Every finding on record at Meadows, The

Based on observation, interview and record review, the facility failed to ensure staff adhered to the facility policy for Self-Administration of Medications, in regard to providing a secure area to store medication and in regard to documenting the frequency of use of a self-administered medication for 1 of 1 applicable Residents (#83) that were deemed appropriate to self administer medications, out of a total sample of 13 residents. Findings include: Resident #83 was admitted to the facility in July 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident scored a 15 out of 15 on his/her Brief Interview for Mental Status Exam (BIMS), indicating he/she is cognitively intact. Review of the facility policy, entitled, Self-Administration of Medications, dated 2/2021, included the following: * Self -administered medications are stored in a safe and secure place, which is not accessible by other residents. * If the resident is able and willing to take responsibility for documenting self-administration of medications, the resident is instructed on how to complete a record indicating the administration of the medication. * Nursing staff reviews the Self-Administered Medication Record for each nursing shift, and transfers pertinent information to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/20/22 at 7:21 A.M., the surveyor observed a levoalbuterol (medication used for shortness of breath) inhaler resting on Resident #83's overbed table, located next to his/her bed. On 7/20/22 at 1:15 P.M., the surveyor observed a levoalbuterol inhaler resting on top of Resident #83's bed. On 7/21/22 at 7:15 A.M., the surveyor observed a levoalbuterol inhaler resting on the overbed table, next to Resident #83's bed. Review of the physician's order, dated 7/12/22, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Self-Administration of Medication tool, electronically signed and dated on 7/20/22, indicated that the interdisciplinary team assessed Resident #83 and determined he/she can leave medications at the bedside and self administer. Review of the MAR, dated July 2022, failed to indicate if staff asked Resident #83 if he/she had any as needed use of his/her levoalbuterol inhaler per the facility policy. During an interview on 7/21/22 at 8:39 AM, Licensed Nurse #1 said that she asks Resident #83 often if he/she has used the inhaler and recalls the Resident saying he/she used it once on Licensed Nurse #1's time. Licensed Nurse #1 said she can't speak for other shifts. Licensed Nurse #1 said that she did not document any as needed usage of the inhaler on the MAR. During an interview on 7/21/22 at 11:00 A.M., the Director of Nursing said that there are cognitively impaired resident's that wander on the unit where Resident #83 resides and all medications must be secured.

Based on record review and interview, the facility failed to prevent 1 Resident (#17) from sustaining a fall, out of a total sample of 13 residents. Findings include: Review of the facility policy titled, Falls and Fall Risk, Managing, dated 12/2018, indicated the following: *The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systemic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. Resident #17 was admitted to the facility in June 2022 with diagnoses that included Alzheimer's Disease and spinal stenosis. Review of Resident #17's most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #17 had a Brief Interview for Mental Status score of 9 out of a possible 15, which indicated he/she has moderate cognitive impairment. The MDS also indicated Resident #17 requires minimal assistance from staff for mobility tasks. Review of Resident #17's fall care plan created on 6/7/22 indicated the following intervention: *Uses 1 assist and gait belt for all ambulation. Use additional assist as needed when Resident is not feeling well, feeling weak or dizzy. Device used for ambulation: Rollator. Review of Resident #17's Activity of Daily Living (ADL) care plan created 6/7/22 indicated the following intervention: *Assist of Resident using 1 staff assist. Use gait belt for all hands on transfers from one surface to another. Explain all procedures prior to starting. Advise Resident what is expected to him/her during the transfer. Reassure Resident of safety as needed. Review of an incident report dated 7/10/22, indicated Resident #17 sustained a fall in his/her room while walking. The report indicated a CNA was assisting the Resident to the bathroom but had left him/her to walk alone while she obtained toileting supplies. The incident report failed to indicate Resident #17 was wearing a gait belt when he/she fell . During an interview on 7/20/22 at 2:08 P.M., Certified Nursing Assistant (CNA) #1 said the nurses give a verbal report at the start of shift and the CNAs are told the needs of all residents. CNA #1 said if a resident requires a gait belt or assistance with mobility, this would be told during the verbal report. CNA #1 said staff should use gait belts on all residents who require assistance with ambulation. CNA #1 said Resident #17 has fallen and would definitely require assistance and a gait belt if ambulating. During an interview on 7/20/22 at 2:12 P.M., Nurse #1 said Resident #17 requires assistance from staff and the use of a gait belt when ambulating. During an interview on 07/21/22 at 8:04 A.M., the Director of Nursing (DON) said the nursing staff verbally communicates residents' needs to the CNAs at the start of shift. The DON said Resident #17 is care planned to have assistance and a gait belt when ambulating and had been left alone at the time of his/her fall.

Based on observation and interview the facility failed to ensure medications were stored in a secure manner and not accessible to unauthorized persons on 1 of 1 resident units. Findings include: Review of the facility policy, entitled, Self-Administration of Medications, dated 2/2021, included the following: * Self -administered medications are stored in a safe and secure place, which is not accessible by other residents. On 7/20/22 at 7:21 A.M., the surveyor observed a levoalbuterol (medication used for shortness of breath) inhaler resting on a resident's overbed table, located next to his/her bed. On 7/20/22 at 1:15 P.M., the surveyor observed a levoalbuterol inhaler resting on top of a resident's bed. The door was open with resident walking up and down the corridor. On 7/21/22 at 7:15 A.M., the surveyor observed a levoalbuterol inhaler resting on the overbed table, next to a resident's bed. During an interview on 7/21/22 at 11:00 A.M., the Director of Nursing said that there are cognitively impaired residents that wander on the unit where Resident #83 resides and all medications must be secured.

