Every finding on record at Maple Grove Nursing & Rehab Center

Based on observations, resident interviews, staff interviews, clinical record review, and facility document review, the facility staff failed to provide a safe, clean, homelike environment for 1 of 3 sampled residents, Resident #1. This failure resulted in Resident #1 sustaining several injuries from a rodent, which required emergent treatment and constituted harm.The findings included: For Resident #1, the facility staff failed to provide a safe, clean, homelike environment that was free of a rodent in the resident's bed. A mouse was found to be in Resident #1's bed that resulted in compromised skin to the resident's left lower leg, resulting in being transferred to a higher level of care, antibiotics, tetanus vaccine, and rabies vaccinations. Resident #1's diagnosis list indicated diagnoses that included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, atrial fibrillation, weakness, and chronic kidney disease-stage 3. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 5/18/25, assigned the resident a brief interview for mental status (BIMS) summary score of 4 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A review of a Pest Control Service report dated 4/3/25 read in part, .Interior Service.CC=Crack & Crevice.Exterior Service.ST=Spot Treatment.Target Pest.Rats/Mice.Contrac-Blox [a rodenticide bait block used for pest control, primarily for eliminating rats and mice].14 blox [fourteen units].12 glue boards [a pest control device consisting of a flat tray coated with a strong adhesive, designed to trap and immobilize pests like rodents and insects when they step on it].Multiple rodent bait stations placed throughout problem area. A review of Resident #1's clinical record revealed the following documentation: A Discharge/Transfer Summary Note dated 4/7/2025 at 23:04 (11:04 PM) read in part, .Found mouse in bed with resident, resident has multiple open areas to back of left lower leg.Summary of physician interaction and notification regarding transfer: send to ER (emergency room at hospital) for evaluation and treatment. A review of an ED (emergency department at hospital) report dated 4/7/25 read in part, .Chief Complaint Animal Bite.Visit Diagnosis Animal bite.Patient presents from.nursing facility.accompanied by her grand daughter {sic}. A nurse from the facility called over to report that when they were doing checks on the patient tonight, they found a mouse beneath the covers, and noted that it had pooped in her bed, and had chewed on her left leg. Patient has a history of a stroke, has no sensation on the left side of her body. They were concerned about the bites, and sent her to the ER for evaluation.Patient denies any pain on that side. She has never been bitten by a mouse before, denies any prior history of any rabies vaccinations.LLE (left lower extremity)-multiple scattered excoriations and small superficial lacerations along L (left) calf. Bleeding has stopped.Patient was started on Augmentin 500 mg b.i.d. (twice daily) x 7 days (for seven days) for infection prophylaxis. We discussed the risks and benefits of rabies treatment given the bite from a mouse, patient and her granddaughter did want to go ahead with both rabies immune globulin and the rabies vaccine. Patient was given the 1st (first) dose of the vaccine today, she will need to return on April 11th, 15th, and 22st {sic} for doses 2, 3, and 4 of her rabies vaccine.Problem Addressed: Animal bite: complicated acute illness or injury.Wound care performed on pt (patient) left lower leg. A Nurse's Note dated 4/8/2025 at 03:29 (3:29 AM) read in part, .Resident returned to facility with new orders. Augmentin 500/125 (milligrams) take 1 tablet every 12 hours x 7 days (for seven days). Follow up April 11th, 15th, 22nd for doses 2, 3, and 4 of rabies vaccine. Resident received 1st dose this day. A review of a facility synopsis of events dated 4/8/25 read in part, .Incident date: 04/07/25.Resident.is a [AGE] year old female, Resident was found on staff rounds to have scratches and bites on her Left leg on the calf muscle, a mouse was found in the resident's bed and appears to have bitten and scratched the resident.Resident was sent to the emergency room per MD (medical doctor) orders.Employee action initiated or taken, investigation to follow. Resident was assessed and sent to ER for evaluation. The facility synopsis of events file contained an LPN (licensed practical nurse) statement dated 4/7/25 which read in part, .Called to room by CNA, (certified nursing assistant) Mouse in bed with resident noted open area on lower back calf, mouse feces and urine noted at site. CNA #1 witness statement dated 4/8/25 read in part, .pulled the blanket down and her (Resident #1) gown up to check her brief.I seen the mouse on her calf and blood on the pillow sheet between her legs.We tried to catch the mouse as it was running around the room.(Resident #1) got sent out to the hospital and we set a mouse trap out and around an hour later caught the mouse on the trap and we disposed of it. We kept the door closed at all times so it couldn't scander {sic} off into the hallway. Another CNA witness statement dated 4/8/25 read in part, .we pulled the blanket back and saw a mouse that was sitting beside her (Resident #1) leg that was bleeding. We tried to catch the mouse but it ended up escaping, we set a trap and caught it then {sic} which I killed it. A medical provider order with a start date of 4/8/25 read in part, .Amoxicillin-500-125 mg (milligrams) Give 1 tablet by mouth two times a day for animal bite for 7 days. Review of a Skin & Wound Evaluation dated 4/8/25 read in part, .rodent scratches/bite.Wound Measurements 1. Area 20.6 cm (centimeters) 2. Length 4.2 cm 3. Width 5.2 cm.Resident has superficial scratches/bites to left posterior lower leg. Resident was seen in the ER last night and seen by NP (nurse practitioner) today. A review of a Pest Control Service report dated 4/8/25 read in part, Interior Service.Target Pest.Rats/Mice.Contrac-Blox.x 12 (twelve units).2 RTUs (Rodent Treatment Unit: This term refers to tamper-resistant bait stations used in professional pest control to safely secure rodenticides. The RTU bait station protects the poison from children, pets, and non-target wildlife while allowing mice and rats to enter and consume the bait).10 Blox in Attic.2 EVs (These are electrically powered devices designed to repel or eliminate pests, such as rodents or insects, through methods like high-frequency sound). A review of the final facility synopsis of events dated 4/11/25, read in part, .Resident was found in the bed on rounds with scratches to the back of her left calf and a mouse in the bed that had inflicted the scratches. The mouse ran away, the doctor was notified, and resident was transferred to the ER where she was treated with tetanus vaccine and antibiotics as well as rabies vaccines and returned to the facility and placed in a different room. The pest control company came in the next day to check for any problems with rodents, no problem was identified, Pest control will come weekly for the next four weeks to check all traps and check for mouse activity. No further mice have been seen at the facility and resident scratches are healing without any signs of infection. On 10/21/25 at 2:27 PM surveyor spoke with registered nurse #1 (RN#1) and she informed surveyor her office was right next to Resident #1's room and she has never seen any mice, or evidence of mice and she keeps crackers in her desk drawer. RN#1 informed surveyor she took care of the area on Resident #1's calf and she believed it looked more like a cluster of small scratches, as she did not see any puncture wounds to indicate there was a bite from the mouse and she said the area healed rather quickly. On 10/21/25 at 2:52 PM, surveyor spoke with licensed practical nurse #1 (LPN#1) via phone conversation about the injuries that Resident #1 sustained on 4/7/25 and she informed surveyor that one of the CNAs called-out because Resident #1 had places on her leg. LPN#1 stated when entering Resident #1's room, she saw the mouse and it ran but there were a couple of mouse droppings on the bed. LPN#1 stated she had never saw a mouse in the facility before and that's the best she could remember about the incident. On 10/21/25 at 3:01 PM, surveyor spoke with registered nurse #3 (RN#3) via phone conversation and she was not Resident #1's nurse but recalled a CNA yelled out and all the nurses go when a CNA calls for help. She saw Resident #1's leg was bleeding and a couple of mouse droppings were present on the pillow beside the resident's leg. RN#3 saw the mouse at the bottom of the bed when the blankets were pulled back and she remembered there was a glue trap in the nutrition room, so she put the glue trap in the resident's room and caught the mouse that night. RN#3 informed surveyor she has worked at the facility for eight years and she only saw one other mouse in the med room (medication storage room), but could not recall when that was. On 10/21/25 at 3:25 PM, surveyor spoke with other staff #2 (OS#2) and he informed surveyor glue traps are kept in the nutrition room by the refrigerator and kept in the facility kitchen for rodent precautions and prevention. He said a glue trap would only be in a resident room if there was a sighting or evidence of rodents. OS#2 informed surveyor that outside mouse bait is by the kitchen and entrances of the facility. He informed surveyor he could not locate where the mouse got into Resident #1's room and pest control went into the attic as well and put poison up there after the incident. OS#2 informed surveyor that months before he had seen mice outside of the building by the laundry room and traps were placed there. On 10/21/25 at 3:51 