Every finding on record at Park Ridge Nursing Center

Based on observations, interviews and record reviews, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for three (Residents #54, #39 and #87) of three residents reviewed for oxygen therapy. All three residents were observed receiving oxygen at flow rates not prescribed by their physicians. The findings include:1.On 03/17/26 at 9:15 AM, Resident #54 was observed wearing a nasal cannula (NC) connected to an oxygen (O2) concentrator with the flow rate set at 1.75 liters per minute (LPM). (Photographic evidence obtained) The resident was asked if she adjusted her O2 concentrator flow rate and she replied, I don't touch that. On 03/17/26 at 11:40 AM, another observation was made of Resident #54 wearing a NC connected to an O2 concentrator with the flow rate set at 1.5 LPM. (Photographic evidence obtained)A review of Resident #54's medical record revealed an admission date of 04/04/25 with diagnoses including solitary pulmonary nodule, dementia, psychotic disturbance, mood disturbance, anxiety, diastolic (congestive) heart failure, and chronic respiratory failure with hypoxia.A review of Resident #54's active physician's orders revealed an order for O2 at 2L-4L via NC, every shift related to chronic respiratory failure with hypoxia. The had a start date of 05/16/25. Another order dated 05/16/25, noted a change from as needed oxygen administration to continuous oxygen administration due to frequent episodes of shortness of breath/dyspnea with exertion.A review of Resident #54's active care plan, created on 04/04/25, revealed a focus area noting the resident was diagnosed with emphysema/COPD (chronic obstructive pulmonary disease). The goal included that the resident would display an optimal breathing pattern daily through the next review date. Interventions included instructions to administer oxygen therapy as ordered by the resident's physician. 2. On 03/16/26 at 10:41 AM, Resident #39 was observed wearing a NC attached to an O2 concentrator with the flow rate set at 1.5 LPM. (Photographic evidence obtained) The resident's spouse stated Resident #39 had severe dementia and could not respond to questions. The spouse explained that the resident was not mentally or physically capable of adjusting the O2 concentrator flow rate.On 03/17/26 at 9:13 AM, another observation was made of Resident #39 wearing a NC attached to an O2 concentrator with the flow rate set at 1.5 LPM. (Photographic evidence obtained)A review of Resident #39's medical record revealed an admission date of 08/21/23 with diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, shortness of breath, pneumonia, need for assistance with personal care, acute upper respiratory infection, and acute and chronic respiratory failure. A review of Resident #39's active physician's orders revealed an order for O2 at 2L-4L via NC continuously, every shift. The order started on 05/09/25. A review of Resident #39's annual MDS assessment, dated 02/19/26, revealed that the resident had impairment in both upper and lower body extremities on both sides and was dependent in all areas of mobility. A review of Resident #39's active care plan revealed a focus area noting that the resident had altered respiratory status related to a history of difficulty breathing, SOB (shortness of breath) and wheezing. The goal included that the resident would have no signs or symptoms (s/sx) of poor oxygen absorption; the resident will maintain a normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern, and have no complications related to SOB though the next review date. Care plan interventions instructions included the administration of medication/inhalers/bronchodilators/nebulizer treatments as ordered; monitor for effectiveness and side effects; and provide oxygen as ordered. 3. On 03/16/26 at 10:38 AM, Resident #87 was observed wearing a NC attached to an O2 concentrator with the O2 flow rate set at 1.5 LPM. (Photographic evidence obtained) The resident was not interviewable.On 03/17/26 at 9:17 AM, another observation was made of Resident #87 wearing a NC attached to an O2 concentrator with the flow rate set at 1.5 LPM. (Photographic evidence obtained) A review of Resident #87's medical record revealed an admission date of 12/10/26 with diagnoses including encephalopathy, Alzheimer's disease, chronic obstructive pulmonary disease (COPD), mood disorder, dementia, psychotic disturbance, mood disturbance, and anxiety, and congestive heart failure (CHF). A review of Resident #87's active physician's orders revealed an order for O2 at 2-4 LPM via NC continuously, every shift. The order had a start date of 02/26/26. During an interview on 02/18/26 at 1:03 PM, Licensed Practical Nurse (LPN) B described her process to ensure residents received oxygen at the ordered flow rates. At the start of her shift, she checked physicians' orders for all residents receiving O2. She went to her assigned resident rooms, checked the O2 concentrator settings and documented them in the medication administration record (MAR). She stated she checked O2 saturation levels once or twice during her shift. She checked O2 concentrator settings during her rounds. LPN B was asked to review O2 orders for her assigned residents, (#39 and #54). After her review, she reported that both residents had orders for O2 at 2-4 LPM via NC. LPN B was shown the photographs of the O2 concentrator flow rate for Resident #39 and she stated, The flow rate is 1.5 LPM. LPN B was shown photographs of the O2 concentrator flow rate for Resident #54, and she stated, The flow rate is 1.5 LPM. During an interview on 03/18/26 at 1:17 PM, LPN C stated she was assigned to Resident #87. She explained that her process of O2 administration included checking residents' O2 orders and matching them to the O2 concentrator flow rate. She stated her process to ensure that the O2 flow rates were accurate included her assessment of the resident's O2 saturation levels. Any saturation level below 95 was to be reported to the resident's physician. LPN C was asked to review Resident #87's O2 order. After review, she noted the order was for administration of O2 at 2-4 LPM via NC. During an Interview on 03/19/26 at 2:00 PM, the Director of Nursing (DON) explained that the process to ensure nursing staff were administering oxygen at the appropriate flow rates included following doctors' orders, monitoring for hypoxia, SOB and O2 saturation. If a resident's O2 saturation was below 90, the nurse was instructed to reach out to the provider and inform them of the change. A review of the facility's policy titled Oxygen Administration (Implemented on 12/01/22), revealed: Policy Explanation and Compliance Guidelines -. 4. The resident's care while receiving oxygen will include their assessment, orders, and specialized care plan needs, such as, but not limited to . d. Monitoring of SpO2 (oxygen saturation) levels daily, starting at the lowest rate ordered and adjusting to a higher ordered rate as needed to maintain saturation above 90%, unless otherwise stated in the physician's order.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 23 residents sampled, Resident #32. The findings include: During a tour of the facility on 5/13/2024 at 12:40 pm Resident #32 was observed resting in his bed. The resident had the covers pulled up to his neck, fully covering his entire body from the neck down. The resident was greeted by members of the survey team. He attempted to respond verbally to the greeting; however, his speech was mumbled and unintelligible. While mumbling the resident pulled the covers down revealing his upper body. He lifted his left forearm. The survey team observed a white medical bandage with 5/8 and initials written in red ink near the center of the bandage. The resident was asked if the area caused him any pain. Again, he responded with unintelligible mumbles. (photographic evidence obtained) Review of the electronic medical record for Resident #32 revealed he was admitted into the facility on [DATE]. His most recent readmission was on 2/7/2024. His diagnoses included metabolic encephalopathy; major depressive disorder; esophagitis unspecified with bleeding; aphasia; peripheral vascular disease (PVD); unspecified dementia; anorexia; and cerebral infarction pneumonitis due to inhalation of food and vomit. Record review revealed physician orders which included treatment to skin tear left outer elbow, cleanse with wound cleanser and pat dry. Apply Xeroform, cover with dry dressing daily and as needed, if loose or soiled every day shift every other day for skin tear tx. Order date 5/8/2024. Per review of the treatment administration record (TAR) the treatment was completed on 5/10/2024, 5/12/2024, and 5/14/2024. Record review revealed a Care Plan with a review start date of 5/9/24 and a target completion date of 5/16/2024. Focuses included: I have a (actual/potential) impairment to my skin integrity r/t PVD, diabetes. Goal: I will be free of skin impairments through the review date. Interventions on 5/8/2024 and 5/13/2024 included: treatment as ordered and follow facility protocols for treatment of skin impairments. An interview was conducted on 5/15/2024 at 2:40 pm with Employee C, a licensed practical nurse (LPN). She stated she had been employed in the facility approximately 30 days. She stated she was familiar with Resident #32. She confirmed that the resident had a skin tear to his left forearm as well as a skin prep to his left heel. She stated she could not always make out what the resident was saying. She stated his vitals are taken everyday and he is checked to ensure he has been changed [incontinence care]. She was asked who was responsible for changing the resident's bandages. She replied that it was the responsibility of the nurses. She stated that she had done it before. She was asked to access the TAR to confirm when the bandage had been changed and the nurse who changed it. She replied that she was not familiar with how to do that. An interview was conducted on 5/15/2024 at 3:09 pm with Employee D, LPN. She stated she was familiar with Resident #32. She stated she changed the dressing on his left forearm on 5/14/2024 adding that it should be changed every other day. She stated there was confusion in the way the order was written. It was not to be changed daily. She stated she would update the order. She was asked if there were any concerns with the skin tear and/or bandage when she changed the dressing on 5/14/2024. She stated she didn't notice any problems when she changed the dressing adding that it was intact. She was asked to provide the dates the bandage had been changed prior to her changing it on 5/14/2024. She stated it should have been changed on 5/10/2024 and 5/12/2024. She confirmed if the bandage was changed as ordered it would have have reflected 5/12/2024 when she changed it on 5/14/2024. She advised the survey team that she didn't see any problems with that on 5/14/2024 when she changed the bandage. She confirmed the date of the order was 5/8/2024. In the presence of the survey team she reviewed the TAR. She confirmed that she signed off on the TAR indicating she changed the bandage on 5/14/2024. She stated Employee C signed off on the TAR on 5/10/2024 and 5/12/2024 indicating that she changed the bandage as ordered. An interview was conducted on 5/15/2024 at 3:25 pm with the Director of Nursing. She reviewed the TAR for Resident #32 with the surveyor. She confirmed the check in the box under the date indicated the treatment was done. She confirmed the treatment order was for every other day. She stated the bandage should have been changed 5/10/2024, 5/12/2024, and 5/14/2024. She was shown the picture of the dressing taken on 5/13/2024 at 12:40 pm reflecting 5/8/2024. She stated there should not have been a check mark under 5/10/2024 nor 5/12/2024 indicating the treatment was done. She stated the nurse should have documented why the treatment was not done. Record Review revealed the facility developed a policy for Wound Treatment Management. The policy was reviewed/revised on 1/4/2024. Per Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 45673

Based on observations, staff interview, record review, and facility policy review , the facility failed to ensure that the resident, who required oxygen therapy was provided such care consistent with professional standards of practice, the comprehensive care plan, and physician's orders for one (Resident #18) of 23 residents sampled. The findings include: Observation on 05/13/24 at 12:19 PM revealed Resident #18's oxygen concentrator was set at 2 liters per minute (LPM), but the oxygen tubing was not placed in resident's nostrils. The tubing was observed uncovered and hanging close to floor. (photographic evidence obtained) Observation on 05/15/24 at 1:57 PM revealed Resident #18 being transferred back to bed via Hoyer lift with 2 staff assisting. Employee A, CNA, made resident comfortable in bed and then left the room. The resident's oxygen nasal cannula was not placed in her nostrils at this encounter. The tubing was in a bag hanging on the concentrator. (photographic evidence obtained) The surveyor waited in the room to observe the resident and to observe if the nurse would arrive to place nasal cannula. Employee A returned to the room and placed the resident's call light in reach. She left the room again. The resident's nasal cannula was not placed in her nostrils at this encounter. Record review revealed Resident #18, date of birth 05/11/1935, was admitted to the facility on [DATE] with diagnoses of senile degeneration of the brain, contracture of muscle, dementia in other diseases classified elsewhere, moderate with anxiety, anorexia, arteriosclerotic heart disease, cough, abnormal posture, and allergy. A review of the Quarterly MDS dated [DATE] revealed Resident #18 had a Brief Interview for Mental Status (BIMS) of 11/15 required eating supervision or touching assistance. She required staff assistance with transfers and bed mobility, and required substantial/maximal staff assistance with toileting. She had a condition/chronic disease that may result in a life expectancy of less than 6 months and was also receiving oxygen therapy and hospice services during the lookback. A review of Resident #18's orders revealed she had orders including Oxygen 2-4L via nasal cannula continuously every shift. A review of the Care Plan revealed there was no care plan focus for oxygen therapy. A review of Community Hospice Notes revealed pertinent information that pertained to respiratory status and oxygen use of 2-3Lpm via nasal cannula with oxygen saturations ranging from 92-97 %. No concerns identified. On 05/15/24 at 2:16 PM an interview was conducted with Employee B, CNA, who had assisted Employee A transfer Resident #18 to bed. When asked what her role was in managing a resident's oxygen she stated, We don't manage the oxygen because it's a medicine. When asked what she would do if resident was using oxygen and had a change of condition she stated, I would get the nurse. When asked what the CNA's role is concerning residents who use oxygen she stated, If the tubing falls out of the nose, we can put it back in, or we go and get the nurse if something else needs to be done to it, but that's about it. Review of the policy, Oxygen Administration, Date Reviewed/Revised 01/04/24, revealed the following: Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. 1. Oxygen is administered under orders of a physician, except in the case of an emergency. 48947