Based on observation and interview, the facility failed to 1. ensure that staff properly stored personal protective equipment (PPE) when not in use on 1 of 2 nursing units and 2. failed to ensure that facemasks were properly worn while entering a room to care for a resident on droplet precautions for potential Covid-19 symptoms on 1 of 2 nursing units. Findings include: Review of the Centers for Disease Control (CDC) website, page titled, Strategies for Optimizing the Supply of Facemasks, updated June 28, 2020, indicated facemasks should be carefully folded so that the outer surface is held inward and against itself to reduce contact with the outer surface during storage. The folded mask can be stored between uses in a clean sealable paper bag or breathable container. 1. The facility failed to ensure that staff properly stored personal protective equipment (PPE) when not in use on 1 of 2 nursing units. On 11/17/20 at 9:55 A.M., the surveyor observed Nurse #1 outside a resident room. There was a precaution cart and a sign indicating droplet precautions. Nurse #1 removed her face shield and surgical mask, placed both directly on top of a medication cart unprotected and proceeded to put on a kn95 mask and new face shield and enter the room with the droplet precaution sign. At 10:23 A.M., Nurse #1 came out of the room with the droplet precaution sign, removed and stored the kn95 mask and shield and proceed to put the contaminated surgical mask and shield from on top of her medication cart back on. At this time, she said the residents in that room were on droplet precautions with Covid-19 symptoms and their test results were pending. Nurse #1 also said she usually stores her surgical mask and shield in a paper bag when not in use, but she had forgotten to bring the bag with her. At 12:41 P.M., the Infection Preventionist (IP) #1 said that she was not able to locate a specific policy for PPE storage, only that it should be stored in an appropriate receptacle. The IP #1 said that the top of the medication cart was not considered an appropriate receptacle. 2. The facility failed to ensure that staff facemasks were properly worn while entering a room to care for a resident on droplet precautions On 11/17/20 at 9:55 A.M., the surveyor observed Certified Nursing Assistant #1 (CNA) enter a resident's room. There was a precaution cart and a sign indicated droplet precautions. CNA #1 was wearing a surgical mask underneath a kn95 mask. During an interview with Nurse #1 on 11/17/20 at 10:23 A.M., the residents in the room were on droplet precautions with Covid-19 symptoms and test results were pending. Nurse #1 also said that she removes her surgical mask before putting on a kn95 mask, but it is okay to wear one underneath as well. At 10:32 A.M., CNA #1 came out of the room with the droplet precaution room sign. At that time, she said that Nurse #1 had told her to remove the surgical mask from under her kn95 mask, but she wasn't sure why. During an interview on 11/17/20 at 11:00 A.M., IP #1 said that when staff change from a surgical mask to a kn95 mask to enter a room with droplet precautions they should safely store the surgical mask on a paper towel or in a paper bag when not in use. IP #1 also said that the staff should not wear a surgical mask under a kn95 mask (double mask). At 12:41 P.M., IP #1 said there was no policy for wearing two masks because it is not the facility policy and should not be done.

Based on observation, interview and policy review, the facility failed to 1) screen employees, non essential personnel and visitors for signs and symptoms of COVID-19 prior to entry to the facility and 2) failed to ensure staff wore a mask while in a resident care area. Findings include: 1) The facility failed to screen employees, non essential personnel and visitors for signs and symptoms of COVID-19 prior to entry to the facility. Review of facility policy titled Employee and Personnel Risk Assessment, Monitoring and Work Restrictions dated 4/6/2020 indicated the following: -Screen all healthcare personnel (HCP) at the beginning of their shift for fever and symptoms. -Actively take their temperature and document absence or presence of illness. If they are ill, have them put on a facemask and leave the workplace. -HCP who work in multiple locations may pose higher risk and should be asked about exposure to facilities with recognized COVID-19 cases. Review of facility policy titles The(NAME)Visitation and Video Calls Policy, undated, indicated the following: -Visitors are required to be screened and have their temperature taken prior to entering the visitation location. - A temperature greater than 99.6 or having any of the following symptoms: shortness of breath, sore throat, myalgia, chills, new onset of loss of taste or smell, means you will not be permitted to visit. Review of facility screening logs indicated the following incomplete screening logs (logs missing temperature readings and/or answers to questions regarding signs and symptoms of COVID-19): -Visitor Screening logs dated 10/8/20; 10/11/20;10/13/20; 10/27/20; 10/30/20; 11/01/20 - Non Essential Personnel log dated 10/01/20 -Start of shift daily Employee Screening logs dated 10/06/20; 10/12/20; 10/30/20; 11/09/20 Further review of Employee Screening log dated 11/09/20 indicated 3 entries with yes checked off in response to two screening questions regarding having symptoms of COVID-19 and exposure to a person with COVID-19. During an interview on 11/09/20 at 9:10 A.M., Receptionist #1 said that screening logs should be reviewed for completeness and accuracy prior to entry to the facility and that if there are any issues she will contact the Infection Control Nurse or Director of Nursing to inform them. Receptionist #1 said that the yes answers to the questions regarding having symptoms of COVID-19 and exposure to a person with COVID-19 must have been checked by mistake and that if anyone checks yes to the questions, she will inform the Director of Nursing or Infection Control Nurse. During an interview on 11/09/20 at 10:27 A.M., the Infection Control Nurse said that she tries to review the screening logs but they are not necessarily reviewed daily. The Infection Control Nurse said that if any questions have a yes answer, she or the Director of Nursing would ask additional questions prior to allowing entry to the building. The Infection Control Nurse said that no one should be allowed entry to the facility if they do not fill out the screening log completely. 2) The facility failed to ensure staff wore a facemask while in a resident care area. Review of The Centers for Disease Control and Prevention (CDC) guidance titled Preparing for COVID-19 in Nursing Homes, updated 6/25/20 indicated: -HCP should wear a facemask at all times while they are in the facility. During an observation of the Gardenview Unit on 11/09/20 at 7:55 A.M., the Director of Nursing was observed not wearing a face mask while on the resident care unit. During an interview on 11/09/20 at 8:21 A.M., the Director of Nursing acknowledged she was not wearing a face mask while on the unit and said she normally wears a face mask.

