Every finding on record at Oxley Park Health and Rehabilitation

Based on observations, staff interviews, and review of the Food and Supply Storage policy, the facility failed to ensure foods were properly covered, sealed, labeled, dated, and discarded, and failed to maintain clean kitchen equipment. These failures resulted in improper food storage and unsanitary food preparation conditions, creating a risk of cross contamination and foodborne illness for 85 residents receiving oral diets.Findings include:Review of the facility's policy titled Production, Purchasing, Storage: Food and Supply Storage, revised on 1/17, documented under Procedures. Most products contain an expiration date. The words sell-by, best-by, enjoy-by or use-by should precede the date. The sell-by date is the last date that food can be sold or consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the use by, sell-by, best-by, or enjoy by date should be discarded; Cover, label and date unused portions and open packages. Use the [NAME] orange label, Medvantage label or Ecolab Prep N Print label; complete all sections on the label. Products are good through the close of business on the date noted on the label.Observation and interview on 03/03/2026, beginning at 8:58 AM with the Certified Dietary Manager (CDM), revealed that the following concerns were identified and confirmed:The walk in freezer contained a box of frozen pie dough rounds with an expiration date of 12/23/2025.The walk in freezer contained a box of macaroons with an expiration date of 02/04/2026.The walk in refrigerator contained a white Styrofoam plate with leftover hamburgers that were not labeled or dated.The walk in refrigerator contained a bag of shredded lettuce with brown leaves that was unsealed and without a label.The walk in refrigerator contained a box of cucumbers covered with a white film and an expiration date of 02/27/2026.The dry pantry contained a box of graham crackers with an expiration date of 03/02/2026.The dry pantry contained a box of sweet chocolate chips with an expiration date of 12/16/2025.Two basket deep fryers contained blackened, used grease, a greasy black substance on the top of the fryer, and crumbs on both the left and right sides of the fryer.The can opener contained a greasy black substance.The Certified Dietary Manager (CDM) confirmed these concerns and stated that dietary staff needed re education regarding proper labeling, dating, and discarding of food items.Interview on 03/04/2026 at 2:23 PM with the Registered Dietitian (RD) revealed that it was her expectation that staff properly label, store, date, and discard expired food.Interview on 03/05/2026 at 10:40 AM with the Administrator revealed that her expectations were for dietary staff to ensure all food was properly labeled and stored, and that expired food was discarded. She stated that it was her expectation that all dietary staff receive education on how to properly label, date, store leftover foods, and discard expired foods.

Based on observations, staff and resident interviews, record review, and review of the facility policies titled Hand Hygiene, the certified medical assistants (CMAs) failed to use proper hand hygiene for three of three residents sampled, residents (R) R8, R63, and R91 when administering their medications. This failure increased the risk of infection transmission among residents and staff.Findings include:Review of the policy titled Hand Hygiene, revised 12/27/2025 documented Intent, it is the intent of this facility to promote and facilitate appropriate hand washing as set forth by the guidelines of CDC. Hand Hygiene is the single most important means of preventing the spread of infection. The use of gloves does not replace hand washing. Survey Tag F880, S483.80 (a)(1 - 2) (4) (e-f). Guidelines- Associates should use alcohol-based hand rub or wash hands with soap and water for the following indications: Immediately before touching a patient. Before performing an aseptic task (e.g., placing an indwelling device or handling indwelling devices). Before moving from a soiled body site to a clean body site on the same patient. After touching a patient or the patient's immediate environment. After contact with blood, body fluids or contaminated surfaces. Immediately after glove removal.1.Review of the electronic medical record (EMR) revealed R8 was admitted on [DATE] with pertinent diagnoses including, but not limited to, benign prostatic hyperplasia with lower urinary tract symptoms and Type 2 diabetes mellitus with hyperglycemia.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment.Review of the Physician's Orders for R8 included, but was not limited to, an order dated 12/19/2025 for Lantus Solostar U 100 insulin 60 units subcutaneously twice daily, with multiple approved injection sites listed.2. Review of the EMR revealed R63 was admitted on [DATE] with pertinent diagnoses including Type 2 diabetes mellitus with hyperglycemia, other abnormalities of gait and mobility, and chronic kidney disease stage 4 (severe).Review of the significant change MDS dated [DATE] revealed a BIMS score of 6, indicating severe cognitive impairment.Review of the Physician's Orders for R63 included, but was not limited to, an order dated 12/13/2025 for Aspercreme (lidocaine) 4% topical patch, one patch daily to the neck, to be removed after 8 hours.3. Review of the EMR revealed R91 was admitted on [DATE] with pertinent diagnoses including unspecified dementia with anxiety, hyperlipidemia, anxiety disorder, alcohol abuse with unspecified alcohol induced disorder, depression, essential hypertension, constipation, gastroesophageal reflux disease, and insomnia.Review of the annual MDS dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment. Section GG revealed R91 used a walker and required supervision or touching assistance for ADLs and was independent with eating.Review of the Physician's Orders for R91 included, but was not limited to, an order dated 09/20/2024 for artificial tears twice daily and an order dated 03/05/2024 for lisinopril 20 mg, 1/2 tablet daily, with parameters to hold for systolic blood pressure less than 120.Observation on 03/04/2026 at 9:30 AM with of CMA EE revealed CMA EE did not perform hand hygiene prior to medication setup. CMA EE primed the insulin pen with 2 units and then dialed 60 units. No hand hygiene was performed upon entering the resident's room. R8 was given oral medications, followed by an inhaler; the resident rinsed their mouth. No hand hygiene was performed. CMA EE then grasped R8's left arm and administered insulin without wearing gloves and without performing hand hygiene. CMA EE exited the room without performing hand hygiene and began preparing medications for R63.Observation/ Interview on 03/04/2026 at 9:55 AM revealed CMA EE did not perform hand hygiene prior to medication setup or prior to administering medications to R63. CMA EE donned gloves to apply the lidocaine patch but did not sanitize hands before putting on gloves. After removing gloves, she did not perform hand hygiene. When interviewed, CMA EE stated she realized after the fact that she had not worn gloves when administering insulin to R8. She confirmed she did not perform hand hygiene during medication administration.Observation/Interview on 03/04/2026 at 10:31 AM revealed CMA DD did not perform hand hygiene prior to setting up medications or upon entering R91's room. She donned gloves and administered eye drops, removed gloves, and then applied a blood pressure cuff. She administered oral medications and used hand sanitizer only upon exiting the room. CMA DD stated she had been employed at the facility for about two years and confirmed she did not perform hand hygiene as required. She acknowledged that hand hygiene was important to prevent cross contamination.Interview on 03/05/2026 at 10:23 AM with Register Nurse (RN) BB revealed she had been employed since October 2025. She stated hand hygiene was important to limit the spread of infection and that staff had received hand hygiene education twice since she began employment.Interview on 03/05/2026 at 10:31 AM with RN CC revealed she had been employed approximately six months. She confirmed staff should use hand hygiene and appropriate PPE when providing resident care. She stated staff received infection control in services and that hand hygiene audits were completed.Interview on 03/05/2026 at 11:05 AM with Director of Nursing (DON) revealed she had been employed for six months. She stated she expected staff to use proper hand hygiene and PPE when entering rooms and to wear gloves when needed.Interview on 03/05/2026 at 1:49 PM with the Assistant Director of Nursing / Infection Preventionist (ADON/IP) revealed she had been employed about eight months as the infection preventionist and became ADON two months ago. She confirmed hand hygiene should be completed when providing care, when passing out trays, when hands were visibly soiled, and when entering and exiting resident rooms.