Based on observation, interview, and record review the facility failed to ensure medical records were maintained on each resident that are complete, accurately documented, readily accessible and systematically organized for one of 23 residents sampled, Resident #32. The findings include: During a tour of the facility on 5/13/2024 at 12:40 pm Resident #32 was observed resting in his bed. The resident had the covers pulled up to his neck, fully covering his entire body from the neck down. The resident was greeted by members of the survey team. He attempted to respond verbally to the greeting; however, his speech was mumbled and unintelligible. While mumbling the resident pulled the covers down revealing his upper body. He lifted his left forearm. The survey team observed a white medical bandage with 5/8 and initials written in red ink near the center of the bandage. The resident was asked if the area caused him any pain. Again, he responded with unintelligible mumbles. (photographic evidence obtained) Review of the electronic medical record for Resident #32 revealed he was admitted into the facility on [DATE]. His most recent readmission was on 2/7/2024. His diagnoses included metabolic encephalopathy; major depressive disorder; esophagitis unspecified with bleeding; aphasia; peripheral vascular disease (PVD); unspecified dementia; anorexia; and cerebral infarction pneumonitis due to inhalation of food and vomit. Record review revealed physician orders which included treatment to skin tear left outer elbow, cleanse with wound cleanser and pat dry. Apply Xeroform, cover with dry dressing daily and as needed, if loose or soiled every day shift every other day for skin tear tx. Order date 5/8/2024. Per review of the treatment administration record (TAR) the treatment was completed on 5/10/2024, 5/12/2024, and 5/14/2024. Record review revealed a Care Plan with a review start date of 5/9/24 and a target completion date of 5/16/2024. Focuses included: I have a (actual/potential) impairment to my skin integrity r/t PVD, diabetes. Goal: I will be free of skin impairments through the review date. Interventions on 5/8/2024 and 5/13/2024 included: treatment as ordered and follow facility protocols for treatment of skin impairments. An interview was conducted on 5/15/2024 at 2:40 pm with Employee C, a licensed practical nurse (LPN). She stated she had been employed in the facility approximately 30 days. She stated she was familiar with Resident #32. She confirmed that the resident had a skin tear to his left forearm as well as a skin prep to his left heel. She stated she could not always make out what the resident was saying. She stated his vitals are taken everyday and he is checked to ensure he has been changed [incontinence care]. She was asked who was responsible for changing the resident's bandages. She replied that it was the responsibility of the nurses. She stated that she had done it before. She was asked to access the TAR to confirm when the bandage had been changed and the nurse who changed it. She replied that she was not familiar with how to do that. An interview was conducted on 5/15/2024 at 3:09 pm with Employee D, LPN. She stated she was familiar with Resident #32. She stated she changed the dressing on his left forearm on 5/14/2024 adding that it should be changed every other day. She stated there was confusion in the way the order was written. It was not to be changed daily. She stated she would update the order. She was asked if there were any concerns with the skin tear and/or bandage when she changed the dressing on 5/14/2024. She stated she didn't notice any problems when she changed the dressing adding that it was intact. She was asked to provide the dates the bandage had been changed prior to her changing it on 5/14/2024. She stated it should have been changed on 5/10/2024 and 5/12/2024. She confirmed if the bandage was changed as ordered it would have have reflected 5/12/2024 when she changed it on 5/14/2024. She advised the survey team that she didn't see any problems with that on 5/14/2024 when she changed the bandage. She confirmed the date of the order was 5/8/2024. In the presence of the survey team she reviewed the TAR. She confirmed that she signed off on the TAR indicating she changed the bandage on 5/14/2024. She stated Employee C signed off on the TAR on 5/10/2024 and 5/12/2024 indicating that she changed the bandage as ordered. An interview was conducted on 5/15/2024 at 3:25 pm with the Director of Nursing. She reviewed the TAR for Resident #32 with the surveyor. She confirmed the check in the box under the date indicated the treatment was done. She confirmed the treatment order was for every other day. She stated the bandage should have been changed 5/10/2024, 5/12/2024, and 5/14/2024. She was shown the picture of the dressing taken on 5/13/2024 at 12:40 pm reflecting 5/8/2024. She stated there should not have been a check mark under 5/10/2024 nor 5/12/2024 indicating the treatment was done. She stated the nurse should have documented why the treatment was not done. Review of the facility policy for Documentation in Medical Record, reviewed/revised on 1/4/2024, revealed the following: Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Per Policy Explanation and Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 3. Principles of documentation include but are not limited to: a. Documentation shall be factual, objective, and resident centered. i. False information shall not be documented. b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. 45673

Based on the kitchen food service observations, staff interviews, facility document review and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all but one of the residents in the facility (65 residents from a census of 66 residents). The facility failed to ensure that the dietary staff was trained and knowledgeable about the proper procedures for hand hygiene, disposable glove use, food storage, proper cooling methods and proper sanitation practices in the kitchen. Specific instruction on hand hygiene, food handling and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: During the initial kitchen tour on 02/01/2021 at 9:52 AM, the floor around the ice machine had food debris (rice) in the grooves between the tiles and rust marks on the floor. There was grease and built-up dirt and debris on floors under the storage tables, racks, dish machine and ware washing sinks. Large baking pans and insulated domes and plate holders were wet nesting. The fryer had stuck-on grease on the sides and front. A pipe and electrical outlet from the floor to the ceiling was observed to have built-up dirt and debris. (Photographic evidence obtained) These observations were made again on 02/03/2021 at 11:50 AM and on 02/04/2021 at 9:42 AM. During observations of the kitchen and lunch meal service on 02/03/2021 from 11:30 AM until 12:20 PM, the Dietary Staff was observed: At 11:36 AM, Employee A, Food Preparation Cook, was observed to change her gloves without washing her hands after taking the temperature of the fortified soup. At 11:43 AM, Employee B did not wash her hands upon re-entering the kitchen. She began to wipe down the preparation area with a sanitizing cloth. She left the kitchen again at 11:48 AM. Upon returning to the kitchen she did not wash her hands. She went to the clean side of the dish room and picked up a baking tray from a rack of recently cleaned dishes. Her cell phone rang in her pocket. She took the phone out of her pocket and looked at it. She then put it back in her pocket and took the clean baking tray to the preparation table, thereby contaminating the clean tray. At 11:45 AM, Employee D was observed to leave the kitchen with meal tickets in her hands. She returned to the kitchen and did not wash or sanitize her hands. She proceeded to assist with meal tray preparation. At 11:50 AM, Employee C came back to the kitchen after delivering a tray cart to one of the nursing units for meal service. She did not wash her hands or sanitize her hands. She began to assemble more meal trays for food service. At 12:02 PM, Employee E came into the kitchen and washed his hands at the hand sink. When he was done, he shut the faucet off with his bare hands, thereby re-contaminating his hands, and then took a paper towel and dried his hands. He then went to the dirty side of the dish room and moved several soiled pans and racks. He then went to the mop bucket and began mopping the floor. When he was finished mopping the floor, without washing his hands, he donned a pair of latex gloves and proceeded to the clean side of the dish room. He moved clean pans out of the dish room to the preparation area. At 12:10 PM, Employee C was observed touching the soiled pans on the dirty side of the dish room. She then went to the clean side of the dish room and unloaded a rack without washing her hands in between the dirty side and the clean side, thereby contaminating the clean dishes. Her cell phone charging/head phone cord was hanging out of her pocket approximately 12 to 18 inches coming into contact with multiple surfaces in the kitchen. During an interview with Employee C at 12:15 PM, she stated she had not been trained to wash her hands with soap and water after working on the dirty side of the dish room before going to the clean side. She stated she was permitted to have her phone in her pocket at work. She did not know that she should wash her hands after touching her cell phone. During an interview with Employee D at 12:17 PM, she stated she had worked at this facility for two years. She thought she received training on handwashing and glove use about two weeks ago by the new Certified Dietary Manager (CDM). She stated she was trained to either wash her hands or sanitize her hands when she entered the kitchen. During observations of the kitchen on 02/04/2021 At 9:45 AM, Employee F washed his hands at the hand sink for 10 seconds and then shut the faucet off with his hands. He then took paper towels and dried his hands. At 9:50 AM, Employee F washed his hands at the hand sink for 10 seconds and then shut the faucet off with his hands. He then took paper towels and dried his hands. At 9:55 AM, he sanitized his hands with hand sanitizer and donned a pair of latex gloves. During an interview with Employee F on 02/04/2021 at 9:57 AM, he stated he had worked at the facility for a year and had received training on hand hygiene. During an interview with the CDM at 10:10 AM, she confirmed that dietary staff had to wash their hands with soap and water. Hand sanitizer was not enough. On 02/04/2021 at 10:20 AM, a large plastic container of chicken noodle soup was observed in the walk-in cooler. It appeared to be one gallon of soup. It was covered and date-marked 02/03/2021. During an interview with the CDM on 02/04/2021 at 10:25 AM, she stated the soup was homemade by her staff yesterday (02/03/2021). There was one resident in the facility who wanted soup for his dinner meal, so they made him soup every day. She stated the soup was placed in the container and then put in the walk-in cooler after dinner last night. When asked for the temperature log for the proper cooling of the soup, she stated she did not have one. She did not think the staff took the temperature of the soup as it cooled. She confirmed that the dietary staff closed the kitchen between 8:30 and 9:00 PM every night and returned the next day at approximately 5:30 AM. She confirmed no one was working last night to take the temperature of the cooling soup at two hours to make sure it reached 70 degrees Fahrenheit or below, and again at six hours to make sure it reached 41 degrees Fahrenheit or below, ensuring the soup had cooled quickly enough to prevent the growth of bacteria. Review of the dietary in-service training sheet dated 01/20/2021, revealed the subject of the training was sanitation and infection control. Proper sanitation and How to wash your hands was covered. The subject matter was presented by the CDM. Only dietary staff attended the training. (Copy obtained) Review of the facility policy and procedure entitled Hand Hygiene, Reference #4008, effective 11/01/2017, revealed it read: All staff shall use the hand-hygiene techniques as set forth in the following: Always after removing gloves. Procedure: Wash hands thoroughly, using rigorous scrubbing action for at least 15 seconds. Rinse hands and wrists under running water. Dry hands with clean paper towel. Turn off faucets with used paper towel and discard. (Copy obtained) Review of the facility policy and procedure entitled Handwashing/Hand Hygiene, revised August 2015, revealed: This facility considers hand hygiene the primary means to prevent the spread of infections. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. Rinse hands thoroughly under running water. Hold hands lower than wrists. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. Perform hand hygiene before applying non-sterile gloves. (Copy obtained) Review of the dietary staff training form entitled Wash Your Hands to Stop COVID-19 revealed: When? Before, during and after preparing food. After touching surfaces in common areas that may be frequently touched by other people. Scrub hands for at least 20 seconds. (Copy obtained) Reference: United States Food and Drug Administration Food Code 2017. 3. PUBLIC HEALTH AND CONSUMER EXPECTATIONS. Clean environment. Page 10. https://www.fda.gov (Accessed 0n 2/4/2021): It is a shared responsibility of the food industry and the government to ensure that food provided to the consumer is safe and does not become a vehicle in a disease outbreak or in the transmission of communicable disease. This shared responsibility extends to ensuring that consumer expectations are met and that food is unadulterated, prepared in a clean environment, and honestly presented. Reference: United States Food and Drug Administration Food Code 2017. Section 3-501.14 Cooling (A). Page 124. https://www.fda.gov (Accessed on 2/4/2021): (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57ºC (135ºF) to 21ºC (70°F); P and (2) Within a total of 6 hours from 57ºC (135ºF) to 5ºC (41°F) or less. Reference: United States Food and Drug Administration Food Code 2017. Sections. 2-301.13 Special Handwash Procedures. 2-301.14 When to Wash. (A-I). Page 79. https://www.fda.gov (Accessed on 2/4/2021): FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in ¶ 2-403.11(B); (D) Except as specified in ¶ 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands.

