had hypertension. The goal was that the resident would be free of complication related to hypertension. Interventions included to give anti-hypertensive medications as ordered. The quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 7 which indicated the resident cognition was severely impaired. Review of the November 2021 MAR (Medication Administration Record) revealed [MEDICATION(S)] ER 60 mg was not given on November 2, 6, 7 and 8, 2021 and included the number '9' which meant other/see nurses notes. Review of corresponding e-MAR (electronic MAR) notes revealed the following: - November 2, 2021 stated waiting for delivery - November 6, 2021 stated out of stock, reordering - November 7, 2021 stated awaiting for delivery - November 8, 2021 stated Still not available. Will follow up with pharmacy. The progress notes were reviewed and did not reveal the medication was administered on November 2, 6, 7 and 8, 2021. The progress notes also did not reveal that a physician was notified when the medication was unavailable those days. Review of the resident blood pressure for November 2021 revealed the following blood pressure (BP) readings for the days the resident did not receive the blood pressure medication: November 2, 2021 at 9:08 a.m. BP was 164/62 November 6, 2021 at 6:21 a.m. BP was 140/74 November 7, 2021 at 6:55 a.m. BP was 150/60 November 8, 2021 at 7:03 a.m. BP was 132/68. During a medication observation conducted on November 10, 2021 at 8:53 a.m. with a Registered Nurse (RN/staff #35), the RN stated that she had not received [MEDICATION(S)] ER 60 mg from the pharmacy for resident #5 and that she would check the Omnicell later. The RN was not observed to administer [MEDICATION(S)] ER to the resident at that time. An interview was conducted with the RN (staff #35) on November 10, 2021 at 2:00 p.m. The RN stated that when a medication is not available, the process is to check the Omnicell Pyxis, call the pharmacy, request the medication STAT (immediately), and notify the physician. She stated normally the physician would give an order to hold the medication and administer once available. She stated she was not aware that the medication [MEDICATION(S)] ER was not given and was not available on November 2, 6, 7 and 8, 2021. The RN stated that the medication should have been given and that was a long time without the medication. She stated she did not know what happened. An interview was conducted with a Licensed Practical Nurse (LPN/staff #43) on November 10, 2021 at 2:06 p.m. She stated when a medication is not available, the process is to click on number '9' in the MAR, enter a note in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff #43 stated the pharmacy should be called to find out when the medication will be delivered. She stated if the delivery is late, then the physician should be notified and the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she notified the physician on November 6, 2021 and called the pharmacy. She stated the pharmacy told her they needed to track down the order and the pharmacy asked to be called back. Staff #43 stated that she did not get a chance to call the pharmacy back and the physician had stated to make sure the resident received the medication. The LPN stated that she had passed it on to the evening shift and the evening shift had stated they will pass it on to the morning shift so that the regular nurse on the unit could take care of it. She stated on November 7 and 8, 2021 she did not get a chance and did not call the physician as she thought the physician was going to say the same thing. An interview was conducted with an LPN (staff #3) on November 12, 2021 at 10:44 a.m. He stated that when a medication is not available, it is important the resident receive the medication even if the facility has to pay for the medication. He stated the nurses need to look for the medication, if not available, call the pharmacy and notify the physician. He stated normally the physician will give an order to hold until available. The LPN stated everything needs to be documented in a progress note. The LPN stated if there is no documentation the medication was given and the physician was notified then that meant it did not happen. Staff #3 stated nurses must notify the physician when a medication is not given to a resident and document it in the progress notes. An interview was conducted with a RN (staff #10) on November 12, 2021 at 11:48 a.m. She stated if a medication is not available then the Omnicell Pyxis should be checked, pharmacy should be called immediately and the physician should be notified. She stated notification to the physician should be documented in the progress notes. An interview was conducted with the Director of Nursing (DON/staff #86) on November 12, 2021 at 2:04 p.m. The DON stated if a medication is not available, her expectation from the staff is to go to Omnicell Pyxis as many of the medications are stored in the Omnicell. She stated if the medication is not in the Omnicell then her expectation is for the staff to call the physician. The DON stated the physician usually gives an order to put the medication on hold until available. She stated if a nurse failed to give a medication, she expected the nurses to document in the e-MAR that the medication was on hold and the physician was notified. The DON stated the physician should be aware whenever the residents are not administered their medications. Staff #86 stated the facility randomly check/audit the MARs to make sure the medications were given. The facility policy titled Following Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy further stated the order establishes the medical necessity for the services provided. The policy stated the healthcare providers are notified by the licensed nurses if medications are held. The policy also stated that the licensed nurses should notify the healthcare provider for further directions when a medication has not been received from the pharmacy and is unavailable in the Omnicell. Further, the policy stated the licensed nurses should document on the e-MAR/TAR in PCC (Point Click Care) after administration of medication or rendering of treatment.

Based on observations, clinical record reviews, staff interviews, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for two of five sampled residents (#6 and #15). The medication error rate was 6.67%. The facility census was 39 residents. The deficient practice could result in additional medication errors. Findings include: -Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's order revealed an order dated [DATE] for Aspirin 81 milligram (mg) tablet by mouth one time a day every Wednesday and Saturday for PVD (peripheral vascular disease). During a medication administration observation conducted on [DATE] at 8:44 a.m., a RN (Registered Nurse/staff #35) was observed to administer one tablet of Aspirin [MEDICATION(S)] Coated (EC) 81 mg to resident #6 instead of one tablet of Aspirin 81 mg. -Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's order revealed an order dated [DATE] for [MEDICATION(S)] tablet 25 microgram (mcg)/1000 units two tablets by mouth one time a day for Vitamin D deficiency. During a medication administration observation conducted on [DATE] at 9:01 a.m., staff #35 was observed to pour one tablet of Vitamin D instead of two tablets in the medication cup. The RN was observed to pour a total of nine tablets. Staff #35 was asked to count the total medication poured following the preparation of medication for resident #15. The RN counted and stated there were nine tablets in the medication cup. The nurse then administered the medications to resident #15. Following the administration of medications to resident #15, staff #35 was asked to count how many tablets the staff was supposed to administer the resident. Staff #35 looked at the MAR (Medication Administration Record), counted and stated she was supposed to give a total of ten tablets. She then stated that maybe she miscounted before as she knew she gave the resident everything. The RN stated that she would let the DON (Director of Nursing) and the physician know. An interview was conducted with a Licensed Practical Nurse (LPN/staff #43) on [DATE] at 12:10 p.m. She stated that her medication cart contained Aspirin 81 mg EC, 81 mg chewable, 325 mg EC and 325 mg regular. She stated if the physician order stated Aspirin 81 mg, she would clarify whether it is chewable or EC with the physician. She stated the facility just have two kind of Aspirin 81 mg, EC and chewable. An interview was conducted with a RN (staff #96) on [DATE] at 12:48 p.m. She stated the facility had Aspirin 81 mg chewable, 81 mg standard, 81 mg EC, 325mg standard, 325 mg EC. She stated if a resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the medication cannot be given before the clarification. A second interview was conducted with staff #35 on [DATE] at 1:30 p.m. She stated she had Aspirin 81 mg chewable and EC. She stated if the physician wants the resident to receive chewable then the order will specify chewable. She stated when the resident admits from hospital, the hospital specifies which kind of Aspirin. She then stated if the order stated Aspirin 81 mg then Aspirin 81 mg EC can be given as the order specifically does not state chewable. An interview was conducted with the DON (staff #86) on [DATE] at 2:04 p.m. The DON stated her expectation is for the nurses to compare the medication with the MAR, and ensure the medication is correct, is the correct dose, and is not expired. She stated the medication ordered and what is on hand should match. She stated if the order is for Aspirin 81 mg and the order did not say EC then the medication should be of regular route. The DON stated if Aspirin EC is given then the order should state Aspirin EC. She stated if the order is Aspirin 81 mg then regular Aspirin should be administered. She stated if Aspirin 81 mg regular is not available then her expectation is for the nurses to go to central supply, as central supply has the medications. The DON stated nurses should not be giving Aspirin 81 mg EC if the order did not specify EC. She stated staff #35 informed her about resident #15, who was supposed to receive two tablets of Vitamin D. She stated she was informed and the physician was informed. Review of the facility policy titled, General Dose Preparation and Medication Administration revised [DATE] revealed prior to administration of medication, facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. The policy further stated that the facility staff should confirm that the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on clinical review, staff interviews, and facility policy and procedures, the facility failed to ensure thorough pain management was consistently provided to one sampled resident (#2). The census was 39. The deficient practice could result in residents' pain not being addressed. