Every finding on record at Parkview Health and Rehabilitation Center

Based on record review and staff and resident interviews the facility failed to invite a cognitively intact resident to participate in the planning of the resident's care for 1 of 3 residents reviewed for participation in care plan meetings. (Resident #12) Resident #12 was admitted on [DATE]. Review of the electronic medical record for Resident #12 revealed a form titled, Care Plan Attendance Sheet dated 11/11/2022 contained the Residents name, Responsible Party's (RP) name and the people who had attended the meeting. The Social Worker and the Unit Manager reviewed the plan of care with Resident #12's family member. Resident #12 did not attend the meeting. The medical record included no evidence that Resident #12 was invited to participate in the care plan meeting conducted on 11/11/2022. Review of the most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was cognitively intact. Record review for Resident #12 revealed no evidence of any care plan meetings conducted after 11/11/2022 and no evidence that the resident was incorporated into his care planning process. An interview on 4/25/23 at 3:35 PM with Resident #12, revealed he had never attended a care plan meeting or had been asked to attend one. Resident #12 stated that he wanted to go to his care planning meetings. During an interview on 4/27/23 at 9:26 AM, Social Worker #1 (SW) explained that all residents with a cognitive score between 13-15 were cognitively intact and should have been invited to care plan meetings. SW #1 said the invitations to care plan meetings were provided to the resident and the responsible party after the MDS nurse set the assessment date. SW #1 said herself and SW #2 were responsible for distributing the care plan meeting invitations. Resident #12 was set for a meeting in February 2023 following completion of the 2/1/23 MDS assessment. There was no invitation letter sent for this care plan meeting and no care plan meeting occurred for Resident #12. SW #1 was not sure why Resident #12 had not received invitations to the care plan meetings. SW#1 further explained that care plan meetings were done upon admission and on a quarterly basis, following the completion of the quarterly MDS assessments. An interview with the Director of Nursing (DON) on 4/28/23 at 2:13 PM, revealed Resident #12 should have been invited and involved in their care plan meetings. The DON revealed care plan meetings needed to be documented in the record to include everyone in attendance. The delivery of a care plan letter to a resident and/or family member, as well as a declination to attend a meeting, needed to be documented. The DON further explained all residents needed to at least be invited to participate in the care planning process.

Based on record review and staff interviews the facility failed to complete Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD), which was the last day of the assessment period) for 2 out of 12 sampled residents (Resident #19, and #52). Findings include: 1. Resident #19 was admitted to the facility on [DATE]. A review of Resident #19's 5-day/admission MDS assessment with an ARD of 11/4/22 was signed as completed on 11/14/22. An interview with MDS Coordinator on 4/27/23 at 9:31 AM, revealed she did not sign the MDS assessments as completed. The MDS Coordinator reported that the Corporate MDS Nurse Consultant signed the assessments after she filled them out and was unable to say why the assessments were signed as completed late. A telephone interview on 4/28/23 at 9:07 AM, with the Corporate MDS Nurse revealed she signed the completed assessments, both remotely and in the facility. She did not know which assessments were signed late. Interview with Administrator on 4/28/23 at 2:15 PM, indicated all MDS assessments should be completed in a timely manner. She went on to explain the facility MDS Nurse was a Licensed Practical Nurse, the corporate MDS nurses were Registered Nurses, and they signed the completed assessments. 2. Resident #52 was admitted to the facility on [DATE]. A review of Resident #52's admission MDS assessment with an ARD of 11/23/22 was signed as completed on 12/8/22. An interview with MDS Coordinator on 4/27/23 at 9:31 AM, revealed she did not sign the MDS assessments as completed. The MDS Coordinator reported that the Corporate MDS Nurse Consultant signed the assessments after she filled them out and was unable to say why the assessments were signed as completed late. A telephone interview on 4/28/23 at 9:07 AM, with the Corporate MDS Nurse revealed she signed the completed assessments, both remotely and in the facility. She did not know which assessments were signed late. Interview with Administrator on 4/28/23 at 2:15 PM, indicated all MDS assessments should be completed in a timely manner. She went on to explain the facility MDS Nurse was a Licensed Practical Nurse, the corporate MDS nurses were Registered Nurses, and they signed the completed assessments.

