Every finding on record at Hialeah Shores Nursing and Rehab Center

Based on observation, record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) assessment for one (Resident #28) out of one resident reviewed for dental assessments. Resident #28 was coded incorrectly as being edentulous. The findings included: Observation and interview with Resident #28 was conducted via a Spanish translator on 2/27/2024 at 7:45 AM. The resident was sitting up in bed, preparing for breakfast, using a hearing amplifier device to hear. The resident had natural teeth, missing teeth on the bottom and had bilateral hand contractures. She revealed, she had not seen a dentist in a long time and wanted to see the dentist. Review of the Demographic Face Sheet for Resident #28 documented the resident was admitted on [DATE] with a diagnosis of heart failure, chronic obstructive pulmonary disease, chronic kidney disease, schizophrenia, hearing loss and major depressive disorder. Review of the Minimum Data Set (MDS) Annual Assessment for Resident #28 dated 12/22/2023 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 11 out of 15 indicating mild cognitive impairment and the resident was able to make her needs known. The resident required partial/moderate assistance for eating and dependent assistance for ADLs (Activities of Daily Living), no natural teeth or tooth fragments edentulous and was coded Yes. Review of the Dental Care Plan for Resident #28 documented the following: Focus: Resident with some natural teeth loss. Resident has lower natural teeth (some missing pieces) (written 6/19/2023; reviewed and updated); Goals: Resident will not have any s/s (signs/symptoms) of discomfort/complications related to teeth loss left unmanaged through next review date; Resident will not have any s/s of discomfort/complications related to teeth loss or use of dentures left unmanaged through next review date and Interventions: Dental consult as needed/as per facility protocol; Assist resident with oral care daily as needed; Assess for loose fitting dentures and report as needed. On 2/29/2024 at 8:55 AM, interview with the Social Services Director. She stated, She has some natural teeth. On 2/29/24 at 9:46 AM, interview and record review with Staff A, Registered Nurse (RN) MDS (Minimum Data Set) Coordinator on 2/29/2024 at 9:46 AM. She stated, We had a part time MDS Coordinator who conducted the assessment and the assessment is incorrect. It is a coding error. The resident does have teeth. She is not edentulous. The care plan reflects that she has teeth. We are going to do a modification of the MDS. Record review of the facility's policy titled, Conducting an Accurate Resident Assessment (no written date) documented: Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (comprehensive, quarterly, significant change in status); Policy Explanation and Compliance Guidelines: 2) Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths and areas of decline. The assessment will be documented in the medical record. Review of the facility's policy titled, Resident Assessment -RAI (no written date) documented: Policy: This facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI); Policy Explanation and Compliance Guidelines: 2) The assessment will include at least the following: k. Dental and nutrition status and 3) The assessment process will include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts.

Based on record review and interview the facility failed to ensure the arbitration agreements presented to three residents (Resident number 12, Resident number 52 and Resident number 153) out of three residents reviewed informed residents or their representatives of the nature and implications of any proposed binding arbitration agreement, to inform their decision on whether or not to enter into such agreements. There were 105 residents residing in the facility at the time of the survey. The findings included: Record review of the Binding Arbitration Agreements on facility letterhead documented the following: 1) The facility offers arbitration agreements; 2) The facility asks residents or their representatives to enter into an arbitration agreement, 3) The facility had residents who entered a binding agreement on or after 9/16/2019 and 4) The Admissions Coordinator is responsible for the binding arbitration agreements. Review of the facility Arbitration Agreement documented the following: Resident number 12 signed and dated on 1/10/2024, Resident number 52 signed and dated on 1/18/2024 and Resident number 153 signed and dated on 2/15/2024 failed to show the arbitration agreements allowed the resident or anyone else to communicate with federal, state or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. On 2/27/2024 at 11:34 AM, interview and record review with the Admissions Coordinator confirmed that the Arbitration Agreement did not document that the binding arbitration agreement allowed the resident or anyone else to communicate with federal, state or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman.

Based on observation, interview, and record review, the facility failed to maintain the privacy for one resident (Resident # 59) out of one resident for privacy as evidenced by, posting a visible sign on the wall of Resident # 59 room disclosing Protective Health Information (PHI). There were ninety- nine residents residing in the facility at the time of this survey. The findings included: Observation completed on 11/28/2022 at 10:26 AM revealed Resident #59 resting in bed. Resident #59 was alert but has some confusion. Observation revealed a paper attached to the wall at the head of the resident's bed with the resident's name and a sign indicating Heart Monitor in Use sign that stated, Please do not unplug unit. Unplug the power cord will prevent the patient's heart from being monitored. Thank you, [ name of diagnostic company]. (photographic evidence obtained). When the charge nurse was asked about the sign, Staff B, Charge Nurse reported that resident has a pacemaker underneath the skin on the left upper chest and there is a memory device plugged to the wall to record and monitor the heart. Charge nurse reported resident use the pacemaker for two years with the purpose of long-term use. On 11/29/22 at 08:38 AM, observed Resident #59 sleeping in bed. Head of bed was elevated. The heart monitor device was plugged inside the wall. The sign related to the heart monitor in use was not on the wall. On 11/30/22 at 02:48 PM, Resident #59 was observed sitting in chair, watching television. The sign related to the heart monitor in use was no longer posted on the wall. Record review of Resident #59 face sheet revealed initial date of admission 05/04/2022. Diagnoses included but not limited to: Hypertensive heart disease, Myocardial Infarction, Dementia, Coronary Artery Disease, Pacemaker Placement and Cardiomegaly. Record review of Minimum Date Set (MDS) Quarterly assessment dated on 09/04/2022 revealed: Section C- for cognitive pattern documented a Brief Interview of Mental Status (BIMS) score of 3 out 15 indicating Resident #59 is severely cognitive impaired. Section G- for Functional Status indicated total dependence with extensive assistance for Activities of Daily Living (ADL). Review of Resident #59's care plan dated on 05/05/22 revealed: Resident cardiac stability will maintain as evidenced by no shortness of breath, cyanosis, edema, chest pain, stable. Interview with the DON (Director of Nursing) on 12/01/2022 at 3:50 PM revealed that she did not see the sign that was posted on Resident #59' wall at the head of the bed. When this surveyor showed the picture taken during the initial observation of the visible sign indicating: Heart Monitor in Use with Resident #59 name, heart monitor, and diagnostic testing center telephone number to the DON. The DON stated that she was not aware and acknowledged that the sign should not have been posted and that the sign was removed. During the interview the DON added that they are providing education to the staff about resident's privacy. When a resident is admitted with a medical device such as a pacemaker, she ensured that she has provided teaching to full time regular staff for each unit. Therefore, the regular full-time staff would be knowledgeable about their residents' pertinent diagnoses, conditions, and comorbidities. On 12/01/2022 at 4:30 PM, both the ADON (Assistant Director of Nursing) and (Director of Nursing) acknowledged that the sign was disclosing PHI (protective health information). They did not know who posted the sign on the wall. They believed that it was important to protect resident health information and to promote safety to all the residents. Rewiew of the facility's Policy and Procedures on Privacy dated 2016 revealed: Policy: It is the policy of the facility to ensure that resident's privacy is respected. The Procedures of the Policy about privacy are included but not limited to: 1. The resident has a right to be treated with respect 2. Keep residents personal identifying information covered and out of sight.

Based on observations, interviews and record review, the facility failed to ensure linens and residents personal laundry items were handled in a sanitary manner to prevent cross contamination and the spread of infection. as evidenced by failure to wear appropriate Personal Protective Equipment (PPE) during handling of soiled linen and failure to ensure hand hygiene supplies are readily available on hand in area where soiled laundry was being handled. On 01/27/21 at 10:19 AM, observation revealed housekeeping Staff K wearing gloves, bending over a three feet tall yellow barrel, and moving linens from one barrel to another without wearing a gown. An interview was conducted with staff K, and she explained that she was sorting the resident's soiled linens. Staff K stated that the residents laundry items are placed in the linen container on the units, then those containers are brought outside, and they sort them into a blue bag, then they are placed in the trailer area. During an interview Staff K was asked why she was not wearing a gown. Staff K stated that she forgot to put a gown on. During the interview, Staff K removed her gloves and placed her hands into her pocket did not perform hand hygiene. Staff K pulled a cell phone and proceeded to make a call. Staff K was asked about performing hand hygiene, Staff K stated that she goes inside the facility thru the double door, to the soiled utility room and perform hand hygiene. Observation revealed Staff K walked inside the facility approximately 15-20 feet to the soiled utility room . On 01/27/21 at 10:25 AM, observation revealed the Director of Housekeeping handing a trash bag to Staff K and asked her to put gloves on. Staff K was observed donning gloves without performing hand hygiene. On 01/27/21 at 10:26 PM, during an interview the facility's Director of Housekeeping stated that the resident's linens are sent outside the facility for cleaning. She added that they only do residents' personal laundry in the facility. The Director of Housekeeping was asked about hand hygiene outside after sorting soiled laundry and removal of gloves. The Director of Housekeeping stated that they had to go inside the facility to do hand washing. The Director of Housekeeping stated that they used to have a sink outside, but it was removed about 2 years ago due to some type of water accumulation issues. The Director of Housekeeping explained that a hand sanitizer canister was outside, but it was moved inside the facility 10 days ago due to concerns with the canister's battery getting wet. The Director of Housekeeping was apprised that staff was observed not wearing a gown while sorting the soiled linens. The Director of Housekeeping stated that the staff must use a gown when sorting linen. A side by side review of the outside laundry area (trailer area) with the Director of Housekeeping was conducted. The review revealed no disposable or reusable gowns in the area. The Director of Housekeeping stated that she gets the disposable gowns from central supply. On 01/27/21 at 10:57 AM, during tour of the Personal Laundry area with the Director of Housekeeping and Housekeeping Staff U. It was revealed that the sorting of residents' soiled linen is done outside .The tour revealed three stacked washers and dryers in a 10 x 12 feet room in progress. Staff U stated that the residents' laundry items are identified and sorted outside in a barrel and placed in a nylon bag, then washed and dried. The clean dried clothes are sorted on an aluminum rolling cart, and then hanged in the transport cart with a cover. On 01/28/21 at 7:32 AM, observation revealed an aluminum rolling cart with personal clothing. The clothing items were exposed and dangling touching the uncovered area of the cart . Furthermore, observation revealed a fan blowing directly onto the uncovered dangling clothing on the uncovered cart. On 01/28/21 at 2:23 PM, an interview was conducted with the ADON/IP and she was apprised of the personal laundry and clothing touching the uncovered area of the cart and the lack of provisions for hand hygiene in the area outside where soiled laundry was being sorted . The ADON/IP stated that it is an infection control issue because the cart barrier bag should cover the cart completely. The ADON/IP stated the hand sanitizer should have been outside not inside. Review of the facility's policies titled Personal Protective Equipment-Gloves revised on 01/2021 documented the use of disposables gloves is indicated: when handling soiled linen or items that may be contaminated .wash your hands after removing gloves . Review of the facility's policies titled Infection Control- Linen Management dated January 2020 documented .dirty linens are handled in accordance with standards precautions .dirty linens are not to come in contact with staff clothing (i.e. a gown may be required .) Review of the facility's policies titled Standards Precautions revised on 01/2021 documented .standard precaution include-hand hygiene, use of personal protective equipment (e.g., gloves, masks, eyewear).