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated on April 6, 2016 stated the resident has the potential for chronic pain related to PVD, [CONDITION(S)] and a history of right ankle fracture. The goals were that the resident would verbalize adequate relief of pain or ability to cope with incompletely relieved pain, and would not have an interruption in normal activities. Interventions included to administer [MEDICATION(S)] as per orders, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain interventions, and review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Review of the Order Listing Report revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 5 indicating the resident had severe cognitive impairment. The assessment included the resident had not been on a scheduled pain medication regimen and had not received prn pain medication during the 5 days lookback period. Review of the Medication Administration Record (MAR) dated October 2021 revealed that the resident's pain level was assessed at a 3/10 on October 7, 4/10 on October 8, and 4/10 on October 30, 2021. Further review of the MAR for October 2021 revealed that [MEDICATION(S)] 325 mg tablet give 2 tablets orally every 4 hours as needed for pain 1-10 was not administered on October 7, 8, or 30, 2021. Progress notes dates October 7, 8, and 30, 2021 did not reveal that pain medication was offered, administered, or declined by the resident. An interview was conducted on November 12, 2021 at 1:33 p.m. with a licensed practical nurse (LPN/staff #3). During the interview, he reviewed the MAR for October 2021 and stated that the resident's pain was assessed at 3/10 on October 7, 4/10 on October 8, and 4/10 on October 30, 2021. He also identified an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated that according to the MAR, the pain medication was not offered. Then, he referred to the progress notes and stated there was no documentation on the 7th or the 8th or the 30th indicating the pain medication was offered or that the resident declined the mediation. The LPN continued to review the clinical record and stated that the pain medication was not offered or given and if the medication was not offered, the resident may have continued to have pain. The Director of Nursing (DON/staff #86) was interviewed on November 12, 2021 at 1:43 p.m. She stated that the nurses assess each resident for pain daily and it is documented on the MAR. The DON stated pain medication orders include a pain scale and that she expects the staff to administer pain medication as per the pain scale and to document that it was administered on the MAR. The DON stated that she and the LPN (staff #3) are responsible for reviewing the MAR to make sure documentation is complete. Staff #86 stated if pain was assessed and no medication was administered, she would review the progress notes to see if the resident declined the pain medication. Review of the facility's policy regarding medication administration revised January 1, 2013 stated to document medication administration for example when medications are refused on the appropriate forms. The facility's policy, Administering Pain Medications, dated March 31, 2020 stated the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following: -Assessing the potential for pain; -Recognizing the presence of pain; -Identifying the characteristics of pain; -Addressing the underlying causes of the pain; -Developing and implementing approaches to pain management; -Identifying and using specific strategies for different levels and sources of pain; -Monitoring for the effectiveness of interventions; and -Modifying approaches as necessary.

Based on observations, clinical record review, resident and staff interviews, and review of policy and procedures, the facility failed to ensure one sampled resident (#320) received treatment and care in accordance with professional standards of practice related to the application of [CONDITION(S)]-[CONDITION(S)] Deterrent (TED) hose as ordered. The census was 39. The deficient practice could result in a lack of proper care being provided to residents. Findings include: Resident #320 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] included the resident scored 14 on the Brief Interview for Mental Status (BIMS) indicating the resident did not have cognitive deficits. The assessment also included the resident required the assistance of one person for dressing. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan (undated) revealed the resident had an activities of daily living self-care performance. Interventions included the physician had ordered TED hose and the resident needed assistance to put on the TED hose every morning and to remove them at bedtime. The Treatment Administration Record (TAR) for November 2021 included the TED hose were applied November 4, 2021 on the day shift and continued to be applied every day shift through November 10, 2021 as ordered. Additionally, the TAR revealed the TED hose were removed on the night shift November 4 through 9, 2021. On November 8, 2021 at 12:12 PM, resident #320 was observed sitting in a wheelchair. The resident's lower extremities were resting on the wheelchair foot pedals, the resident's feet were edematous, and no TED hose were observed on the resident's lower extremities. Another observation was conducted of the resident on November 8, 2021 at 2:15 PM. The resident was not wearing TED hose as ordered. During an observation conducted of the resident on November 9, 2021 at 12:13 PM, the resident was observed with no TED on and the resident's lower legs were edematous. On November 10, 2021 at 11:08 AM, an interview was conducted with the resident. The resident was observed dressed and in a wheelchair. A white pair of TED hose were observed lying on the resident's bed. When asked about the TED hose, the resident stated it was the first time she had ever seen them and that staff had never put them on her before. The resident stated she had not refused the TED hose because she had never seen them and that if staff asked, she would allow staff to apply the TED hose. Resident #320 stated that she would like to see the staff try to apply the TED hose now because her feet are very swollen and it would be difficult to apply due to the size of her feet and ankles. An interview was conducted on November 10, 2021 at 11:15 AM with a Licensed Practical Nurse (LPN/staff#33). The LPN stated that an intervention for lower extremity [CONDITION(S)] would include to encourage the elevation of the legs, apply TED hose in the morning and remove them at bed time. The nurse explained that TED hose is a form of compression that increase circulation and decrease [CONDITION(S)] in a resident's legs. Additionally, she stated that application or removal of TED hose will be documented in the TAR. The LPN stated that if a resident refuses cares then they will retry and assess why the resident refused. The LPN stated that if the resident does not want to wear the TED hose after 3 attempts in a row then they will notify the physician and document all refusals in the resident's record. The nurse stated that a risk factor for not wearing TED hose with lower extremity [CONDITION(S)] is that the resident's legs or feet will continue to increase in size and there would be a decrease in cardiac circulation throughout the resident's body. After reviewing the TAR, the LPN stated that on November 10, 2021 the TAR indicated the TED hose was applied. The LPN stated that resident #320 is alert and oriented and that the resident required TED hose for her lower leg [CONDITION(S)]. The nurse stated that resident #320 had refused to have the TED hose applied to her legs today and that this was the first time the resident had refused to wear them for her. The LPN stated that she forgot to document the resident's refusal. Staff #33 further stated that on November 9, 2021, the nurse had removed the resident TED hose after lunch but did not document the occurrence of the removal. An interview was conducted on November 10, 2021 at 11:30 AM with a Certified Nursing Assistant (CNA/staff #38). The CNA stated that she is familiar with resident #320 care needs and that the resident is alert and oriented but is sometimes a little forgetful first thing in the morning. The CNA stated that this resident does have [CONDITION(S)] in her feet and that the staff have to apply the TED hose in the morning and that the night staff will remove the TED hose when the resident goes to bed. The CNA stated