Every finding on record at High Hope Care Center

Based on record review and interviews, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment related to PASARR (Preadmission Screening and Resident Review) Level II determinations for 2 (#7, #58) out 3 resident reviewed for PASARR. Findings: Resident #7 A review of Resident #7's EMR (electronic medical record) revealed an admission date of 05/04/2024 with diagnoses that included, but were not limited to, unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, recurrent severe without psychotic features, and generalized anxiety disorder. Further review of Resident #7's EMR revealed a PASRR Level II Evaluation Summary and Determination with an issue date of 09/30/2024. Review of Residents #7's comprehensive MDS assessment with an Assessment Reference Date (ARD) of 05/15/2025 revealed the PASARR Level II status was coded as not indicated. On 03/18/2026 at 10:30 a.m., an interview was conducted with S7MDS who was responsible for resident MDS assessments. S7MDS stated that she was unaware of Resident #7's Level II PASARR status. S7MDS confirmed the last comprehensive MDS assessment was on 05/15/2025 was coded incorrectly. Resident #58 A review of Resident #58's EMR revealed an admission date of 02/18/2026 with diagnoses that included, but were not limited to, anxiety disorder due to known physiological condition, schizophrenia, and unspecified intellectual disabilities. Further review of the EMR revealed a PASRR Level II Evaluation Summary and Determination effective 02/13/2026 through 08/14/2026. Review of Residents #58's comprehensive MDS assessment with an ARD of 02/24/2026 revealed the PASARR Level II status was coded as not indicated. On 03/17/2026 at 1:47 p.m., a concurrent record review and interview was conducted with S7MDS. S7MDS reviewed Resident #58's PASRR documentation and confirmed Resident #58 had a Level II determination effective 02/13/2026. S7MDS stated she had not previously used this documentation to verify PASARR status and confirmed the MDS assessment was coded inaccurately.

Based on observation, record review, and interview, the facility failed to ensure all drugs and biologicals remained locked in stored compartments of 1 medication cart when unattended during medication pass.Findings:On 03/18/2026, review of the facility's Medication Storage policy and procedure indicated Date Reviewed/Revised: 2026. The policy read, in part, All drugs and biologicals will be stored in locked compartments (i.e., medication carts. and During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.On 03/17/2026 at 2:51 p.m., when approaching the Hall W nurses' station, Med Cart A was observed midway down the hallway. There was no nurse in sight. Approaching the cart, it was observed that the back of the cart was near the wall of the hallway, with the front face of the cart facing the center of the hallway and providing access to the drawers of the cart. No nurse attended the cart or was within line of sight of the cart. The locking mechanism for the drawers was protruding from the front center of the cart, indicating it was unlocked. Drawers were successfully pulled open confirming the cart was unlocked. Drawers contained resident's medications and associated biologicals. At this time, S8LPN appeared from a nearby resident's room. S8LPN confirmed the medication cart was unlocked and unable to be seen and accessed when she stepped away from the cart.

Based on observations, interviews and review of the facility's policy and procedures, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: bulk items, juice, and snacks stored without the used by/expiration date, and without the date the items were delivered and/or opened; andbuildup of grime and water stains on bottom shelf of a food preparation table and dish covers storage rack. This deficient practice had a potential to affect 90 residents who consumed food from the kitchen. Findings: 1. On 03/16/2026, a review of the facility's policy titled, Storage of Food and Non-Food Items with last reviewed date of 02/27/2026, read in part, Policy: All food or non-food items are stored in a safe and sanitary manner .Procedure: 1. Dry Storage .E. Food items are marked with the date of delivery as they are stored. Boxes, cans and bags are marked individually.On 03/16/2026 at 8:56 a.m., a tour of the dry food storage area and an interview was conducted with S2DS who stated she was in charge of the kitchen. The following items were observed: Three large plastic bulk storage containers with individual labels of flour, fish fry, and rice without the dates to indicate when they were delivered, opened and placed in the containers, or the used-by date for the items. S2DS stated the containers were supposed to be dated with the date they were placed in the container and the use-by date from the original container the items were removed. She stated she did not have the original boxes anymore therefore did not know the date. Further observation of the dry storage area revealed 7 containers with 710 ounces each of liquid that were not labeled with the use-by date, expiration date, or delivery date: 3 concentrated orange juice, 1 concentrated apple juice, and 3 concentrated cranberry juice. S2DS stated the juices were removed from a box with dates that should have been placed on the containers at the time they were removed from the original box. Continued observations revealed a drawer with crackers and snack packs that were not labeled with the use-by date: 72 wheat crackers snack packs, 82 cheese crackers, and 87 [NAME] snack packs. S2DS stated the items came in boxes with use by dates and the dates should have been saved with the items, but were not. 2. On 03/16/2026 a review of the facility's policy titled Cleaning Schedule with a last reviewed date of 02/27/2026 read in part, Policy: A cleaning schedule is established by the dietary manager for the daily, weekly and monthly cleaning procedures in the dietary department. Proper cleaning procedures are followed for each piece of equipment. Procedure: 1. All equipment and work areas are cleaned after each use or on a routine basis. 2. A cleaning schedule is established by the dietary manager. The cleaning schedule lists the cleaning tasks to be performed, the person or position responsible for each task and the time frame for cleaning 3. The cleaning schedule is posted in the dietary department . On 03/16/2026 at 9:15 a.m., an observation was made of a two shelves metal rack that was used to store the hard plastic meal covers. The rack was observed with brown grime around the legs and white water stains on the bottom shelf of the cart. S2DS confirmed the findings. She stated that the white water statins were hard to come off, but there should be no grime on the rack. S2DS stated staff should have cleaned the rack before storing the meal covers. Further observation revealed the bottom shelf of the metal food preparation table had a buildup of grime around the legs. There were hamburger buns stored in a plastic bag which were in a hard plastic container on the shelf. S2DS confirmed the findings. She stated the prep table should not be like that, there was a cleaning schedule for staff to clean the kitchen equipment. On 03/16/2026 at 10:39 a.m., an interview was conducted with S1ADM who was responsible for the day to day functions of the facility. He stated that he was made aware of the findings in the kitchen by S2DS and confirmed the above findings.

