Every finding on record at Havenwood-Heritage Heights

Based on interview and record review, the facility failed to submit to the Centers for Medicare & Medicaid Services (CMS) complete and accurate direct care staffing information based on payroll data for Fiscal Year Quarter 1 2026 (October 1 - December 31).Findings include:Review on 4/20/26 of the facility's Payroll Based Journal Staffing Data Report for Fiscal Year Quarter 1 2026 (October 1 - December 31) revealed that the facility failed to submit data for the quarter.Interview on 4/21/26 at 8:45 a.m. with Staff B (Administrator) confirmed the above and stated that the facilities Payroll Based Journal Staffing Data for Fiscal Year Quarter 1 2026 had been rejected.

Based on interview and record review, it was determined that the facility failed to have a water management plan that included all the necessary elements to prevent the growth and spread of Legionella and other opportunistic waterborne pathogens in a facility with a census of 64 residents.Findings include:Review on 4/21/26 of the facility's Water Management Plan, dated 1/1/26, revealed the facility used guideline materials from the Center for Disease Control for Legionella and other opportunistic pathogens to establish the facility plan. Further review revealed, The water system will be visually inspected monthly to include sinks/showers, holding tanks and mixing valves Inspection and maintenance of thermal mixing valves (TMVs) will occur monthly to make sure that adequate temperatures are maintained to prevent the growth of legionella Flushing of low use water systems will be completed monthly .HHH [Havenwood Heritage Heights] will contract with an outside contractor to provide testing for our water system annually. The water management plan did not contain a risk assessment, and the control measures were generic without specific locations or interventions for correction when controls were not met. There were no control measures for empty resident rooms. Interview on 4/22/26 at approximately 9:02 a.m. with Staff A (Maintenance Director) confirmed that the water management plan did not specify control measures or specific interventions when measures were not met. Staff A shared that they did not have documentation of interventions for out of range control measures. Staff A revealed that they were unable to produce evidence of annual water testing for 2025 and was unaware if it was completed. Staff A additionally revealed that maintenance did not monitor empty rooms and that the responsibility when empty rooms occur was the responsibility of the housekeeping department. Interview on 4/22/26 at approximately 9:34 a.m. with Staff C (Social worker) revealed that the facility currently had 2 empty resident rooms for greater than 7 days. (Dates last occupied were 4/7/26 and 4/13/26.)Interview on 4/22/26 at approximately 9:42 a.m. with Staff D (Director of Environmental Services) revealed that housekeeping was responsible for terminal cleaning when a resident room becomes empty, but they did not perform any other activities such as flushing faucets.

Based on interview and record review, it was determined that the facility failed to ensure that residents were offered or provided education on the risks and benefits of the pneumococcal vaccination for 4 of 5 residents reviewed for immunizations (Resident identifiers are #12, #18, #30, and #67). Findings include: Resident #12 Review on 3/12/25 of Resident #12's medical record revealed that Resident #12 was [AGE] years old and was admitted to the facility in 9/2023. Resident #12's immunization record revealed that pneumovax 23 was given on 9/25/12 and prevnar 13 was given on 9/3/15. Further review of Resident #12's medical record revealed that there was no indication that further pneumococcal vaccination was offered or that education was provided on the pneumococcal vaccination. Resident #18 Review on 3/12/25 of Resident #18's medical record revealed that Resident #18 was [AGE] years old and was admitted to the facility in 5/2024. Resident #18's immunization record revealed that the pneumovax 23 was given on 10/1/03. Further review of Resident #18's medical record revealed that there was no indication that further pneumococcal vaccination was offered or that education was provided on the pneumococcal vaccination. Resident #30 Review on 3/12/25 of Resident #30's medical record revealed that Resident #30 was [AGE] years old and was admitted to the facility in 2/2024. Resident #30's immunization record revealed that the pneumovax 23 was given on 9/1/09. Further review of Resident #30's medical record revealed that that there was no indication that further pneumococcal vaccination was offered or that education was provided on the pneumococcal vaccination. Resident #67 Review on 3/12/25 of Resident #67's medical record revealed that Resident #67 was [AGE] years old and was admitted to the facility in 2/2025. Resident #67's immunization record revealed that the Prevnar 13 was given on 10/24/16 and pneumovax 23 given on 10/15/18. Further review of Resident #67's medical record revealed that that there was no indication that further pneumococcal vaccination was offered or that education was provided on the pneumococcal vaccination. Interview on 3/12/25 at 10:53 a.m. with Staff A (Infection Preventionist) confirmed the above findings. Review on 3/12/25 of facility policy titled, Pneumococcal Vaccine: Residents, dated 9/10/2024, revealed: . 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccine status will be conducted within five (5) working days of the resident's admission if no conducted prior to admission. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. (see current vaccine information statements at http.www.cdc.gov/vaccines/hcp/vis/index/html for educational materials.) Provision of such education shall be documented in the resident's medical record . Review on 3/12/25 of the Center for Disease Control and Prevention guideline titled, Vaccines and Immunizations -Adult Immunization Schedule - Pneumococcal Vaccination, dated November 21, 2024, retrieved from https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-notes.html, revealed: .Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 or 1 dose of PCV21 at least 5 years after the last pneumococcal vaccine dose .Previously received only PPSV23: 1 dose PCV15 or 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PPSV23 dose.