that on November 8, 2021 she was assigned to work with resident #320 and that she was going to go get resident #320 a new pair of TED hose that would fit the resident's legs better. Staff #38 stated that she got busy and forgot to bring the TED hose to the resident. Staff #38 stated that she left her shift that day and never brought resident #320 a pair of TED hose. Additionally, the CNA stated that the TED hose was not brought to the resident until today (November 10, 2021). She stated the resident did not want them on and refused them. After informing the CNA the resident had stated that she would not refuse having the TED hose applied by staff because her feet were so swollen, the CNA stated that the TED hose had not been on the resident and that she would go and apply the TED hose at this time. An interview was conducted with the Director of Nursing (DON/staff #86) on November 10, 2021 at 11:51 AM. The DON stated that TED hose requires a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that the nurses should document in the TAR when the TED hose are applied and removed. Further, she stated that if a resident refused any cares that refusal should be documented in the clinical record. The DON reviewed resident #320 TAR and stated that the nursing documentation indicated that the TED hose were applied that morning, November 10, 2021 at 6:00 AM, by the floor nurse. Further, the DON stated that if the resident was not wearing the TED hose then the documentation in the resident record should indicate that. Additionally, the DON stated there should be documentation if the resident wanted the TED hose removed or if the resident refused to have the TED hose applied. The DON stated that if the resident is not wearing the TED hose and the TAR indicates that they were applied, then that would not meet her expectation for application, removal, or refusal of TED hose. The facility's policy for Following Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order establishes the medical necessity for the services provided. Licensed nurses are to carry out healthcare provider orders as written per their scope of practice. Licensed nurses after administration of medication or rendering of treatment, will document on the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's policy titled Activities of Daily Living (ADL) Care Documentation dated April 4, 2018 stated it is the expectation that the activities of daily living (ADL) care outlined in the resident's care plan will be delivered to the resident as scheduled. ADL care which has been rendered will be documented in the resident's medical record. Activities of Daily Living (ADL) performed will be rendered as per the care plan and resident preferences. Explain all procedures to the resident before completing each task. ADL care will be rendered as care planned and encouraging resident involvement. ADL care that is not performed during a shift shall be reported to the charge nurse on duty of that shift and to the incoming associates of the next shift. It should also be entered into the medical record. ADL care that is not performed whether because of resident declination or other circumstance should be documented in the resident's record along with the reason the ADL care was not performed by the nurse/designee. Repetitive refusal or declination of ADL care should be reported to the charge nurse, nurse, or designee and then appropriately communicated to the resident's responsible party and/or physician/healthcare provider as necessary.

Based on clinical record review, facility document, staff interviews, and facility policy and procedures, the facility failed to provide an ongoing resident centered activities program based on the comprehensive assessment, care plan, and resident's preferences for one of two sampled residents (#220). The deficient practice could result in residents not participating in activities which could impact their mental and social well-being. Findings include: Resident #220 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Optimum Life Program Admission Data Collection form dated July 20, 2021 revealed the resident's short-term memory and long-term memory was OK and that the resident's preferences for activities included cards/other games, arts/crafts, exercise sports, trips/shopping/outings, TV/movies, and hobbies. Also included was that the resident's current participation in activities was active and the resident's preferred time for engagement in the programs and activities was morning. Continued review of the Optimum Life Program Admission Data Collection form dated July 20, 2021 revealed that while in the facility it was very important to the resident to be around animals such as pets, keep up with the news, go outside to get fresh air when the weather is good, and do favorite activities. Included was that it was also somewhat important for the resident to do things with groups of people, and not very important to listen to music and have books, newspapers, and magazines to read. Further review of the Optimum Life Program Admission Data Collection form dated July 20, 2021 revealed the resident would be suited for four 1:1 in room activities of choice such as hydration, pet therapy, 10-minute massages, and popcorn. Review of the care plan initiated on July 20, 2021 revealed the resident was dependent on staff for activities, cognitive stimulation, and social interaction. The goal was that the resident would maintain involvement in cognitive stimulation and social activities as desired. Interventions included for all staff to converse with the resident while providing care; encourage the resident's family to maintain ongoing involvement via telephone, in person, etc. in order to enhance the resident's quality of life; introduce the resident to residents with similar background and interests, and encourage/facilitate interaction; invite the resident to scheduled activities; thank the resident for attendance at activity function; when the resident chooses not to participate in organized activities, encourage the resident to turn on the television; music in room to provide sensory stimulation; and the resident needs assistance/escort to activity functions. However, review of the progress notes dated July 19, 2021 through July 26, 2021 did not reveal evidence that activities had being offered or declined by the resident. Review of the discharge Minimum Data Set assessment dated [DATE] revealed the resident was discharged return not anticipated on July 26, 2021 to another nursing home. Review of a facility document signed by the Director of Nursing (DON/staff #86) included activities now may be held in a group setting with a handwritten date 4/4-10/2021. An interview was conducted on November 9, 2021 at 1:03 p.m. with the Activities Coordinator (staff #56), who stated that she completes the Optimum Life Program Admission Data Collection assessment when a resident is admitted . She said the assessment includes the activities a resident likes to do and that she tries to offer these activities to the resident. During the interview, staff #56 reviewed her documentation regarding activity participation and stated that she did not have any documentation to show the resident participated in any activities, was offered activities, or that the resident declined to participate. Then the Activities Coordinator stated that the residents were not allowed to meet in groups in July 2021, so she gave the nurse activities to pass out to the residents, so they would have something to do in their rooms, but that she never checked to see if the activities were offered to the residents. Staff #56 stated that she met with the residents a lot and these visits occurred through a closed window. Staff #56 stated that she would knock on the window, and make a funny face to let residents know that someone was there. She stated that she did not enter the residents' rooms because of COVID. On November 9, 2021, an interview was conducted at 2:40 p.m. with the DON (staff #86), who stated that the Activities Coordinator completes an assessment when a resident is admitted and initiates a care plan based on the resident's cognition and interests. The DON stated that if a one-to-one is needed in order for the resident to participate in activities, she expects it to be provided. The DON stated that in July 2021, the facility was only accepting residents who had been vaccinated, so isolation would not have been required and all residents could leave their rooms for group activities. Staff #86 stated that it is her expectation that the Activities Coordinator or the nurses would come to her if a resident is not participating in activities so they could try to determine why the resident is not participating. She also said that the Activities Coordinator should have progress notes to show that the resident participated in activities. A review of the facility's policy regarding activities dated April 4, 2018 stated residents shall have the right to choose the types of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the facility. As much as possible, the facility will provide activities, social events, and schedules that are compatible with the residents' interests, physical and mental assessment, and overall plan of care. Staff will document the reasons for any limitations in the resident's medical record. The policy also stated that activities will be scheduled periodically during the day, as well as during evenings, weekends, and holidays. The facility's policy, Quality of Life-Dignity, dated April 4, 2018 stated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be assisted in attending the activities of their choice, including activities outside the community.

Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurate for one resident (#22). The sample size was 12. The deficient practice could result in inaccurate discharge tracking information. Findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note dated September 25, 2021 at 10:24 AM revealed the resident was discharged home with home health and all remaining medications, prescriptions, and all belongings. The note included discharge instructions were given to the resident and the resident's spouse, the resident was transported via private vehicle by the resident's spouse, and the resident was assisted to the vehicle by staff. However, review of the discharge MDS assessment dated [DATE] revealed the resident was discharged to the hospital. During an interview conducted on November 10, 2021 at 9:57 AM with the Director of Nursing (staff #86), she stated that her expectation is that all the documentation on the MDS assessment be accurate when it is completed. An interview was conducted with the MDS Registered Nurse (staff #49) on November 10, 2021 at 12:01 PM. She stated that she reviews the chart and progress notes for each resident prior to completing the MDS assessment in addition to any interviews which need to be conducted. Staff #49 stated that the Director of Nursing had just advised her that the resident was not coded correctly for discharge location. She stated that after reviewing the clinical record she realized she had entered the data incorrectly. Staff #49 further stated that the facility had no specific policy on completion of the MDS assessment that they used the RAI manual as their guide. The RAI manual instructs to review the clinical record including the discharge orders for documentation of discharge location and code the corresponding 2-digit code. The manual included the assessment must accurately reflect the resident's status.

Based on clinical record review, facility documentation, staff interviews, and review of policy and procedure, the facility failed to notify one resident (#4) and the resident's representative of the transfer or discharge and the reasons for the move in writing, and send a copy of the notice to the Office of the State Long Term Care Ombudsman. The sample size was 3. The deficient practice could result in the resident/resident representative and/or the Ombudsman not being aware of the transfer and reason for transfer. Findings include: Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nurse progress note dated August 15, 2021 revealed the resident appeared very anxious with shortness of breath and labored respirations. Lung sounds wheezing with diminished lung sounds. Increased respirations with low oxygenation. Primary care provider responded with the recommendation to send the resident 911 to emergency room for evaluation and treatment. A physician order dated August 15, 2021 included to send the resident to the hospital for treatment and evaluation. A nurse progress note dated August 15, 2021 revealed the resident was sent to the hospital 911 per physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Power of Attorney notified of transfer. Review of a transfer form dated August 15, 2021 revealed that the resident representative was notified of the transfer and was aware of the clinical situation, the form included the representatives phone numbers. Review of a nurse progress note dated August 20, 2021 revealed the resident returned to the facility from the hospital. However, review of the clinical record did not reveal evidence the resident and the resident's representative were informed of the transfer to the hospital in writing. Review of the facility documentation of Ombudsman notifications of discharges did not include notification of the August 15, 2021 transfer to the hospital for resident #4. An interview was conducted on November 10, 2021 at 11:04 a.m. with a Registered Nurse (RN/staff #35). She stated that if a resident had a change of condition she would call the physician. She stated that if the physician gave orders to send the resident to the hospital she would notify the family. The RN stated that a transfer form would be filled out in the computer and a copy would go to the hospital with the resident. The RN stated that she had never shown a family member the transfer form. An interview was conducted on November 12, 2021 at 10:38 a.m. with the Director of Nursing (DON/staff #86). She stated that she spoke with social services and case management and that neither they, nor the nursing staff, provide a written transfer notice to the resident or the resident's representative when a resident is discharged to the hospital and anticipated to return to the facility. The DON stated that resident #4, resident #4's representative, and the Ombudsman did not receive a written notice of transfer of the resident's August 2021 transfer to the hospital. Review of the facility policy for Emergency Discharges dated March 31, 2021 revealed: Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will prepare a transfer form to send with the resident and notify the representative or other family member. The policy did not include the provision of written transfer information to the resident/resident representative or Ombudsman.

Based on closed clinical record review, staff interviews, and policy review, the facility failed to report an allegation of verbal abuse for one sampled resident (#120) to the State Survey Agency and to Adult Protective Services (APS). The deficient practice could result in further allegations of resident abuse not being reported. Findings include: Resident #120 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance with most activities of daily living. Review of a nursing progress note dated 12/7/2019 at 08:56 revealed the resident's spouse arrived to the facility at 08:55, dragged the resident on a wheelchair from the TV room where the resident was watching holiday movies after eating breakfast into the resident's room. The spouse was yelling at the resident saying, why did you not answer your phone when I called you. The spouse took the resident into the room, slammed the door, and said with a loud voice this is where you need to stay, so that when I call you, you will answer your phone. The note included the writer immediately went into the resident's room and asked the resident's spouse what the problem was. The resident's spouse stated why was the resident not in the room to answer the phone when the spouse called. The resident's spouse was informed that at the time of the call, the resident was in the dining room eating breakfast. The resident's spouse removed their eye glasses and slammed them on the chair and it fell down. The resident's spouse was told that if the aggressive behavior did not stop, security would be called to remove the spouse from the premises. The note included the spouse knew the resident was a fall risk and had fallen many times. The note also included the resident's spouse immediately wheeled the resident outside with anger, the writer informed the weekend supervisor who went after them to make sure all was well. Further review of the clinical record did not reveal evidence that this allegation of abuse had been reported to the State Survey Agency or APS. In an interview conducted with a Certified Nursing Assistant (CNA/staff #72) on November 10, 2021 at 7:15 AM, the CNA stated that she has had abuse training and that if she witnessed any one being abused, she would immediately remove the resident from the area, notify the nurse, the Director of Nursing, and the police. She stated that she could not recall the resident and was not aware of this incident. In an interview conducted with a Licensed Practical Nurse (LPN/staff #43) on November 10, 2021, the LPN stated that she does not recall the resident or any incident of family yelling. She stated that she has received training on abuse. The LPN stated that if she would see any resident being abused, she would immediately intervene and ensure the safety of the resident. The LPN stated that she would then report the incident to the Director of Nursing, the Administrator and the police. During an interview conducted with a Registered Nurse (RN/staff #96) on November 10, 2021 at 9:54 AM, the RN stated that they receive abuse training annually. The RN stated that she would report an allegation of abuse to the Administrator and the Director of Nursing (DON), or the supervisor. Staff #96 stated that if no one was available, she would notify the State Agency of the allegation within 2 hours. The RN stated that she had no recollection of this incident or if the DON or the Administrator were notified. She stated that she would consider the spouse yelling at the resident to be potential verbal abuse. An interview was conducted on November 10, 2021 at 10:44 AM with the Administrator (staff #31), who stated the incident occurred prior to his arrival as Administrator. He stated there were no records of any information regarding allegations or complaints. Review of the facility policy regarding Abuse, Neglect and Exploitation effective date April 4, 2018, revealed all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property shall be reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse. Such alleged violations shall be reported to the State Survey Agency and Adult Protective Services.

