Every finding on record at Palace at Kendall Nursing and Rehabilitation Cente

Based on observations interviews and records reviewed the facility's staff failed to safely secure medications and biologicals on one (First floor cart one) out of three medication carts on the facility's first floor. As evidenced by medications observed unsecured on unattended medication cart one. This deficient practice increased the risk to residents' safety. The findings included. During an observation on 04/20/2026 at 8:33 AM, it was noted that medications and eye drops were left unattended on medication cart one located on the first floor. The cart was parked next to the hallway, and the nurse was in a resident's room two doors across the hallway. A resident was observed propelling in wheelchair down the hallway. (Photo evidence).On 04/20/2026 at 8:48 AM Staff B, Licensed Practical Nurse (LPN) returned to the medication cart.In an interview on 04/20/2026 Staff B, LPN, was asked about the unattended medications left on top of the cart. Staff B, LPN revealed a resident had an emergency and she should not have left the medications on top the cart unattended because anyone could have taken them. During an interview on 04/23/2026 at 1:51 PM Staff G, Registered Nurse (RN), First floor Unit Manager was informed of the identified concerns and shown photographic evidence of medications left unattended. Staff G, RN First Floor Unit Manager stated that staff should not leave medications out of view. She (Staff B, LPN) had an emergency but still she should have the medications with her. Review of the facility's Policy titled Medication Storage. Last Revision Date: April 28, 2015, and Last Review Date: January 28, 2026, indicates: The facility safely stores medications.Procedure:1. Medication storage at the facility is designed to:c. Minimize the risk of medication diversion, and;d. Reduce potential dispensing errors.Review of the facility's policy titled: Medication Preparation and General Guidelines. Effective: April 12, 2015, and Reviewed: January 28, 2026. Procedures indicated:16) During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Based on observations, record review and interviews the facility failed to follow infection control protocol for one (Resident #50) out of two residents sampled who receive respiratory treatments as evidenced by two separate observations of Resident # 50's respiratory equipment not being stored in plastic bag after use. The findings included:Observation and interview on 04/21/2026 at 09:28 AM revealed Resident #50 in bed awake, alert and oriented a nebulizer mask noted on the bedside table was not in a plastic bag. (Photographic evidence). When asked about the nebulizer mask Resident # 50 revealed the mask had been sitting on the bedside table since 06:00 AM that morning (04/21/2026). Record review of Resident #50's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but are not limited to: Chronic obstructive pulmonary disease (COPD), wheezing and pulmonary edema. Record review of Resident #50's Care Plan for April 2026 revealed Mitigation strategies to prevent respiratory exposure/infection. Interventions included: Reinforce hand washing and sanitizing practices, Standard and transmission-based precautions as indicated and Resident will be assessed for fever, bilateral breath sounds (BBS), shortness of breath (SOB), coughing, sneezing or other respiratory symptoms and/or other complaints every (Q) shift. Record review of the admission Minimum Data Set (MDS) dated [DATE] revealed in Section C for Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of a 15 which indicates the resident is cognitively intact. Section GG for Functional Abilities revealed dependence on toileting, showering, lower body dressing and sit to lying. Section I for Active Diagnosis revealed a diagnosis of COPD. Record review of Resident #50's physician's order sheets revealed orders dated 04/08/2026: Albuterol Sulfate solution for nebulization (NEB); 0.63 mg(milligram)/3 mL (milliliter); alpha-methyltryptamine: 3 mL; inhalation Special Instructions: To be administer over 15 minutes, every 8 Hours - as needed (PRN).Order dated 03/30/2026: Ipratropium bromide solution; 0.02 %; 2.5 mL; inhalation Special Instructions: To be administered over 15 minutes, every 6 Hours: 11:00 PM, 05:00 AM, 11:00 AM, 05:00 PM.Order dated 03/30/2026 -Change aerosol mask and tubing for neb TX (treatment) administration weekly and PRN.on Tue (Tuesday) 07:00 PM - 07:00 AM shift.During an interview on 04/22/2026 at 12:20 PM Staff A, Licensed Practical Nurse (LPN) stated: When a nebulizer mask is not in use, it should be stored in a clean plastic bag at the bedside. If it has been left in the bag on the dresser for several hours, it should be replaced to maintain cleanliness and prevent contamination. Nebulizer masks are typically changed according to facility policy or manufacturer guidelines, or sooner if they become soiled, damaged, or contaminated. If unsure of the exact schedule, staff should refer to infection control policy or consult the nurse/educator for clarification. During an interview on 04/22/2026 at 11:35 AM the Director of Nursing stated All oxygen-related equipment, such as a nebulizer mask, is stored in a designated storage bag that hangs on the dresser beside the bed. Equipment is changed weekly on Tuesdays, including the bag if needed. When not in use, items are kept in the bag to maintain cleanliness. The mask should be either replaced or properly cleaned according to protocol.

Based on observations, interviews, and record reviews, the facility did not implement effective plans of action to correct identified quality deficiencies in the problem area related to repeated deficient practices for F880 Infection Prevention and Control, as evidenced by staff failed to store respiratory equipment in a plastic bag after use for Resident #131. The findings included.Review of the facility's survey history revealed the facility was cited F880 Infection Prevention and Control during the recertification survey with an exit dated 13/03/2024.The Administrator stated in an interview on 04/23/2026 at 1:10 PM that the facility held its Quality Assurance and Performance Improvement (QAPI) meetings on the third Wednesday of every month. Committee members included the Administrator, Risk Manager/Director of Social Services/Director of Nursing, Medical Director, Infection Control/Prevention Officer, Consultant Pharmacist, and Department Heads. The QAPI team reviewed multiple data sources to identify gaps, trends, or opportunities for improvement in systems of care. These sources included Minimum Data Set (MDS) patterns, Nursing Home Compare indicators, state survey results, resident care plan progress, complaint trends, satisfaction feedback, caregiver turnover, emergency room visits, hospital utilization, and infection control data. The facility monitored trends and implemented strategies to support ongoing improvement.

Based observations, record reviews, and interviews; the facility's staff failed to provide privacy for one (Resident #38) out of two sampled residents during medication administration. Staff administered medications to Resident #38 in the hallway in front of the first-floor nursing station. There were 176 residents residing in the facility at the time of the survey. The findings includeObservation on 04/20/2026 at 9:20 AM revealed Staff L, a Licensed Practical Nurse (LPN) administering medications to Resident # 38 in the hallway in front of the first-floor nursing station. Staff L, LPN did not redirect or reeducate Resident #38 about privacy during medication administration.Record review of a demographic sheet revealed Residet # 38 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Encounter for surgical aftercare following surgery on the digestive system and Dementia.Record review of a Minimum Data Set reference dated 03/20/2026 revealed Resident # 38 had a Brief Interview for Mental Status score of 11 indicating moderate cognitive impairment.Record review of the facility's policy and procedure titled, Right to Personal Preferences revised 01/06/2025 indicated: 3. Dignity and Autonomy: Residents have the right to be treated with respect and dignity .During an interview on 04/20/2026 at 9:23 AM, Staff L, LPN, was asked about privacy during medication administration. Staff L, LPN, stated, I should have administered the medications in the resident's room and pulled the curtain to provide privacy. I am not allowed to give medications in the hallway, but I gave medications to [Resident # 38] because the resident was going to look at the plants.Interview on 04/20/2026, at 2:50 PM with Staff G, RN, First Floor Supervisor regarding privacy during medication administration. Staff G stated, Nurses are not supposed to administer medications in the hallway for residents' privacy.During an interview on 04/22/2026 at 3:46 PM, the Director of Nursing stated, Medications are to be administered in the rooms and if a resident refuses the staff are to educate the resident and update the care plan.