Based on record review and interview, it was determined that the facility failed to ensure that PRN (as need) psychotropic drugs were limited to 14 days and document the rationale in the resident's medical record for extending PRN psychotropic drugs beyond 14 days for 1 of 6 residents reviewed for unnecessary medications in a final sample of 16 residents (Resident Identifier is #67). Findings include: Review on 3/13/25 of Resident #67's February 2025's Physician's Orders revealed the following physician's order written on 2/23/25 with a stop date of 2/26/25: 1. Lorazepam 2 mg/ml conc [concentrate] 0.25 ml [milliliters] (0.5 mg [milligram]) SL[sublingual] every 4 hrs [hours] PRN mild anxiety/agitation . 2. Lorazepam 2 mg/ml conc 0.5 ml (1 mg) SL every 4 hrs PRN mod [moderate-severe anxiety/agitation. Review on 3/13/25 of Resident #67's February 2025's Physician's Orders revealed the following physician's order written on 2/27/25 with no stop date: 1. Lorazepam 2 mg/ml conc [concentrate] 0.25 ml [milliliters] (0.5 mg [milligram]) SL[sublingual] every 4 hrs [hours] PRN mild anxiety/agitation . 2. Lorazepam 2 mg/ml conc 0.5 ml (1 mg) SL every 4 hrs PRN mod [moderate-severe anxiety/agitation. Review on 3/13/25 of Resident #67's medical record revealed no rationale for extending the above PRN order beyond 14 days. Review on 3/13/25 of Resident #67's Medication Administration Record (MAR) for February 2025 and March 2025 revealed that Resident #67 received no doses of PRN Lorazepam medication in February 2025 and one PRN dose of Lorazepam was given on 3/11/25. Interview on 3/13/25 at approximately 10:00 a.m. with Staff B (Director of Nursing) confirmed that the above orders did not have a rationale for the PRN order to be extended beyond 14 days. Review on 3/13/25 of the facility's policy titled, Medication Administration, dated 9/5/02, revealed: 27. If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team, with support from the consulting the Consultant Pharmacist as needed, shall reevaluated the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated. a. If PRN medication is for an Antipsychotic or Psychotropic medication, applicable stop date for reassessment will be completed.