Based on observation, interview and record review, the facility failed to maintain an effective infection control program by failing to ensure laundry staff wore appropriate personal protective equipment (PPE) while sorting soiled laundry to prevent the spread of infection.Findings:A review of the facility's policy titled Laundry and Bedding, Soiled, last reviewed 01/27/2026, read as follows; Onsite Laundry Processing 1. Hand hygiene products, as well as appropriate PPE (i.e., gloves and gowns) are available and used while sorting and handling contaminated linens.During a tour of the facility's laundry room on 03/17/2026 at 2:05 p.m., S4LS, a laundry staff member, was observed sorting visibly soiled laundry. At that time, S4LS was not wearing a disposable gown. He confirmed that the laundry was from residents and was soiled. S4LS further acknowledged that a disposable gown should have been worn while sorting soiled resident laundry but was not.On 03/17/2026 at 2:07 p.m., an interview was conducted with the housekeeping and laundry supervisor identified as S5HS, who affirmed that S4LS was handling contaminated resident laundry and should have been wearing a disposable gown as a part of his PPE.On 03/18/2026 at 2:35 p.m., an interview was conducted with S6IP who is a certified infection preventionist and is responsible for the facility's infection control program. S6IP validated that facility protocol required staff to wear PPE that included disposable gowns when sorting resident soiled laundry.

Based on record review, and interviews the facility failed to provide quarterly statements for resident personal funds accounts for 1 (#17) resident out of 5 residents reviewed for personal funds. Findings: Review of Resident #17's EMR (electronic medical record) revealed an admit date of 08/10/2023 with diagnoses that included major depressive disorder, panic disorder and sleep apnea. Further review revealed she was her own Responsible Party (RP). Review of Resident #17 EMR revealed an MDS (Minimum Data Set) assessment dated [DATE] that revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. On 03/16/2026 at 10:34 a.m., during an interview with Resident #17. She stated she had personal funds in an account at the facility. Resident #17 further reported she had never received a quarterly statement since being at the facility. On 03/17/2026 at 11:15 a.m., an interview was conducted with S2AC, she reported she was responsible for ensuring the resident quarterly statements were sent out for the resident or RP with funds entrusted to the facility. S2AC stated if a resident was their own RP, they would receive their quarterly statement, and it was hand delivered to the resident. S2AC confirmed Resident #17 was her own responsible party and received a hand delivered statement quarterly. S2AC could not confirm if Resident #17 received a quarterly statement. There was no evidence presented prior to exit of the survey that the resident had received quarterly statements.

Based on record reviews and interviews, the facility failed to notify the State's Long-Term Care Ombudsman of emergency transfers in writing for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed for transfer and discharge requirements. Findings: Review of Resident #1's Electronic Medical Record (EMR) revealed, in part, Resident #1 was admitted to the facility on [DATE]. Further review of the EMR revealed Resident #1 had an emergency transfer to a local hospital on [DATE]. Review of the facility's Ombudsman notification list of emergency transfers dated 03/01/2025-03/31/2025, Resident #1's transfer on 03/04/2025 was not listed and there was no further evidence the Ombudsman had been notified of the transfer. On 07/09/2025 at 12:30 p.m., a concurrent records review and interview was conducted with S1SSD (Social Services Director). S1SSD confirmed that the accuracy of the State's Long-Term Care Ombudsman list of emergency transfers was her responsibility. S1SSD reviewed Resident #1's EMR and confirmed she had an emergency transfer on 03/04/2025. She then reviewed the Ombudsman list of emergency transfers and confirmed this emergency transfer was not listed and should have been as required. On 07/09/2025 at 1:00 p.m., a request was made for a policy regarding the notification of the State's Long-Term Care Ombudsman of emergency transfers. A policy was not provided by the time of exit.