Based on observations, records reviewed and interviews the facility's staff failed to ensure that an assistive device for hearing was in place for one (Resident #70) out of two sampled residents with a hearing device. Observations showed Resident #70's prescribed hearing device was not in place, even though staff documented in the Electronic Health Records that they had applied the device. At the time of the survey, 16 residents resided in the facility that used hearing devices.The findings included: Observation on 04/20/2026 at 9:43 AM revealed Resident #70 in bed, pulling on a call light wrapped around the bed railing and biting it. Resident #70 shrugged shoulders when greeted. There were two hearing aid devices on the nightstand; one was on a charging device and the other inside a plastic bag (photo evidence). A follow up observation on 04/20/2026 at 11:48 AM revealed Resident #70 seated in a recliner in the dining area not wearing a hearing aid device. Resident #70 was not following staff directions. On 04/20/2026 at 12:16 PM, two hearing aid devices was observed on the nightstand; one on a charging device and the other inside a plastic bag (photo). On 04/21/2026 at 4:02 PM Resident #70 was in bed. The two hearing aid devices were observed on the nightstand, one on a charging device and the other inside a plastic bag (photo evidence). On 04/22/2026 at 11:36 AM, the hearing aid devices were observed on the nightstand one on a charging device and the other inside a plastic bag (photo evidence). On 04/22/2026 at 1:13 PM Resident # 70 was observed in the activities area, no hearing aid device was in place with her head down and not engaged in any activity. Record review of a demographic sheet revealed Resident # 70 was readmitted on [DATE] with that diagnosis included: Unspecified dementia and Cerebrovascular disease. Record review of a Quarterly Review Minimum data set reference dated 02/24/2026 revealed Resident # 70 had a Brief Interview for Mental Status of 00 indicating severe cognitive impairment, used a hearing aid, usually understands others, was dependent for Activities of Daily Living. Record review of Resident # 70's medical record revealed care plan indicating the resident has a history of hard of hearing; has bilateral hearing amplifiers kept at bedside as per family preference starting on 03/03/2026 with an approach to: Follow Resident's preferences. 2. Inform Interdisciplinary team and staff of Resident's preferences. 3. Maintain communication with responsible party of Resident's preferences. 4. Monitor and assist with any changes the Resident may have with his/her personal preferences to update plan of care. Record review of a physician's order sheet revealed Resident # 70 had orders dated 02/04/2026 to apply Hearing Amplifiers-Left /Right after AM (morning) care once a day and order dated 02/05/2026 to remove Hearing Amplifiers-Left /Right after PM (evening) care. Kept in room at bedside as per family preference once a day on night shift.Record review of a 14-day administration history dated 04/09/2026 to 04/22/2026 revealed nursing staff signed that both hearing amplifiers were applied after morning care on 04/20/2026 and 04/21/2026. Record review of Resident # 70's clinical record revealed no progress notes indicating Resident # 70 refused to wear the hearing amplifiers. On 04/22/2026 at 1:42 PM Staff K, Activities Staff revealed Resident#70 does not wear hearing aids. On 04/22/2026 at 2:32 PM Staff J, Certified Nursing Assistant (CNA) stated, I have been working for one year and half. When I have residents with hearing aids, I keep it on the charger and place it in the ear when I come on shift. I did not place the hearing aid for Resident # 70 today. There is reason. I realize I should have. On 04/22/2026 at 2:56 PM Staff N, RN revealed she had not spoken with the assigned CNA about applying Resident #70's hearing device. Interview on 04/22/2026 at 3:10 PM Staff H, RN third-floor unit manager stated: [Resident # 70] has orders for hearing amplifiers after morning care once a day from 7:00 AM to 7:00 PM. It doesn't say as needed and the device is available at the bedside. The nurses are aware that there is a physician's order for the hearing amplifier. The CNAs are made aware during morning discussion that this resident requires a hearing amplifier. I make rounds to ensure the amplifier is in place but sometimes the resident removes it. There are no notes indicating the resident removes the hearing amplifier. On 04/22/2026 at 3:25 PM Staff N, RN and surveyor went to Resident #70's room and observed one ear amplifier being charged and the other in a plastic bag (photo). Staff N, RN stated, I don't know why both aren't charging. (photo) During an interview on 04/22/2026 at 3:39 PM the Director of Nursing stated: The nursing staff apply and remove hearing devices according to the physician's order. After applying the device, the nurse signs the order. If a resident has a tendency to remove the device, nursing staff are responsible for monitoring throughout the shift, educate the resident and encourage the resident to use the device. If the resident continues to be non-complainant there should be progress notes and a care plan about the behavior. The Social Services department is also involved. On 04/22/2026 at 5:09 PM Staff I, Social Worker revealed residents are care planned when they receive the hearing amplifiers. If a resident does not want to wear them, the care plan is revised, and a note is written and no staff reported Resident #70 not wanting to wear the amplifiers. Record review of the facility's policy and procedure titled, Handling, Care, and Loss Prevention of Resident Hearing Aide(s) and Amplifier Last Review: July 10, 2025 indicated: I. PURPOSE: To ensure maximum effectiveness of hearing aides/amplifiers (devices) in meeting resident needs, promote psychosocial wellbeing, and prevent accidental loss or mishandling of hearing aids. II. POLICY: Hearing aides and /or amplifiers (devices) will be under the care and custody of the assigned licensed nurse unless otherwise specified. Devices will be stored by nursing staff when not in use or as per resident preferences. II. PROCEDURE: Each shift the nurse assigned to a resident with devices will be responsible for ensuring that the resident devices are present and accounted for.Devices are to be kept stored in handling case or container, labeled with appropriate resident identification information.Gently insert resident devices in the off position after explanation of procedure and adjust volume if needed setting/test hearing aide for effectiveness if needed.Nursing staff must ensure that the devices are properly functioning, and batteries are changed as needed.

Based on observations, records reviewed interviews facility staff did not administer oxygen therapy at the prescribed rate for one resident (Resident #81) out of one resident investigated as evidenced by Resident # 81 was observed receiving oxygen via nasal cannula at 3.5 Liters Per Minute (LPM) instead of 2 LPM. At the time of the survey, 72 residents in the facility had oxygen orders. The findings included. On 04/21/2026 at 8:20 AM, Resident #81 was observed in bed sleeping the oxygen concentrator was set at 3.5 LPM.On 04/22/2026 at 9:34 AM, Resident #81 was observed asleep with the nasal cannula in place and the oxygen concentrator was set at 3.5 LPM. Record review Resident #81's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but were not limited to: Encounter for Palliative Care; Other Viral Pneumonia; Acute Pulmonary Edema. Review of orders dated 03/10/2026 showed Oxygen at a rate of 2 Liter per Minute as needed. Change Oxygen tubing and/or mask and ensure equipment is functioning properly weekly and as needed. Review of Resident # 81's admission Minimum Data Set (MDS) dated [DATE] Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) summary score of 12 out of 15 indicating moderate cognitive impairment. Section GG (Functional Abilities) revealed the resident needed substantial/maximal assistance Activities of Daily Living and Section O (Special Treatments, Procedures, and Programs) documented the resident had oxygen therapy as needed. Review of the Care Plan initiated on 03/11/2026 with target date 06/24/2026 revealed the resident was at risk for altered airway clearance and shortness of breath (SOB) due to heart failure; 3/22/26-Pneumonia/ pulmonary edema. Goal: The resident will be able to breath without any respiratory distress through next review date. Interventions: Administer oxygen (O2) via nasal cannula as ordered by physician. May obtain pulse oximetry reading as needed as ordered, as indicated for respiratory compromise. During an interview on 04/22/2026 at 12:25 PM, Staff E, Registered Nurse (RN), stated that the resident's order for oxygen was for 2 LPM and did not realize the concentrator was set at 3.5 LPM. Staff E,RN explained that the protocol for oxygen therapy required staff to check the oxygen saturation of all residents who received oxygen, including those with as needed orders, to determine whether oxygen administration was necessary and to set the oxygen concentrator according to the physician's order.Review of the facility's Policy and Procedures for Oxygen Administration reviewed 05/04/2019 and 01/26/2022 indicated. Purpose: To ensure safe, effective and appropriate administration of oxygen therapy to residents with clinical need while minimizing risks such as improper use and fire hazards. Policy Statement: Oxygen is considered a medication and must be prescribed by a licensed provider. Procedure: 1-Physician Order Requirement- Oxygen must be ordered with: Flow rate (e.g., 2 L/min) Delivery method (nasal cannula, mask, etc.) Frequency (continuous or PRN).