Based on observations, interviews and record review the facility failed to ensure a multi dose insulin vial was labeled with a date of opening for 1 of 1 resident (Resident #55) sampled for medication administration on the east wing; 2)failed to ensure the west wing medication room refrigerator temperature was within required range during medication room storage review; 3) failed to ensure the facility medication rooms were clutter free, as evidenced by three oxygen concentrators and mechanical lift in the medication room on the west and a mechanical lift in the east wing medication room observed during medication room review; 4)failed to ensure resident medications were kept safe and attended for 1(Resident #49) out of 6 residents reviewed for medication administration observation on the east wing; 5) failed to keep medication cart #1 locked when unattended on the east wing during medication cart review and 6) failed to ensure residents personal effects/belongings were not stored in the medication cart/controlled substance box during medication cart review(Resident #2 and #134). The findings included: 1) On 01/25/21 at 11:49 AM, insulin administration for Resident #55 performed by Staff C was conducted. Observation revealed Staff C performed hand hygiene, walked to the medication room, and retrieved a plastic box from the refrigerator. Staff C walked back to the medication cart, pulled a white foam tray, retrieved a bottle of insulin from the plastic box and placed it on a white foam tray with. Observation revealed Staff C, without changing her gloves and without disinfecting the insulin rubber [MEDICATION NAME] inserted the insulin syringe into the insulin bottle, draws the insulin, wiped the resident left arm and administered the insulin. Staff C removed her gloves, left the residents room and without performing hand hygiene, opened the medication cart and placed the insulin bottle that was carried into the resident's room in the plastic box. Staff C was asked to retrieved Resident #55's insulin bottle from the plastic bag for review. The review revealed the insulin bottle with a manufacturer expiration date of 04/2023, revealed no labeling to indicate an opened date or a discard date. A subsequently interview was conducted with Staff C and she stated that the insulin bottle should be labeled with an opened date because they have to be discarded some many days after opening. Staff C confirmed that she did not disinfect the insulin bottle rubber [MEDICATION NAME] before withdrawing the insulin and added that she should have done so. On 01/28/21 at 2:35 PM, an interview was conducted with the ADON and she was apprised regarding Staff C not disinfecting the insulin vial rubber [MEDICATION NAME] before drawing insulin and an the unlabeled insulin bottle. The ADON stated they have to disinfect the vial rubber before inserting the syringe. The ADON was asked to submit the facility's insulin administration procedure. Review of the facility's policy titled Vials and [MEDICATION NAME] of injectable medications revised on 01/2021 documented .the date opened and the initials of the first person to use the vial are recorded on sticker on the bottom of multi-dose vials .the rubber [MEDICATION NAME] is inspected for deterioration . 2) On 01/25/21 at 12:35 PM, a side by side review of the facility's west wing medication room was conducted with the Assistant Director of Nursing (ADON). The review of the medication room refrigerator thermometer read 70 degrees (Fahrenheit), the door shelves was warm to touch, and there was small amount of water accumulation underneath a plastic bag that contained a medication bottle. Review of the facility's refrigerator temperature readings log record for January 2021 documented 40 degrees F(Fahrenheit) every day. The log documented the temperature must be at 41 degrees Fahrenheit or less, freezer temperature must be at or below 0 degrees. The ADON noted the refrigerator temperature of 70 degrees and she proceeded to move the refrigerator regulator and moved the thermometer to the back of the first shelf and closed the door. After five minutes of the door being closed, observations revealed the thermometer reading of 60 degrees Fahrenheit. The ADON was asked what would be done about the refrigerator out of range temperature, the ADON stated that she will have maintenance check the refrigerator. On 01/25/21 at 2:21 PM, a side by side observation of the west wing medication room refrigerator with the ADON was conducted. Observation revealed a thermometer reading of 54 degrees Fahrenheit. The ADON stated that they will be changing the refrigerator and the medications will be moved to another refrigerator. On 01/25/21 at 4:43 PM, another side by side observation of the west wing medication room refrigerator with the ADON was conducted. The review revealed two thermometers in the refrigerator, one read 40 degrees and the other read 44 degrees. The ADON stated that the refrigerator was exchanged, and they believed it was a faulty thermometer. Observation revealed medications in the refrigerator had not been replaced at the time of observation. On 01/26/21 at 9:40 AM, during an interview the facility's Consultant Pharmacist (CP) stated that all the bottles of insulin that were unopened were replaced this morning (01/26/21). He added that the bottles of insulin that were opened were not removed because they will be discarded on discard date. The CP stated that bottles of insulin can be stored either in the refrigerator or in the medication cart. The CP stated that other medications in the refrigerator were replaced on the evening of 01/25/21 and the morning of 01/26/21. A side by side review of the west wing medication room refrigerator on 01/26/21 at 9:50 AM, revealed thermometer reading temperature was 40 degrees Fahrenheit. 3) On 01/25/21 at 12:35 PM, a side by side review of the facility's west wing medication room was conducted with the Assistant Director of Nursing (ADON). Observation revealed a cluttered room measuring approximately 10 X 8 with a mechanical lift, three oxygen concentrator and three IV (intravenous) pole inside the room. The ADON was apprised of cluttered medication room. The ADON stated they kept the mechanical lift in the medication room due to safety and to charge it. The ADON stated that the oxygen concentrator machines were kept in the medication room for emergencies and added that one could be removed from the room. The ADON stated that the facility have an oxygen room on the east wing. On 01/25/21 at 5:00 PM, observation of the facility's east wing medication room revealed a mechanical lift stored in the room. On 01/28/21 at 3:14 PM, the ADON, she was apprised of cluttered medication rooms. She stated, this is an old building and that they kept the oxygen concentrators in the medication room for emergencies. Review of the facility's policy titled Medication Storage in the facility revised on 01/2021 documented .medication rooms, carts and medication supplies are locked or attended by persons with authorized access .medications requiring refrigeration or temperature between 38 and 46 degrees Fahrenheit are kept in a refrigerator with a thermometer to allow for temperature monitoring .medication storage areas are kept .free of clutter . 4) On 01/26/21 at 4:52 PM, medication administration observation performed by Staff G, a Registered Nurse (RN) for Resident #49 in the east wing was conducted. Observation revealed Staff G, pulled a white foam tray from the medication cart drawer, a medication cup and poured into the following medications into the cup one tablet of [MEDICATION NAME] (iron medication) 325 milligram (mg) and one tablet of [MEDICATION NAME] (a blood pressure medication) 25 mg. Further observation revealed Staff G entered the resident's room with the white foam tray and the medication cup with the two tablets, placed the foam tray on top of the resident's over bed table. Staff G left the resident's medication on the table unattended, entered the resident's bathroom and performed hand hygiene for 60 seconds. Observation revealed Staff G was not watching/attending Resident #49's medications left on the table. Staff G donned gloves returned to the resident's bedside and assisted the resident with the medications. On 01/26/21 at 5:05 PM, during an interview Staff G stated that he realized while he was doing hand washing, that he left the medications on the table. Staff G added that he is supposed to keep the medications within his eyesight. On 01/28/21 at 2:45 PM, an interview was conducted with the ADON and she was apprised regarding Staff G leaving the resident's medications unattended in the resident's room while performing hand washing. The ADON stated the staff should keep an eye on the resident's medication at all times. 5) On 01/27/21 at 2:12 PM, a side by side review of the facility's east wing medication cart #1 was conducted with Staff S, a Registered Nurse. During the review at 2:23 PM, observation revealed Staff S walked approximately 8-10 feet away from the medication cart down to the hallway and went into a resident's room, leaving the medication cart unlocked and with the first drawer ajar. Staff S returned to the medication cart and was asked if she is supposed to leave the medication cart unlocked. Staff S stated the cart is supposed to be locked. On 01/28/21 at 2:30 PM, an interview was conducted with the ADON and she was apprised regarding Staff S leaving the medication cart unlocked and went into a resident's room to answer the resident phone. 6) On 01/26/21 at 10:50 AM, a side by side review of the facility's west wing medication cart #1 was conducted with Staff C, a Registered Nurse. The review revealed a loose greenish color capsule in the cart's second drawer, an opened Declogger tube feeding dated 01/09/21 in its plastic wrapping on the bottom drawer. Subsequently, an interview with Staff C was conducted and Staff C stated that the Declogger tube is a single use and it had to be discarded after use. Staff C added she did not know why the tube was in the drawer. Further review of the cart's controlled substance box revealed, a plastic bag with a pair of glasses and a phone charger labeled with Resident #2's name. Staff C stated she did not know why those personal items were in the controlled substance box. Staff C added she was not sure if Resident #2 was in the facility or not. Continued review revealed a wallet with two rubber bands around it, no name and no label noted. Staff C stated she did not know who the wallet belonged to. Staff C stated that resident's personal belongings are given to Social Services and they would contact the family for them to pick them up. Staff C stated those personal items are not supposed to be in the controlled box. On 01/26/21 at 4:22 PM, a joint interview was conducted with the facility's Social Services Director (SSD) and Staff P, a Social Services Assistant (SSA). They both were apprised of the personal belongings (glasses, cell phone charger and a wallet) observed in the medication cart's controlled box. The SSD stated Resident #2 was sent to the hospital via 911 and she was expected to return to the facility. The SSD added that the resident's responsible party wanted her to return to the facility and that was the reason her personal belongings to stayed in the facility. The SSD stated that when a resident goes to the hospital, the Certified Nursing Assistant is responsible to collect all belongings and bring them to Social Services. The SSD stated that residents' personal belongings are kept by Social Services if they expected the resident's return. The SSD added that if the resident does not come back to the facility, they call the family and either the family pick up the personal belongings or they donate them. The SSD stated that she placed Resident #2 personal belongings such as her clothes and shoes in the storage. The SSD stated that if a resident has glasses, dentures, cell phones, those are kept in the Social Services office. The SSD stated Resident #2 cell phone, charger and glasses were given to her today (01/26/21) and added that she did not know that the staff had them. Staff P stated the wallet belonged to Resident #134, a new admission that came in on 01/15/21. The SSD stated that she was notified today (01/26/21) of Resident #134's wallet being kept in the controlled substance box. The SSD stated that she spoke with the resident and he stated he wanted to keep the wallet with him and it was given back to him. The SSA stated he had ID card, insurance card and no money in the wallet. (Photographic evidence)

Based on record reviews observation and interviews during this revisit survey, the facility's Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) failed to identify quality concerns to implement effective plans of action related to Pharmacy services and Quality of Care. The facility was recited on this revisit for 483.25 for Quality of Care: F 684 related to skin condition that is non pressure related; F 686 for Treatment/Services to prevent/heal Pressure ulcers, F 697 for Pain Management and Pharmacy Services: F 761 for Label/Store Drugs and Biologicals. These uncorrected deficient practices has the potential to affect all residents residing in the facility. The findings included: On the recertification survey with an exit date of January 28, 2021 the facility was cited under regulatory 483.25 for Quality of Care: F 684 related to skin condition that is non pressure related; F 686 for Treatment/Services to prevent/heal Pressure ulcers and F 697 for Pain Management. The facility was also cited under regulatory grouping 483.45 for Pharmacy Services: F 761 for Label/Store Drugs and Biologicals. The facility's Plan of Correction included but was not limited to: Tag F684 - 483.25 - Quality of Care-In-service completed on reporting and documentation of skin conditions/assessments. A Tracking Form was created for the supervisor to report to the Director of Nurses (DON) or designee the residents skin assessments on a daily basis. The DON or designee will review documentation weekly and review interventions for any findings. The DON or designee will report findings during the Quality Assurance Meeting monthly. Tag 686 - 483.25 Treatment/Services to prevent/heal pressure ulcer. In-services were provided to the Wound Care Team on when to wash hands during treatment, what type of soap to utilize, scissor cleaning, wound care clean field observation, and no phones during treatments. Weekly observation of wound care procedure by DON or designee for three months then monthly once DON feels confident that procedure is being done as per policy. The DON or designee will report finding of weekly observation of wound care procedures monthly to the Quality Assurance Committee. Tag 697 - 483.25 Pain Management - The DON or designee will conduct random weekly audits to ensure care plan interventions for pain are being implemented by nursing staff. Findings will be reported to the quality assurance committee monthly. Tag 761 - 483.45 - Label/Store Drugs and Biologicals-Weekly Medication Cart Audit includes checking for items that should not be present and for loose medications. The DON and/or designee will conduct random audits and will compile findings and report to the Quality Assurance Committee. During the revisit conducted on May 19 - 20, 2021 it was revealed through observation, interviews and record reviews: F684 - The facility failed to ensure consistency with the care and services to meet professional standards related to non-pressure related wounds for six out of six residents reviewed (Resident #2, Resident #29, Resident #76, Resident #135, Resident #136 and Resident #137). As evidenced by wound dressings noted to be undated and outdated dressings. F686 - The facility failed to provide treatment, consistent with professional standards of practice, for existing pressure injuries for 4 of 5 residents (Resident #12, Resident # 29, Resident # 51, and Resident # 135) sampled for wound care observation, out of 12 residents residing in the facility with Pressure ulcers/injuries at the time of this survey. F697 - The facility failed to ensure the adequate pain management interventions were followed for one resident with the potential for alteration in comfort/pain related to extensive wound care treatments. As evidenced by, Resident # 29 orders to be medicated 30 minutes before wound care treatment was not followed as ordered, resulting in discomfort during wound care treatment and inadequate assessment interventions to adequately respond to the management of pain for Resident #29. This affected one of 6 residents reviewed for wounds (Resident #29). F761 - The facility failed to ensure items on the treatment cart were labelled with opened dates. The facility failed to ensure medication carts are free of loose medications. As evidenced by multiple stock items on the treatment cart were noted with no opened date and loose medications were noted on one out of four medication carts (the Yellow wing medication cart). On 05/20/2021 at 04:15 PM, the identified concerns were discussed with the Nursing Home Administrator (NHA), the Director of Nursing (DON), the Assistant Director of Nursing (ADON) and Pharmacy Representative. The NHA stated, the concerns identified concerns were a one-day incident isolated, breakdown moment and is not a chronic situation that will not happen again. The NHA stated, training staff takes time and THEY will work together with the Director of Nursing and will monitor closely. They will continue with in-services. The NHA stated, they understand there was a failure in their system to monitor pain management as well. Interview with the Director of Nursing (DON) on 05/20/2021 at 04:20 pm revealed, she did the monitoring herself and checked the reports weekly. Now after this happened, they have instituted to have a second nurse with the wound care nurse to go through this. The DON stated during the implementation and monitoring of the plan of correction, they never identified any kind of concerns. The DON stated residents with pressure ulcers are to be given medication for pain 30 minutes before wound care.