Based on record reviews and interviews, the facility failed to ensure that residents who required dialysis received such services consistent with professional standards of practice for 1 (Resident #25) out of 1 (Resident #25) residents reviewed for dialysis services by failing to collaborate with the dialysis provider through dialysis communication forms. Findings: On 02/19/2025, a review of the facility's policy titled Hemodialysis, last reviewed January 2025, indicated; The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. A review of Resident #25's medical record revealed an admitted [DATE] with diagnosis that include, in part but not limited to; end stage renal disease, metabolic encephalopathy, and acute on chronic diastolic congestive heart failure. A review of Resident #25's Physicians orders revealed an order for the resident to attend hemodialysis on Monday, Wednesday, and Friday. A review of Resident #25's medical record revealed Dialysis Communication forms did not have post treatment vital signs on the following dates: 11/01/2024, 11/08/2024, 11/15/2024, 11/18/2024, 11/29/2024, 12/04/2024, 12/11/2024, 12/13/2024, 12/16/2024, 12/26/2024, 12/27,2024, 01/08/2025, 01/10/2025, 01/13/2025, 01/19/2025, 01/23/2025, 01/24/2025, 01/29/2025, 02/05/2025, 02/07/2025, and 02/10/2025. On 02/19/2025 at 8:24 AM, a concurrent records review and interview was conducted with S2LPN (Licensed Practical Nurse). S2LPN confirmed nursing staff is responsible for assessing Resident #25's complete vital signs before and after hemodialysis treatment and documenting them on the dialysis communication form. She reviewed Resident #25's dialysis communication binder and confirmed the assessment and documentation of vital signs were incomplete. On 02/19/2025 at 8:51 AM, a concurrent records review and interview was conducted with S3DON (Director of Nursing). S3DON confirmed the nursing staff is responsible for assessing Resident #25's complete vital signs before and after hemodialysis treatment and documenting them on the dialysis communication form. She reviewed Resident #25's dialysis communication binder and confirmed the assessment and documentation of vital signs were incomplete.

Based on record review and interviews, the facility failed to refer residents with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (#36) out of 3(#31, #36, #53) sampled residents investigated for PASARR in a final sample of 33 residents. Findings: On 02/19/2025, a review of the facility's policy titled, Resident Assessment - Coordination with PASARR Program last reviewed January 2025, indicated 1. Negative Level I Screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. A review of Resident #36's record revealed an admitted [DATE] with diagnoses that included in part, recurrent major depressive disorder and anxiety disorder. A further review of Resident #36's record revealed a Level I PASARR dated 02/07/2022 determined a Level II was not required. Further review of Resident #36's hospital records revealed the resident admitted to an inpatient psychiatric hospital on 07/18/2023. The resident discharged to the facility on [DATE] with a new diagnosis of schizoaffective disorder. A review of Resident #36's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/2024 revealed in part, Section I1600 Active Diagnoses was marked to indicate the resident had a diagnosis of schizophrenia. Further review of Resident #36's records revealed no evidence that a Level II PASARR had been submitted to the appropriate state-designated authority after a new diagnosis of schizoaffective disorder on 07/27/2023. On 02/19/2025 at 10:14 AM, a record review was conducted with S1SW (Social Worker). She confirmed a Level I PASARR dated 02/07/2022 determined a Level II was not required. S1SW confirmed the resident had an inpatient psychiatric hospitalization with new diagnosis of schizoaffective disorder on 7/27/2023. She confirmed a PASARR was not submitted to the appropriate state-designated authority after a new diagnosis of schizoaffective disorder.