Based on observation, interview and record review, the facility staff failed to ensure that physician orders [REDACTED].#12 and #191) out of a total sample of 14 Residents. Findings include: 1) For Resident #12 the facility failed to follow a physician's orders [REDACTED]. Resident #12 was admitted to the facility in 4/2018 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE], indicated that Resident #12 had a severe cognitive impairment, scoring a 3 out of 15 on the Brief Interview for Mental Status and required extensive assistance with eating. On 8/1/19 at 9:49 [NAME]M., the surveyor observed Nurse #1 administer medications to Resident #12. Nurse #1 gave Resident #12 a cup of regular thin water and instructed him/her to take a sip to wash down the medication. Resident #1 immediately began coughing forcefully. He/she was clutching the bed linens with both hands. Resident #12's face and hands became dark red from the force of the coughing and the clutching of the linens. This continued for approximately 5-10 minutes before Resident #12 was able to regain his/her breath. He/she continued to cough sporadically for another 5-10 minutes. Review of the physician's orders [REDACTED].#12 had a diet order to receive nectar thickened liquids. During an interview with Nurse #1, on 8/1/19 at 10:25 [NAME]M., she said that she should not have given Resident #12 thin water, she should have given him/her a nectar thickened drink. 2) For Resident #191 the facility staff failed to follow a physician's orders [REDACTED]. Resident #191 was admitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set, dated dated [DATE], indicated that Resident #191 had a moderate cognitive impairment, scoring an 8 out of 15 on the Brief Interview for Mental Status and required extensive assistance with bed mobility and transfers. Review of the treatment administration record for 8/2019 indicated that there was a physician's orders [REDACTED]. On 7/31/19 at 10:30 [NAME]M., 7/31/19 at 3:30 P.M., and on 8/1/19 at 10:50 [NAME]M., the Surveyor observed Resident #191 lying in bed. There was a low air flow mattress set to 360, not 280. During an interview with Unit Manager #1, on 8/1/19 at 2:00 P.M., she said that the air mattress should have been set according to the physicians order.

Based on observation, interview and record review, the facility staff failed to provide 1 Resident (#30) with services necessary to carry out self feeding tasks. Findings include: Resident #30 was admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. Review of the most recent Minimum (MDS) data set [DATE] revealed that Resident #30 had a Brief Interview for Mental Status score of 3 out of a possible 15 which indicated that he/she had severe cognitive impairment. Review of Resident #30's medical record indicated he/she was treated by occupational therapy from 4/10/19 - 5/6/19. An occupational therapy discharge summary dated 5/7/19, indicated that he/she required supervision for all self-feeding tasks. Further review of the medical record indicated that Resident #30 was treated by speech therapy from 6/14/19-7/11/19. A speech therapy discharge summary dated 7/11/19 indicated that the Resident required close supervision for all oral intake. A speech therapy note from 7/11/19 indicated that comprehensive education was provided to the nursing staff regarding the recommendation that close supervision be provided for all oral intake. On 7/31/19 at 8:20 [NAME]M., Resident #30 was observed lying in bed in his/her room with breakfast in front of him/her. No supervision was being provided while he/she was eating. On 8/1/19 at 9:02 [NAME]M., Resident #30 was observed lying in bed in his/her room with breakfast in front of him/her. No supervision was being provided while he/she was eating. On 8/2/19 from 8:26 [NAME]M., to 9:02 [NAME]M., Resident #30 was in bed with breakfast in front of him/her. The Resident's door was closed and the surveyor did not observe any staff enter the room to provide supervision while he/she was eating. During an interview on 8/01/19 at 10:42 [NAME]M., the Speech Therapist said that all recommendations upon discharge from services are written both in the discharge summary and also in a communication book that is kept on the unit. She said that the communication book explains all recommendations for assist needed for feeding and ordered diets. During an interview on 8/02/19 at 8:26 [NAME]M., Nurse #1 said that the nurses use the speech communication book to obtain all info needed for diets ordered and resident needs at mealtimes. During an interview on 8/2/19 at 9:02 [NAME]M., Certified Nursing Assistant #1 said that Resident #30 can not eat alone. She said that the Resident becomes very tired during eating tasks and needs constant supervision to keep her awake during meals. During an interview on 8/2/19 at 9:51 [NAME]M., the Speech Therapist said that she recommends supervision for everyone that is eating a meal in bed. When told that Resident #30 was eating breakfast alone in his/her room with the door closed, the Speech Therapist said that goes against her recommendations for Resident #30. During an interview on 8/2/19 at 9:52 [NAME]M., Nurse #1 said that Resident #30 needs supervision for all meals because she falls asleep while eating. She said that staff goes in intermittently but does not stay. When asked how supervision for meals can be provided if staff are only intermittently present, she said it can't and that staff should be with Resident #30 at all times when eating. During an interview on 8/02/19 at 10:04 [NAME]M. the Director of Therapy said that Resident #30 should not be eating breakfast in her room without supervision.

Based on observation, record review and interview, the facility staff 1. failed to attempt appropriate alternatives prior to installing bed rails and 2. failed to ensure the bed rails were the size ordered by the physician for 3 residents (#29, #99 and #15) from a total of 15 sampled residents. Findings include: 1. Resident #29 was admitted to the facility in 5/2018 with [DIAGNOSES REDACTED]. Review of the current physician orders [REDACTED]. Review of the Side Rail Risk Assessment, dated 8/25/18, indicated the resident used bilateral quarter bed rails for positioning in bed. The assessment did not indicate that alternatives were attempted prior to the use of the bed rails. Review of the current care plan indicated the resident may use bilateral quarter side rails as an enabler for assistance with bed mobility. On 10/9/18 at 12 Noon and on 10/10/18 at 12:30 P.M. the surveyor observed that the side rails attached to the resident's bed were one-half side rails and not quarter side rails as specified in the physician's orders [REDACTED]. On 10/11/18 at 2:00 P.M. during interview, Resident #29 stated he/she does use both side rails in bed. 2. Resident #99 was readmitted to the facility in 10/1/18 with [DIAGNOSES REDACTED]. Review of the current physician orders [REDACTED]. Review of the Side Rail Risk Assessment, dated 7/21/18, indicated the resident used bilateral half bed rails for mobility. There was no indication in the assessment that alternatives to the side rails were attempted prior to their use. On 10/9/18 at 11:17 A.M. and on 10/10/18 at 7:06 A.M. the resident was observed in bed with bilateral one half side rails raised and not quarter side rails as per the physician order [REDACTED]. On 10/10/18 at 03:45 PM, the DNS (Director of Nursing Services) said that the wood and metal side rails attached to the resident beds were one half side rails and not one quarter side rails. 3. Resident #15 was admitted in 11/2014 with [DIAGNOSES REDACTED]. Review of Resident #15's 10/2018 physician orders [REDACTED]. Review of Resident #15's initial bed side rail assessment, dated 2014, indicated, he/she used bilateral quarter bed rails for positioning in bed. The assessment did not indicate that alternatives were attempted prior to the use of the bed side rails. Review of Resident #15's care plan indicated, may use bilateral quarter side rails as an enabler for assistance with bed mobility. On 10/10/18 at 8:20 A.M., the Surveyor observed Resident #15 asleep in bed with raised 1/2 bilateral side rails. The side rails were padded. The Surveyor interviewed the Director of Nurses (DON) on 10/10/18 at 2:30 P.M. The DON said that the Facility used the nursing admission assessment and then quarterly assessments to assess residents for side rails. The DON said that alternatives to bed side rails were not included in the initial or quarterly assessment process.