Based on observation, record review and interviews, the facility failed to follow infection control procedures and protocols for six residents (#73, #78, #14, #109, #115, #133) out of ten residents receiving enteral feedings as evidenced by observations of tube feeding connectors uncapped while feeding was not in progress. The findings include: During observation on 09/30/24 at 10:01 AM resident #73 was not in room; on the right side of the resident's bed A feeding bottle labeled [Formula Brand] was observed hanging on a pole, not in progress, and the connector tip was uncapped. Review of the medical records for Resident # 73 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Dysphagia, oropharyngeal phase. Review of the Physician's Orders Sheet (POS) for 10/01/2024 revealed the Resident #73 had orders that included but not limited to: [formula] at 50 milliliters per hour via PEG (Percutaneous endoscopic gastrostomy) x (times) 18 hours. Special Instructions: Off at 8:00 AM. On at 2:00 PM, Every Shift, Day shift - Off 8:00 AM, Day shift - On 02:00 PM. Flush peg tube with 15 ml of H2O every shift. Every Shift, Day shift 7:00 AM - 07:00 PM, Night shift 07:00 PM - 07:00 AM. PEG site care Q (each shift and PRN (as needed) Every Shift, Day shift 07:00 AM - 07:00 PM, Night shift 07:00 PM - 07:00 AM. Record review of Resident #73 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status (BIMS) Score 0, on a 0-15 scale indicating the resident is severely cognitively impaired. Section GG (functional status) revealed Resident#73 is dependent on staff assistance for all ADLs (Activities of Daily Living. Review of Resident # 73's Care Plans Reference Date 01/13/2021 revealed the Resident is at risk for complications related to tube feeding such as aspiration, infection, intolerance to feeding, fluid overload/deficits, etc. Resident will tolerate tube feeding without signs/symptoms of complications or infections and will remain patent. 48906 On 9/30/24 at 10:35 AM Resident#14 was in bed with eyes closed, A feeding bottle labeled [Formula Brand] was observed hanging on a pole, not in progress, and the connector was uncapped. A connector cap was observed on the pole. (photo evidence) On 10/02/24 at 1:15 PM Resident #14 was in bed with eyes closed, A feeding bottle labeled [Formula brand]1.5 calorie was observed hanging on a pole, not in progress, and the connector was uncapped. A connector cap was observed on the pole. (see photo) Record review of demographic sheet for Resident #14 revealed an admitted [DATE], readmitted [DATE] with diagnosis that included: Encounter for attention to gastrostomy. Record review of an Annual Minimum Data Set (MDS) with a reference date of 08/05/2024 in revealed Section C (Cognitive Status) a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment and section GG (functional status) resident was dependent for all Activities of daily living (ADL). Record review of a physician's order sheet for July 3, 2023 revealed orders for [Formula] calories via Percutaneous Gastronomy tube (PEG) at a rate of 60 milliliters per hour (ml/hr.) and auto flush water (H2O) via PEG at a rate of 45 ml/hr. for 20 hours every; the documented directions indicated: off at 10: 00 AM and on at 2:00 PM every day. Review of Care Plan initiated on 8/13/24 with a goal for Resident to tolerate tube feeding without nausea/vomiting, diarrhea, constipation or aspiration by next review revealed interventions that included: [Formula brand] calories via PEG at 60 ml/hr. for 20 hours and auto flush of H20 at 45 ml/hr. via peg tube for 20 hrs. Maintain and improve current weight and stay hydrated On 9/30/24 at 9:00 AM Resident #78 was observed in bed, the feeding bottle labeled [Formula brand] was hanging on pole next to bed. The feeding was not in progress, the tubing was suspended in the air with a connector piece that was uncapped. On 10/01/24 at 9:07 AM Resident #78 was observed in bed. The feeding was hanging on the pole and not in progress was the tubing suspended in the air uncapped. Record review of a demographic sheet for Resident #78 revealed resident was admitted to the facility on [DATE] with diagnosis that included: Gastrostomy status. Record review of a quarterly MDS with a reference date of 9/09/2024 Section C (Cognitive Status) revealed the BIMS score was undetermined, and Section GG (functional status) revealed Resident#78 was dependent on staff assistance for all ADLs. Record review of a Physician's order sheet for June 2024 revealed Resident #78 has orders for [Formula brand]feeding at a rate of 60 ml/hr. and an auto flush of H20 at a rate of 46 ml/hr. via PEG tube for 20 hrs. every shift on the day shift with directions to turn off at 10:00 AM and on at 2:00 PM every day. Record review of a maintain and improve current weight and stay hydrated care plan initiated on 6/18/24 with a goal to tolerate tube feeding without diarrhea revealed interventions included: [Formula brand] calorie feeing at a rate of 60 ml/hr. via PEG for 20 hrs and an auto flush of water at 46 ml/hr. via peg tube for 20 hrs. On 9/30/24 at 10:29 AM Resident #109 was observed in bed, A feeding bottle labeled [Formula brand] feeding hung on a pole, was not in progress, and the connector was without a cap. On 10/02/24 at 1:55 PM Resident #109 was observed in bed, A feeding bottle labeled [Formula brand] hanging on a pole, was not in progress, and the connector had no cap. Record review of demographic sheet for Resident #109 revealed an admitted [DATE] with diagnosis that included: Gastro-esophageal reflux disease without Esophagitis. Record review of a Significant Change in Status MDS with a reference date of 9/5/24 Section C (Cognitive Status) revealed a BIMS score was undetermined, and Section GG (functional status) revealed Resident#109 was dependent on staff assistance for all ADLs. Record review of a physician's order sheet for May 2024 revealed orders for [Formula brand] at 60 ml/hr. via PEG and an auto flush of H20 at a rate of 46 ml/hr. via PEG tube for 20 hrs off at 10:00 AM and on at 2:00 PM every day. Record review of a at risk for Aspiration, GI, disturbances on care plan initiated on 9/12/2024 with a goal to tolerate tube feeding through NRD (Next Review Date) and tube feeding will remain patent without signs of infection revealed interventions included: Observe and report side effects and complication such as abdominal pain/ discomfort, constipation, diarrhea, aspiration, tube dysfunction, infection to Physician . On 9/30/24 at 10:40 am Resident #115 was observed in bed with oxygen in progress at 2 L/min, no distress observed. A feeding bottle labeled [Formula] was hanging on the pole next to bed and the connector was uncapped. On 10/01/24 at 8:59 AM Resident #115 was observed in bed with oxygen in progress at 2 L/min, no distress observed. A feeding bottle labeled [Formula] hanging on the pole next to bed and the connector was uncapped. Record review of demographic sheet for Resident #115 revealed an admitted [DATE] and readmitted [DATE] with diagnosis that included: Encounter for attention to gastrostomy. Record review of a MDS with a reference date of 9/10/24 Section C (Cognitive Status) revealed a BIMS score of 00, indicated severe cognitive impairment and Section GG (functional status) revealed resident was dependent on staff assistance for all ADLs Record review of a physician's order sheet for September 2024 revealed orders for Jevity 1.5 at 35 ml/hr. and auto flush of H2O at 45 ml/hr. for 20 hours every shift off at 10:00 AM and on at 2:00PM every shift every day off at 10:00 AM and on at 2:00 PM. Record review of an at risk for aspiration care plan initiated on 9/12/2024 with a goal for tube feeding site to remain patent without signs of infection through NRD revealed interventions included: Observe and report side effects and complication such as abdominal pain/ discomfort, constipation, diarrhea, aspiration, tube dysfunction, infection to Physician, check feeding tube placement patency every shift and as needed and tube feeding site care as prescribed by MD. On 9/30/24 at 3:13 PM Resident#133 was observed in bed, no distress noted. A feeding bottle of [Formula Brand] was hanging on a pole next to resident's bed not in progress, and the connector was not capped. On 10/01/24 at 9:11am Resident#133 was observed in bed, no distress noted. A feeding bottle of [Formula brand] was hanging on a pole next to resident's bed not in progress, and the connector was not capped. Record review of demographic sheet for Resident#133 revealed an admitted [DATE] and a readmitted [DATE] with diagnosis that included: Encounter for attention to gastrostomy. Record review of a Significant Change in Status MDS with a reference date of 8/6/24 Section C (Cognitive Status) revealed a BIMS score was undetermined, and Section GG (functional status) revealed Resident#133 was dependent on staff for all ADLs. Record review of a maintain and improve current weight and stay hydrated care plan initiated on 6/18/24 with a goal to tolerate tube feeding without diarrhea revealed interventions that included: [Formula] at 70 ml/hr. via PEG x 20 hrs and Auto flush of H20 at 60 ml/hr. via peg tube x 20 hrs. On 10/02/24 at 1:56 PM Staff A, Registered Nurse (RN) observed attempting to re-connect the feeding tube for Resident #14. Staff A, RN did not clean the connector and was stopped by surveyor. Staff A, RN was asked if the connector should be capped while feeding is not in progress and cleaned before being attached to resident, and Staff A, RN replied, The cap is supposed to be covered by the connector while feeding is off. On 10/02/24 at 2:01 PM Staff A, RN was showed by surveyor the other residents (#73, #14, #78, R#109, R#115, #133) who had feeding tube with connectors uncapped. Staff A, RN stated, In this case I need to change the entire tubing and will do so now. On 10/02/24 at 3:17 PM Staff B, Registered Nurse (RN) stated, When the tubing system for a feeding is disconnected from the resident, the connector should be placed into the cap for infection control purposes. When the nurses are ready to reconnect, they should remove from the cap and reconnect. For the instance when the connector is suspended in the air uncapped, the nurse should change the line and then reconnect. On 10/03/24 at 2:46 PM The Director of Nursing (DON) stated, The night shift are responsible for setting up a new bottle and the day shift nurses reconnects the tubing. The connector should be capped while not in progress to prevent contamination. If a nurse finds it uncapped the whole system should be replaced. Record review of Policy entitled, Infection Control program effective date: July 29, 2014, Last revised date: January 2021 last review date: March 27, 2024. Policy: The facility has established and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

Based on observation, record review and interviews, the facility failed to provide an environment free from potential safety hazards for one resident (R#109) out of out of 18 residents with padded assist rails as evidenced by observations of two quarter side rails in the up position and one was without padding. The findings included: On 9/30/24 at 10:25 AM Resident #109 was observed in bed with eyes open, holding a toy. Two quarter length side rails observed in the up position. The right-side rail had a blue padding attached and the left side rail had no padding. There was a padding on the recliner near the resident. (see photos) On 10/01/24 at 8:57 AM, Resident #109 was observed in bed, two quarter side rails noted in the up position. The left sided rail had no padding. There was a padding on the recliner near the resident. (see photos) Record review of a demographic sheet for Resident #109 revealed an admitted [DATE] with diagnosis that included: Seizure. Record review of a Significant Change in Status Minimum Data Set (MDS) with a reference date of 9/5/24 Section C (Cognitive Status) revealed a Brief Interview for Mental was undetermined and Section GG (functional status) revealed Resident#109 was dependent on staff for all Activities of Daily Living. Review of a May 2024 physicians order sheet revealed an order for two assist rails up (in place) due to (seizure precautions) with padding every shift every day. Record review of a Potential for injury due to seizure disorder care plan initiated on 9/12/2024 with a goal to not sustain any injury related to seizure disorder thru Next review date revealed interventions that included: two assist side rails down, horizontal, with padding to rails as prescribed. On 10/03/24 at 12:14 PM; Staff B, Registered Nurse (RN) Unit Manager for the third floor was notified by surveyor of the observations and asked what is the order for Resident #109's side rails. Staff B, RN revealed, Resident #109 is ordered to have two padded side rails in the up position for seizure precaution to prevent injury. Upon admission if a resident has a history of seizure an order for side rails to be padded is received. All staff are responsible for ensuring the side rails are in the up position and padded by doing rounds. The only reason the padding would be removed is for hygiene care and it should be replaced. On 10/03/24 at 12:29 PM Staff C, RN stated, The side rails for [Resident#109] are to be kept in the up position with padding for seizure precautions. I monitor the side rails to make sure they are in the correct position by doing rounds. Padding should be in place at all times. On 10/03/24 at 12:35 PM Staff E, Certified Nursing Assistant (CNA) (translated by ADON) when asked about the positioning of the side rails for Resident#109; Staff E stated, I am the CNA assigned to [Resident#109]. I am aware of the need for the side rails to be up and padded for safety measures. I am made aware of the interventions by the nurses during line up to inform every morning and rounds. On 10/03/24 at 2:39 PM The Director of Nursing was informed by surveyor a concern of no padding on one side rail and the positioning of the side rail for Resident#109 and the DON revealed, there is a positioning device log that is used by staff and updated each morning to show all the residents with side rails and how they should be positioned. The purpose of padding the siderail is an extra measure to protect against trauma and friction for involuntary movements. If a resident has an order for side rails in the up position with padding. The padding should be on at all times while the resident is in bed, except during hygiene care and repositioning and it should be replaced; family are also educated to put it back in place if they remove it. Record review of Policy entitled, Safety Management Plan effective date: January 1, 2014 Last revision date: December 16, 2014 Last reviewed date: January 24, 2024 Policy: The Palace manages risks within the environment that has minimal physical hazards and therefore, reduces the risk of injury.