Based on observations, interviews and record review, the facility failed to ensure accurate counting, reconciliation, and disposal of controlled medications for 2 of 4 (Resident #34 and #73) residents sampled during medication storage review. The findings included: 1) On 01/26/21 at 10:25 AM, a review of the facility's west wing medication cart #2 controlled medications box was conducted with Staff Q, a Licensed Practical Nurse (LPN). Observation revealed a blister card/pack for Resident #34 labeled as [MEDICATION NAME] (anticonvulsant and a controlled substance medication) tablets 100 milligrams (mg) to take one tablet by mouth twice daily. There were 28 tablets noted in the card/pack. Review of Resident #34's Individual Patient's Control Drug Record (medication accounting control) for [MEDICATION NAME] documented 27 tablets remaining on hand. The record documented [MEDICATION NAME] one tablet removed from the controlled substance box on 01/25/21 at 9:00 AM, one tablet removed on 01/25/21 at 5:00 PM and one tablet removed on 01/26/21 at 9:00 AM. On 01/26/21 at 10:31 AM, an inquiry was made regarding the accounting discrepancy of the [MEDICATION NAME]. Staff Q, LPN stated that she counted Resident #34's [MEDICATION NAME] tablets with the 11:00 PM to 7:00 AM shift's off going nurse and noticed the discrepancy. Staff Q, LPN stated that she informed the nursing supervisor (Staff R) a little after 9:00 AM, at the time she was going to administer the medication. Staff Q added that the supervisor informed her that she was going to contact the 3:00 PM to 11:00 PM shift nurses. Staff Q stated [MEDICATION NAME] counting was done on as required with the incoming and off going nurse, but the supervisor was not notified of the discrepancy until she did this morning (01/26/21) Staff Q stated that the extra tablet in the controlled box for Resident #34 indicated that the resident did not receive a dose of [MEDICATION NAME] on 01/26/21 at 5:00 PM as per physician orders. Review of the facility's Narcotic Count record documented had signatures for the oncoming and off-going nurses on 01/25/21 for all three shift and signatures on 01/26/21 for the oncoming and off-going nurses for the day shift. On 01/26/21 at 11:53 AM, a joint interview was conducted with the facility's Director of Nursing ( DON) and the Assistant Director of Nursing (ADON). They both were apprised of the controlled medication counting/reconciliation discrepancy related to Resident #34's [MEDICATION NAME]. The DON stated that they found out about the discrepancy after the surveyor reviewed the controlled substances with Staff Q. The DON was asked about the steps that the facility will follow regarding the controlled substance discrepancy, the DON stated that she was waiting for Staff G, a Registered Nurse (RN), arrival to start an investigation. On 01/26/21 at 12:14 PM, the Nursing Supervisor, Staff R stated during an interview that she works day shift. Staff R stated she was informed by Staff Q that there was a discrepancy with the narcotics, before 10:00 AM today (01/26/21) and she could not recall the exact time that she reported it, but it was before medication pass. Staff R stated that the nurse (Staff Q) did not realize that there was an extra [MEDICATION NAME] tablet for Resident #34. Staff R stated that she called the evening and night nurses and added that the evening nurse Staff G,RN will arrive soon to the facility for them to investigate. Staff R stated after the facility conduct the investigation, the next step will be to discard the extra pill. Staff R stated she did not inform the Director of Nursing (DON) until later, at around 11:00 AM. Staff R stated that the facility's policy was to notify the DON and the Assistant Director of Nursing (ADON) and added that there was a little delay, to start the investigation to find out what happened with the controlled substance. Staff R was asked about the timeframe to report a medication error to the DON. Staff R stated that she was not sure if there was a timeframe for reporting a medication error. Staff R stated the delay was due to a combination of factors because she got involved with something else and could not find the DON or the ADON. Staff R was asked if she had notified the DON and the ADON. Staff R stated that they (DON and ADON) had found out prior to her informing them and the surveyors had already informed them. Staff R added that she started the investigation when she called Staff G around 10:45 AM and that Staff G had called her back around before 11:45 AM. Staff R stated the night shift nurse did not answer her call. Review of Resident #34 clinical record documented an initial admission to the facility on [DATE] and a readmission on 01/16/20 with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of Resident #34's Medication Administration Record [REDACTED]. Resident # 34's nursing documentation lacked evidence to indicate that Resident #34 refused [MEDICATION NAME] at 5:00 PM on 01/25/21 or that the medication was on hold. On 01/26/21 at 5:05 PM, during an interview Staff G,RN stated he has been working for the facility for a month. Staff G,RN was asked about Resident #34's controlled substance [MEDICATION NAME]. Staff G stated that he got distracted and signed off for the [MEDICATION NAME] as removed from the controlled substance box on the Narcotic Count record and the MAR indicated [REDACTED]. Staff G stated that he did conduct the controlled substance/narcotic count with the night shift nurse and he picked up that he did not administer Resident #34's [MEDICATION NAME] 100 mg at 5:00 PM on 01/25/21. On 01/27/21 at 9:39 AM, during an interview Staff Q stated that Resident #34's physician and family were contacted. She added that the resident has not had any [MEDICAL CONDITION] for a long time. On 01/27/21 at 9:45 AM, observation revealed Resident #34 resting comfortable in bed. Attempted to conduct an interview with the resident, the resident stated she was fine. However, the resident was not able to follow or respond to any other questions asked. 2) On 01/26/21 at 10:50 AM, a side by side review of the facility's west wing medication cart #1 was conducted with Staff C, a Registered Nurse (RN). The review revealed an emptied blister card in the medication cart attached to the trash can with Resident #79's name on it and a round beige color capsule in one of the empty spaces of Resident #79 blister card (Photographic evidence). An interview with Staff C was conducted immediately. Staff C, RN stated that she did not know what the round beige color capsule was doing in the trash can and did not know who it belonged to. On 01/26/21 at 11:30, a side by side review with Staff C of the controlled substance Dronabinol capsule 2.5 milligrams (mg) blister card for Resident #73 was conducted. The review revealed that the capsule found in the west wing medication cart #1's trash can match the capsule in Resident #73's blister card for Dronabinol, a controlled substance medication. Subsequently, an interview with Staff C was conducted; Staff C stated that she pulled Resident #73's Dronabinol capsule from the controlled substance box and the resident refused to take it. Staff G stated she then discarded it into the medication trash can. She was asked to explain the facility's controlled substance disposal process; Staff C stated that she should have another nurse, discard the controlled substance together and it should be documented on the narcotic control sheet. Staff C was asked why she did not follow the process; in response Staff C stated that she did not know why she did not and added she had a lot on her mind. On 01/26/21 at 11:55 AM, the DON and ADON were immediately notified and a joint interview conducted related to the observation of concerns related to the controlled substance Dronabinol capsule for Resident #73 observed in the west wing medication cart #1's trash can, discarded by Staff C on duty. During the interview, the DON was asked to submit the facility's policy related to controlled substance medication reconciliation. Review of Resident # 73 clinical record documented an initial admission to the facility on [DATE] and a readmission on 01/04/21 with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the resident's MAR indicated [REDACTED]. Review of the resident Individual Patient's Control Drug Record for Dronabinol 2.5 mg capsule documented one capsule removed on 01/26/21 at 9:00 AM, signed off by Staff C. Review of Resident #73 Individual Patient's Control Drug Record and the MAR for 01/26/21 lacked documentation of Resident #73 refusal of Dronabinol a controlled substance medication. Review of the facility's policy titled Disposal of Controlled Medications revised on 01/2021 documented .if a dose of a controlled medication is removed from the container for administration but not given for any reason it is destroyed by using the drug disposal system in the presence of two licensed nurses and or RN (registered Nurse) supervisor. The disposal/destruction is documented on the proof of use sheet on the line representing that dose . Review of the facility's policy titled Medication Error Report revised on 01/01/2021 documented .forward report to Director of Nursing immediately .carry out physicians' orders for care, and report medication error to charge nurse on next shift .

Based on observations, interviews and records reviewed, the facility failed to ensure the monitoring, assessment, and adequate response to manage the pain verbally reported by one resident (Resident #16) that reported concerns with pain, out 22 sampled residents. There were 88 residents residing in the facility at the time of the survey. The Findings Included: During observation and interview on 1/25/21 at 4:45 PM, Resident #16 reported she had a lot of pain that never goes away on her waist. She reported she received medications, for pain and that she would be getting them soon. The pain got better after the meds but never goes away. Record review of the clinical records for Resident # 16 revealed, the resident was re-admitted to the facility on [DATE]. Admission records indicated that Resident # 16 complained of pain and was assessed for pain on 8/7/20 at 6:30 PM. Her admitting [DIAGNOSES REDACTED]. Record review of the Care Plan for Resident # 16 revealed care plan dated, 08/07/20 last updated on 11/16/20, for the potential for alteration in comfort/pain related to (R/T) diagnosis ( DX) Compression fracture at L3 (third lumbar spine vertebra), chronic pain .The goal was that the resident would be free of signs and symptoms of discomfort/pain 30-60 minutes after medication are given through Next Review Date (NRD) Interventions included: Evaluate for Pain. Observe for non-verbal communication such as grimacing, body language, restlessness Administer mediation for pain as needed (PRN) and monitor responses. Record review of the Quarterly Minimum Data Set (MDS) for Resident # 16 dated 11/14/20 revealed that the resident had a score of 8 on the Brief Interview for Mental Status (BIMS), which indicated that the resident was moderately impaired. Further review of the MDS revealed that Resident #16 had clear speech patterns, was able to be understood and she was able to understand others. Interview and observation on 1/26/21 at 9:45 AM, revealed, Resident #16 again complained that she was in pain and reported pain level 10 out of 10, in her waist. Resident #16 reported that she received medications but the pain remained and that the pain Gets better but never goes away. The resident grimaced and moaned as she spoke. During dining observation on 01/26/21 at 12:25 PM Resident #16 was noted sitting up in her bed and set to eat, she reported that she remained in pain. Review of the MEDICATION ORDERS FOR [REDACTED]. Review of the Medication Administration Record [REDACTED]. There was no documentation indicating monitoring of the effectiveness of the pain medication. Review of the Nurses Notes for November 2020, December 2020 and January 2021, revealed no entry to suggest that the above mentioned resident pain concerns were addressed. Review of the facility's Pain Management Policy, effective date 01/2005 revealed, the Purpose: The purpose of this policy is that each resident receives necessary care and services that is in accordance with professional standards of practice, resident's care plan and the resident's choice. Guidelines included but not limited: A. The resident has the right to receive a timely response to any reports or perception of pain. E. Pain Assessment will be completed/updated with each new report of pain. L. Interdisciplinary team will consider, as appropriate, whether pain interferes with the optimal level of patient's/resident's function or rehabilitation. On 1/27/21 at 10:30 AM, Certified Nursing Assistant (CNA) Staff U, explained that Resident #16 usually remained in bed and refused to get out of bed. When encouraged to get out of bed, Resident #16 complained that she was in pain. Staff U stated , She usually refuses and says I'm in so much pain here, or there, and refuses. I can't remember the last time she got out of bed, only once when I think they had to change the bed . Sometimes she says something like they took out my blood or my legs hurt. When asked if she reported pain complaints to the nurse. Staff U stated, that she reported to the nurse when the resident complained that she had a stomach pain, maybe last week Interview on 1/28/21 at 6:50 AM with Registered Nurse (RN), Staff V and Staff W, RN revealed they were both familiar with Resident # 16. Staff V and Staff W explained their process for ensuring that residents remained free of pain for residents that remain in bed, we make sure they get up and out of bed three times a week . we assess for pain at least three times a day. They are encouraged to communicate pain. We look at residents' facial expression, notice changes in condition, at times we have as needed (PRN) pain meds for the residents . Whether or not the patient is alert and oriented, we make sure to assess the resident and contact the doctor as necessary. During the interview and review of clinical records for Resident #16's, both nurses reviewed Resident #16's diagnoses, they explained and acknowledged that the resident suffered conditions that might cause pain that included Polio[DIAGNOSES REDACTED], chronic pain and muscular weakness. The nurses reported that the admission pain assessment was used to document any concerns of pain. The pain assessment record initiated on 08/07/2020 showed only three entries, 08/07/20, 08/19/20 and on 11/14/20, the record indicated that the resident did not receive any medications or treatment for [REDACTED].

Based on observations,record review and interviews, the facility failed to implement the pain care plan for one resident (Resident #16) that reported concerns with pain, out 22 sampled residents. The facility had 7 residents on a pain management program out of the 88 residents residing in the facility at the time of the survey. The Findings Included: During observation and interview on 1/25/21 at 4:45 PM, Resident #16 reported she had a lot of pain that never goes away on her waist. She reported she received medications, for pain and she would be getting them soon. The pain got better after the meds but never goes away. Record review of the Face Sheet for Resident # 16 revealed, the resident was re-admitted on [DATE] to the facility. Admission records indicated that Resident # 16 complained of pain and was assessed for pain on 8/7/20 at 6:30 PM. Her admitting [DIAGNOSES REDACTED]. Record review of the Care Plan for Resident # 16 revealed care plan dated, 08/07/20 last updated on 11/16/20, for the potential for alteration in comfort/pain related to (R/T) diagnosis ( DX) Compression fracture at L3 (third lumbar spine vertebra) , chronic pain. The goal documented that the resident would be free of signs and symptoms of discomfort/pain 30-60 minutes after medication is given through Next Review Date (NRD) . Interventions included: Evaluate for Pain. Observe for non-verbal communication such as grimacing, body language, restlessness . Administer mediation for pain as needed (PRN) and monitor responses. Record review of the Quarterly Minimum Data Set (MDS) for Resident # 16 dated 11/14/20 revealed that the resident had a score of 8 on the Brief Interview for Mental Status (BIMS), which indicated that the resident was moderately impaired. Further review of the MDS revealed that Resident #16 had clear speech patterns, was able to be understood and she was able to understand others. Interview and observation on 1/26/21 at 9:45 AM, revealed, Resident #16 again complained that she was in pain and reported pain level of 10, in her waist. Resident #16 reported that she received medications but pain remained and that the pain Gets better but never goes away. The resident grimaced and moaned as she spoke. During dining observation on 01/26/21 at 12:25 PM, Resident #16 was noted sitting up in her bed and set to eat, she reported that she remained in pain. Review of the MEDICATION ORDERS FOR [REDACTED]. Review of the Medication Administration Record [REDACTED]. There was no documentation indicating monitoring of the effectiveness of the pain medication. Review of the Nurses Notes for November 2020, December 2020 and January 2021, revealed no entry to suggest that the above mentioned resident pain concerns were addressed. Review of the facility's Pain Management Policy, effective date 01/2005 revealed, the Purpose: The purpose of this policy is that each resident receives necessary care and services that is in accordance with professional standards of practice, resident's care plan and the resident's choice. Guidelines included but not limited: A. The resident has the right to receive a timely response to any reports or perception of pain. E. Pain Assessment will be completed/updated with each new report of pain. L. Interdisciplinary team will consider, as appropriate, whether pain interferes with the optimal level of patient's/resident's function or rehabilitation. Interview on 1/27/21 at 10:30 AM, Certified Nursing Assistant (CNA) Staff U, explained that Resident #16 usually remained in bed and refused to get out of bed. When encouraged to get out of bed, Resident #16 complained that she was in pain. Staff U stated, She usually refuses and says I'm in so much pain here, or there, and refuses. I can't remember the last time she got out of bed, only once when I think they had to change the bed . Sometimes she says something like they took out my blood or my legs hurt. When asked if she reported pain complaints to the nurse. Staff U stated, that she reported to the nurse when the resident complained that she had a stomach pain, maybe last week Interview on 1/28/21 at 6:50 AM, Registered Nurse (RN), Staff V and Staff W, RN revealed they were both familiar with Resident # 16. Staff V and Staff W explained their process for ensuring that residents remained free of pain,for residents that remain in bed, we make sure they get up and out of bed three times a week . we assess for pain at least three times a day. They are encouraged to communicate pain. We look at residents' facial expression, notice changes in condition, at times we have as needed (PRN) pain meds for the residents . Whether or not the patient is alert and oriented, we make sure to assess the resident and contact the doctor as necessary. During the interview and review of clinical records for Resident #16's, both nurses reviewed Resident #16's diagnoses, they explained and acknowledged that the resident suffered conditions that might cause pain that included Polio[DIAGNOSES REDACTED], chronic pain and muscular weakness. The nurses reported that admission pain assessment was used to document any concerns of pain. The pain assessment record initiated on 08/07/2020 showed only three entries, 08/07/20, 08/19/20 and on 11/14/20, the record indicated that the resident did not receive any medications or treatment for [REDACTED].

Based on observation, record review, and interview, the facility failed to provide care and services for an ongoing skin condition and a change in skin integrity for one (Resident #72) out of two sampled residents for skin conditions (non-pressure related). There were a total of 88 residents present in the facility at the time of this survey. The Findings include: Observation on 01/25/2021 at 11:00 AM revealed Resident #72 seated in his wheelchair on the outside patio engaged in an activity. Further observation of the resident revealed a bump on the right side of his forehead. The resident was not interviewable. Observation on 01/26/2021 at 12:45 PM revealed Resident #72 by the nurses' station; the resident was noted with discoloration on left side of his chin, below his lips. Observation on 01/27/2021 at 10:19 AM revealed Resident #72 on the outside patio seated in his wheelchair; activities were taking place with music. The resident still had a bump on the right side of his forehead. When Resident #72 removed his facemask he still had discoloration to the left side of his chin; he was not in any pain or distress. Record review of the nursing admission assessment dated [DATE] revealed Resident #72 was admitted to the facility with a soft bump on his forehead; the right side. Record review of the wound care notes dated 10/10/2019 revealed Resident #72 was noted as having a bump to the right forehead; however, there was no other documentation about the resident's bump on his forehead. Record review of the medical record revealed no documentation of a dermatology consult related to the bump on Resident #72's head. Record review of Resident #72's medical record revealed no documentation about discoloration to the resident's chin. Record review of the Weekly Body Audits for December 2020 and January 2021 revealed no documentation of Resident #72 having a bump on his forehead or discoloration to his chin. Interview with the Registered Nurse (Staff C), Certified Nursing Assistant (Staff D), and the Wound Care Nurse on 01/27/2021 at 11:24 AM revealed Resident #72 was admitted to the facility with the bump on the right side of his forehead; it was a cyst. It never changed in color, and there was no discharge, which was why they never did anything about it. The Wound Care Nurse stated that sometimes it was better not to touch the bump because it could be worse for the resident. Resident #72 was never seen by the dermatologist, and the Wound Care Nurse never communicated with the resident's family to see what the bump was. However, she reported that when she went and saw the resident today she assessed the left side of the Resident #72's chin under the lip; there was excoriation and it was light purple. This was the first time the Wound Care Nurse had been made aware of the change in the resident's skin. Staff C stated that it was her first time seeing it too; she was going to complete an incident report, and contact the physician and the family. The Wound Care Nurse reported that the color of the excoriation indicated that it was something recent. Staff D worked with Resident #72 twice a day, and she provided the resident with activities of daily living (ADL) care. Staff D stated that she worked with the resident yesterday, 01/26/2021, but she did not see the discoloration to the resident's chin; today was the first time she saw it. She saw it during breakfast, but she did not tell Staff C because she was busy, and then she went and helped another resident. However, Staff D stated that she was going to report it to the nurse before the end of her shift. She understood that when she saw a change in Resident #72's skin she had to report it right away. Interview with the Wound Care Nurse on 01/27/2021 at 2:50 PM revealed that the she spoke with Resident #72's son and he stated that the resident got the bump from a fall in a basement back in 1975. The Wound Care Nurse stated that she should have spoken to the family before about the resident's bump on his forehead, and the nursing staff should have reported to her immediately when they saw the excoriation to Resident #72's skin.