PM, surveyor spoke with CNA#1 via phone conversation and she informed surveyor she and another CNA (who no longer works at facility) came on shift at 10:00 PM on 4/7/25 and started their first round and got to Resident #1's room at approximately 10:20 PM. The other CNA entered room before her and the other CNA pulled the blanket back and saw the mouse and told her there was a mouse. CNA#1 entered the room and saw the mouse gnawing on Resident #1's leg and then the mouse ran under the sink, behind the trash can and she got the charge nurse. CNA#1 informed surveyor everyone was freaking out because there's a first time for everything and they sent Resident #1 out to the ER. CNA#1 denied ever seeing any mice at the facility before this incident and stated she has not seen any mice since. She believed there was a tiny hole under the sink and it was plugged-up. CNA#1 agreed the mouse was definitely nibbling on the resident's leg. During the course of the survey, this surveyor performed multiple observations, including resident rooms, common areas, nourishment rooms, dining rooms, and restrooms and did not observe any rodents or signs of rodents during these observations. On 10/21/25 at 5:00 PM, this surveyor and the administrator observed the outside perimeter of the facility and did not see any evidence of rodents or rodent activity. Surveyor observed the dumpster area and no pests were observed. A mouse trap house was visible outside of the laundry vents, but no signs of rodents were visible in the trap. On 10/21/25 at 5:39 PM, surveyor spoke with the administrator and she denied mice ever being in the facility prior to the incident with Resident #1. She stated they did not know how the mouse got into the facility and informed surveyor the exterminator comes monthly and could not figure out how the mouse got in. The facility administrator provided the surveyor with a copy of the facility's Plan of Correction dated 4/7/25 which read as follows: Problem:Resident noted with small field mouse in bed with her. Notes small abrasions to leg area. Immediate Response-what was done at the time:Immediately removed field mouse. Assessed resident, provided first aide and sent to ER where she received tetanus, antibiotics, and rabies vaccine. PI (performance improvement) Meeting: 4/8/25How to identify other residents:Alert and oriented residents interviewed regarding presence of pests in the facility, no issues identified. Skin checks completed on current residents to ensure no further indication of scratches/bites. None were found.Date of Compliance: 4/8/25What measures were put in place to prevent reoccurrenceEducated on immediately notifying administration if pests are noted in the building.Date of completion 4/8/25Pest control came to facility on 4/8/25 to assess and treat. Will follow coordinated plan for increased monitoring and treatment.Date of completion weekly through 4/24/25 (note-additional treatments were completed on 4/10/25, 4/17/25, 4/24/25, and once monthly thereafter)Maintenance Personnel assessed outside of the facility to identify any holes or ports of entry.Date of completion: 4/8/25How to monitor to ensure the problem does not reoccurAdministrator or designee to complete rounds throughout the facility twice weekly x 4 weeks to ensure no signs of pests.Date of completion: 7/7/25Surveyor reviewed credible evidence and confirmed that each item had been completed and on-going monitoring was confirmed. Interviews with staff were conducted and it was confirmed staff are knowledgeable on what to do in the event any pests are observed in the facility. A review of Resident Council Minutes for March, April, and May 2025 did not disclose any issues/concerns of facility staff failing to provide a safe, clean, homelike environment that is free from rodents in patients beds. A review of the current sampled residents revealed no concerns with facility staff failing to provide a safe, clean, homelike environment that is free from rodents in patients' beds. Throughout the course of the survey, this surveyor interviewed multiple residents, including the resident council president and vice president, observed multiple locations in the facility, and did not receive any resident or family concerns regarding this issue. This concern was discussed with the administrator and director of nursing on 10/21/25 at 6:00 PM during the exit conference. No further information was provided prior to exit on 10/21/25. This is a past non-compliance deficiency.

Based on observation and staff interview, the facility staff failed to ensure proper disposal and/or containment of the facility's garbage/waste. The findings included: On 10/15/24 at 11:47 AM this surveyor employee # 1 made an observation of the facility's garbage disposal area located outside the facility but on the campus. There was one dumpster noted. All of the doors on the dumpster were shut. However, there was a large pile of debris beside the dumpster that included 5 computer screens and key boards, at least 5 wooden pallets, multiple wet, decorative [NAME] of hay, a case of outdated chicken noodle soup, two nightstands, multiple drinking straws, medication cups, drinking cups and surgical masks. Employee # 1 stated, They came and emptied it this morning, I don't know why they didn't pick this stuff up too. We couldn't put it in there because it was too full so we had to put it here. On 10/15/24 at 4:35 PM the survey team met with the Administrator, Director of Nursing, Assistant Director of Nursing and the Admission's Coordinator. This concern was discussed. The Administrator stated, We had to have our dumpster switched out because it had holes in it and they replaced it with that smaller one. They are coming back to pour a concrete pad and I am going to tell them to bring me the bigger size back. No further information was presented to the survey team prior to the exit conference.

Based on observation, staff interview, and facility document review, the facility staff failed to ensure the safe and secure storage of medications and biologicals for 2 of 2 facility medication carts. The findings were: During a medication pass and pour observation on 10/16/24 at 8:03 AM, this surveyor observed Licensed Practical Nurse (LPN) # 1 leave the medication cart unattended with a vial of DuoNeb (ipratromium/albuterol liquid medication that is inhaled as a mist through a nebulizer machine). LPN # 1 left the cart on the A hall while they went to the medication room to look for another medication. During a medication pass and pour observation on 10/16/24 at 8:45 AM, this surveyor observed Registered Nurse (RN) # 1 leave a cup of Miramax (powdered laxative) mixed with 3 ounces of water on the medication cart unattended while they went to the medication room to look for another medication. When asked if leaving medication on the cart is acceptable, they stated, What should I have done? The policy entitled, Medication Storage with a revised date of 8/28/24 was reviewed and read in part, 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments. c. 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 10/16/24 at 11:40 AM the survey team met with the Director of Nursing, Administrator, and the Regional Director of Clinical Services. This concern was discussed at that time. No further information was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team for one (1) of 17 sampled residents, (Resident #4). The findings included: For Resident #4, the facility staff failed to review and revise the resident's comprehensive person-centered care plan to discontinue the focus for indwelling catheter that had been discontinued on 7/8/24. Resident #4's diagnosis list indicated diagnoses, which included, but not limited to, Alzheimer's Disease, Atrial Fibrillation, Diabetes Mellitus Type 2 (two), Neuromuscular Dysfunction of Bladder, Bipolar Disorder, and Chronic Viral Hepatitis C. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/18/24 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident had severe impairment in cognitive abilities. Surveyor observed Resident #4 on 10/15/24 at 12:55 PM and no indwelling catheter was present at the time of the observation. Review of the comprehensive person-centered care plan included a focus area that read in part, .resident requires a catheter . with a revision date of 8/8/24. On 10/15/24 at 3:44 PM, surveyor interviewed licensed practical nurse #2 (LPN#2). LPN#2 informed surveyor that Resident #4 did not have a catheter, and it had been discontinued. LPN#4 reviewed the electronic health record and informed surveyor the resident had been in the hospital in July 2024 and the catheter had been discontinued on 7/8/24. A review of the medical provider's orders confirmed the indwelling catheter had been discontinued on 7/8/24. This concern was discussed at the end of day meeting on 10/15/24 at 4:31 PM with the administrator, director of nursing, social worker, and assistant director of nursing and again on 10/16/24 at 11:40 AM with the regional director of clinical services, area social worker, director of nursing, and administrator. Surveyor requested but did not receive a care plan policy and was informed by the administrator that the facility utilizes the RAI (Resident Assessment Instrument) manual for care planning guidelines. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 with a revision date of October 2023, read in part on page 10, .f. Evaluation-Critically reviewing individualized care plan goals, interventions and implementation .assessing the need to modify the care plan (i.e., change interventions) to adjust to changes in a resident's status, goals, or improvement or decline . No further information regarding this concern was presented to the survey team prior to the exit conference on 10/17/24.