Based on observations, interviews and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one resident (Resident #26) receiving hospice services and for two (Resident #3 and #32) of seven residents observed during medication administration. The facility also failed to demonstrate the correct administration of a narcotic medication for one (Resident #17) of six sampled residents reviewed for medication storage from a total sample of 35 residents. The findings include: 1. During a tour of the facility on 02/03/21 at 11:42 AM, Resident #26 was observed in a wheelchair at the nurses' station. She was wearing blue, ankle-length non-skid socks. Mild, non-[MEDICAL CONDITION] was observed at both ankles. The resident was alert and oriented to self and denied having any pain. On 02/03/21 at 1:38 PM, Resident #26 was observed having lunch in her room at the bedside. She was wearing blue, ankle-length non-skid socks. Mild non-[MEDICAL CONDITION] was observed at both ankles. On 02/03/21 at 2:21 PM, during an interview with Employee G, Licensed Practical Nurse (LPN), he confirmed that Resident #26 had orders for compression stockings (TED hose) and did not have them on at the time. Employee G added that the certified nursing assistants (CNAs) were responsible for putting them on when getting the resident up and for taking them off in the evening. He added that the nurses were responsible for checking to ensure the compression stockings were on correctly and to assess for any signs of discomfort. When asked whether Resident #26 had compression stockings in her room, the nurse stated he was not sure. He stated there were more stockins in the medication room if the resident did not have any in her room. Employee G checked the resident's room and the medication room, but was unable to locate any TED hose. He then proceeded to the central supply room to look for more TED hose. A medical record review for Resident #26 revealed that she was admitted to the facility on [DATE] with a re-entry on 03/04/14. Her [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the quarterly minimum data set (MDS) assessment, dated 11/22/20, revealed that the resident had a brief interview for mental status (BIMS) score of 03 out of 15 possible points, indicating a severe cognitive impairment. The resident was assessed to require extensive assistance with transfers, bed mobility and toilet use, and supervision with eating. Resident #26 was careplanned for activities of daily living (ADL)/self care performance deficit related to dementia, unsteady balance, non-ambulatory status, limited mobility and joint pain. Interventions included TED hose as tolerated, observe/document/report to medical doctor any changes as needed (PRN) regarding any potential for improvement, reasons for self-care deficit, expected course and decline in function. A review of the Community Hospice nursing progress note, dated 12/9/2020, revealed that the resident was admitted to Community Hospice Palliative Care (CHPC) with senile degeneration of the brain. The resident required extensive assistance with ADLs and transfers to her wheelchair. She required assistance with meals, but was able to feed herself finger foods. She had a 2.6 pound weight gain from September to November 2020, but she now had bilateral ankle [MEDICAL CONDITION]. Ted hose were ordered. A review of the Community Hospice refortification note, dated 12/17/20, revealed, Resident alert and oriented to person, poor appetite, assistance with all meals and care. Weight gain two pounds (lbs.) [MEDICAL CONDITION] noted, so technically loss of weight - TEDs added, last Mid-Arm Circumference (MAC) 28 centimeters (cm), loss of 1 cm since March. She has had 6 lbs. loss since admission, she is weaker. Will recheck MAC and [MEDICATION NAME]. Further review of the progress notes for January 2021 and the Treatment Administration Record (TAR) for January 2021 revealed no documentation of TED hose. On 02/04/21 at 10:33 AM, the Director of Nursing (DON ) stated the CNAs were responsible for putting on the TED hose while getting the resident up in the morning. She added that the TED hose were to remain on as the resident could tolerate them or to be removed at bedtime. When asked if there was any documentation of the application and removal of TED hose, the DON stated there was no documentation, because the TED hose were supposed to be worn as tolerated. When asked how she ensured whether the resident tolerated the hose or refused them, she stated she was not sure as it was not documented. She added that the resident was on palliative care, so the compression stockings were for comfort only. There was no reason to document their application, removal or the resident's refusal to wear them. 2. During medication administration observation on 2/3/21 at 11:00 AM, Employee H, Licensed Practical Nurse (LPN), was observed alone as she prepared medications for Resident #3. Employee H pulled the following medications from the medication cart: Aspirin 81 milligram (mg) tablet, Magnesium 400 mg tablet, Vitamin D3 50 microgram (mcg) tablet, Potassium Chloride 20 milliequivalent (meq) tablet, [MEDICATION NAME] 50 mg tablet, [MEDICATION NAME] 10 mg tablet and [MEDICATION NAME] 2 mg tablet. She verified each medication label against the current Medication Administration Record [REDACTED]. She stated she checked what was written on the Medication Administration Record [REDACTED]. Continued observation revealed that she poured the medications into a medication cup and gave the medications to be administered to Resident #3 to another Employee, LPN I. On 2/3/21 at 11:15 AM, Employee I, LPN, was observed administering the medications that were prepared by Employee H to Resident #3. Employee I was not present when Employee H prepared and verified the medications for Resident #3. Reconciliation of the observed medications administered with the resident's medical record did not reveal medication errors but Employee I, LPN, was not present during the medication preparation and she did not verify the medications with Employee H or the MAR prior to administering the medications. 3. During the medication administration observation on 2/3/21 at 11:40 AM, Employee H, LPN, was observed as she prepared medications for Resident #32. Employee H pulled the medication Simbrinza 1-02% (eye drops) from the medication cart. She verified the medication label against the current MAR indicated [REDACTED]. Employee I was observed behind the computer screen and did not participate when Employee H verified the medication for Resident#32. Employee H gave the eye-drops she prepared to be administered to Employee I, LPN. On 2/3/21 at 11:45 AM, Employee I, LPN, was observed administering the eye drops medication prepared by Employee H to Resident #32. During an interview with Employee I on 2/3/21 at 11:56 AM, she stated the internet went down earlier and Employee H was running behind on her medication administration. She further stated Employee H was new to the facility and she was trying to help her with her medication administration. Reconciliation of the observed eye-drops medication administered with the resident's medical record did not reveal medication errors but Employee I, LPN, did not verify the medication with Employee H or the MAR prior to administering the medication. An interview was conducted with Employee H, LPN, on 2/3/21 at 3:05 PM. She stated, I can see how this could be considered an error. I am not a new nurse. I am new to the facility and she (Employee I) was helping me catch up because the internet went down earlier. I should probably change the documentation because I did not give the medication for Resident #3 or Resident #32. During an interview with Employee I, LPN, on 2/4/21 at 4:45 PM, she stated she was still unsure what she did wrong. Employee I stated, I looked when (Employee H) was preparing the medications. During an interview with the Regional Director of Nursing on 2/4/21 at 4:50 PM, she stated her expectation was that during training periods, the nurse could allow trainees to document in the record while assisting with medication administration, but both nurses would verify the medications prior to administering them. 4. On 2/4/21 at 10:10 AM, an observation was made of the second-floor medication room refrigerator with the Director of Nursing (DON), revealing a medication card of [MEDICATION NAME] 2.5 mg (with 22 capsules remaining) for Resident #17. On 2/4/21 at 10:15 AM, a review of the Narcotic Logbook with Employee G, LPN, revealed a discrepancy in the amount of a narcotic medication [MEDICATION NAME] for Resident #17. The Narcotic Logbook, dated 2/3/21, showed the medication [MEDICATION NAME] 2.5 mg and the amount remaining was recorded as 24 capsules for Resident #17. An immediate interview was conducted with Employee G on 2/4/2021 at 10:15 AM. Employee G stated during the morning medication administration, he administered one capsule of [MEDICATION NAME] 2.5 mg for Resident #17 and forgot to sign it out of the Narcotic Logbook at 7:00 AM today. He was unable to account for the other capsule missing. He stated, I pulled the other [MEDICATION NAME] early and that is wrong. I already put it in a pudding cup to melt because Resident #17 likes it that way, and I plan to give it at 4:00 PM. It's not the right procedure and I know that I am not supposed to do it this way. Employee G verified the amount remaining documented on the Narcotic logbook should always match what was in the locked refrigerator and locked cart for the resident. During an interview conducted on 2/4/2021 at 11:00 AM, the Regional DON stated an investigation was initiated immediately to determine the location of the missing capsule of [MEDICATION NAME] 2.5 mg medication for Resident #17. She stated it was found that Employee G had pulled the dose early. The Regional DON stated, We found a pudding cup in his cart containing one round white tab and we compared it with the [MEDICATION NAME] capsules and they did not match. He was relieved of his assignment and asked to give a written statement. His statement differed from his verbal account. He was escorted off the property pending investigation. We reported him to our human resources department and they will ask him to do a drug test. If he does not take the drug test, we will report him to the nursing board. The DON and myself inspected his cart and completed a narcotic count. We also spoke to the residents on his assignment and no other issues were found. He is on leave until the investigation is completed. On 02/04/21 at 11:30 AM, during an interview with Resident #17, she verified that she received her [MEDICATION NAME] medication this morning and she did not have any concerns related to the administration of her medications. A medical record review revealed that Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].

Based on observation, interview and record review, the facility failed to maintain medical records that were accurately documented in accordance with accepted professional standards of practice, by failing to ensure that an account of all controlled drugs was maintained for one (Resident #17) of six sampled residents reviewed for medication storage from a total of 35 sampled residents. The findings include: On 2/4/21 at 10:10 AM, an observation was made of the second-floor medication room refrigerator with the Director of Nursing (DON), revealing a medication card of [MEDICATION NAME] 2.5 mg (with 22 capsules remaining) for Resident #17. On 2/4/21 at 10:15 AM, a review of the Narcotic Logbook with Employee G, LPN, revealed a discrepancy in the amount of a narcotic medication [MEDICATION NAME] for Resident #17. The Narcotic Logbook, dated 2/3/21, showed the medication [MEDICATION NAME] 2.5 mg and the amount remaining was recorded as 24 capsules for Resident #17. An immediate interview was conducted with Employee G on 2/4/2021 at 10:15 AM. Employee G stated during the morning medication administration, he administered one capsule of [MEDICATION NAME] 2.5 mg for Resident #17 and forgot to sign it out of the Narcotic Logbook at 7:00 AM today. He was unable to account for the other capsule missing. He stated, I pulled the other [MEDICATION NAME] early and that is wrong. I already put it in a pudding cup to melt because Resident #17 likes it that way, and I plan to give it at 4:00 PM. It's not the right procedure and I know that I am not supposed to do it this way. Employee G verified the amount remaining documented on the Narcotic logbook should always match what was in the locked refrigerator and locked cart for the resident. During an interview conducted on 2/4/2021 at 11:00 AM, the Regional DON stated an investigation was initiated immediately to determine the location of the missing capsule of [MEDICATION NAME] 2.5 mg medication for Resident #17. She stated it was found that Employee G had pulled the dose early. The Regional DON stated, We found a pudding cup in his cart containing one round white tab and we compared it with the [MEDICATION NAME] capsules and they did not match. He was relieved of his assignment and asked to give a written statement. His statement differed from his verbal account. He was escorted off the property pending investigation. We reported him to our human resources department and they will ask him to do a drug test. If he does not take the drug test, we will report him to the nursing board. The DON and myself inspected his cart and completed a narcotic count. We also spoke to the residents on his assignment and no other issues were found. He is on leave until the investigation is completed. On 02/04/21 at 11:30 AM, during an interview with Resident #17, she verified that she received her [MEDICATION NAME] medication this morning and she did not have any concerns related to the administration of her medications. A medical record review revealed that Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].

