Every finding on record at MRC the Crossings

Based on observations, interview, and record review, the facility failed to store and label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 5 residents (Resident #14) reviewed for medication storage and labeling. RN A failed to remove Resident #14's expired insulin from the nursing cart. This failure could place residents at risk of receiving expired and ineffective medications.Findings include: Record review of Resident #14's admission Record dated 3/12/26 revealed an [AGE] year old female who admitted to the facility on 0114/2026 with diagnoses including acute diastolic congestive heart failure (occurs when the left chamber of the heart becomes stiff and cannot relax to fill with blood properly leading to sudden and severe congestion and symptoms like breathlessness), type II diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar levels in the blood as a result of the body's inability to use insulin properly), acute kidney failure (the sudden loss of kidney function, causing waste to build up in the blood), and dependence on renal dialysis (artificial life-sustaining treatment and is required to replace failed kidney function by removing toxins and excess fluid). Record review of Resident's #14's Annual MDS dated [DATE] revealed she had a BIMS score of 15 out of 15 which indicated her cognitive function was intact. Record review of Resident #14's Order Summary Report dated 03/12/2026 revealed a discontinued order for Lantus SoloStar subcutaneous Solution Pen Injector 100 Unit per ml insulin glargine inject 24 unit subcutaneously in the morning for DM II with an end date of 2/27/26. Record review of facility staffing sheet dated March 11, 2026, revealed RN A worked the 06:30 am to 06:30 pm shift. Observation and interview on 03/11/2026 10:15 am of nurse cart for 1500 with RN A and in the top drawer of the cart observed Insulin pen Basaglar (insulin glargine) injection pen dated 2/5/26 in black ink for Resident #14 also written on the side of insulin pen in black ink. The insulin dial was at zero indicating the injector pen was empty and contained no remaining doses. RN A said that Resident #14 was no longer on the medication, and she did not know why she had not removed the insulin pen from the cart. She said the date was 02/09/2026 and had just expired. When surveyor showed her the pen again, she said the date was 02/05/2026. When asked how long the insulin should be kept on the cart, RN A repeated that Resident #14 was no longer taking the medication and she removed the insulin pen. When asked why she was removing it, RN A said because it had expired and Resident #14 did not take the medication anymore because it had been discontinued. RN A said she was responsible for ensuring the medication cart was appropriately cleaned and stocked and for removing any outdated or expired medications. In a follow up interview with RN A on 03/12/2026 at 09:37 am who said that a possible adverse reaction of Resident #14 receiving expired insulin could be ineffective glucose control and worsening diabetes signs/symptoms. RN A repeated that Resident #14 never received the expired medication as the injector pen was empty. In an interview with the DON on 03/12/2026 at 3:17 pm who said Resident #14's expired Basaglar (insulin glargine) injection pen should not have been on the cart. The DON said that insulin was only good for 28 days and if the insulin pen was dated 02/05/2026 on 03/11/2026 then the pen was expired. The DON said a possible adverse reaction of Resident #14 receiving expired insulin could be ineffective glucose control and worsening diabetes signs/symptoms. The DON said RN A was responsible for ensuring the nurse cart was stocked and all expired or outdated medications were removed. The DON said the pharmacist also conducted monthly cart checks for expired and outdated medications and that Resident #14 had not received the expired insulin because RN A explained the pen was zero with no doses and she completed her own record review of the order for the insulin medication and confirmed it had been discontinued on 02/27/2026. Telephone interview with Pharmacist on 03/13/2026 at 3:36 pm who said that she had not completed the 30-day pharmacy review for the facility yet for the month of March and that any expired and discontinued medication/s should be discarded and removed from the cart. The Pharmacist said most insulins expire 28 days from open date. Record Review of policy Medication Monitoring and Management dated 2006 revealed in part: In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist, perform on-going monitoring for appropriate, effective and safe medication use.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. The facility failed to ensure foods were covered and sealed appropriately.These failures could place residents at risk of food borne illness and disease.Findings included: Observation and interview on 3/10/26 at 8:56 am with the Dining Service Director of one large plastic bin with clear closable lids was open and had sugar in it.An observation at 8:59 am of one 3- gallon tub of chocolate chip ice cream in the walk-in freezer, the lid was not on the ice cream. Interview with DM he said that a staff member left the sugar bin open and forgot to close it. He did not know who because they all used the sugar. He said that the ice cream should have been closed. The sugar and ice cream being opened could cause cross contamination. The ice cream could have frost bite and could ruin the quality of food for residents. An observation and interview at 10:20 am on 3/11/26 with the Dining Service Director of a total of 3, 3-gallon tubs, a 3-gallon tub of strawberry sorbet and 3- gallon tubs of strawberry ice cream and cherry vanilla ice cream with lids partially open and one dark colored hair on the partially opened 3-gallon tub of strawberry sorbet, located in the stand-alone freezer in kitchen across from prep station. Interview with the Dining Service Director, he said that lids being opened could cause cross contamination, affect the value of the food, and could make someone sick. An interview on 3/11/26 at 12:06 pm with the Administrator regarding additional opened sorbet and ice cream, she said she was aware and that the ordered plastic lids to all ice cream containers. An interview on 3/11/26 at 2:20 pm and with the Administrator she said that food items left open could cause rodents, bugs and cross contamination, the ice cream could be off tasting for residents. An interview with the DON on 3/11/24 at 2:24 pm, she agreed with the Administrator that food items left open could cause rodents, bugs and cross contamination, the ice cream could be off tasting for residents.Interview on 3/13/26 at 1:40 pm with the Director of Dining , he said that they provided in-services to the dining team which were responsible for food storage. He said that they also disposed of ice cream and closed the lid to the sugar container and that the negative outcome could be airborne contamination could make residents sick. Record review of the In-service sheet dated 3/10/26 for the dining team, read in part.all items need to be closed.keep bins closed. Record review of the facility policy and procedure entitled, Food and Supply Storage, dated revised 1/24 read in part.All food shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption.Cover unused portions.Frozen storage: Store bulk materials in NSF approved containers that have tight fitting lids.