Based on observations, staff interviews, record review, and the facility policy titled Food Preparation and Distribution, the facility failed to ensure pureed therapeutic diets were properly prepared for two of two sampled residents(R) receiving a therapeutic pureed diet. In addition, R58 was observed receiving a pureed meal that was of lumpy consistency. This deficient practice had the potential to cause medical complications and place the residents at risk for unmet nutritional needs.Findings include: 1.Review of the policy titled Food Preparation and Distribution, dated 12/27/2025, documented INTENT-It is the intent of this center to prepare and distribute food in a manner that minimizes the risk of food-borne illness and promotes safe food handling practices. GUIDELINE.During preparation of modified consistency foods, safe food handling should be followed. During preparation, standardized recipes should be followed. Observation and interview on 03/04/2026 at 11:08 AM conducted with the Certified Dietary Manager (CDM), Registered Dietitian (RD), and Dietary Aide (DA) AA revealed that four residents in the facility received a puree diet. Observation of the preparation of pureed chopped steak showed that DA AA used an excessive amount of thickener, which overflowed the measuring spoon while pouring. The consistency was too thick, per the CDM and RD. DA AA then added an unmeasured amount of water to the puree on two occasions to obtain the proper modified consistency. During the observation, DA AA received assistance from the CDM and RD on how to properly measure each ingredient. During the interview, DA AA stated that neither she nor other staff used a recipe when preparing pureed meals. She added that a recipe was only followed when the State was present. DA AA reported that she prepared pureed meals from memory rather than using a standardized recipe. Interview on 03/04/2026 at 12:15 PM with the CDM revealed that DA AA was difficult to work with and tended to be resistant to change. The CDM further reported that DA AA did not consistently follow established procedures. The CDM stated that dietary staff required refresher training on the preparation of puree diets and indicated that it was her expectation that staff always use standardized recipes. Interview on 03/04/2026 at 2:23 PM with the RD regarding the puree process revealed that she had never observed the dietary staff complete a puree process until that day. She stated that she was unaware that staff were not using recipes. She emphasized that if the correct consistency was not achieved, it could put a resident at risk of choking. The dietitian expected all dietary staff to consistently use recipes and further expected that staff receive additional education on completing the puree process in accordance with guidelines. Interview on 03/05/2026 at 10:40 AM with the Administrator revealed that DA AA did not find the recipe as ordered during the puree process. The Administrator stated that it was her expectation that all dietary staff follow standardized recipes when preparing meals. She advised that training would be provided for all food service staff immediately. 2. Record review of R58's electronic health record (EHR) revealed diagnoses that included but not limited to dysphagia, diffuse traumatic brain injury with loss of consciousness of unspecified duration, subsequent encounter, and Gastro-esophageal reflux disease without esophagitis (GERD) Record review of R58's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed for Section C (Cognitive Patterns) a Brief Interview of Mental Status (BIMS) score of nine which indicated moderate cognition impairment. Section K (Swallowing/Nutritional status) revealed that the resident received a mechanically altered diet (which required change in texture of food or liquid, puree food). Review of R58's physician order (revealed a dietary order dated 1/7/2026) for puree 4. Record review of R58's care plan (created 01/07/2026) listed a nutrition Risk Focus area which included an intervention that stated observe for worsening swallowing and/or chewing problems/offer frequent fluids, provided assistance as need. Observation on 03/03/2026 at 12:32 PM revealed R58 in the room sitting on the bed receiving a meal that was of non-pureed consistency. Continued observation of the resident meal included pork chops (appearance was lumpy with mixture of ground meat), vegetable (lumpy), bread (thick and lumpy), and. gravy lumpy. Observation/Interview on 03/03/2026 at 1:40 PM of R58's meal with the Director of Nursing (DON) and Administrator, both administrative staff confirmed that R58's meal was of non-pureed consistency. The Administrator reported this error was a from a lack of guidance. The Administrator reported that her plan was to follow up with the dietary staff today in order to educate the dietary staff on pureed preparation. She will also have the Register Dietician follow up the dietary staff. The DON described the risk for any resident on a puree diet receiving food of non-puree consistency could potentially cause choking/aspiration. Interview on 03/ 04/2026 at 4:42 PM, the Registered Dietician (RD) reviewed the photo of R58s meal and confirmed that plated food items did not meet the standard of a pureed food item. She confirmed dietary staff failed to completely achieve the ultimate consistency of ensuring that each food items were pureed and free from a lumpy texture.

Based on observations, staff interviews, and review of the facility's policies titled, Storage Areas, and Personal Hygiene, the facility failed to discard food in the walk-in cooler by the expiration date and failed ensure dietary staff wore hair restraints while in the food prep area of the main kitchen. The deficient practice had the potential to effect 86 of 92 residents receiving an oral diet. Findings included: Review of the facility's policy titled, Storage Areas revealed, with a review date of [DATE] revealed, Intent: It is the intent of this center to store food in a manner that maintains quality and safety. Guideline: Items should be inspected for quality and temperature control upon receipt. Items should be covered, sealed, labeled, and dated appropriately. Review of the facility's undated policy titled, Personal Hygiene revealed, Intent: It is the intent of this center to establish guidelines for dining and nutritional services associates that promote personal hygiene and infection prevention measures. Guideline: Hair restraints- a hairnet and/or beard restraint should be worn while in the food prep, production, and serving areas. During the tour of the kitchen on [DATE] starting at 8:45 am with the Dietary Manager (DM), the following concerns were identified during the tour: Walk in cooler- A bag of lettuce with a received date of [DATE] and an expiration date of [DATE]. A box of 17 potatoes, one that was green in color and several others that were rotting evidenced by them being black with a fuzzy white and dark brown substance. The potatoes had a received date of [DATE] and an expiration date of [DATE]. Observation and interview on [DATE] at 9:30 am with the DM confirmed the expired bag of lettuce, expired box of potatoes, and discarded them. She revealed that she and her staff were responsible for labeling and dating items when they are received, when opened, and when they are expired. The DM revealed her expectations for staff were to discard expired items and not leave them in the cooler, pantry, or freezer. Observation and interview on [DATE] at 12:10 pm revealed Dietary Aide CC had a hairnet partially covering her head of hair. Dietary Aide CC's hair was tied up into a bun with only the bun being covered, exposing the rest of her hair. The corporate Registered Dietician confirmed that the dietary aide, and all kitchen staff, should have their entire head of hair covered and asked Dietary Aide CC to cover her entire head of hair. Observation and interview on [DATE] at 12:55 pm revealed [NAME] DD with a hairnet partially covering her head of hair. Dietary Aide DD's hair was tied up into a ponytail with only the ponytail covered, exposing the rest of her hair. The DM confirmed that all hair should be covered and that it was her expectation that all staff while handling and serving food have their entire head of hair covered. She asked [NAME] DD to cover her entire head of hair with a hair covering.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Patient's Plan of Care, the facility failed to follow a care plan related to oxygen (O2) use for one of 23 residents (R) (R184). Specifically, the facility failed to ensure the care plan for R184 was followed pertaining to the rate of oxygen ordered. Findings included: Review of the facility's policy titled, Patient's Plan of Care dated 12/27/2024 revealed, Guideline: each patient will have a person-centered comprehensive care plan developed and implemented to address the patients' medical, physical, mental, and psychosocial needs while also honoring their preferences and goals. Procedure-The patient's care plan should be reviewed after each MDS assessment and revised based on changing goals, preferences and needs of the patient and in response to current interventions. The comprehensive care plan should also be updated as ongoing clinical assessments identify changes. Review of the medical record for R184 revealed diagnoses including but not limited to chronic obstructive pulmonary disease, atrial fibrillation, heart failure, and dependence on supplemental O2. Review of the physician orders revealed an order for O2 dated 1/10/2025, Oxygen: nasal canula (NC) 2 liter per minute (LPM) nasally every 8 hours. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section O (Special Treatments and Programs) indicated R184 was receiving O2 therapy and hospice. Review of the care plan initiated on 1/10/2025, revealed that R184 had respiratory difficulties and risk for further decline, as evidenced by Oxygen: nasal canula (NC) 2 liters per minute nasally every 8 hours. Interventions: Administer medications and treatment as ordered. Observation and rounding on 1/30/2025 at 9:01 am with the Director of Nursing (DON) revealed the resident lying in bed receiving oxygen at a rate of three liters per minute (LPM). The DON confirmed the resident's oxygen to be on 3 LPM. The DON checked the electronic health record and confirmed the order was for 2 LPM. It is her expectation that staff review and follow care plan. Interview on 1/30/2025 at 3:50 pm with Minimum Data Set (MDS) Coordinator revealed her expectations of staff were to follow the care plan.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Patient's Plan of Care, the facility failed to revise a care plan related to oxygen (O2) use for one of 23 residents (R) (R184) receiving O2. Findings included: Review of the facility's policy titled, Patient's Plan of Care dated 12/27/2024 revealed, Procedure-The patient's care plan should be reviewed after each MDS assessment and revised based on changing goals, preferences and needs of the patient and in response to current interventions. The comprehensive care plan should also be updated as ongoing clinical assessments identify changes. Review of the physician orders revealed an order for O2 dated 1/10/2025 oxygen: nasal canula (NC) 2 liter per minute (LPM) nasally every 8 hours. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating little to no cognitive impairment. Section J (Health Conditions) indicated shortness of breath, and Section O (Special Treatments, Procedures, and Programs, indicated R184 was receiving O2 therapy. Review of the care plan, initiated on 1/10/2025, revealed that R184 had respiratory difficulties/risk for further decline, as evidenced by, Oxygen: nasal canula 2/LPM nasally every 8 hours. Interventions included: administer medications and treatment as ordered. Observation and rounding on 1/30/2025 at 9:01 am with the Director of Nursing (DON) revealed R184 lying in bed receiving O2 at a rate of 3/LPM. The DON confirmed the O2 was set on 3 LPM and confirmed the order was for 2 LPM. The DON revealed R184 was known to change the O2 rate. She accessed the care plan and verified R184 was not care planned for adjusting the O2 rate and should be. The DON revealed that her staff should be checking the O2 more frequently since R184 is known to adjust the rate. It was the DON's expectation that staff review and follow the care plan. The DON left the interview and later provided a revised care plan dated 1/30/2025 that included patient noted to adjust her own liter flow on O2, with no interventions added. Interview on 1/30/2025 at 3:50 pm with the Minimum Data Set (MDS) Coordinator revealed that nurses and different interdisciplinary team members contribute to the comprehensive assessment and individualize the care plan to fit the resident's ongoing needs. She revealed they have weekly and morning meetings and discuss updates.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Use of Oxygen (O2) Therapy, the facility failed to ensure that the physician's order was followed for one of 23 Residents (R) (R184) reviewed for O2 administration. The deficient practice had the potential to place the resident at risk for medical complications related to O2 not being administered as ordered by the physician. Findings included: Review of the facility's policy titled, Use of Oxygen Therapy dated 12/27/2024, revealed under Guideline: Physician's order for O2 should be obtained and include: O2 with the flow as ordered. Review of the medical record for R184 revealed diagnoses including but not limited to chronic obstructive pulmonary disease, atrial fibrillation, heart failure, and dependence on supplemental O2. Review of the physician orders revealed an order for O2 dated 1/10/2025 Oxygen: nasal cannula (NC) 2 liter per minute (LPM) nasally every 8 hours. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating little to no cognitive impairment. Section J-shortness of breath and Section O-oxygen therapy and hospice. Observations on 1/28/2025 at 10:50 am, and on 1/29/2025 at 8:25 am, revealed R184 lying in bed receiving O2 therapy via NC at 3 LPM. Observation and rounding on 1/30/2025 at 9:02 am with the Director of Nursing (DON) revealed R184 lying in bed receiving O2 via NC at 3/LPM. The DON confirmed R184's O2 was set on 3 LPM. The DON checked the electronic health record and confirmed the O2 order was for 2/LPM. The DON revealed her expectation that staff followed physician orders.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Skilled Nursing Services: Transmission-Based Precautions, the facility failed to ensure staff applied (don) and removed (doff) Protective Personal equipment (PPE) appropriately for Droplet Precautions in two of 12 rooms. The deficient practice had the probability to increase the spread of infection to other residents in the facility. Findings included: A policy was requested but the facility did not have a policy to address doffing and donning PPE. Observation on 1/28/2025 at 3:00 pm revealed doffing (removing) receptacles outside the room filled with gowns, masks, gloves, and face shields. Certified Nurse Assistant (CNA) FF was observed leaving a droplet precaution room wearing gloves, face shield, mask, and gown. She then doffed PPE outside the room into a receptacle (wastebin). Interview on 1/28/2025 at 3:16 pm with CNA FF confirmed she was providing care to residents that were on droplet precautions and removed the PPE that was worn during care outside of the room door instead of inside. Interview on 1/30/2025 at 10:08 am with the Director of Nursing (DON) confirmed and verified she observed CNA FF leaving the droplet precaution room and removing the PPE outside the room. An interview on 1/30/2025 at 9:25 am with the Infection Preventionist confirmed and verified that she also observed CNA FF leave the room with PPE on. She stated her expectations were that PPE was to be doffed inside the room and the outside receptacles were for masks.