Based on record review and interview, the facility staff failed to provide written information of the facility's bed hold policy at the time of the resident's transfer to the hospital for 1 Resident (#99) from a total sample of 15 residents. Findings include: Resident #99 was admitted to the facility in 9/2015 with [DIAGNOSES REDACTED]. Record review indicated that the resident was transferred to the hospital on [DATE] due to increased lethargy and dry heaving. The facility staff notified the physician who ordered that the resident be sent to the hospital emergency room for an evaluation. The facility staff notified the resident's representative of the resident's condition and transfer to the hospital. Record review indicated the resident returned to the facility on [DATE]. On 10/11/18 at 9:30 A.M., the surveyor requested to review the notice of the bed hold policy provided to the resident's representative at the time of the resident's transfer to the hospital. The Administrator said that the facility staff did not provide a bed hold notice specifying the duration of the bed-hold policy, during which the resident is permitted to return and resume residence in the nursing facility. The Administrator indicated that Resident # 99's bed is automatically held as the resident is a life member of the community.

Based on observations, the Facility staff failed to maintain Infection Control practices designed to prevent the development and transmission of disease and infection during meal services. Findings include: 1. On 10/09/18 at 12:12 P.M., the surveyor observed a dietary aide ( #2) serving soup without wearing gloves. During the process of serving, the Surveyor observed dietary aide #2 touch the cover of a swing top trash barrel with her bare hand. The hand was then contaminated. Dietary aide #2 then prepared to pass out the next meal without handwashing. The dietary aide's thumb had touched the resident's plate of food. On 10/09/18, the utensils the dietary aide used for serving touched the soiled trash barrel cover and then the resident food. On 10/11/2018, the Surveyor spoke with the Director of Nursing who stated that having a barrel like that around could cause infection control issues.

Based on record review and interviews, the facility failed to accurately code assessments for 5 residents, (#2, #3, #11, #1, #4), out of a total of 13 sampled residents. Findings include: 1. For Resident #2, the facility failed to accurately code his/her level of risk for the development of a pressure ulcer. Resident #2 was admitted to the facility in 4/2016 with [DIAGNOSES REDACTED]. Review of Resident #2's most recent comprehensive Minimum Data Set, (MDS), dated [DATE], and quarterly assessment dated [DATE], indicated that he/she was not at risk for developing a pressure ulcer. Review of a facility document titled Norton Plus Pressure Ulcer Scale dated 4/13/17, indicated Resident #2 had a Norton Plus Pressure Ulcer Scale score of 11, (11-15 = moderate risk). Review of a facility document titled Norton Plus Pressure Ulcer Scale dated 7/07/17, indicated Resident #2 had a Norton Plus Pressure Ulcer Scale score of 12, (11-15 = moderate risk). 2. For Resident # 3, the facility failed to accurately code his/her ability to complete a cognitive assessment Resident #3 was admitted to the facility in 8/2015 with [DIAGNOSES REDACTED]. Review of Resident #3's quarterly MDS dated [DATE], sections B0700 and B0800 indicated that he/she sometimes understands and is sometimes understood. Further review indicated MDS section C0100 and D0100 incorrectly coded as 0 (no, is rarely/never understood/understands). Review of section J1800 indicated an incorrect coding for any falls since prior assessment (OBRA or scheduled PPS), whichever is more recent. Section J1800 was coded, no. Review of the clinical record indicated that the Resident had a fall on 6/10/17 after the prior assessment dated [DATE]. 3. For Resident #11, the facility failed to accurately code his/her level of risk for the development of a pressure ulcer. Resident #11 was admitted to the facility in 8/2014 with [DIAGNOSES REDACTED]. Review of Resident #11's quarterly MDS dated [DATE], and quarterly assessment dated [DATE], indicated that he/she was not at risk for developing a pressure ulcer. Review of a facility document titled Norton Plus Pressure Ulcer Scale dated 2/27/17, indicated Resident #11 had a Norton Plus Pressure Ulcer Scale score of 15, (11-15 = moderate risk). Review of a facility document titled Norton Plus Pressure Ulcer Scale dated 5/20/17, indicated Resident #11 had a Norton Plus Pressure Ulcer Scale score of 12, (11-15 = moderate risk). During review of the findings with the MDS Nurse on 7/27/17 at approximately 11:52 A.M., she said that she agreed the MDS' were coded incorrectly and would ensure correct coding in the future. 4. For Resident #1, the facility failed to appropriately code his/her communication abilities and participation in the MDS process. Resident #1 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. Review of his/her most recent MDS dated [DATE] indicated that he/she requires assistance for bathing and dressing. Further review of Resident #1's MDS dated [DATE] indicated the following: -Hearing, Speech and Vision section, (Section B), indicated that Resident #1 is usually understood and usually understands others. -Cognitive Patterns, (Section C), indicated that Resident #1 is never/rarely understood and staff completed the mental status assessment instead of attempting to interview Resident #1. -Mood, (Section D), indicated that Resident #1 is never/rarely understood and staff completed the Resident Mood assessment. -Preferences for Customary Routines and Activities, (Section F), indicated that Resident #1 was able to be interviewed and was able to rate 16 questions regarding the importance of preferences in his/her daily life. -Pain Management, (Section J), indicated that Resident #1 was able to participate in the pain assessment and indicated that he/she had no recent pain. -Participation in Assessment, (Section Q), indicated that Resident #1 did not participate in the assessment. During interview with the Director of Nursing, (DON), on 7/27/17 at 8:35 A.M., the concerns regarding coding issues for Resident #1's MDS were discussed. 5. For Resident #4, the facility failed to appropriately code his/her communication abilities and participation in the MDS process. Resident #4 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. Review of his/her most recent MDS dated [DATE] indicated that he/she requires assistance with bathing, dressing and eating. Further review of Resident #4's MDS dated [DATE] indicated the following: -Section B indicated that Resident #4 understands and is understood by others. -Section C indicated that Resident #4 is never/rarely understood and staff completed the mental status assessment instead of attempting to interview Resident #4. -Section F indicated that Resident #4 was able to be interviewed and was able to rate 16 questions regarding the importance of preferences in his/her daily life. -Participation in Assessment, (Section Q), indicated that Resident #4 did not participate in the assessment. During interview with the Director of Nursing, (DON), on 7/27/17 at 8:35 A.M., the concerns regarding coding issues for Resident #4's MDS were discussed.