Based on record review, observation, interview, and policy review, it was determined that the facility failed to follow policies for managing healthcare personnel with symptoms of SARS-CoV-2 (COVID-19) working in the facility (Staff identifiers are F, G, H, I, J, K, L, and M) and to sanitize a dining utility cart between uses on 1 of 2 units observed (second floor dining room). Findings include: Observation on 2/21/24 at 8:00 a.m. of the facility's staff entrance revealed COVID-19 screening for staff to attest every time a staff member enters the facility. Observation further revealed a form that each staff member has to record the date, time, name, temp, and yes or no to Have you experienced any new symptoms of COVID-19 in the past 48 hours? and In the past 10 days, have you tested positive for COVID-19 or had contact with anyone confirmed to have COVID-19? Interview on 2/21/24 at 8:10 a.m. with Staff N (Administrator) revealed that the facility was currently in an outbreak with COVID-19, 9 residents were on isolation precautions and 21 staff had tested positive on 2/19/24. Review on 2/22/24 of the facility's policy titled Infection Control Program - COVID -19 Residents/Staff/Visitor dated 1/19/24, revealed .Staff that present with high risk exposure and/or clinical manifestations of Covid -19 will be managed on a case by case basis in accordance with this policy, Staff Illness policy and current CDC [Centers for Disease Control and Prevention] guidelines .It is the responsibility of the Employee to .Avoid reporting for work with a possible infectious illness . Review on 2/22/24 of the facility's contact tracing list and investigation revealed that Staff F's (Housekeeping) symptom (cold symptoms) on set began on 2/16/24, tested positive on 2/19/24, and their last day of work was 2/19/24. Review on 2/22/24 of the facility's payroll log revealed Staff F worked on 2/16/24 for 10.62 hours and on 2/19/24 began work at 4:26 a.m. until he/she left the facility after testing positive for COVID-19. Review on 2/22/24 of the facility's contact tracing list and investigation revealed that Staff G's (Dining Services) symptom (runny nose) on set began on 2/17/24, tested positive on 2/19/24 and their last day of work was 2/19/24. Review on 2/22/24 of the facility's payroll log revealed Staff G began work at 7:57 a.m. on 2/19/24 until he/she left the facility after testing positive for COVID-19. Review on 2/22/24 of the facility's contact tracing list and investigation revealed that Staff H's (Dining Services) symptoms (runny nose and cough) on set began on 2/16/24, tested positive on 2/19/24, and their last day of work was 2/19/24. Review on 2/22/24 of the facility's payroll log revealed Staff H worked on 2/16/24 for 7.33 hours, on 2/17/24 for 7.3 hours, on 2/18/24 for 7.27 hours, and on 2/19/24 began work at 5:56 a.m. until he/she left the facility after testing positive for COVID-19. Review on 2/22/24 of the facility's contact tracing list and investigation revealed that Staff I's (Dining Services) symptom (cold symptoms) on set began on 2/17/24, tested positive on 2/19/24, and their last day of work was 2/19/24. Review on 2/22/24 of the facility's payroll log revealed Staff I worked on 2/19/24 for 3.72 hours until he/she left the facility after testing positive for COVID-19. Review on 2/22/24 of the facility's contact tracing list and investigation revealed that Staff J's (Dining Services) symptoms (cough and congestion) on set began on 2/16/24, tested positive on 2/19/24, and their last day of work was 2/18/24. Review on 2/22/24 of the facility's payroll log revealed Staff J worked on 2/16/24 for 6.52 hours, on 2/17/24 for 7.22 hours, and on 2/18/24 for 7.33 hours. Review on 2/22/24 of the facility's contact tracing list and investigation revealed that Staff K's (Dining Services) symptom (runny nose) on set began on 2/17/24, tested positive on 2/19/24, and their last day of work was 2/18/24. Review on 2/22/24 of the facility's payroll log revealed Staff K worked on 2/17/24 for 7.28 hours and on 2/18 for 7.1 hours. Review on 2/22/24 of the facility's contact tracing list and investigation revealed that Staff L's (Dining Services) symptom (cold symptoms) on set began on 2/18/24, tested positive on 2/19/24, and their last day of work was 2/19/24. Review on 2/22/24 of the facility's payroll log revealed Staff L worked on 2/18/24 for 7.9 hours and on 2/19/24 for 5.52 hours until he/she left the facility after testing positive for COVID-19. Review on 2/22/24 of the facility's contact tracing list and investigation revealed that Staff M's (Housekeeping) symptom (cough) on set began 2/17/24, tested positive on 2/19/24, and last day of worked was 2/18/24. Review on 2/22/24 of the facility's payroll log revealed Staff M worked on 2/17/24 for 7.78 hours and on 2/18/24 for 8.1 hours. Interview on 2/22/24 at 8:45 a.m. with Staff N and Staff O (Director of Nursing) confirmed that Staff F, G, H, I, J, K, L, and M worked while symptomatic. Interview further revealed that the above staff were attesting upon entrance no to being symptomatic but once staff tested positive, they started their investigation and asked the positive staff when their symptoms started. Interview on 2/22/24 at 10:30 p.m. with Staff P (Infection Prevention) revealed that education about staying home when feeling sick was an ongoing effort but Staff P provided education in October during a flu clinic and in December during National Influenza Vaccine Week. Review on 2/22/24 of the facility's policy titled Staff Illness dated 1/19/24, revealed .Requirements: Prior to shift, all staff will self-screen for illness . Staff with a potential communicable disease or infected skin lesions, are prohibited from having contact with resident and/or their food until they have cleared per nationally recognized standards and regulations .It is the responsibility of the staff to: Not report to work if ill . Review on 2/22/24 of the CDC Interim Guidance for Managing Healthcare Personnel [HCP] with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html, updated September 23, 2022, revealed, .Evaluating Healthcare Personnel with Symptoms of SARS-CoV-2 Infection HCP with even mild symptoms of COVID-19 should be prioritized for viral testing with nucleic acid or antigen detection assays .If using NAAT [Nucleic Acid Amplification Test] (molecular), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining work restrictions and confirming with a second negative NAAT. If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or a second negative antigen test taken 48 hours after the first negative test. For HCPs who were initially suspected of having COVID-19 but, following evaluation, another diagnosis is suspected or confirmed, return-to-work decisions should be based on their other suspected or confirmed diagnoses. 38218 Observation on 2/21/24 at approximately 12:20 p.m. in the second floor dining room revealed a utility cart containing 4 used breakfast trays. The lunch cart arrived at the dining room and Staff A (Licensed Nursing Assistant (LNA)) removed the 4 used breakfast trays (been distributed to residents and then returned after meal) from the utility cart and placed them on the countertop. Staff A then proceeded to take a lunch tray from the lunch cart and place it on the utility cart where the used breakfast trays had been without sanitizing the cart. Interview on 2/21/24 at approximately 12:20 p.m. with Staff B (LNA) revealed that the kitchen staff that delivered the lunch trays usually took the used breakfast trays downstairs on the utility cart. Staff B stated that the utility cart should have been sanitized before placing the lunch tray on the utility cart. Review on 2/21/24 of the facility policy titled Health Services Center Dining Program dated 1/20/23 revealed: .4 At the conclusion of the meal nursing personnel will return the trays to the cart. Dining personnel will retrieve the cart from the HSC (Health Service Center) and return them to the kitchen so all items can be cleaned and sanitized.

Based on observation, interview, and record review, it was determined that the facility failed to properly label medication in 1 of 4 medication carts observed (second floor 2F unit medication cart). Findings include: Observation on 2/21/24 at approximately 10:30 a.m. of the second floor 2F unit medication cart revealed an open Lispro insulin flex pen without an open date and/or an open expiration/discard date that was in use for Resident #119. Interview on 2/21/24 with Staff E (Medication Nurse Assistant) confirmed the above finding. Review on 2/22/24 of the facility's policy titled Storage and Destruction of Medications dated 2/8/18, revealed: .3.medications shall include all necessary information, such as .Date opened Review on 2/22/24 of Humalog Insulin Lispro Injection manufacturer specifications, dated 3/2013, revealed: .16.2 Storage and Handling .In-use HUMALOG vials, cartridges, pens, and HUMALOG KwikPen .must be used within 28 days or be discarded, even if they still contain HUMALOG .