Based on record review and interview, the facility failed to notify the State Long Term Care Ombudsman of facility-initiated transfers for 1 (Resident #73) out of 3 (#17, #56, #73) sampled residents. The deficient practice has the potential to affect a census of 92. Findings: Review of the facility's policy titled, Discharge the Resident, read in part, #5. For each emergency to the hospital, the SSD (Social Service Designee) will report to state ombudsman, in a monthly report and documented on the emergency transfer log. Review of Resident #73's medical record revealed that the resident was admitted to the facility on [DATE] with diagnoses that read in part; Partial Traumatic Amputation of Right Foot, Level Unspecified, Aphasia, Acute Osteomyelitis Right Ankle and Foot, Metabolic Encephalopathy, Cerebral Vascular Accident, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder and Anxiety. Review of Resident #73's nurses' notes revealed on 01/11/2024 at 1:30 p.m., the resident was sent to the hospital and returned to the facility on [DATE] at 2:00 a.m. Review of the Emergency Transfer Log for January 2024 revealed no documented evidence that Resident #73's transfer to the hospital on 01/11/2024 was not identified on the log. On 02/19/2024 at 1:45 p.m., an interview was conducted with S2SSD. She confirmed she is responsible for completing the emergency transfer log and sending it monthly to the Ombudsman. S2SSD reviewed the Resident #73's EMR (Electronic Medical Record) and confirmed the resident was transferred to the hospital on 01/11/2024. She reviewed the emergency transfer log for January 2024 and confirmed the resident was not listed as an emergency transfer on 01/11/2024 and should have been.

Based on record reviews and interview, the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs. The facility failed to provide the minimum required staffing hours for 2 of 13 weekends reviewed. Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 4 2023 (July 1 to September 30) revealed the submitted weekend staffing data was excessively low. Review of the facility's staffing pattern reports for the month of November 2023 revealed the facility provided 200.68 hours on 11/05/2023 and were required to provide 220.9 hours. Further review revealed the facility provided 195.71 hours on 11/12/2023 and was required to provide 204.45 hours. On 02/20/2024 at 3:30 p.m., an interview was conducted with S5ADM (Administrator). S5ADM reviewed the facility's staffing pattern for the month of November 2023 and acknowledged the facility did not provide the minimum hours required on 11/05/2023 and 11/12/2023.

Based on observations, interviews and record review, the facility failed to serve food in accordance with professional standards for food service safety as evidenced by failing to ensure that dietary staff utilized the appropriate facial hair covering while working in the kitchen and food service area. This deficiency had the potential to affect 90 residents who consumed food prepared in the kitchen. Findings: A review of the facility's Policy and Procedure titled Employee Hygiene and Personal Cleanliness was conducted. The policy included, in part: Employees must wear a hairnet at all times, covering all hair. On 02/18/2024 at 8:45 a.m., an observation was conducted of S4DA (Dietary Aide) working in the kitchen washing dishes. S4DA was observed with a full beard and mustache that was not covered. On 02/18/2024 at 10:30 a.m., a follow up visit to the kitchen was performed. An observation was conducted of S4DA as he worked in and around the food service line area as food was being prepared for the lunch meal without a facial hair net covering his beard. S3DM (Dietary Manager) was present during this observation but did not instruct him to apply a facial hair cover at that time. On 02/18/2024 at 11:35 a.m., an observation was conducted of S4DA as he handled the food and drinks for the residents' lunch trays. No facial hair covering was observed on S4DA's face. On 02/18/2024 at 11:40 a.m., an interview was conducted with S3DM. S3DM confirmed there was a policy for hair covering in the food service area. She confirmed that S4DA should have worn a beard restraint, which was the appropriate facial hair covering, but had failed to do so while working in the kitchen and food service area.

Based on record review and interviews, the facility failed to accurately maintain resident records by failing to document weekly weights for 1 (#72) out of 2 (#72, #73) sampled residents. Findings: Review of the facility's policy Charting and Documentation revealed in part: The following information is to be documented in the resident medical record: .Treatment and services performed . Review of the facility's policy Weight monitoring revealed in part: A weight schedule will be developed upon admission for all residents: .Residents with weight loss - monitor weight weekly. Review of Resident #72's medical record revealed a readmitted [DATE] with diagnoses including Depression, Anxiety, Cerebral Vascular Accident, Dysphagia, Chronic Obstructive Pulmonary Disease, Hypertension and Muscle Weakness. A review the physician's orders, dated 09/02/2022, revealed an order for weekly weights every Friday, discontinued on 01/12/2023, with a new order, dated 01/12/2023, for weekly weights. Review of Resident #72's weight record revealed the last documented weight was 134.8 pounds on 12/05/2022. On 01/25/2023 at 10:00 a.m., an interview was conducted with S2LPN (Licensed Practical Nurse), she confirmed Resident #72 had an order for weekly weights and there was no weight documented in resident record after 12/05/2022. On 01/25/2023 at 10:18 a.m., an interview was conducted with S1DON (Director of Nursing), she confirmed resident #72 had an order for weekly weights and the weekly weights had not been documented in Resident #72's medical record since 12/05/2022. She reported all weights or residents' refusal to be weighed were to be documented in the resident's record as ordered. S1DON also reported the LPN's were responsible for ensuring the weekly weights were done on residents and recorded in the medical record.

