Every finding on record at Northdale Rehabilitation Center

Based on record review, staff interview, and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Reviews (PASRR) for residents with a mental disorder and individuals with intellectual disability following a qualifying mental health diagnosis for 10 (Residents #17, #36, #60, #84, #88, #10, #8, #58, #73, and #87) out of 21 residents sampled for PASRRs. Findings included: Review of Resident #17's admission record showed the resident was admitted to the facility on [DATE]. The admission record showed diagnoses to include Bipolar disorder and anxiety disorder. Review of a level I PASRR for Resident #17 dated 01/27/24 showed a blank PASRR and the qualifying diagnoses were not checked. Review of Resident #36's admission record showed the resident was admitted to the facility on [DATE]. The admission record showed diagnoses to include Major depressive disorder and anxiety disorder. Review of a level I PASRR for Resident #36 dated 11/09/23 showed a blank PASARR and the qualifying diagnoses were not checked. Review of Resident #60's admission record showed the resident was admitted to the facility on [DATE]. The admission record showed diagnoses to include Major depressive disorder, generalized anxiety disorder, and epilepsy. Review of a level I PASRR for Resident #60 dated 04/19/23 showed a blank PASRR and the qualifying diagnoses were not checked. Review of Resident #84's admission record showed the resident was admitted to the facility on [DATE]. The admission record showed diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and Alzheimer's disease. Review of a level I PASRR for Resident #84 dated 07/20/23 showed a blank PASRR and the qualifying diagnoses were not checked. The review further showed a level II PASRR was not considered. Review of Resident #88's admission record showed the resident was admitted to the facility on [DATE]. The admission record showed diagnoses to include Major depressive disorder and other specified anxiety disorders. Review of a level I PASRR for Resident #88 dated 09/12/23 showed a blank PASRR and the qualifying diagnoses were not checked. On 05/20/24 at 3:18 p.m., an interview was conducted with the Regional Nurse Consultant (RNC). She stated the PASRRs should be updated if there were new diagnosis or if they were not correctly documented upon admission. She stated if they required a review for a level II PASARR, it should be submitted. An interview was conducted with the Director of Nursing (DON) on 05/20/24 at 3:25 p.m. The DON reviewed the requested level I PASRRs and stated there were concerns related to the diagnoses not checked. She said, They should have been checked. Our process is to make sure before the resident comes to the facility, we read their history and make sure they have a current PASRR. We have psych or their provider evaluate the resident and update the PASRR with current diagnoses. The DON stated they reviewed PASRRs in their morning meetings. She stated they should have been updated accordingly. The RNC stated on 05/20/24 at 03:20 p.m. the facility did not have a PASRR policy. 48823 Review of the Admission Record dated 10/15/2019 for Resident #58 showed the resident was admitted on [DATE] with original admission on 10/15/2019. The record included the resident diagnoses of dementia (11/1/2023), anxiety (10/22/2019), major depressive disorder (10/22/2019), persistent mood affective disorder (11/21/2023), hallucinations (11/07/2023), cognitive communication deficit (11/05/2019). Review of Resident #58's Pre-Admission Screening and Resident Review (PASRR) , dated 9/18/2023 showed: a. Under Section I B - Finding is based on (check all that apply) only documented history was checked. Review of medical record/Minimum Data Set (MDS) for Resident #58 dated 04/29/2024 revealed. Section A - admitted [DATE], assessment date 04/29/2024. Section C - cognitive patterns revealed a Brief Interview for Mental Status (BIMS) 02 which revealed resident is cognitively impaired. Section I - active diagnoses under neurological revealed non-Alzheimer's dementia, under psychiatric/mood disorder revealed depression, and under other revealed persistent mood affective disorder Review of plan of care focuses for Resident #58 dated 5/22/2024 revealed. Has impaired cognitive function related to dementia (11/1/2023) Uses psychotropic medication therapy related to depression, dementia, and anxiety (11/3/2023) Is at risk for decreased nutritional status related to dementia (11/1/2023) Is at risk for activity of daily living self-care deficit related to dementia (11/1/2023) Review of psych health progress note for Resident #58 dated 4/16/2024 revealed. Reason for visit is re-evaluation of an established patient. History of present illness includes but is not limited to - past psych history major depressive disorder (MDD), anxiety disorder, and dementia. The residents' record showed an incomplete level I PASRR Review of the Admission Record dated 5/2/2024 for Resident #73 showed the resident was admitted on [DATE] with initial admission on 11/22/2023. The record included the resident diagnoses of anxiety (date 11/22/2023), and vascular dementia (date 11/22/2023). Review of Resident #73 Pre-Admission Screening and Resident Review (PASRR) , dated 7/18/2023 showed: a. Under Section I B - Finding is based on (check all that apply) documented history and individual, legal representative or family report was checked. b. Under Section II question 5 -related neurocognitive disorder (including Alzheimer's disease? - yes was checked. c. Under Section II question 7 - yes was checked for comprehensive mental status exam and medical/functional history prior to onset accompanying the level I PASRR (no information provided with PASRR). Review of medical record/Minimum Data Set (MDS) for Resident #73 dated 05/05/2024 revealed. Section A - admitted [DATE], assessment date 5/5/2024. Section C - cognitive patterns revealed a Brief Interview for Mental Status (BIMS) 00 which showed resident was cognitively impaired. Section I - active diagnoses under neurological revealed non-Alzheimer's dementia, under psychiatric/mood disorder showed anxiety. Review of plan of care focuses for Resident #73 dated 5/22/2024 showed. Uses psychotropic medication therapy related to insomnia (12/26/2023) At risk for mood problem related to insomnia (5/7/2024) At risk for decreased nutritional status related to dementia (11/22/2023) Resident has impaired cognitive function related to dementia (11/22/2023) Review of psych health progress note for Resident #73 dated 2/27/2024 showed: Reason for visiting psychotropic medication interdisciplinary review. History of present illness includes but is not limited to - past psych history includes dementia and anxiety. The residents' record showed an incomplete level I PASRR Review of the Admission Record dated 10/13/2023 for Resident #87 showed the resident was admitted on [DATE] with initial admission on 9/2/2023. The record included the resident diagnoses of dementia (primary diagnosis date 10/13/2023), mood disorder (date 10/16/2023), major depressive disorder (date 10/16/2023), and anxiety (date 10/13/2023). Review of Resident #87 Pre-Admission Screening and Resident Review (PASRR) , dated 8/28/2023 showed: Section 1 A - anxiety disorder and depressive disorder were checked Section I B - Finding is based on (check all that apply) documented history was checked (no documentation was attached). Section II question 5 - dementia was checked no. Section II question 7 - does the individual have validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease)/ no was checked Review of medical record/Minimum Data Set (MDS) for Resident #87 dated 03/04/2024 showed: Section A - admitted [DATE], assessment date 03/04/2024. Section C - cognitive patterns showed a Brief Interview for Mental Status (BIMS) 09 which indicated resident was moderately impaired. Section I - active diagnoses under neurological revealed non-Alzheimer's dementia, under psychiatric/mood disorder revealed anxiety and depression, and other mood disorders due to known physiological condition. Review of plan of care focuses for Resident #87 dated 5/22/2024 showed: Resident has impaired cognitive function related to dementia (9/8/2023) Uses psychotropic medication therapy related to major depressive disorder (10/17/2023) At risk for mood problem related to insomnia (5/7/2024) At risk for decreased nutritional status related to dementia (11/22/2023) Review of psych health progress note for Resident #87 dated 4/16/2024 revealed. Reason for visiting re-evaluation of an established patient. History of present illness includes but is not limited to - dementia and anxiety. Currently on Seroquel, does no have a diagnosis will decrease at bedtime and then discontinue. Assessment today revealed resident has advanced dementia. The residents' record showed an incomplete level I PASRR 50732 Review of Resident #10's admission record showed she was admitted to the facility on [DATE] with diagnoses to include major depressive disorder. Review of Level I Preadmission Screening and Resident Review (PASRR) for Resident #10 dated 08/03/2022 revealed an incomplete PASRR with the qualifying diagnosis not checked. Review of Resident #8's admission record showed she was admitted to the facility on [DATE] with diagnoses to include major depressive disorder and anxiety disorder. Review of Level I PASRR for Resident #8 dated 04/18/2018 revealed an incomplete PASRR with the qualifying diagnoses not checked.