Based on observations, facility documents, staff interviews, and policy review, the facility failed to ensure nursing staffing information was complete and posted on a daily basis. The deficient practice resulted in information not being readily available to residents and visitors. Findings include: -During the initial entry on November 8, 2021 at 08:27 a.m., the Daily Associates Posting dated November 5, 2021 was observed on the reception desk. Further observation revealed the posting did not include the total number of scheduled hours and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. Behind the Daily Associates Posting dated November 5, 2021 was a Daily Associates Posting dated November 8, 2021. Review of the nursing staffing information revealed the posting did not include the census or the total number of scheduled hours for licensed and unlicensed nursing staff per shift. -On November 9, 2021 at 7:55 a.m., the Daily Associates Posting dated November 9, 2021 was observed on the reception desk. Further observation revealed that the posting did not include the resident census or the total scheduled hours for licensed and unlicensed nursing staff for each shift. Behind the Daily Associates Posting dated November 9, 2021 was a Daily Associates Posting dated November 8, 2021. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . -Upon entry to the facility on [DATE] at 7:00 a.m., the Daily Associates Posting dated November 10, 2021 was observed on the reception desk. The posting did not include the resident census or the scheduled hours for licensed and unlicensed nursing staff per shift. Behind the Daily Associates Posting dated November 10, 2021 was a Daily Associates Posting dated November 9, 2021, which did not include the census or the total scheduled hours or the actually hours worked by licensed and unlicensed nursing staff each shift for that day. Review of the Daily Associates Posting from October 9, 2021 to November 7, 2021 revealed the postings were missing the actual hours worked by licensed and unlicensed nursing staff per shift. An interview was conducted with the staffing coordinator (staff #66) on November 10, 2021 at 8:42 a.m. He stated that the process for staff posting is that he fills out the associates scheduled portion of the form the day before for each shift and the actual associates portion of the form the next day sometime during the morning. He stated that the census portion for each shift is filled out by 9:00 a.m. the following day. Staff #66 stated that for the weekend, he will fill in scheduled staff numbers for the weekends and the weekend supervisor would fill in the census. Staff #66 stated he will fill in the actual staff numbers on Monday. The staffing coordinator stated the weekend supervisors are responsible for posting the daily staffing on the weekends. He stated that on Monday, he will fill in the actual numbers of staff that worked. Staff #66 stated that he never fills in any numbers on actual associates until the next day because he is not sure if things will change. Staff #66 stated that he has never filled out the actual hours staff worked. He stated complete staffing information should be posted daily. An interview was conducted on November 10, 2021 at 8:54 a.m. with the Director of Nursing (DON/staff #86) and the Administrator (staff #31). The DON stated that her expectation is that the staff posting be filled out daily and completely. The DON stated that the practice of completing the actual hours worked by staff was done previously and she was not sure when that stopped. The Administrator stated that he was unsure of how to fill in the actual hours worked in a timely and accurate manner as the data is historical that they need to find a process to accomplish this. Both the DON and the Administrator stated that they were aware that the form was not being filled out completely or in the timely manner required. Based on review of the facility policy for Daily Associate Posting (April 4, 2018) revealed daily a designated associate will post the community specific number of direct caregivers scheduled for each shift in 24 hours by categories of nursing associates as well as the total number of hours worked by both licensed and unlicensed associates directly responsible for resident care. The policy further stated that the staff member will post the facility name, current date and resident census for 24 hours. The policy revealed notification will be made to associates, residents and visitors of the facility census, the number and categories of nursing associates scheduled for each shift, as well as the total number of actual hours worked by licensed and unlicensed nursing associates per shift that are directly responsible for resident care.

Based on clinical record review, facility documentation, staff interviews and policy review, the facility failed to ensure one resident (#7) was free from neglect, due to an unsafe transfer. Findings include: Resident #7 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 13, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS included the resident required extensive assistance with bed mobility, transfers and hygiene, and had impairment to both upper and lower extremities. A care plan for activities of daily living dated (MONTH) 4, (YEAR) revealed the resident had a self care performance deficit related to weakness, decreased mobility and left side [MEDICAL CONDITION]. The goal was for the resident to maintain her current level of function. Approaches included the resident utilizes a wheelchair for mobility and requires two staff to assist when being transferred in the Hoyer lift. Review of a care plan revealed the resident was at risk for falls related to weakness, decreased mobility and impaired balance. The goal was the resident would not sustain serious injury. Approaches included to anticipate and meet the resident's needs, and for a Hoyer lift with the assistance of 2 persons for transfers. A nurse's progress note dated (MONTH) 20, (YEAR), revealed the nurse was called by a certified nursing assistant (CNA/staff #218) to the resident's room. The resident was laying on her left side near the foot of the bed, with her head resting on the bed frame. The Hoyer lift was noted to be in a high position and the sling was on. Staff #218 reported to the nurse that the resident had slipped out of the sling. Per the note, there was blood underneath the resident's head and the resident was not responding. The nurse called EMS to have the resident transported to the hospital. The resident became more responsive and complained of pain to her left hip. Review of the facility's investigative report revealed that resident #7 was non-ambulatory and required the use of a Hoyer lift for all transfers. On (MONTH) 20, (YEAR), staff #218 attempted to transfer the resident from the bed to the wheelchair, without a second staff member. During the transfer, the resident slid out of the sling and landed on the floor, hitting the right side of her head on the floor. The resident lost consciousness for 1 to 2 minutes. When the resident regained consciousness, a neurocheck was completed and the resident was within normal limits. The resident was then assessed by two nurses and had a hematoma/laceration to the left side of her forehead, and a laceration to her left elbow. The resident also complained of pain to her right hip. 911 was called and the resident was transferred to the hospital. The facility's investigative report further included that staff #218 was interviewed by the Administrator (staff #180) and stated that she had received training on using the Hoyer lift and knew that two staff were always needed when transferring a resident. Per the report, staff #218 was involuntarily terminated on (MONTH) 22, (YEAR) for not following facility policy and best practice, when transferring a resident in the Hoyer lift. Review of the hospital discharge summary dated (MONTH) 24, (YEAR) revealed that resident #7 had a left femur fracture, a left elbow laceration and a scalp laceration which resulted from a fall, while being transferred in the Hoyer lift. As a result of this incident, the facility implemented corrective action as follows: -A facility memo dated (MONTH) 20, (YEAR) was sent to Nursing staff/CNA from the Director of Nursing (DON/staff #199) and revealed the following: The goal of any transfer between surfaces such as bed or chair is to move the resident safely and easily while preventing injury to both the resident and staff. When