Based on observation, interview and record review, the facility failed to ensure a functioning resident call system in the resident rooms and bathrooms. The residents were using hand bells in place of the faulty resident call system. This practice affected any resident who was able to use their call light, including two sampled residents (#2 and #4), out of a facility census of 61 residents. The findings include: During a tour of the facility on 11/2/20 at 10:30 AM, Certified Nursing Assistant (CNA) A was observed rounding and responding frequently to resident rooms. It was discovered that the residents had no functioning call system in the facility. The residents were using hand bells at bedside to call for assistance. During an interview with Resident #2 on 11/3/20 at 10:00 AM, when asked whether the call light was being answered timely, she stated, Ninety-nine percent of the time they do, but last night I rang my bell for assistance and I waited two hours. I just went to the bathroom myself. I normally go to the bathroom by myself during the day, but I have [MEDICAL CONDITION] and it's hard for me to see during the night. During an interview with Resident #4 on 11/3/20 at 2:30 PM, he stated, The call button and lights do not work. I have this hand bell. When asked whether his call light was being answered timely, he stated, Sometimes. I have to ring ring ring this hand bell and sometimes they hear it. Sometimes they don't. I have to wait and ring the bell again and again until someone hears it. The average wait time is half hour if they hear the bell. We have been using this handheld bell for some time now, almost two months. They keep saying we are going to get the call system fixed but we never did. During an interview with the Administrator on 11/3/20 at 11:35 AM, she verified that the facility's resident call system was not currently in working order. When asked how long the facility had not had a functioning call system in the resident rooms, she replied, It's been about a month now. Since 10/1/2020. We ordered the call system adapter last month and it is being installed today. The call system should be working later today. We have been doing frequent resident rounding. We have a designated CNA on each unit every shift to ensure resident rounding. They check residents every fifteen minutes. The Administrator provided an email from the Branch Manager dated 11/3/2020, that revealed, The adapter plates for the room stations were originally ordered on [DATE]. As you know they just came in and are being installed with the new room stations. The system should be completed this week. A review of Resident #4's medical record revealed an admission date of [DATE] and a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. A review of Resident #4's medical record also revealed that the resident was cognitively intact.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program by not conducting appropriate visitor screenings to prevent the transmission of [DIAGNOSES REDACTED]-CoV-2 (COVID-19) during three of three opportunities observed. The has the potential to affect the staff and 69 residents of the facility. The findings include: 1. Upon entrance into the facility on [DATE] at 9:05 AM, Employee A, Administrative Assistant, failed to screen Surveyor #1 for symptoms consistent with COVID-19, history of travel to high-risk locations, and contact/exposure to individuals with symptoms. Only a temperature was taken. 2. On 7/14/20 at 9:07 AM, Employee A failed to screen Surveyor #2 for symptoms consistent with COVID-19, history of travel to high-risk locations, and contact/exposure to individuals with symptoms. Only a temperature was taken. 3. On 7/14/20 at 9:08 AM, Employee A failed to screen Surveyor #3 for symptoms consistent with COVID-19, history of travel to high-risk locations, and contact/exposure to individuals with symptoms. Only a temperature was taken. 4. An interview was conducted with Employee A on 7/14/20 at 12:25 PM. The employee confirmed that she was responsible for conducting the visitor screenings on 7/14/20. She was asked to explain the facility's screening processes. The employee explained that her process is to simply check the temperature of the visitor and document the temperature on a paper log kept at the screening station. Following the temperature screening, the visitor would be asked to perform hand hygiene and then would be permitted entry. The employee confirmed that she was not screening visitors for symptoms consistent with COVID-19, history of travel to high-risk locations, and contact/exposure to individuals with symptoms. 5. An interview was conducted with the Regional Director, a Registered Nurse, on 7/14/20 at 12:43 PM. She was asked about the facility's screening processes for visitors. The Regional Director confirmed that upon entry into the facility, visitors were to be screened for fever, respiratory symptoms, and recent travel. She explained that the findings from the screening were to then be documented on the screening form and the person conducting the screening then signs the form. 6. A copy of the facility's screening policy, titled Entrance Screening, was reviewed. The policy indicated that all non-staff individuals entering the building must sign in and complete the screening prior to entrance into any other area of the facility. The policy also indicated that screens will be completed and signed by the receptionist/first contact person in the facility. 7. A COVID-19 Screener Competency, signed by the facility and dated 3/2/20, was reviewed for Employee A. Requirement #1 on the form indicated the screener Understands the need to screen individuals visiting the facility for fever, respiratory symptoms, history of travel to high-risk places and/or contact/exposure to individuals with symptoms or history of travel to high-risk places. The form was checked Yes to indicate the employee was competent in the requirement at the time the competency was conducted.

Based on record reviews and interviews, the facility failed to maintain adequately documented medical records for narcotics administration, for five (5) sampled residents (Residents #2, #3, #4, #5 and #6), from a sample of six (6) residents. The findings include: 1. A record review Resident #2 revealed a physician's orders [REDACTED]. [MEDICATION NAME] (narcotic/pain medication) 10/325 mg (milligrams), give one tablet, every 6 hours as needed for non-acute pain. A review of the narcotic medication sign out sheets revealed the medication was signed out on the following dates/times: 12/13/19 - 0000 (Midnight) 12/14/19 - 0100 (1:00 AM) 12/20/19 - 2345 (11:45 PM) 12/28/19 - 2100 (9:00 PM) A review of her electronic medical record (EMAR) revealed [MEDICATION NAME] was not documented as being administered to the resident on any of the above dates/times. 2. A record review for Resident #3 revealed the following physician order: [MEDICATION NAME] (narcotic/pain medication) 5/325 mg, give one tablet, by mouth, every 8 hours as needed for non-acute pain. A review of the narcotic medication sign out sheets revealed the medication was signed out on the following dates/times: 1/1/20 - 20:27 PM (8:27 PM) 1/2/20 - 2100 (9:00 PM) 1/3/20 - 0940 (9:40 AM) 1/7/20 - 2 doses; 9:45 AM and 20:40 (8:40 PM) 1/8/20 - 9:00 AM 1/9/20 - 9:00 AM 1/10/20 - 2 doses; 9:00 AM and 2025 (8:25 PM) 1/13/20 - 9:00 AM A review of her electronic medical record (EMAR) revealed [MEDICATION NAME] was not documented as being administered to the resident on any of the above dates/times. 3. A record review for Resident #4 revealed the following physician order: [MEDICATION NAME] (narcotic/pain medication) 5 mg, give one tablet, by mouth, every 12 hours as needed for non-acute pain. A review of the narcotic medication sign out sheets revealed the medication was signed out on the following dates/times: 12/20/19 - 1330 (1:30 PM) 12/21/19 - 10:00 AM 12/22/19 - 11:00 AM 12/23/19 - 2300 (11:00 PM) 12/25/19 - 1800 (6:00 PM) 12/26/19 - 0913 (9:13 AM) 12/28/19 - 2000 (8:00 PM) 12/29/19 - 0300 (3:00 AM) 1/1/20 - 0800 (8:00 AM) 1/2/20 - (YEAR) (8:16 PM) 1/10/20 - 1440 (2:40 PM) 1/12/20 - 0900 (9:00 AM) 1/13/20 - 0900 (9:00 AM) A review his electronic medical record (EMAR) revealed [MEDICATION NAME] was not documented as being administered to the resident on any of the above dates/times. 4. A record review for Resident #5 it revealed the following physician order: [MEDICATION NAME]/[MEDICATION NAME] (narcotic/pain medication) 5-325 mg, give one tablet, orally, every 4 hours as needed for non-acute pain. A review of the narcotic medication sign out sheets revealed the medication was signed out on the following dates/times: 1/2/20 - 0515 (5:15 AM) 1/5/20 - 6:00 PM 1/7/20 - 1800 (8:00 PM) 1/8/20 - 6:00 PM Pill #22 signed out, no date and/or time documented 1/11/20 - 2100 (9:00 PM) 1/12/20 - 1900 (7:00 PM) A review of her electronic medical record (EMAR) revealed [MEDICATION NAME]/[MEDICATION NAME] was not documented as being administered to the resident on any of the above dates/times. 5. A record review for Resident #6 revealed that she had a physician's orders [REDACTED]. [MEDICATION NAME] (narcotic/pain medication) 50 mg, give one tablet, by mouth, three times daily as needed. A review of the narcotic medication sign out sheets revealed the medication was signed out on the following dates/times: 12/17/19 - 1809 (6:09 PM) 12/24/19 - 1953 (7:53 PM) A review of her electronic medical record (EMAR) revealed [MEDICATION NAME] was not documented as being administered to the resident on the above dates/times. 6. An interview was conducted with the Director of Nursing (DON) on 1/14/20 at 2:34 PM regarding documenting the narcotics in the electronic medication record. She expects the nurses to document the narcotics in the EMAR as soon as they are signed out of the book. She stated that the EMAR and sign out sheets need to match. A second interview was conducted with the DON on 1/14/20 at approximately 4:20 PM and she reviewed the documentation for Residents #2, #3, #4, #5 and #6. She confirmed the documentation did not match, as per facility policy and procedure. She stated that staff would be re-educated on the correct way to document and account for all narcotics. 7. A review of the facility's policy and procedure it revealed the following: Control Substance Administration & Accountability Date Implemented: 11/2018 Date Reviewed/Revised: 5/2019 Reviewed/Revised by: DON Policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place to prevent loss, diversion or accidental exposure. Policy Explanation and Compliance Guidelines: 1. General Protocols: f. In all cases, the dose noted on the usage form or entered into the system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record. g. The Controlled Drug Record serves the dual purpose of recording both narcotic disposition and patient administration. i. The Charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. Spot checks are performed to verify: i. Control substances that are destroyed are appropriately documented; and ii. Medications removed from either the system or medication cart/cabinet have a documented physician order.

Based on interviews and review of resident and hospital clinical records, the facility failed to permit a resident admitted for long-term care (Resident #1) readmission to the facility following a Baker Act transfer from a total of three residents reviewed for transfer/discharge. The findings include: A telephone interview was conducted with the hospital Social Worker/Case Worker on 12/9/19 at 9:56 AM. She stated Resident #1 was sent from the facility to the hospital emergency room and was admitted to the geriatric psychiatric unit on 8/24/19 for aggressive behavior. On 8/26/19 she left a message for the facility Admissions Coordinator and requested a return call regarding what day the resident could return. A little later that day, she confirmed she spoke with the facility Admissions Coordinator who told her the facility didn't feel the resident was appropriate because of his aggressive behavior and they felt the resident needs a psychiatric facility. When asked when the resident was stabilized, she replied, The resident was stabilized and totally compliant and controlled with meds on 8/27/19. He showed no aggression, and no issues, and ready for discharge on 8/28/19. On 8/28/19, she stated she talked with the resident's sister, who told her the facility called her and said they wouldn't take him back. The resident was discharged from the hospital to an assisted living facility on 9/19/19. On 12/9/19 at 10:42 AM, a telephone call was placed to Resident #1's family member. The family member stated she was contacted by a facility staff person and told that her brother would not be able to return to the facility because of his aggressive behaviors and physically striking out at others. She confirmed her conversation with the hospital case worker on 8/28/19 stating, Yes I told her the facility wouldn't take back my brother. She stated that when he was discharged from the hospital, he went to an assisted living facility, but left from there and is currently in another nursing home. When she was asked if resident had any increased confusion, anxiety and/or behavioral changes observed as a result of the transfer to another facility she replied, No, he seemed more relaxed and secure in the hospital and did well with his transfer to assisted living, and now he's in the nursing home doing even better. An interview was conducted with the facility Admission Coordinator on 12/9/19 at 10:51 am. He confirmed that Resident #1 went to the hospital due to aggressive behaviors on 8/24/19. He stated that he talked with the Administrator concerning the resident returning to facility and she told him the resident was not appropriate to return. He confirmed that he had a conversation with the Social Worker at the hospital, but did not remember the date or her name, and told her that due to resident behaviors and physical contact with other residents and staff, he was not appropriate to return to the facility. He also confirmed that he talked to the resident's sister and told her that the resident would not be able to return to facility, but she was already aware of it. A closed record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The discharge Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/24/19, found a return was anticipated, and that it was an unplanned discharge to an acute hospital with return anticipated. He required extensive assistance with activities of daily living (ADL). There was no active discharge plan to return to the community. On 8/24/19, Resident #1 was Baker Acted by the facility due to physically grabbing a female resident's arm, hitting and kicking staff while they were removing him from her room, refusing medications, and refusing care. The facility had a care plan in place for Resident #1 for impaired social communication and cognitive function and/or impaired thought processes related to [MEDICAL CONDITION] drug use, [MEDICAL CONDITION], anxiety, restlessness, and agitation. The goal was for Resident #1 to be able to communicate basic needs on a daily basis through next facility review. Interventions included: Administer meds as ordered, engage in simple, structured activities that avoid overly demanding tasks, supervision/assistance with decision making, monitor/document/report to physician any changes in cognitive function, and behavioral consults as needed. The resident was also on 1 to 1 care on 8/24/19 until the Baker Act was enforced. Review of facility progress note on 8/24/19 revealed the psych nurse visited resident and resident was Baker Acted as of 12:30 PM today. Attempt was made to contact resident sister twice during shift to update her on resident. Resident was sent out to hospital emergency room via ambulance for further eval and treatment. Resident is alert and oriented at this time. Risk Management, Social Worker, Director of Nursing and Medical Director were made aware. There was no additional documentation provided by the facility, either electronic or handwritten, regarding communication between the facility and the hospital following Resident #1's transfer on 8/24/19 related to his condition, treatment, progress or emotional state. An interview was conducted with the facility Social Service Director on 12/9/19 at 10:20 AM. She confirmed Resident #1 was sent to the hospital on [DATE] and did not return to the facility, but said she had no contact with the hospital Social Worker. An interview was conducted with Director of Nursing on 12/9/19 at 11:42 AM. She confirmed Resident #1 was sent to the hospital on [DATE] and did not return to the facility, but said she had no contact with the hospital Social Worker. She stated, I believed once he was stabilized, he could have returned. An interview was conducted with the Administrator on 12/9/19 at 11:52 PM. She confirmed Resident #1 went to the hospital on [DATE] and did not return to the facility. She stated, We didn't make the decision not to take him back; we would make that decision as a team. When asked who had contact with the hospital Social Worker, she replied, I think the Marketing Liaison may have talked to them, but I'm not sure. She then added, We didn't give him any discharge notice because we were expecting him to come back; I don't know why he didn't come back. A review of Social Worker's notes from the hospital dated 8/26/19 revealed she left a message for the facility's Admissions Director and requested a return call regarding what day the patient can return to nursing home. Shortly thereafter, she received a call from the Admission Director who stated their facility doesn't feel he is appropriate because of his aggressive behavior. They feel he needs a psych facility. There is an abuse case on him. They put a call into (assisted living facility) They feel he needs a psych facility. On 8/28/19, the hospital Social Worker noted she talked with the resident's sister who told her that the nursing home won't take him back. A review of the hospital psychiatric notes revealed Resident #1 was admitted on [DATE] from nursing home under Baker Act because he was aggressive, combative and violent toward staff. Patient was seen in emergency room and admitted to geriatric unit for stabilization. He was discharged on [DATE] to an Assisted Living Facility.