Based on observation, interview, and record review, the facility did not ensure proper medication storage for six (Residents #57, #60, #97, #88, #8 and #10) out of 21 residents sampled for three of three days. Findings included: During a facility tour on 05/19/24 at 11:48 a.m., Resident #57 was observed with a bottle of a medication labeled (Mucus relief) at bedside. The resident did not answer when asked how often he took the medication. Review of an admission record for Resident #57 showed he was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) dated [DATE] showed the resident had a BIMS (Brief Interview for Mental Status) score of 12, which indicated his cognition was moderately impaired. Review of physician orders for Resident #57 dated 05/22/24 revealed the resident did not have self-administration orders. The orders showed the resident was not prescribed this medication. Review of a care plan dated 10/28/23 revealed Resident #57 did not have a focus to keep medications at bedside or to self-administer. During tours conducted in Resident #97's room on 05/19/24 at 12:48 p.m., 05/20/24 at 4:58 PM and 05/21/24 at 11:25 a.m., observations were made of [brand name] eye drops on top of his nightstand. Resident #97 stated he had been using the eye drops multiple times a day due to itchy eyes. Review of an admission record for Resident #97 showed he was admitted to the facility on [DATE]. An MDS dated [DATE] showed the resident had a BIMS of 13, which indicated his cognition was moderately impaired. Review of physician orders for Resident #97 on 05/21/24 at 11:30 a.m., showed the resident did not have self-administration orders. Review of physician orders dated 05/22/24 showed an order for eye drops was initiated on 05/21/24. Review of a care plan dated 03/14/24 revealed Resident #57 did not have a focus to keep medications at bedside or to self-administer. On 05/19/24 at 11:4., Resident #88 was observed in his room with a bottle of Multi Vitamin tablets on his bedside table. The resident stated he had been taking these vitamins daily for months. Review of an admission record for Resident #88 showed he was readmitted to the facility on [DATE]. An MDS dated [DATE] showed the resident had a BIMS score of 15, meaning he was cognitively intact. Review of Physician orders for Resident #88 on 05/19/24 at 12:45 p.m., revealed the resident did not have self-administration orders. Review of physician orders dated 05/22/24 showed an order was initiated on 05/21/24 to self-administer the medication. Review of a care plan initiated 09/12/23 showed the resident did not have a focus to keep medications at bedside or to self-administer. On 05/21/24 at 12:04 p.m., an observation was made of [brand name] eye drops at Resident #60's bedside table stored in a clear plastic bag. She stated she used the eyedrops almost daily for itchy eyes. She stated sometimes the staff helped her with her eye drops. Review of an admission record for Resident #60 showed she was readmitted to the facility on [DATE]. An MDS dated [DATE] showed the resident had a BIMS score of 15, meaning she was cognitively intact. Review of Physician orders for Resident #60 dated 05/22/24 revealed the resident did not have self-administration orders. The orders showed the resident was not prescribed this medication. Review of a care plan initiated 01/11/23 showed the resident did not have a focus to keep medications at bedside or to self-administer. On 05/21/24 at 8:23 a.m., an interview was conducted with Staff D, Registered Nurse (RN) who observed Resident #97's eye drops at bedside. She stated they had removed other medications from some rooms, but she did not know this resident had any medications at bedside. She explained the policy was to have any medications locked up and an assessment to follow if a resident was able to self-administer. On 05/21/24 at 11:30 a.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN). She stated all their residents required supervision for all medication administration. She stated if she saw medications at the bedside or in the resident's possession, she would confiscate them and notify the physician. An interview was conducted on 05/21/24 at 12:50 p.m. with Staff C, RN Unit Manager. She confirmed medications should be secured and not left unattended in resident's rooms. She stated the residents should have orders. She stated medications included topical creams, eye drops, ear drops and any over-the-counter substances. She stated some families liked to bring medications to the residents. She stated they were constantly educating residents and families. She stated when staff find these medications, they should remove them and notify the physician and the Responsible Party for follow-up. On 05/21/24 at 12:54 p.m., an interview was conducted with Staff F, RN Unit Manager. She confirmed the residents should not have medications at the bedside. She stated all medications should be secured even if a resident had self-administration orders. She stated as far as she was concerned, none of their residents had self-administration orders. A follow-up interview was conducted on 05/21/24 at 1:22 p.m. with the Director of Nursing (DON) and the Regional Nurse consultant (RNC). The DON stated there should be no medications left at the bedside. She stated if they were able to keep them, they must be locked, and the resident must be able to tell what they were for. She stated the resident should have orders and a care plan. The RNC stated the medications should be locked for the safety of their residents and their roommates. She stated all medication administration should be supervised unless the resident had orders. The DON confirmed they did not currently have anyone on self-administration orders. (Photographic evidence was obtained). 50732 On 5/19/2024 at 11:15 a.m., during a facility tour, Resident #10 was observed with three bottles of medication at bedside. The medications observed were [brand name] glaucoma medication, [brand name] lubrication eye drops, [brand name] nasal spray, and [brand name] pain relief cream. When the resident was asked about the medications, she stated that she sometimes took the medications herself and other times the staff helped her. (Photographic Evidence Obtained) On 5/20/2024 at 4:30 p.m. and 5/21/2024 at 3:00 p.m., Resident #10 was observed with only one medication, [brand name] pain relief cream, at the bedside. (Photographic Evidence Obtained) Review of an Admission Record for Resident #10 showed she was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Review of the Physician orders for Resident #10, dated 05/22/2024, showed the resident did not have self-administration orders on any medications. The resident was prescribed [brand name] Glaucoma medication and [brand name] pain relief cream, however, there were no Physician orders for [brand name] of lubrication eye drops or [brand name] for nasal spray, which were both over-the-counter medications. Review of the Active Care Plan revealed Resident #10 did not have a focus to keep medications at the bedside or self-administer. On 05/21/24 at 11:50 a.m., an interview was conducted with Staff E, LPN. She stated if a resident had medications on them, she would call the doctor to obtain self-administration orders if appropriate. She stated [brand name] for Resident #10 was a medication and should be treated as so. She stated the resident should have been assessed for safety. During tours conducted in Resident #8's room on 5/19/2024 at 12:40 p.m. and 5/20/2024 at 4:00 p.m., observations were made of [brand name] immune support gummies, an over-the-counter supplement, on top of her dresser. Resident #8 was unable to verbalize responses to questions due to her medical condition. (Photographic Evidence Obtained) Review of an Admission Record for Resident #8 showed she was admitted to the facility on [DATE]. A quarterly MDS, dated [DATE], Section C - Cognitive Patterns revealed a BIMS score of 0 out of 15, indicating the resident has severe cognitive impairment. Review of the Physician Orders for Resident #8, dated 05/22/2024, revealed the resident did not have self-administrations orders for any medications. The orders showed the resident was not prescribed this medication. Review of the Active Care Plan revealed Resident #8 did not have a focus to keep medications at bedside or self-administer.

Based on observation, interview, and facility policy review, the facility failed to ensure their pest control program was effective during three of four days of survey in six (Rooms #69, #70, #133, #135, #143 and #157) out of 26 rooms and affecting one (Resident #88) out of 21 sampled residents. Findings included: During multiple facility tours on 05/19/24, 05/20/24, and 05/21/24, observations were made of live and dead insects and ants in resident rooms #69, #70, #133, #135, #143 and #157. On 05/19/24 at 11:45 a.m., the Environmental Services (EVS) manager and surveyor observed a live insect crawling outside room [ROOM NUMBER]. She stated the insect was a cockroach. She stated their process was to kill the bug and document on the maintenance log. She stated she would disinfect the area where she stomped at the insect and let maintenance know. On 05/19/24 at 11:47 a.m., an interview was conducted with Resident #88 who was alert and oriented with a BIMS (Brief Interview for Mental Status) of 15. He stated he had lived at this facility for several years and his room had always had a problem with ants and roaches. He stated he had mentioned it to staff several times. During this interview the surveyor observed numerous dead ants on the resident's window sill and live ants on the floor and the walls by the dresser. During a tour of room [ROOM NUMBER] on 05/19/24 at 12:14 p.m., an observation was made of a live insect. On 05/19/24 at 12:43 p.m., an observation of an insect was made by the resident's head of the bed. On 05/19/24 at 1:11 p.m., an observation was made of a live insect on the floor by the resident's bed. During subsequent tours on 05/20/24 and 05/21/24, similar observations of insects were made in resident's rooms. On 05/21/24 at 01:37 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Maintenance (DOM). The DOM stated he was to be notified when there were sighting of pests and insects at the facility. He stated the staff were to document the location of the sighting so the contracted vendor could treat the areas accordingly. The DOM stated he was notified there were roaches in resident rooms. He reviewed photographic evidence and stated he did not know about any of the resident rooms having ants. He stated he was surprised there were that many ants in the resident's room. The NHA stated the facility had a binder at the front lobby that was used to communicate pest sightings. The DOM stated whoever made an observation should notify him via phone or write it down in the book. He reviewed the pest log book and confirmed there was no documentation of insect/pest sightings at the facility. The NHA stated it appeared the problem was communication. He stated nursing staff should be following their process of reporting any incidents of pests/insects observed in resident's areas. Review of a document titled pest sighting/evidence log showed from November 2023 to April 2024 it was documented checked logbook without pest/insect sighting documentation. During survey period on 05/19/24 and 05/20/24 and 05/21/24 the log confirmed there were sightings of roaches. Review of a facility policy titled, Pest Control dated 02/20/18, showed a purpose: routine inspections are conducted at each facility for evidence of pests. Insect or pest sightings are documented in the pest control book at the nurse's station and communicated to the maintenance supervisor. (Photographic evidence was obtained).

Based on observation, interview, and record review, the facility failed to reasonably accommodate the needs of one (Resident #45) of 21 residents related to not placing the call light within the resident's reach. Findings included: On 05/19/2024 at 1:00 p.m., the call light was observed on the floor, behind the headboard of Resident #45's bed. (Photographic Evidence Obtained.) On 5/20/2024 4:46 p.m., the call light was observed on the floor, behind the headboard of Resident #45's bed. The call light had not been moved from the previous day. (Photographic Evidence Obtained.) On 5/21/2024 11:57 a.m. the call light was observed on the floor, behind the headboard of Resident #45's bed. The call light had not been moved from the previous day. (Photographic Evidence Obtained.) Review of Resident #45's Admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included but were not limited to repeated falls. Review of Resident #45's Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. A review of Resident #45's active care plan included the following: -Focus effective 4/16/2024 of Risk for Falls AEB (as evidenced by) gait/balance problems, history of falls, generalized weakness. Interventions include Assistive devices as needed (walker). Bed in low position. Call light and frequently needed items in reach. Cue for safety awareness. On 5/21/2024 at 3:15 p.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN). She confirmed the expectation was that all call lights should always be accessible and within reach of the resident. Staff A also confirmed the expectation of the staff was to make sure the call light was within reach of the resident before exiting the resident's room. On 5/21/2024 at 3:40 p.m., an interview was conducted with Staff B, Certified Nursing Assistant (CNA). She confirmed the expectation was that call lights should be within reach of the resident. Staff B stated, If the call light is on the floor, pick it up and put it within reach of the resident. On 5/21/2024 at 4:15 p.m., an interview was conducted with Staff C, Registered Nurse (RN)/Unit Manager (UM). She confirmed the expectation was that all call lights should be within reach of the resident. Staff C also confirmed that if the call light was not within reach of the resident, the call light should be readjusted for the resident. Staff C stated the facility had Staff Angels that were assigned resident rooms to check daily to make sure the residents had no concerns, and the call lights were within reach of the resident. Staff C was shown the pictures taken of the call light in Resident #45's room. Staff C said, Well, the resident sometimes readjusts the light. She does leave the room sometimes and walks around with her walker. I've seen her talking to the DON (Director of Nursing) in her office before. On 5/21/2024 at 1:25 p.m., the DON confirmed the expectation was that call lights should be within reach of the resident. On 5/22/2024 at 11:10 a.m., the DON stated the facility did not have a call light policy.

Based on observation, interview, and facility policy review, the facility failed to ensure Air Conditioning (A/C) filters were maintained in a safe and sanitary manner in seven (69, 70, 132, 133, 135,136 and 157) of 26 resident rooms during three of three days of survey. Findings included: During multiple facility tours on 05/19/21, 05/20/21 and 05/21/24 observations were made of A/C filters with dirt and blanketed debris in rooms 69, 70, 132, 133, 135,136 and 157. (Photographic evidence was obtained). On 05/22/24 at 9:32 a.m., an interview was conducted with the Director of Maintenance (DOM) and the Nursing Home Administrator (NHA). The NHA stated they did not have a policy on A/C maintenance but would contact their corporate to obtain a copy. The DOM stated the A/C filters were last cleaned on 02/23/24. He stated they had a checklist they followed to make sure they covered all the rooms. He stated their policy was to clean the filters and change them quarterly. He stated he had just looked at some of the rooms. He said, I looked at the A/C filters. Some of them were very bad and some were not as bad. We will start cleaning today. Review of the August 2023 facility policy titled HVAC [Heating, Ventilation and Air Conditioning] Systems Inspection and Maintenance] showed the center's HVAC systems are inspected and maintained periodically to ensure proper functioning. Review of the procedure showed: Filters: (1.) Clean/replace air conditioner filters as needed. All filters may not need to be replaced or cleaned every week, but all filters must be changed in a 4-week period (monthly). Equipment Inspection: (4.) Change all filters, . Seasonal Maintenance: (5.) Filters must be cleaned or changed on a regular basis. Determine if filters should be changed more frequently.