Based on observation, interview and record review, the facility failed to ensure the dignity of four residents (R) (#66, #58, R#90, R#80) of 25 sampled residents. Specifically, staff were observed standing while feeding residents in their rooms and one residents was called a feeder, by a staff member, in the resident's presence. The sample size was 25 residents. Findings include: 1. Observation, during lunch, on 3/26/18 at 1:10 p.m. revealed that Certified Nursing Assistant (CNA) NN was in the resident's room and was observed standing while and assisting R# 66 eat. Observation, during supper, on 3/28/17 at 5:30 p.m. revealed that CNA OO was in the resident's room and was observed to be standing while feeding R# 58. Observation, during supper on 3/28/18 at 5:44 p.m. revealed that prior to feeding R#90, but in the presence of R#90, that CNA UU reported to the Director of Nursing (DON) that she did not have anymore feeders. Interview on 3/28/18 at 5:48 p.m. with CNA OO revealed that dignity includes providing privacy and respecting resident's rights. CNA OO reported that referring to a resident as a feeder is not acceptable. CNA OO reported that there has not been any discussions or training that said whether staff should stand or sit when assisting with meals. CNA OO reported that if there is a chair in the room the preference would be to sit so that the resident is eye to eye. CNA OO reported that there was not a recliner chair in resident # 58's room on yesterday and that is why CNA 00 stood to assist with the meal. Interview on 3/29/18 at 9:41 a.m. with CNA PP who reported that CNA PP does not sit when offering coaching or encouragement to residents when the residents are feeding themselves. CNA PP further revealed that dignity is shown to residents by knocking before entering, referring to the resident as Mr. or Mrs., by pulling curtains or closing blinds before providing care, and notifying resident of what care will be provided. CNA PP revealed that standing while assisting with meals does not show the resident dignity. Interview on 3/29/18 at 9:52 a.m. with CNA NN who revealed that he/she has been told that it does not matter if he/she sits or stands when providing assistance to residents with their meals. It was further revealed that dignity for residents is shown by pulling curtains and closing blinds before providing care, making sure residents are covered completely when taking to the shower room if in a hospital gown. CNA NN reported that standing during meal service is not considered as a dignity issue. CNA NN revealed that the previous DON had stated that it does not matter if a CNA sits or stands when helping a resident with meals. CNA NN further revealed that if resident R#66 is facing the wall he/she will stand to assist with meals. However, if R #66 is facing the window she sits when assisting with meals. Interview on 3/29/18 at 10:57 a.m. with the DON revealed that staff should be sitting when assisting residents with meals in the room. Interview on 3/29/18 at 10:27 a.m. with CNA QQ revealed that CNA QQ stated she did not have any training on the dining experience but has received training on dignity. CNA QQ revealed that staff should not refer to residents as a feeder. If there is a chair in the room CNA QQ reported that she will sit but if there is not a chair available CNA QQ will stand. CNA QQ further reported that it has not been discussed whether staff should sit or stand when assisting with meals. Interview on 3/29/18 at 11:50 a.m. with the DON revealed that a part of the orientation training includes that staff are trained to sit with the residents so that they will be on their level and engage with them while assisting with the meal. Agency CNAs are given a brief training on meal service and then they are paired with a buddy CNA. The DON further revealed that training is also done on an as needed basis. Interview with the Assistant Director of Nursing (ADON)/Education Coordinator on 3/29/18 at 11:55 a.m. who reported that Making Meals and Mealtime Meaningful and Dementia program is used when training CNAs on meal service. This mealtime inservice module is done annually and meal time checkoff is done during orientation. ADON reported that they have been monitoring meal service daily to assure trays are delivered on time, residents are properly positioned when eating, and whether the CNA is sitting or standing. ADON denies seeing any CNAs standing while serving meals to residents. 2. Observation on 3/26/18 at 12:26 p.m. revealed that the North hall front lunch trays arrived and at 12:29 p.m. a food tray was placed in room [ROOM NUMBER] by Certified Nursing Assistant (CNA) JJ. Further observation revealed that CAN JJ stood while feeding R#80. Interview with CNA KK on 3/29/18 at 10:25 a.m., revealed that you should sit while feeding residents.