Based on interview and record review, it was determined that the facility failed to ensure that Significant Change in Status Minimum Data Set (MDS) were completed timely by the 14th calendar day of a resident being admitted to hospice services for 2 of 3 residents reviewed for hospice in a final sample of 16 residents (Resident Identifiers are #31 and #35). Findings include: Resident #31 Review on 2/21/24 of Resident #31's Hospice Medicare Election Statement dated 2/14/23 revealed that Resident #31 was admitted to hospice care on 2/14/23. Review on 2/21/24 of Resident #31's Significant Change in Status MDS with an Assessment Reference Date (ARD) of 2/28/23 revealed it was completed on 3/14/23, fourteen days late. Interview on 2/22/24 at 1:55 p.m. with Staff D (MDS Coordinator) confirmed that the above MDS assessment for Resident #31 should have been completed within fourteen days after signing onto hospice services and was completed late. Resident #35 Review on 2/21/24 of Resident #35's Hospice Medicare Election Statement dated 9/21/23 revealed that Resident #35 was admitted to hospice care on 9/21/23. Review on 2/21/24 of Resident #35's Significant Change in Status MDS with an ARD of 10/9/23 revealed it was completed on 10/23/23, eighteen days late. Interview on 2/22/24 at 12:06 p.m. with Staff D revealed that he/she follows the Resident Assessment Instrument for guidance on coding and completing MDS forms. Interview on 2/22/24 at 1:55 p.m. with Staff D confirmed that the above MDS assessment for Resident #35 should have been completed within fourteen days after signing onto hospice services and was completed late. Review on 2/22/24 of the facility's undated policy titled MDS Completion and Submission Timelines revealed, .Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes . 2. Timeframes for completion . of assessments is based on the current requirements published in the Resident Assessment Instrument Manual .

Based on observation, interview, and record review, it was determined that the facility failed to follow physician's orders and standards of practice during medication administration observation for 1 out of 3 residents observed (Resident identifier is #3). Findings include: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders, The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 2/1/23 of Resident #3's February 2023 Medication Administration Record (MAR) revealed the following physician's order: Miralax powder, Give 17 grams of powder in 8 ounces (oz) of fluid of choice daily at 8:00 a.m. Observation on 2/1/23 at approximately 7:20 a.m. during medication administration with Staff A (Licensed Practical Nurse) revealed that he/she was about to enter Resident #3's room without the resident's ordered Miralax. Interview on 2/1/23 at approximately 7:20 a.m. with Staff A confirmed the above findings and they were done preparing medications and were not going to administer Resident #3's ordered Miralax. Review on 2/1/23 of the facility policy titled, Medication Administration, Dated 10/7/22 revealed: .3. Medications must be administered in accordance with the orders, including any required time frame Reference for the professional standard of practice for the administration of medication is the 10th Edition of Clinical Nursing Skills and Techniques, Perry-Potter page 602 which revealed the following: Preadministration Activities, . 7. Avoid touching tablets and capsules. Observation on 2/1/23 at approximately 7:20 a.m. with Staff A (Licensed Practical Nurse) revealed that he/she dropped 3 pills on the medication cart (2 pills landing on the medication cart and 1 pill landing on the keyboard) and picked the 3 pills up with his/her bare fingers and placed the medication in a medication cup. Further observation revealed Staff A open a capsule with his/her bare fingers and emptied the capsule into a medication cup. Staff A administered the 3 medications that fell to the resident. Interview on 2/1/23 at approximately 7:20 a.m. with Staff A confirmed the above findings. Staff A stated that he/she does not wear gloves when opening capsules. Interview on 2/2/23 at approximately 11:30 a.m. with Staff B (Director of Nurses/Infection Preventionist) confirmed that medications in capsule should not be opened without gloves and medications that land on the medication cart should not be administered.

Based on interview and record review, it was determined that the facility failed to assure that medical records were complete and accurate for 1 resident in a final sample of 16 with records reviewed. (Resident identifier is #21.) Findings include: Review on 2/24/22 at approximately 11:54 a.m. of Resident #21's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 02/24/22 at approximately 2:20 p.m. with Staff D Registered Nurse confirmed no documentation of removal of [MEDICATION(S)] on February 2022 MAR for Resident #21 on 2/1/22,2/5/22, and 2/9/22. Staff D stated that there is no system in place to assure that patch removal is documented.