Based on observation, interview, and record review, the facility failed to ensure rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 6 residents (Resident #5) reviewed for call systems.The facility failed to install a functioning call light system for Resident #5's room located on the 1500 hall.This failure could place residents at risk for a delay in care and services, increased falls, excessive wait times, pain, and a decreased quality of life.Finding included:Record review of the face sheet for Resident #5 dated 03/13/2026 revealed an [AGE] year-old female admitted to the facility on [DATE] in room [ROOM NUMBER] with diagnoses of unspecified dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (memory loss/cognitive decline where the specific type is not identified, the severity is not defined, and no significant psychological or behavioral symptoms are present).Record review of Resident #5's undated care plan revealed the following:Focus: The Elder is risk for falls r/t (related to) unsteady gait.Goal: The Elder will be free of serious injury from falls through the review date.Intervention: Be sure the Elder's call light is within reach and encourage the Elder to use it for assistance as needed. The elder needs a safe environment such as even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls, personal items within reach. Record Review of Resident # 5's Quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS ( Brief Interview for Mental Status ) score 14 out of 15; indicating Resident # 5's cognition was intact. In an interview and observation on 03/10/2026 at 10:28 am with Resident #5 in room [ROOM NUMBER], she said that her call light had not worked for months, caused staff to respond to care slowly, and she had to wait between 15 to 20 minutes for care. She said that she had reported to staff that the call light did not work, but she could not remember the date, time, or which staff she reported the repair to. Observation at this time of Resident #5 to have pressed the call light, the indicator light did not flash on the wall at the bedside, and the indicator light did not come on in the hallway outside of the room. In an interview and observation on 03/10/2026 at 10:30am with MA D, who said that Resident #5's call light was functioning on 03/09/2026, and Resident #5 had not reported to her that the call light was not functioning. MA D said that residents had a right to a functioning call light at all times. She said that residents without a functioning call light were not able to alert staff of care needs, incidents, accidents, or changes in conditions. Observation at this time of MA D to enter the room of Resident #5 to test the call light for functioning. Observation of MA D to press the call light, the indicator light did not flash on the wall at the bedside, the indicator light did not come on in the hallway outside of the room, and the indicator light did not come on at the nurses' station. Observation of MA D to report that the call light in the room of Resident #5 did not function to LVN E. In an interview and observation on 03/10/2026 at 10:38am with LVN E, who said that Resident #5's call light was functioning on 03/09/2026, and Resident #5 had not reported to her that the call light was not functioning. She said that repair requests are reported to the Maintenance Director and requests are maintained in an electronic system. LVN E said that residents had a right to a functioning call light at all times. She said that residents without a functioning call light were not able to alert staff of care needs, incidents, accidents, or changes in conditions. Observation at this time of LVN E to report that the call light in the room of Resident #5 did not function to the Maintenance Director. In an interview and observation on 03/10/2026 at 10:49am with MA D, who said that Resident #5's call light was repaired and functioning. Observation of MA D to test the call light of Resident #5, and the indicator light did flash on the wall at the bedside, in the hallway outside of the room, and at the nurse's station. In an interview on 03/10/2026 at 11:29am with both the DON and ADON, they were informed that Resident #5 was observed without a functioning call light. In an interview on 03/10/2026 at 11:35 am with the Administrator, she was informed that Resident #5 was observed without a functioning call light. In an interview on 03/13/2026 at 10:13am with the DON, who said that clinical staff should check for call light placement and functioning when entering a resident's room, but they are not required to document that the task is completed. She said that repair requests are reported to the Maintenance Director immediately and requests are maintained in an electronic system. She said that the Maintenance Director should ensure that call systems are functioning in each resident's room, she was unsure of how often the Maintenance Director checked the call lights for functioning, or how the Maintenance Director documented that the task was completed. She said that residents had a right to a functioning call light at all times. She said that residents without a functioning call light were not able to alert staff of care needs, incidents, accidents, or changes in conditions. In an interview on 03/13/2026 at 12:14pm with the Maintenance Director, who said that he should ensure that each resident has a functioning call light at all times. He said that monthly checks are completed to ensure that each resident has a functioning call light. He said that there was no documentation that the monthly checks were being completed. He said that repair requests are reported to the Maintenance Director immediately and requests are maintained in an electronic system. He said that there were no outstanding repair requests for call lights, and requests to repair call lights are addressed immediately. He said that routine checks of the call light systems are designed to catch when residents call lights are not functioning. He said that if the checks are not documented there was no way to show that they had been completed. He said that residents had a right to a functioning call light at all times. He said that residents without a functioning call light were not able to alert staff of care needs, incidents, accidents, or changes in conditions. He said that he received a repair request for the call light in the room of Resident #5 on 03/10/2026, and the repair was completed the same day. In an interview on 03/13/2026 at 12:37pm with the Administrator, who said that any staff that entered a resident's room should check for call light placement and functioning, but they are not required to document that the task is completed. She said that repair requests are reported to the Maintenance Director immediately and requests are maintained in an electronic system. She said that the Maintenance Director should ensure that call systems are functioning