Based on record review and staff interviews, the facility failed to transmit Minimum Data Set (MDS) assessments to the Centers for Medicare & Medicaid Services (CMS) within the regulatory timeframe for 2 of 12 residents reviewed (Resident #11 and #19). 1.Resident #11 was admitted to the facility on [DATE]. A review of Resident #11's most recent admission MDS assessments with an Assessment Reference Date (ARD) of 10/28/22 revealed it was signed as completed on 11/6/22. The assessment was transmitted to CMS on 12/8/2022. An interview with the Corporate MDS Consultant on 4/28/23 at 9:07 AM, revealed she completed facility MDS assessments. The corporate billing office transmitted the assessments. She was unaware the assessments were transmitted late. During an interview on 4/28/23 at 10:42 AM, the Director of Receivables from the Corporate Billing department revealed the MDS assessments were transmitted every morning by a support person from the billing department. All completed MDS assessments were transmitted Monday through Friday. Any assessments that were in the queue were transmitted. An Interview on 4/28/23 at 2:13 PM, with the Director of Nursing (DON) revealed MDS assessments needed to be transmitted in a timely manner per regulations. 2.Resident #19 was originally admitted on [DATE], discharged and subsequently readmitted on [DATE]. a. A review of Resident #19's initial admission /5-day MDS assessment with an ARD of 9/6/22, revealed it was signed as completed on 9/12/22. The assessment was transmitted to CMS on 10/13/22. b. A review of Resident #19's most recent admission/5-day MDS assessment with an ARD of 11/4/22, revealed it was signed as completed on 11/14/22. The assessment was transmitted to CMS on 12/8/22. An interview with the Corporate MDS Consultant on 4/28/23 at 9:07 AM, revealed she completed facility MDS assessments. The corporate billing office transmitted the assessments. She was unaware the assessments were transmitted late. During an interview on 4/28/23 at 10:42 AM, the Director of Receivables from the Corporate Billing department revealed the MDS assessments were transmitted every morning by a support person from the billing department. All completed MDS assessments were transmitted Monday through Friday. Any assessments that were in the queue were transmitted. An Interview on 4/28/23 at 2:13 PM with the Director of Nursing (DON) revealed MDS assessments needed to be transmitted in a timely manner per regulations. He was aware that there were late assessments.