Based on observations, interviews and record review the facility failed to ensure one resident (Resident #137) out of two sampled residents receive quality of care and treatment in accordance with professional standards as evidenced by observations of an undated dressing on the left side of Resident #137's face. The findings included: On 09/30/24 at 10:14 AM two surveyors observed Resident #137 in bed with a dressing on the left side of Resident #137's face that also covered the left ear with no date. On 10/01/24 at 9:49 AM two surveyors observed Resident#137 in bed with a dressing on the left side of Resident #137's face that also covered the left ear with no date. Record review of the demographic sheet for Resident#137 revealed an admitted [DATE] with diagnosis that included: Other specified disorders of left ear with left ear skin lesion and changes in skin texture. Record review of a Significant Change in Status Minimum Data Set (MDS) with a reference date of 7/15/2024 Section C (Cognitive Status) revealed a Brief Interview for Mental Status (BIMS) score of 7 on a scale of 00-15, indicated moderate cognitive impairment. Section GG (Functional status) revealed Resident#137 required set up clean assistance for eating and personal hygiene, substantial/maximal assistance for shower/bathe and was dependent for toileting and transfers. Section I (Active diagnosis) revealed diagnosis of Basal Cell Carcinoma of skin of left ear and external auricular canal. Section M (Skin conditions) revealed Resident #137 received application of non-surgical dressings with or without topical medications other than to feet and application of ointments/medications other than to feet. Record review of an Impaired skin integrity due to Basal Cell Carcinoma to left ear care plan for initiated on 7/23/24 with goals that included: lesion to left ear will decrease in size without signs and symptoms of infection through next review date revealed interventions that included: Staff to assess surgical site and inform the physician for any signs of infection. Apply gauze and secure with tape to top left ear as prescribed. Record review of a physician's order sheet revealed orders dated 6/11/24 directions: clean very gently left ear skin lesion with normal saline, pat dry, apply gauze, secure with tape every day and as needed and 7/08/24 for Acetaminophen 500 milligrams (mg) tablet give two tablets by mouth once a day 30 minutes before skin treatment of the left ear for pain. On 10/02/24 at 3:22 PM Staff B, Registered Nurse (RN) unit manager for the third floor stated, Each time the nurses change a dressing the new bandage should be dated to determine the last date it was changed. The only reason it should not be dated is if the dressing temporarily placed until a nurse can do a proper dressing change and date it. The dressing change for [Resident#137] should be done on the day shift. On 10/03/24 at 2:49 PM, the Director of Nursing (DON) stated, When a bandage is changed the date is changed at that time and should be written on the bandage to indicate the last date of change and by whom it was changed. Record review of Policy entitled, Person Centered Quality of Care effective date: July 29, 2012, last revision date: August 10, 2014 last review date: January 7, 2024 Policy: The facility embraces, supports and has adopted a person-centered approach to care, services and treatment. The facilities identify and provide needed care and services that are resident centered, in accordance with the residents'' preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs.

Based on observation, record review and interviews, the facility failed to update a side rails care plan for one resident with a seizure disorder (#109) out of 18 residents with padded assist rails as evidenced by a physician's order for Resident #109 with directions to keep both side rails in the up position and a care plan with interventions that included side rails to be in the down position. There were 171 residents residing in the facility at the time of survey. The findings included: On 9/30/24 at 10:25 AM Resident #109 was observed in bed with eyes open, holding a toy. Two quarter length side rails observed in the up position. The right-side rail had a blue padding attached and the left side rail had no padding. A padding was noted on the recliner near the resident. Record review of a demographic sheet for Resident #109 revealed an admitted [DATE] with diagnosis that included but not limited to: seizures, psychotic disturbance, anxiety disorder restlessness and agitation. Record review of a Significant Change in Status Minimum Data Set (MDS) with a reference date of 9/5/24 Section C (Cognitive Status) revealed a Brief Interview for Mental was undetermined and Section GG (functional status) revealed Resident#109 was dependent on staff for all Activities of Daily Living. Record review of a May 2024 physicians order sheet revealed an order for two assist rails up (in place) due to (Seizure precautions with padding) every shift every day. Record review of a Potential for injury due to seizure disorder care plan initiated on 9/12/2024 with a goal to not sustain any injury related to seizure disorder thru next review date revealed interventions that included: two assist side rails down, horizontal, with padding to rails as prescribed. On 10/03/24 at 1:33 PM; Staff D, Registered Nurse (RN) was asked to explain why the interventions for the side rails in the care plan differ from the orders,; Staff D stated: The nurses will follow the physician's order. We create the care plan according to the physician's order. The interventions are always resident specific. On 10/03/24 at 2:39 PM, the Director of Nursing (DON) was informed by surveyor about the difference in the care plan interventions for Resident #109's side rails and the physician's order. The DON replied, The reason the interventions do not match the order is because The MDS nurse used the old template for the seizure disorder care plan and the new template should have been used. There is a positioning device log that is used by staff and updated each morning to show all the residents with side rails and how they should be positioned. Record review of a Policy entitled, Care Planning effective date: 7/12 last revision date: January 7, 2017, last reviewed date: January 24, 2014. Policy: The facility develops and implements a plan of care for each resident to ensure they receive personalized, high-quality care that meets their individualized needs and preferences, while promoting dignity, independence, and quality of life.

Based on record review and interview, the facility failed to maintain communication with hospice to ensure continuation of care for 1 (Resident #7) out of 5 residents reviewed for hospice care, as evidenced by no updated hospice communication notes available in Resident #7's medical records. This had the potential to affect the 38 residents receiving hospice care in the facility at the time of this survey. The findings included: During Observation on 05/07/23 at 08:54 AM, Resident #7 was in bed being fed by a Certified Nursing Assistant, a unilateral floor mat was at the beside. On 05/08/23 at 08:24 AM, Resident #7 was in bed asleep, no distress was noted. On 05/09/23 at 12:04 PM, resident #7 was in bed awake watching Television, no distress was noted. Record review of the facility's hospice notes revealed, the most recent documentation available for Resident #7: was on 4/3/23-Focus visit plan completed, 4/5/23 -nursing comprehensive assessment was completed. Review of the medical records for Resident #7 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Do Not Resuscitate (DNR), Diet- No restrictions, Honey Thick, Pureed. Review of the Physician's Orders Sheet for May 2023 revealed, Resident #7 had orders that included but not limited to: Encounter for palliative care. Record review of Resident #7 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Resident's Brief Interview for Mental Status Score-unable to be determined. Section G for Functional Status documented resident is total dependence with two-persons assistance for Activities of Daily Living. Section H for Bowel and Bladder documented resident is -always incontinent of bowel and bladder. Section J for Health Conditions documented no shortness of breath and no schedule or as needed pain medications received in the last 5 days. Section K for Nutritional Status documented no unknown weight loss/ gain. Section N for Medications documented resident received anticoagulants and antibiotics in the last 7 days. Section O for Special Treatments, Procedures, and Programs documented resident received hospice care in the last 14 days. Record review of Resident # 7's Care Plans Reference Date 03/14/2023 revealed: Resident has a diagnosis of End Stage Cerebral Atherosclerosis, receiving Palliative care under hospice. Interventions up to and including: Contact Hospice and Physician regarding resident's status, discuss plan of care with all individuals concerned, provide palliative care and other modalities of treatment necessary as affirmed by individuals concerned. Review of the facility's hospice contract revealed on 10/10/2002-[Vi .] Hospice contract was signed with [Vi .] as general manager and facility's Chief Financial Officer. Interview on 05/09/23 at 08:10 AM with the Registered Nurse Unit 1 nursing Manager (Staff B) stated, hospice nurses come to the facility at least twice a week, the hospice staff sign in at the front desk, we communicate about the resident's care needs, the hospice staff leave their notes in the hospice binder located at the nurse's station. When a resident has to be placed on hospice initially, social services take care of coordinating the care with the hospice team. Surveyor and Staff B reviewed the hospice binder, the last nursing comprehensive assessment was completed on the resident on 04/05/2023, and on 4/3/23-last Focus visit plan completed. Interview on 05/09/23 at 08:21 AM with the Hospice Registered Nurse it was reported, right now we have about 38 residents here on hospice care, we have three (3) hospice nurses assigned to this facility and we come here almost every day, we leave our patient notes here almost every day, we complete the hospice notes, take it to the office, discuss the resident in our meetings, the physician signs, coordinate the care plan and then we bring a printed copy back to the facility. The notes get updated weekly-Tuesday to Tuesday. I will check with the hospice nurse that is assigned to this resident to see where the notes are. Review of the contract between [Vi .] Hospice and the facility documented the following: In section 2.10-facility shall prepare and maintain complete and detailed medical records for each hospice patient receiving inpatient services hereunder in accordance with prudent record keeping procedures and applicable laws, rules, and regulations. Facility personnel shall make a signed record entry each time any inpatient services are rendered. Such medical records shall include progress notes and clinical notes describing all inpatient services provided, and a copy of each hospice patient's plan of care. Review of the facility's policy titled, End of Life Care revision date May 3, 2015, states: End of life may include addressing the clinical, psychosocial, and spiritual concerns of the resident and their family or loved ones.

Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for two (Resident #13, and Resident #195) out of 3 residents reviewed for resident assessments. As evidenced by inaccurate coding of MDS section O for Special Treatments, Procedures, and Programs. Oxygen therapy for Resident #13 and Hospice care for Resident #195. There were 172 residents residing in the facility at the time of this survey. The Findings Included: During observation on 05/07/23 at 09:00 AM, resident #13 was observed in the wheel chair eating breakfast, oxygen (02) was running via nasal canula (NC). On 05/08/23 at 08:24 AM, the resident was observed in bed asleep, the 02 was running at 2 liters per minute (LPM) via NC, the call light was on the bed. On 05/09/23 at 09:30 AM, the resident was observed in bed asleep, the 02 was running at the correct rate. Review of the medical records for Resident #13 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Palliative Care, Chronic obstructive pulmonary disease, unspecified and Shortness of breath. Review of the Physician's Orders Sheet for May 2023 revealed, Resident #13 had orders that included but were not limited to: 01/30/2023-oxygen (O2) @ at 2 Liters per minute (LPM) via NC continuously every Shift, Change Oxygen tubing and/or mask, and ensure equipment is functioning properly weekly and as needed once a day on Tuesdays and Ensure red Oxygen sign is in place outside the door of resident room at all times, while O2 tank/concentrator is in room every Shift. Record review of Resident # 13's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) is 4, indicating the resident is cognitively impaired. Section G for functional status documented the resident requires extensive assistance with one person assistance for Activities for Daily Living (ADLs). Section H for Bowel and Bladder documented Resident is always incontinent of bowel and bladder. Section J for Health Conditions documented Resident experienced no shortness of breath. Section K for Nutritional Status documented resident has no unknown weight loss/gain. Section N for Medications documented resident received diuretics and opioids in the last 7 days and Section O for Special Treatments, Procedures, and Programs documented resident received hospice care in the last 14 days, Oxygen therapy not coded. Record review of Resident #13 's Care Plans Dated 01/20/2023 revealed: Resident at risk for altered airway clearance related to Shortness of Breath. Interventions including: Oxygen via nasal canula as prescribed, ensure red Oxygen sign is in place outside the door of resident room at all times, while O2 tank/concentrator is in room, and change Oxygen tubing and/or mask, and ensure equipment is functioning properly weekly and as needed. Interview on 05/09/23 at 07:46 AM the Registered Nurse MDS (Staff A), when asked to check the orders to verify the resident is on continuous oxygen, Staff A confirmed the order, surveyor had Staff A check the last two Quarterly MDS's on record dated 04/24/23 and 02/01/2023, Section O for treatments, programs, and procedures. Staff A confirmed the resident was not coded for oxygen therapy on the two quarterly MDS assessments. Staff A stated she will look into what happened with the resident's MDS and get back to the surveyor. Interview on 05/09/23 at 10:55 AM Staff A stated, we looked at the resident's MDS, made the necessary corrections and resubmitted the MDS today. Received all documentation requested. Review of the facility's policy and procedures titled, Scope of Assessments and Re-assessments revision date 12/06/2021 states: The facility assesses and reassesses its residents according to applicable law/regulation and facility policy. Procedure 1-By the time all discipline-specific assessments and the MDS have been completed, the following information will be collected and documented: a. Current diagnosis, pertinent history, medication history, current medication, and current treatments. 47124 Record review of Resident #195 revealed, the resident was admitted on [DATE] under Hospice. Medical diagnoses included but were not limited to; heart failure, encounter for palliative care, acute embolism, and thrombosis of deep veins of bilateral lower extremity (03/15/2023), Status post thrombectomy (03/30/2023). The current Physician Orders included code status, Do Not Resuscitate. The Minimum Data Set, dated dated dated [DATE] for a significant change in Status. In Section C, the brief interview of mental status score was 12 meaning the resident was moderately impaired. In Section G, bed mobility was extensive assistance by one-person physical assist. Transfer was total dependent with two-person physical assistance. Eating was supervision with setup assistance. Toilet use was total dependent with one-person physical assistance. In Section O, while a resident, it stated that Resident #195 received no cancer treatments, no oxygen therapy, no for intravenous medications, transfusions, dialysis, hospice, isolation or quarantine. Resident #195 has been admitted under hospice since 7/15/22. In the care plan, Problem/Need documents, Resident #195 had a diagnosis of end stage heart failure. Receiving palliative care under hospice. Further decline is expected and unavoidable as end stage disease progresses. Date open 4/13/23. The goal stated, resident will have all psychosocial needs met by next review date. Interventions included were contact hospice and medical doctor regarding resident's status. Next review date 7/13/23. On 05/10/23 at 10:06 AM, in an interview with the MDS coordinators Staff A, Registered Nurse & Staff E, Registered Nurse. When asked Is the resident on hospice?, Has the resident been a resident here at the facility?. Staff A stated Yes, resident #195 is currently in hospice and has always been on hospice. I see that there this no check next to hospice care. I'll look into it, and I'll get back with you. On 05/10/23 at 11:00 AM, Staff A reports, We submitted a data entry error [5/10/23 10:19 AM] and here is correction page.

Based on observation, interview, and record review, the facility failed to ensure 1 out of 2 residents sampled for food preferences (Resident #702) was honored in his choice of food preferences during meal times. The facility had a census of 172 residents at the time of the survey. The findings included: Review of the facility's resident rights policy and procedures last reviewed January 13, 2023 revealed: The facility respect and honor resident rights. The facility informs residents about their rights and responsibilities upon admission. The facility respects the resident cultural, psychosocial, personal, and spiritual values, beliefs, and preferences, respects the resident rights to participate in decisions about his or her care, treatment, and services. Review of the facility's policy and procedures on resident food preferences revised on January 13, 2023 revealed: The purpose of the food preferences and assessment is to best meet resident's dietary needs, food habits, calorie intake, and quality of life. It also stated that Registered Dietitian interviews residents and/or care provider to assess resident's nutritional status and gather food preferences. Registered Dietitian updates kitchen software, meal tracker, according to residents' responses with likes, dislikes, substitutions, special instructions, refusal, and snacks are all updated in this system. Residents and/or care givers are able to update food preferences as needed on an ongoing basis. On 05/07/2023 at 09:20 AM, during an interview with Resident #702's private duty aide (PDA) #1 regarding Resident #702's food preference, the PDA stated that Resident #702 received bacon on his breakfast food tray, which is against the resident's food preferences. Observation on 05/07/2023 at 09:20 AM revealed Resident #702's breakfast tray had 1 pancake, 2 slices of bacon, a small cup of syrup, 2 pieces of stripped waffles, a cup of hot water, 1 packet of coffee decaf, 2 packets of Splenda, and a diet Ginger-Ale soda. Review of Resident #702's breakfast food tray cart for 05/07/2027 revealed the resident circled: Coffee Decaf, 2 packets of Splenda, 2 packets of Creamer, pancakes, cream of wheat, margarine, syrup (diet syrup). Review of Resident #702's medical record dated 04/27/2023 revealed that Resident #702 was admitted on [DATE]. Resident #702's medical record also revealed his religion preference is Judaism. Further review showed Resident #702's hospital medical record dated 04/27/2023 also revealed the resident's religion preference is Jewish. Review of Resident #702's Initial Nutrition Assessment, dietary Nutrition Risk assessment dated [DATE] revealed that Resident #702 is alert and oriented times 3 (AAOx3) and able to report food preferences at time of interview. Further review of Resident #702's updated initial nutrition assessment, the dietary nutrition risk assessment dated [DATE] revealed that Resident #702 is alert and oriented times 3 (AAOx3) and able to report food preferences at time of interview. Review of Resident #702's Minimum Data Set (MDS) dated [DATE] revealed that the Resident Brief interview for Mental Status Score was 15, indicating the resident is cognitively intact. Review of Resident #702's Interdisciplinary Care Plan dated 04/28/2023 showed: Resident personal food preferences will be honored through next review date; however, there was no mention on the resident's likes or dislikes of food. Review of Resident #702's nutritional food preferences revealed, No Concentrated Sweets (NCS), low fat low cholesterol diet, Fluid Rest. 1000 ml/day (milliliters/day) (780 ml diet, 220 ml NURS) No pork/chicken/ham/bacon . Turkey bacon ok. On 05/09/23 at 12:34 PM, during an interview with Resident #702's private duty aide (PDA) #2, PDA #2 stated, When he first came, they gave him pork when he first came; they fixed it. He doesn't eat bacon. On 05/10/23 at 12:14 PM, when asked Resident #702 if he eats bacon, Resident #702 replied, no pork, no chicken, no bacon pork, no bacon turkey, I'm Jewish. No bacon at all. On 05/10/23 at 12:19 PM, during an interview with Staff F, a Registered Dietitian regarding Resident #702's food preferences, Staff F stated, He follows kosher but not strict diet. He doesn't eat pork but eat turkey bacon. I talked to the daughter he doesn't eat chicken, but he can eat stew chicken. They have a selective menu, and they choose from that menu for the week. They can choose whatever they want to eat. On 05/10/23 at 12:30 PM, further interview with Resident #702 in front of the two Dietitians, Staff F and Staff G regarding his food preferences, Resident #702 stated that he does not want bacon at all. Resident #702 stated, No chicken bacon, no turkey bacon, no pork. On 05/10/23 at 12:33 PM Staff H, Certified Nursing Assistant for Resident #702 stated, He cannot eat pork, but he can eat chicken. When showed the food card from Resident #702's food tray during the lunch time, Staff H read it and stated, Oh!!!. Staff H was unaware that Resident #702 did not eat chicken and was also unaware if Resident #702's food preferences was related to his religion. On 05/10/23 at 12:37 PM, interview with Staff I, Resident #702's Registered Nurse (RN) revealed that she was aware that Resident #702 is Jewish. Staff I stated that when she receives the resident for the first time, she asked for the food preferences. Staff I then stated, I remember exactly for preferences for breakfast. I remember he asked for cut of cheese, fruits, and apple sauce. I don't remember exactly bacon. I know he always has a private aide, and the private aide always helps him get the food. The private aide is very aware of what he wants. I don't remember exactly if he eats the bacon. It was in the menu, basically they probably served him the bacon. If he as a Jewish person requested not to eat bacon, he is supposed not to have it in the menu. On 05/10/23 at 12:46 PM, when asked Staff J, RN Manager about receiving any complaint regarding Resident #702's food preferences, Staff J stated, Never, never. I never received any complaint from the family. After they received the food tray card, they reviewed it, and they went and corrected it. I guess they gonna have to go and update it.