Based on observation, staff interview, facility document review, and during the course of a medication pass and pour observation, the facility staff failed to maintain processes to prevent the spread of infection and disease, and to ensure that Point of Care Devices are utilized safely, when used on multiple residents, by properly cleaning a glucose monitor between residents. The findings included: On 10/16/24 at 8:24 AM this surveyor observed Licensed Practical Nurse (LPN) # 1 during a medication pass, obtain a blood sugar level on a resident. They returned to the medication cart and used two alcohol prep pads to clean the glucometer they had used. When asked what the facility policy is for cleaning glucometers they stated, We use alcohol pads, that's what we've always done. We clean them before and after each patient. On 10/16/24 AT 9:06 AM this surveyor interviewed the Assistant Director of Nursing. When asked what the policy for cleaning glucometers was, they stated, We clean them with alcohol preps before and after we use them. Surveyor asked for the policy and the manufacturers recommendations. When they returned with the policy they stated, We've already started the education with all the nurses. This surveyor reviewed the booklet EvenCare Blood Glucose Monitoring System User's Guide. On page 45, the booklet read in part, EvenCare G 2 Meters and lancing device are validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products are validated for disinfecting the EvenCare G 2 meter and lancing device: Dispatch Hospital Cleaner Disinfectant Towels with Bleach (EPA registration Number: 56392-8), Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipes with alcohol (EPA Registration Number: 59894-10), Clorox Healthcare Bleach Germicidal Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12), Medline Micro-Kill Bleach Germicidal Bleach Wipes (EPA Registration Number: 37549-1). The policy entitled, Glucometer Disinfection with a revised date of 9/2/24 was reviewed. The policy read in part, 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 2. If the manufacturers are unable to provide information specifying how the glucometer should be cleaned and disinfected then the meter will not be used for multiple residents. 3. The glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus. On 10/16/24 at 11:40 AM the survey team met with the Director of Nursing, Regional Director of Clinical Services and the Administrator. This concern was discussed. The Director of Nursing stated, I think they were doing that because it is what we did during COVID, alcohol kills the virus. No further information was provided to the survey team prior to the exit conference.

Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to obtain a physician's order for oxygen for one of 17 residents in the survey sample, resident # 23. The findings included: Resident # 23's diagnoses included but were not limited to chronic obstructive pulmonary disease (COPD), morbid obesity, heart failure and hypertension. The minimum data set (MDS) assessment with an assessment reference date of 8/29/24 assigned the resident a brief interview for mental status (BIMS) score of 15 out 15, indication intact cognition. On 10/15/24 This surveyor observed resident # 23 in their room. They were using oxygen via nasal cannula and the setting was 4 liters per minute (LPM). When asked if they knew how much oxygen they were getting they stated, Two (2) I believe. When asked if they needed the oxygen all the time or just sometimes they stated, I use it all the time. During a review of the clinical record an order that read, C-PAP on at QHS (every hour of sleep) and off in the AM with settings- IP-18, EP-5, back up rate-10 and PRN (as needed) during the day with oxygen at 2 LPM bleed in two times a day related to chronic respiratory failure. The order was dated 8/15/24. There was no order in the record for resident to have oxygen during the day at 4 LPM. On 10/15/24 at 4:06 PM this surveyor interviewed Registered Nurse (RN) # 2. They stated they knew that resident used oxygen but was unsure of the order and needed to look it up. They were unable to locate an order for resident to have oxygen at 4 LPM via nasal cannula. They stated they would check with charge nurse who was more familiar with the resident. On 10/15/24 at 4:10 PM this surveyor interviewed Licensed Practical Nurse (LPN) # 2. They stated, I feel like he did have an order but it was prn (as needed). He's been back and forth to the hospital so that is probably what happened. I don't think he has ever had an order for 4 liters. He doesn't need it all the time. I checked his O 2 sat and it was 92% so I called the provided and got an order for oxygen at 2 LPM PRN. I already put it in the record. This surveyor reviewed the policy entitled, Medical Gas (Oxygen) with an implementation date of 1/1/24, that read in part, 1. Oxygen is administered under orders of a physician, except in the case of an emergency. On 10/15/24 at 4:35 PM the survey team met with the Administrator, Director of Nursing, Assistant Director of Nursing and the Admissions Director. This concern was discussed at that time. No further information was provided to the survey team prior to the exit conference.

Based on observation, staff interview, family interview, and clinical record review, the facility staff failed to develop and/or implement a person-centered, comprehensive dietary care plan for 1 of 17 sampled residents, (Resident #6). The findings included: For Resident #6 the facility staff failed to develop and implement a comprehensive person-centered dietary care plan to address the resident's medical needs and/or preferences of being lactose intolerant. Resident #6's diagnosis list indicated diagnoses that included, but were not limited to, Arteriosclerotic Heart Disease, Hypertension, Old Myocardial Infarction, Atrial Fibrillation, Dementia, Age-Related Osteoporosis, Gastro-Esophageal Reflux Disease, and Diabetes Mellitus Type 2 (two). The most recent minimum data set (MDS) with an assessment reference date (ARD) of 9/20/24 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident had severe impairment in cognitive abilities. Surveyor interviewed resident's daughter via phone conversation on 10/15/24 at 7:06 PM. Daughter informed surveyor Resident #6 was lactose intolerant, and that facility continued to send milk on resident's tray at times after she had informed them of resident being lactose intolerant on several occasions. A review of the progress notes revealed a Social Services note dated 7/2/24 that read in part, .Care plan meeting w (with) resident's daughter and IDT (interdisciplinary team) .Discussed diet . A review of the comprehensive person-centered dietary care plan revealed no indication that Resident #6 was lactose intolerant. On 10/16/24 at 8:15 AM, surveyor interviewed dietary manager #1 (DM#1) and requested and received a copy of Resident #6's tray ticket dated 10/16/24 that read in part, .Allergies .Lactose .Milk . On 10/16/24 at 1:09 PM, surveyor interviewed dietary manager #1 (DM#1) and he stated he does resident preferences, and he does not do the care plans, the registered dietician does the care plans. On 10/16/24 at 1:16 PM, surveyor attempted to contact registered dietician via phone call and left a voice message. At 3:58 PM, the administrator informed surveyor the dietician does not update the care plan, the MDS nurse does the updates for care plans. This concern was discussed on 10/16/24 at 11:40 AM with the regional director of clinical services, area social worker, director of nursing, and administrator. Surveyor requested but did not receive a care plan policy and was informed by the administrator that the facility utilizes the RAI (Resident Assessment Instrument) manual for care planning guidelines. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 with a revision date of October 2023, read in part on page 10, .d. Care Planning-Establishing a course of action with input from the resident (resident's family .) .that moves a resident toward resident-specific goals .e. Implementation-Putting that course of action (specific interventions derived through interdisciplinary individualized care planning) . No further information regarding this concern was presented to the survey team prior to the exit conference on 10/17/24.