Based on observations, record review and staff interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by a medication error rate of 10.34% (3 errors out of 29 opportunities) for Resident #235 and Resident #62. The findings included: 1a. A medication administration for Resident #235 was observed on 4/27/23 at 9:26 AM, Nurse #1 administered a simethicone 125 milligram (mg) tablet orally. Review of physician orders 4/14/23 revealed Resident #235 was prescribed simethicone tablet chewable 80 mg by mouth four times a day for heartburn. An interview on 4/27/23 at 2:25 PM, Nurse #1 stated she gave the 125 mg simethicone dose, even though the order was for 80 mg. The 125 mg was the standard dosage provided in the medication cart for the over-the-counter medication. She further revealed she could have contacted Central Supply to obtain 80 mg simethicone tablets. The physician interview on 4/27/23 at 3:18 pm, revealed she was not aware that simethicone 125 mg had been administered to Resident #235 instead of 80 mg. She further revealed that 125 mg simethicone was an acceptable dosage for Resident #235. During an interview on 4/27/23 at 3:27 PM, the Central Supply Secretary revealed the facility's over-the-counter medications were supplied by a vendor. She stated she ordered over-the-counter medication as ordered by the physician. The nurse documented the prescribed over-the-counter medication and dose on a form located at the nurse's station. The vender filled and delivered orders every Tuesday. She indicated she obtained the medication from the vender, the facility pharmacy, or a local pharmacy. An interview on 4/28/23 at 3:15 PM, the Director of Nursing (DON) revealed each nursing station had a form that the nurses filled out for prescribed over-the-counter medication. He further revealed there was a back-up pharmacy to fill over-the-counter medication orders for new prescriptions. He revealed the nurse should have notified the physician when there was a discrepancy between the physician order dose and the dose that was available on the cart during medication pass. 1b. During the medication administration observed on 4/27/23 at 9:26 AM for Resident #235, Nurse #1 did not administer nasal spray sodium chloride nasal solution 0.65% (saline), one spray in each nostril. Review of the physician orders 4/14/23 revealed Resident #235 was prescribed sodium chloride nasal solution 0.65 % (saline) 1 spray in each nostril three times a day for epistaxis (nosebleeds). Nurse #1 was interviewed on 4/27/23 at 2:25 PM, and revealed the nasal spray was not given because she overlooked and missed the order for the nasal spray for morning medication pass. 2. A medication administration was observed on 4/27/23 at 4:35 PM, for Resident #62. Nurse #2 administered 2 grams of diclofenac sodium topical gel 1% to the back of the left hand. Review of the physician orders revealed two orders for diclofenac sodium external topical gel 1%: a) order dated 3/27/23 for diclofenac sodium external topical gel 1%, 2 grams applied for bilateral shoulder pain three times a day, and b) order dated 3/29/23 for diclofenac sodium gel 1%, 2 grams applied to the lower back four times a day for lower back pain. On 4/27/23 at 5:43 PM, Nurse #2 stated there were orders for diclofenac sodium topical gel 1%, 2 grams for Resident #62's back and shoulder areas. She continued Resident #62 denied pain to his back but indicated his left hand and wrist had pain. She indicated she would contact the physician for an order to include left hand and wrist treatment for pain. An interview on 4/28/23 at 3:15 PM, the DON revealed when a resident told the nurse about a pain in a new area, the nurse should have completed an assessment, notified the physician, and obtained a new order for the right patient, right location, right dose, right time, and documented what was done.

Based on observations, record review, resident and staff interview the facility failed to serve food that was palatable and at an acceptable temperature for 2 of 5 residents (Resident #150 and Resident #154) that were reviewed for food palatability. Findings included: An observation was made of the steam table in the kitchen on April 6, 2022, at 12:20 PM. The lunch meal was already on the steam table and cook #1 revealed she had taken the temperatures already. Cook #1 used a digital thermometer to recheck the temperature of the food on the steam table and they were: tomato soup 195 degrees F, grilled cheese sandwich 187 degrees F, spring vegetable stick 168 degrees F and hamburger patties 187 degrees F. A test tray was prepared at 12:33 pm on April 6, 2022, from the kitchen steam table and contained tomato soup, grilled cheese sandwich, and spring vegetable stick. The test tray was delivered to the 200 hall with 14 resident meal trays at 12:37 pm. The last resident ' s meal tray was delivered at 12:55 PM. The Dietary Manager (DM) used the digital thermometer, and the food temperatures were tomato soup 154 degrees F, grilled cheese sandwich 90 degrees F, and spring vegetable stick 111 degrees F. The food items were tasted by the DM and surveyor. The soup was warm, the grilled cheese sandwich was hard to cut and cold and the spring vegetable sticks were hard and cold. The DM agreed that both the grilled cheese sandwich and spring vegetable sticks were hard and cold. During an interview with Resident #150 on April 6, 2022, at 1:10 PM, he stated it was hard to mess up a grilled cheese sandwich and soup, but his food was cold, and the grilled cheese sandwich was hard. Resident #150 indicated the vegetable sticks were nasty and cold. Observation of the resident ' s plate revealed he only took a few bites of the grilled cheese sandwich, spring vegetable stick and the soup. During an interview with Resident #154 on April 6, 2022, at 1:30 PM, he indicated that his lunch was cold, hard, not enough and he wanted something else. During an interview with the DM on April 8, 2022, at 9:30 am she revealed she had only been at the facility for 2 weeks and had already received resident complaints about cold food. The DM added she had conducted some test tray checks and thought the reason the food was cold was because the trays set on the halls for a while before they were delivered to the residents. The DM indicated her staff did what was expected in the kitchen with insulated bases, closed food carts and kept food temperature above the requirement on the steam table. The DM stated it was her expectation that food was served timely, at the appropriate temperature and tasted good. During an interview with the Administrator on April 8, 2022, at 10:30 am, she stated it was her expectation that that all meals were served timely, were palatable and at an appropriate temperature.