in each resident's room, she was unsure of how often the Maintenance Director checked the call lights for functioning, or how the Maintenance Director documented that the task was completed. She said that it was her expectation that the Maintenance Director completed the task, documented the task was completed, and she could only assume that the Maintenance Director had completed the task. She said that if the Maintenance Director was completing the task it would catch that residents were having issues with call light functioning. She said that residents had a right to a functioning call light at all times. She said that residents without a functioning call light were not able to alert staff of care needs, incidents, accidents, or changes in conditions. Record review of electronic work orders from 01/01/2026-03/13/2026 with no outstanding repair request for call light malfunction for Resident #5 prior to 03/10/2026. Record review of the policy titled, Call System, Resident, and dated September 2022 read in part, . Policy Heading.Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Policy Interpretation and Implementation. 1.Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.3.The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remain functional.5.The resident call system is routinely maintained and tested by the maintenance department. Record review of the policy titled, Answering the call light, and dated 2001 read in part, The purpose of this procedure is to ensure timely responses to the resident's request and needs. General Guidelines.4. Be sure that the call light is plugged in and functioning at all times. 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on observation, interview and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7% based on 2 out of 26 opportunities, which involved 1 of 5 residents (Resident #44) and 1 of 3 staff (LVN A) observed during medication administration reviewed for medication error. LVN A failed to ensure Resident #44's medications were crushed individually and within professional standards. LVN A failed to ensure Resident #44's Levaquin (antibiotic) and Ferrous Sulfate (Iron) were not crushed and mixed together. LVN A failed to ensure Resident #44's Levaquin (antibiotic) and Ferrous Sulfate (Iron) were not given at the same time. These failures could place residents at risk of receiving ineffective medications and increased risk of severe stomach irritation, continued infections, possible overdose, and medication toxicity. Findings include: Record Review of Resident #44's admission record dated 03/12/2026, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute on chronic congestive heart failure (a life-threatening sudden worsening or pre-existing long-term heart failure that includes rapid fluid accumulation in the lungs and body, usually triggered by infections), anemia (a blood disorder characterized by a lack of healthy red blood cells), and pneumonia (an infection that inflames the air sacs in one or both of the lungs, causing them to fill with fluid or pus). Record review of Resident's #44's Annual MDS dated [DATE] revealed she had a BIMS score of 14 out of 15 which indicated normal thinking and memory with no or very little impairment. Record review of Resident #44's Order Summary Report dated 03/12/2026 revealed and active order with a start date of 02/22/2026 for Ferrous Sulfate Oral Tablet 325 (65 Fe [Iron]) MG (Ferrous Sulfate) Give 1 tablet by mouth one time a day for supplement on hold from 03/11/2026 at 5:02pm until 03/14/2026 at 5:01 pm. Record review of Resident #44's Order Summary Report dated 03/12/2026 revealed an active order with a start date of 03/11/2026 for Levaquin 500 mg Give 1 tablet by mouth one time a day for pneumonia until 03/14/2026. Continued record review revealed the following order: May crush medication or open capsules as needed unless contraindicated. Record review of Resident #44's MAR printed 03/12/2026 revealed Ferrous Sulfate Oral Tablet 325 (65 Fe [Iron]) MG (Ferrous Sulfate) Give 1 tablet by mouth one time a day for supplement and Levaquin tablet 500 mg Give 1 tablet by mouth one time a day for pneumonia until 03/14/2026 and were documented as administered by LVN A on 03/11/2026 at 09:00 am. Record review of facility staffing sheet dated March 11, 2026, revealed LVN A worked the 06:30 am to 06:30 pm shift. Observation and interview on 03/11/2026 at 09:52 am of medication administration pass for Resident #44 with resident consent. LVN A prepared Resident #44's medications by placing each pill in a small clear 30 ml sized cup. LVN A placed all of the pills that included Levaquin 500 mg 1 tablet and Ferrous Sulfate Oral tablet 325 (65 Fe [Iron]) 1 tablet into a translucent plastic pouch and crushed them all together. LVN A then poured the pulverized medications which were all deep brown in color, back into the small clear 30 ml medicine cup and mixed a plastic spoonful of applesauce into the pulverized medications creating a paste-like, dark colored mixture. When asked if she always crushed iron tablets, LVN A said she had before and when asked if she should crush iron tablets, she said she crushed Resident #44's medications because of her swallowing difficulty and when asked if she should crush all the medications together, LVN A said there was an order to crush medications as needed. LVN A said she usually mixed Resident #44's medications in applesauce and that Resident #44 liked applesauce. LVN A proceeded to Resident #44's bedside with the paste-like, dark colored mixture inside the 30 ml medication cup. Resident #44 was seated in her wheelchair at the bedside and was appropriately dressed and groomed in a teal-colored matching top and bottom lounge wear set. LVN A explained to Resident #44 that she was receiving her medications and Resident #44 frowned up her face as LVN A administered the first spoonful of the dark colored past-like mixture. Resident #44 swallowed and then made a wrenching sound like she was going to vomit. When surveyor asked if LVN A had ever taken iron tablets as a supplement, LVN A said she heard iron can taste terrible. When asked if Resident #44 usually wrenched when she was given her iron and other medications crushed with applesauce, LVN A said not all of the time. LVN A provided Resident #44 with sips of water in between approximately 4 spoonfuls of the dark colored paste-like mixture of medications with Resident #44 frowning after each bite and shaking her head back and forth between spoonfuls. Resident #44 said that she did not understand why medication had to taste so bad and then said she wanted to rinse out her mouth in the bathroom and brush her teeth. LVN A assisted Resident #44 to the bathroom where the resident was assisted with rinsing out her mouth and brushing her teeth. In an interview with LVN A on 03/11/2026 at 4:36pm who said she was not sure which medications could be crushed together and