Based on interviews and record reviews, the facility failed to provide services which met professional standards of quality by failing to complete physician-ordered vital signs required for the medical management of five (Residents #7, #18, #25, #29 and #69) out of 26 residents on one unit who were reviewed for physician-ordered vital signs. Professional Standard of Care is defined in Chapter 766.102 FS as, the prevailing professional standard of care for a given health care provider shall be that level of care, skill and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The Florida Nurse Practice Act, Chapter 464.003 FAC defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which treatments a prescribed or authorized by a duly licensed practitioner practice administration of treatments and medications, in the care of the ill, injured, or informed and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The findings include: An interview was conducted with Employee C, Certified Nursing Assistant (CNA), on 01/16/19 at 12:06 PM. When she was asked who entered/documented vital signs taken for each resident, Employee C stated, The nurse will give the CNA a sheet with the resident who needs to have vital signs taken. The CNA reported that she put the vital signs sheet on the front desk face down. She reported that the CNA entered routine vital signs, but if the resident was ordered vital signs each shift or as needed, the nurse would enter the vital signs. Employee B, Licensed Practical Nurse (LPN), was interviewed about the procedure for vital signs on 01/16/19 at 12:11 PM. She stated she did hers differently. She reported she had [MEDICAL TREATMENT] residents who she had to obtained vital signs for. She further reported that there were medications requiring regular vital signs to be obtained, and you had to do the daily charting. She confirmed it was the nurses' responsibility to get the documentation of the vital signs into the computer. Employee D, LPN, and nurse manager on the 2nd floor was interviewed on 01/16/19 at 12:14 PM. She provided a three-ring binder of the vital signs for residents on the unit being reviewed, and the sheets were reviewed. They were all blank except for the 1/16/19 dated sheet, which only had 2 residents' vitals taken at the time. She reported that every resident on the unit should have weekly vital signs on a Saturday and on any shift required/or as ordered. Employee D was interviewed about who checked to ensure that the vital signs were completed as ordered. At first she reported that she did not know, then she stated, The nurses. She reported that all residents should have had vital signs down the hallway. If the resident did not have vital signs taken, she stated that there would be a documented reason why they were not obtained. Employee D, the Nurse Manager for the 2nd floor reviewed 26 residents' electronic medication administration records (EMARs) on 01/16/19 at 12:22 PM. She confirmed the following vital signs were not obtained and/or documented appropriately. She also confirmed the entry made on 1/12/19 for Resident #29 with the vital signs documented as having been obtained for 1/05/19. There was no documented note for the 1/12/19 vital signs. She agreed that Ob should not be documented for 1/12/19 and Op should not be documented for the 12/30/18 as vital signs. She reported that if the vitals were not done they were missed physician's orders [REDACTED]. During a review of the medical record for Residents # 7, 18, 25, 29 and 69, the following was documented: The Medication Administration Record [REDACTED]. A review of the MAR for Resident #7 was conducted. The entry for Saturday 1/12/19 was documented as Ob (observation) with the initials confirmed to be nursing staff Employee E. There were no available documented vital signs, including blood pressure, to be reviewed for the entry. A review of Resident #7's MAR for (MONTH) (YEAR) for 12/01/18, revealed that Employee E documented Op (not pain identified) and under the line for Saturday 12/15/2018 and 12/29/2018, entered by nursing staff Employee E, the comment Ob which indicated no behaviors observed for the vital signs documentation. The MAR indicated [REDACTED]. The (MONTH) 2019 MAR for Resident #18 was reviewed for vital signs and documented under the date for 1/12/19 was Ob (no behaviors observed) for vital signs. The entry was made by Employee E. A review of the MAR for (MONTH) (YEAR) documented for Resident #18 for 12/1/18, Op (no pain indicated) and Ob for 12/29/18, which indicated that no behaviors were observed for vital signs. This entry was documented by Employee E. There were no vital signs including blood pressure, heart rate or temperature documented for the dates of concern. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. This was documented by Employee E. This was confirmed by review of the signature page and the MAR key for code entry. A review of the (MONTH) (YEAR) MAR for Resident #25 was conducted and it was documented on 12/1/18 and 12/29/18 (a Saturday), Op for no pain was noted under the vital signs. On Saturday, 12/15/18, Employee E entered Ob for the vital signs order. No vital signs were provided for this date including blood pressure or heart rate. The documentation was entered by Employee E. The Medication Administration Record [REDACTED]. Resident #29 had a physician's orders [REDACTED]. A review of the 1/6/19 entry revealed no vital signs were obtained. On 1/12/19 it was documented that vital signs were completed as Ob (no behaviors) per nursing initials. (Employee E). There were no vital signs recorded. It was also documented for Resident #29 on the MAR indicated [REDACTED]. Employee E was the nurse who documented the entry with no vital signs available for review. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A review of the (MONTH) 2019 MAR indicated [REDACTED]. A review of the MAR indicated [REDACTED]. There were no vital signs available for review. On Saturday 12/29/18, Employee E documented Ob again. Only two Saturdays of the five Saturdays that required vital signs during (MONTH) (YEAR) were completed and documented for Resident #69. A review of the facility-provided job description for Certified Nursing Assistant (CNA) revealed under the position purpose to Take and record vital signs (Temperature, pulse, respiration, blood pressure, etc.). A review of the facility-provided job description for Floor Nurse revealed the documented purpose: oversee, provide and coordinate nursing care in compliance with facility policy and procedures and to assess residents' care needs and take appropriate action. Essential functions documented: Take and record vital signs (Temperature, pulse, respiration, blood pressure, etc.) and meet residents needs documented under cooperate.

Based on interview and record review; the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, by failing to complete physician-ordered vital signs required for the medical management of five (Residents #7, #18, #25, #29 and #69) out of 26 residents on one unit who were reviewed for physician-ordered vital signs. The findings include: An interview was conducted with Employee C, Certified Nursing Assistant (CNA), on 01/16/19 at 12:06 PM. When she was asked who entered/documented vital signs taken for each resident, Employee C stated, The nurse will give the CNA a sheet with the resident who needs to have vital signs taken. The CNA reported that she put the vital signs sheet on the front desk face down. She reported that the CNA entered routine vital signs, but if the resident was ordered vital signs each shift or as needed, the nurse would enter the vital signs. Employee B, Licensed Practical Nurse (LPN), was interviewed about the procedure for vital signs on 01/16/19 at 12:11 PM. She stated she did hers differently. She reported she had [MEDICAL TREATMENT] residents who she had to obtained vital signs for. She further reported that there were medications requiring regular vital signs to be obtained, and you had to do the daily charting. She confirmed it was the nurses' responsibility to get the documentation of the vital signs into the computer. Employee D, LPN, and nurse manager on the 2nd floor was interviewed on 01/16/19 at 12:14 PM. She provided a three-ring binder of the vital signs for residents on the unit being reviewed, and the sheets were reviewed. They were all blank except for the 1/16/19 dated sheet, which only had 2 residents' vitals taken at the time. She reported that every resident on the unit should have weekly vital signs on a Saturday and on any shift required/or as ordered. Employee D was interviewed about who checked to ensure that the vital signs were completed as ordered. At first she reported that she did not know, then she stated, The nurses. She reported that all residents should have had vital signs down the hallway. If the resident did not have vital signs taken, she stated that there would be a documented reason why they were not obtained. Employee D, the Nurse Manager for the 2nd floor reviewed 26 residents' electronic medication administration records (EMARs) on 01/16/19 at 12:22 PM. She confirmed the following vital signs were not obtained and/or documented appropriately. She also confirmed the entry made on 1/12/19 for Resident #29 with the vital signs documented as having been obtained for 1/05/19. There was no documented note for the 1/12/19 vital signs. She agreed that Ob should not be documented for 1/12/19 and Op should not be documented for the 12/30/18 as vital signs. She reported that if the vitals were not done they were missed physician's orders [REDACTED]. During a review of the medical record for Residents # 7, 18, 25, 29 and 69, the following was documented: The Medication Administration Record [REDACTED]. A review of the MAR for Resident #7 was conducted. The entry for Saturday 1/12/19 was documented as Ob (observation) with the initials confirmed to be nursing staff Employee E. There were no available documented vital signs, including blood pressure, to be reviewed for the entry. A review of Resident #7's MAR for (MONTH) (YEAR) for 12/01/18, revealed that Employee E documented Op (not pain identified) and under the line for Saturday 12/15/2018 and 12/29/2018, entered by nursing staff Employee E, the comment Ob which indicated no behaviors observed for the vital signs documentation. The MAR indicated [REDACTED]. The (MONTH) 2019 MAR for Resident #18 was reviewed for vital signs and documented under the date for 1/12/19 was Ob (no behaviors observed) for vital signs. The entry was made by Employee E. A review of the MAR for (MONTH) (YEAR) documented for Resident #18 for 12/1/18, Op (no pain indicated) and Ob for 12/29/18, which indicated that no behaviors were observed for vital signs. This entry was documented by Employee E. There were no vital signs including blood pressure, heart rate or temperature documented for the dates of concern. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. This was documented by Employee E. This was confirmed by review of the signature page and the MAR key for code entry. A review of the (MONTH) (YEAR) MAR for Resident #25 was conducted and it was documented on 12/1/18 and 12/29/18 (a Saturday), Op for no pain was noted under the vital signs. On Saturday, 12/15/18, Employee E entered Ob for the vital signs order. No vital signs were provided for this date including blood pressure or heart rate. The documentation was entered by Employee E. The Medication Administration Record [REDACTED]. Resident #29 had a physician's orders [REDACTED]. A review of the 1/6/19 entry revealed no vital signs were obtained. On 1/12/19 it was documented that vital signs were completed as Ob (no behaviors) per nursing initials. (Employee E). There were no vital signs recorded. It was also documented for Resident #29 on the MAR indicated [REDACTED]. Employee E was the nurse who documented the entry with no vital signs available for review. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A review of the (MONTH) 2019 MAR indicated [REDACTED]. A review of the MAR indicated [REDACTED]. There were no vital signs available for review. On Saturday 12/29/18, Employee E documented Ob again. Only two Saturdays of the five Saturdays that required vital signs during (MONTH) (YEAR) were completed and documented for Resident #69. A review of the facility-provided job description for Certified Nursing Assistant (CNA) revealed under the position purpose to Take and record vital signs (Temperature, pulse, respiration, blood pressure, etc.). A review of the facility-provided job description for Floor Nurse revealed the documented purpose: oversee, provide and coordinate nursing care in compliance with facility policy and procedures and to assess residents' care needs and take appropriate action. Essential functions documented: Take and record vital signs (Temperature, pulse, respiration, blood pressure, etc.) and meet residents needs documented under cooperate.