The facility failed to provide meaningful engaging activities for 1 resident, (#9), out of a total of 13 sampled residents. Findings include: Resident #9 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. Review of his/her most recent Minimum Data Set, (MDS), dated [DATE] indicated that he/she has severe cognitive impairment and is totally dependent for all activities of daily living. Review of Resident #9's most recent activity assessment dated [DATE] indicated that Resident #9 enjoys having staff and family read to him/her, enjoys being outside, likes to be around people in large and small groups. Review of Resident #9's most recent social services assessment dated [DATE] indicated that Resident #9 is unable to make his/her own needs known, unable to speak, and staff anticipates, identifies and accommodates his/her needs. Review of Resident #9's Activity Careplan, initiated 2015, indicated the following: Problem: Resident needs to be escorted to all programs, Resident is non-verbal. Goal: Resident will continue to observe programs weekly with active/passive participation over the next review period. Approaches: Provide monthly activity calendar and encourage to attend musical theme activities, ball toss, music entertainment, movie matinees. Keep family/friends updated and involved. When Resident is in his/her room, put the television on channel 547 at family request as Resident enjoys the big band music. Resident benefits from time spent outside in the fresh air being with friends and loved ones. On 7/26/17, the Surveyor made direct observations of Resident #9 beginning at 10:07 A.M. Resident #9 was seated in his/her wheelchair facing an aquarium in the Spa Room adjacent to the nurses station. No other residents or staff were in the room. A CD of easy listening/relaxation music was playing, and the surveyor heard the music and observed that the song was set on repeat. At 10:22 a large group of residents were observed seated in the courtyard outside, (an activity included in Resident #9's care plan). Resident #9 continued to sit alone and no staff approached to engage or offer to bring him/her outside. At 10:42 A.M., two staff entered the Spa Room and spoke with Resident #9 as sensory activities were about to begin in the Spa Room. Resident #9 had been seated alone in the Spa Room for 35 minutes without staff engagement and listening to the same song on repeat. Simultaneously, other residents on the unit were seated outside, which is an activity that he/she has been identified as benefiting from and enjoys. On 7/27/17, the Surveyor made direct observations of Resident #9 beginning at 9:48 A.M. Resident #9 was seated in his/her wheelchair facing an aquarium in the Spa Room next to another resident. No staff were present, no music was playing, and no activity or engagement was taking place. At 9:56 A.M., the Therapeutic Activity Director, (TAD), entered and removed the other resident, leaving Resident #9 alone. At 10:18 A.M., the Social Club Director entered the Spa room, spoke briefly with Resident #9, put on music, then promptly left the room. The Surveyor observed the CD player and listened to the music and noted that the song was playing on repeat. At 10:31 A.M., the TAD began to offer to bring residents outside, but most declined. The TAD did not offer this to Resident #9 and he/she continued to sit alone in the Spa Room. At 10:44 A.M., a nurse brought another resident into the Spa Room, administered medications to that resident and then left the room. The nurse did not interact with Resident #9, and he/she continued to sit alone in the spa room while the CD played the same song on repeat. At 10:49 A.M., a CNA brought in another resident next to Resident #9 and left the room without engaging with Resident #9. At 10:52 A.M. Unit Manager #1 announced that the sensory activities were going to begin in the Spa Room. Resident #9 was observed for 64 minutes in the Spa Room and for 34 of those minutes, he/she was sitting alone with the same song playing on repeat. With the exception of one encounter with the Social Club Director, (which was less than one minute), Resident #9 received no engagement and did not participate in any meaningful activity while other residents on the unit were in the activity area participating in scheduled activities. During interview with Unit Manager #1 on 7/27/17 at 10:52 A.M., she said that the facility aides take turns running the sensory activities scheduled for 10:30 A.M., 2:30 P.M., and 4:00 P.M. She said that those activities take place in the Spa Room and last approximately 30 minutes. During a follow up interview on 7/28/17 at 9:57 A.M., Unit Manager #1 said that Resident #9 usually spends his/her time in the Spa Room. On 7/28/17, the Surveyor observed Resident #9 resting in bed at 8:41 A.M. The television was on and set on channel 548, the Easy Listening channel. Resident #9's Activity Careplan and a note taped to the TV indicated that the resident preferred Singers and Swing channel 547. During interview with CNA #1, on 7/27/17 at 12:08 P.M., she said that Resident #9 enjoys jazz music and likes singing. CNA #1 said that the resident often hums along to songs. This information was not included in Resident #9's careplan and the CNA did not report that the resident enjoys being read to or enjoys going outside as outlined in his/her careplan. During interview with CNA #2 on 7/27/17 at 12:10 P.M., she said that Resident #9 enjoys when his/her children come to visit and sing to him/her and that Resident #9 enjoys group singing activities. This information was not included in Resident #9's careplan and the CNA did not report that the resident enjoys being read to or enjoys going outside as outlined in his/her careplan. During interview with Activity Assistant #1 on 7/28/17 at 8:44 A.M., she said she was not sure what activities Resident #9 enjoys. She said that since Resident #9 does not speak, it's hard to know what he/she likes. During a follow up interview with Unit Manager #1 on 7/28/17 at 9:57 A.M., she said that Resident #9 enjoys going outside and listening to music. She did not include that Resident #9 enjoys singing as reported by CNA #1 and CNA #2. During interview with Family Member #1 on 7/28/17 at 11:23 A.M., he/she reported that Resident #9 seems to enjoy when visitors sing to him/her and that they have heard Resident #9 hum along to songs, (as reported by CNA #1 and CNA #2, which was not reflected in Resident #9's activity careplan). Family Member #1 also said that Resident #9 enjoys going outside, having his/her poetry read to her, and that the family put a note on Resident #9's TV regarding his/her preferred music channel. During interview with the Director of Nursing, Interim Administrator, the Social Club Director and the TAD on 7/28/17 at 10:01 A.M., the above observations and concerns were reviewed.