Based on observation, interview and record review, the facility failed to maintain an accurate receipt of administration of controlled medications and failed to store medications for 1 out of 5 carts checked. The findings included: On 05/09/23 at 11:22 AM, during an observation with Staff C, Licensed Practical (LPN) of cart number three on the third floor. A purple pill which was Levothyroxine 75 mg was found on the bottom of the drawer below the resident's medication blister packs. Staff C placed the medication in a drug buster container and shook the bottle. During the review of the controlled medication record book for resident #176's Hydrocodone 10-325 mg (milligram) tabs controlled medication record. The record bood documented there were 28 tablets remaining, but in the blister pack there were 27. Staff C corrected the sheet that it was 27 remaining. At 5/9/23 8:51 AM, Staff had given a Hydrocodone tab to resident #176. On 05/09/23 at 01:27 PM, during an interview with Staff C, LPN. Staff C was asked, What is the facility's policy and procedure regarding the controlled medication count? Staff C stated, Everyone knows that once the narcotic medication is given. The nurse must write down that it was given to the resident on the narcotic count sheet. It's unacceptable. I feel very bad that it has happened. On 05/10/23 at 11:08 AM, during an interview with Staff C, LPN. Staff C was asked, What in-services and educations were given to staff about controlled medications? Staff C stated, We do several in-services during the year for different topics including narcotics. They did an in-service with narcotics with everyone yesterday. They are on top of in-services for narcotics all the time. I have worked here for several years. When I give the narcotic, I immediately sign for it in the narcotic count sheet in narcotic book. In the in-service, I was told, when you take it out, you scan and sign out the narcotic out immediately. Make sure the amount remaining is the same in the blister pack. The supervisors and the nurses do an extra counting of narcotics during the day. This didn't have to happen. This error. On 05/10/23 at 10:45 AM, in an interview with Staff D, Registered Nurse, Unit Manager. When Staff D was asked, What is the facility's policy regarding controlled medications? Staff D stated, When you give the controlled medications, click on that medication in the electronic health record to sign for it, and administer it to the resident. On the narcotic sheet, sign that the medication is given. If you give the medication, you sign for it. We have 2 shifts. The narcotics are counted between oncoming/offgoing nurses. Record review for Resident #176 revealed, the resident was admitted on [DATE]. Medical diagnoses included encounter for palliative care and primary diagnosis of degenerative disease of nervous system. Hydrocodone-acetaminophen - Schedule II tablet. Dosage is 10-325 milligrams for 1 tablet and to be given orally two times a day for pain. In the Minimum Data Set, dated dated dated [DATE], brief interview of mental status is a 2 meaning severe cognitive impairment. In Section I, active diagnosis is Arthritis, Non-Alzheimer's Dementia, pressure ulcer of sacral region, stage 4 and osteoarthritis, unspecified site. In Section N, opioids were given in the last 7 days. In section O, hospice care and 3 days of active range of motion are ordered. In review of the Policies and Procedure titled, Narcotics: Control of Medication. Page 1 of 5. Effective 2017. Reviewed December 2022. In section, 4. Administration of Medication. When a medication is administered, the licensed nurse administering the medication enters the following information on the medication administration record (MAR) and accountability record for controlled substances. Date and time administration (MAR, accountability record), amount administered (MAR, accountability record), and remaining quantity (accountability record). Initials of the nurse administering the dose, completed after the medication is administered (MAR, accountability record).

Based on observations, record reviews, and interviews the facility failed to ensure infection control measures were followed for one (resident #185) out of four residents with catheters at the time of this survey. The findings included: Observation and interview on 11/18/2019 at 3:11 PM revealed resident #185 in low positioned bed. Resident#185 revealed he had a suprapubic catheter. The catheter drainage bag was observed touching the floor and the hook that held the privacy bag for the catheter was not anchored on the bed. Observation on 11/19/2019 at 9:13 am revealed resident #185 was in a Geri chair next to his bed. The catheter drainage bag was in a privacy bag that was not anchored on the chair and touching the floor. Observation 11/20/2019 at 9:18 am revealed resident #185 was sitting in Geri chair in his room near his bed and the catheter bag was not anchored and touching the floor. Record review of Care plan dated 8/14/2019 for Resident's #185 revealed resident #185 care planned for suprapubic catheter. Goals and interventions and approaches included patency will be maintained. Approach item #10 indicated to secure catheter with leg strap and Approach #12 noted staff to provide care/hygiene to suprapubic catheter every shift. Interview with Staff A, Certified Nursing Assistant (CNA)on 11/20/2019 at 9:22 am revealed they place the catheter drainage bag at the bottom of the wheel chair inside the privacy bag. Staff A CNA stated, it cannot touch the floor. Staff A revealed it was an infection control problem, because the bag was touching the floor. CNA, Staff A stated that when the bed is at low position sometimes the bag can touch the floor, but it should not touch it. Interview with Staff B, Registered Nurse (RN) Unit Supervisor on 11/20/2019 at 9:30 am, stated they must place the catheter bag on the frame of the bed, we cannot let it hang or on the floor. Staff B , RN Unit Supervisor stated that the bag probably fell by mistake and that she needed to check. Staff B, RN Unit Supervisor revealed they placed the bag on a hook because the catheter bag must be placed and anchored to the chair or the bed. Interview with the Chief Nursing Officer ( CNO) on 11/20/2019 at 3:52 PM revealed. All catheters are placed below the kidney level, depending on the residents' level of care she doesn't have a concern if it's on the floor. However, if it's inside the protective cover, it minimizes the risk. She stated we use a cover protector for dignity and to prevent contact with the bag. She stated we have a protective barrier to minimize potential for everything and for dignity. Record review of the facility's policy titled: The Care and Maintenance of Urinary Catheter Policy revised (MONTH) 2019 revealed. Procedure #8 Urinary catheter care and maintenance procedures shall include the following: Urinary catheter care shall be provided every shift and as needed, or as per physician's orders [REDACTED].