Based on record review and staff interviews, the facility failed to obtain a Physician's signature and a concurring Physician's signature for a Physician order [REDACTED].#90 and R#89)). The sample size was 25 residents 1. Review of medical record for R#90 revealed a POLST with a choice to allow natural death/DNR that was signed by one Physician on 3/27/18 and a friend, that was not the residents Power of Attorney, on 3/27/18 but there was no concurring Physician's signature. Further review of the Medical Record for R#90 revealed that there was not a Health Care Agent for R#90. Interview on 3/28/18 at 1:07 p.m. with Social Services Director (SSD) revealed that she talks to each resident and family about their desired code status. It was determined that if a Power of Attorney for healthcare (POA) is not on file two Physician's signatures would be needed on the POLST form. Further interview with SSD revealed that she had spoken with the resident's daughter and that the resident's daughter agreed with allowing the residents friend to sign the POLST form. Interview and review of the POLST form with SSD revealed that SSD revealed that the form probably should not have been added to the resident's medical record until all signatures had been obtained. Interview on 3/28/18 1:20 p.m. with Licensed Practical Nurse (LPN) SS, revealed that resident's family signed a DNR on Monday but if the form was not signed by a Physician resident #90 would remain a full code. LPN SS was not sure how many signatures were needed on the form and reported follow up with someone else would be needed to answer this question. Interview on 3/28/18 at 1:25 p.m. with the Resident Care Coordinator (RCC) TT revealed that she thought that R#90's friend was the residents POA. Review of the chart, with RCC TT, revealed the signed POLST form that had only one Medical Doctors (MD) signature and revealed that the residents friend was not the resident's healthcare agent. RCC TT acknowledged that two MD signatures were needed if there is no power for attorney of healthcare on file. When RCC TT reviewed the medical record, it was determined that the choice to allow natural death/DNR was on record but that the record should reflect a Full Code status for R #90. 2. Review of the clinical record for R #89 revealed a POLST signed the spouse of R#89 on 8/17/17 but there was no evidence that the spouse was the residents Health Care Agent. Review of the POLST revealed that it only had one Physician's signature with no concurring Physician signature. Interviews on 3/29/18 at 3:35 p.m. with SSD revealed that R#89 is to allow natural death/DNR. SSD provided a form dated 8/19/88 that was signed by the resident with the choice made to not prolong life after he had been determined brain dead. Further review revealed that there was not a document stating that the wife of R#89 was the residents Health Care Agent.

Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage (SNFABN) to two of three residents (R) reviewed (R#67 and R#74), who were discharged off Medicare Part A services, and remained in the facility. The sample size was 25. Findings include: 1. Record review revealed that R#67 was discharged from Medicare Part A services on 1/19/18 and remained in the facility. However, the only notice that was provided to the resident was the Notice of Medicare Non-Coverage (NOMNC) (Form CMS- ). There was no evidence that the facility had issued an SNFABN (Form CMS- ) to R#67 or to the resident's responsible party, providing the opportunity to continue with skilled services, at her cost, if Medicare did not reimburse. 2. Record review revealed that R#74 was discharged from Medicare Part A services on 3/19/18 and remained in the facility. However, the only notice that was provided to the resident was the Notice of Medicare Non-Coverage (NOMNC) (Form CMS- ). There was no evidence that the facility had issued an SNFABN (Form CMS- ) to R#74 or her responsible party, providing the resident the opportunity to continue with skilled services, at her cost, if Medicare did not reimburse. During an interview on 3/29/18 at 9:05 a.m., with the Financial Controller revealed that she started her position in (MONTH) (YEAR) and was in charge of sending out the Medicare notices. Further interview revealed that she did not know that she was to use the Form CMS- and that she had never used this form.

Based on observation, staff interview, and record review, the facility failed to ensure that the Annual Minimum Data Set (MDS) [DIAGNOSES REDACTED].#43) of 25 residents reviewed. Findings include: Record review revealed that R#43 was admitted to the facility with the [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] reveals that sections A through F were not completed due to Section B0100: Comatose being coded. However, during review of the medical record, revealed that there was not an active [DIAGNOSES REDACTED]. Review of the physician progress notes [REDACTED]. Review of the Resident's care plan, dated 2/7/18, revealed the following problems: at risk for falls; at risk for bruising due to waving arms and bumping against hard objects; resident exhibits agitation, irritation, and /or pain as evidenced by physically aggressive behaviors such as hitting at staff during care; grinds teeth at times and scratches self at times; and restorative therapy to maintain function and mobility. Continued review revealed that resident may refuse therapy at times. Review of the Activity assessment dated [DATE] reveals R #43 chooses to spend her time in her room resting, listening to music, and watching television. Continued review revealed that R#43 has attended large group activities such as church services, special events, social functions, and birthday parties. Also, has attended small groups with day room and beauty shop. Resident's one on one activity is range of motion (ROM) exercises as tolerated where reminiscing about the types of music she used to listen to and the resident's family. The resident interacts by following with her eyes and sometimes with head movement. She can become combative; however, talk with her and she will relax. There has been no change since last assessment. Observation on 3/27/18 at 2:30 p.m. revealed resident lying in bed on her back, knees bent to the right, hands clenched, arms flexed at elbows, and able to move arms in flexed position over her head. Interview with Minimum Data Set (MDS) Coordinator MM on 3/28/18 at 10:20 a.m. revealed the resident is not able to respond and/or speak. Continued interview revealed that she has [MEDICAL CONDITION] and that is why we coded her as coma/vegetative state. She came to us from another nursing home in that state. The person that did this before me and the consultant told us not to try interviewing this resident because she is unable to understand and/or speak to us due to the [MEDICAL CONDITION]. During further interview at 10:30 a.m., revealed that after reading the Resident Assessment Instrument (RAI) Manuel section regarding coma, she confirmed that R#43 had been coded incorrectly. She stated that she had looked back to (YEAR) MDS's for coding section B0100 for this particular resident.