Based on interview and record review, it was determined that the facility failed to notify the responsible party of a resident after a fall for 2 residents out of 3 residents reviewed for falls in a final sample size of 16 residents. (Resident identifiers are #9 and #45.) Findings include: Resident #9: Review on 2/24/22 at 7:29 a.m. of Resident #9's advanced directives revealed that Durable Power of Attorney (DPOA) was activated on 2/14/20. Review on 2/24/22 at approximately 9:00 a.m. of Resident #9's nurse's note of 2/23/22 written at 6:33 a.m. revealed that Resident #9 fell at 4:30 a.m. There was no documentation that the DPOA (Family A) had been notified. Interview on 2/24/22 at approximately 9:20 a.m. with Family A revealed she/he had not received any phone calls from the facility in the past week for Resident #9. Review on 2/24/22 at approximately 1:10 p.m. of Resident #9's Resident Incident Report dated 2/23/22 at 4:35 a.m. revealed .Narrative of Incident and Description of Injuries: Staff heard resident fall. Was found lying on the floor on [pronoun omitted] right side. Lower body in room. Mid/upper body in tent and hallway. Pull-ups partially pulled down and gown wet with urine. She was awake/alert/confused (baseline) . Further review of this form revealed that family notification was left blank. Review on 2/24/22 at approximately 1:10 p.m. of Resident #9's Resident Falls Checklist dated 2/23/22 at 4:30 a.m. revealed under notification of DPOA was left unchecked. Interview on 2/24/22 at 1:16 p.m. with Staff A (Clinical Coordinator) confirmed that Resident #9 fell on [DATE]. Staff A stated that Family A should have been notified of the fall. Staff A confirmed that there was no documentation that Family A was notified. Interview on 2/24/22 at 1:45 p.m. with Staff C (Director of Nursing) confirmed that Family A should have been notified of Resident #9's fall on 2/23/22. Interview on 2/24/22 at approximately 3:00 p.m. with Staff A revealed that he/she had spoken with Family A in the past hour and confirmed that they had not been notified of the fall. Resident #45 Review on 2/24/22 at approximately 8:21 a.m. of Resident #45's nurses notes dated 1/2/22 at 12:17 a.m., 7:23 a.m., and 6:59 p.m. revealed documentation that Resident #45 was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally there was no nurses note dated 1/1/22 that the resident had fallen. Interview on 2/24/22 at 2:28 p.m. with Staff A confirmed that there was no documentation that Resident #45's responsible party had been notified of the fall on 1/1/22. Staff A stated that the facility communicated with the responsible party via email, however, there was no email regarding notification of this fall. Review on 2/24/22 of Resident #45's Resident Incident Report dated 1/1/22 at 6:31 a.m. revealed .Narrative of Incident and Description of Injuries: Alerted by 6-2 aide that he/she observed [Resident #45] sitting on the floor in the activity room. Supervisor made aware. No injuries apparent. Sneakers on. Assisted up from the floor with supervisor permission . Further review of this form revealed that family notification was left blank. Review on 2/24/22 of Resident #9's Resident Falls Checklist dated 1/1/21 at 6:30 a.m. revealed under notification of DPOA was circled with a checkmark. The form did not indicate when the DPOA was notified. Interview on 2/24/22 at 2:37 p.m. with Staff C confirmed that there was no documentation of when Resident #45's DPOA had been notified of the fall, including in a nurse's note, email, or resident incident report. Staff C confirms this is where this documentation should be.

1. Based on record review and interview, it was determined that the facility failed to ensure that PRN (as needed) [CONDITION(S)] drugs were limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 resident out of 6 residents reviewed for unnecessary [CONDITION(S)] medications in a final sample size of 16 residents. (Resident identifier is #50.) Resident #50 Review on 2/23/22 of Resident #50's medical record revealed the following physicians order: [MEDICATION(S)] [MEDICATION(S)] (2 mg (milligram)/ml (milliliter) give 0.25 ml sl (sublingual) Q (every) 4 hours PRN for agitation, for restlessness, dated 1/14/21. Interview on 2/24/22 at approximately 2:10 p.m. with Staff C (Director of Nursing) confirmed that there was no stop date indicated on the PRN [MEDICATION(S)] order and no rationale from the physician documented to extend past the 14 days for the [MEDICATION(S)] [MEDICATION(S)] PRN order. 2. Based on interview and medical record review, it was determined that the facility failed to ensure that consent was obtained for a resident's [CONDITION(S)] drug, including black box warning information, for 2 out of 7 residents reviewed for [CONDITION(S)] medication use in a standard sample size of 16 residents. (Resident identifiers are #63, and #364.) Findings include: Resident #63 Review on 2/23/22 of Resident #63's physician's orders revealed an order dated 2/11/22 to begin [MEDICATION(S)] 25 mg (milligrams) by mouth twice daily. Further review of Resident #63's physician's orders revealed an order dated 2/18/22 to increase [MEDICATION(S)] to 37.5 mg twice daily and to give an extra dose [MEDICATION(S)] 25 mg times one on 2/18/22. Review on 2/23/22 of Resident #63's Electronic Medication Administration Record for February 2022 revealed that [MEDICATION(S)] 37.5 mg was administered 2/19/22 thru 2/23/22. Review on 2/24/22 at approximately 7:41 a.m. of Resident #63's medical record revealed there was no written or verbal consent obtained for [MEDICATION(S)] 37.5 mg twice daily, including black box warning. Interview on 2/24/22 at approximately 1:10 p.m. with Staff A (Clinical Coordinator) confirmed there was no consent for the [MEDICATION(S)] 37.5 mg, including black box warning had been reviewed with power of attorney. Resident #364 Review on 2/24/22 at 8:58 a.m. of Resident #364's medical record revealed active physician's order for [MEDICATION(S)] concentrate (Antipsychotic) 2 mg (milligrams)/1 ml (milliliter)- give 0.5 mg every 6 hours as needed for agitation , hallucination or anxiety with an initiation date of 2/17/21. Further review of Resident #364's medical record revealed a blank psychoactive medication therapy informed consent in Resident #364's chart with a sticker Resident #364's name. Further review of the consent form revealed there was no black box warning information on the consent form. Interview on 2/24/22 at approximately 1:30 p.m. with Staff C (Director of Nursing) confirmed that there was no consent completed or signed for [MEDICATION(S)] use for Resident #364. Staff C confirmed that the blank psychoactive medication therapy informed consent form in Resident #364's chart did not have any black box warnings identified on the form.