Based on observation, interview, and record review, the facility failed to ensure the Comprehensive Resident Centered Care Plan was updated related to falls for one (Resident #58) of four sampled residents. Findings included: During an observation on 05/21/2024 at 1:15 p.m., Resident #58 was sitting at bedside in the wheelchair. She was dressed and groomed for the day. White, open back sliders were on her feet. A pair of tennis / enclosed shoes were next to the wall. She had fluids at the bedside. A scoop mattress was in place. The bed was in the lower position. The call light was within reach. Review of the care plans showed Resident #58 was at risk for falls as evidenced by history of repeat falls due to confusion, gait/balance problems, and generalized weakness and was initiated on 11/01/2023. Interventions included to offer / assist to watch TV in the dining room before dinner as of 05/13/2024 and anti-tippers to wheelchair as of 05/19/2024. Resident #58 was admitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to dementia, repeated falls, weakness, abnormalities of gait and mobility, right foot drop and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 02 or severely impaired. Section GG showed she required partial to moderate assist for toileting and maximum assist for sit to stand. Review of progress notes showed a Situation, Background, Assessment, and Recommendation (SBAR) dated 05/10/2024 at 21:34 (9:34 p.m.) showed Falls. Review of the Post-Fall Review dated 05/14/2024 (4 days post fall) showed on 05/10/24 at 17:15 (5:15 p.m.), the resident was observed sitting on her buttocks next to her wheelchair. She stated she fell out of her wheelchair on to her buttocks, while she was trying to reach her TV remote. Resident denied any pain. Interdisciplinary Team (IDT) reviewed incident; resident usually ate in dinner in the dining room. Updated the care plan to offer/assist to watch TV in the dining room before dinner. During an interview on 05/21/2024 at 1:51 p.m., the Director of Nursing (DON) stated she was unable to locate documentation in the progress notes regarding the fall on 05/10/2024 (the date of the fall). The DON verified the documentation regarding the fall was only in the Post-Fall Review with the IDT on 05/14/2024 (four days post fall). She verified an intervention was not into place, per the care plan review, until 05/13/2024 (3 days post fall). The DON stated the interventions were to be put into place at the time of the fall. The IDT reviewed the fall and the care plan at the time of the meeting. The Therapy Director (TD) stated the resident was already on case load during the incident. The Occupational Therapist working with her educated her on using a reacher for reaching. Review of the facility's policy, Comprehensive Person-Centered Care Plans, revised 8/2023 showed the center will develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Fundamental Information: The comprehensive care plan will describe the following: 1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. A comprehensive care plan will be: iii. Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments and as changes in the resident's care and treatment occur. The Comprehensive plan of care will should include the following: reflect interventions to meet both short and long term resident goals; include interventions to prevent avoidable decline in function or functional level; include interventions to attempt to manage risk factors; be periodically reviewed and revised by the interdisciplinary team as changes in the resident's care and treatment occur. Procedure: 13. Re-evaluate and modify care plans: as needed to reflect changes in care, service and treatment; with significant change in status assessment. 14. Care plan evaluation will occur in response to changes in the resident's physical, emotional, functional, psychosocial, or communicative status as they occur.

Based on observation of the dish machine, review of the dish machine records and service provider's report, and interview with facility and service provider staff, the facility failed to ensure the dietary staff were following the manufacturer's guidelines for the dish machine, related to monitoring the temperature of the wash and rinse water, or monitoring the level of chemical sanitizer used by the dish machine. Findings included: An observation was made of the dish machine in the main kitchen on 03/07/2022 beginning at 9:30 a.m. Staff I, Dietary Aide was observed running dish racks with breakfast dishes through the dish machine. She was asked to describe the procedure she followed to ensure the dish machine was running correctly. She reported she attaches a small stick (T stick) to a dinner plate and runs the plate through the dish machine. The strip turns black when the water temperature is 160 degrees Fahrenheit (F). She confirmed she did not know the temperatures that were required for either the wash or the rinse temperature. (Instructions on the T stick read: Insert tip in center of food, wait 5 seconds. Tip will turn all black when food is done. Additional instructions on the T stick container indicated the sticks could be used to monitor the temperature of water.) An observation (which began at 9:30 a.m. on 03/07/2022) of the wash and rinse thermometer dials on the dish machine while the dish machine was washing breakfast dishes, revealed the wash was 158 degrees F and the rinse was 162 degrees F. The dish machine log book was reviewed and noted to include a page for March 2022 on which the used T sticks were attached to the page with tape. The tip of each T stick had turned black indicating the temperature of 160 degrees F had been reached. A second page for March 2022 was reviewed which documented the temperature of 180 degrees F for three meals for the first six days of the month. The temperatures for the dish machine for cleaning the breakfast dishes on 03/07/2022 had not been documented. The staff were asked where the face plate was posted on the dish machine as that would provide the manufacturer's guidelines for the wash and rinse temperature. Staff were not aware where the face plate was posted or even that the face plate would provide the required temperatures. (The face plate was located and noted to be under the metal track where clean dishes in racks exit the machine. The face plate was illegible when it was in that position and even attempts at photographing the face plate were not successful.) On 03/08/2022 at 9:40 a.m., the Dietary Manager reported the company that serviced the dish machine had been in on 03/07/2022 and reported their dish machine was a low temperature machine that used a chemical to sanitize the dishes. The service report was provided and noted to include a wash temperature of 150 degrees F and a rinse temperature of 176 degrees F with chemical sanitation at 100 ppm (parts per million). Notes on the service report indicated the machine used chemical sanitation and the wash and rinse temperatures were higher than they needed to be. An observation of the dish machine at that time was requested as there was no discussion on 03/07/2022 of the staff's responsibility in checking the level of the chemical sanitizer when dishes were washed. A large bucket of sanitizer was observed connected to the dish machine which staff identified as providing sanitizer to the rinse water at every cycle. Staff G, Assistant Dietary Manager, confirmed they did not test the level of sanitizer, but it was used as a back up to the hot water cycles that washed and rinsed the dishes. The dish machine was observed for wash and rinse temperatures after many cycles had been run to ensure the temperatures were adequate for washing the breakfast dishes. At 9:55 a.m. on 03/08/2022 the thermometers for both the wash and rinse cycles were above the required 160- and 180-degrees F. However, as the Dietary Aide continued to run racks of breakfast dishes through the machine, the temperatures dropped to 148 degrees for the wash and 170 degrees for the rinse. The Assistant Dietary Manager observed the temperature dials with the surveyor for several cycles and confirmed that the required temperatures were not being reached. The Dietary Aide running the racks through the machine was not watching the dials and had not stopped running the racks through the machine, to wait until the temperature increased to the required levels. On 03/08/2022 at 10:15 a.m. a representative from the dish machine service company was interviewed. He reported the facility's dish machine was a hot water temperature machine, however, the machine also was connected to the chemical sanitizer as a backup in case the hot water temperatures were not maintained. The representative confirmed there was a booster heater attached to the dish machine to ensure the temperatures remained at the manufacturer's required temperatures. He confirmed a chemical sanitizing agent was released during each rinse cycle, but would evaporate with hot water, therefore not providing the chemical sanitizer, which was probably the case with this facility. Material Safety Data Sheets for liquid sanitizers used in dish machines include this warning: Not combustible; however, at temperatures exceeding 156°F, decomposition occurs releasing oxygen. The oxygen released could initiate or promote combustion of other materials. The representative reported the face plate had been removed from under the machine and posted on the front of the machine so staff could easily refer to it. It was reported, according to the face plate, the manufacturer required a minimum of 160 degrees F for the wash water and 180 degrees F for the rinse water. Staff referred to the use of the T sticks to ensure the wash water was 160 degrees F and referred to the temperature log to show that consistently the rinse water was 180 degrees. The use of the T sticks to monitor the wash water was discussed with the Dietary Manager and staff. The T sticks, attached to a plate as described, run through the entire wash and rinse cycles of the dish machine, and are only observed at the end of the cycles. It is not known at what point the water temperature measured 160 degrees F and cannot be assumed that it was during the wash cycle. The Dietary Manager was present during the interviews and observations described above. She admitted she did not know much about the dish machine or the face plate which had the temperatures or level of chemical sanitizing agent required to ensure the dishes, utensils, and glassware were clean. On 03/10/2022 at 11:30 a.m., during a final visit to the kitchen, the Dietary Manager reported the booster heater was checked by maintenance to ensure it was adjusted correctly, and the chemical sanitizer had been disconnected from the machine. She reported staff would be monitoring the temperature dials for the correct temperatures while the dishes were being washed and rinsed.

Based on observation, record review and interview the facility failed to develop baseline care plans for one residents (#196) out of 34 sampled residents, related to the provision of pain management and the prevention of falls for newly admitted residents with fall risks. Findings included: A review of Resident #196's medical record revealed the resident was admitted to the facility on [DATE] with a primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of Resident #196 on 03/07/22 at 04:05 PM revealed the resident lying in her bed, which was noted to be in the low position. The resident was noted to be pushing her roommates over-bed table away from her and voiced that she didn't want it that close to her bed. The residents' roommate voiced that she thought Resident #196 was trying to get out of bed unassisted. An observation of Resident #196 on 03/08/22 at 10:25 AM revealed the resident was noted to be in bed. The resident's right arm was noted to be in a sling. An interview with the resident was conducted at this time and she reported she has the sling for pain as she may have fallen. A review of Resident #196's medical record revealed a history and physical (HPI) dated 2/25/22 which revealed the following: Chief complaint fall and fracture HPI: [AGE] year-old with history of dementia brought in by son with chief complaint right arm pain status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Family member walked into the house from the garage, in follow-up patient on the tiled floor. Patient has history of dementia and does not remember falling and denies hitting head, loss of consciousness, headache, neck pain, back pain, pelvic pain, or lower extremity pain. She is just complaining of the right arm and shoulder pain. Son reports that she falls frequently at home . A review of the Medical Certification For Medicaid Long-Term Care Services And Patient Transfer Form (AHCA Form 5000-3008) dated 2/28/22 indicated the primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Skilled SOAP (subjective, objective, assessment, plan) note dated 2/28/22 21:42 revealed Assessment: Patient is [AGE] year-old female with Dx: Fall with R (right) Shoulder Dislocation A review of the Skilled SOAP note dated 3/4/22 20:00 revealed Objective: Patient was observed on the floor as if she had slid out of her wheelchair, did not announce to anyone that she had fell , resident was found by her roommate's daughter after she returned from a stroll with her mother. A review of the facility report dated 3/5/22 03:26 revealed the following: time of fall was 5:55 PM Patient was observed on the floor. The resident was in front of her wheelchair with her head against the foot rest and her legs apart with the Foley still attached to the bottom of the wheelchair, the probable cause was that after dinner she wanted to get back in bed, but with weakness and her R shoulder dislocation that she is unable to get herself into bed. call light was on the ground next to the wheelchair, bed was at low position her wheelchair positioned right next to the bed and the foot rest were both in place at the time. A review of the resident medical record revealed an Admission Data Set assessment dated [DATE] which indicated under Section O. Safety, the resident had No Falls within the past 3 months. The form indicated a predisposing condition of Fractures was not present. A review of the Fall Risk Evaluation completed on 3/5/22, after the resident's actual fall in the facility on 3/4/22 revealed in section A, the resident had No Falls in the past 3 months. A review of the resident's care plan dated 3/5/22, revealed there was no care plan in place until 3/5/22, after the resident had an actual fall in the facility. An interview was conducted on 03/08/22 at 2:51 PM with the Director of Nursing. The DON revealed the Medical Certification For Medicaid Long-Term Care Services And Patient Transfer Form (AHCA Form 5000-3008) dated 2/28/22 should be used to get all the information needed for a new admission. She reported for the admission assessment dated [DATE] the staff who completed the assessment should have had documented 2-3 falls under the section of History of Falls. 3. A review of the facility policy titled Baseline (Interim/Initial/POC) Plan of Care with a revised date of 2/18/2019 revealed the following: The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours of a resident's admission.