performing mechanical lift transfers (Hoyer Lift, Sara Lift) licensed/certified nursing staff members must have two licensed/certified staff members present at all time to ensure safety is maintained. No mechanical lift transfers should be performed by a single staff member as this could lead to injury to residents or staff. This is facility protocol! Non-compliance with facility protocol will lead to disciplinary action. -According to Training Attendance Records dated (MONTH) 22, 23 and 24, (YEAR), licensed and non-licensed staff attended training regarding Hoyer lift transfers/mechanical lifts. -Additional trainings were completed as follows: a Training Attendance Record dated (MONTH) 6, (YEAR) included that nurses attended a training on abuse and neglect, policy and procedures for Hoyer lifts and supervision of CNA's, and a Training Attendance Record dated (MONTH) 7, (YEAR) included a CNA training for Hoyer lifts, transfers and slings, and the training included that staff provided a return demonstration. -The facility also completed Mechanical Lift Audits from (MONTH) 5, (YEAR) through (MONTH) 2, 2019. The audits included resident's names, if they utilized a Hoyer lift and how many staff were required to assist. On (MONTH) 6, 2019 at 12:44 p.m., an interview was conducted with a CNA (staff #176), who said that she has received training on how to use the Hoyer lift and there must be two staff to assist with the transfer at all times. She said that she also attended training on how to use the Hoyer lift a couple of months ago. On (MONTH) 6, 2019 at 12:50 p.m., an interview was conducted with a licensed Practical Nurse (LPN/staff #209), who stated that she had attended training on how to use the Hoyer lift a few months ago. She said there must be two staff present when transferring a resident in the Hoyer lift at all times, and that she would make sure the cloth/sling is under the resident. She also said that one staff should make sure the wheelchair does not move and is stable. An interview was conducted on (MONTH) 7, 2019 at 8:28 a.m. with the Administrator (staff #180). She stated that staff #218 attended orientation, which included Body Mechanics/Safe Lifting. She stated that this training included the Hoyer lift. She said that staff are trained, receive a demonstration and then must demonstrate how to use the Hoyer lift safely. She said there must always be two staff when using the Hoyer lift. She said when the CNA attempted to use the Hoyer lift by herself and the resident fell , the facility implemented a Corrective Action Plan. She said the plan was to provide in-service training for all employees. She stated that during the in-service trainings, the incident about the resident falling out of the Hoyer lift was discussed and the importance of following facility policy, which requires two staff at all times, when using the Hoyer lift for transfers. She stated that all staff have received in-service training. Review of the facility policy on mechanical lifts dated (MONTH) 4, (YEAR), revealed that all Hoyer mechanical lifts will always be operated by 2 staff members. Review of the Abuse/Neglect policy revealed that the facility is committed to maintaining a safe environment for each resident, visitor and associate. The policy included that the resident has the right to be free from abuse and neglect. Per the policy, neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on observations, staff interviews and policy review, the facility failed to ensure that residents were treated in a dignified manner during dining. The deficient practice could negatively impact the psychosocial well-being of residents. Findings include: -An observation was conducted in a resident room on (MONTH) 5, 2019 at 12:35 p.m. A Certified Nursing Assistant (CNA/staff #176) was observed feeding a resident who was seated, and the CNA was standing while feeding the resident. Another observation was conducted in this same resident's room on (MONTH) 5, 2019 at 12:43 p.m. The CNA (staff #176) was again observed standing while feeding the same resident who was seated. An interview was conducted with a Registered Nurse (RN/staff #161) on (MONTH) 7, 2019 at 10:18 a.m. She stated that the expectation of a staff member feeding a resident should be in a seated position. She stated that she does remember the CNA (staff #176) was standing to feed the seated resident in their room. She said that staff should sit to assist a resident with a meal, because staff wants the meal to be relaxing and enjoyable. An interview was conducted with a CNA (staff #176) on (MONTH) 7, 2019. She stated that when feeding a resident it is important to pay attention to swallowing and chewing and to assist them from eye level, a seated position. She stated that she remembered that she was standing to feed the resident and that she probably should have been eye to eye and sitting when she was feeding him. She stated that it is important to be at the resident's eye level so that they can see you and see what you are doing. She said facility instructions has linked the position you feed a resident to dignity and respect. She stated that in this instance, she did not meet the facility expectation for assisting a resident to eat. An interview was conducted with a Restorative Specialist (CNA/staff #26) on (MONTH) 7, 2019 at 11:00 a.m. He stated that when assisting a resident to eat, the expectation is that the staff member would be sitting right next to the resident who they are assisting. He said this is important so the staff member can be at eye level with the resident, and not standing over them, and that this is to maintain respect and dignity for the resident. An interview was conducted with the Director of Nursing (DON/staff #199) on (MONTH) 7, 2019 at 11:35 a.m. She stated that when a staff member is providing feeding assistance to a resident, they are educated to be in a sitting position and making eye to eye contact with the resident. Review of a facility policy for assisting a resident with meals revealed to sit at the resident's eye level when assisting the resident, and that Nursing Assistants use specific techniques to meet the resident's individual needs. -An observation was conducted in the Main Dining room located between the 300 and 400 units on (MONTH) 6, 2019 at 12:23 p.m. and the lunch meal was in process. At this time, a kitchen staff member server (staff #189) was overheard saying He is a feeder, right? to the Kitchen Supervisor (staff #33). An interview was conducted with staff #189 on (MONTH) 7, 2019 at 8:48 a.m. She stated that she has been instructed not to call a resident a feeder and that she finds it really disrespectful, because the resident needing assistant is a normal resident, like anyone else. She stated it is important because you wouldn't know if the resident heard you or how it would make the resident feel. She stated that she did remember saying He is a feeder to her co-worker at lunch time on (MONTH) 6, and that she did not catch herself saying that. An interview was conducted with the Kitchen Supervisor (staff #33) on (MONTH) 7, 2019 at 8:54 a.m. He stated that he remembered staff #189 saying He is a feeder to him in the dining room at lunch time (MONTH) 6. He recalled that the dining room was full and contained both residents and family members. He stated that it is not okay to say that a resident is a feeder, because of resident rights and respect and dignity, and that the staff member (#189) did not meet facility expectations. An interview was conducted with the nutrition consultant (staff #217) on (MONTH) 7, 2019 at 8:57 a.m. She stated the staff have been previously trained and know better than to call a resident a feeder. An interview was conducted with the Administrator (staff #180) on (MONTH) 7, 2019 at 11:31 a.m. She stated the facility expectation is that residents are treated with dignity and respect. She stated the staff are educated that the resident is not to be labeled by a condition or diagnoses, and that the expectations were not met in this instance, as the staff member referred to a resident as a feeder. Review of a facility policy for Quality of Life/Dignity revealed that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The policy included that: residents shall be treated with dignity and respect always; treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth; and that associates shall always speak respectfully to residents, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, [DIAGNOSES REDACTED].