Based on interview, it was determined that the facility failed to ensure that all hospice patients did not experience a lack of services, to include volunteers, for 1 of 1 residents reviewed for Hospice services out of a survey sample of 16. (Resident identifier is #14.) Findings include: Interview on 2/23/22 at approximately 1:23 p.m. with Resident #14's Durable Power of Attorney for Healthcare (DPOA-HC) revealed that they were told that hospice volunteers were not allowed into the facility. Resident #14's DPOA-HC stated that they had agreed to Hospice so Resident #14 could have extra help and visitation through volunteers. Interview on 2/24/22 at approximately 12:45 p.m. with Staff B (Registered Nurse) revealed that the facility only allowed Hospice Nurses and Licensed Nursing Assistance, not volunteers, to enter the building due to COVID-19. Interview on 2/24/22 at approximately 1:00 p.m. with Staff C (Director of Nursing) confirmed the above information.

Based on observation, interview, record review and policy review, it was determined that the facility failed to follow facility smoking policy for 1 out of 1 resident who smoked. (Resident identifier is #11.) Findings include: Review on 5/22/19 of facility's policy titled, Resident Smoking while in the Health Service Center, dated 10/07/16, revealed .complete a smoking evaluation .review status of resident's smoking privileges at least quarterly and more often as needed .update the resident's care plan to indicate the current status of smoking privileges/restrictions Review on 5/22/19 of facility's smoking evaluation, revision date 10/7/16, revealed .for resident who wishes to smoke, perform evaluation on admission, quarterly, at a significant change, or if there has been an incident of unsafe smoking observed or reported Interview on 5/21/19 at 11:42 a.m. with Resident #11 revealed that Resident #11 smoked once a day at the parking lot with staff supervision. Resident #11 stated that they kept their cigarettes in their bedside drawer and that the nurses kept their lighter. Observation on 5/21/19 at 11:42 am in Resident #11's room revealed that Resident #11 had a box of cigarette in their bedside table. Review on 5/23/19 of Resident #11's current smoking care plan revealed that Resident #11 wanted to continue to smoke and that Resident #11 will not smoke without someone present, Resident #11 will smoke 1 cigarette per outing, and Resident #11's friend will accompany resident outside of sliding glass doors, down the ramp, and outside the fence to smoke. Review on 5/23/19 of Resident #11's chart and EHR (Electronic Health Record) revealed that Resident #11's smoking evaluation was completed on 10/7/16. Further review of Resident #11's chart and EHR revealed no other smoking evaluation after 10/7/16. Interview on 5/23/19 at 8:45 a.m. with Staff B (Registered Nurse) confirmed that Resident #11 was the only resident who smoked. Staff B revealed that there was no smoking evaluation done. Staff B stated that they do not do smoking evaluation. Staff B was unable to provide more information regarding smoking evaluation. Interview on 5/23/19 at 8:45 a.m. with Staff D (Unit Coordinator) revealed that Resident #11 was supervised when smoking and that Resident #11 utilized a smoking apron. Interview on 5/23/19 at 9:00 a.m. with Staff A (Unit Manager) revealed that there was no smoking evaluation done after 10/7/16. Staff A stated that they did not know about the smoking policy and smoking evaluations. Staff B also stated that the care plan was not updated as Resident #11 needed a smoking apron and that Resident #11's lighter would be kept at the nurse's medication cart when not used by Resident #11.

Based on interview and review of the facility policy, it was determined that the facility failed to include two of the seven required components that assure the facility is doing all that is within its control to prevent occurrences of abuse and neglect. Findings include: Review on 9/21/17 of the facility policy for abuse and neglect titled Resident Abuse, Neglect, & Exploitation dated 5/31/2017 revealed that of the seven required components that must be included in the facilities abuse policy two were not included. The components are: Screening, training, protection, prevention, identification, investigation, and reporting/response. The two components that were not included in the facility's policy are screening and identification. Interview on 9/21/17 at approximately 2:10 p.m. with Staff B (Director of Nursing) confirmed that the two components had been left out of the current policy when it was put into effect on 5/31/17.