which ones could not, LVN A said she would need to check. LVN A said she had a list of medications that could be crushed and list of medications that could not be crushed that were kept on the nursing medication cart and surveyor provided with copies of the lists. LVN A then said she looked it up and Resident #44's iron should not have been crushed with her Levaquin and that Resident #44's iron should not have been taken with her Levaquin because it could decrease the efficacy of the Levaquin antibiotic. LVN A said that after she looked it up the medications should be given at least 2-4 hours apart and she would notify Resident #44's physician. LVN A said that the resident could be at risk for her infection worsening or not improving from receiving the iron and antibiotic together. Record review of Resident #44's EMR on 03/12/2026 at 8:32 am revealed Resident #44's Ferrous Sulfate 325 (65 Fe [Iron]) MG (Ferrous Sulfate) Give 1 tablet by mouth one time a day for supplement was placed on hold at 5:07pm on 03/11/2026. Interview with DON on 03/12/2026 at 3:17pm who said that Resident #44's iron and Levaquin should not have been crushed together and should not have been administered together. The DON said that iron should not be crushed and iron taken with Levaquin could decrease the efficacy of the antibiotic Levaquin. The DON said that there was a list of medications that should not be crushed on each nursing cart for the nursing staff to reference and that each medication should have been crushed separately. The DON said she did not know why LVN A crushed all of Resident #44's medications or why they were all crushed together. The DON said she started staff in-service training and Resident #44's Ferrous Sulfate order had been placed on hold until her Levaquin antibiotic was completed. The DON said that the resident could be at risk of continued infection from her antibiotic being rendered ineffective by the iron. Telephone interview with Pharmacist on 03/13/2026 at 3:36 pm who said that she had not completed the 30-day pharmacy review for Resident #44 yet because the resident had not been at the facility for 30-days yet. The Pharmacist said that Resident #44's Ferrous Sulfate (Iron) should not have been crushed. The Pharmacist said that Resident #44's Levaquin should not have been crushed with the iron and the Pharmacist said they should not have been taken all together. The Pharmacist said iron can decrease the efficacy of antibiotics and other medications and she would have recommended that the iron be stopped or held until the course of antibiotic treatment was completed. The Pharmacist said that Ferrous Sulfate (iron) should not be crushed because they are often developed with special coatings or as extended release, ensuring more steady absorption and reducing side effects like nausea and stomach upset/discomfort. The Pharmacist said she would have recommended to administer the Levaquin at other times away from other medications, for example, she would have recommended to administer the Levaquin at 10 am and 10 pm. Record review of facility provided list of Medications Not to Be Crushed dated as revised 12/19 revealed in part: Iron Salts* (time released) [NAME] Grad 500, [NAME]-Sequels, Slow Fe. Record Review of policy Medication Monitoring and Management dated 2006 revealed in part: The consultant pharmacist reviews written records to determine that: 5). Alteration of dosage forms, such as pill crushing, has not impaired therapeutic response.C. The interdisciplinary team reviews the resident's medication regime for efficacy and actual or potential medication-related problems (on and on-going basis/quarterly. 17. The resident is not taking other medications, nutritional supplements, including herbal products, or foods that would be incompatible with the prescribed medication. Record review of policy Crushing Medications dated revised October 2024 revealed: Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders.1. The medical director and director of nursing services, in conjunction with the consultant pharmacist, shall identify appropriate indications and procedures for crushing medications.d. Crushing each medication separately and administering each with food is considered best practice. However, separating and administering crushed medication is not appropriate for all residents. Issues related to safety, needs, preferences, medication schedule, and functional ability will determine the most resident-centered approach.

Based on observation, interview and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 resident (Resident #30) of 18 residents reviewed for care plan accuracy. The facility failed to ensure Resident #30's care plan was updated to reflect her current feeding status of puree diet. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. Findings include: Record review of Resident #30's face sheet dated 11/09/23 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included respiratory failure, shortness of breath, chronic obstructive pulmonary disease, muscle weakness, anxiety disorder. Record review of Resident #30's admission MDS dated [DATE], section C revealed a BIMS score of 15 which indicated the resident was cognitively intact. Record review of Resident #30's care plan dated 09/27/23 reflected that Resident #30 was care planned for tube feeding related to a swallowing problem, and weight loss. Date initiated was 09/27/23. The goal reflected the resident will maintain adequate nutritional and hydration status. The care plan did not include the information on her diet of puree texture. Record review of Resident #30's physician's order dated 10/04/23 revealed an order - Regular diet Pureed texture, Regular consistency, thin. puree with gravy and broth per ST Active 10/04/2023 to 11/04/2023 Observation and interview on 11/07/23 at 10:00AM, revealed Resident #30 was in her bed using her tablet. She was alert and oriented. In an interview, she said her breakfast was good. She said she was happy that she could eat again. Observation and interview on 08/12/23 at 12:15AM , revealed Resident #30 was in the dining room having lunch. Her meal was a regular, puree diet. She said her food was good and had no complaints. In an interview with LVN D on 11/08/23 at 10:00AM, he said Resident #30 had a G-tube for her medication only. He said Resident #30 was previously on G-tube feedings but the G-tube feeding was discontinued sometime ago, and the G-tube was left for her medication. During an interview with the MDS coordinator on 11/09/23 at 1:00PM, she said Resident #30's care plan was done by the interdisciplinary team. She said the dietitian usually updated the care plan whenever there were new orders. In an interview with the Dietitian on 11/09/23 at 1:30PM, she said she wrote her notes on Resident #30's clinical record. She said she should have updated the care plan to reflect her diet change from tube feeding to oral puree diet. She said not updating the care plan could result in Resident #30 not being served her meals. She said she would update Resident #30's care plan to reflect her puree diet. Record review of facility's policy on care plan dated 2001 updated March 2022 read in part-policy statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1 The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. .9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition. b. when the desired outcome is not met;