Based on record review and interviews, the facility failed to implement physician's order to obtain blood pressure measurements twice daily as ordered for 1 ( #27) of 27 sampled residents. Findings: Resident #27 was admitted to the facility on [DATE] with diagnoses including but not limited to, Congestive Heart Failure, Hypertension, and End Stage Renal Disease. Further review of Resident #27's record revealed the resident had dialysis scheduled on Mondays, Wednesdays, and Fridays. Review of Resident #27 physician's orders dated 01/10/2023 revealed the following order: B/P (blood pressure) BID (two times a day) for Hypertension (high blood pressure). Review of the January 2023 TAR (Treatment Administration Record), revealed no documentation of blood pressures or initials of a nurse, as ordered, since start date of 01/10/2023. Further review of the medical record revealed no documentation of blood pressures documented twice per day. In an interview on 01/25/2023 at 11:00 a.m., with S6LPN, she stated that she did not see where this information was being documented. She stated that she took Resident #27's blood pressure before and after dialysis. In an interview on 01/25/2023 at 03:30 p.m. with S1DON, she stated that after looking through the record of Resident #27 there was no documentation of blood pressures done twice per day. She confirmed the blood pressures ordered for twice per day on Resident #27 were not done.

Based on observation and interview, the facility failed to maintain a clean, sanitary environment in accordance with professional standards when unclean cookware and service dishware was placed nearby similar, but clean, kitchenware. This deficient practice had the potential to effect a resident census of 81. Findings: During a tour of the facility kitchen on 12/06/2021 at 10:55 a.m., inspection of an assortment of baking sheets, muffin tins, and drinkware revealed the following that was placed on a wire rack intended for clean cookware and service dishware: - 3 each, unclean, half-sheet baking pan with remnants of dried, hardened food product and stacked with moisture in between each - 4 each, unclean 24-count muffin tins with remnants of dried, hardened food product and greasy, oily film on each of their top surface - 3 each of 4 inch metal steam table service pans with remnants of dried, hardened food product on the inside surface and stacked with moisture in between each - 3 each of 2 inch metal steam table service pans with remnants of dried, hardened food product on the inside surface and stacked with moisture in between each - No less than 2 dozen clear plastic 5-ounce drinking cups, stacked 2-4 high on top of each other, with excess moisture in between the stacked cups S1DM verified the wire rack where these items were placed was designated for clean cookware and dishware. S1DM confirmed the condition of each of the items as described above, and that they should not have been placed on the wire rack with other similar, but clean, items.

Based on observations and interviews the facility failed to ensure controlled substances were maintained safe and sanitary. This occurred by the nurses were taping and reinserting the narcotic medication back into the blister packages. This occurred in 3 of the blister packages reviewed during narcotic count. Findings: On 01/23/19 at 2:54 p.m., a narcotic count with S2LPN (Licensed Practical Nurse) on her medication cart revealed Client #140's blister package of [MEDICATION NAME] 50 (fifty) mg(milligram) tablet ( Prescription # 79) blister #57 pill was busted with a piece of tap over the blister. Further observation revealed Client #140's [MEDICATION NAME] 5/325 mg tablet (Prescription # 32) blister #10 pill was busted out and put back in this blister pack. At this time S2LPN revealed she was not sure what the policy was when a narcotic medication was busted out of its blister pack. On 01/23/19 at 3:19 p.m., a narcotic count with S3LPN on her medication cart revealed Client #24's blister package of [MEDICATION NAME] 5/325 milligrams (Prescription # 49) tablet #6 pill was busted out of the blister and put back in the blister pack. At this time, S3LPN stated that she would have to go and destroy this pill with S1DON (Director of Nursing). On 1/23/19 at 3:45 p.m., an interview with S1DON revealed the nurses should be destroying the narcotic that are busted out of the blister pack and not putting them back into the blisters.