Based on records reviewed,observations and interviews, the facility failed to provide treatment, consistent with professional standards of practice, for existing pressure injuries for 1 of 1 resident (Resident #29) sampled for wound care observation, out of 9 residents with Pressure injuries Review of Resident #29's clinical record documented an admission to the facility from a local hospital on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 2 of 15 which indicates severe cognitive impairment. Resident # 29 is totally dependent on staff for care and was admitted with pressure injuries/ulcers. On 01/28/21 at 9:08 AM, wound care for Resident #29 was observed being performed by Wound Care Nurse, Registered Nurse(WCN/RN), Staff E, assisted by Staff F, a Certified Nursing Assistant (CNA) and Staff T, a Registered Nurse (RN). Observation revealed Staff E, WCN/RN retrieved two large white foam tray from the treatment cart and gathered the following wound care supplies and placed them on the trays: a wad of gauzes, two red bags, one [MEDICATION NAME] Blue Ready-Border dressings; Staff E removed a pair of scissors from her top scrub uniform pocket and cut up pieces of retention dressing tape, placed the pieces of retention dressing tape on top of the treatment cart (which is considered dirty),dated each of the pieces of tape, then placed them on the white foam tray, four medication cups, a tongue depressor, poured [MEDICATION NAME] cream into a medication cup, poured Santyl collagen, Medi honey paste, six vials of normal saline solution (NSS), two Stretch Conforming Gauze (Kling roll), pulled another wad of gauzes, pulled the pair of scissors again from her scrub pocket and cut up more dressing retention dressing tape and placed the pair of scissors back in her pocket, dated the pieces of tape and placed them on top of the treatment cart then placed them on the white foam tray. Staff E,RN poured [MEDICATION NAME] solution into two medication cups, pulled eight NSS vials from the treatment cart, locked the cart and carried the two white foam trays with supplies to the resident's room. Observation revealed Staff T, RN placed a blue pad over the resident's bed table and over it she placed a bag of Personal cleaning cloths and extra blue pads. Further observation revealed Staff E, RN placed the two foam trays on top of the blue pad barrier and next to the Personal cleaning cloths and extra blue pads. On 01/28/21 at 9:36 AM, observation revealed Staff E,RN entered the resident's bathroom and poured Hair/Body shampoo solution from the container, located to the right side of the bathroom sink, into her hands instead of the hand soap that was located to the left of the sink, and performed hand hygiene. Observation revealed Staff E had a bandage on her right thumb. Observation revealed Staff T then entered the resident's bathroom and poured hand soap from the container located to the left side of the sink, into her hands and performed hand hygiene. Staff F, CNA then entered the resident's bathroom and poured Hair/Body shampoo solution from the container into her hands instead of the hand soap and performed hand hygiene. Further observation revealed Staff E, Staff F and Staff T donned gloves. Observation revealed Staff E opened a red biohazard bag and placed it at the bottom of the resident's bed, then removed the old dressing from Resident #29's left knee. Staff F removed her gloves and did not perform hand hygiene and donned a pair of gloves. Observation revealed Staff E removed her gloves after the removal of the old dressing, proceeded to the bathroom, poured hair/shampoo solution, and performed hand hygiene. Staff E donned gloves, reached the clean field for a gauze and a NSS vial, poured the NSS over the gauze and proceeded to clean wound on the resident's left knee with the soaked gauze. Staff E did not change gloves and continued wearing the same pair of gloves used to clean the wound, she then reached the clean field and retrieved a gauze, pat dried the wound, and again reached over to the clean field to retrieved Santyl collagen ointment and applied it to the resident's wound, reached again to the clean field to retrieved a dry gauze, covered the wound with the gauze, retrieved a piece of tape to secure the gauze in place. Staff E explained that Resident #29 will be turned for her to do the sacrum wound. Observation revealed Staff E removed her gloves, performed hand hygiene with hair/shampoo solution instead of using hand soap. Staff E with an uncovered one centimeter long open wound on her right thumb donned gloves. Staff E removed the old dressing from Resident #29's left hip, the dressing contained small amount of drainage. Staff E removed her gloves and performed hand hygiene with hair/shampoo solution instead of using hand soap. Observation revealed Staff E donned gloves, reached the clean field, retrieved a blue pad, placed the pad underneath the resident buttocks to cover feces that was coming out. Staff E reached to the clean field with the same pair of gloves, retrieved a dry gauze, a NSS vial, poured the NSS over the gauze and proceeded to cleanse the excoriated area (an abrasion area where the skin is torn or worn, scraped off) on the left buttock. Staff E reached the clean field, retrieved a dry gauze and a NSS vial, poured the NSS over the gauze, and cleansed the residents left buttock again, pushed the blue pad under the resident buttock to cover the feces, reached the clean field for a dry gauze and NSS vial, poured NSS over the gauze, and then cleansed buttock again. Staff E continued to reach the clean field with same gloves she used to clean the resident's excoriated buttocks without removing her gloves and performing hand hygiene. Staff E reached the clean field, retrieved the [MEDICATION NAME] cream, opened the applicator packaging and applied it to the resident's buttock. Staff E with the same gloves reached the clean field, retrieved a gauze, opened a NSS vial and poured it over the gauze and cleansed the left hip wound. Staff E reached the clean field two more times with the same gloves she used to clean the left hip wound. Staff E, then retrieved a dry gauze, pat dry the wound, removed her gloves and performed hand hygiene with hair/shampoo solution instead of using hand soap. Staff E donned gloves, retrieved Medi-honey paste from the clean field and applied it to the wound, covered the wound with a gauze and applied tape. Staff E then repositioned the blue pads, removed Resident #29's old dressing from the sacrum wound, removed gloves and performed hand hygiene with hair/shampoo solution instead of using hand soap. Staff E donned gloves reached the clean field for another red bag, then a dry gauze and a vial of NSS, poured the NSS over the gauze and cleansed the sacrum wound. Staff E cleansed the sacrum wound three times, each time she reached the clean filed after cleaning the wound (from dirty to clean) and without changing gloves, Staff E reached the clean field, opened the applicator packaging, then proceeded to apply Medi-honey paste to the sacrum wound, covered the wound with a dry gauze and applied tape. Observation revealed Staff E removed her gloves and performed hand hygiene with hair/shampoo solution instead of using hand soap. Observation revealed Staff F wrist phone ringing during the wound care and with her right gloved hand, she touched the wrist phone screen to turned it off, then without changing gloves, Staff F repositioned Resident #29's cover sheet and rubbed the resident naked back with her right gloved hand because the resident complained of her back itching. Staff F continues wearing the same pair of gloves and retrieved Personal Cleansing Cloth from the clean field twice to clean the resident's bottom, turned the resident over her left side, then removed her gloves, performed hand hygiene with hair/shampoo solution instead of using hand soap. Further observation revealed Staff E donned gloves, removed the resident's left foot bootie, lifted the left leg on pillow, reached the clean field for a blue pad and placed it under the left foot. Staff E proceeded to remove the left foot soiled/old dressing and without changing gloves and performing hand hygiene, Staff E reached the clean field for a vial of NSS, proceeded to soak the old dressing with the NSS, and again reached the clean field with the same pair of gloves and touched the old dressing. Staff E continued wearing the same pair of gloves and reached the clean field multiple times to cleanse the residents left foot wound. Staff E removed her gloves and performed hand hygiene with hair and body shampoo instead of antibacterial/anti-microbial hand soap. Staff E donned gloves, opened a [MEDICATION NAME] (type of wound dressing) packaging, pulled a pair of scissors from her pocket, cut up a piece of [MEDICATION NAME] dressing and placed the pieces back into the packaging. Staff E then placed the pair of scissors on the clean field on the white foam tray and retrieved a dry gauze and proceeded to cleanse the resident left foot, retrieved NSS, soaked the [MEDICATION NAME] dressing, then squeezed the [MEDICATION NAME] to get rid of extra NSS, then applied the soaked cut up piece of [MEDICATION NAME] on the left foot wound and covered it with dry dressing. On 01/28/21 at 10:55 AM, during an interview Staff E was asked about placing the scissors used during wound care into her pocket. Staff E stated that she placed the pair of scissors into her pocket because it did not touch anything dirty. She added that the facility's policy does not address cleaning of the scissors. Staff E confirmed that her uniform pocket is considered a dirty area and that the scissors should have been cleaned before it was used to cut up the pieces of [MEDICATION NAME] dressing. On 01/28/21 at 11:15 AM, a joint interview was conducted with Staff E (RN), Staff F (CNA) and Staff T (RN) regarding the use of hand soap (antibacterial/anti-microbial soap) and Hair/Body shampoo solution. Staff E confirmed that she performed hand hygiene using hair/body shampoo solution instead of the antibacterial soap throughout wound care. She added that she had a blister on her right thumb and the bandage came off during wound care and she did not replace it. Staff E stated that the hair/body shampoo was gentler on her blister. Staff F stated she used the hair/body shampoo and started to use the antibacterial soap after the surveyor inquired about the use of the hair/body shampoo and the antibacterial soap. Staff F was asked about the facility's hand hygiene and the use of soap, Staff F stated, soap is soap and that she did not know the facility's policy related to which solution she should use during hand hygiene. Staff T, RN stated that staff must perform hand hygiene with an antibacterial soap. Staff E, Staff F and Staff T were apprised that hair/body shampoo solution is not antibacterial/anti-microbial soap. On 01/28/21 at 12:52 PM, during an interview Staff E WCN was apprised regarding the cross contamination during and reaching to the clean field with the same gloves used to clean the wounds. Staff E stated that she usually changed gloves after cleaning a wound but did not know what happened this time. Staff E confirmed she reached to the clean field with the same pair of gloves used to cleanse the wounds. An inquiry was made regarding Staff F reaching to the clean field to retrieved Personal cleansing cloth Staff E stated that Staff F should not have reached her clean field. 01/28/21 at 2:23 PM, an interview was conducted with the facility's Infection Preventionist/Assistant Director of Nursing (IP/ADON). The IP/ADON was apprised regarding cross contamination observations during wound care for Resident #29. She stated that Staff E should have changed gloves after cleaning a wound, before applying the treatment (medication). Review of the facility's policies titled Wound care policies and procedures stages; Wound care policies and procedures Skin care and pressure ulcer treatment revised on 01/2021 provided by the Director of Nursing, did not address wound care steps to be followed by the wound care nurse. Review of the facility's policies titled Hand washing/Hand Hygiene effective date 03/2020 documented employees must wash their hands for at least twenty seconds using anti-microbial or non-anti-microbial soap and water under the following conditions: before and after direct resident contact .before and after performing any invasive procedure (e.g. finger stick blood sampling) before and after assisting a resident with personal care .before and after changing a dressing .hand hygiene is always the final step after removing and disposing of personal protective equipment .the use of gloves does not replace hand washing/hand hygiene .vigorously lather hands with soap and rub them together for at least twenty seconds . Review of the facility's policies titled Personal Protective Equipment-Gloves revised on 01/2021 documented the use of disposables gloves is indicated: when handling soiled linen or items that may be contaminated .wash your hands after removing gloves .

Based on observations, interviews and record reviews, the facility failed to distribute food under sanitary condition as evidenced by staff failure to perform hand hygiene during dining in one of four wings during distributions of meals. 2) Staff failed to wear hair net while in the kitchen. These deficient practices have the potential to affect eighty-one residents that ate by mouth, out of eighty-eight residents residing in the facility in the facility during the time of this survey. The findings included: Review of the Hand washing/ Hand hygiene Policy and Procedure dated 03/2020 revealed This facility considers hand hygiene the primary means to prevent the spread of infections. It further showed that All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visible soiled, use and alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for all the following situations: before and after direct contact with residents. On 01/25/21 at 12:15 PM, dining observation revealed Staff A, Restorative Certified Nursing Assistant (CNA), was delivered meals to thirteen residents and did not perform hand hygiene before and after food trays were delivered. Staff A delivered food trays to residents residing in room [ROOM NUMBER]A, set the table, put the napkins on the resident in 45A chest, left the room and did not perform hand hygiene. Staff A continued delivered food trays to residents' rooms 45B, 45C, 46A, 46B, 46C, 47A, 48A, 48B and 48C. At 12:19 PM, Staff A set the table for resident 48C, she helped the resident with positioning for eating and left the room without performing hand hygiene. Staff A kept continued delivered food trays to residents rooms 49A, 49B and 49C and still did not perform hand hygiene before and after food trays were delivered. On 01/25/21 at 12:46 PM, Staff A, Restorative CNA), translated by Staff B, Registered Nurse, RN, revealed that CNA stated that she had to wash her hands before and after she feeds residents and she sanitizes her hands between one food tray delivery to another. When she was asked if she sanitized her hands today before and after food tray delivery, she stated that she sanitized her hands when she felt that her hands needed to be sanitized, but not always. Staff A ten stated and confirmed that she forgot to use the hand sanitizer between the resident's food tray delivery today. On 01/28/21 at 11:54 AM, during an interview the Infection Preventionist/ Assistant Director of Nursing (ADON), revealed that before and after feeding a resident, the staff should perform hand hygiene and before and after food trays deliver, the staff had to sanitize their hands. 2) On 01/27/21 at 9:56 AM, observation revealed through the west wing kitchen door square glass, a female with straight loose long black hair in the back of the kitchen area and not wearing a hair net. Further observation revealed Staff-I, a maintenance staff, inside the kitchen standing next to the food trays covered carts, talking to the kitchen staff, and not wearing a hair net. On 01/27/21 at 10:04 AM, an interview was conducted with the Dietary supervisor as she was coming out of the kitchen through the west wing hallway door. She stated she is in the kitchen most of her time. She was asked why she was not wearing a hair net when she was in the kitchen. The Dietary supervisor stated that she came from the patio and put a hair net on. The Dietary supervisor confirmed she has long black hair. She was apprised that surveyors saw her in the back of the kitchen without a hair net. The Dietary Supervisor was asked about Staff-I presence in the kitchen at the same time she was in the kitchen and stated he was checking about a work that needed to be done in the kitchen. She confirmed Staff I was not wearing a hair net and stated he is supposed to wear a hair net. On 01/28/21 at 8:40 AM, Staff I stated that on 01/27/21 in the morning he went into the kitchen and added he just entered to put trash in the basket. He then stated that they have hair nets, but he will use when he does any maintenance work in the kitchen. Staff-I confirmed he was in the kitchen and was not wearing a hair net. He stated he should have worn a hair net and that he will next time. On 01/28/21 at 2:23 PM, the facility's Assistant Director of Nursing was apprised regarding staff not wearing a hair net while inside the kitchen.