Based on observations, interview, and record review the facility failed to develop a comprehensive care plan related to respiratory care and treatment for one resident (#59) of three residents reviewed for respiratory care. Findings included: A review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Evaluation Scoring Report dated 2/2/22 revealed a Brief Review for Mental Status (BIMS) score of 15, indicating intact cognition. An observation of Resident #59's room was conducted on 03/07/22 at 10:40 AM. The resident was noted to have a nebulizer machine at the bedside on the night stand. The machine was noted to have a clear clasp where the mask was noted to be clipped to. The mask was not bagged or stored to prevent contamination. Photographic evidence obtained. A review of the resident's current order summary for March 2022 revealed orders for the following: -[MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3) mg (milligrams)/3 ml (milliliters). 3 ml inhale orally via nebulizer every 6 hours for [CONDITION(S)]. Start date: 1/29/2022. -Budesonide Suspension 0.5 mg/2 ml. 2 ml inhale orally via nebulizer two times a day for SOB (shortness of breath). Rinse mouth with water after use. Do not swallow. Start date: 2/4/2022. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3) mg/3 ml. 3 ml inhale orally via nebulizer every 6 hours for [CONDITION(S)], The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -Budesonide Suspension 0.5 mg/2 ml. 2 ml inhale orally via nebulizer two times a day for SOB. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the medical record revealed no care plan or directive anywhere in the record for Resident #59. An interview was conducted on 03/09/22 at 12:27 PM with Staff E, Resident Care Coordinator Specialist, Licensed Practical Nurse (LPN). She stated she develops care plans with needed interventions. She reported typically if a resident requires the use of oxygen or nebulizer treatments they would have a care plan in place which would include intervention for the care and maintenance of the nebulizer equipment. She reported they would have to add a care plan for Resident #59, and a focus related to respiratory care to include the maintenance of the respiratory equipment. She reported that she overlooked this care plan. A request was made of the facility to provide a policy related to comprehensive care plan. At the conclusion of the survey no policy was provided for review.

Based on record reviews, and interviews the facility failed to accurately assess the weight and to notify the physician of a significant weight gain for one resident (#12) following a transfer to an acute care facility for diuresis of fluid out of thirty-four sampled residents. Findings included: Resident #12 was admitted on [DATE] and readmitted on [DATE] following a transfer to an acute care facility on 2/24/22. The Admission Record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note dated 2/28/22 at 2:47 p.m. identified the staff had spoken with an acute care facility regarding Resident #12. The note indicated the resident was having excessive fluid removed and had been transferred from the Intensive Care Unit (ICU) to the Cardiac Unit. A review of Resident #12's Weights and Vitals Summary indicated the resident weighed 248.2 pounds (lbs.) on 2/23/22, one day prior to the residents transfer to an acute care facility. The March 2022 Treatment Administration Record (TAR) for Resident #12 included a physician order: Daily weights for Congestive Heart Failure (CHF) in the morning every Monday, Wednesday, Friday related to Heart Failure unspecified. Notify MD (Medical Doctor) for weight gain of 3 pounds or more, start date 1/28/22, Hold date from 3/2/22 to 3/3/22, discontinued (D/C) date 3/9/22 at 8:29 p.m. The March TAR indicated a weight of 276.6 lbs. was obtained for Resident #12 on Friday 3/4/22, no weight was obtained on Monday 3/7/22, and the resident refused on Wednesday 3/9/22. The documentation of Resident #12's weights indicated the resident had gained 28.4 lbs. from 2/23/22 to 3/4/22 despite being at an acute care facility from 2/24 to 3/3/22 where excessive fluid was removed. A provider note, dated 3/4/22, indicated the patient (pt.) sent to hospital with lethargy, shortness of breath (sob) and bilateral lower extremity (BLE) [CONDITION(S)], [MEDICATION(S)] held with improvement, now returns to facility in fair conditions. The review of system (ROS) did not indicate that Resident #12 had [CONDITION(S)]. The provider note, dated 3/7/22, indicated the resident had returned (from the hospital) without a [MEDICATION(S)] order. (According to webmd.com, [MEDICATION(S)] is used to reduce extra fluid in the body ([CONDITION(S)]) caused by conditions such as heart failure, liver disease, and kidney disease.) The note on 3/7/22 did not identify that the resident had any [CONDITION(S)]. The Cardiology consult note, dated 3/7/22, identified cardiology was consulted for management of multiple chronic Cardiovascular (CV) conditions. The consult indicated the resident was recently hospitalized for acute on chronic respiratory failure, acute on chronic diastolic heart failure, (and) pulmonary [CONDITION(S)]. The note indicated +lower extremity [CONDITION(S)]. The cardiologist instructed staff to monitor for acute fluid retention and monitor daily weight. The Subjective, Objective, Assessment, and Plan (SOAP) note on 3/5/22 at 3:00 p.m., indicated Resident #12 was compliant, and no [CONDITION(S)] was noted. A review of further SOAP notes dated 3/4 to 3/8/22 at 5:00 p.m. did not indicate staff had documented the resident had any [CONDITION(S)]. A review of the SOAP note, dated 3/4, did not identify that the physician was notified of the weight gain on 3/4/22. The progress notes, dated 3/4/22, did not identify that the physician was notified of the resident's weight gain, following the residents return from the hospital. The Director of Nursing (DON) stated, at 2:45 p.m. on 3/9/22, the facility scales were able to calibrate, and the aides obtain weights. The DON reported the Unit Manager should be checking weights since Resident #12's monitoring of weights was not due to dietary issues. A review of Resident #12's TAR with the DON indicated the resident refused to be weighed on 3/9 and she would have to find out what happened on 3/7 as nothing was documented. She stated the order for daily weights was scheduled for three times a week and would need to be clarified as the Cardiologist note instructed to monitor daily weights and acute fluid retention. She reviewed the progress notes and confirmed the nursing notes did not indicate if the resident was having any [CONDITION(S)]. On 3/9/22 at 3:34 p.m., the DON stated she had sent Resident #12 out to the hospital for congestive heart failure (CHF), poor controlled Diabetes Mellitus, and pulmonary embolism. The DON reported the resident was non-compliant with fluid restriction and that was the reason she had to go out to the hospital for intravenous (IV) diuretic. The DON stated she would have the resident re-weighed, as the weight (276.6 lbs.) must have been documented in error. The care plan for Resident #12 identified the resident was at risk of decreased nutritional status and dehydration related to (r/t) diagnosis (dx) of Type 2 Diabetes Mellitus (T2DM), acute respiratory failure (ARF) with [CONDITION(S)], heart failure (HF), [CONDITION(S)], chronic pulmonary embolism, low back pain, hypertensive urgency, therapeutic diet, diuretic therapy, [CONDITION(S)], (and) altered lab values. The resident was at risk for unintentional weight fluctuations r/t [CONDITION(S)], use of diuretic therapy, (and) HF dx. The care plan related to the residents' risk of decreased nutritional status was created on 12/5/21, initiated and revised on 3/4/22. The interventions indicated Licensed Practical Nurses and Registered Nurses (LPN/RN) were to monitor weights as ordered. The policy, Physician Orders, revised on 10/24/17, identified that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, interview and record review the facility failed to appropriately monitor newly admitted residents to prevent falls for one resident (#196) of 34 sampled residents. Findings included: A review of Resident #196's medical record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of inferior dislocation of right humerus and other diagnoses that included unspecified dementia without behavioral disturbances and anxiety disorder. An observation of Resident #196 on 03/07/22 at 4:05 PM revealed the resident lying in her bed which was noted to be in the low position. The resident was noted to be pushing her roommates over-bed table away from her and voiced that she didn't want it that close to her bed. The resident's roommate voiced she thought Resident #196 was trying to get out of bed unassisted. An observation of Resident #196 on 03/08/22 at 10:25 AM revealed the resident was in bed. The resident's right arm was noted to be in a sling. An interview was conducted with the resident, and she reported she has the sling for pain as she may have fallen. A review of Resident #196's medical record revealed a history and physical (HPI) dated 2/25/22 which revealed the following: Chief complaint fall and fracture HPI: [AGE] year-old with history of dementia brought in by [family member] with chief complaint right arm pain status post and unwitnessed fall 30 minutes prior to arrival. Family member walked into the house from the garage and in follow-up patient on the tiled floor. Patient has history of dementia and does not remember falling and denies hitting head, loss of consciousness, headache, neck pain, back pain, pelvic pain, or lower extremity pain. She is just complaining of the right arm and shoulder pain. [Family Member] reports that she falls frequently at home . A review of the Medical Certification For Medicaid Long-Term Care Services And Patient Transfer Form (AHCA Form 5000-3008) dated 2/28/22 indicated the primary diagnosis for Resident #196 was Right Shoulder Dislocation with other diagnosis that included Frequent Falls. A review of the Skilled SOAP (subjective, objective, assessment, plan) note dated 2/28/22 21:42 (9:42 p.m.) revealed, Assessment: Patient is [AGE] year-old female with Dx: Fall with R (right) Shoulder Dislocation A review of the Skilled SOAP note dated 3/4/22 20:00 (8:00 p.m.) revealed, Objective: Patient was observed on the floor as if she had slid out of her wheelchair, did not announce to anyone that she had fell , resident was found by her roommate's [family member] after she returned from a stroll with her mother. A review of the facility report dated 3/5/22 03:26 (3:26 a.m.) revealed the following: time of fall was 5:55 PM Patient was observed on the floor. The resident was in front of her wheelchair with her head against the foot rest and her legs apart with the Foley still attached to the bottom of the wheelchair, the probable cause was that after dinner she wanted to get back in bed, but with weakness and her R shoulder dislocation that she is unable to get herself into bed. call light was on the ground next to the wheelchair, bed was at low position her wheelchair positioned right next to the bed and the foot rest were both in place at the time. A review of the resident medical record revealed an Admission Data Set assessment dated [DATE] which indicated under Section O. Safety, the resident had No Falls within the past 3 months. The form indicated a predisposing condition of Fractures was not present. A review of the Fall Risk Evaluation completed on 3/5/22, after the resident's actual fall in the facility on 3/4/22 revealed in Section A, the resident had No Falls in the past 3 months. A review of the resident's care plan revealed there was no care plan in place until 3/5/22, after the resident had an actual fall in the facility. An interview on 03/08/22 at 2:51 PM was conducted with the Director of Nursing (DON). The DON stated the Medical Certification For Medicaid Long-Term Care Services And Patient Transfer Form (AHCA Form 5000-3008) dated 2/28/22 should be used to get all the information needed for a new admission. She reported for the Admission assessment dated [DATE] the staff who completed the assessment should have had documented 2-3 falls under the section of History of Falls. A policy related to falls was requested of the facility, but not provided.