Based on observations, record review and staff interview, the facility failed to submit applications for Preadmission Screening/Resident Review (PASRR) Level II Assessments to the appropriate state designated mental health authority for evaluation and determination of specialized services for two residents (R#89 and R#48) reviewed with mental illness [DIAGNOSES REDACTED]. Findings include: Record review on 3/28/18 revealed that Resident (R) #89 admitted to facility on 8/11/17 with [DIAGNOSES REDACTED]. A Pre-Admission Screening and Resident Review (PASRR) level one was approved on 8/11/17. Review of Minimum Data Set (MDS) indicators revealed that R#89 had [DIAGNOSES REDACTED]. Interview on 3/29/18 at 12:30 p.m., with MDS staff, registered nurse/resident assessment instrument (RN/RAI) director LL; and licensed practical nurse/resident assessment instrument (LPN/RAI) coordinator MM revealed that the Admissions department did all the PASRR screens. The level one PASRR would have been done before entering the facility and if a resident had a change that required a level two screen, Admissions did it. Interview on 3/29/18 at 12:45 p.m. with the 200 Hall Registered Nurse/Resident Care Coordinator (RN/RCC) AA revealed that if a resident had a change in status or behaviors after entering the facility that warranted a PASRR two, they would send them out for evaluation to either the hospital or a behavioral facility. Interview on 3/29/18 at 3:00 p.m. with Social Services Director (SSD) revealed she reviewed Interdisciplinary Progress Notes for documentation of behaviors, a change in status, new diagnoses, or anything out of the norm. If she found something she went to Admissions, Admissions and Financial department does another PSARR one to see if it triggers. Change in status of residents are addressed and discussed in morning meetings and care plan meetings so everyone knows about it. Interview also revealed that residents who had a change in status are sent to the hospital or to a behavioral unit for evaluation. Interview on 3/29/18 at 3:35 p.m. with the LPN Patient Transition Coordinator revealed - a resident needs a PASRR Level one to be admitted , if denied for Level one, need to be sure that a Level two is started before admission, and she has denied residents before because they did not have a level two. The Process for when a resident is admitted to the facility and they do not have a [DIAGNOSES REDACTED]. That way we know that we are tracking. If a resident has a psychiatric [DIAGNOSES REDACTED]. At that time, Corporate will ask us for notes such as pyschiatric notes. They will review the notes and and get back with us. If Corporate feels that additional services are needed then they send us the paperwork. Further interview with the Transition Coordinator revealed that if a resident was coming from hospital and the PASSR is not right, she would have to get it righ. The hospital doesn't want to keep residents until we can get a level two and she has denied residents because they didn't have a level two. The Transition Coordinator revealed that if SSD picked up on a mental status change, either from nurses notes or observation of behavior, for a resident then she would let the Transition Coordinator know in writing. The SSD does not have access to to the computer system for Level II PASSR's so she would come to me and I would submit the information to Corporate. Then Corporate reviews this information and then they get back with us if they feel additional services are needed for a resident and would send us that paperwork. Review of Physician orders [REDACTED].#89 was prescribed [MEDICATION NAME] for severe agitation; [MEDICATION NAME] for increased agitation; and [MEDICATION NAME] for agitation. For the period (MONTH) 1 through 31, (YEAR) resident was prescribed [MEDICATION NAME] for increased agitation; [MEDICATION NAME] sodium for dementia with behavior disturbances to psychotic features. The period between (MONTH) 1, (YEAR) through 28, (YEAR) resident was prescribed [MEDICATION NAME] for increased agitation indefinitely; [MEDICATION NAME] sodium for dementia with behavior disturbances to psychotic features; quetiapine for [MEDICAL CONDITION]; [MEDICATION NAME] for [MEDICAL CONDITION]; [MEDICATION NAME] for depression; ABH cream topically for agitation. Physician orders [REDACTED].; [MEDICATION NAME] 2mg po BID for [MEDICAL CONDITION]; quetiapine 400mg po every evening for [MEDICAL CONDITION]; [MEDICATION NAME] 25 mg po at bedtime for depression; ABH cream topically Q6H for agitation. Record review of Interdisciplinary Progress Notes, Nurses notes, and care plans, for R#89) revealed the resident had episodes of confusion, agitation and aggressiveness as indicated by the following documented behaviors. Resident often called staff operator, mama or pet names, thought staff were maids, uncooperative, refused medications, held medication and food in mouth then spit out on floor, refused care, wandered at night through facility by self-propelling in wheelchair and would get angry when staff tried to redirect, would stay awake all night and sleep all day, would get frustrated when trying to communicate and convey thoughts, grabbed at staff, hollered and yelled out loud, which upset other residents, and would not stop even when staff tried to redirect. Resident had a terminal illness, received Hospice services and he was on antidepressant, antianxiety and antipsychotic medications. He was on behavior monitoring every shift and the care plan had been revised, since his admission, to address behaviors. Review of the Medication Administration Record [REDACTED]. The resident was admitted to the facility with [DIAGNOSES REDACTED]. There was no indication that the facility completed an application for PASRR Level II, or submitted an application to the state designated mental health authority for the evaluation and determination of specialized services. Further, there is no documentation to indicate that any specialized services were provided to the resident in the facility. 2. Resident (R)#48 was admitted to the facility from an acute care hospital and had an approved Level I PreAdmission Screening/Resident Review assessment(PASRR) completed by the hospital. [DIAGNOSES REDACTED]. She was later given [DIAGNOSES REDACTED]. There is no evidence in the record that a request for a PASRR Level II assessment was completed when the resident began to experience behaviors related to these diagnoses. A review of a Nursing Summary, dated 3/2/18, revealed R#48 was experiencing grief due to the recent death of her husband. She refused dental and podiatry treatments. The note further stated R#48 was taking [MEDICAL CONDITION] medications related to depression, [MEDICAL CONDITION], mood swings, [MEDICAL CONDITION] and anxiety. A Social Services note, dated 3/8/18, indicated R#48 complained of feeling depressed, having trouble sleeping, feeling tired, having very little energy, and loss of appetite. Review of the Plan of Care for R#48 revealed a problem dated 11/2/17, which stated R#48 was experiencing grief due to the recent death of her husband. The goal was that she would be able to discuss her feelings of loss and show no significant decline in mood for the next 90 days. Interventions included providing her with opportunities to discuss feelings of loss, assisting her to contact clergy if desired, working with resident to find activities of interest, observing for changes in mood and sleep patterns, notification to physician as needed, providing reading materials and education concerning grief and loss, and encouraging family support. An additional problem concerning R#48's history of behaviors was dated 2/24/17, and included making false accusations toward staff, hallucinations and delusions of seeing worms with wings coming out of her arms, a belief that people are digging tunnels under her room, and believing her personal items were being taken. These issues were noted to be related to being sexually assaulted years ago, with a [DIAGNOSES REDACTED]. The goal was that R#48 would not injure herself or others because of her behaviors, with interventions including assuring the safety of others, consulting with the physician concerning exacerbation of behaviors, requesting a pharmacist's review of her medications, administering medications as ordered, and talking to her in a calm manner. A Telepsychiatry Medication Follow-up was completed by the facility psychiatrist on 1/16/18. Medications were recommended to remain the same, with a follow-up visit in one to three months. On 3/29/18 at 3:04 p.m. during an interview with the Social Services Director (SSD), she verified that R#48 did not have a Level II PASRR assessment. During an interview on 3/29/18 at 3:35 p.m. with the Patient Transition Coordinator, she stated each resident who applies for admission is required to have a Level I PASRR completed prior to admission. She further stated that if an applicant is denied admission due to certain mental health issues, they will be recommended for a Level II PASRR assessment, which will indicate whether the applicant would benefit from mental health counseling or other services. The Patient Transition Coordinator also stated that if an applicant is admitted to the facility without a [DIAGNOSES REDACTED].

Based on observations, staff interviews, and record review, the facility failed to review and update the care plan and interventions to prevent falls for one resident (R#26) in a sample of 39 residents. Resident (R)#26 was admitted to this facility with [DIAGNOSES REDACTED]. Per review of a comprehensive assessment dated [DATE] and a quarterly assessment dated [DATE], R#26 requires extensive assistance of one person for bed mobility, transfer, dressing, and toileting. R#26 is also coded as having functional and range of motion limitations on upper and lower extremities on one side. R#26 was observed on 3/27/18 at 2:00 p.m. wheeling herself about the facility using one arm and one foot to propel her wheelchair. She appeared anxious and was tearful, asking others where she was supposed to be. On 3/28/18 at 9:20 a.m. R#26 was observed in her room combing her hair. On 3/28/18 at 3:15 p.m. R#26 was observed in her room, sitting in her wheelchair and searching through her personal items. At this time, the resident was not wearing her shoes or socks, but non-skid socks and non-skid shoes were sitting on the floor next to her feet. Per record review, R#26 experienced four falls in the past six months. Falls occurred on 10/22/17 at 5:30 p.m. when she slipped while trying to get into bed without assistance, 12/12/17 at 6:50 p.m., when she was found sitting on the floor in her room after sliding out of her wheelchair, 1/1/18 at 6:00 p.m. when she slipped off the side of the bed while trying to get into bed without assistance, and 3/23/18 at 9:30 a.m., when she was witnessed to fall onto the floor while trying to get into bed without assistance. A plan of care, dated 11/11/16 for R#26 includes the problem of R#26 being at risk for falls. The goal is resident will not have falls requiring hospitalization during review period. Intervention listed is call light in reach. Also on the plan of care, dated 8/4/17 is the problem Resident prefers to be independent with transfers and performs transfers unsafely at times. Interventions are as follows: re-educate on use of call light, encourage to use call light upon first urge to void, encourage use of non-skid socks, encourage to call for assistance with transfers, and place resident in high traffic areas during times of confusion. An entry on the care plan, dated 10/22/17, after a fall, states found sitting on floor in room - slipped trying to get into bed unassisted - no injury. There was no documentation of review or update of the care plan interventions. On 10/26/17, an entry on the care plan states Increased risk for falls/injury due to impaired cognition/mobility and history of falls. Resident often transfers to toilet without calling for assistance - goal: resident will have no injury requiring hospitalization during the review period - interventions: call light in reach. On 12/12/17 an entry on the care plan after a fall states sitting on floor in room - no injury- slid from wheelchair. There is no evidence of review of the care plan or change in interventions. An additional care plan entry, dated 12/12/17, after a fall states fall without injury - goal: Resident will not have fall resulting in injury - interventions: resident assisted to bed to prevent additional fall and/or injury as resident requested - resolved date: 12/12/17. There is no evidence of review of the care plan or change in interventions. On 1/1/18 after a fall, the following entry was made on the care plan. found sitting on floor in room - slid off bed trying to get in bed unassisted - no injury. There was no evidence of review of the care plan or update of interventions. After a fall on 3/23/18, the following entry was made on the care plan. witnessed by housekeeper to fall on buttocks trying to get into bed unassisted - no injury. An intervention added on the same date states assisted to bed by staff as needed/as tolerated per desire of independence. During an interview on 3/29/18 at 2:21 p.m. with the Assistant Director of Nursing (ADON), who is in charge of the Falls Program, she stated she is made aware of a fall through the 24-hour report or a Falls Packet being completed and placed in her mailbox. The ADON further states that she is responsible for auditing the documentation stating the cause of the fall and assuring that new interventions have been put in place. She verified that the care plan was not reviewed and interventions were not updated after R#26 experienced four falls. During an interview with the Minimum Data Set (MDS)/Care Plan Coordinator on 3/29/18 at 3:30 p.m., she stated that a new program had been put into place to make the care plan more visible and accessible to the nurses when a fall occurs. Per the MDS/Care Plan Coordinator, all fall care plans are written on gold color paper so that they are easily located in the chart. She verified that new interventions were not put into place after each fall for R#26 and stated this was not done because the resident was very independent and she would not call for help. She further said that there were no other interventions that were appropriate for R#26.