Based on staff interview and clinical record review, the facility staff failed to ensure accurate Minimum Data Set (MDS) assessments for 3 of 20 residents, Residents #29, #57, and #4. The findings included: 1. For Resident #29, the facility staff failed to code the residents dialysis status on an annual MDS assessment. Resident #29's diagnoses included end stage renal disease and dependence on renal dialysis. Section C (cognitive patterns) of Resident #29's annual MDS assessment with an assessment reference date (ARD) of 08/08/24 included a brief interview for mental status (BIMS) score of 4 out of a possible 15 points. Per the MDS manual a score of 4=severe impairment in cognitive skills for daily decision making. Section O (special treatments/procedures/programs) was not coded to indicate this resident was receiving dialysis services. On 10/15/24, during initial tour of the facility the facility staff identified this resident as being out of the building for a dialysis treatment. Resident #29's comprehensive care plan included the focus area requires hemodialysis. Resident #29's clinical record included a provider order for Hemodialysis three times a week for kidney failure. The date of the order was documented as 12/20/23. On 10/15/24 at 1:16 p.m., the Administrator was made aware of the inaccurate MDS assessment and stated this resident had been on dialysis since they had been at the facility, and they would have the staff complete a modification MDS. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #57, the facility staff coded the residents discharge MDS assessment as they had discharged to a short-term general hospital when in fact they were discharged home. Resident #57's diagnoses included pleural effusion and atrial fibrillation. Section C (cognitive patterns) of Resident #57's discharge MDS assessment with an assessment reference date (ARD) of 08/30/24 included a brief interview for mental status (BIMS) score of 11 out of a possible 15 points. Per the MDS manual a score of 11=moderately impaired in cognitive skills for daily decision making. Section A (identification information) was coded to indicate this was a planned discharged , return not anticipated, and was coded to indicate Resident #57 was discharged to a short-term general hospital. Resident #57's clinical record included a progress note dated 08/30/24 that read in part, .requested to be d/c'd (discharged ) today with days remaining . On 10/16/24 at 11:40 a.m., during a meeting with the Administrator, Director of Nursing, Regional Director of Clinical Services, and the Area Director of Social Services the issue with the inaccurate coding of the discharge MDS assessment was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 49622 3. For Resident #4, the facility staff coded the resident as having an indwelling catheter on the 7/18/24 minimum data set (MDS) assessment, however, the resident's catheter had been discontinued on 7/8/24. Resident #4's diagnosis list indicated diagnoses, which included, but not limited to, Alzheimer's Disease, Atrial Fibrillation, Diabetes Mellitus Type 2 (two), Neuromuscular Dysfunction of Bladder, Bipolar Disorder, and Chronic Viral Hepatitis C. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/18/24 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident had severe impairment in cognitive abilities. Surveyor observed Resident #4 on 10/15/24 at 12:55 PM and no indwelling catheter was present at the time of the observation. Review of the comprehensive person-centered care plan included a focus area that read in part, .resident requires a catheter . On 10/15/24 at 3:44 PM, surveyor interviewed licensed practical nurse #2 (LPN#2). LPN#2 informed surveyor that Resident #4 did not have a catheter, and it had been discontinued. LPN#4 reviewed the electronic health record and informed surveyor the resident had been in the hospital in July 2024 and the catheter had been discontinued on 7/8/24. A review of the medical provider's orders confirmed the indwelling catheter had been discontinued on 7/8/24. Further review of the clinical record revealed the most recent MDS dated [DATE] had Section H-Bladder & Bowel, being coded in section H0100-Appliances with; A. Indwelling Catheter. This concern was discussed at the end of day meeting on 10/15/24 at 4:31 PM with the administrator, director of nursing, social worker, and assistant director of nursing and again on 10/16/24 at 11:40 AM with the regional director of clinical services, area social worker, director of nursing, and administrator. Surveyor was informed by the administrator that the facility utilizes the RAI (Resident Assessment Instrument) manual for MDS guidelines. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 with a revision date of October 2023, read in part, .Section 1.4 Problem Identification Using the RAI . on page 10, .a. Assessment-Taking stock of all observations, information, and knowledge about a resident from all available sources (e.g., medical records, the resident .) . No further information regarding this concern was presented to the survey team prior to the exit conference on 10/17/24.

Based on staff interview, employee record review, and facility document review, the facility staff failed to follow their policy/procedures for screening of new employees for 1 of 25 new employees, new employee #15. The findings included: The facility staff failed to follow their policy for screening of new employees. The facility staff failed to provide evidence of screening for new employee #15. New employee #15 was identified as the Medical Director and had a hire date of [DATE]. The Administrator provided the surveyor with a copy of their policy titled, Abuse, Neglect and Exploitation. This policy read in part, .Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself, third-party agency or academic institution. 3. The facility will maintain documentation of proof that the screening occurred . During the employee record review the surveyor requested evidence of screening of new hires. New hire #15's employee record did not include a criminal background check or reference checks. The license in the employee file expired on [DATE]. The facility staff were able to pull a current license with an expiration date of 2026. The Administrator stated they were trying to obtain the screenings from a third-party company. On [DATE] at 11:40 a.m., during a team meeting with the Administrator, Director of Nursing, Regional Director of Clinical Services, and Area Director of Social Services, the issue with the missing screening/credentials regarding new employee #15 was reviewed. On [DATE] at 9:44 a.m., the Administrator stated they had contacted the Regional Medical Director and left messages with the Human Resource department. The Administrator stated when new employee #15 was hired they were licensed in the Commonwealth of Virginia a background check, and fingerprints had been completed and accepted by the previous company. They were currently merging with another company and that company was in the process of completing background checks. Prior to the exit conference on [DATE] the Administrator provided the survey team with a sworn statement and a copy of a Virginia State Police Background check that had been obtained on [DATE] the status read NO IDENTIFIABLE RECORD(S). No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, facility document review and during a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5%. There were 2 errors in 32 opportunities for a medication error rate of 6.25 %. These errors affected Resident #38. For Resident #38 the facility staff failed to administer the correct doses of the medications Vitamin D3 ([MEDICATION(S)]) and [MEDICATION(S)]. [MEDICATION(S)] is a calcium channel blocker used to treat hypertension. The findings included: Resident #38's face sheet listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #38's most recent quarterly Minimum Data Set with an assessment reference date of 04/12/22 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. The Surveyor observed registered nurse (RN) #1 during a medication pass and pour on 05/16/22 at 8:00 A.M. RN #1 prepared Resident #38's medications and administered them to the resident. Surveyor observed RN #1 prepare Vitamin D3 25 mcg (1000 units), one tablet and [MEDICATION(S)] 90 mg, one tablet. The Surveyor reconciled Resident #38's medications on 05/16/22 at 9:30 A.M. Resident #38's clinical record contained a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 2000 unit by mouth one time a day for supplement and [MEDICATION(S)] HCl Tablet. Give 180 mg by mouth one time a day related to [CONDITION(S)] of native coronary artery without [CONDITION(S)] pectoris (I25.10); Essential (primary) hypertension (I10). Surveyor spoke with RN #1 on 05/16/22 at 10:00 A.M. regarding Resident #38's medications. Surveyor asked RN #1 to confirm the dosages for Vitamin D3 and [MEDICATION(S)]. RN #1 read the resident's orders and confirmed to the surveyor that they had only administered one tablet of each medication, when it should have been two tablets of each. Surveyor requested and was provided with a facility policy entitled, Safe medication administration practices, long-term care, which read in part, Introduction: To promote a culture of safety and prevent medication errors, nurses must adhere to the 'rights of medication administration'. The rights are to identify the right resident by using at least two resident identifiers, select the right medication, give the right dose, give the medication at the right time, give the medication by the right route, and provide the right documentation. The concern of the facility failing to ensure a medication error rate of less than 5 % was discussed with the Administrator and Director of Nursing on 05/17/22 at 12:30 P.M. No further information was provided prior to exit.