Based on observations, interviews and record reviews, the facility 1) failed to ensure one resident (#5) received respiratory care consistent with professional standards of practice, by failing to monitor the resident's respiratory treatment, leaving the face mask snuggly attached to the resident's face from approximately 8:50 a.m. to 11:05 a.m. for a dependent resident, 2) failed to ensure one resident's (#198) nebulizer mask was on appropriately to receive treatment, and 3) failed to store one resident's (#59) nebulizer mask appropriately out of three residents sampled. Findings included: 1. During a tour of the west hall on 3/7/22 at 10:29 a.m. a nebulizer treatment could be heard while walking the hall. Staff A, Licensed Practical Nurse (LPN) was observed walking toward therapy where the residents' rooms started with the wound cart and stopped at the last room. At 10:31 a.m. on 3/7/22, Resident #5 was observed wearing oxygen at 2.5 liters via nasal cannula and a face mask attached snuggly below the resident's nose connected to the running nebulizer. The nebulizer was observed without mist or moisture. An observation was conducted of Staff A, LPN on 3/7/22 at 10:42 a.m. Staff A was moving closer to the nurses' station stopping at another resident room with the wound care cart, while Resident #5 was observed wearing oxygen at 2.5 liters via nasal cannula and the face mask running without mist observed. The resident opened her eyes and started to move her mouth trying to move the face mask. The mask was strapped snuggly against her face below her nose. An observation was conducted of Staff A, LPN on 3/7/22 at 10:50 a.m. Staff A was going to assess a resident for oxygen level, then back to wound care two doors away from Resident #5's room. Resident #5's nebulizer could be heard near the wound cart. An observation was conducted of Staff A, LPN on 3/7/22 at 10:56 a.m. Staff A was continuing to complete wound care while Resident #5's nebulizer could be heard at the wound cart. An interview was conducted with Staff A, LPN on 3/7/22 at 11:01 a.m. Staff A stated Resident #5 was nonverbal and confirmed her oxygen saturation was stable. Staff A stated Resident #5 needed two breathing treatments because her oxygen level was eighty something earlier, and increased to 93% or 94%, she stated she does not need to stay near the resident while receiving breathing treatments even if her oxygen level was eighty something. Staff A, LPN confirmed she had called the physician to obtain a second breathing treatment but could not say when her oxygen was in the eighties or when she started the second breathing treatment. Staff A, LPN went into the resident's room and was walking around the bed, she left the face mask on the resident and went to the nurses' station saying she needed her equipment. A review of the Minimum Data Set (MDS), Section G-Functional Abilities, dated 3/4/22, reflected bed mobility as total dependence and two plus person physical assist. Personal hygiene as one-person physical assist. During an interview with the Director of Nursing (DON) on 3/7/22 at 2:04 p.m. she stated the nurse does not need to be at the bedside during nebulizer treatments but should check back in 10 to 15 minutes. During an interview with the DON on 3/7/22 at 2:25 p.m. she confirmed the nebulizer treatment was signed out at 8:50 a.m. and should have been removed once the treatment was completed about 15 minutes later. The DON stated she would need to ask Staff A, why the nebulizer mask was on the resident at 11:00 a.m. if the treatment was at 8:50 a.m., and stated the resident had another treatment at noon that could have been started. During a phone interview with Resident #5's [family member] on 3/8/22 at 11:52 a.m. she confirmed Staff A called her on 3/7/22 at 4:00 p.m. after verifying the time of the call on her cell phone and said that her mother had oxygen levels of 92% and was anxious so the nurse sat at her bedside holding her hand until her oxygen was 100 %. A review of the medication administration times on 3/7/22 for [MEDICATION(S)]-[MEDICATION(S)] solution 0.5-2.5 (3) mg (milligrams)/3 ml (milliliters) inhale orally via nebulizer every four hours for wheezing ordered for 8:00 a.m. was documented as given at 8:50 a.m. and 12:18 p.m. A review of current active physician orders for March 2022 revealed the following:: [MEDICATION(S)]-[MEDICATION(S)] solution 0.5-2.5 (3) mg/3 ml inhale orally via nebulizer every four hours for wheezing started on 1/6/22 and ended 3/7/22. [MEDICATION(S)]-[MEDICATION(S)] solution 0.5-2.5 (3) mg/3 ml inhale orally via nebulizer every 6 hours as needed for wheezing started on 3/7/22. Keep head of bed at minimum 45 degrees during nebulizer treatment to facilitate adequate ventilation every 6 hours as needed dated 3/7/22 at 10:18 p.m. Change nebulizer tubing weekly on Thursday 11(p.m.) -7 (a.m.) shift started on 3/7/22 at 10:18 p.m. Administer nebulizer treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Auscultate lung sounds prior to and post treatment. Document # (number) of minutes administered started on 3/7/22 at 10:18 p.m. Rinse nebulizer mask after each use and allow to air dry started on 3/7/22 at 10:18 p.m Oxygen via nasal cannula 3 liters every shift dated 12/29/21. Monitor temperature and oxygen levels every shift. Notify provider if temp (temperature) over 100.4 or oxygen less than 90%, dated 12/27/21. A review of COVID screening from 2/28/22 to 3/8/22 at 2:57 a.m. reflected lungs clear. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of oxygen saturations on all three shifts for the month of March 2022 were documented as 94% or above. A review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Treatment Administration Record (TAR) for March 2022 reflected oxygen via nasal cannula at 3 liters every shift with oxygen levels above 94% from March 1st to March 7th. A review of the resident care plan reflected a focus area of oxygen therapy and nebulizer's related to impaired gas exchange initiated on 1/3/22. Interventions included: medications and treatments as ordered initiate on 1/3/22, monitor for signs and symptoms of respiratory distress, respirations, pulse oximetry, increased heart rate initiated on 1/3/22. The resident has oxygen via 3 liters continuously initiated on 1/3/22. A resident focus area of impaired cognition related to dementia and does not verbalize her needs initiated on 11/16/18. Interventions included: monitor physical appearance for nonverbal communication initiated on 11/16/18. A resident focus area for bilateral contractures of upper bilateral hands initiated on 1/3/22. Interventions included: resident unable to verbalize her pain, monitor for nonverbal signs initiated on 11/26/18. A resident focus area for impairment with inability to achieve full functional range of motion for bilateral upper and lower extremities initiated on 2/19/21. Interventions included: assist to move through tolerated range, supporting joints above and below area to all major joints of upper extremities initiated on 2/19/21. A review of the Minimum Data Set (MDS) for a Brief Interview for Mental Status (BIMS) dated 2/22/22 unable to assess. Section O: Special Treatments reflected no oxygen in use. During an interview with Staff A, LPN and the DON on 3/7/22 at 2:57 p.m. the DON stated Staff A, stated she gave two breathing treatments and called the physician to get approval for a second nebulizer treatment. The DON confirmed the two treatments documented were at 8:50 a.m. and 12:18 p.m. and stated the resident does get anxious when having the face mask put on her so Staff A, left the mask on the resident. Staff A confirmed she called the resident's [family member] after she called the physician. During an interview with the DON on 3/7/22 at 3:53 p.m. she stated Staff A, was suspended pending investigation, and confirmed she was doing full facility training on nebulizers as the Medical Director was also Resident #5's physician and was not made aware of oxygen levels in the eighties and did not approve a second nebulizer treatment. The DON confirmed the Medical Director was reviewing all nebulizer treatments in the facility and changed Resident #5's nebulizer treatments to every six hours as needed. A review of facility policy entitled, Aerosol (nebulizer) Therapy, revised 4/24/18, two pages, reflected: 11. Monitor the resident's heart rate, respiratory rate and breath sounds prior to administration of medication . 13. Place the mask or mouthpiece on the resident. 14. Sit in an upright or semi-upright position if possible. Use slow diaphragmatic breathing with an inspiratory hold. Nebulize solution for approximately 10 minutes or until all the solution has been administered . 16. Clean nebulizer once treatment is completed. a. Dismantle and rinse nebulizer under warm water. b. allows to air dry. C. reassemble and place in plastic storage bag. 17. Assess therapy for efficacy by: a. Periodic observation of the amount and color of sputum produced during and immediately after a treatment. b. Monitoring the resident for adverse reactions such as [CONDITION(S)], sudden bronchospasm, nausea, and vomiting. C. Monitor the resident's breath sounds before and after therapy. 2. An observation was conducted of Resident #198 on 03/10/22 at 7:55 AM. The resident was sitting up on the side of his bed and in the process of receiving a nebulizer treatment. An observation of the resident's nebulizer mask was noted to be away from his face and not covering his nose. There was no nurse noted to be in the room. An observation of the hallway revealed that Staff B, Registered Nurse (RN) at the nurse's cart which was parked across the hall outside of room [ROOM NUMBER]. Staff B, RN was noted to have her back to the room while she poured medication. An observation was conducted on 03/10/22 at 8:05 AM. Staff B, RN was noted to lock the medication cart, enter room [ROOM NUMBER] across the hall and push the door closed behind her. Resident #198 continued on with his treatment and the mask continued to be away from his face and not appropriately placed. An interview on 03/10/22 at 8:07 AM with the Director of Nursing (DON), while outside of Resident #198's room, revealed the nurse is allowed to leave a resident while receiving a nebulizer treatment as long as the staff stays in the vicinity of the resident room. She reported that although Staff B, RN is in another room with the door pulled closed that is considered in the vicinity of Resident #198's room. The DON was unable to verbalize if the nurse was able to hear or see if the resident was in any distress while receiving the treatment. An interview was conducted on 03/10/22 at 8:10 AM with Staff B, RN. She confirmed the resident's nebulizer mask was not appropriately placed on his face. She reported that maybe the resident shifted, and the nebulizer mask loosened. The nurse was observed to pull on both sides of the blue rubber straps attached to the nebulizer mask and appropriately secure the mask around the resident's mouth and nose. At this time, the nurse verbalized the treatment was complete and removed the mask and placed it into a clear bag located in the resident's top nightstand drawer. The nurse was not noted to clean the mask prior to placing it in the bag. The nurse reported that she was unsure if the resident received all of his treatment. An interview was conducted on 03/10/22 at 8:25 AM with Staff C, RN/Unit Manager. Staff C stated if a facemask is not fitted correctly it should be re-adjusted to fit appropriately. She reported when a nebulizer mask is removed it should be disinfected and re-bagged. An observation of the mask through the clear bag revealed the inside of the mask was wet. Staff C, RN confirmed the inside of the mask was wet. Staff C, RN proceeded to change the nebulizer mask and tubing. 3. A review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Evaluation Scoring Report dated 2/2/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. An observation was conducted of Resident #59's room on 03/07/22 at 10:40 AM. The resident was noted to have a nebulizer machine at the bedside on the night stand. The machine was noted to have a clear clasp where the mask was noted to be clipped to. The mask was not bagged or stored to prevent contamination. (Photographic Evidence Obtained) A review of the resident's current order summary for March 2022 revealed the resident has current orders that include the following: -[MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3) mg/3ml. 3ml inhale orally via nebulizer every 6 hours for [CONDITION(S)]. Start date: 1/29/2022, -Budesonide Suspension 0.5mg/2ml. 2ml inhale orally via nebulizer two times a day for SOB (shortness of breath). Rinse mouth with water after use. Do not swallow. Start date: 2/4/2022. A review of the MAR for March 2022 revealed the following: -[MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3) mg/3ml. 3ml inhale orally via nebulizer every 6 hours for [CONDITION(S)], The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -Budesonide Suspension 0.5mg/2ml. 2ml inhale orally via nebulizer two times a day for SOB (shortness of breath). The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility policy titled Aerosol (Nebulizer) Therapy, with a revised date of 04/24/2018, revealed the following: Clean nebulizer once treatment is completed. a. Dismantle and rinse nebulizer under warm water. b. Allow to air dry. c. Reassemble and place in plastic storage bag. Assess therapy for efficacy by: a. Periodic observation of the amount and color of sputum produced during and immediately after a treatment.