Based on record review and staff interview, the facility failed to ensure that [MEDICAL CONDITION] medications were not ordered as needed (PRN) for more than fourteen (14) days unless clinically indicated for six (6) residents (R) (#95, #68, #26, #48, #89, #30). The sample size was twenty-five (25). The facility census was 103. Findings include: 1. Review of the medical record for Resident (R) #68 revealed [DIAGNOSES REDACTED]. Review of R#68's Physician orders [REDACTED]. Start [MEDICATION NAME] 2 mg per milliliter (ml) give 0.5 ml sublingual every six hours as needed (prn) for agitation. Review of the gradual dose reduction (GDR) for R#68's revealed a GDR dated [DATE]: [MEDICATION NAME] 1 mg PO/PR Q4 hour prn for agitation/Anxiety-indefinitely. Dear Doctor, RE: CMS-F758: INDEFINITE PRN [MEDICAL CONDITION]-EXCESSIVE DURATION [MEDICATION NAME] 1 mg PO/PR Q4H PRN (orally or rectally every four hours as needed) for Agitation/Anxiety-indefinitely CMS regulations state that a PRN (as needed) [MEDICAL CONDITION] medication order should be limited to 14 days unless the attending physician or prescribing practitioner documents their clinical rationale in the medical record and indicates the duration for the PRN order. CMS has clarified that by definition, indefinitely means for an unspecified period of time, so extending a prn order indefinably would not meet the intent of this regulation. In order to keep the center in compliance, please specify an appropriate duration for the above ordered PRN [MEDICAL CONDITION]: ( ) 30 days ( ) 60 days ( ) 3 months ( ) 6 months The doctor wrote indefinitely. 2. Review of R#95's medical record revealed a [DIAGNOSES REDACTED]. {sic.)anixety indefinitely. Interview on [DATE] at 9:30 a.m. with the Director of Nursing (DON), the Administrator, Registered Nurse Consultant and RN RCC AA all reported that the doctor comes in every week and assesses the resident and the pharmacist said that the doctor could use the word indefinite. Continued interview also revealed that the doctor's orders here at the facility supersede any policy that the facility may have in place. Reported that we do what the doctor orders. Interview on [DATE] at 8:35 a.m. with Registered Nurse (RN) Resident Care Coordinator (RCC) AA, on the South hall revealed that she and the other RCC go through the pharmacy recommendations when the Pharmacist comes in monthly and the doctor comes every two weeks. We will give the doctor the information about the residents regarding behaviors or whatever they need care wise, related to the residents. In continued interview with RN RCC AA, reported that we were having an issue back when this new regulation about [MEDICAL CONDITION] first came out, about as needed (prn) [MEDICAL CONDITION] medications, but we went by what the pharmacists recommended and it was said the word indefinite could be used. Review with RN CC AA of the pharmacy recommendations for Resident R#95 and R#68 revealed that the Physician wanted the prn medication ordered to be available as indefinite. Interview on [DATE] at 10:20 a.m. with the Administrator revealed that an email from the facility Pharmacist regarding use of PRN [MEDICAL CONDITION] and the Administrator stated that we agree with the Doctor, that the doctor is providing a rational on the recommendation sheets, as needed (PRN) indefinite. Review, at this time, of R#68's and R#95's pharmacy recommendation dated [DATE] revealed the doctor did not indicate an appropriate duration for the above ordered prn [MEDICAL CONDITION]. The doctor's documentation on the pharmacy recommendation revealed, indefinite, Patient requires intended medication as needed. Review of the pharmacy recommendation dated [DATE] there is underlined: CMS has clarified that by definition, indefinitely means for an unspecified period of time, so extending a PRN order indefinitely would not meet the intent of this regulation. 3. Resident (R)#26 was admitted to this facility with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Per Medication Administration Records (MAR), the medication was administered to the resident four times in (MONTH) (YEAR) and two times in (MONTH) (YEAR) for crying, anxiety, and wandering. A care plan originated [DATE] indicates resident has episodes of anxiety as evidenced by tearfulness and wandering up and down hallways searching for her deceased husband. Interventions include administering medications as ordered, monitoring for adverse side effects and psychiatry consult as ordered, as well as non-pharmacological interventions for resident's anxiety. Record review reveals Monthly Medication Regimen Reviews were performed by the pharmacist. Note to Attending Physician forms dated [DATE], [DATE], [DATE], and [DATE] were completed by the Pharmacist to remind the Physician of updated regulations related to the use of [MEDICAL CONDITION] medications on a PRN basis and the requirement limiting a PRN order to 14 days. The Physician's response included Patient requires intermittent medications administered and Benefit of availability when clinically indicated as the rationale for continued use beyond 14 days, and indefinitely as the duration. 4. Resident (R)#48 was admitted to this facility [DATE] with [DIAGNOSES REDACTED]. Per physician's orders [REDACTED]. This order originated on [DATE]. Review of Medication Administration Record [REDACTED]. A care plan, initiated [DATE] for R#48, indicates the resident has the following history of hallucinations and delusions. Interventions for these issues include pharmacy consult for review of medications, documentation of behaviors, Telemed as indicated, and administer medications as ordered. A Physician's Progress Note dated [DATE] says R#48 is seen in periodic follow up of medical conditions. Complains of not being able to sleep at night and cries a lot. There is no mention of medications in this note. A Physician's Progress Note dated [DATE] includes no mention of medication review. Monthly Medication Regimen Reviews are performed by the Pharmacist. A Note to Attending Physician dated [DATE] requests the Physician provide clinical rationale for continued use of [MEDICATION NAME] on a PRN basis and indicate the duration for the medication. Documentation by the attending Physician, dated [DATE] indicates clinically avoidable as the clinical rationale for continued use of the medication beyond 14 days and indefinite as the duration of the order. An additional Note to Attending Physician dated [DATE] explains that indefinitely means for an unspecified period of time and was not appropriate related to the intent of the regulation which prohibits PRN medications being used for more than 14 days. Documentation by the physician, dated [DATE] indicates the duration of the order as indefinitely and documentation of the rationale states Patient requires intermittent medication administration. 5. Review of the clinical record for R#30 revealed that the resident was admitted to the facility with a [DIAGNOSES REDACTED]. Review of R#30's (MONTH) (YEAR) Physician order [REDACTED]. Review of the Pharmacy Evaluation and Recommendations by Eldercare Pharmacy dated [DATE], [DATE], and [DATE] revealed that PRN [MEDICATION NAME] 0.5 mg BID PRN for anxiety is ordered for an undefined duration as determined by R#30's attending physician on [DATE]. Continued review revealed that on [DATE] the Consultsnt Pharmacisit wrote a note to the attending physician regarding the reqiremnt pertaining to indefinite PRN [MEDICAL CONDITION] medication use The note indocated indefinitely means for an unspecified period of time, so extending a PRN order indefinitely would not meet the intent of the regulation. During further review, the attending Physician wrote a response on [DATE] on the same document that the medication was effective, and the patient required indefinite intermittent medication administration with the benefits outweighing the risks. Review of the Medication Administration Record [REDACTED]. Review of the physician progress notes [REDACTED]. However, no further evidence of any documentation regarding the indefinite prn use of [MEDICATION NAME]. 6. Review of the medical record for Resident (R) #89 revealed he admitted and had [DIAGNOSES REDACTED]. Record review of physician's orders [REDACTED].#89 revealed order for [MEDICATION NAME] injection (an anti-anxiety agent) two milligrams per one milliliter (2mg/1ml,), give 0.5ml (1mg) Intramuscularly (IM) every six hours (Q6H) as needed (PRN) for agitation indefinitely. Review of the Physician orders [REDACTED].#89 was prescribed [MEDICATION NAME] for severe agitation; [MEDICATION NAME] for increased agitation; and [MEDICATION NAME] for agitation. For the period (MONTH) 1, (YEAR) through (MONTH) 31, (YEAR) R#89 was prescribed [MEDICATION NAME] for increased agitation; [MEDICATION NAME] sodium for dementia with behavior disturbances to psychotic features. The period between (MONTH) 1 through 28, (YEAR) resident was prescribed [MEDICATION NAME] for increased agitation indefinitely; [MEDICATION NAME] sodium for dementia with behavior disturbances to psychotic features; quetiapine for [MEDICAL CONDITION]; [MEDICATION NAME] for [MEDICAL CONDITION]; [MEDICATION NAME] for depression; ABH cream topically for agitation. Physician orders [REDACTED]. bedtime for depression; ABH cream topically Q6H for agitation. Review of the medical record revealed that the consulting Pharmacist sent multiple notifications on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. No change in the PRN [MEDICATION NAME] was made and no duration added.to the Physician requesting he assess and evaluate the PRN [MEDICAL CONDITION] medications for R#89 and put a duration. The physician would write benefits outweigh risks, or is clinically indicated indefinitely, but would not put a stop or duration date. Each recommendation (MRR) that the Pharmacist sent had the recent updates, also known as (a.k.a.) the Mega Rule to the Requirements of Participation for Long Term Care (LTC). Centers for Medicare and Medicaid (CMS) have added new regulations limiting PRN antipsychotic medication to 14 days and it cannot be renewed unless the attending or prescribing practitioner evaluates the resident. The guidance pertaining to this new regulation specifies that report of the patients condition from facility staff to the prescriber does not constitute an evaluation. PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days and the rationale should be documented in the medical record and indicate the duration for the PRN order. There is no exception for Hospice, end of life or palliative care. Antipsychotic medications were ordered with a duration of indefinitely for period [DATE] through [DATE]. Multiple observations were made over a period of four days. Each time the resident was in bed either asleep, sitting up eating or sitting up visiting with his spouse. Record Review on [DATE] revealed physician orders [REDACTED]. One clarification order dated [DATE] had duration as indefinitely. Record Review revealed orders for PRN [MEDICATION NAME] with a duration of indefinitely. Record review revealed physician orders; MAR; diagnoses; behaviors, behavior monitoring forms, and documentation that showed PRN [MEDICATION NAME]/[MEDICATION NAME] was used for the period [DATE] through [DATE] for anxiety and agitation with no stop date.