Based on observations, staff interviews, and the review of a facility document, it was determined the facility staff failed to accurately label a medication for one (1) of 18 sampled residents as evidenced by the label not corresponding with the correct duration of the medication to be administrated to the resident (Resident #52). The findings include: Resident #52 was in the facility in the time of this survey, 3/9/2020 thorough 3/12/2020. On the most recent MDS (Minimum Data Set), the resident was coded as requiring extensive assistance of 2 staff members for dressing and personal hygiene and being totally dependent on 2 staff members for bathing. Resident #52 was also coded as having a BMS (Brief Interview for Mental Status) had problems with long and short term memory and was moderately impaired in decision making Resident #52's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During the medication observation on 3/10/ at 8:12 am with LPN (licensed practical nurse) #1, the surveyor observed LPN #1 prepared medications to be given to Resident #52. The nurse handed me the medication card for the medication [MEDICATION(S)] which read in part, [MEDICATION(S)] 5 MG (milligram) Tablet EA (each) Give 10 MG by mouth two times a day for 7 days . LPN #1 proceed to administrator this medication to the resident. When the nurse returned to the medication cart, the surveyor asked LPN #1 according to the directions on the MAR (Medication Administration Record) when was the date that the [MEDICATION(S)] was to be stopped on the 7th day. The nurse researched the MAR and stated The label hasn't been changed because the doctor changed that on 3/3/2020 to be given two times a day with no stop date. The surveyor notified the regional nurse of the above documented findings at 8:25 am at which time the surveyor requested a copy of the facility's policy on medication labels or what to do when the dosage or the duration of the medication had been changed. The regional nurse provided the surveyor with a copy of the policy titled Labeling of Medications at 11 am on 3/10/2020, which read in part as follows: .10. Only the issuing pharmacy may place a drug label on a medication container. 11. The pharmacy must be informed of any changes in directions for the use of drug . 13. Only a physician or pharmacist may change a medication label . The surveyor notified the administrator, chief nursing officer, regional nurse, director of nursing, regional maintenance officer and regional human resources officer of the above documented findings on 3/10/2020 at approximately 4:30 pm and again on 3/12/2020 at 4:45 pm. No further information was provided to the surveyor prior to the exit conference on 3/12/2020.

Based on interviews and document review, it was determined the facility staff failed to ensure pharmacist medication regimen reviews were acted on by a provider for two (2) of 18 sampled residents (Resident #38 and Resident #48) as evidence by the absence of provider response documentation. The findings include: 1. The facility staff failed to ensure a provider acted on Resident #38's medication regimen review, dated 1/22/2020. Resident #38's diagnoses included, but were not limited to: high blood pressure, kidney disease, coronary artery disease, anxiety, depression, and chronic [CONDITION(S)]. Resident #38's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 1/24/2020, had the residents Brief Interview for Mental Status (BIMS) scored as a 14 out of 15 and the Resident Mood Interview scored as 16 out of 27. Resident #38 was assessed as requiring extensive assistance of two (2) or more individuals with bed mobility, transfers, dressing, and toilet use. Resident #38's progress notes included a pharmacy note, dated 1/22/2020, that indicated the pharmacist's completed medication regimen review recommendation(s) would be found in a separate report. No report dated 1/22/2020 regarding pharmacy recommendations was found within Resident #38's clinical record. On 3/12/2020 at 11:05 a.m., the facility's Regional Director of Clinical Services (RDCS) provided the surveyor with the aforementioned pharmacist's medication regimen review report dated 1/22/2020. The following information was found in this pharmacist report: Comment: (resident's name omitted) has a PRN [as needed] order for a sedative/hypnotic without a stop date. [MEDICATION(S)] 30 mg Q [every] hs [bedtime] PRN [as needed] for [CONDITION(S)]. Recommendation: Please consider discontinuing or adding a stop date to the current order . The area within the report for a physician's response was blank; no notation was made of whether the pharmacist's recommendation would be accepted or declined and no provider signature and date were documented. The RDCS confirmed this pharmacy recommendation dated 1/22/2020 had not been acted on by a provider until 3/12/2020 at 10:43 a.m. when the [MEDICATION(S)] order in question was discontinued; this was after the surveyor had asked about the 1/22/2020 pharmacist recommendations. The RDCS reported that providers including physicians, nurse practitioners, and physician assistants were allowed to address pharmacist's medication regimen review recommendations. Resident #38's clinical documentation included evidence of provider visits document on the following dates and times: 1/23/2020 at 12:50 p.m.; 1/27/2020 at 12:37 p.m.; 2/6/2020 at 1:00 p.m.; 2/7/2020 at 12:20 p.m.; 2/17/2020 at 1:05 p.m.; 2/21/2020 at 12:25 p.m.; and 2/24/2020 at 4:53 p.m. At none of the aforementioned visits did the provider address the Resident #38's 1/22/2020 pharmacist recommendation. The following information was found in the facility's Omnicare policy titled, 9.1 Medication Regimen Review (with the latest effective date of 11/28/16): 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR (medication regimen review) and the Director of Nursing to act upon the recommendations contained in the MRR . 8. Facility should alert the Medication Director when MRRs are not addressed by the attending physician in a timely manner. During a survey team meeting on 3/12/2020 at 4:51 p.m., the failure of facility staff members to ensure Resident #38's 1/22/2020 pharmacist's recommendation was addressed by a provider was discussed for a final time with the facility's administrative team (Chief Nursing Officer, Administrator, Director of Nursing , Regional Maintenance director, Corporate Human resources Director, and RDCS). No additional information regarding this issue was provided prior to the exit conference. 2. The facility staff failed to ensure a provider acted on the pharmacist's medication regimen review, dated 01/22/2020, related to [MEDICATION(S)] (given daily for depression) for Resident #48. Resident #48's clinical record was reviewed on 03/11/2020 and 03/12/2020. Within the admission record, the resident's diagnoses included, but were not limited to, [CONDITION(S)] disease, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and other specified depressive episodes. Section C (cognitive patterns) of the resident's MDS (minimum data set) assessment, with an assessment reference date of 02/18/2020 included a BIMS (brief interview for mental status) summary score of 14 out of 15. The progress notes included a pharmacy note, dated 01/22/2020, that indicated the pharmacist's completed medication regimen review recommendation(s) would be found in a separate report. No report dated 01/22/2020 regarding pharmacy recommendations was found within Resident #48's clinical record. The facility's regional director of clinical services was asked about this referenced report on the morning of 03/12/2020. At 3:45 p.m. on 03/12/2020, the facility's director of nursing (DON) and administrator provided the surveyor with the pharmacist's consultation report dated 01/22/2020. The administrator acknowledged the report was not found in Resident #48's clinical record; the report had been emailed to the facility. The pharmacist's consultation report, dated 01/22/2020, read that Resident #48 received [MEDICATION(S)] 40mg daily for depression and the recommendation read, Please reduce [MEDICATION(S)] to 20mg daily with the end goal of discontinuation. Rationale for Recommendation: [MEDICATION(S)] has a high incidence of anorexia and decreased appetite. The area within the report for a physician's response was blank; no notation whether the pharmacist's recommendation would be accepted or declined and no signature or date. The DON acknowledged the pharmacist's recommendation had not been addressed. Resident #48's clinical record included an order, dated 11/12/19, for [MEDICATION(S)] HCl Capsule 40 MG Give 1 capsule by mouth one time a day related to OTHER SPECIFIED DEPRESSIVE EPISODES to be started on 11/13/19. The resident's medication administration record (MAR) provided evidence Resident #48 had received [MEDICATION(S)] HCL Capsule 40 MG every morning at 9:00 a.m. in the month of January and February 2020 and through the 12th day in March 2020. The administrator provided two printed forms from the clinical record progress notes: 1) C-Health Nursing Facility Progress Note dated 02/25/2020, signed by a nurse practitioner and 2) a Psychiatric Evaluation with a date of service being 02/24/2020 electronically signed by a psychiatric-mental health nurse practitioner (PMHNP). The administrator stated that since both of these providers had seen Resident #48 after the pharmacist's consultation on 01/22/2020, either of them could have reviewed and acted on the pharmacist's recommendations but there was no evidence that either of them reviewed the pharmacist's recommendations. The facility's Omnicare policy titled, 9.1 Medication Regimen Review with the latest effective date of 11/28/16 read in part, 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR (medication regimen review) and the Director of Nursing to act upon the recommendations contained in the MRR. And, 8. Facility should alert the Medication Director when MRRs are not addressed by the attending physician in a timely manner. The administrative team including the facility's chief nursing officer, administrator, DON, regional maintenance director, corporate human resources director, and regional director of clinical services were informed of the above described concern during a meeting on 03/12/2020 at 4:51 p.m. No further information regarding this issue was provided prior to the exit conference.