Based on observation, interview, and record review the facility failed to test residents and facility staff, including individuals providing services under arrangement and volunteers for COVID-19 for 1 of 1 direct care staff members (LVN A) reviewed for weekly COVID-19 testing for residents and staff. LVN A was not tested or screend for COVID-19 before returning to work as a direct caregiver. This failure could affect all residents and place residents them at risk for exposure and spread of the COVID-19 infection. Findings include: Observation and interview with LVN A on 06/08/21 at 09:18 AM revealed she wore a blue surgical mask and said she was an as needed staff member. She was observed working the 1500 unit of the facility and was seen moving a medication cart and seated behind the desk at the 1500 units nursing station. She said she was not sure if the facility was still doing weekly COVID-19 testing on employees. She said today was her first day back at work and working the unit after 6 weeks off the working schedule. She said no one asked or requested she present a negative test result in order to return to work. She said she was unsure what the facilities current COVID-19 testing policies were. She said she had not been fully vaccinated against COVID-19. Interview with the DON on 06/09/21 at 10:58 AM revealed LVN A had not been tested prior to returning to work on the schedule and had not been fully vaccinated. The DON said she had not gotten to her in time, to test her before she started to work. She said she did ensure all staff were screened at the front entrance daily and proper PPE was worn daily. She said ordinarily the process would be she or her designee, would meet with the Staffing Coordinator on Mondays. She said if any as needed staff were coming in, they would test them with a rapid COVID-19 test prior to allowing them to work. She said the Staffing Coordinator, must not have realized LVN A's status. She said she would contact LVN A to get her tested immediately. She said LVN A was not back on the schedule until later in the week and would have to have a negative test result prior to allowing her to work again. When asked what the process should be for monitoring as needed staff and ensuring the current staff do not bring active infections into the facility, the DON stated, I missed it. She should have been tested . I just didn't get her in time. The DON said she was the facility Infection Preventionist and her designee was her ADON. A policy and procedure on how the facility tested staff for COVID-19 was requested from the DON. She did not provide a policy which specifically addressed staff testing for COVID-19. Interview with Staffing Coordinator on 06/09/21 at 1:19 PM stated all as needed staff were not tested unless they picked up a shift so in the case of LVN A, it was just an oversight. She said LVN A had recently been on leave and had a baby so she was out and it slipped her mind and it didn't register when she put her back on the schedule to make her get tested on the Monday prior to her working on Tuesday morning. Staffing Coordinator stated they did not have any other as needed staff at the moment besides LVN A. She said messages related to schedules and staff testing dates were posted through the same application. The Staffing Coordinator said the facility tested every Monday from 7am-9am and if staff did not show up for testing, she would reach out to them and if still unable to reach them, she will notify the DON and or ADON so they could try to notify and follow up with them. She said the as needed staff were scheduled via window works and once she sees them on the schedule, she reached out to them to come and get tested and the incident with LVN A not being tested prior to working the unit was just an oversight. The Staffing Coordinator said they met with the DON and ADON weekly to review the staffing schedules and any open shifts, but no one caught the return of LVN A. She said the DON and ADON, would be oversight over her, to check to see if staff had been vaccinated or tested . She said HR was in charge of keeping track of all vaccinated staff and HR kept a list of those staff members not vaccinated. She said once the facility went to a once per week schedule, for COVID-19 testing of staff, she did not keep up with which staff tested and which did not. Interview with the ADON on 06/09/21 at 1:39 PM revealed either she or the DON would be responsible for ensuring staff were tested weekly. She said they like to schedule staff for the week and testing was completed every Monday due to the infection rate in the county being at a certain percentage. She said HR kept a list of staff who were not vaccinated because all those who were fully vaccinated were removed from the list. She said HR was responsible for keeping up with the list because vaccine records were part of the employee files. She said she and the DON just missed LVN A and their plan moving forward was to review scheduling and the schedule more often and monitoring those on leave and as needed work status. She said with regard to LVN A who worked without being tested or vaccinated, was an oversight. She said they just forgot. She said all as needed and agency staff were required to have a negative test before they worked. Interview with the Administrator on 6/10/21 at 3:12pm, a facility policy and procedure on staff COVID-19 testing was requested but was not received. Record review of LVN A's HR file revealed LVN A signed an acknowledgement statement on the facilities weekly COVID-19 testing policy which was dated 06/10/21. Further record review of facility provided emails, revealed emailed communications from the When to work application used for employee communications which indicted testing dates and times on April 11, 2021, April 19, 2021, April 23, 2021 and April 30, 2021. Record review of facility policy and procedure titled Emergency Procedure-Pandemic Influenza, read in part, . 5. Follow Pandemic Influenza Plan in regard to managing high-risk employees and for guidelines as to when infected employees can return to work 6. Adherence to infection control policies and procedure is critical 7. Determine when to restrict admissions and visitations 1. The facility Infection Preventionist is responsible for coordinating education and training on seasonal and pandemic influenza 5. Influenza Vaccinations of staff are encouraged and monitored .