Based on interviews, observations and record review of the facility's grievance log and policy, the facility failed to support Resident's Right relating to the assurance of prompt efforts conducted in resolving grievances for one resident (#186) out thirty-four sampled residents. The resident reported concerns with staff interaction that went unaddressed and unresolved. This facility practice has the potential to affect all adults residing in this facility at the time of this survey. The Findings Included: Interview and observation on 7/30/2018 at 10:25 AM revealed, resident #186 was alert and oriented, and able to verbalize her needs. The resident stated that she felt unlinked and ignored by staff. Resident #186 reported that her problem in the facility was that she spoke English, and because of that, she felt sad. The resident explained, she heard one of her CNAs mutter, Oh English! and was annoyed that the resident did not speak Spanish. The resident also indicated that her inability to communicate with her Spanish speaking CNAs made her feel guilty, isolated, and sad. The resident had discussed about her concerns with family and staff. Record review of the Grievance Log revealed, no grievances reported by or on the behalf of resident #186 during the year. Interview on 07/31/2018 at 9:35 AM with Staff A, a Certified Nursing Assistant (CNA) revealed, staff A's primary language was Spanish, but she managed to communicate with resident # 186 in English. Staff A reported, the resident had verbalized some of the mentioned concerns. Staff A reported, the resident reported to staff A that she did not understand some of the staff. Staff A made no mention of following the facility's grievance procedure. Instead, the CNA made two recommendations to the resident, try slowing down (when speaking) or tell the nurse. Interview on 08/02/2018 at 9:56 AM with the Social Services Director revealed, the facility acknowledged that grievances might constitute a lot of little stuff. The facility appointed a Director of Resident Services to handle daily resident concerns, including room changes and concerns related staff-resident interactions. All facility staff received training in the grievance process. Upon discussion of the above-mentioned resident concerns, the Social Services Director indicated that the CNAs responsibility was to apologize to the resident and to communicate the resident's concerns to the unit supervisor. During an interview on 08/02/2018 at 11:17 AM, the Director of Resident Services reported, she addressed concerns from residents, families or staff. The Director of Resident Services was not aware that resident #186 had concerns related to staff-interaction. After discussing, the above-mentioned resident concerns the Director of Resident Services agreed that it was the facility's responsibility to address the resident concerns, to the resident's satisfaction. The Director of Resident Services reported, The CNA should have communicated that to the superiors, and eventually I would have gotten the information and looked for a solution. Interview on 08/02/2018 at 2:18 PM, with staff B, a Rehab Aide revealed, staff B was familiar with resident #186 and talked to this resident almost every day. The Rehab Aide reported, the resident was hard of hearing. Staff B added, the resident communicated feelings of loneliness and mentioned that she had difficulty communicating with her CNAs that spoke some English. Staff B expressed an understanding of the grievance procedure and stated that she remembered talking to a nurse about the resident's concerns with staff. During an Interview on 08/02/2018 at 3:59 PM, with staff C, a Registered Nurse and Charge nurse, she revealed, she was familiar with resident # 186. The nurse reported, I was not made aware that the resident had a problem communicating with staff, if she had, she would have made accommodations to meet the residents needs. Staff C also reported, this should have been communicated to me, and the resolution would have been to get another CNA.

Based on interviews, observations and record review, the facility failed to provide activities that met resident's psychosocial needs for one out of 34 sampled residents (resident#195) reviewed for activities. Resident #195 expressed that the facility did not provide activities to meet her needs. This facility practice has the potential to have a negative impact on the care and wellbeing of all residents in the facility at the time of the survey. The Findings Included: Record review of the facility's policy and procedure titled Activity, revealed: I. Purpose: The function of the activities department is geared toward the following objectives. II. Policy: Objective III. Procedure: (included but not limited to: ) 1. To provide activities during the resident's leisure that meet the individual's needs and interests, facilitating a mood receptive to treatment and other disciplines. 2. To assist resident in a satisfactory adjustment to facility placement, educating the individual in the social patterns of living in the institutional setting. 3. To contribute to the development, restoration or maintenance of sound mental, emotional, spiritual and physical health. 4. To assist resident in perusing and acquiring some recreational interest through stimulation, enthusiasm, positive encouragement and personal achievement. Record review of the Face Sheet revealed that resident # 195 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Observation and interview on 7/30/18 at 9:36 AM with resident # 195 revealed, resident #195 was alone in her room, laying on her bed. The resident reported, her concerns included feelings of loneliness and lack of activities. Interview and observation on 08/01/2018 at 1:40 PM revealed, resident # 195 was in the activity room. Resident #195 indicated that this was the first time staff had offered her the chance to participate in the activity program. She again expressed feelings of loneliness. During an interview on 08/02/2018 at 11:52 AM, with the Director of Resident Services and resident #195, the resident communicated her concerns to the patient services director. The resident explained that activity staff visited her room for the first time two days ago. The resident also reported, that would be the second time since admission that staff invited her to the activity program. A review of resident #195's Psychosocial assessment dated [DATE] revealed, the resident's lifelong interest, preferences and routines. The Assessment noted, Reads, and enjoys activities. The Narrative summary of the above-mentioned assessment also noted, {Resident #195) is an [AGE] year old female. At this time, AAOX2 (alert and oriented times two). Resident is able to verbalize feelings, needs and answer questions without difficult at times . Record review of the physician orders [REDACTED]. Interview on 08/02/18 at 12:19 PM with the Activities Director and her Assistants, Staff C and Staff D revealed, the Activities Director reported that care planning for activities began upon resident admission. The Activities Director reported, Upon admission, activities does an initial assessment, to find out what the resident's like, what they use to do, and background. From there we start the care planning process for activities, depending on their preference and level of function, some might need an activity for cognitively impaired, and we assist everybody that wants to go to activities. We have a sensory stimulation program for residents that are unable to interact. We also keep a log for that. During the above-mentioned interview, the activity staff agreed that Activities was important for long-term residents as well as short-term residents. Upon discussion of the above-mentioned resident concerns, the activity staff explained that they invited ALL residents (including resident #195) to activities every day. However, the activity staff was unable to provide any evidence that they invited resident #195 to any of the activity programs. Record review of the progress notes and care plans for resident # 195 revealed, no documentation to show that the staff offered activities or that the resident attended or refused to attend any of the activity programs.

Based on observation, record review and staff interview, the laundry staff failed to store the clean linen, soiled linen and clean resident clothing in the laundry room appropriately. The facility failed to utilize impervious Personal Protective Equipment in order to prevent cross contamination. The findings include: Observation of the laundry area on 08/17/2017 at 10:45 AM revealed, the Director of Environmental Services, Laundry staff A, Laundry staff B, Laundry staff C were observed in the clean laundry area folding clean linen. Observation of the folding table revealed miscellaneous items including a water bottle, two water containers, a bottle of air freshener, two clipboards and two cellular phones resting next to the clean folded linen observed uncovered. An interview conducted with laundry Staff C on 08/17/2017 at 10:50 AM revealed, the linen on the folding table was uncovered and there were miscellaneous items next to the clean linen on the folding table. Observation of the resident's clothing cart revealed the resident's clothing was uncovered. An interview conducted with laundry Staff A on 08/17/2017 at 10:55 AM revealed, the resident clothing were clean and uncovered. Observation of the clean laundry area revealed, there were two uncovered linen carts located in front of the dryers near an air conditioning vent which was circulating air. An interview conducted with laundry Staff B on 08/17/2017 at 11:00 AM revealed, the linen carts located in front of the dryers contained clean wet linen. Staff B stated the carts were uncovered because she was waiting to load the linen. Observation of the washer area revealed a box of latex gloves and there were no gowns observed for sorting linen. An interview conducted with the Environmental Services Director on 08/17/2017 at 11:20 AM revealed, the staff utilized latex gloves and paper gowns to sort clothing, however there were no gowns in the laundry area. Observation of the washer area on 08/17/2017 at 11:30 AM revealed, there were two uncovered soiled linen carts underneath a fan which was circulating air. An interview conducted with laundry Staff A on 08/17/2017 at 11:30 AM revealed the bins underneath the fan contained soiled linen which were uncovered. Staff A stated the carts were uncovered because she was waiting to load the linen. An interview conducted with the Environmental Services Director on 08/17/2017 at 11:45 AM revealed, the soiled and clean linens were uncovered. The resident's clean clothing was uncovered. There were miscellaneous items on the folding table that contained clean uncovered linen. There was no Personal Protective Equipment in the laundry area to sort soiled linen only latex gloves. The air conditioning vent was circulating air on the uncovered clean wet linen in the clean linen area. The fan was circulating air on the uncovered soiled linen in the washer area. An interview conducted with the Infection Control Nurse on 08/17/2017 at 12:00 PM confirmed, the clean, soiled linen and the clean resident clothing were uncovered. There should not be any miscellaneous items on the folding table. There should be impervious Personal Protective Equipment in the laundry area for sorting linen in order to prevent cross contamination. Review of the policy and procedure effective 02/05/2012 for Linen Handling Control noted; All laundry employees while sorting and folding clean linen must wear a protective gown and gloves.