Based on observations, staff interviews, and review of a facility document, it was determined the facility staff failed to ensure ensure that residents receive treatment and care for one (1) of 18 sampled residents (Resident #23) as evidenced by a failure to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #23 was a resident in the facility at the time of this survey on 3/9/2020 through 3/12/2020. The resident had the admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (Minimum Data Set) coded the resident as having a BIMS (Brief Interview for Mental Status) score of 10 out of a possible score of 15. Resident #23 was also coded as requiring extensive assistance with (2) or more staff members for dressing and personal hygiene and being totally dependent on (1) or more staff members for bathing. During the medication pass observation on 03/10/20 at 08:40 AM LPN (licensed practical nurse) #1 was preparing medications on the top of the medication cart outside the resident's room. As LPN #1 prepared the medication in which she stated it was [MEDICATION(S)] to the surveyor she continued to verbally state to the surveyor, LPN #1 stated to the surveyor, I have to check her heart rate before I give this medicine. The nurse placed the medication in which she had stated earlier to the surveyor that it was [MEDICATION(S)] and continued to place this pill in a medicine cup. The surveyor observed LPN #1 place this cup to the side and the LPN did not place any other medications in this medicine cup. The surveyor continued to observe LPN #1 check the medication cards with the residents MARs (Medication Administration Records). When LPN #1 had placed another pill in the second medication cup that had other medications in it. After this pill was placed in this cup, LPN #1 handed this medication card to the surveyor. The surveyor wrote this medication information from the label of the medication card in which was handed to her after this statement which read in part, .[MEDICATION(S)] 125 mcg (micrograms) 1 po (by mouth) daily. Hold if HR (heart rate) BELOW <60 . At 8:47 am, LPN #1 took both medicine cups and entered Resident #23's room along with the surveyor accompanying the nurse. The nurse gave the medicine cup that was full with the resident's medications to the resident and the resident proceeded to take all of these medications. This medicine cup was the cup that contained the [MEDICATION(S)] and the surveyor did not observe the nurse checking the resident's pulse before the [MEDICATION(S)] was administrated. After that, LPN #1 checked the pulse of the resident and gave the [MEDICATION(S)] from the medication cup that only had this one pill in it. At 9 am, the surveyor asked LPN #1, why she checked the resident's pulse before she gave the resident the medication [MEDICATION(S)]. LPN #1 stated, I checked the pulse before I gave the [MEDICATION(S)]. The surveyor had notified her of the above documented observations. The nurse stated, I'm so sorry I checked the pulse before I gave the [MEDICATION(S)] but I should had checked it before I gave her the [MEDICATION(S)]. The surveyor notified the regional nurse on 3/10/2020 at 9:15 am, of the above documented findings. The surveyor requested and received the policy titled, 6.0 General Dose Preparation Products and Services from Pharmacy which read in part, .4.1.2 Confirm that the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor reviewed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Hold if HR (heart rate) below 60 . This medication order had a date of 2/26/2020 as the order and start date of 2/26/2020 as documented on the Order Summery Report for Resident #52. The administrator, chief nursing officer, regional nurse, director of nursing, regional director of maintenance and regional director of human resources were notified of the above documented findings on 3/10/2020 at 4:45 pm in the conference. The surveyor again notified all named parties in the next end of the day conference on 3/11/2020 at approximately 4:30 pm. No further information was provided to the surveyor prior to the exit conference on 3/12/2020.

Based on observations, staff interviews, and review of a facility document, it was determined the facility staff failed to maintain an infection prevention and control program for one (1) of 18 sampled residents as evidenced by bringing a bottle of blood glucose strips into the resident's room and not cleaning the bottle before storing them in the medication cart and by not changing a pair of dirty gloves before opening the resident's blinds (Resident #23) The findings included: Resident #23 resided in the facility while an unannounced Medicare/Medicaid survey was conducted from 3/9/2020 through 3/12/2020. The resident had the admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (Minimum Data Set) coded the resident as having a BIMS (Brief Interview for Mental Status) score of 10 out of a possible score of 15. Resident #23 was also coded as requiring extensive assistance with two (2) or more staff members for dressing and personal hygiene and being totally dependent on one (1) or more staff members for bathing. During the medication pass observation on 3/10/2020 at 8:45 am, the surveyor observed LPN (licensed practical nurse) #1 administrated the medications the physician had ordered to be given at the 8am medication pass. While LPN #1 was in the room with the resident, the resident requested LPN #1 to open her blinds. LPN #1 proceeded to open the blinds with the gloves that LPN #1 had previously had on while she was sticking the resident's finger to obtain blood for the blood glucose level. LPN #1 removed her gloves and washed her hands. The surveyor had also observed LPN #1 bring in a bottle of blood glucose strips that had several strips in it. After washing her hands, LPN #1 exited the resident's room, placed the bottle of blood glucose strips in the medication cart drawer for storage. The surveyor did not observe LPN #1 clean and wipe down the bottle of blood glucose strips prior to putting them in the medications cart. At 8:47 am, the surveyor asked LPN #1 what should she had done prior to opening the resident's blinds in her room. LPN #1 stated, I should had taken my dirty gloves off and washed my hands before I opened the blinds. The surveyor then asked what she should had done before bringing the bottle of blood glucose strips and storing them in the medication cart drawer. LPN #1 stated, I should had wiped the bottle down with a cleaning wipe. At 9 am, the surveyor notified the regional nurse of the above documented findings. The surveyor requested the facility's policy on the cleaning of multi-use resident supplies once they are brought out of the resident's room. At 11:25 am, the chief nursing officer provided the surveyor with the policy titled, 6.0 General Dose Preparation and Medication Administration which read in part, .6.4 Clean any reusable equipment or supplies . The surveyor notified the administrator, chief nursing officer, regional nurse, director of nursing, regional maintenance officer and regional human resources officer of the above documented findings on 3/10/2020 at approximately 4:30 pm and again on 3/12/2020 at 4:45 pm. No further information was provided to the surveyor prior to the exit conference on 3/12/2020.