Based on observation, resident interview, staff interview, clinical record review and policy and procedure review, the facility failed to ensure one resident (#27) out of 38 sampled residents had access to the call light while seated in her wheelchair or lying in her bed in her room. Not having access to the call light presents the potential for accidents and injury. The findings include: Resident #27 was observed on 01/14/19 at 1:22 PM sitting in her wheelchair between the two beds in her room. She stated she wanted to get in her bed. The call light was not within reach. She asked where it was and when told, she said she could not reach it. The call light was clipped to the bedspread behind her. The call light was engaged for her. The call light was answered on 01/14/19 at 1:29 PM by Employee F, Licensed Practical Nurse (LPN). Employee F shut the call light off and asked Resident #27 if she wanted to get in bed. Resident #27 said yes. Employee F left the room at 1:30 PM, but did not put the call light back on. She did not assist the resident to get into bed. Employee F pulled the privacy curtain between the beds so Resident #27 could not be seen from the hallway. Employee F returned to the medication cart and continued working. From 1:30 PM until 1:49 PM, several direct-care staff members walked by Resident #27's room, but did not enter. The call light remained off. On 01/14/19 at 1:49 PM, Resident #27 was asked if anyone had come to help her and she stated, They are supposed to be coming. Her call light was clipped to the bedspread behind her in the same position it was in upon the first observation. She was asked to put her call light on again and was handed the call light. She was able to press the pneumatic cushion and the light came on. Employee F entered the room at 1:50 PM. She shut the call light off again. She was heard to say to the resident that someone would be in to help her soon. Employee F left the room at 1:50 PM and was not observed to tell any staff member to put Resident #27 in bed. She returned to the medication cart and started looking at the computer screen. Several Certified Nursing Assistants (CNAs) walked past the resident's room and did not enter to assist her. The call light remained off. On 01/14/19 at 1:55 PM, Employee R, CNA, went into Resident #27's room and closed the door. At 2:10 PM Employee R opened the door and left the room. Resident #27 was lying in her bed. Her call light was clipped to the bedspread on her left side. When asked if she could reach the call light she patted the bedcovers with her right hand in an attempt to find it. She stated No, I can't find it. The resident did not use her left hand to reach for the call light. On 01/15/19 at 1:46 PM, Resident #27 was observed seated in her wheelchair between the beds in her room. The call light was clipped to the bedspread behind the resident. She stated she could not reach it. On 01/16/19 at 9:30 AM, Resident #27 was seated in her wheelchair between the two beds in her room. The call light was clipped to the bedspread behind her; out of her reach. Resident #27 was observed lying in bed on 01/17/19 at 1:45 PM. Employee G, CNA, was in the room bagging up soiled linen. The privacy curtain was drawn. After the CNA left the room, the resident was observed lying in the bed with her bedcovers on. The call light was draped over the tray table that was against the wall under the call light panel. The tray table was on the resident's left side. During an interview with Employee G on 01/17/19 at 1:48 PM, she stated she had just put Resident #27 in bed for a nap. When asked if the resident could use her call light, she stated that she could use it. She was asked to look at the position of the call light. She went into Resident #27's room, saw the call light and confirmed that the call light was not positioned where the resident could reach it. She took the call light and put it at the left of the resident's torso on top of the bed covers. The resident was asked if she could reach the call light and she felt around for it. Employee G then took the call light and positioned it so the resident could reach it with her right hand. A review of the Care Plan dated 11/14/2018, revealed the resident was care planned for a risk for falls. The interventions included: Assist of two staff and mechanical lift for all transfers; Be sure call light is within reach and encourage resident to use it for assistance as needed; Provide a prompt response to all requests for assistance; Provide a safe environment with a working and reachable call light. A review of the Minimum Data Set (MDS) annual assessment dated [DATE], revealed it was very important to choose her bed time and to do her favorite activities. Review of the MDS dated [DATE] revealed the resident was diagnosed with [REDACTED]. She was assessed as being totally dependent with transfers and requiring a two-person physical assist. She had impairment on both sides in her upper extremities. During an interview with the Director of Nursing (DON) on 01/17/19 at 1:55 PM, she stated Resident #27 could use her call light. The DON stated she had gone in to answer her call light before. She stated her expectation of staff was that the staff would answer call lights immediately when they came on, or as soon thereafter as possible. They would place the call light within reach for the residents who could use them. When informed of the observations this week, she stated that the staff should be putting the resident's call light within reach and making sure it is on the right side so she could use it with her right hand. During a second interview with the DON on 01/17/19 at 2:39 PM, she stated the nurse should have assisted the resident to get into bed. During an interview on 01/17/2019 at 4:30 PM with Employee R, Restorative CNA, she stated Resident #27 received active range of motion on her right arm and hand and passive range of motion on her left arm and hand two times a day, three days a week. She went to an exercise class in the activities room at 9:30 AM. She stated Resident #27 could use her call light, but she did not use her left hand to press the button. She stated Resident #27 had a stroke and had left-sided weakness. A review of the policy and procedure for the Call System revealed it read: 2. Resident call activation button will be placed within reach and preferred position for ease of use by the resident. 3. Staff are to ensure correct placement of call activation button as they exit the resident rooms and upon resident rounds.

Based on observation, interviews and facility record review, the facility failed to ensure one resident's (Resident #51) right to make a free choice of room selection and roommate, out of four residents reviewed for choices, out of 38 sampled residents. The findings include: A review of the Minimum Data Set (MDS) assessment dated [DATE], documented that Resident #51 had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 points, indicating that Resident #51 was moderately cognitively impaired. On 1/07/19 at 2:35 PM, a New Roommate/Notification of Room Change was entered for room [ROOM NUMBER]-D, and a current room was documented as 400-A. A review of the Room Change Notification completed by Employee N, Social Worker, revealed that the resident was notified, the doctor was notified, the roommate was notified, and the care plan was updated at that time. The resident/family verbally acknowledged the notification of the room change request on 1/07/19. There was no documented refusal of offered rooms or additional reasonable efforts to locate another room for Resident #51. The only other documentation of room change notification was entered by Employee N on 11/29/18 at 1:00 PM. This documented that Resident #51 was temporarily placed in a Rehabilitation bed room [ROOM NUMBER]-A and now is moving to a long-term bed room [ROOM NUMBER]-A and will have a roommate. It also documented that the resident representative was notified by phone. During the initial tour and sample selection on 01/14/19 at 12:21 PM, Resident #51 was assigned on the census (provided on 1/14/2019) to room [ROOM NUMBER]-A. On 01/15/19 at 11:02 AM, an interview was conducted with Resident #51. She reported she was trying to get another roommate, and she confirmed this had been quite a while since she made the request. She also reported that they (the facility) were working on getting her a new neighbor. Resident #51 reported that she spoke with the Administrator and the Director of Nursing. She also reported that she did agree to be moved to another room, and even wanted to be placed in a room with four people. She confirmed that Employee N knew and was working on her request to be moved to another room. She finally reported that they (the facility staff) had been going back and forth since (MONTH) (YEAR). She was admitted on [DATE]. She requested to be put into room [ROOM NUMBER] with her friend. On 01/15/19 at 4:14 PM, an observation was made of Resident #51 in room [ROOM NUMBER]-A sitting in a wheelchair. A tour of room [ROOM NUMBER] was conducted on 01/16/19 at 3:01 PM. Resident #62 was interviewed during the tour, and confirmed there was a roommate in D-bed a couple of days ago, then was gone and that was the mystery. The room had four beds and a wardrobe marked for A, B, C, and D. This indicated that there were four possible occupants in this room. Wardrobe D was empty at this time, and the tour ended on 01/16/19 03:04 PM. Employee M, Certified Nursing Assistant (CNA), was interviewed on 01/16/19 at 3:05 PM. She reported that there was a resident (female) in D-bed, but she moved two or three days ago. Employee W, Registered Nurse (RN)/Unit Manager, was interviewed on 1/16/2019 at 3:07 PM. She stated, If room concerns are reported to the Unit Manager, the nurse manager would go to the room and ask what was the problem. She stated that a lot of times these problems could be fixed. The Unit Manager also confirmed that when a resident reported they were not compatible with their roommate, the Unit Manager would take the resident to Employee N, Social Services Director (SSD), the room change would be initiated, and the information would be provided to the units. All notifications would be made, and the room change was then supposed to happen. The Unit Manager reported that Employee N responded on the same day, and once the resident toured the room and found it acceptable, approval was provided to move the resident, and the CNAs began packing up the resident's belongings. A report was provided to nursing staff and the family was notified. She also reported that there was one resident (Resident #51) who was down on the unit for a while and went back up to the second floor. Now Resident #51 wanted to come back down to the room she was in. The Unit Manager, RN, reported that there was one room available in the quad (4 bedroom), and she reported that no one seemed to want to be in the room with four people. They showed Resident #51 the quad (Resident #51) and it was toured, but she refused that room. The Unit Manager reported that on Monday, 1/14/19, the 109-B bed became available. The Unit Manager stated she was not sure if Resident #51 was going to be offered room [ROOM NUMBER]. The problem was that the resident wanted the same room and did not want to go to another roommate. An interview was conducted with Employee N on 01/16/19 at 3:23 PM. When asked about room change practices, she stated whenever she was notified of a resident's wish for a room change, she went to the room and found out about the likes and dislikes. That was where she started. If the resident did not get along with their roommate and conflicts were not resolved, she immediately looked for an alternate room. Employee N further stated that Resident #51 was in room [ROOM NUMBER]-A. She continued, Her thing is that she is new to the facility and wanted to use a bedside commode. room [ROOM NUMBER]-A was not accommodating and staff would have to ambulate her (Resident #51) to the commode. They could not fully accommodate the wheelchair. room [ROOM NUMBER]-A was available at the time and the bathroom was right at the doorway so all the staff would have to do was to pivot her to get her into the bathroom. Now that Resident #51 was upstairs, she wanted to come back to her old room to be with her friend who moved up to room [ROOM NUMBER] -A on Monday 1/14/2019. An interview was conducted with Employee N on 01/16/19 at 3:33 PM, and she stated that the last encounter with Resident #51 was on 11/29/2018. Employee N reported that Resident #51 had not been down to the office to see her lately. She also reported that Resident #51 was offered to move to room [ROOM NUMBER]-D (quad room with 4-residents), but her sister-in-law was against it. Employee N reported that Resident #51 and her sister-in-law made decisions together. An interview was conducted with the Admissions Coordinator on 01/16/19 at 3:27 PM. She reported that there were six rooms available currently (Rooms 204-A, 210-B, 211-B, 105-D, and 109-B). An interview was conducted with Employee N on 01/16/19 at 3:38 PM. She reported that Resident #51 was alert and could vouch for herself. She had disabilities, but was cognitively intact and could make her needs known. Employee N reported that there was a conversation regarding the nature of the room change refusal and this was not documented. On 01/16/19 at 3:45 PM, an interview was conducted with Resident #51 by Employee N about room changes. Resident #51 expressed excitement in being introduced to another room. room [ROOM NUMBER]-D was toured on 01/16/19 at 03:56 PM. Resident #51 was brought to room [ROOM NUMBER] by Employee N, the Unit Manager and Resident #51 agreed to be moved to room [ROOM NUMBER] D at the time. Resident #51 requested that the change occur that day. An interview was conducted with Resident #51 on 01/17/19 at 9:06 AM. She reported that she was very happy. Based on a review of the facility's current census, Resident #51 now resided in room [ROOM NUMBER]-D. A review of the electronic medical record for Resident #51 was conducted and documented that on 1/07/19, there was a notification of room change: 1/07/19 at 2:35 PM -current room [ROOM NUMBER]-A, new room [ROOM NUMBER]-D, resident notified on 1/07/19, family notified and doctor notified all on 1/07/2019. Reason for room change/transfer documented that Resident #51 requested to move in a long-term room on the first floor. Resident #51 stated she enjoys talking with the resident in 105-C, and she did not mind sharing the room with three other people. Voluntary Agreement to room change documented. The writer was Employee N, Social Service Director, who documented the writer spoke with the sister of Resident #51 about the room change, and she verbally acknowledged she was aware that Resident #51 wanted to change rooms. State and Ombudsman notified. No documented refusals to accept offered rooms. A review of the medical record for Resident #51 documented a transfer notification on 11/29/18 at 1:00 PM, and it revealed that was the last encounter with the social service department. Employee N stated that anyone could report a need to change rooms to her and that would initiate the room change process. A review was conducted of the medical record for Resident #51, and it was documented on a new roommate/notification of Room change. On 1/07/19, 400-A was documented as the current room. New room number (requested 105-A) assigned date and time of notification was on 1/07/2019 at 2:35 PM. The box checked indicated that the Room transfer was requested by resident and/or family/responsible person. The facility was made aware and documented that it was aware of the room change request at this time. The room change did not occur and there was no documented reason why the facility did not follow through with the room change request until brought to their attention during the recertification survey on 1/16/19 at 3:33 PM. A review of the facility current census obtained on 1/17/2019 documented that Resident #51 was relocated to room (105-D) on 1/16/2019 following interviews above. On 1/17/19 at 9:25 AM, the Administrator was interviewed. He spoke to Resident #51 about trying to find another room for her, and he stated that they knew that she did not like her roommate, and they were trying to find the best place for her. The Administrator stated that they had to find an opening, a resident that she could talk to and a bathroom that would be suitable. The whole situation. They had known about the room request for a couple of days. He reported that if Resident #51 wanted to be in a room with fou4 people, then she could do that. The Administrator confirmed that it had been nine (9) days since the documented request, and there were no documented refusals of rooms available to present to the survey team, or documentation to explain the facility's progress (or lack thereof) with the resident's request. An interview was conducted with Employee Q, Business Office Employee, on 01/17/19 at 9:54 AM. She was asked for the number of rooms that were available from 1/07/2019 (the dated of the room change request documented for Resident #51) to 1/16/2019 (the date Social Services interviewed Resident #51 and then followed through with the initial room change request). A review of the progress note revealed that there were no documented behaviors related to altercations or difficulty for Resident #51 since her admission date of [DATE]. A review of the care plan focus documented on 12/11/2018 for Resident #51 revealed the following, I will continue to participate in daily activities of choice. Interventions included, Encourage to socialize with other residents with similar interests and Praise me for all attempts to socialize. The care plan also instructed to discuss my activity preferences and allow me to make choices. A review of the facility Detailed Census Report obtained on initial entrance dated 1/13/19 for recertification survey documented that Resident #51 resided in room [ROOM NUMBER]-A. The room in which the surveyor initial interview was conducted, and Resident #51 expressed that she was told the facility was working on finding a room. A review of the Midnight Census Report revealed the following: 1/07/19- 100 hallway had 5 empty beds 105-D, 108-A, 116-A, 116-B and 116-C; 200 hallway had 7 empty beds, 300 hallway had 1 empty bed and 400 hallway had 3 empty beds. 1/08/19- 100 hallway had 4 empty beds-105-D, 116-A, 116-B and 116-C. The 200 hallway had 8 empty beds. 300 hallway had (0) empty beds. The 400 hallway had 3 empty beds. 1/09/19-The 100 hallway had 4 empty beds-105-D, 116-A, 116-B and 116-C. The 200 hallway had 6 empty beds. The 300 hallway had (0) empty beds. The 400 hallway had 3 empty beds. 1/10/19-The 100 hallway had 4 empty beds: 105-D, 116-A, 116-B and 116-C. The 200 hallway had 6 empty beds. The 300 hallway had (0) empty beds. The 400 hallway had 3 empty beds. 1/11/19-The 100 hallway had 3 empty beds: 116-A, 116-B and 116-C. The 200 hallway had 7 empty beds. The 300 hallway had (0) empty beds. The 400 hallway had 1 empty beds. 1/12/19-The 100 hallway had 3 empty beds: 116-A, 116-B and 116-C. The 200 hallway had 7 empty beds. The 300 hallway had (0) empty beds. The 400 hallway had 1 empty beds. 1/13/19-The 100 hallway had 3 empty beds: 116-A, 116-B and 116-C. The 200 hallway had 7 empty beds. The 300 hallway had (0) empty beds. The 400 hallway had 1 empty beds. 1/14/2019-The 100 hallway had 3 empty beds: 116-A, 116-B and 116-C. The 200 hallway had 7 empty beds. The 300 hallway had (0) empty beds. The 400 hallway had 1 empty beds. 1/15/19-The 100 hallway had 5 empty beds: 105-D, 109-B, 116-A, 116-B and 116-C. The 200 hallway had 4 empty beds. The 300 hallway had (1) empty beds. The 400 hallway had 1 empty beds. 1/16/2019-The 100 hallway had 5 empty beds: 105-D, 109-B, 116-A, 116-B and 116-C. The 200 hallway had 5 empty beds. The 300 hallway had (0) empty beds. The 400 hallway had 1 empty beds. A review of the midnight census report from 1/16/19, provided on 1/17/2019 at 8:56 AM, revealed that Resident #51 occupied room [ROOM NUMBER]-D; a room that was toured on 1/16/2019 with Resident #51 also was documented as empty and available on this same census; room [ROOM NUMBER]-B. Confirming the census provided reveals rooms that are readily available to be occupied by residents. A review of the facility provided, A Matter of Rights; A Guide to Your Rights and Responsibilities as a Resident was conducted. On Page 10, it was documented under Freedom of Choice that You are entitled to make decisions, whenever possible, for yourself and based on your own interests and preferences. A review was conducted of the facility policy for Room Change/Roommate Assignment and the heading read, Changes in room or roommate assignment shall be made when the facility deems it necessary or when the resident requests the change.