Based on observation, interview, and record review, the facility failed to use results of the comprehensive assessment to develop and implement a comprehensive person-centered care plan for 2 of 6 residents (Residents #1 and Resident #2) reviewed for Comprehensive Care Plans. --Resident #1's Comprehensive Care Plan did not document he was on contact isolation. --Resident #2's Comprehensive Care Plan did not document her language difficulties. These failures affected 2 residents and placed them at risk of not having their individually assessed needs determined and met. Findings: Resident #1 Record review of the Admission Record for Resident #1 revealed he was [AGE] years old. His admitted was 6/14/19 with the [DIAGNOSES REDACTED]. Record review of the Comprehensive Care Plans for Resident #1 dated 10/4/19 read in part, .The resident has a venous/stasis ulcer of the bilateral lower extremities .Interventions/Tasks: Apply compression dressing for drainage/[MEDICAL CONDITION] control .Monitor/document/report as needed for signs/symptoms of infection: Green drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, fever . There was no documentation for his isolation. Record review of the Order Summary Report for Resident #1 dated 2/24/20 read in part, .Contact Isolation for Staphylococcus Aureus . Record review of the Progress Notes for Resident #1 dated 2/27/20 read in part, .Resident continues on antibiotic [MEDICAL CONDITION] to wounds . There was no documentation in the progress notes of isolation. Record review of the updated Care Plan for Resident #1 dated as initiated on 3/4/20 read in part, .Resident requires isolation precautions related to Staphylococcus Aureus to wound . Interventions/Tasks: May leave room if wound drainage is contained, per resident request . During an interview and observation on 03/03/20 at 08:51 AM revealed Resident #1 was in his room sitting up in his wheelchair wearing a nasal cannula. He was fully dressed. He was observed with both of his legs wrapped and both feet were swollen. Isolation gowns and gloves were observed on his door. There were yellow and red biohazard bags hung in his room. During an observation on 03/04/20 at 7:30 AM Resident #1 was sitting in the dining room in his wheelchair eating his breakfast on his own. His legs were both wrapped, and he was wearing socks over his toes/lower feet. He was sitting at a table by himself. During an observation on 03/04/20 at 12:15 PM Resident #1 was sitting in the dining room in his wheelchair eating his lunch on his own. His legs were both wrapped, and he was wearing socks over his toes/lower feet. He was sitting at a table by himself. During an observation on 03/04/20 1:00 PM Resident #1 was back in his room sitting in his wheelchair. Isolation gowns continued to be on his door. There were yellow and red trash biohazard bags hung in his room. During an interview on 03/04/20 at 1:05 PM with RN A said Resident #1 was on contact isolation due to an infection in his legs. She said it was contained if he kept the wraps on his legs. She said he could come out of his room only if he left the wraps on his legs. She said sometimes he would remove the wraps on his own and decide to stay in his room. During an interview on 03/04/20 at 1:10 PM with MA A said Resident #1 no longer received an antibiotic. She said he was on contact isolation for his leg wounds and she wore gloves when she gave him his medications. During an observation on 3/5/20 at 9:55 AM Resident #1 was sitting in his wheelchair in his room with the TV on and his eyes closed. Both of his legs were wrapped, and he was wearing socks over his toes. Isolation gowns continued to be on his door and yellow and red biohazard bags hung in his room. During an interview on 3/5/20 at 10:00 AM CNA A said Resident #1 was on contact isolation for an infection in his feet/legs. She said she wore a gown and gloves when she provided care for him. She said he could come out of his room as long as he kept his legs wrapped. During an interview on 3/5/20 at 10:05 AM the MDS Nurse said resident #1 had an order for [REDACTED]. Resident #2 Record review of the Admission Record for Resident #2 revealed she was [AGE] years old. Her admitted was 9/28/16 with the [DIAGNOSES REDACTED]. Record review of the Care Plan dated as initiated on 3/26/19 for Resident #2 read in part, .The resident has a communication problem related to [MEDICAL CONDITION]. Interventions/Tasks: Anticipate and meet needs. Be conscience of resident position when in groups, activities, dining room to promote proper communication with others. Monitor for changes in condition. Reassurance and patience when resident attempts to communicate. Refer to speech therapy for evaluation and treatment as ordered. Use short phrases which require yes or no answers . There was no documentation of the resident saying repetitively That's fine or that's not fine. There was no documentation of the resident pointing to things she wanted, or of showing she was in pain. Record review of the Significant Change Minimum Data Set ((MDS) dated [DATE] for Resident #2 read in part, .Sometimes understood, usually understands. Bims score of 12. Active [DIAGNOSES REDACTED]., [MEDICAL CONDITION], Anxiety disorder, Depression, [MEDICAL CONDITION] . Record review of the Quarterly MDS dated [DATE] for Resident #2 read in part, .Usually understood, usually understands. BIMS score of 09. Active [DIAGNOSES REDACTED]., [MEDICAL CONDITION], Anxiety disorder, Depression, [MEDICAL CONDITION] . During an observation and interview on 03/03/20 08:58 AM Resident #2 was sitting up in her bed with ear phones on listening to the TV. She only repeated the words That's fine when she answered questions. During an interview on 03/05/20 at 10:05 AM the MDS Nurse said she had spoken to Resident #2 and she could understand what she wanted. She said Resident #2 said I'm fine or I'm not fine when she was answering yes or no questions. She said she was not care planned for this specifically. Record review of the Care Plans, Comprehensive Person-Centered Policy dated as revised on 12/2016 read in part, .a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident . Policy Interpretation and Implementation: . 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change .