Based on observation, record review, and staff interview the facility failed to ensure that the prevention methods for the spread of infection are consistently practiced as evidence by the availability of hand hygiene products in place prior to exiting the Biohazard waste room. This has the potential to affect one of four rooms in the facility that are used by staff from three different facility departments. The findings include: 1. Observation of the wound care nurse on 06/26/2014 at 10:40 am after conducting wound care revealed, the nurse entered the biohazard waste room on the north wing that contained three biohazard waste containers, two linen containers, and one trash container. The nurse lifted one of the biohazard container lids with her right hand, placed the biohazard waste bag that contained soiled dressings from her left hand inside the biohazard waste container, touched the door knob to open the door with her right hand, exited the biohazard waste room, placed her right hand on the nozzle that contained the Epi-Cleanz Instant Foam Hand Antiseptic, and sanitized her hands with the foam sanitizer. The nurse proceeded to enter the employee pantry that contained a sink, a microwave, and a refrigerator. The nurse opened the faucet, utilized the soap dispenser, and washed her hands. An interview conducted with the wound care nurse on 06/05/2014 at 10:55 am revealed the biohazard waste room did not contain a sink, a soap dispenser or paper towels to wash and dry her hands, or a hand sanitizer to sanitize her hands. The nurse stated she washed her hands in the pantry, since there was no other sink to wash her hands after emptying the biohazard waste. An interview conducted with the Charge Nurse on 06/25/2014 at 11:55 am revealed, the pantry is utilized for the employees to warm up their food and to store the resident's juices and food in the refrigerator brought in by the family. An interview conducted with the Certified Nursing Assistant (CNA) assisting with wound care on 06/25/2014 at 11:00 am revealed, when she disposes of soiled linen she enters the biohazard waste room, disposes of the linen in the laundry bin and sanitizes her hands outside of the biohazard waste room. The CNA confirmed, there is no hand sanitizer inside the biohazard waste room. An interview conducted with the Infection Control Nurse on 06/25/2014 at 11:35 am revealed, the nurses should sanitize their hands after disposing of biohazard waste. Observation of the biohazard waste room located on the first floor on 06/25/2014 at 2:45 PM revealed it contained a hopper, two biohazard waste containers, four linen containers, 6 trash containers, there was no hand sanitizer observed inside the biohazard waste room. The foam sanitizer dispenser located outside the biohazard waste room was observed to have a nozzle which has to be has to be pushed in order to obtain the foam.( Epi-Cleanz Instant Foam Hand Antiseptic. 62% Ethyl Alcohol with added moisturizer.) Observation of the four sanitizer dispensers located on the first floor west wing at 2:50 PM revealed, the sanitizer dispensers were heavily coated with dust. Observation of the four sanitizer dispensers located on the first floor north wing at 2:55 PM revealed, the sanitizer dispensers were heavily coated with dust. 2. Observation of the housekeeping staff on 06/25/2014 at 2:20 PM revealed, the housekeeping staff entered the biohazard waste room with trash, and closed the door. The housekeeping staff was observed exiting the room, utilizing the hand sanitizer located outside the biohazard waste room, and walking towards the elevator. An interview conducted with the charge nurse on the fist floor on 06/26/2014 at 2:55 PM confirmed, the hand sanitizer outside the biohazard waste room was heavily coated with dust. Observation of the third floor biohazard waste room on 06/25/14 at 3:00 PM revealed, two biohazard waste containers, 6 trash containers, 4 linen containers and a hopper. There was not a hand sanitizer observed inside the biohazard waste room. Observation of the four sanitizer dispensers located on the third floor west wing at 3:05 PM revealed, the sanitizer dispensers were heavily coated with dust. Observation of the four sanitizer dispensers located on the third floor north wing at 3:10 PM revealed , the sanitizer dispensers were heavily coated with dust. Observation of the same housekeeping staff at 3:05 PM revealed, she entered the biohazard waste room with trash, and closed the door. The housekeeping staff was observed exiting the biohazard waste, room, utilizing hand sanitizer located outside the biohazard waste room , and walking towards the elevator. An interview conducted with the Restorative Nurse at 3:05 PM confirmed, the sanitizer dispenser outside the biohazard waste room was heavily coated with dust. Observation of the Biohazard waste room on the west wing on 06/25/2014 at 3:10 PM revealed, there were three biohazard waste containers, six trash containers, and two linen containers and one hopper. There was not a hand sanitizer observed inside the biohazard waste room Observation of the four sanitizer dispensers located on the second floor west wing at 3:15 PM revealed, the sanitizer dispensers were heavily coated with dust. Observation of the four sanitizer dispensers located on the second floor north wing at 3:20 PM revealed, the sanitizer dispensers were heavily coated with dust. An interview conducted with the second floor charge nurse on 06/25/2014 at 3:25 PM confirmed, the sanitizer dispenser outside the biohazard waste room was heavily coated with dust. An interview conducted with the Director of Nursing on 06/26/2014 at 9:30 am confirmed, there was not a hand sanitizer inside the biohazard waste room, and the staff should sanitize their hands after the disposal of the Biohazard Waste. Review of the policy for hand hygiene effective June 25, 2013 revealed, the purpose is "to decrease the spread of infection". 1. When to wash hands with soap and water or hand sanitizer: " When hands are visibly dirty or contaminated or visibly soiled with blood or other body fluids."

Based on observation, interview and record review, the facility failed to ensure that a comprehensive care plan was developed based on the assessment for the use of an anti-[MEDICAL CONDITION] medication for resident number one hundred-eighty six (R#186). This has the potential to affect one out of five residents reviewed for unnecessary medications. Creating a comprehensive care plan with related approaches and interventions directly affects the care and treatment provided to the resident. The findings include: Record review of the face sheet for resident #186 revealed, the resident was admitted to the facility on [DATE]. The active [DIAGNOSES REDACTED]. The POS generated on 06-03-14 and on 06-04-14 do not have [MEDICAL CONDITION] listed as one of the resident's diagnoses. There was a POS with a generated date of 06-06-14 with a new order for [MEDICATION NAME] 25mg (milligram) tablet; to give 0.5 tablet (12.5mg) by oral route once daily. A [DIAGNOSES REDACTED]. Record review of the Behavior/Intervention Monthly Flow record for June 2014 had the [DIAGNOSES REDACTED]. The noted behavior was Hallucinations. The monitoring started on 06-06-14 in the evening. According to the monitoring form the numbers of episodes were noted as 6 during the night of 06-06-14. The Medication being monitored was [MEDICATION NAME] 12.5mg. The Medication Administration Record [REDACTED]. On 06-25-14 at 8:40am R#186 was observed in her room lying in bed. Both side rails are padded and in the up position. The resident is well groomed. She was able to respond slowly to some questions with one word. She confirmed she had breakfast and received her medications by answering yes. She confirmed that she wears a brace on her left hand by pointing to the left arm. On 06-25-14 at 11:55am interview with (Nurse#1), the attending nurse revealed, (R#186) receives an antipsychotic medication at night. The Behavior/Intervention Monthly Flow record reviewed with nurse #1 revealed, the resident has only had one episode of behaviors since she started on the medication. The nurse reported, it takes at least 10 days for the medication to really be effective and R#186 had been doing well lately on the medication. Record review of the nurses notes dated on 06-06-14 at 3:00pm revealed, R#186 had elevated anxiety, was calling her husband's name, and screaming. The staff gave her liquids, repositioned her and redirected R#186 with no results. The physician was in the facility, and R#186 was seen. The resident was given a new physician order [REDACTED]. On 06-25-14 a record review of the care plan section of the medical record has an interdisciplinary care plan dated 01-21-2014. The problem/need listed is the potential for adverse drug reaction r/t (related to) the use of antidepressant. Resident exhibits sad, pained worried facial expressions. (diagnosis) Dx: Depression. The short-term goal noted was the resident will remain free from any s/s (signs and symptoms) of adverse drug reactions thru the NRD (next review date). This care plan was revised on 4-17-14 with the next review date (NRD) noted as 7-17-14. The approaches and interventions listed were to: -Observe the resident daily and assess for dry mouth, tremors, loss of appetite, [MEDICAL CONDITION] and constipation. -Allow the resident to express feelings, if able to do so. -Conduct Psych follow-ups whenever necessary. -To observe activity and take necessary precautions due to risk for falls. -Provide redirection and other non-pharmacological interventions. -Administer medications as ordered by MD (doctor). -The medications listed on this care plan were [MEDICATION NAME] and Escatolopram. -The medical record did not contain a care plan that listed interventions or approaches relating to the use of the [MEDICAL CONDITION] medication. On 06-25-14 at 1:34pm during an interview with the Minimum Data Set (MDS)/Care Plan nurse, it was reported, there should have been an interdisciplinary care plan for R#186 for the use of the antipsychotic medication. A record review with the MDS/Care plan nurse was conducted at this time. She confirmed, there wasn't a care plan for the [MEDICATION NAME]. She said that [MEDICATION NAME] is classified as an antipsychotic medication. She did not realize that R#186 was prescribed [MEDICATION NAME]. A review at this time of the Psychiatric progress notes dated 06-06-14 had the [DIAGNOSES REDACTED]. The plan noted was to add [MEDICATION NAME]. The MDS Care plan nurse took R#186 medical record for further review because she stated that she needed to add a care plan for the use of a [MEDICAL CONDITION] medication that includes related interventions and approaches. On 06-25-14 at 3:00pm the MDS Care plan nurse reported that she revised the current care plan by adding [MEDICATION NAME] and dated it for 06-25-14. She stated that she would plan a meeting with the Psychiatrist in order to discuss the medications prescribed for R#186 and expressed concerns regarding the current use of two different types of antipsychotic medications. A review of the care plan revision submitted revealed that the approaches and interventions were not revised and only the reassessment comments section of the care plan was updated. On 06-26-14 at 7:50am an interview and record review of the care plans conducted with the Director of Nursing (DON) revealed, the revised care plan done on 6-25-14 does not have interventions/approaches specific for the use of an antipsychotic medication. On 06-26-14 at 9:00am, the DON presented a print out of information related to the [MEDICATION NAME]. She confirmed that [MEDICATION NAME] is classified as an antipsychotic. She stated, the [MEDICATION NAME] was prescribed for (R#186) to use when an antidepressant ([MEDICATION NAME]) is not working. She agreed, there should have been a care plan relating to the use of an antipsychotic medication. On 06-26-14 at 9:00am, the DON submitted the facility's policy on care planning. The policy effective date is noted as July 2012 with a revision date of 01-29-13. The policy was approved by the DON. The policy has noted that the care, treatment and services are planned to ensure that they are appropriate to the resident's needs. Therefore, it is the policy to provide an individualized, interdisciplinary plan of care for all residents that is appropriate to the residents needs, strengths, limitations and goals. Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the resident that are reasonable and measurable.