Based on observation, record review and interview the facility failed to ensure pain management was provided for one resident (#194) of 34 sample residents. Findings included: A review of Resident # 194's medical record revealed she was admitted to the facility on [DATE] with the primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Social Service Evaluation dated 2/23/22 revealed a Brief Review for Mental Status (BIMS) score of 14, indicating cognitively intact. An observation of the resident was conducted on 03/07/22 at 10:20 AM. The resident was sitting up in bed holding on to her left leg below the knee and grimacing. An interview with Resident #194 was conducted at this time, she reported she is in pain and has used the call light two times to get her pain medication and the aide came in and turned the light off and said she would let the nurse know. She reported that she has been asking for the pain medication since the breakfast trays were distributed. An interview was conducted on 03/07/22 at 10:30 AM with Staff D, Registered Nurse (RN). Staff D, RN stated about 15 minutes ago the aide did tell her the resident needed her pain medication and that she was about to administer her medication now. The resident asked the nurse what time she last received her pain medication, and the nurse reported the resident last received her pain medication at 3:50 AM., Staff D reported the breakfast tray usually comes between 7:00 AM to 7:30 AM. A review of the resident's current physician orders for March 2022 revealed the following: [MEDICATION(S)] Tablet 5-325 mg (milligram) give 2 tablet by mouth every 4 hours for moderate to severe pain. A review of the progress note dated 3/7/22 08:00 (8:00 a.m.) revealed Skilled SOAP (subjective, objective, assessment, plan) Note-Subjective: pt. c/o (patient complaints of) pain in L (left) leg, on other concerns; Objective: VSS (vital signs stable), no distress noted, pt. in bed; Assessment: post fall w/L (with left) ankle fx (fracture), [CONDITION(S)], CHF ([CONDITION(S)]), CABG (Cardiac Arterial Bypass Graft), [CONDITION(S)] ([CONDITION(S)]), AFIB ([CONDITION(S)]), COVID; Plan; Continue with current POC (Plan of Care). A review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medication Administration Audit Report for 3/7/22 revealed the resident had [MEDICATION(S)] scheduled for 4:00 AM, and the resident received this dose at 3:49 AM. A continued review of the Medication Administration Audit Report for 3/7/22 revealed the resident was scheduled to receive [MEDICATION(S)] at 8:00 AM and received the [MEDICATION(S)] dose at 10:36 AM. A review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 03/08/22 at 3:37 PM with the Director of Nursing (DON). She stated pain should be addressed as needed and if the resident is due for pain medications it should be administered as ordered by the physician, taking into account the 1 hour before and 1 hour after scheduled time rule. She reported if a medication were late the physician would need to be called, notified, and give an order to administer the medication outside of the scheduled time. The DON confirmed the resident had a current order for [MEDICATION(S)] 2 tabs every 4 hours for moderate to severe pain and confirmed the medication is to be administered on a routine schedule. A review of the Medication Administration Audit Report for 3/7/22 was conducted with the DON. The DON confirmed the resident received her [MEDICATION(S)] at 3:49 AM and again at 10:35 AM. (more than 2 hours after the scheduled dose was due). The DON confirmed the resident did not receive her 8:00 AM dose of [MEDICATION(S)] on time. A review of the facility policy titled Medication Pass Guidelines, with a revised date of 04/25/2017 revealed the following: -Purpose To assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner.

Based on observations, record reviews, and interviews the facility failed to monitor the behaviors and side effects of [CONDITION(S)] medications for one resident (#12) out of five residents sampled for the task of unnecessary medications. Findings included: Resident #12 was admitted on [DATE], discharged to an acute facility on 2/24/22 and readmitted on [DATE]. The Admission Record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #12's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] (HCl) capsule Delayed Release particles 20 milligram (mg) - Give 2 capsule by mouth two times a day for depression. The order started on 2/11/22, was on hold from 3/2 to 3/3/22, and discontinued on 3/8/22. The March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . - [MEDICATION(S)] (HCl) capsule Delayed Particles 20 mg - Give 2 capsule by mouth two times a day for depression. The March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The order did not instruct staff to document behaviors related to the administration of [MEDICATION(S)]. A review of the Behavior Monitoring and Interventions Report, printed on 3/10/22 at 11:24 a.m., identified the following: - No documentation of behaviors during the day or evening shift on 3/4/22. - No documentation of behaviors during the evening shift on 3/5/22. - No documentation of behaviors that were or were not exhibited on the day and evening shift on 3/6/22. - No documentation of whether behaviors had been exhibited on the evening shift of 3/7/22. - No documentation of whether behaviors had been exhibited during the day shift on 3/8/22. - No documentation of whether behaviors had been exhibited during the day or evening shift on 3/9/22. A review of the care plan for Resident #12 identified the resident uses antidepressant medication related to (r/t) poor adjustment with depressed mood and was at risk for adverse reactions to [CONDITION(S)] medication. The focus was initiated, created, and revised on 12/16/21. The interventions instructed staff to Monitor ongoing signs/symptoms (s/s) of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, [CONDITION(S)], negative (neg.) mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, (and) constant reassurance. Resident #12's care plan indicated the resident was resistive to care, refusal of showers, non-compliant with fluid restrictions, refusal of peri-care, refusal of weights r/t adjustments to admission/new environment. The March 2002 Treatment Administration Record (TAR) indicated Resident #12 had refused to have the weight obtained at 8:00 a.m. on 3/9/22. The Behavior Monitoring Report did not identify that the resident had any refusals of care. An interview was conducted with the Director of Nursing (DON) on 3/10/22 at 2:37 p.m. She stated the staff should be documenting behaviors and side effects every shift. A review of the policy entitled, [CONDITION(S)] Medication Assessment and Monitoring, revised on 10/30/2018, identified the purpose was To administer and monitor the effects of [CONDITION(S)] medications. The policy indicated the following: - The Interdisciplinary Team assessed and monitored the appropriateness, effectiveness, and side effects associated with [CONDITION(S)] medications for each resident via the Minimum Data Set (MDS) process. - Monitoring of residents receiving antipsychotic medication will be completed by a licensed nurse as per acceptable standards of practice using the behavior monitoring record. - Each resident's drug regiment must be free from unnecessary drugs. An unnecessary drug is any drug when used: -- c) Without adequate monitoring; or -- d) Without adequate indications for its use; or The documentation portion revealed that staff should Record behavior, interventions, and the effectiveness of interventions taken in the behavior monitoring record.