Based on record reviews and interviews, the provider failed to ensure Resident #140's Hospice agency was leaving documentation in the Resident's Hospice chart as required by the contract between the Nursing Home and Hospice Agency. This occurred in 1 (Resident #140) of 7 (Residents #24, #28, #34, #67, #80, #88, #140). Findings: Record review of the contract between the hospice agency providing care for Resident #140 and the nursing facility dated 1/17/19 under the heading read, Service to be provided by hospice'. Further review of this document read in part, If a resident of Nursing facility or his/her legal representative request the provisions of Hospice Services, Hospice agrees to perform an assessment of such residents and shall notify the Nursing facility, in writing, whether such resident is authorized for admission as a Residential Hospice Patient .Hospice shall furnish Nursing facility with a copy of the Hospice Plan of Care . the Hospice will provide the Nursing Facility with any modification to the Hospice Plan of Care .All physicians orders communicated to Nursing Facility on behalf of Hospice in connection with the Hospice Plan of Care shall be in writing and signed by the applicable attending physician or Hospice physician . Hospice shall maintain adequate records for all physicians' orders communicated in connection with the Hospice Plan of Care .The patient chart will be updated upon each visit by all Hospice disciplines . If a phone call is made from the Nursing Facility to Hospice regarding the patient, Hospice will document this on a communication note and place in chart upon next visit. This will be the manner in which Nursing Facility and Hospice will communicate with each other to ensure patient needs are meet 24 hours a day/7days a week . Record review of Resident #140's physician's orders [REDACTED]. On 1/24/19 at 9:18 AM an interview with S4LPN (Licensed Practical Nurse) revealed Resident #140 was on hospice care. She revealed the hospice nurse comes to see the resident every day and the hospice aid for hospice comes and bath him around three times a week. On 1/24/19 at 10:06 AM an interview with S1DON (Director of Nursing) revealed Resident #140 was admitted to hospice on 1/17/19. She revealed the hospice agency does not leave any binder or documentation as the other agency. She revealed the hospice agency should have left Resident #140's care plans, certification, physician orders, and any type of communication to the nurse or C.N.A On 1/24/19 at 11:15 AM an interview with S5 RN Hospice Nurse revealed he had seen Resident #140 every day since his admission on 1/17/19. He revealed he did not leave any documentation in the Nursing Facility in regards to the residents hospice care. He revealed his agency should leave a binder for the resident's hospice care plan, certification, and physician orders. He also revealed the Nurse and Aid assessment should be left in this binder for every visit.

Based on observations, record reviews and interviews, the provider failed to: 1. Follow their policy to post an isolation precaution sign on Client #140's door to prevent the spread of infection in 1 of 1 (Resident #140) residents observed for isolation precautions and, 2. Follow their sanitary protocol for oxygen tubing to be covered with a bag during transportation to and from therapy for 1 (Resident #83) of 16 residents, who used oxygen as needed. This occurred out of a total of 39 sampled residents. Findings: 1. Resident #140. Record review of the facilities policy titled, Isolation-Categories of Transmission-based precautions read in part, Contact Precautions: 1. In addition to Standard Precautions, Implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the residents environment. Examples, b. Diarrhea associated with [MEDICAL CONDITION]. 8. Signs-The facility will implement a system to alert staff to the type of precaution resident require. a. This facility utilizes the following system for identification of Contact Precautions for staff and visitors; Sign states contact precautions-In addition to standard precautions-Stop-visitors see nurse. Record review of Resident #140's Physician order [REDACTED]. On 1/21/19 at 2:13 PM an observation revealed on the right side of Resident #140's door was an isolation cart. At this time, an interview with S2LPN (Licensed Practical Nurse) revealed Resident #140 was on contact isolation for [MEDICAL CONDITION] (C Diff). On 1/22/19 at 11:09 AM an interview with S7 C.N.A. (Certified Nurse Assistant) revealed she takes care of Resident #140. She stated he was on contact isolation precaution for [MEDICAL CONDITION]. She revealed staff and family should wear gown and gloves when providing care to the resident. She confirmed there was no isolation sign on Resident #140's bedroom door on Monday (1/21/19) or Tuesday (1/22/19). On 1/23/19 at 11:14 AM an interview with S2 LPN revealed she takes care of Resident #140. She revealed he was on contact isolation for [MEDICAL CONDITION] and staff are to wear gown and gloves when providing care. She revealed visitors are to be made aware by putting an isolation precaution sign on the door. At this time S2LPN revealed she did not notice a contact isolation sign on the client's door Monday (1/21/19) and/or Tuesday (1/22/19). On 1/23/19 at 11:46 AM an interview with S6 Infection Control Nurse revealed the House Keeper came to her yesterday (1/22/19) and stated Resident #140 did not have a Contact Isolation Precaution sign on his door. She revealed it was the facilities policy that the staff and family should be educated when the residents are on contact isolation. She also revealed Resident #140 was on isolation precautions and there should have been a sign on his door and on top of the isolation cart. 2. Client #83: An interview was conducted on 01/22/19 at 03:00 p.m. with resident #83. Resident #83 indicated he has sleep apnea and using oxygen while he sleeps. On 01/22/19 at 3:02 p.m., resident #83 was observed in physical therapy. Further observation of resident #83 revealed he had some tubing hanging out of his front right pocket while he sat down in his wheelchair. Resident indicated he brings his tubing with him to therapy in case he needs oxygen while he is in therapy. S8PTA (Physical Therapist Assistant) indicated there are oxygen concentrator machines kept in therapy in case a resident needs oxygen. During an interview on 01/22/19 at 3:22 p.m., S1DON (Director of Nursing) recalled resident #83 agreeing to wear his [MEDICAL CONDITION] (Continuous Positive Airway Pressure) machine at night after he was admitted to facility. At 3:40 p.m., S1DON observed resident #83 pass in hallway with oxygen tubing hanging outside of his front, right pocket. S1DON indicated that is an infection control breech. S1DON stated the oxygen tubing is to be transferred in a bag not inside of a resident's pocket as per protocol. During an interview on 01/22/19 at 3:44 p.m., S8PTA (Phyical Therapist Assistant) denied resident had oxygen tubing inside his front pocket until asked about it by surveyor. S8PTA indicated all residents bring their own tubing with them for if they need oxygen while in therapy. S8PTA denied knowledge of how residents are to transport their oxygen tubing to and from therapy. S9PTS (Physical Therapy Supervisor) joined the interview. S9PTS indicated the facility does not have tubing available for residents if they need oxygen while in therapy. S9PTS denied knowledge of how residents are to transport their tubing to and from therapy. S9PTS did not answer if it was appropriate for a resident to transport his tubing inside of his front pocket. At this same time, S10TPM (Therapy Program Manager) joined the same interview. S10TPM indicated residents are to transport their oxygen tubing for concentrator to therapy. S10TPM expects staff transporting residents to and from therapy to ensure that the resident's tubing is kept safe during transportation. S10TPM stated that tubing located inside of a resident's front pocket is not sanitary and is an infection control issue. On 1/22/19 at 3:50 p.m., S1DON confirmed resident #83 was wheeling himself back into his room with the oxygen tubing hanging out of his front pocket. An interview on 01/22/19 at 03:55 p.m., S1DON (Director of Nursing) indicated therapy is expected to have tubing inside the department for a resident to be connected to oxygen as needed. S1DON denied knowledge that residents are to transport their tubing to and from therapy in case they need oxygen during therapy. S1DON stated tubing should be transferred in a bag to prevent contamination not inside of a resident's front pocket as per protocol. In an interview on 1/23/19 at 10:15 a.m., S6 Infection Control Nurse indicated oxygen tubing should be transported to therapy in a sanitary manner with the tubing put inside of a bag as per protocol. It is an infection control breech if the tubing is kept inside of a resident's pocket.