Based on record review and interview, it was determined that the facility failed to develop comprehensive care plans for 2 residents out of a sample size of 18 residents. (Resident Identifiers are #3 and #9.) Findings include: Resident #9 Review on 9/21/17 of Resident #9's medical record in the nursing note dated 6/15/17 02:28 p.m. revealed that Resident #9 had a pacemaker. Review on 9/21/17 of Resident #9's care plans revealed that there was not a care plan for the pacemaker. Interview on 9/21/17 at approximately 2:00 p.m. with Staff A (Registered Nurse) confirmed that there was not a care plan for Resident #9's pacemaker. Resident #7 Review on 9/18/17 of Resident #7's comprehensive care plan indicates Resident #7 is receiving a regular diet. Interview on 9/22/17 with Staff H (Registered Dietician) revealed that Resident #7 since 8/28/17 Resident #7 has been receiving a mechanical soft diet with ground meat. The Facility failed to ensure that Resident #7's comprehensive care plan reflected the actual diet Resident #7 was receiving. Resident #3 Review on 9/21/17 of Resident #3's [DIAGNOSES REDACTED].#3 had a pacemaker in place. Review on 9/21/17 of Resident #3's current Care Plan, dated 7/13/17, revealed that there was no care plan for Resident #3's use of a pacemaker. Interview on 9/22/17 at approximately 11:00 a.m. with Staff E (Registered Nurse) confirmed that Resident #3 had a pacemaker and that there was no care plan in place for the pacemaker.

Based on observation and interview, it was determined that the facility failed to discard expired medications found in the medication room on Lighthouse Lane and medication cart on Melody Lane medication cart. Findings include: Observation on 9/22/17 at approximately 7:15 a.m. of the Melody Lane medication storage room refrigerator revealed the following expired medications: [REDACTED] Prochloroperazine 25 mg (milligram) suppositories expiration date 6/17. (House Stock) Glycerin suppositories expiration date 1/17. (House Stock) Interview on 9/22/17 at approximately 7:15 a.m. with Staff D (Licensed Practical Nurse) confirmed that the above medications were expired. Observation on 9/22/17 at approximately 8:10 a.m. of the medication cart on Melody Lane revealed the following expired medications: [REDACTED] Melatonin 3 mg (milligram) expiration date 3/16. (Resident # 10) Nitrostat 0.4 mg expiration date 5/25/17. (Resident #19) Nitrostat 0.4 mg expiration date 6/29/17. (Resident #20) Nitrostat 0.4 mg expiration date 6/28/17. (Resident #21) Risperdal 0.25 mg expiration date 7/19/17. (Resident #22) Tylenol 325 mg expiration date 9/6/17. (Resident #23) Sennokot S 8.6/50 mg expiration date 9/6/17. (Resident #23) Tylenol 325 mg expiration date 6/28/17. (Resident #24) Acidophilus with Pectin expiration 6/14/17. (Resident #24) Preservision Areds expiration date 5/30/17. (Resident #25) Sennokot S 8.6/50 mg expiration date 9/16/17. (Resident #26) Siltussin 100 mg/5 ml (milliliter) expiration date 9/3/17. (Resident #27) Siltussin 100 mg/5 ml expiration date 3/26/17. (Resident #27) Siltussin 100 mg/5 ml expiration date 5/14/17. (Resident #28) Clindamyocin 300 mg expiration date 6/23/17. (Resident #29) Interview on 9/22/17 at approximately 8:20 a.m. with Staff D and Staff C (Medication Nurse Assistant) confirmed that the above medications were expired. Interview on 9/22/17 at approximately 2:30 p.m. with Staff B (Director of Nurses) revealed that there was not a facility policy and procedure for discarding expired medications. Observation on 9/21/17 at approximately 3:00 p.m., of the Medication Room refrigerator on Lighthouse Lane, revealed an opened vial of Tuberculin Purified Protein Derivative, which was not dated. Review on 9/21/17 of the Manufacturer's instructions for the Tuberculin Purified Protein Derivative revealed that A vial of Tubersol which has been entered and in use for 30 days should be discarded. Interview on 9/21/17 at approximately 3:00 p.m. with Staff G (Licensed Practical Nurse) confirmed that all multidose vials were to be dated when opened and that this multidose vial was not dated.