Based on observations, clinical record reviews, and interviews, the facility failed to respect the right to dignity for three (#56, #59, and #60) of 16 residents receiving extensive or total assistance with eating as evidenced by staff members standing over, in front of, and to the side of the residents while assisting them with mid-day nutrition. Findings included: On 12/29/20 at 1:00 p.m., an observation was conducted of Staff Member F, Certified Nursing Assistant (CNA), standing in front of Resident #56 while assisting with eating. The observation revealed the resident was dependent on the staff member with oral intake and she did not attempt to feed herself. During this observation, Resident #56's roommate, Resident #59, was assisted with the mid-day meal by Staff Member G, CNA. Resident #59 was sitting in a wheelchair with an over-the-bed (obt) table in front of her wheelchair. The staff member was standing on the other side of the obt. Resident #59 held a carton of milk but did not attempt to use utensils or fingers to feed herself. At 1:00 p.m., the resident room next to Resident #56's and 59 was also observed. Resident #60 was sitting in a wheelchair with the short side of an obt in front of her. Standing to the side of Resident #60 and in front of the long side of the obt was Staff Member E, CNA. The meal tray was sitting on the obt in front of the staff member. Resident #60 did not attempt to feed herself. At 1:02 p.m., Staff Member F brought Resident #56's lunch tray out of the room and placed it in the meal cart. Staff Member F reported that it was common for staff to stand up while assisting residents with eating. At 1:07 p.m., while Staff E was assisting Resident #60, a chair was observed in the resident's room approximately 4 foot from the staff member. At 1:12 p.m., Staff E & G continued to stand while assisting Resident #59 and Resident #60 with the lunch meal. Staff Member E removed the meal tray, at 1:14 p.m., from Resident #60's room. The staff member stated that they (CNA's) sat with the residents in the dining room to assist them with eating but now there was no chair in the room. Following this statement, Staff E acknowledged that there was a chair in Resident #60's room and stated, well there is. Staff E reported that she was educated on how to assist residents with eating and confirmed that the education included not standing while assisting the residents. At 1:21 p.m., after finishing the lunch meal with Resident #59, Staff G confirmed she had been educated on how to assist residents with eating and staff members were to be sitting. She reported Resident #59 had been trying to lay her head down so the staff member had to stand up to assist her and did not think there was a chair in the residents' room. The staff member looked into the room during the interview and confirmed that there was a chair on the other side of the residents' bed. 1. A review of Resident #56's Admission Record revealed [DIAGNOSES REDACTED]. The 5-day Minimum Data Set ((MDS) dated [DATE] identified a score of 0 out of 15 on the Brief Interview for Mental Status (BIMS), which indicates severe cognitive impairment. The MDS also identified that Resident #56 was totally dependent on one staff member for eating. A review of the staff documentation of Resident #56's Eating - Self Performance from 12/1 - 12/30/20 days indicated that out of 85 opportunities the resident received total assistance from staff 53 times, extensive assistance 3 times, limited assistance twice (2), and was marked not applicable 27 times. Resident #56's care plan identified that the resident had the following focus care areas: *Activities of Daily Living self-care deficit related to increased weakness, decreased balance and coordination; - at risk for decreased nutritional status and dehydration related to past medical history (PMH) as well as the need for a therapeutic and mechanically (mech) altered diet; The interventions for this focus area included: nursing staff to assist with meals as needed. 2. Review of Resident #59's Admission Record revealed [DIAGNOSES REDACTED]. The 5-day MDS, dated [DATE], identified the BIMS score as 10 out of 15, indicating a moderate cognitive impairment. The MDS functional status section indicated that the resident required extensive assist from one person for eating. The staff documented eighty-nine (89) opportunities of Resident #59's self-performance while dining. The performance was as following: - Independent: 24 times; - Supervision: 5 times; - Limited: 17 times; - Extensive: 6 times; - Total Dependent: 9 times; - Not Applicable: 28 times. The care plan for Resident #59 identified an Activities of Daily Living (ADL) deficit as evidenced by the requirement of needing assistance to complete ADL's and that the resident was at nutritional and hydration risk related to a multitude of issues including the need for some assistance with meals. The interventions included instructions for staff to cue as needed during meals as the resident tends to fall asleep, encourage and assist as needed to consume foods, and/or supplements, and fluids, and to assist with eating as needed. 3. Review of Resident #60's Admission Record revealed [DIAGNOSES REDACTED]. The 5-day MDS, dated [DATE], identified a Brief Interview of Mental Status score of 0 indicating a severe cognitive impairment. The MDS revealed the resident was totally dependent upon one staff member for eating. A review of the 12/1 - 12/30/20 eating self-performance task for Resident #60 revealed that out of 85 opportunities, the resident required the following assistance: - Independent: 1; - Limited: 2; - Extensive: 1; - Total: 54; - Not Applicable: 26. A review of Resident #60's care plan indicated that the resident had a self-care deficit related to weakness and the interventions instructed staff to assist with ADL's (including eating) as needed. The care plan identified that the resident was at risk for nutrition /dehydration related to medical history and diagnoses. The interventions instructed staff to assist with ADL's, including eating, as needed. At 12/29/20 at 2:52 p.m., the Corporate Director of Infection Prevention & Control stated she was unable to find a policy regarding dining assistance. She stated the folded cardboard was used as a staff educational presentation due to COVID-19. A photo was taken as she held the cardboard. She stated the expectation was to sit while assisting the resident. When the observation was discussed with her, she stated the facility was told to get rid of all the chairs that were in the rooms due to them being upholstered. The cardboard CNA Meal Assistance education instructed staff to sit while feeding the resident. The Annual Education form, provided by the facility identified that Staff Members F and G had completed the education on 10/16/20 and Staff E had completed the education on 10/14/20. On 12/30/20 at 2:54 p.m., the Director of Nursing (DON) stated the facility was educating staff not to stand while assisting residents to eat and that she had spoken with the involved staff members. The Corporate Nurse stated the facility would be purchasing chairs that could be cleaned in between uses.

Based on observations record review, and interviews, the facility failed to ensure that care plans were implemented related to weights and feeding assistance for two residents (Resident #36 and #34) out of the sampled forty-five residents. Findings included: 1. A record review of the Admission Record revealed that Resident #36 was admitted into the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. The resident had the following current order that was revised 12/11/18: Daily weights x 7 days then q (every) MWF (Monday, Wednesday, and Friday) Resident #36 had the following weights: 02/04/19- 140 lbs 01/02/19- 144.8 lbs 12/20/18- 147 lbs 12/12/18- 150.8 lbs 12/05/18- 150 lbs The resident did not have weights done daily for 7 days and did not have weights done every Monday, Wednesday, and Friday per the physician's orders [REDACTED].>The care plan related to nutrition initiated on 12/07/18 indicated that the focus was to anticipate weight fluctuations related to fluid changes with [MEDICAL CONDITION]/diuretics. The interventions included but were not limited to assist with meals as needed and weights per facility protocol. On 02/27/19 at 12:45 p.m., the Director of Nursing (DON) reported that the weights in the computer were the only weights that she saw for the resident. The DON stated that the Certified Nursing Assistants (CNAs) were responsible for doing weights and her expectations would be to follow the order. The nurse was responsible for notifying the CNAs if the resident needed weights done every MWF. On 02/28/19 at 9:56 a.m., the Registered Dietitian (RD) reported that all residents were weighted on admission, weekly times 4 weeks, and then monthly. The doctor puts in the orders for daily weights when the residents have a history of [MEDICAL CONDITION], [DIAGNOSES REDACTED]. The RD reported that Resident #36 needed more weights because she had heart failure and sometimes they like to get more weights for precautions. The RD reported that when reviewing the residents, if she saw the order, she would approach the nurse and let the nurse know that she needed weights according to the orders. It is important to follow doctor orders, stated the RD. On 02/28/19 at 10:25 a.m., Staff A, CNA, stated that the nurse would let him know about any physician's orders [REDACTED]. On 02/28/19 at 11:01 a.m., Staff B, Registered Nurse (RN) reported that the CNAs were responsible for weights that were ordered by the physician. The nurses were responsible for notifying the CNAs. Staff B reported that the order for the weights was not communicated because it was a transcription error. The policy Comprehensive Person-Centered Care Plans revised 03/28/17 revealed the following: The services provided or arranged by the facility, as outlined by the comprehensive care plan must: ii. Be provided by qualified persons in accordance with each resident's written plan of care. 2. Review of resident #34's electronic record revealed that this resident had [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) dated (MONTH) 11th 2019 revealed that this resident has a BIMS score of 00 Interview on 2/25/19 at 10:35 AM with resident #34's spouse revealed that the spouse reported that the resident has had some wt loss. He was unsure as to what interventions were currently in place to address the weight loss. Review of Resident #34's care plan for Activities of Daily Living, dated 6/27/11 with the most recent revision date of 4/10/14, revealed that this care plan addresses Activities of Daily Living (ADL) self care deficit, as evidenced by weakness, decreased ability to perform selfcare adls the care plan had interventions that included for staff to Assist with daily hygiene, grooming, dressing, oral care and eating as needed. Review of Resident #34's care plan for altered nutrition status, dated 4/21/14 with most recent revision date of 12/20/18, with a goal to consume 50% of most meals per day. The interventions included Encourage and assist as needed to consume foods and/or supplements and fluids offered. Review of Resident #34's electronic record revealed that on 9/4/18 the residents weight was 132.0, and 6 months later the resident had a weight taken on 2/5/19 which indicated that the residents weight was 125.00. Observations on 2/28/19 at 7:47 AM of Resident #34 revealed that her morning meal tray was set up on her over bed table directly in front of the resident. The resident was observed to be sleeping, inspection of her morning meal revealed that the tray was set up but nothing ha been eaten. Continued observation on 2/28/19 at 8:03 AM of the resident revealed that the resident was still asleep with her morning meal tray in front of her. None of the residents meal had been eaten. Continued observation on 2/28/19 at 8:11 AM of the resident revealed that the resident was still asleep with her morning meal tray in front of her, with her meal still untouched. Continued observation on 2/28/19 at 8:26 AM of the resident revealed that the resident was still sitting up in her bed, with the over bed table in front of her and her morning meal still sitting on the over bed table. Continued observation of the residents room on 2/28/19 at 8:45 AM revealed that Staff F, CNA entered the residents room and picked up the tray and removed it from the resident's room. The resident remained asleep when the meal tray was removed from the room. It was noted that Staff F did not ask the resident if she was done with her meal, or if she wanted an alternate meal. An interview with Staff F at this time revealed that different staff try to feed the resident to see if she will eat from different staff. She reported that the resident's husband also brings the resident breakfast. She reported that she was not assigned to the resident for this shift. The resident's room could be seen from the nurses station. It was noted that no staff entered the room to assist the resident with her morning meal from 7:47 AM to 8:45 AM when StaffF entered the room to retrieve the residents meal tray. An interview on 2/28/19 at 8:52 AM with Staff G, CNA, revealed that this resident needs to be fed. She reported that she is assigned the resident for this shift, however, the CNA on the floor was assigned to feed her. An interview on 2/28/19 at 8:54 AM with Staff H, RN, revealed that when the resident first received her meal, 2 or 3 different staff went into the resident's room and tried to feed her. She reported that the resident refused her meal. She reported that the resident received her meal around 8:30 AM. Review of the resident's Nutritional Quarterly note dated 1/8/19 revealed the following: -Regular diet -Wt changes <1.5% x 30 days, <6.6% x 90days, <8.8% x 180 days. -Patient is on a regular diet and she eats between 0-25% of her meals and she eats them in her room. Patient also receiving Ready Care daily after meals and fortified foods tid. Review of the (MONTH) Physician order [REDACTED]. -Ready care 2.0 after meal for additional calories and protein 120 ml q serving -Regular diet, Mechanical Soft texture Interview with the Registered Dietician on 2/28/19 at 11:49 AM revealed that the resident does need to be assisted with her meals, and that she eats all meals in her bed. She reported that the resident is currently on the supplement Ready care 2.0 and that she accepts that well. She reported that she expects that the staff offer alternative and offer more soups as she likes to drink.