Based on record review and interview, the facility failed to complete a significant change assessment for 1 resident, (#11), out of a total of 13 sampled residents. Findings include: 1. For Resident #11, the facility failed to complete a significant change assessment after the resident had an overall change in functional status. Resident #11 was admitted to the facility in 8/2014 with [DIAGNOSES REDACTED]. Review of Resident #11's annual Minimum Data Set, (MDS), dated [DATE], indicated that he/she required the following: Extensive assist for transfer Limited assist for bathing Review of Resident #11's quarterly MDS dated [DATE], indicated that he/she now required the following: Limited assist for transfer Extensive assist for bathing During interview with the MDS Nurse on 7/27/17, at 11:52 A.M., she said that she did not know why a significant change MDS was not done and she would notify the MDS coordinator.

Based on observation, record review and staff interview, the facility failed to ensure that it was free of a medication error rate of 5 percent or greater. Two of three licensed nurses (Nurse #1 and Nurse #2) made errors while administering medications on 2 of 2 units observed. There were a total of 2 errors which affected 1 sampled resident (#3) out of a total sample of 13 and 1 of 1 Non-Sampled resident (NS #1 ), with 28 opportunities. The facility had an error rate of 7.14%. Findings include: 1. For Non-Sampled Resident #1 (NS#1) the facility administered an incorrect dose of intravenous antibiotic. Review of the physician's orders [REDACTED].#1 had an order for [REDACTED].) access at 9:00 A.M During observation of a medication pass on 7/26/17 at 8:45 A.M., with Nurse #1, she prepared NS #1's 9:00 A.M. [MEDICATION NAME] as 1 gram in 50 milliliters of solution. Once she had primed the tubing to prepare for the administration, she placed it down on the medication cart. As Nurse #1 gathered additional supplies to administer the I.V. [MEDICATION NAME], the medication began leaking out of the tubing creating a puddle on the front, bottom, and drawers of the medication cart. The tubing continued to leak onto the floor as Nurse #1 brought the mediation and supplies to the room of NS#1. By the time the [MEDICATION NAME] was administered via IV pump approximately 25 ml or 50% of the solution containing the medication had leaked out of the tubing. During an interview with Nurse #1 on 7/26/17 at 9:15 A.M., the observation of the leaking tubing was shared. Nurse #1 acknowledged the puddle of solution on the front, bottom and drawers of the medication cart. She said she did not notice that the medication had leaked out of the tubing at the time. She said because of the leaking, NS#1 did not receive the ordered dose of antibiotic and she needed to let the physician know. 2. For Resident #3, the facility failed to ensure that staff administered the correct medication that was ordered by the physician. Review of the physician's orders [REDACTED].#3 had an order for [REDACTED]. During observation of a medication pass on 7/26/17 at 10:07 A.M., with Nurse #2, she poured this resident's 10:00 A.M. medications, which included 1 tablet of [MEDICATION NAME] 50 mg/Senna 8.6 mg (not [MEDICATION NAME] 100 mg per the physician's orders [REDACTED]. She then mixed the medication in applesauce and administered it to the resident. During interview on 7/26/17 at 11:08 A.M., Nurse #2 said that the previous bottles had [MEDICATION NAME] 100 mg in them. The new medication bottles look alike, but have [MEDICATION NAME] 50 mg/ Senna 8.6 mg and she gave the wrong one.

Based on record review and interview the facility staff failed to maintain a clinical record that was complete and accurate for 2 out of 2 closed records, Residents (#14, #15), in a total sample of 15 residents. Findings include: Resident #14 was admitted to the Facility in ,[DATE], with [DIAGNOSES REDACTED]. On [DATE], Resident #14 was transferred to Hospice House where he/she expired on [DATE]. Review of the clinical record indicated that no doctors order for discharge to the Hospice House was completed and no discharge summary was completed by the physician. Resident #15 was admitted to the Facility in ,[DATE], with [DIAGNOSES REDACTED]. On [DATE], Resident #15 was discharge to the hospital with [MEDICAL CONDITION]. Review of the clinical record indicated that no doctors order for discharge to the hospital was completed and no discharge summary was completed by the physician. During an interview with the Administrator on [DATE], at 12:00 P.M. she said that she was surprised that the documents were not in the record and that all discharges required a physician's orders [REDACTED].