Based on observation, record review and interview the facility failed to provide accurate labeling to ensure safe administration of medications by failing to transcribe narcotic dosage correctly to control sheets for 3 randomly sampled residents (#62, #108, #122) during Medication Storage observation. Findings: At 2:55 p.m. on 3/8/17 a tour of the Medication Storage room on 100 West Hall revealed a blister pack for Resident #62 containing the label: 10 Paparazzo Tablets 0.25 milligrams, RX (prescription number) 90. There was 1 tablet remaining in the blister pack and confirmed by S4, LPN (Licensed Practical Nurse). The Controlled Drug Administration Record for Resident #62 contained the label Alprazolam 0.25mg po (by mouth) daily prn (as needed) and the RX 90. The document had eight entries with the dates 11/15, 11/16, 11/17, 11/19, 11/20, 11/23, 11/24 and 11/25 with no year documented for these dates. The document revealed the amount received as 10 and amount remaining as 2. This discrepancy in documentation was verified by S4 LPN and S1,DON (Director of Nursing). At 3:15 p.m. on 3/8/17 a tour of the Medication Storage room on 100 West Hall revealed a Medications Released on Leave of Absence record dated 12/16/16 for Resident #108 revealed entries for the following medications: [REDACTED] Alprazolam (anti-anxiety) 0.5 mg (milligram) tabs twice daily REX 65 with amount on leaving documented as 42. Chlordiazepoxide HCL (anti-anxiety) cap 25 milligrams as ordered at bedtime prn RX 92 with amount on leaving documented as 13. The Controlled Drug Administration Record for Resident #108 revealed a label of Alprazolam 0.5 mg, administer 1 by mouth twice daily, amount received 60 and amount remaining 43. The RX number was not documented. A Controlled Drug Administration Record for Resident #108 revealed a label for Chlordiazep 25 mg 1 po every hour as needed with the RX 92, amount received 14 and documented amount remaining 12. Both findings were verified by S1 DON and S4 LPN. S1 DON stated The RX number should be documented on Controlled Drug Administration Records. On 03/09/2017 at 8:35 a.m., an inspection of the 200 East Hall Medication Cart revealed a 30 milliliter container with the label Morphine Sulphate solution 100 mg/5ml CC-11 give 1 ml under tongue every 4 hours, RX C 49N for Resident #122. The measuring indicator on the side of the contained revealed a fluid level slightly over 30 mls. The Controlled Medication Administration Record [REDACTED]. S5 LPN verified the fluid level in the container was over the 30 cc mark. 03/09/2017 at 10 a.m., S1 DON stated that the documentation records should be completed, dated and signed. A record review of the facility's Controlled Substances Policy Statement revealed: #4 If the count is correct, a control sheet must be made for each substance which must contain the name of the resident, name and strength of the drug, quantity received, number on hand, name of physician, prescription number, name of issuing pharmacy, date and time received, time of administration, method of administration, signature of person receiving medications and signature of nurse administering medication. #9 Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.