Based on observation, interview, and record review, the facility failed to ensure staff prepared food in accordance with professional standards for food service for 1 of 5 staff (Cook A) reviewed for professional standards in that: -Cook A was not wearing a hair net while preparing food. This failure placed 48 residents at risk of cross contamination and a diminished quality of life. Findings include: Observation on 3/26/19 at 9:45 AM revealed Cook A wearing hairnet on beard, but not wearing a hairnet on his head while preparing food. Observation on 3/26/19 at 10:45 AM revealed Cook A wearing hairnet on beard, but not wearing a hairnet on his head while preparing food. Observation on 3/26/19 at 11:40 AM revealed Cook A wearing hairnet on beard, but not wearing a hairnet on his head while preparing food. Observation on 3/27/19 at 11:41 AM revealed Cook A wearing hairnet on beard, but not wearing a hairnet on his head while preparing food. During an interview on 3/27/19 at 11:43AM with the Dietary Manager she said all dietary staff were to wear hairnets. The Dietary Manager emphasized if a dietary staff member had short hair a hairnet was still to be worn. During an interview on 3/28/19 at 11:45AM with the Hospitality Manager she said all dietary staff were to wear hairnets. During an interview on 3/28/19 at 12:25PM with Cook A he said hairnets were to be worn at all times. Record Review of the facility's undated Unidine Employee Handbook - Personal Appearance - For Associates Working in Food Service Accounts revealed: hairnets or hats should be worn as appropriate. Record Review of the facility's Unidine Uniform Policy dated (MONTH) (YEAR) - Mandatory Uniform Standards per Team Member Handbooks - revealed skull caps or toques must be worn by production team members at all times while in food production: subsequently under General Considerations All Team Members states approved hair restraints must be worn.

Based on observation, interview, and record review the facility failed to implement a comprehensive person-centered care plan for each resident consistent with the residents that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 12 residents (Resident #11) reviewed for comprehensive care plans in that: -- the facility failed to identify on Resident #11's care plan the [MEDICAL CONDITION] medication the resident was receiving This failure affected 1 resident and placed 31 additional residents who received psychoactive medications at risk of not having their care needs assessed which could cause a decline in physical, mental, and psychosocial health. Findings include, Record review of Resident #11's admission sheet revealed he was [AGE] years old and was admitted to the facility 9/25/17. His [DIAGNOSES REDACTED]. Record review of Resident #11's Admission MDS dated [DATE] revealed the resident had a BIMS score of 9 which indicated the resident was moderately cognitively impaired. Record review of Resident #11's Physician order [REDACTED]. Record review of Resident #11's comprehensive plan of care dated 9/28/17 revealed no care plan for Resident #11's use of the medication [MEDICATION NAME] or the side effects to be monitored. During an interview on 3/9/18 at 9:48 a.m. the MDS Coordinator said she did not know why she did not care plan that Resident #11 was receiving [MEDICATION NAME]. She said by not care planning this, it did not allow her to document any side effects or any problems the resident may experience due to taking the [MEDICAL CONDITION] medication. Record review of Mosby's Nursing Drug Reference 23rd Edition 2010 revealed: [MEDICATION NAME] - Selectively inhibits serotonin, [MEDICATION NAME] uptake by brain, potentiates behavioral changes. Uses: Depression. Record review of the facility Comprehensive Care Plans Policy Statement not dated revealed: An individualized person centered comprehensive care plan consistent with each resident rights, that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychological needs and preferences that are identified in the comprehensive assessment is developed for each resident within 7 days after completion of the comprehensive assessment (MDS). The CMS form 672 revealed 32 residents received psychoactive medications.

Based on observation, interview, and record review the facility failed to offer bedtime snacks to two of nine residents and eight residents in a confidential group meeting who were reviewed for assessability of bedtime snacks (Resident #7 and Resident #8 ) in that: --Resident #7 was not offered an HS snack --Resident #8 was not provided an HS snack. --eight residents in a confidential group meeting were not provided HS snacks. The facility failure affected ten residents and placed an additional 32 residents at risk of low blood sugar, experiencing hunger in the evening hours, weight loss, and a diminished quality of life. Findings include: Resident #7 Record review of Resident #7's admission sheet revealed she was [AGE] years old and was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #7's Minimum Data Set ((MDS) dated [DATE] revealed a BIMS summary score of 14 which meant the resident was cognitively intact. Observation on 3/6/18 at 10:00 a.m. revealed Resident #7 seated in her wheelchair near her bed. There were different kinds of snacks on the top of her draw. During an interview on 3/6/17 at 10:04 a.m. Resident #7 said she had all the snacks in her drawer because she had been living in the facility for the past two years and nobody had ever offered her an evening snack. She said when she asked for snacks she was told by staff that they were out of snacks. Resident #8 Record review of Resident #8's admission sheet revealed he was [AGE] years old and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. During an interview on 3/8/18 at 12:20 p.m. with RD A, the facility dietitian, she said she had written an order for [REDACTED]. Record review of Resident #8's Physician order [REDACTED]. Record review of Resident #8's MDS assessment dated [DATE] revealed his cognitive skill for daily decision making was scored as independent. During an interview with the Resident #8's family member said the resident was not offered an HS snack. On 3/8/18 at 10:00 a.m. during a confidential Resident Council meeting 8 of 8 residents said they were not offered any HS snacks. During an interview on 3/8/18 at 12:15 p.m. the Dining Supervisor said each resident unit had a snack cart and food service staff replenished the carts daily. She said the residents usually have to ask the CNAs for a snack. During an interview on 3/9/19 at 9:25 a.m. the Director of Operations Food Services, said Food Services staff delivered snacks to the floor and nursing staff was supposed to pass the snacks to the residents. Record review of the facilitie's Standards Of Nursing Care dated 4/2014 revealed: -Snacks are to be provided to residents as ordered by physician or requested by residents. HS Snacks are to be offered to all residents daily: Type of Snacks: Ordered/diabetic snack - snack ordered by the physician and provided by dietary. General snack - snacks are to be available to all residents in the evening- Facility Matrix for Providers revealed 42 residents had the ability to eat snacks.