Based on observation, record review and staff interview, the facility failed to provide services in accordance with the plan of care for 1 Residents (#4) in a total sample of 15 residents. Findings include: 1. For Resident #4, who had a history of [REDACTED]. As a result, the resident sustained [REDACTED]. Resident #4 was admitted to the facility in 11/2014 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] identified the resident as having a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident's cognition was severely impaired. It also identified him/her as requiring extensive assistance in transfers and limited assistance in ambulation. Document review indicated the resident experienced two falls since admission to the facility in 11/2014. Review of the plan of care for falls upon admission indicated interventions including the following: *Observe for unsteady/unsafe transfer or ambulation and provide stand by or balance support as needed. *Use limited assist and gait belt for all transfers. *Use limited assist and gait belt for all ambulation. These interventions remained unchanged through 8/23/15. A nursing note dated 8/23/15 at 1:24 a.m. indicated that at 6:30 P.M. (the previous evening), the resident fell while walking back to his/her chair after using the bathroom. The resident reportedly lost his/her balance and slid down the side of the wall and the aide helped to lower him/her to the floor. Document review entitled Safety Rules General included the following information: A gait belt is to be used for all transfers which require any kind of hands on assistance or steadying of the resident. Review of the Incident report describing the above incident included the following information: On 8/22/15 at approximately 6:35 P.M., the resident was walking towards (his/her) chair in (his/her) room and the Certified Nurse Aide (C.N.A.) was standing behind (him/her) following (him/her) when the resident turned to sit, (his/her) leg quickly got weak, (he/she) lost (his/her) balance, missed the chair and the resident fell . The C.N.A. was unable to respond quick enough to prevent the resident from falling. The C.N.A., who is new to the facility, did not have a gait belt around the resident. The resident fell , landing on (his/her) buttocks and back. The resident suffered an acute distal left clavicle deformity. On 10/06/15, at 12: 20 P.M., the resident was observed initially asleep in bed. The resident's overbed tray table contained the resident's lunch tray, which was partially eaten. The resident awoke shortly thereafter and Surveyor #1 asked the resident if he/she was going to finish his/her meal. The resident said he/she had all he/she wanted and went back to sleep. On 10/07/15 at 8:45 A.M. and 9:15 A.M., the resident was observed asleep in bed. On 10/07/15 at 10:45 A.M., the resident was observed seated in a wheelchair attending a musical activity. On 10/07/15 at 11:30 A.M., an interview was held with the Administrator. The Administrator said that the C.N.A. did not follow the facility's protocol as she did not use a gait belt when walking with the resident and that this was an unfortunate incident. The facility failed to implement the use of a gait belt that was identified as an intervention on the resident's Fall care plan. As a result, the resident sustained [REDACTED]. Please refer to F323.

Based on observation, record review and staff interview, the facility failed to provide effective interventions to prevent falls for 1 resident (#4) in a total sample of 15 residents. Findings include: 1. For resident #4, who had a history of [REDACTED]. Resident #4 was admitted to the facility in 11/2014 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] identified the resident as having a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident's cognition was severely impaired. It also identified him/her as requiring extensive assistance in transfers and limited assistance in ambulation. Document review indicated the resident experienced two falls since admission to the facility in 11/2014. Review of the plan of care for falls upon admission indicated interventions including the following: *Observe for unsteady/unsafe transfer or ambulation and provide stand by or balance support as needed. *Use limited assist and gait belt for all transfers. *Use limited assist and gait belt for all ambulation. These interventions remained unchanged through 8/23/15. A nursing note dated 8/23/15 at 1:24 A.M. indicated that at 6:30 P.M. (the previous evening), the resident fell while walking back to his/her chair after using the bathroom. The resident reportedly lost his/her balance and slid down the side of the wall and the aide helped to lower him/her to the floor. Document review entitled Safety Rules General included the following information: A gait belt is to be used for all transfers which require any kind of hands on assistance or steadying of the resident. Review of the Incident report describing the above incident included the following information: On 8/22/15 at approximately 6:35 P.M., the resident was walking towards (his/her) chair in (his/her) room and the Certified Nurse Aide (C.N.A.) was standing behind (him/her) following (him/her) when the resident turned to sit, (his/her) leg quickly got weak, (he/she) lost (his/her) balance, missed the chair and the resident fell . The C.N.A. was unable to respond quick enough to prevent the resident from falling. The C.N.A., who is new to the facility, did not have a gait belt around the resident. The resident fell , landing on (his/her) buttocks and back. The resident suffered an acute distal left clavicle deformity. On 10/06/15, at 12: 20 P.M., the resident was observed initially asleep in bed. The resident's overbed tray table contained the resident's lunch tray, which was partially eaten. On 10/07/15 at 8:45 A.M. and 9:15 A.M., the resident was observed asleep in bed. On 10/07/15 at 10:45 A.M., the resident was observed seated in a wheelchair attending a musical activity. On 10/07/15 at 11:30 A.M., an interview was held with the Administrator. The Administrator said that the C.N.A. did not follow the facility's protocol as she did not use a gait belt when walking with the resident and that this was an unfortunate incident. The facility failed to properly ambulate this resident with a gait belt that resulted in this resident falling and sustaining a major injury: an acute distal left clavicle deformity.

Based on record review, staff interview and observation,the facility failed to provide services which met professional standard for medication administration for 1 resident (Resident #8) from a total sample of 15 Residents. Findings include; Standard reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Review of Resident #8's clinical record on 10/8/15 indicated that the resident was admitted to the facility in 10/2015 with [DIAGNOSES REDACTED]. Review of Resident #8 physician's orders [REDACTED].#8 had an order for [REDACTED].M., and 8:00 P.M., through 10/7/2015. On 10/8/15 at 8:28 A.M., Surveyor #1 observed Resident #8 sitting in a chair in his/her room. Resident #8's IV pole and pump were behind him. Hanging from the resident's IV pole was a partially empty bag of medication with tubing which was not connected to the resident. Observation of the medication bag indicated a pharmacy label which read [MEDICATION NAME] 2 grams mixed in 100 ml of 5% [MEDICATION NAME]. It was dated by the pharmacy as 10/7/15 and timed for 8:00 P.M., dose. Charge Nurse #1 and Surveyor #1 measured the amount of fluid containing the [MEDICATION NAME] left in the medication bag for a total of 25 ml. The infusion line (from the medication bag to the resident) was observed and the line was full with medication. During an interview with Charge Nurse #1 on 10/8/15 at 8:30 A.M., she said she was unaware of why the 10/7/15 8:00 P.M. dose of IV [MEDICATION NAME] was left on the resident's IV pole and had not been completely infused. Charge Nurse #1 said that during shift report at 7:00 A.M., there was no difficulties reported to her concerning the resident's infusion. She said she planned to notify the Director of Nurses (DON) and the physician that the resident did not receive his/her full dose of the antibiotic. Charge Nurse #1 said she was aware the medication was mixed in 100 ml of 5% [MEDICATION NAME] and not 50 ml. She said, she had spoke with the pharmacist when the order was obtained and learned a dose of 2 grams of [MEDICATION NAME] has to be mixed in 100 ml of [MEDICATION NAME] and not 50 ml. However, Resident #8 did receive the correct dose of [MEDICATION NAME] although mixed differently from the physician order.