Based on record reviews and staff interviews, for one (Resident #83) of one hospitalized residents reviewed, the facility failed to permit the resident's return following her hospitalization . The findings include: During a record review of Resident #83's hospitalization , the facility's recapitulation of the resident's transfer to the hospital revealed the resident was readmitted on [DATE] from the acute care hospital on a stretcher. She had a DNR (Do Not Resuscitate) status and was a long-term resident of the facility. All medications were discontinued while at the hospital. Oxygen was ordered at 3L NC (three liters per nasal cannula), and she was unable to make her needs known. The resident was observed with a wound on the sacrum, which had soiled the sheets. At 10:20 PM on 12/24/18, the resident's physcian gave an order to send the resident to the emergency room for further evaluation. Her temperature was 100.2 F, her pulse was 94 and her blood pressure was recorded as 100/54. At 10:46 PM on 12/24/18, the resident was sent to an acute care hospital for further evaluation. The resident's POA (power of attorney) was reportedly verbally abusive toward the staff, and threatened them with physical harm. Therefore, the facility decided to not allow the resident to return. The acute care hospital was informed of the facility's decision. The resident was discharged by the facility on 12/27/18 at 10:48 AM. Her medical [DIAGNOSES REDACTED]. An interview with the Social Services Director (Employee N) on 1/17/18 at 2:00 PM, revealed she was not involved with discharges. She deferred to the Business Office Manager (Employee Q), who deferred to the Administrator. On 1/17/18 at 2:15 PM, the Administrator stated that the facility had no bed-hold at the time, and the resident's daughter had threatened to harm the nursing staff on duty, therefore the facility had to obtain a No Trespass Order for Resident #83's Power of Attorney (POA), the resident's daughter. The facility felt the resident was already discharged to the hospital and was no longer their resident, hence their decision not to permit the resident to return. The Administrator was asked if he provided a written statement of discharge to the family, and he stated No. The policy regarding admission and discharge was requested. The information booklet provided on Transfer and Discharge was reviewed, and noted the The facility will not transfer a resident to a hospital or allow a resident to go on therapeutic leave without first providing written information to the resident and a family member or legal representative specifying the applicable bed hold policy. It also noted that a discharge would not be made solely for the convenience of staff. The facility did not give a written 30-day discharge notice or any written discharge notice to the family. Confirmation was requested that a discharge notice had been issued, but Employee T stated he did not issue one. He was asked if he reported the discharge to the Ombudsman as required, and he replied No.

Based on observation, resident interview, staff interview, clinical record review and policy and procedure review, the facility failed to implement the comprehensive care plan for one resident (#27) out of 38 sampled residents. Failure to implement the care plan approaches places the resident at risk of not receiving appropriate interventions, and could potentiate medical or physical complications and/or injury. The findings include: Resident #27 was observed on 01/14/19 at 1:22 PM sitting in her wheelchair between the two beds in her room. She stated she wanted to get in her bed. The call light was not within reach. She asked where it was and when told, she said she could not reach it. The call light was clipped to the bedspread behind her. The call light was engaged for her. The call light was answered on 01/14/19 at 1:29 PM by Employee F, Licensed Practical Nurse (LPN). Employee F shut the call light off and asked Resident #27 if she wanted to get in bed. Resident #27 said yes. Employee F left the room at 1:30 PM, but did not put the call light back on. She did not assist the resident to get into bed. Employee F pulled the privacy curtain between the beds so Resident #27 could not be seen from the hallway. Employee F returned to the medication cart and continued working. From 1:30 PM until 1:49 PM, several direct-care staff members walked by Resident #27's room, but did not enter. The call light remained off. On 01/14/19 at 1:49 PM, Resident #27 was asked if anyone had come to help her and she stated, They are supposed to be coming. Her call light was clipped to the bedspread behind her in the same position it was in upon the first observation. She was asked to put her call light on again and was handed the call light. She was able to press the pneumatic cushion and the light came on. Employee F entered the room at 1:50 PM. She shut the call light off again. She was heard to say to the resident that someone would be in to help her soon. Employee F left the room at 1:50 PM and was not observed to tell any staff member to put Resident #27 in bed. She returned to the medication cart and started looking at the computer screen. Several Certified Nursing Assistants (CNAs) walked past the resident's room and did not enter to assist her. The call light remained off. On 01/14/19 at 1:55 PM, Employee R, CNA, went into Resident #27's room and closed the door. At 2:10 PM Employee R opened the door and left the room. Resident #27 was lying in her bed. Her call light was clipped to the bedspread on her left side. When asked if she could reach the call light she patted the bedcovers with her right hand in an attempt to find it. She stated No, I can't find it. The resident did not use her left hand to reach for the call light. On 01/15/19 at 1:46 PM, Resident #27 was observed seated in her wheelchair between the beds in her room. The call light was clipped to the bedspread behind the resident. She stated she could not reach it. On 01/16/19 at 9:30 AM, Resident #27 was seated in her wheelchair between the two beds in her room. The call light was clipped to the bedspread behind her; out of her reach. Resident #27 was observed lying in bed on 01/17/19 at 1:45 PM. Employee G, CNA, was in the room bagging up soiled linen. The privacy curtain was drawn. After the CNA left the room, the resident was observed lying in the bed with her bedcovers on. The call light was draped over the tray table that was against the wall under the call light panel. The tray table was on the resident's left side. During an interview with Employee G on 01/17/19 at 1:48 PM, she stated she had just put Resident #27 in bed for a nap. When asked if the resident could use her call light, she stated that she could use it. She was asked to look at the position of the call light. She went into Resident #27's room, saw the call light and confirmed that the call light was not positioned where the resident could reach it. She took the call light and put it at the left of the resident's torso on top of the bed covers. The resident was asked if she could reach the call light and she felt around for it. Employee G then took the call light and positioned it so the resident could reach it with her right hand. A review of the Care Plan dated 11/14/2018, revealed the resident was care planned for a risk for falls. The interventions included: Assist of two staff and mechanical lift for all transfers; Be sure call light is within reach and encourage resident to use it for assistance as needed; Provide a prompt response to all requests for assistance; Provide a safe environment with a working and reachable call light. A review of the Minimum Data Set (MDS) annual assessment dated [DATE], revealed it was very important to choose her bed time and to do her favorite activities. Review of the MDS dated [DATE] revealed the resident was diagnosed with [REDACTED]. She was assessed as being totally dependent with transfers and requiring a two-person physical assist. She had impairment on both sides in her upper extremities. During an interview with the Director of Nursing (DON) on 01/17/19 at 1:55 PM, she stated Resident #27 could use her call light. The DON stated she had gone in to answer her call light before. She stated her expectation of staff was that the staff would answer call lights immediately when they came on, or as soon thereafter as possible. They would place the call light within reach for the residents who could use them. When informed of the observations this week, she stated that the staff should be putting the resident's call light within reach and making sure it is on the right side so she could use it with her right hand. During a second interview with the DON on 01/17/19 at 2:39 PM, she stated the nurse should have assisted the resident to get into bed. During an interview on 01/17/2019 at 4:30 PM with Employee R, Restorative CNA, she stated Resident #27 received active range of motion on her right arm and hand and passive range of motion on her left arm and hand two times a day, three days a week. She went to an exercise class in the activities room at 9:30 AM. She stated Resident #27 could use her call light, but she did not use her left hand to press the button. She stated Resident #27 had a stroke and had left-sided weakness. A review of the policy and procedure for the Call System revealed it read: 2. Resident call activation button will be placed within reach and preferred position for ease of use by the resident. 3. Staff are to ensure correct placement of call activation button as they exit the resident rooms and upon resident rounds.