Based on Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to maintain a complete and accurate clinical record for five of 17 Residents, Residents #8, #13, #27, #161, and #7. The findings included. 1. For Resident #8, the facility staff failed to accurately complete the Residents Record of Informed Consent for [MEDICAL CONDITION] Medication. The record review revealed that Resident #8 had been admitted to the facility 09/12/17. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 05/29/18 had been coded 1/1/3 to indicate the Resident had problems with long and short term memory and was severely impaired in cognitive skills for daily decision making. The Residents clinical record included a form titled Record of Informed Consent for [MEDICAL CONDITION] Medication. Page two of this form read in part. After careful consideration of the information provided to me, I hereby: ( ) Give my permission for the use of the above listed psychoactive medication(s). I understand that once that targeted behavior/symptom is controlled, the dose will be gradually reduced to the lowest possible dosage and frequently or discontinued unless contraindicated by the physician/prescriber. ( ) I DO NOT consent to the use of the psychoactive medication(s) as recommended. I acknowledge that my care planning team has advised me that by not accepting the prescriber's recommendations, I may be at additional medical or psychological risks. This form had been signed by the RP (responsible party) and the facility representative on (MONTH) 14, (YEAR). However, neither box had been checked. The administrative team was notified of the missing information on this form during a meeting with the survey team on 08/29/18 at 5:11 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #13, the facility failed to maintain an accurate record in regards to the Residents feeding tube. The feeding tube had been discontinued. However, the Residents EHR (electronic health record) included an active order regarding the feeding tube. The clinical record review revealed that Resident #13 had been admitted to the facility 05/29/18. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 06/13/18 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. The clinical record included a physicians order dated 07/26/18 to discontinue peg tube. However, the Residents EHR included the order PEG-May cocktail medications to be administered via PEG. the status was listed as being Active. During an interview with Resident #13 on 08/29/18 at 3:43 p.m., the Resident stated she no longer had the feeding tube. The administrative team was notified of the inaccurate record during a meeting with the survey team on 08/29/18 at 5:11 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #27, the Residents EHR (electronic health record) included orders for [MEDICATION NAME] suppository and soapsuds enema. However, the Resident had a [MEDICAL CONDITION]. The record review revealed that Resident #27 had been admitted to the facility 12/02.17. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Resident quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 07/04/18 had been coded 1/1/2 to indicate the Resident had problems with long and short term memory and was moderately impaired in cognitive skills for daily decision making. Section H (bladder and bowel) had been coded to indicate the Resident had a [MEDICAL CONDITION]. The Residents EHR included order for soapsuds enema and [MEDICATION NAME] suppository for constipation. During an interview with the DON (director of nursing) on 08/28/18 at 4:14 p.m., the DON stated he had reviewed the Residents EHR and the Resident did not have BM's (bowel movements) as she had a [MEDICAL CONDITION] in place. The DON stated that when the Resident had been readmitted from the hospital the orders came from the facility standing orders and he had discontinued them. The administrative team was notified of the inaccurate record during a meeting with the survey team on 08/29/18 at 5:11 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference. 4. For Resident #161 the facility staff failed to accurately list Resident's allergies [REDACTED].>Resident #161 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Surveyor spoke with Resident #161 on 08/29/18 at approximately 1030. Resident was alert and oriented. Resident #161's clinical record was reviewed on 08/29/18. It contained a POS (physician's orders [REDACTED]. The POS also contained an entry, which read in part, [MEDICATION NAME] Tablet 5 mg ([MEDICATION NAME] HCl) Give 1 tablet by mouth every 8 hours as needed for pain. The Resident's eMAR (electronic medication administration record) was reviewed and contained an entry, which read in part, [MEDICATION NAME] Tablet 5 mg ([MEDICATION NAME] HCl) Give 1 tablet by mouth every 8 hours as needed for pain. This entry had been initialed as having been administered once each day on 08/27-08/29/18. Surveyor spoke with pharmacist on 08/29/18 at approximately 1155 regarding Resident #161. Pharmacist stated that Resident has a listed allergy to [MEDICATION NAME], but that she had been receiving it while in the hospital prior to admission to the facility. Surveyor spoke with the DON (director of nursing) on 08/29/18 at approximately 1330 regarding Resident #161's listed allergy to [MEDICATION NAME]. Surveyor spoke again with DON on 08/29/18 at approximately 1720. DON stated that he had spoken with Resident and family regarding [MEDICATION NAME] allergy. DON stated that Resident and family confirmed that Resident had previously been taking [MEDICATION NAME] with no adverse effects. DON stated that he had consulted with MD to have allergy to [MEDICATION NAME] discontinued. The concern of the Resident's allergy list being incorrect was discussed with the administrative team during a meeting on 08/30/18 at approximately 1155. No further information was provided prior to exit. 5. For Resident #7 the facility failed to sustain an accurate clinical record regarding nursing notes dated 8/22 and 8/24 inaccurate indicating Resident is taking PO (by mouth) fluids well and the Resident is NPO (nothing by mouth). Per the clinical record review Resident #7 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Quarterly MDS Assessment with an ARD (Assessment Reference Date) of 5/23/18, the resident was coded as having memory problems with short term and OK long-term memory. The record also reflected modified independence with daily decision making, with some difficulty in new situations only. The clinical record included nursing progress notes dated 08/22/2018 and 08/24/2018, that indicated resident # 7 was taking PO fluids well. However it also included an Order Summary Report that indicated the Resident was NPO and the current comprehensive care plan indicated the Resident was to have small amount of thickened liquids at bedside to moisten mouth. DON (Director of Nursing) was requested to provide Nursing Progress Notes for 8/22 and 8/24, current Physician orders. On 08/30/18 at 10:59 am during an interview with DON the requested documents were provided and stated Resident#7 was NPO. On 08/30/18 at 12:24pm DON provided amended physician progress notes [REDACTED].#7 receives thickened liquids at bedside for oral care only. No further information was provided to the surveyor prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to ensure 2 of 17 Residents were free of unnecessary [MEDICAL CONDITION] medications, Residents #25 and #48. The findings included: 1. For Resident #25 the facility staff failed to provide monitoring for the antidepressant medication [MEDICATION NAME]. Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 08/13/18 coded the Resident as 15 of 15 in section C, cognitive patterns. This is an admission MDS. Resident #25's CCP (comprehensive care plan) was reviewed and contained a care plan for Resident at risk for adverse effect related to [MEDICAL CONDITION] medication secondary to dx (diagnosis) of depression. Interventions for this care plan were listed as monitor behaviors related to [MEDICAL CONDITION] medications as needed and observed for adverse effects related to [MEDICAL CONDITION] medications. Resident #25's clinical record was reviewed on 0828/18. It contained a signed POS (physician's orders [REDACTED]. The Resident's clinical record also contained a Side Effects Monthly Flow Sheet for the months of (MONTH) and (MONTH) (YEAR). This flow sheet had not been completed on any day for (MONTH) and had only been partially completed for August. The surveyor spoke with the DON (director of nursing) on 08/30/18 at approximately 1145 regarding Resident #25. DON stated that Resident had been in and out of hospital, but that the flow sheet should have been completed on the days Resident was in facility. The concern of not monitoring the medication was discussed with the administrative team during a meeting on 08/30/18 at approximately 1155. No further information was provided prior to exit. 2. For Resident #48 the facility staff failed to provide an end date for the prn medication [MEDICATION NAME] and administered the prn medication [MEDICATION NAME] without indications for use. Resident #48 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 07/17/18 coded the Resident as having both short and long term memory impairment with modified independent cognitive skills for daily decision making. Section E, behavior indicated that the Resident had no symptoms of [MEDICAL CONDITION] and had behavioral symptoms of rejecting care 1 to 3 days during the look back period. This is an admission MDS. Resident #48's CCP (comprehensive care plan) was reviewed and contained care plans which read in part, Resident has behaviors or history of behaviors