Based on interview and record review, the facility failed to maintain complete medical records for three (resident #1, resident #2, and resident #3) sampled residents as evidenced by the facility not accurately documenting information related to discharge planning. This had the potential to affect 101 residents who were present in the facility at the time of this survey. The Findings included: Record review of the facility's policy and procedures titled, Charting and Documentation, dated 01/2005, revealed, All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. Record review of the medical record for resident #1 revealed that the resident was admitted to the facility on [DATE], and discharged on [DATE]. Record review of the discharge care plan dated 06/10/2019, reviewed and revised 06/21/2019, revealed that resident #1 was care planned for discharge to an assisted living facility (ALF), or nursing home, with goal dates of 09/10/2019 and 09/21/2019. Record review of the Social Services initial assessment dated [DATE] revealed that resident #1's discharge plan was for the resident to be discharged to an ALF or nursing home. Record review of the Social Services progress notes dated 06/10/2019 and 07/02/2019 revealed that it was noted, Discharge plan is to find resident a ALF to live after she completes her rehabilitation or find a nursing home. However, there was no other documentation listed involving resident #1's discharge plan related to finding an ALF or nursing home of the resident's choice, or communication and correspondence with the receiving facility. Record review of the medical facesheet revealed that resident #1 was admitted to the facility on [DATE]. Interview with resident #2 on 09/06/2019 at 11:00 am revealed that he came from the hospital and was in the facility for rehab services, and stated that the care and services were good in the facility. When asked where he was going to go after he completed therapy, the resident stated that he did not know. He reported that no one from the facility had spoken to him about his discharge plans; he did not know if he was going to remain in the facility or go to an assisted living facility (ALF). He did not want to return back to the ALF that he was at previously because it was not good for him. He wanted to go to a retirement community in a different county. Resident #1 stated that he really wanted to know what was going to happen after leaving the facility because he had medical conditions such as [MEDICAL CONDITION] and he needed his oxygen. Record review of the discharge care plan dated 07/04/2019, reviewed and revised on 07/15/2019, revealed that resident #2 was care planned for being discharged to an assisted living facility (ALF) after completion of his rehabilitation program; with a goal date of 10/15/2019. Record review of the social services assessment dated [DATE] revealed that resident #2's discharge plan was to return to an ALF. Record review of the social services progress notes dated 07/12/2019 and 08/21/2019 revealed that resident #2's discharge plan was to return to the same ALF identified at the time of admission. There was no other documentation listed about the resident's discharge plan, or that the resident was asked about which he facility wanted to go to. Record review of the medical facesheet for resident #3 revealed that the resident was admitted to the facility on [DATE]. Interview with resident #3 on 09/06/2019 at 11:28 am revealed that he had been in the facility before sometime ago. He went to an ALF, and due to some medical complications, that were the result of time he spent in the military service, he got sick and he had to come back to the facility. Resident #3 stated that his plan after leaving the facility was to go to a nursing home for veterans that his daughter had found for him. The resident's daughter, as well as himself and a staff member from the facility were working on it. The resident stated that his choice was to go to this nursing home, not return back to the previous assisted living facility. Record review of the discharge care plan dated 08/09/2019, revealed that resident #3 was care planned for being discharged to an assisted living facility (ALF) of his choice after completion of a rehabilitation program; with a goal date of 11/09/2019. Record review of the social services assessment and social services progress note, both dated 08/12/2019 revealed that resident #3's discharge plan was to return to the ALF. The documentation did not list any information about the resident being sent to the nursing home of his choice. Interview with the Social Services Assistant, Director of Nursing (DON), Assistant Director of Nursing (ADON) and Social Services Director on 09/06/2019 at 1:19 pm revealed that when residents were admitted they asked them where they came from, and if they were going to return to back to where they came from such as an assisted living facility, or home. If a resident needed placement, then they started working on that immediately such as if the resident's family had a list of places, and if they needed help finding placement in facilities that had long-term beds available. With finding placement, sometimes they would meet with the family or contact them and asked them if they had any specific place or area in mind. They would get information and contact the facilities and start the process and send whatever documents they would need. Personnel from the other facilities would come and see the resident and evaluate them and talk to the family. In case they did not have a specific place, the facility would provide them with a list of nursing home or ALFs that had long term beds available so that the family could go and visit and see if they approve of the facility. Social services staff remained in contact with the resident and family, as well as the receiving facility. Family will let social services know if they did not like the facility, and if so, then they would continue to provide them with new options. With resident #3, the plan after discharge for him was to go to a nursing home for veterans. Social services staff was working with the nursing home, and they have sent all of the documentation; they respect the resident's wishes. Resident #2 resided in an ALF previously, and he would be going back to that same ALF after discharge. The resident agreed at the time of the initial social services assessment, and when they spoke to the resident again, he did not say anything different. For resident #1 the granddaughter picked a particular nursing home for the resident. She visited the facility and she liked it. The staff members stated that it should have been documented in the residents' medical records to reflect what was done related to discharge and discharge planning. The ADON stated that there was room for improvement with regards to documentation and updates in the medical record.

Based on observation, interview and record review, the facility failed to refer residents, for a Preadmission Screening and Resident Review (PASARR) Level II screening for two (Resident #77, #82) of three residents out of sixteen residents receiving health rehabilitation services for Mental Illness (MI) and/or Intellectual Disability (ID) whom exhibited behaviors. The findings included: 1. Observation of Resident #77 on 2/12/18 at 10:02 am revealed the resident sitting in a wheelchair, receiving therapy and wearing eyeglasses. Record review on 2/13/18 at 11:14 am revealed the following: 1) PARR Level I was completed on 5/26/17 at a local Hospital; 2) Section I, PASARR Level I Screen Decision Making Mental Illness (MI) or suspected MI were checked for Anxiety Disorder, [MEDICAL CONDITION] Disorder and [MEDICAL CONDITION]; 3) Section II, Other Indications for PASARR Screen Decision-Making were checked No; 4) Section IV: PASARR Screen Completion were checked for-No [DIAGNOSES REDACTED]. Level II PASARR not required and 5) Resident admitted to the facility on [DATE]. Review of the Demographic Face Sheet for Resident #77 revealed the resident was originally admitted on [DATE] with diagnoses to include anxiety, [MEDICAL CONDITIONS] and depression. The last admission was on 1/22/18. Review of the Minimum Data Set (MDS) 5-Day Assessment for Resident #77 dated 1/27/18 revealed the Preadmission Screening and Resident Review the resident not currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability and the Brief Interview for Mental Status (BIMS) Summary Score was not scored, indicating cognitive impairment. Review of the Physician order [REDACTED]. Review of the Physician Telephone Order revealed the following: 1) Dated 1/12/18: [MEDICATION NAME] for anxiety, agitation; 2) Transfer resident to { } Psych Unit with [DIAGNOSES REDACTED]. Review of the Behavior Monitoring Sheets for (MONTH) (YEAR) and (MONTH) (YEAR) revealed the resident received the following medications: [REDACTED]. Review of the Care Plans for Resident #77 revealed the following: 1) Problem: Behavioral Problem as evidenced by: Patient began yelling and screaming, physically aggressive, uncooperative, History refuse meds related to (r/t) Diagnosis, Anxiety, [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder (Written 1/22/18, Review 4/22/18) and 2) Problem: Resident is at risk for side effects from antianxiety medication. [DIAGNOSES REDACTED]., new order for [MEDICATION NAME] X (times) 1 dose. The resident had exhibited behavior on several occasions. Review of the Nurses' Notes for Resident #77 dated 1/12/18 at 11:00 am: Resident noted very anxious and confused at this time without apparent cause. Resident wife with resident, trying to slide from wheelchair (w/c), turn aggressive with staff, physically trying to hit the staff. Kicking started early, tried to redirect but resident maintained the same behavior. Staff and wife provided emotional support but ineffective at the time. Called MD to make aware resident's condition and change in behavior. New order given, [MEDICATION NAME] from emergency kit and transfer resident to { } Psych Unit. At 12:00 PM: Ambulance arrived at this time, resident left to { } Psych Unit Hospital with two paramedics and at 10:00 PM: Resident will be admitted to { } Mental Health Unit. Interview with Staff C on 2/15/18 at 11:51 am she stated, He has been out a few times to the hospital for altered mental status. On 1/12/18, the nurse noticed the patient being anxious and confused without apparent reason with the wife present. The patient was attempting to slide down the wheelchair and became aggressive when the staff tried to assist him. If you touch him, he wouldn't let the staff do it. Tried to redirect him and he continued with the same behavior. Called the Medical Doctor (MD), gave order for [MEDICATION NAME] and to transfer to { } Psych. Ambulance came to pick up the resident and was admitted to { } Hospital. He had a [MEDICAL CONDITIONS], communication is limited, strong man and when he gets like that he is very difficult. He has a history of behaviors. Probably should have been reevaluated for a PARR Level II. Interview with Staff D on 2/15/18 at 2:12 PM via Spanish translator stated, Sometimes he will get anxious. When she doesn't understand him, he changes his character. He changes his facial expressions, gets frustrated. Interview with Staff E on 2/15/18 at 2:42 PM stated, He has behaviors such as episodes of angry, yelling at the staff. Unable to speak but will say a certain phrase(NAME) tana when angry. Will try to hit staff sometimes. Has psychiatric treatment with doctor and takes meds for antipsychotics. Interview with the Social Services Director on 2/15/18 at 4:14 PM stated, PASARR Level I was done on 5/26/17 at a local Hospital with a [DIAGNOSES REDACTED]. No PASARR Level II was done. The patient has a care plan for screaming. I know the resident has had several episodes of altered mental status and the paperwork should have been sent to the Local State agency ( ) for Level II evaluation. 2. Observation of Resident #82 on 2/12/18 at 9:28 am revealed the resident sitting up in bed, talking to herself in Spanish. Record review on 2/13/18 at 9:21 am revealed the following: 1) PASARR Level I was completed on 12/20/17 at a local Hospital; 2) Section I, PASARR Level I Screen Decision Making Mental Illness (MI) or suspected MI was checked for [MEDICAL CONDITION]; 3) Section II, Other Indications for PASARR Screen Decision-Making were checked No; 4) Section IV: PASARR Screen Completion were checked for-No [DIAGNOSES REDACTED]. Level II PASARR not required and 5) Resident admitted to the facility on [DATE]. Review of the Demographic Face Sheet for Resident #82 revealed the resident was originally admitted on [DATE] with diagnoses to include [MEDICAL CONDITION] and [MEDICAL CONDITION]. The last admission was on 12/21/17. Review of the Minimum Data Set (MDS) Admission Assessment for Resident #82 dated 1/02/18 revealed the Preadmission Screening and Resident Review the resident not currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability, Brief Interview for Mental Status (BIMS) Summary Score was not scored, indicating cognitive impairment and Active Diagnoses were Anxiety Disorder, Depression, [MEDICAL CONDITIONS] and Cognitive Decline. Review of the Physician order [REDACTED]. Review of the Behavior Monitoring Sheets for (MONTH) (YEAR) and (MONTH) (YEAR) revealed the resident was receiving the following medications: [REDACTED]. Review of the Care Plan for Resident #82 revealed the following: 1) Problem: Other-Patient screaming at and yelling with nonsensical speech for no apparent reason related to [DIAGNOSES REDACTED]. Review of the Nurses' Notes showed the resident exhibited behavior on the following dates: 12/27/17, 1/30/18, 2/05/18, 2/13/18 and 2/15/18. Interview with Staff C on 2/15/18 at 12:11 PM stated, Have observed her talking to herself. Behaviors noted on 12/27/17, 1/30/18, 2/05/18, 2/13/18, 2/15/18. Probably should have been reevaluated for a ASA Level II. Interview with Staff F on 2/15/18 at 2:38 PM via Spanish translator stated, She has behaviors. Interview with Staff G on 2/15/18 at 2:48 PM stated, Behaviors noted such as screaming and nonsensical talking. Behaviors are noted everyday and intermittently. Review of the PASARR Level I was altered with a different date of 1/23/18 when the Discharging Hospital and Local State agency ( ) completed the Level I Screen on 12/20/17. Interview and record review with the Social Services Director on 2/15/18 at 3:55 PM stated, Responsibilities include when I receive the PASARR from the hospital I review it. I call the hospital and ask about it and review it. PASARR Level I was done on 1/23/18 at a local Hospital with a [DIAGNOSES REDACTED]. She don't have any behaviors. We don't determine the Level II, only the State agency ( ). When the nurse document the behavior, it triggers for a review we keep the MDS and psychiatric consult. I was notified the resident has had several behaviors by nursing. I put in a care plan. No, I did not send the papers to the State agency ( ) for a Level II. Yes, I should have sent the papers to the State agency ( ) for a Level II for review. Denied the PASARR Level I was altered with a different date of 1/23/18 when the Discharging Hospital and Local State agency ( ) completed the Level I Screen on 12/20/17. Interview with the Social Services Assistant on 2/15/18 at 3:57 PM stated, The resident was at a local Hospital and the Level I was done on 1/23/18. Denied the PASARR Level I was altered with a different date of 1/23/18 when the Discharging Hospital and Local State agency ( ) completed the Level I Screen on 12/20/17.