Based on record review and staff interview, the facility failed to ensure that the MOLST and the Department of Public Health Office of Emergency Medical Services Comfort Care/Do Not Resuscitated Order Verification Forms were accurate and complete in order to be valid. This involved 11 of 13 resident records reviewed ( #1, 2, 3, 4, 5, 6, 8, 10, 11, 12 and 13) in a total sample of 13. Findings include: 1. For Resident #3, the facility failed to ensure that the Department of Public Health Office of Emergency Medical Services Comfort Care/Do Not Resuscitate Order Verification Form was accurate and complete. Review of the medical record on 7/29/14 at 9:30 A.M., indicated that the Massachusetts Department of Public Health Office of Emergency Medical Services, Comfort Care/Do Not Resuscitate Order Verification Form was signed by the Health Care Agent and the Physician. However, both signatures were illegible and there was no printed name, address or telephone number of the Physician. Although there was a date, it could not be determined if the date was the effective date or expiration date of the order. Further, the section that indicated if the DNR order had an expiration date was blank. At 10:11 A.M. on 7/30/14, Unit Manager #2 said that she was not aware that these omissions made the Comfort Care/Do Not Resuscitate Form invalid. 2. For Residents #1, 2, 11 and 12, the facility failed to ensure that the Massachusetts Medical Orders for Life- sustaining Treatment (MOLST) were complete and accurate and therefore, invalid. A) Review of the MOLST for Resident #1 on 7/29/14, indicated that Section D, a required section, was missing a Legible Printed Name of the Signer and the Telephone Number of the Signer. Likewise, required Section G was missing a Legible Printed Name of the Signer and the Telephone Number of the Signer. Required Sections E and H were missing the Time of the Signature. These omission made the MOLST incomplete and therefore, invalid. B) Review of the MOLST for Resident #2 on 7/29/14, indicated that required Sections D, E, G and H were missing a Legible Printed Name of the Signers, the Time of the Signatures and the Telephone Numbers of the Signers. These omissions made the MOLST incomplete and therefore, invalid. C) Review of the MOLST for Resident #11 on 7/30/14, indicated that for required Sections E and H the Legible Printed Name of the Signers, Telephone Number of the Signers and Time of the Signatures were missing. These omissions made the MOLST incomplete and therefore, invalid. D) Review of the MOLST for Resident #12 on 7/30/14, indicated that for required Sections E and H the Legible Printed Name of the Signers, Telephone Number of the Signers and Time of the Signatures were missing. These omissions made the MOLST incomplete and therefore, invalid. At 10:11 A.M. on 7/30/14, Unit Manager #2 said that she was not aware that these omissions made the MOLST Forms invalid. 3. For Resident #5 the facility failed to ensure that the Department of Public Health Office of Emergency Medical Services Comfort Care/DNR Order Verification form was complete. Resident #5 was admitted to the nursing facility in 4/2013, with [DIAGNOSES REDACTED]. Review of the clinical record revealed that a Comfort Care/Do Not Resuscitate form had been signed by the Resident. The physician had not completed the section indicating a printed name, address and phone number for the physician. 4. For Resident #4, the facility failed to ensure that the MOLST form was complete. Resident #4 was admitted to the nursing facility in 10/2012, with [DIAGNOSES REDACTED]. Review of the clinical record revealed that a MOLST form had been filled out. However, the form did not have the printed name of the physician under section E. 5. For Resident #6, the facility failed to ensure that the MOLST form was complete. Resident #6 was admitted to the nursing facility in 1/2011, with [DIAGNOSES REDACTED]. Review of the clinical record revealed that a MOLST form had been filled out. However, the form did not have the printed name of the physician under section E. 6. For Resident #8, the facility failed to ensure that the MOLST form was complete. Resident #8 was admitted to the nursing facility in 4/2011, with [DIAGNOSES REDACTED]. Review of the clinical record revealed that a MOLST form had been filled out. However, the form did not have the printed name of the physician under section E. 7. Resident #10, the facility failed to ensure that the MOLST form was complete. Resident #10 was admitted to the nursing facility in 5/2014, with [DIAGNOSES REDACTED]. Review of the clinical record revealed that a MOLST form had been filled out. However, the form did not have the printed name of the physician nor the health care agent. The physician's phone number was not on the form under section E. 8. Resident #13, the facility failed to ensure that the MOLST form was complete. Resident #13 was admitted to the nursing facility in 6/2014, with [DIAGNOSES REDACTED]. Review of the clinical record revealed that a MOLST form had been filled out. However, the form did not have the printed name of the physician nor the phone number under section E. Interview with the Social Worker on 7/30/14 revealed that she was unaware that the forms were not complete, thereby making them invalid.

Based on documentation review and staff interview during the Abuse Protocol Review, the facility failed to to conduct a timely and complete screening for 4 of 5 newly hired employees (A, B, C and D) prior to the date of hire. Findings include: For three newly hired Staff (A, B and C), the facility failed to conduct a timely Out of State Registry Verification prior to hire as required. In addition, for Staff (D) the facility failed to conduct a License Verification prior to the date of hire as required. According to the facility's Abuse Prohibition Policy, last reviewed and/or revised on 5/20/14, the facility requires "licensure and certification verification from all States that the potential employee has worked or lived in the past 7 years." Staff (A) was hired on 6/3/14. Review of the facility's pre-screening documentation on 7/29/14 which was conducted for Staff (A), indicated that the Out of State Verification was not conducted until 7/23/14. This was one month and a half after the date of hire. Certified Nurse Aide (CNA) (B) was hired on 5/9/14. Review of the facility's pre-screening documentation on 7/29/14 which was conducted for CNA (B), indicated that the Out of State Verification was not conducted until 7/28/14. This was approximately two and a half months after the date of hire. CNA (C) was hired on 3/19/14. Review of the facility's pre-screening documentation on 7/29/14 which was conducted for CNA (C), indicated that the Out of State Verification was not conducted until 7/23/14. This was four months after the date of hire. Nurse (D) was hired on 4/11/14. Review of the facility's pre-screening documentation on 7/29/14 which was conducted for Nurse (D), indicated that the License Verification was not conducted until 4/24/14. This was not prior to the date of hire as required. Interview with the Human Services Coordinator on 7/30/14 at 10:00 A.M., indicated that although the above mentioned Staff Verifications were conducted timely, they were not printed out until later. She was not able to provide evidence that the screenings were conducted per regulation and facility policy. She further indicated that the system would be revised to be compliant and timely.