Based on observations, resident and staff interviews and policy and procedures, the facility failed to ensure multiple residents' wheelchair arm rests were maintained in a comfortable and sanitary manner. Findings include: A random observation was conducted at 9:23 a.m. on (MONTH) 15, (YEAR) of the left arm rest of one resident's wheelchair. The arm rest had torn and missing plastic, exposing the cloth between the plastic and foam padding and was approximately 1 1/2 by 2 inches. A random observation was conducted at 9:26 a.m. on (MONTH) 17, (YEAR) of the arm rest of another resident's wheelchair. The arm rest had torn and missing plastic, exposing the cloth between the plastic and foam padding and was approximately 1 by 2 inches in size. In addition, a third resident's wheelchair left arm rest was observed to have torn and missing plastic, exposing the cloth between the plastic and foam padding and was approximately 1 by 2 inches in size. Also, the middle area of the wheelchair's left arm rest had an area which was approximately 4 x 2 inches, with multiple cracks in the plastic cover. At this time, one of the residents stated that she was not aware of anything that could be done to repair her wheelchair arm rest. When asked if she would prefer to have the arm rest replaced, she stated that would be very nice. During a random observation conducted at 9:38 a.m. on (MONTH) 17, (YEAR), a fourth resident's wheelchair arm rest had torn and cracked plastic covers, which covered a majority of the surface. During an interview conducted at 9:39 a.m. on (MONTH) 17, (YEAR), a Certified Nursing Assistant (staff #28) stated the wheelchairs are scheduled to be cleaned on the night shift, however, it is everyone's job to ensure the wheelchairs are kept sanitary and comfortable. An interview was conducted at 9:52 a.m. on (MONTH) 17, (YEAR) with a Licensed Practical Nurse (staff #57), who stated the wheelchairs are taken into the shower room and washed on the night shift. She stated that she is not sure how the wheelchair arm rests that are torn or cracked are cleaned. She stated the torn and cracked plastic could cause a resident sitting in the wheelchair to sustain skin tears on their arms. An interview was conducted at 10:10 a.m. on (MONTH) 17, (YEAR) with the central supply staff member (staff #158), who stated when the wheelchair arm rests are torn or cracked, staff should let him know. He stated that he orders the necessary replacements and has them installed on the wheelchairs. He further stated when the arm rest plastic is torn, it could cause a skin tear to the residents' arm, and could also be an infection control problem. Review of the Quality of Life-Homelike Environment policy and procedure revealed that Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on clinical record review, staff interviews and policy and procedures, the facility failed to ensure the Minimum Data Set (MDS) assessment for one resident (#44) was accurate. Findings include: Resident #44 was admitted on (MONTH) 16, (YEAR) and was discharged to a group home on (MONTH) 12, (YEAR). [DIAGNOSES REDACTED]. A nursing progress note dated (MONTH) 12, (YEAR) revealed the resident was alert and oriented and was discharged to a group home, via transport services on this date. A physician's progress note dated (MONTH) 12, (YEAR) revealed the resident was severely deconditioned and needed maximum assistance with all activities of daily living (ADLs). The note included the resident needed a higher level of care and was to be discharged to a group home. However, review of a discharge MDS assessment dated (MONTH) 12, (YEAR), revealed documentation in Section A: Discharge Status that the resident was discharged to an acute hospital setting. An interview was conducted with the Director of Nursing (DON/staff #2) on (MONTH) 17, (YEAR) at 10:26 a.m. She stated that she expected the MDS assessments to be accurate, so they reflect the resident's care needs. An interview was conducted with the MDS Registered Nurse (staff #83) on (MONTH) 17, (YEAR) at 10:39 a.m. Staff #83 stated that she coded the MDS as a hospital discharge and that was a mistake, as the resident was discharged to a group home setting. She further stated that the MDS needs to be accurate. Review of the facility policy titled, Resident Assessment Instrument revealed the following: Information derived from the comprehensive assessment helps staff plan care that allows the resident to reach his/her highest practicable level of function. All persons who complete any portion of the MDS Resident Assessment form must sign the document attesting to the accuracy of the information.

Based on clinical record review, staff interviews and policy and procedures, the facility failed to ensure physician orders [REDACTED].#95). Findings include: Resident #95 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. A baseline care plan dated (MONTH) 13, (YEAR) identified the resident had a potential for pain. An intervention included to administer medications as ordered. Review of the admission physician orders [REDACTED]. The [MEDICATION NAME] order did not include any parameters for administration. Review of the Medication Administration Record [REDACTED]. Per the MAR, the [MEDICATION NAME]/[MEDICATION NAME] was given on (MONTH) 15 for a pain level of 4 and on (MONTH) 16 for a pain level of 6. Further review of the clinical record revealed there was no documentation that the pain medication orders were clarified with the physician, in order to determine when to administer the [MEDICATION NAME] versus the [MEDICATION NAME]/[MEDICATION NAME]. An interview was conducted with a Licensed Practical Nurse (staff #57) on (MONTH) 17, (YEAR) at 9:36 a.m. She stated the initial admission orders [REDACTED]. She also stated that without clear parameters, the nurses would not know which PRN medication to administer. An interview was conducted with the Director of Nursing on (MONTH) 17, (YEAR) at 12:17 p.m. She stated that all PRN pain medications orders need to have pain parameters, so the nurses would clearly know how to administer the medications. According to a facility policy regarding pain management, the purpose of the policy was to identify, treat and manage the resident's pain levels.

Based on clinical record review, staff interviews, and accepted standards of clinical practice, a facility nurse failed to inform the resident's (#1) nursing home physician that his vascular surgeon wished to speak to him about her concerns for the resident's treatment. Findings include: Resident #1 was admitted to the facility status [REDACTED]. Review of the nursing admission record dated May 20, 2017 indicated that the resident noted that pedal pulses present in the left foot along with 3 + [MEDICAL CONDITION] to the left lower limb. Dressing was changed to the right BKA which had staples intact to surgical incision with pink drainage with 4 x 4 sterile dressing and kerlix wrapped. an order for [REDACTED]. Review of clinical record revealed a faxed note dated May 23, 2017 but sent on the 24th from the vascular surgeon's office listing two new orders for medication after examining the resident on May 23, 2017. The surgeon had ordered his [MEDICATION NAME] increased to 1 milligram (mg) twice a day (BID) by mouth for fluid retention. Also ordered was another antibiotic [MEDICATION NAME] 100 mg, BID by mouth. The clinical record also documented by the vascular surgeon indicated that the resident's family was spoken to in detail concerning the resident's condition at this examination. The surgeon also documented that she had contacted the facility and had requested to speak to the nursing home physician caring for the resident and no one was available spoke with the nurse caring for the resident to recommend to the facility's physician to increase the resident's diuretics, recommend to add [MEDICATION NAME], and recommend that the stump dressing be changed to wash with hibacleanse and dress with dry dressing, compression and elevation of both of his legs. Review of the medication order faxed to the facility shows that the order had been called to the nursing home physician on May 24, 2017, and added to the resident's electronic Medication Administration Record [REDACTED]. On December 26, 2017 at 12:27 p.m. an interview was conducted with a registered nurse (RN) on the 200 Hall who said that if residents go out to specialist if they come back with new orders or recommendations then she will contact the skilled nursing facility (SNF) physician or the (NP) nurse practitioner to verify the orders and enter them on the order sheet. When asked about residents with [MEDICAL CONDITION] she said they would monitor the [MEDICAL CONDITION] and chart this [MEDICAL CONDITION] including how far up the leg the [MEDICAL CONDITION] went. December 26, 2017 at 2:45 pm conducted an interview via phone with the doctor and discussed the resident and his concerns. To his knowledge he was never contacted by a nurse from the facility that he was to be contacted and to call the vascular surgeon so that she could pass along her concerns for the residents care including the Ted Hose and change in dressing change. The doctor said he was out of town from May 20, 2017 and returned on May 24, 2017 his associate was covering during this period. (No documentation by the covering physician was seen in the chart) . He does recall okaying the change in [MEDICATION NAME] order to BID 1 mg PO and adding [MEDICATION NAME]. The doctor denied that any discussion with the nurse included adding stockings or elevating the lower extremities and changing the dressing. Requested from the facility to speak with the nurse working with the resident on May 23, 2017 and was given a nurses name who no longer works in the facility but was here when the resident was here. When interviewed via phone on December 27, 2017, the RN stated she could not recall who the resident was and could not remember ever talking to a vascular surgeon on behalf of the facility's doctor. Requested to speak to any nurse that the facility knew was working on the day the vascular surgeon called. But the facility could not provide another name. Review of the clinical record resident's nursing notes May 23, 2017, showed no evidence of a documented call to the staff nurse caring for the resident from the vascular surgeon. No documentation that the facility's physician was ever notified that the surgeon had requested to speak with him concerning the resident's care. Based on acceptable clinical practice the nurse or nurses caring for the resident did not forward a phoned message from another physician with recommendations for the resident's care. The nurse or nurses did not act as patient advocate to see the resident receive the best care with coordination between the two physicians. The nurse or nurses failed to document the phone contact from the vascular surgeon noting her concerns for the resident.