Based on interview and record review, the facility failed to ensure coordination of care for one (Resident #11) of one resident out of nine residents receiving hospice services as evidenced by failure to ensure adequate evidence of communication between the facility and the hospice provider. Written documentation was not available in the medical records. Services provided by Hospice were not coordinated and communicated in written documentation. The findings included: Record review of the Hospice Contract revealed a local Hospice Care Company entered into a written agreement with this facility effective on (MONTH) 28, (YEAR). Coordination of Care: Hospice and Facility shall communicate with one another regularly. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day. Review of the Demographic Face Sheet for Resident #11 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #11 dated 5/23/17 revealed the resident was cognitively impaired, total dependence with one person physical assist for ADLs (Activities of Daily Living) and was coded for Hospice Care. Review of the physician's orders [REDACTED].#11 received Hospice care from a local Hospice Care Company. Review of the Hospice care plan (written 11/03/17) revealed the resident was on Hospice care with a [DIAGNOSES REDACTED]. Interview with the Hospice Certified Nursing Assistant (CNA) on 2/14/18 at 10:28 am it was stated, When I come in I do bed bath, make her bed, do her hair, little housekeeping, put some on lotion, some cream, everything. Come in the morning everyday, five days a week. I don't write down what I do, I memorize it and when I get home, I put it in my computer. No note left for the facility. Nobody ask me to leave a note here on what I do. Interview with the Hospice Nurse on 2/14/18 at 12:12 PM it was stated, I come to see her one time a week or PRN (as needed) if there is a problem. When I come, I evaluate her from head to toe. When I come, I document in my company computer every visit and bring the notes to the facility every two weeks. Interview with Staff H on 2/15/18 at 9:26 am stated, The hospice comes to see the patient and they put their notes in the resident's chart in the section for hospice in the back of the chart. They are to put their notes in the section every time they come to see the resident. Don't know if the CNA has a binder to sign in but Hospice Nurse would put her notes in the section. I agree that the nurses' notes should be in the chart. Interview with the Assistant Director of Nursing (ADON) on 2/15/18 at 9:38 am it was stated, CNA has a separate binder and she signs in when she comes in. I don't know if they do thinning. They probably overlooked the notes being in the chart. The notes for (MONTH) (YEAR) and (MONTH) (YEAR) were faxed to the facility on yesterday to put into the chart. Subsequent interview at 10:13 AM, she stated, The reason why the (MONTH) notes were in the chart was because the resident was on crisis care. She is no longer on crisis care. Interview with the Hospice Nurse on 2/15/18 at 2:16 PM stated, She started on continuous care on 11/02/17 and finished 11/07/17. I put the notes in the chart and I removed them. They told me to remove them because it was too much paper in the chart. The notes are in my system. I brought notes from 11/02/17-11/07/17 and 11/08/17-02/02/18. I remove the notes every month for the next month. Reviewed hospice notes on 2/15/18 from 11/02/17-11/07/17 and 11/08/17-02/02/18, which were brought in by the Hospice Nurse.

Based on observation, interview, and record review, the facility failed to ensure one (resident #93) of five residents reviewed for unnecessary medications had an adequate indication for use of an antipsychotic medications out of 24 residents receiving antipsychotic medications. The findings included: Record review of the medical facesheet for resident #93 revealed the resident originally admitted to the facility on [DATE], and readmitted on [DATE]. Observation on 02/12/2018 at 10:22 am revealed resident #93 in her room in bed sleeping; the resident would not respond to her name or any questions. Observation on 02/12/2018 at 2:21 PM revealed resident #93 still sleeping in her bed without any disturbances. Observation on 02/13/2018 at 10:37 am revealed resident #93 in her room in bed sleeping, and could not be easily aroused. Observation on 02/13/2018 at 1:27 PM revealed resident #93 in bed still sleeping; the resident would not wake up when her name was called and continued to sleep. Observation on 02/14/2018 at 11:02 am revealed resident #93 in her room in bed sleeping. Similar to previous observations, the resident would not awake when her name was called; she continued to sleep. Record review of the physician's orders [REDACTED].#93 was prescribed 200 milligrams (mg) of [MEDICATION NAME], an antipsychotic medication, to be given twice daily for [MEDICAL CONDITION] chronic paranoid type (SCPT). Record review of the Medication Administration Record [REDACTED]. Record review of the Psychiatric Consultation dated 01/29/2018 revealed that resident #93 was evaluated by the psychiatrist. It was noted that the resident would continue with the [MEDICATION NAME] medication at the dosage and frequency of 200 mg twice daily. However, the only [DIAGNOSES REDACTED]. and Dementia. It was not indicated that the resident suffered from SCPT, or that the medication was prescribed for it. Record review of the Behavior Monitoring Records for the months of (MONTH) (YEAR) and (MONTH) (YEAR) revealed resident #93 was monitored for delusional behaviors. At the top of the record it was noted, Document each behavior per shift with the number of episodes and initial 'C' for Continuous. Further review of the records revealed no documented behavioral episodes for the resident. Record review of the Nurses' Notes for the months of (MONTH) (YEAR) and (MONTH) (YEAR) revealed no documentation of resident #93 displaying any delusional behaviors. Further review of the nurses' notes revealed that on 02/11/2018 the resident was observed in bed with moderate sedation. The resident's vital signs were taken, and it was noted, Patient is on antipsychotic medication [MEDICATION NAME] 200 mg twice a day. MD notified and new orders given to decrease [MEDICATION NAME] to 100 mg twice daily. Patient will be under closely monitoring. Call light at reach. Record review of the Telephone physician's orders [REDACTED].#93. Interview with the Certified Nursing Assistant (Staff B) on 02/14/2018 at 1:10 PM, via translation by the Licensed Practical Nurse (Staff A), revealed that resident #93 was totally dependent on staff for activities of daily living (ADL) care. Sometimes when she worked with the resident she could be resistive, but she would have to be patient with the resident and try again with her. She said that sometimes the resident would sleep a lot, and sometimes she would not. Resident #93 was calm and less active yesterday and today, but not sleepy. Interview with Staff A on 02/14/2018 at 1:34 PM revealed that sometimes resident #93 could be very resistive and non-cooperative with care. The resident received [MEDICATION NAME], 100 mg, twice a day via peg tube for SCPT; it used to be 200 mg twice a day but was discontinued because she was observed to be sedated on 02/11/2018. Resident #93 was not receiving [MEDICATION NAME] medication prior to her discharge; she came back from the hospital already prescribed the medication. Record review of the resident #93's closed medical record prior to her hospitalization on [DATE] revealed that she was not receiving the [MEDICATION NAME] medication. Further review of the nurses' notes for the months of (MONTH) (YEAR) and (MONTH) (YEAR) revealed no documented episodes of delusional behaviors. Record review of the hospital records for resident #93 only revealed an order for [REDACTED]. Observation and interview on 02/14/2018 at 1:57 PM revealed resident #93 in bed still sleeping. Staff A and the Director of Nursing (DON) were present in the room, and tried to arouse the resident. The resident moved to her side, but did not open her eyes; she started to scratch her sacral area. Resident #93 did not respond to her name when the staff members called her. Staff A and the DON said that she was sleepy, but responsive; they stated the resident was not sedated. Interview with the Psychiatrist on 02/14/2018 at 2:29 PM, via telephone, revealed that she had been following resident #93 prior to her coming to the facility, and when she was hospitalized . At the previous facility she prescribed the resident [MEDICATION NAME] for [MEDICAL CONDITION] and reacting to internal stimuli. The resident was receiving a higher dosage of the medication, but on 02/11/2018 the medication was reduced when the resident was observed to be sedated. The psychiatrist said that she could not completely take the resident off of the medication, but attempt gradual dose reductions. The resident needed to be monitored, and if she continued with sedation, then they would have to re-evaluate the resident. When informed of the observations of resident #93 continuously sleeping throughout the day, she said that she was going to speak to the facility and give orders for neurological checks, more close monitoring of the resident, and holding any medications that may cause the resident sedation. Interview with DON and the Assistant Director of Nursing (ADON) on 02/14/2018 at 2:53 PM revealed that the ADON spoke to psychiatrist on the phone and she instructed to start resident #93 on neurological checks every six hours for 48 hours, lab work immediately, [MEDICATION NAME] reduced to 50 mg daily, and hold if too sedated. When asked if nursing staff should have informed the psychiatrist of the resident's sleepiness, both staff members said that Staff A was going to call the psychiatrist before ending of her shift. Record review of the facility's policy and procedures titled, Behavior Assessment and Monitoring, dated 1/1/05, Revised 1/1/18, revealed policy did not specifically address antipsychotic medications. It was revealed, If the resident is being treated for [REDACTED]. The staff will continue to document (either in progress notes, behavior assessment forms, or other comparable approaches) specific information about problem behaviors or moods If psychoactive medications are used to treat behavioral symptoms, the nursing staff and Attending Physician will periodically reconsider their indication and consider whether they can be tapered or document why tapering cannot or should not be attempted.

Based on observation, interview and record review the facility failed to 1.) transport soiled linen in an appropriate manner via a vehicle by placing soiled, bagged linen on the driver's side seat, steering wheel and the passenger side seat of a van 2.) store emergency linen in a sanitary manner by utilizing a linen storage shed that contained a black, circular powdery substance along the entire ceiling 3.) store linen carts in a sanitary environment by placing the linen carts in the shower rooms. These processes have the potential for cross-contamination and breaks in infection control standards. The findings included: 1.) Observation on 2/1/2017 at 10:16 am with the Director of Housekeeping revealed that there was a private van parked outside the facility that was packed full with soiled linen in bags. The trunk, the back seat, the driver's side and passenger seats as well as the driver's side steering wheel were completely covered with bagged soiled linen. Interview on 2/1/2017 at 10:18 am with the Director of Housekeeping revealed that the resident's clothes were washed in-house and the soiled linen was sent out to a sister facility. The director of housekeeping confirmed that she saw approximately fourteen bags of soiled linen that covered the entire trunk, back seat, driver's and passenger seats and driver's side steering wheel. Observation and interview on 2/1/2017 at 10:26 am with the Director of Nursing (DON) and the Director of Housekeeping revealed that they saw and acknowledged that there were soiled linen bags covered over the driver's side steering wheel and seat as well as the passenger seat of the van. The DON stated that: In [AGE] years, I have never seen dirty linen bags stacked along the steering wheel of a van before. The DON confirmed that this was an infection control concern. The DON noted that this would be removed right away. The DON said that the front seats of the van would be wiped down right now. 2.) Observation on 2/2/2017 at 1:25 pm with the Director of Housekeeping, the DON, the Assistant Director of Nursing (ADON) and the Administrator revealed that there was an outside storage shed that contained emergency linen that was bagged and boxed on several shelves. There were several boxes of paper towels in this outside storage shed. The entire surface of the ceiling of the storage shed was covered in black, circular and powdery shaped smudges. Interview on 2/2/2017 at 1:25 pm with the DON, ADON, Administrator and the Director of Housekeeping revealed that they confirmed that the storage shed contained bagged emergency linen and that they saw that the entire storage shed ceiling was covered in black smudges. Interview on 2/2/2017 at 3:50 pm with the Director of Housekeeping and the administrator revealed that they did not have a laundry log which described when and how much soiled linen was sent out daily via a van for washing. 3.) Observation on 02/01/2017 at 12:10 pm of shower room [ROOM NUMBER] on the yellow wing of the West nursing unit revealed that there was a reclining chair and yellow receptacle labeled, linen, in the shower area. Observation on 02/02/2017 at 1:22 pm of shower room [ROOM NUMBER] on the yellow wing of the West nursing unit revealed that in the shower area the reclining chair was no long there, nor was there a yellow receptacle labeled, linen. However, there was a cart that was covered, which contained linen; some of the linen was bagged, and other linen was not. Observation on 02/02/2017 at 1:30 pm of shower room [ROOM NUMBER] on the brown wing of the West nursing unit revealed that in the shower area there was a cart that was covered with linen on it; some of the linen was in bags, and other linen was not in bags. Interview with the Administrator, Maintenance Director, and Assistant Director of Nursing (ADON) who was also the Infection Control Nurse on 02/02/2017 at 1:52 pm confirmed that staff should have not stored resident's linen in the shower rooms. Record review of the facility's policy and procedures titled, Linen Handling and Storage, dated 08/01/2005, Revised 01/01/2017, revealed This policy establishes the guidelines for the proper handling and storage of clean and soiled linen. All linen is handled, stored, transported, and process in a manner that will prevent contamination and maintain a clean environment for patients, health care workers, and visitors.

Based on observation, interview, and record review, the facility failed to ensure that resident rooms were: 1) in good condition for four resident rooms (room #2, room #4, room #49, and room #28), 2) and that resident care equipment was stored properly in two resident shower/bathrooms (room #46 and #1), out of 30 resident rooms that were observed for environmental concerns. The findings included Record review of the facility's policy and procedures titled, Environmental Services, dated 01/01/2005, Revised on 01/01/2017, revealed, The facility recognizes and accepts the responsibility of environmental management as among the highest priorities to ensure sustainable development; to establish policies, programs, and practices for conducting operations in an environmentally sound manner; to respect and protect the local, regional, and global environment; and to support just, sustainable, social and economic development while fulfilling our healthcare mission. Observation on 01/31/2017 at 11:22 am of room #49 revealed that for bed A the footboard was not in good condition; the wood was chipped at the top and left side of the footboard. Observation on 01/31/2017 at 11:49 am of room #28 revealed that the footboard for the bed was in disrepair; the wood was chipped at the base of the footboard. Observation on 01/31/2017 at 1:02 pm of room #4 revealed that for bed B the footboard was in disrepair. Observation on 01/31/2017 at 1:07 pm of room #2 revealed that for bed B the footboard on the bed was not in good condition; the wood was chipped with marks etched into the wood. Interview with the Maintenance Director, via translation by the Admissions Director, on 02/02/2017 at 1:28 pm revealed that he checked residents' rooms daily and that there were different teams that would go from room to room to check for any environmental problems as well. The Maintenance Director said that currently there were no major room repairs that he had made in resident rooms. Observation and interview on 02/02/2017 at 1:42 pm of room #49 revealed that the Maintenance Director confirmed that the footboard for bed A needed to be repaired. Observation and interview on 02/02/2017 at 1:44 pm of room #28 revealed that the Maintenance Director confirmed that the footboard for the bed needed to be fixed. Observation and interview on 02/02/2017 at 1:46 pm of room #2 revealed that the Maintenance Director confirmed that the footboard for bed B needed to be repaired. Observation and interview on 02/02/2017 at 1:48 pm of room #4 revealed that the Maintenance Director confirmed that the footboard needed to be repaired for bed B. Record review of the maintenance and repair request logs for the months of October 2016 to January 2017 located at both East and West nursing units revealed no maintenance requests involving the aforementioned concerns related to foot boards. Record review of the receipts and invoices from the months of November 2016 to January 2017 revealed no purchases made to repair the footboards in the residents' rooms. 2). Observation on 01/31/2017 at 10:49 am of room #46 revealed that in the bathroom there was a reclining chair positioned in front of the residents' shower. Observation and interview on 02/02/17 at 1:35 pm of room #46 revealed that the reclining chair was now stored in the residents' shower area behind the privacy curtains. The restorative nurse (Staff F) who was present confirmed that the reclining chair should not be there. Interview with the Administrator, Maintenance Director, and the Assistant Director Nursing (ADON) on 02/02/2017 at 1:52 pm confirmed that resident care equipment should have not been stored in the bathroom or shower room. Observation on 01/30/17 at 11:50 AM revealed that the shower room located between room #1 and room #3 had a blue colored Geri-chair in the section of the room directly under the shower. The rest of the room was not visible from the residents' bathroom because the burgundy colored shower curtain was pulled at this time. There was a housekeeping staff in the area that had completed cleaning the shower room. Observation on 02/01/2017 at 12:01 PM revealed that the shower room located between room #1 and room #3 door was closed. After opening the door, it revealed there was a white shower chair located directly under the shower head/area. There was a blue recliner type Geri-chair which was stored along the right wall of the room. There was a large yellow container that had written in black marker the word LINEN on the front panel. This container was stored along the left wall next to the sink. The room was clean with some moisture on the walls and floor.