Based on observation, interview and policy review, it was determined that the facility failed to prevent the potential for cross contamination during blood glucose monitoring on 1 of 2 units and that the professional standard of practice for hand hygiene was implemented to reduce the spread of infection and prevent cross contamination for 3 of 3 residents observed during medication pass observation. (Resident identifiers are #16, #17 and #18) Findings include Resident #16 Observation on 9/22/17 at approximately 7:30 a.m. of the medication pass on Lighthouse Lane B revealed Staff F, MNA (Medication Nursing Assistant) administering medications to Resident #16. The medications administered to Resident #16 were Tylenol tablets and Artificial Tears eye drops. Staff F administered the Tylenol and then donned gloves to administer the eye drops. Staff F removed the gloves after administering the eye drops and did not wash hands or apply hand sanitizer when done. Staff F walked over to the medication cart to start pouring medications for the next resident, Resident #17. Resident #17 Observation on 9/22/17 at approximately 7:40 a.m. of the medication pass on Lighthouse Lane B revealed Staff F, who had just finished administering medications to Resident #16, go over to the medication cart and started pouring medications for Resident #17. Staff F did not wash hands or apply hand sanitizer before pouring the medications for Resident #17. Staff F brought the medications, which included several tablets as well as Refresh eye drops, to Resident #17. Staff F administered the tablets and then donned gloves to administer the eye drops. Staff F removed the gloves after administering the eye drops and did not wash hands or apply hand sanitizer when done. Staff F walked over to the medication cart to start pouring medications for the next resident, Resident #18. Resident #18 Observation on 9/22/17 at approximately 7:50 a.m. of the medication pass on Lighthouse Lane B revealed Staff F, who had just finished administering medications to Resident #17, go over to the medication cart and started pouring medications for Resident #18. Staff F did not wash hands or apply hand sanitizer before pouring the medications for Resident #18. Staff F brought the medications, which included several tablets as well as Nasal Spray and [MEDICATION NAME] inhaler, to Resident #18. Staff F administered the tablets and then donned gloves to administer the Nasal Spray and the inhaler. Staff F removed the gloves after administering the eye drops and did not wash hands or apply hand sanitizer when done. Review on 9/22/17 of the Facility Policy, Titled Administration of Medications. Date 9/5/02 revealed Procedure: Action .Wash hands using proper hand washing technique. Don gloves when appropriate. Rationale .Decreases transfer of microorganisms when there is any chance of exposure to resident body secretions. Lessens transfer of microorganisms . Interview on 9/22/17 at approximately 2:00 p.m. with Staff B (Director of Nursing) confirmed that hand hygiene was supposed to be done between residents during medication administration. Observation on 9/22/17 at approximately 8:00 a.m. of the glucometer on(NAME)Lane medication cart revealed a brown/red dried substance on the back of the Glucometer. Interview on 9/22/17 at approximately 8:00 a.m. with Staff C (Medication Nurse Assistant) and Staff D (Licensed Practical Nurse) revealed that the glucometer was ready for use. Staff D confirmed that there was a brown/red dried substance adhered on the back of the meter.

Based on record review and interview, it was determined that the facility did not develop a written care plan for three triggered areas for 1 resident in a standard survey sample of 15 residents. (Resident identifier is #8.) Findings include: Record review of the Admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/7/13 revealed that the facility indicated it would care plan for 9 of 10 triggered areas (not care planning for Visual Function). This was confirmed by review of the CAAs (Care Area Assessments) for the triggered areas. Review of the care plans, however, revealed that there was no care plan developed for Cognitive Loss/Dementia, Communication, or Urinary Incontinence and Indwelling Catheter. Interview on 6/12/13 in the afternoon with Staff E, (MDS Coordinator) confirmed that these three triggered areas had not had care plans developed.

Based on medical record review and interview it was determined that the facility failed to create a comprehensive care plan within 7 days after the completion of the comprehensive assessment for 1 resident in a standard survey sample of 15 residents. (Resident identifier is #12). Findings include: Observation of the medication pass on 6/12/13 at approximately 8 a.m. revealed the self administration of a [MEDICATION NAME] wafer left at the bedside to be taken with the residents coffee. Review of the medical record on 6/12/13 and 6/13/13 revealed that Resident #12 had a current self administration care plan but the TUMS medication originally care planned for was stopped and no update for [MEDICATION NAME] had been added. This resident also had a current Dysphagia care plan that read, "Monitor for signs of aspiration." Interview on 6/12/13 with Staff D (RN, Unit Manager) at 9 a.m. revealed that the Dysphagia care plan had been discontinued. Staff D was unable to determine the exact date. Staff D stated that both care plans should have been updated and were not. Interview on 6/12/13 with Resident #12 after lunch revealed an alert and oriented resident who had refused treatment until today for any coughing. The resident stated that they had NEVER choked on the [MEDICATION NAME] only on the "big [MEDICATION NAME] pill." This resident stated that now they did not have to take that pill anymore. Resident #12 went on to say that they softened the "cookie ([MEDICATION NAME] wafer)" in the coffee and that this medication really helped them "stay regular."

Based on morning medication pass, record review and interview the facility failed to ensure medications were administered based on professional standard of quality for 1 resident in a standard survey sample of 15 residents. (Resident identifier is #4). Findings include: During observation of the morning medication pass on 6/12/13 at approximately 9 a.m. with Staff F, (LPN) witnessed Staff F pour and administer the following 8 a.m. medications for Resident #4: [MEDICATION NAME] (1) 250 mg capsule HCTZ (Hydrochlorathiazide) (1) 12.5 mg tablet [MEDICATION NAME] (1) 30 mg tablet [MEDICATION NAME] (1) 75 mg tablet Potassium Chloride (2) 10 meq (Milliquivelent) capsule At this time, the HCTZ fell on to the medication cart and Staff F picked it up with her ungloved hand and placed the medication in the medication cup. Interview on 6/12/13 at approximately 9:30 a.m. with Staff F revealed Staff F's awareness that medications should not be directly handled and should not be administered to residents if medication falls on an unclean surface.