Based on observation, interview and record review the facility failed to ensure that for residents who required assistance with meals that adequate assistance and supervision was provided to 1 of 45 (#34) sampled residents. Findings included: Review of resident #34's electronic record revealed that this resident has [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) dated (MONTH) 11th 2019 revealed that this resident has a BIMS score of 00 Interview on 2/25/19 at 10:35 AM with resident #34's spouse revealed that the spouse reported that the resident has had some wt loss. He was unsure as to what interventions were currently in place to address the weight loss. Review of Resident #34's electronic record revealed that on 9/4/18 the residents weight was 132.0, and 6 months later the resident had a weight taken on 2/5/19 which indicated that the residents weight was 125.00. Observations on 2/28/19 at 7:47 AM of Resident #34 revealed that her morning meal tray was set up on her over bed table directly in front of the resident. The resident was observed to be sleeping, inspection of her morning meal revealed that the tray was set up but nothing ha been eaten. Continued observation on 2/28/19 at 8:03 AM of the resident revealed that the resident was still asleep with her morning meal tray in front of her. None of the residents meal had been eaten. Continued observation on 2/28/19 at 8:11 AM of the resident revealed that the resident was still asleep with her morning meal tray in front of her, with her meal still untouched. Continued observation on 2/28/19 at 8:26 AM of the resident revealed that the resident was still sitting up in her bed, with the over bed table in front of her and her morning meal still sitting on the over bed table. Continued observation of the residents room on 2/28/19 at 8:45 AM revealed that Staff F, CNA entered the residents room and picked up the tray and removed it from the residents room. The resident remained asleep when the meal tray was removed from the room. It was noted that Staff F did not ask the resident if she was done with her meal, or if she wanted an alternate meal. Interview with Staff F at this time revealed that different staff try to feed the resident to see if she will eat from different staff. She reported that the residents husband also brings the resident breakfast. She reported that she is not assigned to the resident for this shift. The residents room can be seen from the nurses station. it was noted that no staff entered the room to assist the resident with her morning meal from 7:47 AM to 8:45 AM when StaffF entered the room to retrieve the residents meal tray. Interview on 2/28/19 at 8:52 AM with Staff G, CNA, revealed that this resident needs to be fed. She reported that she is assigned the resident for this shift, however, the CNA on the floor was assigned to feed her. Interview on 2/28/19 at 8:54 AM with Staff H, RN, revealed that when the resident first received her meal, 2 or 3 different staff went into the residents room and tried to feed her. She reported that the resident refused her meal. She reported that the resident received her meal around 8:30 AM. Review of the residents Nutritional Quarterly note dated 1/8/19 revealed the following: -Regular diet -Wt changes <1.5% x 30 days, <6.6% x 90days, <8.8% x 180 days. -Patient is on a regular diet and she eats between 0-25% of her meals and she eats them in her room. Patient also receiving Ready Care daily after meals and fortified foods tid. Review of the (MONTH) physician Orders revealed that the resident had current orders that included: -Ready care 2.0 after meal for additional calories and protein 120 ml q serving -Regular diet, Mechanical Soft texture Review of Resident #34's care plan dated 6/27/11 with the most recent revision date of 4/10/14 revealed that this care plan addresses Activities of Daily Living (ADL) self care deficit, as evidenced by weakness, decreased ability to perform selfcare adls the care plan had interventions that included for staff to Assist with daily hygiene, grooming, dressing, oral care and eating as needed. Review of Resident #34's care plan dated 4/21/14 with most recent revision date of 12/20/18 with a goal to consume 50% of most meals per day. With interventions that include Encourage and assist as needed to consume foods and/or supplements and fluids offered. Interview with the Registered Dietician on 2/28/19 at 11:49 AM revealed that the resident does need to be assisted with her meals, and that she eats all meals in her bed. She reported that the resident is currently on the supplement Readycar 2.0 and that she accepts that well. She reported that she expects that the staff offer alternative and offer more soups as she likes to drink.

Based on record review and interview the facility failed to follow up on recommendations made by the consultant pharmacist for 1 of 5 (#10) residents sampled for unnecessary medications. Findings included: Review of Resident #10's record revealed that this resident was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of Resident #10's (MONTH) 2019 Physician Orders revealed that that the resident had an order for [REDACTED]. An interview with the Director of Nursing (DON) on 2/27/19 at 11:49 AM revealed that she was not sure if the resident was reviewed in January. She reported that if the resident did not show up on the pharmacy review sheet, which typically means that the resident had a recommendation. Review of the pharmacy review of the medical record for the month of (MONTH) 2019 with a date of 1/23/2019, revealed a recommendation indicating that the resident receives vitamin D, Please monitor a 25-[MEDICATION NAME] D concentration on the next convenient lab day. Adjust Vitamin D dose accordingly. The rational for the recommendation includes; Serum values greater than 200 ng/mL are considered toxic. Review of the hysician Order, with an order date of 2/27/19 10:01 AM revealed a telephone order for Vitamin D Level 03/01/2019 one time only until 03/01/2019 Review of the Practioner Progress Notes for Resident #10 revealed that the ARNP saw this resident 3 times since the recommendation was made on 1/24/19, 1/31/19 and 2/5/19. There was no documentation in the notes that would indicate that the physician or the ARNP was aware or made changes related to the recommendation dated 1/23/19. An interview with the DON on 2/27/19 at 12:45 PM revealed that she spoke to the ARNP who reported that she was not sure why there was no documentation of the physician notification of the pharmacy recommendation. She reported that the resident gets a once monthly dose and that the resident has only received 1 dose since the recommendation. A telephone interview with the Consultant Pharmacist, on 2/28/19 at 11:17 AM, revealed that her expectation was that the lab work to be done on the next convenient lab day within 30 to 60 days depending on any issues the resident/facility may have. She reported that her expectation for notification to the physician regarding the new recommendation, was that the physician should be notified in a timely manner. She reported that she expects that the physician be notified of the recommendation when the physician is next there in the building within 30 to 60 day of the recommendation being made. Review of the facility policy titled Medication Regimen Review with an effective date of 12/01/07; 11/28/16 section titled Procedure #6 revealed that Facility staff should ensure that the attending physician, Medical Director and Director of Nursing are provided with copies of the MMRs; #7.2 indicated that The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it.; #11 indicated that The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident,

Based on observations, interviews, and clinical record review, the facility failed to ensure two (Resident #95 and Resident #94) of 45 residents sampled were free from significant medication errors. Findings included: 1. On 2/28/19 at 9:10 a.m. Nurse D was observed removing [MEDICATION NAME] 5 mg four tablets. The label, dated 2/19/19, indicated the resident was to receive 20 mg for 3 days, then 10 mg for 3 days, then 5 mg for 3 days. Nurse A stated that she was going to medicate Resident #95 with 20 mg of [MEDICATION NAME]. The surveyor intervened and asked Nurse D to re-check the order. Nurse D medicated Resident #95 with two 5 mg tablets for a total 10 mg of [MEDICATION NAME]. A review of the physician's orders [REDACTED]. Give 20 mg by mouth one time a day for [MEDICAL CONDITIONS] for 3 days, AND give 10 mg by mouth one time a day for [MEDICAL CONDITION] for 3 days, AND give 5 mg by mouth one time a day for [MEDICAL CONDITION] for 3 days. A review of the Medical Administration Record (MAR) included Resident #95 received 20 mg of the [MEDICATION NAME] for 3 days from 2/19-2/21/19, but then received no [MEDICATION NAME] on 2/22/19.The next reduced dose of 10 mg was given for 3 days from 2/23-2/25/19, but then Resident #95 received no [MEDICATION NAME] on 2/26/19. The next reduced dose of 5 mg was begun on 2/27/19, and the resident should have received 5 mg of [MEDICATION NAME] that morning, which was documented, but 10 mg was observed to be administered. On 2/28/19 at 10:15 Nurse D reviewed the orders, the MAR and the label of the [MEDICATION NAME]. She confirmed the resident should have received only one tablet earlier that morning as the order indicated the resident was to have 5 mg. She confirmed the resident received 10 mg in error. On 2/28/19 at 10:40 a.m. the Regional Nurse Consultant reviewed the MAR and confirmed the order for [MEDICATION NAME] was entered into the electronic MAR incorrectly and this resulted in the resident missing all of her dosage of [MEDICATION NAME] for 2 days in addition to the medication error that was observed that morning. On 2/28/19 at 11:30 a.m. a telephone interview was conducted with the consulting pharmacist. She stated that [MEDICATION NAME] should be administered as ordered and should be tapered gradually to avoid serious adverse effects associated with steroidal medication. 2. On 02/25/19 at 9:45 a.m, Resident #94 was observed sitting in his room in his wheelchair next to the bed. He reported that he felt really sick and that he had never felt that way before after getting insulin. On 02/26/19 at 12:09 p.m., Resident #64 was observed in his room. The resident reported that he felt better than he did yesterday, but he felt nauseated after eating. A record review of the Admission Record revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had the following current orders: [MEDICATION NAME] Solution 100units/ml- Inject 30 unit subcutaneously at bedtime for DM (diabetes mellitus) hold and call NP (nurse practitioner) for Dose adjustment <90 on BS and inject 18 unit subcutaneously one time a day for DM and call NP for dose adjustment <90 on BS Humalog Solution 100 units/ml- Inject as per sliding scale subcutaneously before meals and at bedtime A review of the Medication Administration Record (MAR) for (MONTH) (YEAR) for [MEDICATION NAME] revealed that [MEDICATION NAME] was not administered on the following days and the blood sugar was not less than 90: 02/16- 130 blood sugar and a 10 was entered in the box 02/18- 200 blood sugar and a 10 was entered in the box 02/19- 200 blood sugar and a 10 was entered in the box 02/21- 120 blood sugar and a 10 was entered in the box 02/23- 180 blood sugar and a 10 was entered in the box 02/24- 142 blood sugar and a 10 was entered in the box 02/25- 157 blood sugar and a 10 was entered in the box. According to the chart codes on the MAR, 10 indicated insulin was not required. There was no other documentation as to why the insulin was not administered when the blood sugars were higher than 90. Section C of the Minimum (MDS) data set [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicated that he was cognitively intact. Section N indicated that the resident received insulin injections 7 days a week. On 02/27/19 at 12:40 p.m., the Director of Nursing (DON) reported that her expectations would be that the insulin was administered unless the blood sugars were less than 90. The nurse who did not administer the insulin on those day was not in the facility and the DON reported that she could not get a hold of her. On 02/28/19 at 11:30 a.m., the Consultant Pharmacist reported that if the insulin was supposed to be held if the order said to hold if the blood sugar was less than 90 then she would assume that the insulin would have been given if the blood sugar was higher than 90. There should have been documentation as to why the medication was not given stated the Consultant Pharmacist. The policy Medication Pass Guidelines revised 04/25/17 revealed the following: Purpose To assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. To systemically distribute medications to residents in accordance with state and federal guidelines. Fundamental Information physician's orders [REDACTED].

Based on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for one (#64) out of 26 sampled residents. Findings included: Resident #64 was admitted on [DATE] with readmission on 10/30/17. The [DIAGNOSES REDACTED]. The 14-day Minimum Data Set ((MDS) dated [DATE] indicated Brief Interview of Mental Status 13, cognitively intact. The 14-day MDS revealed resident answered yes to feeling down, depressed or hopeless 12-14 days, and had trouble falling asleep or sleeping too much 7-11 days. Review of Order Summary Report dated 11/22/17, indicated a physician order [REDACTED]. Review of electronic Medication Administration Record [REDACTED]. The dose of [MEDICATION NAME] XR increased to 75 mg one time a day for depression on 11/15/17. Continued review indicated the resident received [MEDICATION NAME] 0.5 mg on 11/7 and 11/8/17. Resident #64's care plan did not reveal the development or implementation of focuses or interventions in regards to the resident's use of antidepressant or antianxiety medications. During an interview on 11/22/17 at 9:02 a.m., staff member B, MDS coordinator, stated that on a daily basis unit managers and MDS staff review new orders and add a new care plan if needed. The facility discusses new orders during morning meeting as well as new admissions. Staff member B reviewed the current care plan for Resident #64 and confirmed the resident did not have a care plan for either antidepressant or antianxiety medications. The staff member stated medication care plans for antidepressant and antianxiety should had been added at the time the orders were received. Review of Phase 2: Plan, dated 2015, stated the care plan is reviewed and updated to reflect the patient's current status and care delivery needs, as clinically indicated and per state and federal regulations. Phase 3: Implement, stated patient behavioral symptoms are documented in the clinical record. Direct care staff, including nurses, therapy staff and nursing assistants document behavioral symptoms using the Custom Alert function in Point of Care (P(NAME)).