Based on observation, interview, and record review the facility failed to inform residents of the risks and benefits of proposed care, of treatment and treatment alternatives for the prescribed for 2 of 15 residents (#2, and #11) reviewed for resident rights in that: -- Resident #2 was administered [MEDICATION NAME] without signed consent. -- Resident #11 was administered [MEDICATION NAME] without signed consent. These failures affected 2 residents and placed an additional 21 residents receiving any psychoactive medication at risk of being uninformed of potential risks, benefits, and duration of therapy. Findings include: Resident #2 Record review of Resident #2's Admission Record revealed he was [AGE] years old. He was admitted on [DATE] with [DIAGNOSES REDACTED]. Observations on 03/28/17 at 9:00 a.m. and 1:30 p.m., and on 3/29/17 at 8:15 a.m. of Resident #2 he was in his room watching TV. His bed was in the low position. Record review of the Quarterly Minimum (MDS) data set [DATE] for Resident #2 revealed he received anti-anxiety and anti-depressant medications. Record review of the Comprehensive Care Plans dated 3/21/17 revealed Resident #2 was care planned for [MEDICAL CONDITION] medications. The specific medication was not listed. Record review of the Medication Administration Record [REDACTED] - [MEDICATION NAME] 50 mg at 8:00 p.m. was given on March 6th - March 29th, 2017. Record review of the Physician order [REDACTED].#2 revealed physician orders [REDACTED].>- [MEDICATION NAME] 50 mg at bedtime 8:00 p.m. Start date 1/3/17 - End date 3/61/7 (D/C date). - [MEDICATION NAME] 50 mg at bedtime 8:00 p.m. Start date 3/6/17 - End date Open Ended. Record review and of the Order Report dated 3/28/17 revealed Resident #2 was listed as receiving: - [MEDICATION NAME] 50 mg at bedtime, 8:00 p.m., start date 3/6/17. Record review of the consents for Resident #2 revealed there was no consent for [MEDICATION NAME]. During an interview and record review on 3/30/17 at 8:20 a.m. the DON said they did not have consent for Resident #2's [MEDICATION NAME], but they had it now. She provided the consent dated 3/29/17. Resident #11 Record review of Resident #11's Admission Record revealed a [AGE] year old. Resident #11 was admitted to facility on 01/28/17 with the following Diagnoses: [REDACTED]. Record review of Resident #11's Medication Administration Record [REDACTED] -[MEDICATION NAME] 15 mg a 1/2 tablet by mouth once a day was given on March 2nd, 4th, 7th, 8th, 10th, 17th, 18th, 19th, 23rd, and 25th. Record review of the Consents for Resident #11 revealed there was no consent for [MEDICATION NAME]. Record review of the facility's undated policy and procedure for Medication - [MEDICAL CONDITION] Medications revealed in part: - Purpose - To monitor residents receiving [MEDICAL CONDITION] medications. - Procedure - 1. Upon receiving order for [MEDICAL CONDITION] medications Charge Nurse completes Psychoactive Medications - Informal Consent form according to procedure . The facility 672 listed 23 residents that received psychoactive medication.

Based on observation, record review and interview the facility failed to have services furnished by outside resources specified in a written agreement for 1 of 1 residents (#2) who was reviewed for outside resources in that: - The facility did not have a signed [MEDICAL TREATMENT] contract for the company Resident #2 received his [MEDICAL TREATMENT] from. This failure affected 1 resident and placed him at risk of not having arrangements or agreements pertaining to outside resources in place for services the facility did not provide. Findings include: Record review of Resident #2's Admission Record revealed he was [AGE] years old. He was admitted on [DATE] with [DIAGNOSES REDACTED]. He attended [MEDICAL TREATMENT] on Monday, Wednesday and Friday at Davita South Shore with a chair time of 10:30 a.m. Record review of Resident #2's Physician order [REDACTED]. Observations on 03/28/17 at 9:00 a.m., 1:30 p.m., and on 3/29/17 at 8:15 a.m. of Resident #2 watching TV. His bed was in the low position. He had no concerns. He said he was tired. Record review of the facility List of Residents on [MEDICAL TREATMENT] dated 3/28/17 revealed Resident #2 was the only resident on [MEDICAL TREATMENT]. Record review of the Resident Census Sheet for Resident #2 dated 3/30/17 revealed: - 11/14/16 Admission. - 11/25/16 Discharge - Return anticipated. - 12/16/17 Return. - 12/22/16 Hospital leave. - 1/3/17 Return. - 1/14/17 Discharge - Return anticipated. - 1/24/17 Return. - 2/17/17 Hospital leave. - 3/6/17 Return. Record review of the Quarterly Minimum (MDS) data set [DATE] for Resident #2 revealed he received [MEDICAL TREATMENT]. Record review of the Comprehensive Care Plans dated 3/21/17 revealed Resident #2 was care planned for requiring [MEDICAL TREATMENT]. Record review and interview on 1/30/17 at 10:20 a.m. of the Nursing Home [MEDICAL TREATMENT] Transfer Agreement form with the facility and Davita [MEDICAL TREATMENT] revealed the form was not complete. The agreement forms were not signed by the facility or the [MEDICAL TREATMENT] center and they were not dated. The Administrator said the [MEDICAL TREATMENT] contract was still tied up in legal. He said it probably was not initiated in a timely manner. Record review of the Policies and Procedures for Contracts and Agreements dated as revised on 6/10/03 revealed in part: 1. All contracts/agreements will be forwarded to the central services office for review and approval .Documents should be received no less than five working days prior to the expected execution of such contracts. The facility 672 listed 1 resident that received [MEDICAL TREATMENT] services.