Based on observation, interview, and record review the facility failed to assure that the physician's orders would be followed for continuous peg feeding for one resident (Resident #2) out of 36 sampled residents. This deficient practice had the potential to affect the 4 residents receiving peg feedings as reported by the facility. Findings: Resident #2 The review of the record revealed that Resident #2 returned from the hospital on 2-22-17 with a peg tube for a [DIAGNOSES REDACTED]. Further record review revealed that the resident continued to weigh 181 pounds on 3-1-17. The review of the physician's orders revealed that the feeding was to be continuous via pump per peg tube and that the pump may be turned off for short periods of time to provide care. An observation was made of the resident sitting in the common area on 3-8-17 at 10:40 a.m. without the feeding pump. Further observations at 11:10 a.m. and 11:35 a.m. revealed that the resident continued to sit in the common area without the feeding pump. Further observation revealed that the resident went to therapy at 11:55 a.m. and the resident had not received any of the supplement for over an hour. An interview was held with S4 LPN on 3-8-17 at 12:25 p.m. and she stated that she had checked the resident's accucheck around 10:00 a.m. and the resident had just finished her shower and the feeding pump was not connected at that time. She stated that the resident should not have been sitting in the common area for that amount of time without the feeding on and verified that the feeding was to be continuous per the physician's order. She also stated that they should have a meeting to discuss if the resident should have the continuous feeding during therapy.

Based on interview and record review the facility failed to assure that prompt efforts to resolve grievances would be made for 2 residents (Resident #69, #7) out of 36 sampled residents. This deficient practice had the potential to affect the 94 residents residing in the facility. Findings: Resident #69 An interview was held with Resident #69's daughter on 3-6-17 at 12:15 p.m. She stated that she has complained on more than one occasion to administration about the lack of sufficient staff on the weekends. She stated that S1DON told her that they are trying to hire people and there is no one to hire. The review of the grievance log revealed there was no documentation of any grievances made by Resident #69's family. An interview was held with S1 DON on 3-8-17 at 10:35 a.m. and she stated that Resident #69's family had never filed a formal complaint, but had mentioned things in passing that could be fixed immediately. An interview was held with S2Administrator on 3-9-17 at 9:20 a.m. and she stated that she does not remember the resident's daughter complaining about staff shortage. She stated that Resident #69's other children had complained one morning, but she had taken care of the issue, so she did not document anything about it. Another interview was held with Resident #69's daughter on 3-8-17 at 10:35 a.m. and she stated again that she had complained to administration at least twice about the lack of staff on the weekends. She stated that her brother and sister also had a complaint about care that was discussed with the administrator. The family member was interviewed again on 3-9-17 at 11:20 a.m. and she stated that she had complained of the shortage of sufficient staff on 12-4-16. She stated that her brother and sister had complained to the administrator on 2-3-17 and she had a complaint about a CNA on 2-28-17. She stated in the interview that the shortage of staff continued on the last weekend. An interview was held with S3LPN on 3-8-17 at 12:00 p.m. and she stated that Resident #69's daughter had complained about a shortage of staff on several occasions. S2 Administrator stated in the above interview that she fixes problems at times as they are presented to her and does not always document these as grievances. She verified that she did not have any documented grievances from this family. Findings: Resident #7: On 3/6/17 at 11:45 a.m. Resident #7's daughter stated she wanted to make the state surveyors aware of a lack of CNAs (certified nursing assistants) on the weekend shifts. At 11:56 a.m. during a family interview, Resident #7's daughter statyed there were never enough staff on the weekends. On 3/8/17 at 12:04 p.m., Resident #7's daughter stated that several months ago she came on the weekend to find her mother still in bed at noon and unchanged. She stated she was unsure if her mother had been fed. She did not report this incident, however it happened again on a subsequent seekend and she went immediately to S2, Administrator to complain about her mother's care and that only 1 CNA was on duty for the entire 100 Hall. Resident #7's daughter stated that S1 apologized and stated there was a misunderstanding about the CNA who did not show up to work. On 3/8/17 at 2:23 p.m. S1 stated there was no record of the complaint of a lack of staff on the weekends from Resident #7's daughter or that her mother remained in bed at noon, unchanged. A record review of the facilitiy's Filing Grievances/Complaints revealed on #2 that grievances and/or complaints may be submitted orally or in writing.