Based on observation, interview, and record review, the facility failed to revise and update a care plan to include a resident's refusal to wear a dental prosthesis for one (resident #135) out of three residents sampled for dental services out of 16 care plans reviewed. There were a total of 97 residents in the facility at the time of this survey. The findings included: Record review of the facility's policy and procedures titled, Care Plan, dated 07/2005, Revised 01/2017, revealed, The purpose of our resident comprehensive care plan is to: identify the resident's physical, social, emotional, environmental, recreational, spiritual and rehabilitative aspects of care. Identify the role of each service that will participate in the resident's total plan of care, and how the care will be provided The comprehensive plan of care is evaluated through ongoing resident assessment. The care plan is reviewed and updated whenever there is a significant change in the resident's condition, and no less often than 90 days for all other residents. Record review of the medical facesheet for resident #135 revealed that the resident was admitted to the facility on [DATE]. Record review of Annual Minimum Data Set ((MDS) dated [DATE] revealed that resident #135 was encoded as having a score of 3 on the Brief Interview for Mental Status (BIMS) test indicating that the resident was severely cognitively impaired. The resident was also encoded as not having any of the aforementioned oral and dental status problems. Observation on 01/31/2017 at 12:12 pm revealed that resident #135 had bottom teeth, but had no upper teeth. Record review of the Inventory of Personal Effects sheet dated 01/25/2016 revealed that resident #135 was noted to have dentures. Interview with the husband of resident #135 on 01/31/2017 at 12:14 pm, via translation by the receptionist (Staff G), revealed said that the resident had upper dentures, but he believed that they may not fit the resident. The husband said that he had not told anyone because he figured that the resident's certified nursing assistants (CNAs) would take care of it. He said that the resident was still able to chew and eat her food without any problems. Interview with the Certified Nursing Assistant (Staff A), via translation by the Director of Nursing (DON), on 02/01/2017 at 12:36 pm revealed that she worked with resident #135 everyday; she was her regular CNA. Staff A assisted the resident with brushing her teeth. She said that the resident had both upper and bottom dentures. Resident #135 did not wear her upper dentures because she did not like to open her mouth all the way to put them in. Staff A said that since she had worked with the resident she had never seen her with the upper dentures in her mouth; she herself had not tried to use the resident's upper dentures because resident #135 did not allow it. Staff A had not told anyone because she figured everyone was aware of it. But, if she had to notify anyone she would tell the nurse. Interview with the Licensed Practical Nurse (Staff B) on 02/01/2017 at 1:05 pm revealed that she noticed that when she tried to put resident #135's upper dentures in her mouth, the resident would not open her mouth fully; so without them the resident ate better because she opened her mouth. She said that since she had worked with the resident she had never seen her with the upper dentures in her mouth. Staff B did not know if the upper dentures fit or not. She said that she had not told anyone that the resident did not want to wear her upper dentures. If she had to tell anyone, she would tell the social worker and the family; she would tell the Social Worker to see if maybe the resident needed a dental evaluation. Interview with the son of resident #135 on 02/01/2017 at 1:43 pm, via telephone, revealed that before the resident was admitted to the facility, the resident would wear her upper dentures because her cognition was good. However, due to the resident's dementia, once in the facility the resident would refuse to wear her upper dentures; the family had re-fitted the resident's dentures before because they did not fit properly. He no longer wanted to spend money on re-fitting the resident's dentures if she was not going to wear them. Resident #135 was doing better, eating her meals without any problems; the son said that he was happy with the care and services the resident was receiving. Record review of the nurses notes for the months of November 2016 to January 2017 revealed no documentation involving resident #135 refusing to wear dentures or the dentures being ill-fitted. Record review of the social services initial assessment dated [DATE], quarterly social services dated 10/06/2016, and annual assessment dated [DATE] revealed that it was documented that resident #135 had upper dentures. However, there was no documentation indicating that the resident refused to wear upper dentures, or the dentures did not fit. Record review of the Dental Care Plan dated 01/06/2017 revealed that resident #135 was care planned for having some or all natural teeth loss. The resident was noted to wear dentures. The goal included that the resident would not have any signs or symptoms of discomfort or complications related to teeth loss, or use of dentures left unmanaged through next review date 04/06/2017. The interventions included, but not limited to, assisting the resident with oral care daily as needed and assess for loose fitting dentures and report as needed. There was no notation on the care plan to indicate that the resident refused to wear her dentures, or that her family was aware that she did not wear them. Interview with Minimum Data Set (MDS) Coordinator #1 (Staff C), MDS Coordinator #2 (Staff D), MDS Coordinator #3 (Staff E), and the Director of Nursing (DON) on 02/01/2017 at 2:44 pm revealed that all MDS Coordinators were involved in revising and updating resident care plans in the facility. Staff confirmed that resident #135's dental care plan should have been updated to include that the resident refused to wear her upper dentures.