Based on observation, interview and facility document review, the facility failed to ensure that it provided one resident (Resident #70), of one resident reviewed for activities of daily living, assistance with denture care, out of 38 residents sampled. The findings include: A medical record review for Resident #70 documented a readmission to the facility on [DATE] with a physician-ordered liberalized diet, regular texture and thin consistency. Resident #70 was documented with the following admitting Diagnoses: [REDACTED]. A review of the care plan for Resident #70 documented on 12/18/18 that the resident had nutritional problems related to BMI (body mass index of less than 27. Resident #70 was interviewed on 01/14/19 at 2:05 PM, when she reported that she never got her dentures back. Resident #70 reported, They took them and they just disappeared. She reported that facility staff removed them. An observation of Resident #70 revealed that she had no bottom dentures in place. She stated that she complained to staff about this. She was agitated and stated she did not want to continue the interview at that time. An interview was conducted with Employee B, Licensed Practical Nurse (LPN) on 01/16/19 at 10:15 AM about Resident #70. She confirmed she knew that Resident #70 had dentures, but stated the resident would not allow you to put Fixadent in them. Employee B stated when that happened, she would have them flop around in her mouth. Employee B also confirmed that Resident #70 put the dentures in her mouth independently. Resident #70's dentures were observed in a denture cup that was stored in the bed side table. Employee G, Certified Nursing Assistant (CNA) was interviewed on 01/16/19 at 1:14 PM about the mouth care for Resident #70. Employee G confirmed that Resident #70 received total care. Employee G confirmed that Resident #70 was alert and oriented and could make her needs known. Employee G also confirmed that as a CNA, she was supposed to use the care card to review a resident's needs. Employee G stated the care card was posted in the wardrobe for Resident #70 (the known location for the resident care card), and on it was documented that Resident #70 had dentures. The CNA also confirmed, based on the reviewed care card, that she was supposed to assist the resident with her dentures. She did not recall the last time she worked with Resident #70. An observation was made during the interview on 01/16/19 at 1:14 PM of Resident #70 with her dentures missing. She again stated that she did not have her dentures and that someone took them. Employee G stated she would check on the missing dentures, which resident #70 reported were missing for about three months. Resident #70 was observed with thick slices of Roast Beef on her lunch tray, and when asked what she liked to eat, she stated that she enjoyed hamburger, fish and chicken. Employee C, CNA was interviewed on 01/16/19 at 1:23 PM about the CNA assignment and what the CNA would use to get information about her residents. Employee C reported that each resident had a care card in their wardrobe, and the resident would let you know about the care needed. When asked if she knew whether Resident #70 had dentures, she reported that she did not know. She went to the wardrobe for Resident #70, and identified that dentures were marked on the resident care card. (Photographic evidence obtained) Employee D, LPN, was interviewed on 01/16/19 at 1:25 PM, and she reported that Resident #70 was in need of total care from staff. She preferred to stay in bed and the CNAs did everything for her. She further stated the resident could do things for herself with assistance and prompting. Employee D was asked how many times Resident #70 had her lower dentures in place and she was not sure. At this time Employee B, LPN, entered Resident #70's room and stated, She has them in her drawer. Employee B further stated that Resident #70 cannot get the dentures out of the drawer on her own, she cannot walk. It is preferred that she has them in, it is her discretion to wear them or not. An interview was conducted with Resident #70 on 01/16/19 at 1:30 PM. Employee B was present and asked Resident #70 if she knew where her dentures were. Resident #70 reported to Employee B that she did not know where the bottom dentures were, and then exclaimed, How do you expect me to chew? Resident #70 repeated that she did not know the dentures were in the drawer. Employee B handed the resident the dentures and the resident exclaimed, Whoever kept them there? She was observed as she inserted the lower dentures and was examined by Employee B. She placed the dentures in her mouth and they fit. Resident #70 expressed that she could not reach the dentures in the drawer, and she became teary, asking again, Why did you put them in the drawer? Employee B and the Unit Manager were asked whether the resident stated that they were not in her mouth for a month, would this be a valid statement. Employee B and the Unit Manager agreed that Resident #70's statement was reliable. During the earlier interview on 1/16/2019 at 1:14 PM Resident #70 reported that the dentures were missing for three months. On 01/17/19 at 12:07 PM, an interview was conducted with Resident #70, and she stated that she had her dentures in. She also reported that she slept with the dentures in. An interview and observation was conducted with Resident #70 on 01/17/19 at 12:43 PM. She had her dentures in place and stated she was happy to have her dentures back in. She repeated that she did not know that they were placed in the drawer where she could not reach them. A review of the care plan for Resident #70 was conducted, and it documented that Resident #70 ate 50% of her meals daily. She was also diagnosed with [REDACTED]. Tabers, 1997) and facility should evaluate diet change recommendations. Resident #70's care plan also documented that there was a potential for oral dental health problems related to missing/broken teeth; comply with mouth care. She was further documented, I have an ADL self-care performance deficit related to impaired balance, limited mobility and visual deficit. The documented interventions included under Personal Hygiene I require one staff participation with personal hygiene and oral care. The minimum data set (MDS) assessment dated [DATE] was reviewed and documented under oral status: Broken or/loosely fitting partial/denture (NO). The MDS reviewed dated (MONTH) 20, (YEAR) documented under Section L for Oral/Dental Status that Resident #70 was marked for B no natural teeth or tooth fragments (edentulous). Annual documentation was reviewed for Resident #70 under oral care dated on 6/20/2018 Section L - No documented Denture concerns. Nursing Annual Nutrition Evaluation for Resident #70 was reviewed dated 6/6/2017 11:09 AM: Regular diet documented; thin liquids, [MEDICAL CONDITIONS]; [MEDICAL CONDITION], vitamin D deficiency, dementia and adult failure to thrive. Resident #70 is documented to be alert and oriented times three denoted by (AAOx3). A review of the documented monthly nursing evaluation for Resident #70 was conducted and it read under the line for Eating that the resident can dine independently and needed staff support 'set up only' under line 5a. for support under eating. Documented at Line I. under Nutritional/Oral/Dental Status it was documented Resident #70 wears dentures. A review of the Quarterly Nutrition Evaluation documented for Resident #70, dated 11/29/18, at 9:46 AM: Liberalized, regular, thin liquid diet. (Resident #70) refuses to have weights was documented, as well as that she was independent for meals. A review of the annual oral evaluation, dated 9/05/2018, revealed documentation indicating No natural teeth or tooth fragments; edentulous; documented wears dentures or partial. Review of the facility provided job description for Certified Nursing Assistant (CNA) documented position purpose to Prepare residents for meals (take to bathroom, wash hands, comb hair, raise bed, position table, place clothing protector, take to dining room, etc.) Also perform after meal care (remove trays, clean residents' hands/face/clothing, take to bathroom, brush teeth, clean dentures, etc.) and assist residents with daily dental and mouth care. A review was conducted of a Progress Note documented for Resident #70 dated 10/26/18 at 4:06 PM. It was documented by Employee N, Social Worker, that the resident wears upper and lower dentures, denies any dental problems at this time ., and Will continue to monitor and update as needed.

Based on staff interviews and record reviews, the facility failed to provide the necessary care and services to attain or maintain the residents' highest practical well-being by failing to obtain and document post-[MEDICAL TREATMENT] vital signs as ordered by the resident's physician for one (Resident #62) of 30 sampled residents following a return to the facility after completing [MEDICAL TREATMENT] treatment. The findings include: On 11/15/2017 at 9:20:17 AM, an interview was conducted with Employee B, Certified Nursing Assistant (CNA). When asked what the procedure/expectation was when Resident #64 returned from [MEDICAL TREATMENT], the employee stated that the resident would come from [MEDICAL TREATMENT] and go straight to the dining room and have dinner upon returning. I get the vital signs before leaving and send a packed lunch. We send the resident to [MEDICAL TREATMENT] with the [MEDICAL TREATMENT] book. When asked whether the vital signs were checked upon return from [MEDICAL TREATMENT], the employee stated, I do not check vital signs on returns, because (resident) goes straight to dinner upon returning. On 11/16/2017 at 12:02 PM, an interview was conducted with Employee D, Unit Manager. When asked what should be done for a resident prior to going to [MEDICAL TREATMENT], the employee stated, (Resident) gets vital signs prior to leaving. Employee D stated that the assessment should be completed in order to know the resident's baseline before leaving. We document that and send it to [MEDICAL TREATMENT] in the communication book. We hold any blood pressure medications or any medications that would drop the resident's blood pressure. Upon returning, we should get post-[MEDICAL TREATMENT] vital signs and complete an assessment to see if there is any change. Upon review of Resident #62's [MEDICAL TREATMENT] communication book and electronic records in two separate software systems with Employee D on 11/16/2017 at 12:08 PM, she was unable to locate any post-[MEDICAL TREATMENT] vital signs recorded for the resident upon return to the facility following [MEDICAL TREATMENT]. A review of the [MEDICAL TREATMENT] communication book revealed that vital signs were taken prior to the resident leaving the facility, and vital signs were recorded on the communication form that were taken by the [MEDICAL TREATMENT] center staff prior to the resident returning to the nursing home. Employee D verified that there were no post-[MEDICAL TREATMENT] vital signs taken by facility staff upon the resident's return searched all of the resident's paper and electronic records. Employee D verified that there were no documented vital signs recorded for 11/13/2017, and that 11/13/2017 was a [MEDICAL TREATMENT] day for Resident #62. She confirmed that resident did go out for [MEDICAL TREATMENT] on that date, and stated that there should have been documented post-[MEDICAL TREATMENT] vital signs for the resident on that day. She reiterated that the resident was to have vital signs documented post-[MEDICAL TREATMENT] on every [MEDICAL TREATMENT] day, immediately upon return. When Employee D was asked if there was any other area to chart vital signs outside of the electronic record, she stated, No, that is the only area I know of. We do have daily pulse rates, but we do not have the blood pressures. She verified that post-[MEDICAL TREATMENT] blood pressures for the resident were not obtained on 11/14/2017, 11/15/2017, or 11/16/2107 either. When asked whether Employee D knew what was most important to check for a resident upon returning from [MEDICAL TREATMENT] treatment, she replied, Yes, her blood pressure and an assessment, but we are checking her pulse daily. Employee D asked Employee C, Licensed Practical Nurse (LPN), if she had returning vital signs on the resident from 11/15/2017. Employee C replied that she did, and that they should be in the vital signs book. Employees C and D checked the 300 hall and 400 hall vital signs books along with the resident's [MEDICAL TREATMENT] communication book, and confirmed with this surveyor that neither of them were able to locate any post-[MEDICAL TREATMENT] vital signs for the resident. (Photographic evidence obtained) On 11/16/2017 at 1:55:20 PM, the facility's policy on [MEDICAL TREATMENT] was received from the Director of Nursing (DON), which revealed the following: The general medical nurse should document in the resident's medical record every shift as follows: 1. Location of catheter. 2. Condition of dressing (Interventions if needed). 3. If [MEDICAL TREATMENT] was done during shift. 4. Any part of report from [MEDICAL TREATMENT] nurse post-[MEDICAL TREATMENT] being given. On 11/16/2017 at 12:56 PM a review of Resident #62's chart revealed an active physician's orders [REDACTED]. (Photographic evidence obtained) On 11/16/2017 at 2:23 PM, during an interview with the Administrator and the Regional Nurse Consultant (RNC), it was stated that the facility did not have a policy related to following physicians' orders. The RNC stated that they went off of the standards of the electronic record software. The RNC went on to say that she would provide the surveyor with something that the computer software program used as their standard and guideline. On 11/16/2017 at 3:10 PM, The RNC provided a computer software Order Management Procedure form dated 11/16/2017, which revealed the following: Steps: 1. Phone order, verbal order and written physician orders [REDACTED]. 2. 2. The order includes: Order details, Scheduling details, and Source details. 3. 3. Physician orders [REDACTED]. (electronic medication administration record) for scheduled completion unless the resident's medical condition has changed requiring physician notification. 4. Medications, treatments, and laboratory are scheduled within the EMAR for licensed staff to provide direct care. 5. Ancillary orders given by the physician will appear on the order management tab, but do not require scheduling as they are not completed tasks by license staff. (May include, but are not limited to [MEDICAL TREATMENT], Podiatry, Dental, Therapy, etc.) 6. Scheduled orders in the EMAR do require a nurse's signature for completion, but may also include documentation for medication holds and or refusals.

Based on record review and staff interview, the facility failed to ensure the residents' medical records were accurate for one (Resident # 17) of four resident medical records reviewed. Failure to document accurately for a controlled medication can result in drug diversion and adverse consequences to residents' overall health and well-being. The findings include: A record review of the physician orders [REDACTED]. This was ordered on [DATE]. A record review of the Medication Administration Record [REDACTED]. The controlled drug record sheet revealed the dose was only given once, and was signed out of the book once on 11/7/17 at 9 am. When the risk manager was ask about the discrepancy on the Controlled Drug Use Record sheet on 11/16/17 at 11:00 am, she confirmed the inaccurate documentation and revealed that the nurse was in-serviced as part of the facility's quality assurance process for the missed doses of [MEDICATION NAME] for Resident #17. Further review of the Controlled Drug Use Record sheet revealed two doses of the [MEDICATION NAME] were wasted on 11/13/17 at 4 am and 9 am, and only one dose at 9 am had another nurse signed as a witness for wasting the medication. When the risk manager was asked about this discrepancy on the Controlled Drug Use Record sheet, she revealed that the nurse incorrectly documented the entries on 11/13/17, and that only one dose was actually wasted. She stated that it was not documented for the reason the medication was wasted. On 11/12/17 at 2 pm, the medication total count was six (6), and on the next line was documented that the total count was four (4) with no justification in writing explaining the discrepancy. Also noted was a blank space for the dose given on 11/4/17 and 11/5/17 (line 3 and line 4). The nurse also documented 9 pm instead of the number of doses given on 11/12/17. An interview with the risk manager on 11/16/17 at 11:00 am confirmed the documentation was inaccurate. She stated the nurse documented incorrectly. She explained that the Line 29 entry on 11/13/17 was for the 1 pm dose, not the 9 am dose. The nurse also incorrectly documented wasted for the entry on line 28. Stated it was for the line 27 entry. She further explained that they did an in-service for medication error competency for the nurse involved as part of the quality assurance process which included the missed doses. A review of the facility's Medication Pass policy dated January 2017, revealed medications must be signed out at the time of administration to each resident immediately after the medication has been given to each individual resident.