Based on clinical record review, hospital record review, staff interviews, family interview, and review of facility policy and procedure, the facility failed to ensure that the drug regimen of one resident (#2) was free of an unnecessary drug that was administered in excessive dose without adequate monitoring and indications for its use resulting in actual harm. The sample size was six. Findings include: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The hospital transfer orders dated November 19, documented orders to continue the [MEDICATION NAME] ([MEDICATION NAME]) 200 mg (milligrams) four times a day. The physician's admission orders [REDACTED]. The physicians progress note dated November 25, documented that the resident reported that he had a recent hospitalization because of an increase in his medications which made him confused and "out of it." The urology consult note dated December 20, documented that the resident had a prior hospitalization for a questionable [MEDICATION NAME] overdose. The lab report dated December 31, documented that the resident's [MEDICATION NAME] level was 6.5 ug/ml (micrograms per milliliters) which was within normal limits. Review of the November and December MARs (medication administration records) revealed that the resident was administered [MEDICATION NAME] 200 mg four times a day per physician's orders [REDACTED]. The physician's recapitulation orders for January 2011, revealed that the order for the [MEDICATION NAME] was not transcribed onto the order form. Review of the physician's orders [REDACTED]. The January MAR indicated [REDACTED]. The physician's progress note dated January 2, 2011, documented that the resident reported that he had a very bad case, one of the worst spells of face and neck [DIAGNOSES REDACTED]. The physician further documented that the resident was not on [MEDICATION NAME] and that the drugs would be evaluated by the neurologist soon if recurring episodes. Review of the clinical record revealed no change in condition charting was initiated. A physician's orders [REDACTED]. The physician's orders [REDACTED]. The order further documented to begin [MEDICATION NAME] 300 mg four times a day. The physician's note dated January 3, documented that the resident reported no pain from [DIAGNOSES REDACTED] for for the past 12 hours. The physician further documented that the [MEDICATION NAME] was resumed and increased. Review of the daily nurse's notes revealed that the resident was not assessed to be in pain from January 3 through January 8. The physician's orders [REDACTED]. Review of the clinical record revealed no nurse's, physician's, or nurse practitioner's notes, as to why the [MEDICATION NAME] dose was again increased. The daily skilled nurse's note dated January 8, documented the resident had complaints of nausea and vomiting. Review of the clinical record revealed no change in condition charting was initiated. The daily skilled nurse's note dated January 10, documented that the resident had no adverse reaction to the increase in [MEDICATION NAME]. The daily skilled nurse's note dated January 11, at 10 a.m., documented that the resident complained of not feeling well, achy and some nausea. The resident was also having loose stools. Per the nurse's note the nurse practitioner was notified. At 2 p.m., licensed staff documented that the resident was NPO (nothing by mouth) after midnight for an abdominal ultrasound. The nurse documented that the resident stated that he did not "think" the nausea and vomiting was due to the [MEDICATION NAME] increase." The physician's note dated January 11, documented that the resident had increased nausea and vomiting of questionable etiology. The physician's progress note further documented to increase the [MEDICATION NAME] dose after a level was obtained secondary to [MEDICAL CONDITION] and for a neurological consult on Friday, January 14, for [DIAGNOSES REDACTED]. The facility lab report dated January 12, documented that the [MEDICATION NAME] level collected at 4:38 a.m., was high at 14.9 ug/ml. (therapeutic level 4-12). Change of condition charting was started on dated January 12 at 2 p.m. The nurse documented that the resident was confused, rambling, and "somewhat" incoherent. The physician was called. At 4 p.m., licensed staff documented that the nurse practitioner was in to assess the resident and at 5:15 p.m. the resident was transferred to the hospital. The emergency room record dated January 12, documented that the resident presented to the emergency room with symptoms that included some nausea and vomiting past week, not eating well, and some hallucinosis. The physician documented that the resident had recent increase in [MEDICATION NAME] dosage and that he had wide swings in [MEDICATION NAME] dosage. The physician also documented that the resident had prior hallucinosis with [MEDICATION NAME] overdose. The resident was admitted for cardiac monitoring, [MEDICATION NAME] toxicity, and urinary tract infection. The hospital lab report dated January 12 at 6:47 p.m. documented the resident's [MEDICATION NAME] level was critical at 19.2 ug/ml. The hospital history and physical dated January 13, documented that the resident's [MEDICATION NAME] level was found to be critically high at 19.2. The physician documented that the resident was no longer having hallucinations and his [MEDICATION NAME] level was still high at 12.7, but no longer critical. Home medications were listed as [MEDICATION NAME] 200 mg four times a day. The physician's assessment included [MEDICATION NAME] toxicity, confusion which is suspected secondary to the toxicity, [DIAGNOSES REDACTED], chronic pain, and urinary tract infection. The history and physical further documented that the physician stopped the [MEDICATION NAME] and that the levels would be monitored. The hospital discharge summary dated January 14 documented that the resident's confusion and [MEDICATION NAME] toxicity had resolved. No urinary tract infection per the culture. Per the discharge summary the resident's symptoms had improved and he was back to baseline and medically stable. During an interview conducted on July 20, the physician stated that she received a call that the resident was in pain and thought that the resident was "initially" on [MEDICATION NAME] 300 mg four times a day and that was why the resident was placed on that dose when the medication error was discovered. She stated she was unsure why the resident's [MEDICATION NAME] was increased to 400 mg four times a day since there was a lack of documentation to support the increase. She further stated that there was inconsistent documentation by the nursing staff to support any increase in the [MEDICATION NAME], but she had "reason to believe" that the increase was secondary to [DIAGNOSES REDACTED] pain. During a telephone interview conducted on July 21, the resident's family member stated that she received a call from the resident that he was experiencing severe pain in his face and neck and that something must be wrong. She further stated that the resident was in severe pain and that after she questioned nursing staff the resident was put back on his [MEDICATION NAME]; however, because his pain was now not controlled "they" kept increasing the [MEDICATION NAME] and he became toxic. Per the family member the resident had a prior history of [MEDICATION NAME] toxicity and that is how the resident "ended up" at the care facility. Interviews were conducted on July 20, and 21, with multiple licensed staff and administrative staff members. The staff members reported that they had no knowledge of the medication error and they were unsure why the resident's [MEDICATION NAME] level was increased to 400 mg four times a day. The facility's policy on order writing documented the following: "When taking a physician's orders [REDACTED]." The Nursing 2010 Drug Handbook documented that [MEDICATION NAME] given to adults for [DIAGNOSES REDACTED] should begin with an initial dose of 100 mg. bid which may be increased by 100 mg every 12 hours until pain is relieved. "Maximum 1,200 mg. a daily." Maintenance dosage is usually 200 mg to 400 mg twice a day.