Based on observation, interview and record review the facility failed to 1) ensure the nutrition assessments, care plans, follow-ups' and diet order/changes were completed by the Qualified Dietitian for two (R#19, R#92) of four residents out of fourteen total residents that triggered for nutrition; and 2) one (R#31) of nine residents receiving Hospice Services and 3) one (R#32) of three residents triggered for Dental Status. This has the potential to affect all 97 residents residing in the facility at the time of this survey. The findings include: 1) Record review of the facility policy titled subject:Dietitian Services with an effective dated 01/01/2005 revision date of 01/ 7 reveal the policy statement noted a qualified Dietitian will help oversee clinical nutritional Dietary Services in the facility. The Policy Interpretation and Implementation: A Qualified Dietitian will help oversee clinical nutritional services to the residents. A Food Services Manager will oversee the production, storage, and delivery of food. The Dietitian may be a consultant or an employee, depending on the facility's situation. The Dietitian will work closely with the Food Service Manager and clinical staff. A Dietitians qualification shall be based upon: Registration by the Commission on Dietetic Registration of the American Dietetic Association; or Demonstrated education, training or experience in identification of dietary needs, planning and implementation of dietary programs. Our facility's dietitian is responsible for, but not necessarily limited to: a-Reviewing/Oversight of High Risk Residents as reported by facility's Diet Tech and/or Nursing Administration (including but not limited to significant weight loss, Enteral fed residents and significant Weight Loss) b-Developing and planning regular and therapeutic diets; c-Assistance with continuing education programs for Dietary Services and nursing personnel: d-Collaborating effectively with other direct care staff and practitioners to assess and address nutritional issues in the facility's population; Helping the administrator and facility staff review and maintain appropriate quality of meal preparation and menus; f-Helping the Administrator and Food Services Manager review appropriate food safety and sanitation; and h-Providing nutrition-related advice and counseling to residents and families. Record review conducted on 01/30/17 revealed the Telephone Order dated 01/20/17 noted the supplement (Boost VHC) to be D/C (discontinued). Record review of the Physician Order Sheet for January 2017 revealed there was a hand written order noted 120ml supplement to be D/C on 01/05/17. The order to give the supplement three times a day (TID) at 10:00 AM, 2:00 PM and 8:00 PM and record the percentage consumed. Interview on 01/31/2017 at 4:35 PM with the Diet Technician (DT) revealed she increased R#19's supplement. She stated she ordered for R#19 to receive the oral supplement (Boost VHC) to be discontinued from 120ml three times a day (TID). She made the recommendation for the supplement increase to 1-container, which would be approximately 240mls (milliliters) three times a day. She said the current diet order for R#19 was Puree Enhanced Diet with regular liquids. The DT was reviewing R#19's medical record at this time. She stated R#19 was ordered to have weights done weekly. Record review of the Care Plan dated 12/07/16, revised 01/05/17 with target date of 03/08/17 for R#19 noted the risk for unintended weight loss/decline in parameter of nutrition. The care plan had not been signed or documented by the RD Consultant. All notes were by the DT. The approaches noted included: Provide Diet as Ordered Provide Snacks as ordered Assist/feed resident at all meals as needed Counsel on prescribed diet Assess labs as available Assess weight as per policy Notify physician of significant weight changes Offer meal substitution as needed Review negative outcomes of diet non-compliance Speech Therapy as ordered. Record review of the Dietary section revealed the initial Nutrition Assessment for R#19 was dated 09/16/15 which was completed by the DT. The RD saw R#19 on October of 2016 and she saw her 2 weeks ago. When they get the list of the residents ' weights at the beginning of the month. She would check off the residents that needed to be seen by her. She would mark off the tube feeding residents and she will go through the list and then check it off after she actually complete the reviews. She will recommend the supplements. Record review of a Telephone Order dated 01/05/17 revealed it had noted to provide R#19 with 1-Magic cup for lunch and dinner. The record review of R#19 weights were conducted with the DT revealed the monthly weights noted were as follows: 01/02/17=92# 12/01/16=96# November 96# October 95# September 99# August 99# July 103# June 102# May 100# April 104# March 106# February 109# January 113# Record review of the Monthly Weight Record revealed R#19 weights noted were as follows: January 11th and 18th the weight noted was #111. March 2016 the weights ranged from 104# to 106# May 2016 the weights noted ranged from 101# to 103# June 2016 the weights noted were at 101# August 2016 the weight ranged from #99 to 103#. September 2016 the weights noted were 97# to 98# October 2016 the range of weights #96 to 97# Record review of the Dietary Department Nutrition Gang Tackling Nutrition/Food Service dated 01/17/17, 12/16/16, and 11/16/16 revealed, the DT completed the information with no noted signatures from the Registered Dietitian (RD) Consultant. Record review of the Nutritional Assessment form dated 12/06/16 revealed it noted R#19's weight, height, gender, age, UBWR (usual body weight) BMI (body mass index), checked: Underweight, No weight loss or Gain regimen and the Weight Trends: 95-103# x 180 days. Nutritional Orders Diet Orders: Puree enhanced 4-ounce Magic cup L/D, (lunch/dinner) 1-container Boost VHC (very high calorie), TID (three times a day). With Alzheimer, [MEDICAL CONDITION], Cardiovascular:[MEDICAL CONDITION](hypertension), CAD [MEDICAL CONDITION]; Dementia [MEDICAL CONDITIONS](gastro-[MEDICAL CONDITION] reflux), [MEDICAL CONDITION], and [MEDICAL CONDITIONS]. Resident Edentulous-Total Assistant. Skin Condition, Cognitive, and Mental & Communication Factors that may affect eating, Skin Condition, Nutritional Related Labs Oral Nutrition Intake/Nutritional Needs and evaluation. On 01/31/17 at 4:50 PM interview with the Registered Dietitian (RD) Consultant revealed that she did not complete the nutritional assessments for the residents in the Dietary section or the four questions in section-K of the Minimum Data Set (MDS). She explained the DT was Certified, with a four-year degree in Nutrition and she met the State of Florida requirements as the qualified Dietitian. She said she was not aware of any regulations that stated she had to complete the nutritional assessments for the residents. She confirmed that she did review the DT's work, made notes and would sign off on the DT's work after she reviewed it for accuracy. She stated when there was a significant change in the residents condition the DT would let her know usually within a week it occurred and she would try to see those residents' the following week if not sooner. She had some questions and felt there needed to be clarification about the State verses the Federal requirements related to the Qualified Dietitian definition and requirements. Both the DT and RD Consultant confirmed the DT did not have the required Licensure with the State of Florida but held a license in another country. Record review of the Minimum Data Set ((MDS) dated [DATE] revealed it was done due to a significant change. Section-K had noted the height as 65 and the weight was 96#. Record review revealed the following: the telephone order dated 01/05/17 had an order to D/C (discontinue) Boost VHC 120ml TID (three times a day). Interview on 1/31/17 at 4:27 PM with the Certified Nurse Assistant STAFF-Q revealed R#19 received assistance with feeding. She had a puree diet and was a good eater usually consumed 50 % to 75% of her meals. She said she would have to take her time feeding R#19 and she would turn her head if she did not want any more food. Interview on 02/01/17 at 9:10 AM with C N A-STAFF-O revealed the resident consumed 75% of her breakfast meal and received a supplement (Magic Cup) at lunchtime. Interview and brief record review on 02/01/17 at 9:15 AM with the attending Licensed Practical Nurse STAFF-P of the MAR (medication administration record) revealed R#19 received a supplement of Boost VHC increased to 237ml (8 ounce) container TID at 12pm, 2pm and 8pm. Observation on 02/01/2017 at 9:28 AM revealed that R#19 was on the patio in the group activity. She was neatly dressed and well groomed. She was in a Geri chair holding a small stuffed animal. Observation on 02/01/2017 at 12:37 PM of the resident revealed the C N A STAFF-O was sitting next to R#19 with the meal tray on the bedside table assisting with feeding. There was a magic cup-supplement on the tray. The resident had a puree diet. Observation of the resident on 02/02/17 at 7:29 AM revealed she was finishing her breakfast meal with assistance by the C N A. The meal tray revealed R#19 had consumed over 70% of food and beverages. The resident was well groomed and dressed in night clothing. Observation on 2/02/17 at 12:50 PM revealed R#19 was sitting in Geri chair in her room receiving assistance with feeding. The resident was consuming the food as fed and given time to eat. Observation on 2/02/17 at 2:58 PM revealed the resident was on the outside patio in the group activity. The staff were providing residents with an afternoon snack/beverage. Interview on 02/02/17 at 3:01 PM with C N A STAFF-Q revealed R#19 had consumed a high percentage of her breakfast. She stated you have to take your time to feed the resident and she likes the sweet food first especially the fruits. She consumed all of the pancakes this morning because of the sweet syrup. She confirmed the diet was puree and she consumed 75% of her breakfast and lunch. She stated that she mixed the magic cup content with the other food to make it sweet and this will ensure the resident will eat the regular food items. Record review of the Resident Care Card for February 2017 revealed R#19 ' s meal consumption was recorded with the following 0=0 intake 2=50% intake 3=75% intake 4=100% intake 5=Enteral feeding given by nurse Other: Special Devices noted include: Guard Alarm, Side rail, air mattress. The shifts were noted and there was a space for the C N A ' s initials. Record review of the Resident Care Card for February on 2/02/17 had the consumption noted as Breakfast=3 (75%); Lunch=3 (75%); and the AM (morning) Snack=3 (75%). Interview on 02/02/2017 at 3:24 PM with the RD Consultant revealed the process they used to conduct the initial assessment involved the Dietetic Technician. She explained they had a communication log that was used to document all the newly admitted residents during a two-week interval. The DT would complete the initial nutrition assessment for those residents and she would identify residents' that were high risk and needed to be reviewed by her. She would review the records of the residents that were referred to her by the DT after they discussed the results of the DT findings. She stated she might sign off on the records but there were some instances where she might not actually sign the notes indicating she reviewed the record. She stated the residents that she considered as high risk and that must be seen by her would include but not limited to those that received [MEDICAL TREATMENT], Enteral Feedings and experienced Weight Loss (significant). She said all of the enteral fed residents were follow-up by her monthly and as needed. She said the DT could make recommendations. She said for the month of January 2017 she saw over 45 residents. She stated the DT was capable of writing the Nutritional Care Plans. She had a letter of reciprocity that showed the DT was licensed. She explained the DT had more qualifications than the regular diet tech because she had a four-year degree. Record review with the RD Consultant revealed she had signed off periodically on R#19 nutritional progress notes. She explained how she might not write notes all the time that showed she reviewed the residents' record but they discussed all residents each time she visited. For the high risk, some of the residents that have significant weight loss for instance they will review the information together. She said she will review it with the DT and she would go and review the residents' medical record to oversee any orders, changes in weights or conditions. She presented the log that was used for the communication with the Dietetic Technician. Record review of the log titled Nutrition Worksheet/Referral for Dietitian the form had columns that included the Name, Room Number admitted s, Assessment Date, Care Plan, MDS, HT/WT, Tube feeding, [MEDICAL TREATMENT], Decubitus, Recommendation WK Wt. (weekly weights) and Other Follow-up. There were 12 residents listed on the form but it did not include R#19. The RD stated she would sign the form to show the residents that were reviewed and assessed by her. She would do a follow up at least monthly if not twice a month. The residents that had a significant weight loss she would review them at least weekly. They would verbally review information on each residents as far as developing dietary/nutrition interventions. The communication may or may not be documented in the residents' medical record. She would mark the log with a check mark indicating those residents that she reviewed. She stated the logs were not kept for more than two weeks and she did not have copies to show the history of nutritional reviews she conducted for R#19. Record review of the form title Percentage of Change revealed weight R#19 was noted to have Extreme Loss. The weight noted were as follows: Jan/17=92# Dec/16=96# Nov/16=96# Oct/16=95# Sept/16=99# Aug/16=99# Jul/16=103# 2) Observation of Resident #92 on 2/01/17 at 12:37 pm revealed the resident sitting up in bed, eating lunch and being fed by a Certified Nursing Assistant (CNA). She was neatly dressed and well groomed. Record review of the medical facesheet for Resident #92 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for Resident #92 revealed the resident was cognitively impaired; required extensive assistance with one person physical assist for eating; not on a mechanically altered or therapeutic diet. Section K of the MDS was the Swallowing/Nutritional Status assessment of a resident. Furthermore, Section Z. Assessment Administration revealed that Section K-Swallowing/Nutritional Status was signed and completed by the Dietetic Technician (DT) on 8/03/16. Review of the Care Area Assessment (CAA) dated 8/03/16 for Resident #92 revealed the following: 1) Resident was receiving a Regular diet; 2) Resident #92 meal consumption was reported poor; 3) Resident #92 was receiving an oral supplement for additional calories; 4) Resident #92 remained at nutritional risk and potential for nutritional decline and 5) CAA assessment was signed and completed by the DT. Review of the Physician's Order Sheet (POS) for December 2016, January 2017 and February 2017 for Resident #92 revealed the following: 1) Resident received a Regular diet with enhanced foods; 2) Boost Plus 1 container PO (by mouth) TID (three times daily); 3) Magic Cup at lunch (supplement) and 4) [MEDICATION NAME] 400mg PO BID (twice a day) x (times) 30 days for decreased PO (oral intake). Review of the Nutrition Care Plan for Resident #92 (written 7/22/16) revealed the following: Resident at risk for unintended weight loss/decline in parameters of nutrition; Goal: Will stabilize plus or minus 3% through next review date; Approaches: Provide diet as ordered (Regular, Enhanced foods all meals); Provide snacks/supplements (Boost Plus 1 container TID), [MEDICATION NAME] 400mg BID x 30 days); Added on 11/02/16 Magic Cup at lunch; Added on 1/25/17 [MEDICATION NAME] x 30 days; Added on 1/26/17 Enhanced foods. The Nutrition Care Plan was written and updated by the DT. The nutrition care plan was not reviewed or signed by the RD. Review of the admission nutrition assessment dated [DATE] for Resident #31 revealed the assessment was completed by the DT and was not reviewed or signed by the Consultant Registered Dietitian (RD). Review of the quarterly nutrition assessments dated 10/25/16 and 1/23/17 for Resident #92 revealed the assessments were completed by the DT and was not reviewed or signed by the RD. Review of the nutrition progress notes dated 8/08/16, 8/16/16, 8/23/16, 9/02/16, 9/19/16, 9/27/16, 10/04/16, 10/12/16, 10/18/16, 10/25/16, 11/02/16, 11/08/16, 11/15/16, 11/22/16, 11/29/16, 12/02/16, 12/06/16, 12/07/16, 1/04/17, 1/17/17 and 1/26/17 for Resident #92 revealed that the assessments were completed by the DT. The nutrition progress notes were not reviewed or signed by the RD. Review of the weight for Resident #92 revealed the following: 7/21/16 to -161 pounds, 7/25/16-157 pounds, 8/01/16-147 pounds, 8/22/16-143 pounds, 9/01/16-142 pounds, 9/26/16-138 pounds, 10/10/16-136 pounds, 10/31/16-135 pounds, 11/07/16-134 pounds, 11/21/16-133 pounds, 12/01/16-133 pounds and 1/02/16-133 pounds. The resident had a weight loss from 7/21/16 to 1/02/17 of 28 pounds. Interview with the DT on 2/02/17 at 9:34 am revealed the following: 1) Conducted initial nutrition assessment; 2) Consultant Registered Dietitian will review & sign off on the initial nutrition assessment; 3) Consultant RD will sign off on some quarterly nutrition assessments; 4) RD will review and sign off on the progress notes; 5) Able to assess and write assessment on high risk residents and residents with weight loss, then RD will review and sign off on it; 6) Not registered as a diet tech but eligible for RD exam because of license from Philippines; 7) Had license from back home from Philippines; 8) Quarterly Assessment for 10/25/16, Resident #92 had gradual weight decrease; 9) Confirmed that RD did not sign off on the assessment for Quarterly Assessment 10/25/16; 10) Confirmed Assessment for 1/23/17, Resident #92 weight was stable x 90 days however weight history reflected with significant weight loss in 180 days; 11) Confirmed recommended for the resident to continue to receive oral supplement; 12) Confirmed that RD did not sign off on the assessment for 1/23/17; 13) Confirmed last progress note written from the RD was dated 11/16/16; 14) Confirmed that the recommendation for [MEDICATION NAME] came from the DT; 15) Confirmed RD had not reviewed the progress note yet and 16) Confirmed that she would consider the resident as a high risk resident. Interview with RD on 2/02/17 at 3:34 pm revealed that she would only sign off on initial nutrition assessments conducted by the DT but not quarterly nutrition assessments. 3) Observation of Resident #31 on 2/01/17 at 9:00 am revealed the resident sitting in a wheelchair outside on the patio, participating in activities. She was neatly dressed and well groomed. Record review of the medical facesheet for Resident #31 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Significant change in status assessment dated [DATE] for Resident #31 revealed the resident was cognitively impaired; required total dependence with one person physical assist for eating; ate a mechanically altered and therapeutic diet. Section K of the MDS is the Swallowing/Nutritional Status assessment of a resident. Section O: Special Treatment revealed the resident received hospice services. Furthermore, Section Z. Assessment Administration revealed that Section K-Swallowing/Nutritional Status was signed and completed by the Dietetic Technician (DT) on 12/17/16. Review of the Care Area Assessment (CAA) dated 2/17/16 for Resident #31 revealed the following: 1) Resident continue to receive mechanical altered diet for better toleration; 2) Resident receiving high calorie diet for weight maintenance; 3) Oral supplement in place for weight maintenance; 4) Gradual weight decrease reported; 5) Resident was under hospice care due to [DIAGNOSES REDACTED]. Review of the Physician's Order Sheet dated December 2016, January 2017 and February 2017 for Resident #31 revealed the following: 1) Resident was receiving hospice care; 2) Resident received a Mechanical Soft diet with enhanced food at all meals; 3) Prostat 30ml PO QD (every day) x (times) 30 days (supplement); 4) Boost VHC 120ml PO (by mouth) 4 times a day for supplement/weight loss and 5) Milkshake 4 oz. (ounces) at lunch for supplement. Review of the Nutrition Care Plan for Resident #31 (written 2/16/16) revealed the following: Problem: Resident at risk for unintended weight loss/decline in parameters of nutrition; Goal: Resident needs will be met to maintain quality of life/comfort; Approaches: Provide diet as ordered (Mechanical Soft, Enhanced foods all meals); Provide snacks/supplements (Boost VHC 1 container TID, changed 6/09/16 Boost VHC 120ml QID), Milkshake 4 oz. at lunch); Added on 1/27/17 Prostat 30ml QD x 30 days (supplement). The Nutrition Care Plan was written and updated by the DT. The nutrition care plan was not reviewed or signed by the RD. Review of the admission nutrition assessment dated [DATE] for Resident #31 revealed the assessment was completed by the DT and was not reviewed or signed by the Consultant Registered Dietitian (RD). Review of the quarterly nutrition assessments dated 5/11/16, 9/08/16 and 11/04/16 for Resident #31 revealed the assessments were completed by the DT and was not reviewed or signed by the RD. Review of the nutrition progress notes dated 6/28/16, 7/05/16, 8/02/16, 8/08/16, 8/15/16, 8/22/16, 8/26/16, 9/21/16, 9/23/16, 10/19/16, 10/21/16 and 1/27/16 for Resident #31 revealed that the assessments were completed by the DT. The nutrition progress notes were not reviewed or signed by the RD. Review of the weight for Resident #31 revealed the following: 4/01/16-141 pounds, 5/02/16-138 pounds, 6/01/16-134 pounds, 7/01/16-136 pounds, 8/01/16-132 pounds, 9/01/16-138 pounds, 10/03/16-137 pounds and 11/01/16-133 pounds. The resident had a weight loss from 4/01/16 to 11/01/16 of 8 pounds. Interview with the DT on 2/02/17 at 10:02 am confirmed the following: 1) Resident #31 was on Hospice; 2) High risk residents are residents who are losing weight, had poor oral intake, had pressure ulcers, wounds and received hospice services; 3) Conducted Quarterly Nutritional Assessments for Resident #31 on 5/11/16, 9/8/16 and 11/4/16; 4) Confirmed RD did not review or sign off on the Quarterly assessments and should have; 5) Confirmed RD did not review and sign off on the Nutrition Progress notes dated 6/28/16, 7/05/16, 8/02/16, 8/08/16, 8/15/16, 8/22/16, 8/26/16, 9/21/16, 9/23/16, 10/19/16, 10/21/16 and 1/27/16. Interview with the RD on 2/02/17 at 3:29 pm revealed that a resident on hospice was not considered high risk and she only reviews nutrition progress notes written by the DT if there is a concern. 4) Observation of Resident #32 on 1/30/17 at 12:30 pm revealed the resident sitting in a wheelchair, in her room eating lunch. She was neatly dressed and well groomed. Record review of the medical facesheet for Resident #32 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident was discharged on [DATE]. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for Resident #32 revealed the resident was not cognitively impaired; required independent with setup help only for eating; on a therapeutic diet. Section K of the MDS is the Swallowing/Nutritional Status assessment of a resident. Furthermore, Section Z. Assessment Administration revealed that Section K-Swallowing/Nutritional Status was signed and completed by the Dietetic Technician (DT) on 12/17/16. Review of the Care Area Assessment (CAA) dated 12/17/16 for Resident #32 revealed the following: 1) Resident #32 BMI indicated the resident was obese; 2) Resident continued to receive therapeutic diet for cardiac and diabetes mellitus management and 3) CAA assessment was signed and completed by the DT. Review of the Physician's Order Sheet (POS) for December 2016 and January 2017 for Resident #32 revealed the following: 1) Resident received a Regular, No Added Salt (NAS) diet; 2) Diet was changed to Regular, NAS, No Concentrated Sweets (NCS) on 12/05/16 and 3) Prostat 30 ml TID x 60 days for promote healing. Review of the Nutrition Care Plan for Resident #32 (written 12/05/16) revealed the following: Resident at risk for unintended weight loss/decline in parameters of nutrition; Goal: Prescribed weight loss regimen; Approaches: Provide diet as ordered (Regular, No Added Salt. The Nutrition Care Plan was written and updated by the DT. The nutrition care plan was not reviewed or signed by the RD. Review of the admission nutrition assessment dated [DATE] for Resident #32 revealed the assessment was completed by the DT and was not reviewed or signed by the Consultant Registered Dietitian (RD). Review of the nutrition progress notes dated 12/05/16, 12/13/16, 12/15/16, 12/20/16, 12/25/16, 1/04/17 and 1/24/17 for Resident #32 revealed that the assessments were completed by the DT. The nutrition progress notes were not reviewed or signed by the RD. Interview with the DT on 2/02/17 at 10:10 am confirmed the following: 1) Confirmed conducted initial assessment on 12/5/16; 2) Confirmed RD was supposed to sign off on nutritional assessments; 3) Confirmed that RD did not sign off on the initial assessment; 4) Confirmed resident's diet was Regular, NAS upon admission; 5) Recommended no concentrated sweets added to the diet due to resident having a [DIAGNOSES REDACTED].#32 and 8) Confirmed that the RD did not sign off on any nutrition progress notes. Interview with the RD on 2/02/17 at 3:24 pm revealed the following: 1) DT worked at the facility full time and will conduct initial nutrition assessment; 2) When she came in, DT kept a communication log of admissions & indicated for her to review if they were high risk; 3) Confirmed only reviewed the DT assessment if it was high risk; 4) Residents with weight loss, [MEDICAL TREATMENT] and enteral feedings were considered high risk; 5) Confirmed that she didn't review nor sign off on the initial assessment and nutrition progress notes for Resident #32.