Based on observation and staff interviews the facility failed to ensure that items in the walk in cooler were dated and labeled and used before the expiration date, items in dry storage are labeled when not in original container, food on steam table was held at 135 degrees Fahrenheit (F) or higher, and the temperature for refrigerators and freezers in the food pantry on one (1) of two (2) wings were not being documented. This had to potential to affect 92 residents and the census was 99. Findings include: 1. Dietary tour began on 3/6/17 at 10:15 a.m. with Food Service Manager there was one (1) full loaf and one (1) half loaf of bread was observed with no expiration date. Food Service Manager confirmed that the bread was not dated and reported that the items would be removed due to not having a date. 2. In the dry storage area there was a container of corn flakes with no date and a plastic cup in the container. There was also on container of cheerios that had a label of cheerios on the side with a date of 1/15/16 and the top was labeled cornflakes with a date of 2/20/17. Food Service Manager reported that she was not sure why the Cheerios had a 1/15/16 label but FSM reported that the labeling was wrong. 3. During tour of the walk in cooler on 3/6/17 at 10:35 a.m. there was one (1) box of oranges observed to have a green substance on several oranges in the box. There was also a box of prune juice that did not have an open date but the directions on the box revealed Thaw overnight in 38 degrees F cooler. After thawing keep refrigerated and use within 14 days of initial thawing. There was also one 5lb container of cottage cheese with a use by date of 3/5/17. 4. Observation on 3/6/17 at 10:50 a.m. of ice machine in the main dining room revealed pink sludge on dispensing lip of ice machine. The Maintenance Supervisor reported that the ice machine is cleaned quarterly and is due to be cleaned this month. It was further reported that it had been recently decided that he would begin cleaning the ice machine each month. The front cover of the machine was removed and the pink sludge buildup was confirmed. Maintenance Supervisor reported that the facility staff will not be using this ice machine until after it has been cleaned. Interview on 3/6/17 at 10:55 a.m. with FSM who confirmed oranges with green/greyish buildup. FSM reported that it is everybody's responsibility to check to assure that items are not molded. It was reported that oranges are used as snacks on the snack cart. 5. Observation on 3/8/17 at 11:29 a.m. of one (1) box of prune juice no thaw date. 6. Observation of steam table temperatures on 3/8/17 at 12:58 p.m. food temps. There were four (4) hallways already served from the steam table. Steam table temperatures were as follows: Puree pork loin at 1:04 p.m. 110 degrees F; Puree sweet corn at 1:01 p.m. 130 degrees F ; baked sweet potato 1:10p.m. 128 ; Puree sweet potato 1:07 107 and 1:25p.m. 110; second pan pureed corn 162 degrees F at 1:04 p.m.; 2nd pan sweet potatos at 1:12 p.m. 180 degrees F; ground meat at 1:21 p.m. 110 degrees F and at 1:31p.m. 140 degrees F; and alfredo noodles at 1:29 p.m. 100 degrees F. Interview on 3/8/17 with FSM reported that up until this testing there was no concern with the thermometer. Temperatures are checked at beginning and sometimes during meal service. Review of temp log book revealed all foods were above 135 degrees when placed on the serving line. 7. Observation and interview on 3/9/17 at 9:20 a.m. with FSM revealed that the box of prune juice in the cooler had two dates 3/23/17 and 2/26/17 with both listed as the open date. FSM questioned as to why the two dates and she reported that she did not know but would discard the juice. Interview on 3/9/17 at 12:19 p.m. with FSM who reported that she has done inservices in the past related to label and dating of items in walk in cooler. It was reported that items don't typically go past the expiration date because items are used so quickly but have to start monitoring more. FSM reported that the kitchen staff had been using the basic thermometer for eight (8) months to a year but will move back to using the digital thermometer. FSM reported thermometer on yesterday had been used for up to four (4) months before it went out. FSM reported that anything that goes into the cooler the expiration date is abided by. FSM reported that if items are identified to be damaged at delivery they are returned to the vendor. FSM was unsure of when oranges were delivered but reported that once staff identified they were no longer good they should have been discarded. FSM went on to say that she never would have served those oranges to the residents. Interview on 3/9/17 at 12:33 p.m. with the Administrator related to label and dating in the kitchen. The Administrator reported that his expectation is that items will be labeled and dated. He further reported that at the time of arrival food is to be inspected and staff should assure that frozen foods are frozen. At the time ready to utilize products items should be discarded if there are issues related to expiration date or staff unable to identify an open date. Any kitchen staff is responsible for inspecting items prior to serving the item. If the item is spoiled the item should be discarded. The Administrator reported that he wants staff to be as accurate as possible however, if a date can't be determined prefers that items be discarded. Education is provided online to associates and education is continuing. Observation and interview on 3/9/17 at 1:00 p.m. with the Assistant Director of Nursing (ADON) in the South Wing pantry. Review of temperature logs revealed missing temperatures for January and February. ADON unsure of who responsibility it is to assure temp logs are completed daily. Observation and Interview on 3/9/17 at 1:20 p.m. with Director of Nursing (DON) who provided copies of temperature logs for North and South pantry. DON acknowledged that logging the temperature had been identified and she had educated staff on completing the form nightly. While there was improvement with completing the form freezer temperatures for the South Wing were not being documented. DON reported that night shift is responsible for logging pantry refrigerator and freezer temperatures and the Resident Care Coordinator and the nurse management staff should be monitoring a little more closely going forward.