of Resident will become agitated with staff, refusing to be transferred via Hoyer lift and Resident at risk for adverse effect related to [MEDICAL CONDITION] medication secondary to dx (diagnosis) of anxiety, depression. Interventions for this care plan were listed as monitor behaviors related to [MEDICAL CONDITION] medications as needed, MD review for appropriateness, and observed for adverse effects related to [MEDICAL CONDITION] medications. Resident #48's clinical record was reviewed on 08/28/18. It contained a POS (physician's orders [REDACTED]. Behavior Codes: 0) none, 1) afraid, 2) Striking out, 3) Angry, 4) Anxiety, 5) Compulsive behaviors, 6) Continuous crying, 8) Continuous screaming/yelling, 9) Danger to others, 10) Danger to self, 12) depressed, 13) Extreme fear, 14) Hallucinations, 15) Paranoia, 16) Delusions, 17) [MEDICAL CONDITION], 18) Slapping, 19) Mood change, 20) Spitting, 21) Throwing objects,, 22) Pulling [MEDICAL CONDITION] tubing, 23) Pacing every shift for behavior monitoring, and [MEDICATION NAME] Tablet 1 mg Give 1 tablet by mouth every 4 hours as needed for [MEDICAL CONDITION] with psychotic behaviors. The PRN (as needed) order for [MEDICATION NAME] did not include a stop date. Resident #48's eMAR (electronic medication administration record) for the month of (MONTH) (YEAR) was reviewed and contained entries which read in part, [MEDICATION NAME] Tablet 1 mg Give 1 tablet by mouth every 4 hours as needed for [MEDICAL CONDITION] with psychotic behaviors. This entry had been initialed as having been administered once daily on 08/01-08/16/18, 08/20-08/22/18 and 08/27-08/28/18. Resident #48's clinical record contained a Behavior Monthly Flow Sheet with behavior codes of 12) depressed and 4) anxiety to be monitored. This flow sheet was marked as Resident not having exhibited any behaviors of depression and 1 episode of anxiety for the month of August. The Resident's progress notes were reviewed and the surveyor could not locate any progress notes related to Resident's behaviors. The progress notes contained medication administration notes stating that the [MEDICATION NAME] had been administered, but did not state what behaviors were being exhibited. The surveyor spoke with the DON (director of nursing) on 08/29/18 at approximately 1710 regarding Resident #48. DON stated that behaviors in relation to the administration of the medication should have been documented. The concern of not having a stop date and administering the medication [MEDICATION NAME] without indications for use was discussed with the administrative team during a meeting on 08/30/18 at approximately 1155. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review the facility staff failed to ensure adequate foley catheter care for the prevention of urinary tract infections for 1 of 17 Residents, Resident #39. The findings included: The facility staff failed to ensure the Resident's foley catheter drainage bag/drainage tubing did not touch the floor. Resident #39 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 07/26/18 coded the Resident as 14 out of 15 in section C, cognitive patterns. Section H, bowel and bladder, coded the Resident as having an indwelling (foley) catheter. Surveyor observed Resident #39 on 08/28/18 at approximately 1610. Resident was resting in bed, alert and oriented. Surveyor observed Resident's foley catheter drainage bag lying on the floor beside of Resident's bed. Surveyor spoke with Resident at this time and Resident stated that she currently has a UTI (urinary tract infection). Resident #39's clinical record was reviewed on 08/28/18. It contained a laboratory report for a urinalysis and urine culture dated 08//23/18 which indicated the Resident has a UTI. The clinical record also contained a physician's orders [REDACTED]. Surveyor spoke with the infection control nurse on 08/30/18 at approximately 0830 regarding Resident #39. Infection control nurse stated that Resident's foley catheter drainage bag should not be lying in the floor and that this could possibly contribute to a UTI. Surveyor requested and was provided with a copy of policy entitled Catheter Care on 08/30/18. The policy read in part, When checking urinary catheters and containers, follow these rules: 13. Make sure the catheter tubing and drainage bag are kept off the floor. The concern of the Resident's foley catheter drainage bag lying in the floor was discussed with the administrative team during a meeting on 08/30/18 at approximately 1155. No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to accurately assess and monitor the need for oxygen for 1 of 17 Residents, Resident #48. The findings included: For Resident #48 the facility failed to accurately assess the Resident's need for oxygen. Resident #48 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 07/17/18 coded the Resident as having both short and long term memory impairment with modified independent cognitive skills for daily decision making. Surveyor observed Resident #48 on 08/28/18 at approximately 1100. Resident was seated in wheelchair at bedside with family member in attendance. Resident was alert but confused and did not appear to be in any distress. Resident was not observed to be using oxygen at this time. Surveyor observed Resident #48 again on 08/29/18 at approximately 1025. Resident was seated in wheelchair at bedside with family member in attendance. Resident had oxygen in use at this time. Resident #48's clinical record was reviewed on 08/28/18. It contained a signed POS (physician's orders [REDACTED]. The Resident's eMAR (electronic medication administration record) was reviewed and contained an entry which read in part, oxygen sat checks every day and prn (as needed) every day shift for routine. The Resident's recorded oxygen sats ranged from 94-99%. Resident #48's progress notes were reviewed and the surveyor could not locate any notes related to Resident #48's oxygen usage. The surveyor requested and was provided with a copy of Nursing Home Standing Orders which read in part, IV. Symptom Treatment H. Shortness of breath---First check pulse oximeter readings if 02 sat is <90 % (less than), administer 02 at 2L/per min via nasal cannula and have physician review on next round. The surveyor spoke with the DON (director of nursing) on 08/30/18 at approximately 1145 regarding Resident #48's oxygen usage. DON stated that he would expect nurses to document reason for oxygen usage in progress notes. The concern of the facility staff not assessing and monitoring the need for oxygen usage was discussed with the administrative team during a meeting on 08/30/18 at approximately 1155. No further information was provided prior to exit.

Based on staff interview and clinical record review the facility staff failed to ensure an accurate MDS assessment for one of 17 residents Resident #7 The findings included: The facility staff failed to complete an accurate MDS in regards to Resident #7's feeding tube documentation. Per the clinical record review Resident #7 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the Quarterly MDS Assessment with an ARD (Assessment Reference Date) of 5/23/18, the resident was coded as having memory problems with short term and OK long-term memory.Also reflected was modified independence with daily decision making, with some difficulty in new situations only. Resident was ordered to receive supplemental tube feeding and a mechanically altered diet at this time. The surveyor performed a review of Resident #7's clinical record on 8/29 and 8/30/18. During this review, the surveyor noted on the quarterly MDS assessment with ARD of 5/23/18, under Section K 0510 nutritional approaches, feeding tube was not checked. On 8/29/18 at 11:30 am, the surveyor notified the MDS nurse #1 of the above documented findings for Resident #7 in regards to feeding tube under section K of the MDS. The MDS nurse and surveyor reviewed the clinical record together at this time and it was clarified that feeding tube was failed to be checked under section K. At 11:55 am, MDS nurse #1 returned to the conference room and provided the surveyor a copy of the MDS with ARD of 05/23/18. MDS nurse #1 stated Feeding tube should have been checked as the Resident was receiving supplemental tube feeding at that time. The surveyor notified the administrative team of the above documented findings on 8/30/18 at 11:10 am during pre-exit meeting No further information was provided to the surveyor prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to have a completed DDNR (Durable Do Not Resuscitate) for 1 of 17 residents in the survey sample (Resident #1). The findings included: The facility staff failed to have a completed DDNR (Durable Do Not Resuscitate) in the clinical record for Resident #1. Resident #1 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/3/17 coded the resident as having short term and long term memory problems with decision making being moderately impaired. Resident #1 was also coded as requiring extensive assistance of 2 or more staff members for dressing and personal hygiene and being totally dependent on 1 staff member for bathing. During the clinical record review performed by the surveyor on 5/10/17, the surveyor noted that the DDNR in the clinical record of Resident #1 was not dated. The administrative team was notified of the above documented findings on 5/10/17 at approximately 2 pm by the surveyor. The director of nursing stated There's a sticker on the top of it that has a date on it. The surveyor stated It was a sticker from the hospital that had an admitted on it. The DDNR was not dated at the time it was signed. No further information was provided to the surveyor prior to the exit conference on 5/11/17.