Based on observation, resident and staff interview and record review the facility failed to provide comfortable sound levels on one (1) hall, North, of six (6) halls. Findings include: During an interview with resident A on 06/02/2015 at 10:39 a.m. the resident revealed that it is to noisy especially on midnight shift. Resident A also stated that noise increases at change of shift and it remains noisy throughout the night. He/she stated she had told the Administrator and it eased up for a short period of time. During an additional interview on 06/03/2015 at 5:45 p.m. resident A further revealed that on the evening of 06/02/2015 the noise was really bad about 10:00 p.m. resident A stated that although shutting the door takes care of noise, the roommate does not like the door shut. Observation made on 6/03/15 at 10:45 p.m.,on North Halls, revealed loud conversation noted from charting room. Upon reaching the door observed three (3) Certified Nursing Assistants (CNA)s and one (1) Licensed Practical Nurse in charting room talking and laughing. An interview with the Director of Nursing (DON) on 06/04/2015 9:00 a.m. revealed that staff, at any time of day or night, is to keep a calm quiet environment and that particularly at night staff should turn televisions down and keep their voices low to promote a calm and restful environment for the residents. Review of Policy reveals that comfortable sound levels are to be maintained and the environment is to be kept as quiet as possible. Review of Grievance Log reveals a complaint about noise level at night dated 3/20/15 with follow-up documentation of an in-service provided to staff.

Based on observation, staff interview and record review, it was determined that licensed nursing staff and restorative nursing staff failed to share information about one resident ' s (#13) complaints of pain during range of motion exercises and failed to adequately supervise the provision of restorative services to ensure compliance with the " Functional Program " for one resident (#13) in a total sample of 19 residents. This failure resulted in harm for resident #13. Findings include: Resident #13 had been on a " Functional Program " since 7/6/10 for restorative nursing staff to provide active range of motion exercises for both of the resident ' s legs six times a week as tolerated while he/she was seated in a wheelchair. The resident ' s care plan since 6/7/10 included his/her risk for general aches and pains. The goal was that the resident would be given pain medications as needed to relieve pain with an intervention for pain assessment. On 9/23/10 at 11:05 a.m., restorative aide " KK " provided passive range of motion exercises to the resident ' s legs and arms while the resident was lying in the bed which was not according to the planned " Functional Program. " During that observation, the resident yelled out at two separate times when " KK " flexed the resident ' s right knee. " KK " stated at that time that the resident had complained about right leg pain during range of motion exercises since he/she began the functional program on 7/5/10. " KK " stated, at that time, that she had notified the nurses about the resident ' s complaints of pain. However, during interviews with a licensed nurse on 9/23/10 at 11:50 a.m., and with a registered nurse on 9/23/10 at 12:50 p.m., they denied having been made aware of the resident having complained of pain during exercises. During an interview with the supervisory nurse for the restorative program, she stated that she had not been notified about the resident ' s complaints of pain during range of motion exercises. The pain assessments done by licensed nursing staff twice a day in July, August, and September indicated that the resident had no pain. See F309 for additional information regarding resident #13.

Based on observations, record reviews and staff interviews, it was determined that the facility failed to ensure that restorative nursing staff notified supervisory nursing staff about one resident's (#13) complaints of pain during active range of motion exercises from a total sample of 19 residents. This failure resulted in harm for resident #13. Findings include: 1. Resident #13 had been on a "Functional Program" since 7/6/10 for restorative nursing staff to provide active range of motion exercises for both of the resident's legs six times a week as tolerated while he/she was seated in a wheelchair. This "Functional Program" developed by the physical therapist included encouraging the resident to walk with a rolling walker and to refer the resident to the therapist if any concerns arose. The resident's "Restorative Intervention Plan" included active range of motion exercises. The resident's care plan since 6/7/10 included his/her risk for general aches and pains. The goal was that the resident would be given pain medications as needed to relieve pain with an intervention for pain assessment. Restorative aide "KK" was observed on 9/23/10 at 11:05 a.m. providing passive range of motion exercises to the resident's legs and arms while the resident was lying in the bed which was not according to the planned "Functional Program" . The resident yelled "Oh!" when "KK" flexed the resident's right knee and again when "KK" flexed it a second time. When "KK" stopped the range of motion exercises to the resident's right leg, he/she had no further complaints of pain. "KK" stated at that time that the resident had complained about right leg pain during range of motion exercises since he/she began the functional program on 7/5/10. "KK" stated that she/he had notified the nurses about the resident's complaints of pain. However, on 9/23/10 at 11:50 a.m., licensed nurse "LL" stated that she/he had not been notified that resident #13 had complained about having pain during range of motion exercises. On 9/23/10 at 12 noon, supervisory nursing staff "NN" stated that he/she was unaware that the resident had complained about any pain during range of motion exercises. On 9/23/10 at 12:50 p.m., registered nursing staff " DD " who was responsible for restorative services, stated that she/he had not been notified that the resident had complained of pain during range of motion exercises. Although according to staff's documentation on the "Restorative Intervention Plan" that the resident refused range of motion exercises from 7/5 - 7/9/10, 7/11 to 7/15/10, 7/17 to 7/20/10, 7/25 to 7/26/10, and 7/28 - 7/30/10, there was no evidence that it was identified as a concern. The "Functional Program" developed by the physical therapist was for active range of motion exercises to be done while the resident was seated in the wheelchair. However, passive range of motion exercises were observed done on 9/23/10 while he/she was lying in bed. Despite the restorative nursing staff's statement on 9/23/10 at 11:05 a.m. that nursing staff was aware of the resident's continuing to experience pain during range of motion, the pain assessments done by licensed nursing staff twice a day in July, August, and September indicated that he/she had no pain. The resident had a physician's orders [REDACTED]. Despite restorative staff "KK's" statement that the resident had complained of pain since beginning the "Functional Program" (7/5/10), the pain assessments did not document the resident as ever having any pain from July to September 21, 2010. According to nursing staff's documentation on the Medication Administration Records (MARS) for 7/10, 8/10 and 9/10, the resident had not been given [MEDICATION NAME] for pain. The physician had discontinued the [MEDICATION NAME] on 8/23/10 because of it not having been given for 60 days.

Based on observations, it was determined that the facility failed to maintain sanitary conditions in the storage and food preparation areas of the kitchen. Findings include: General observations were made on 9/21/10 at 11:15 a.m. and/or on 9/22/10 at 12:15 p.m. and/or on 9/23/19 at 9:00 a.m. and 9:15 a.m. 1. The tops of the sugar, rice, corn meal and flour bins stored in the dry storage area were soiled and sticky. The tops of those food bins were still soiled and sticky on 9/22/10 at approximately 12:15 p.m. and 9/23/10 at approximately 9:00 a.m. 2. One of the two ovens had debris and large pieces of food under the floor of the oven. The debris and pieces of food were still present on 9/23/10 at 9:00 a.m. 3. The walk in cooler had two, plastic storage containers that were not labelled for contents. One was dated 9/9/10 and the other was dated 9/16/10. In an interview on 9/21/10 at 11:15 a.m., the dietary supervisor said that one container contained a peanut butter and jelly mixture and, the other contained a pimento cheese sandwich mixture. On 9/23/10 at 9:15 a.m., another plastic container which contained an unidentified brown substance was stored in that cooler. 4. There was a dirty and stained, dark green utility cart in the dry storage area. There was a large crack in the top shelf. 5. On 9/22/10 at 8:20 a.m., the small trash can under the handwashing sink was heavily soiled with dirt and dried spills. 6. The toaster on the counter was heavily soiled with a build up of blackened crumbs. 7. The meat slicer was soiled with dried juices and debris. The slicer had been covered prior to that observation.