Based on record review, resident and staff interviews the facility failed to provide a dignified experience for Resident #149 who indicated she waited over 3 hours for her call bell to be answered and this made her feel ignored and bad. This was evident for 1 of 5 residents reviewed for dignity. Finding included: Resident #149 was admitted to the facility on [DATE] with current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #149 ' s admission minimum data set (MDS) assessment had not been completed yet, however Resident #149 was able to make her needs known to staff. During an interview with Resident #149 on 04/05/2022 at 11:30 am revealed her first night at the facility was horrible. Resident #149 indicated she and her roommate got hot and the call bell was put on around 8:00 PM for help with the room temperature and for assistance going to the bathroom. She stated the physician did not want her to try and go to the bathroom by herself. Resident #149 indicated she waited so long she texted a friend around 10:30 pm and her friend called the facility to get her some help. She added a male staff member came to the room around 11:00 PM. Resident #149 indicated during the time he was present in the room she went to the bathroom and got back in bed. Resident #149 stated the male staff members behavior made her feel bad and vulnerable. Resident #149 added she was a ' little afraid of the staff ' s behavior. Resident #149 was thankful for the outside help she received from her friend. Resident #149 indicated this information was reported to someone at the facility the next day, but she couldn ' t remember the name of the staff member she told because she was so new to the facility Review of the grievance log on 04/05/2022 revealed no grievance from Resident #149, however on 04/06/2022 the Administrator provided a grievance from Resident #149 and stated it had been placed under another resident ' s name. An interview was conducted with the Social Worker (SW) on 04/07/2022 at 11:35 am. She indicated she was aware of the incident and stated she had to get the information from the Administrator. SW also indicated that Resident #149 was able to communicate her needs and wants. Review of the grievance revealed the investigation was still being completed by the Administrator. The male staff member who worked with the resident was contacted and no returned call was received. An interview with Nurse Aide #2 on 04/07/22 at 10:30 PM, indicated she worked on 03/31/22, but she was not assigned to Resident #149. She indicated she had no knowledge of any call bell being on for 3 hours or longer. Nurse Aide #2 indicated they answered all the call lights whether they were their assigned resident or not. During an interview with Nurse #2 on 04/08/2022 at 11:52 AM, Nurse #2 indicated he was the Nurse on the hall on 03/31/2022. He indicated after completing the medication pass, he was at the nurse ' s station and received a call from someone outside of the facility that Resident #149 needed help to the bathroom and had waited a long time. Nurse #2 indicated he went to the room and assisted Resident #149 to the bathroom. He stated he was not aware of where the residents Nurse Aide was at that time and was not sure how long the call light had been on Interview with the Director of Nursing (DON) on 04/08/22 at 12:30 PM revealed he expected the staff to treatment residents with respect and dignity. Interview with the Administrator on 04/08/22 at 1:00 PM revealed it was her expectation all residents were treated with respect and dignity. The Administrator stated when she spoke with Resident #149, she did not say anything about her wait time only that the Nurse was unprofessional.

Based on record review, observation, resident and staff interviews, the facility failed to assess a resident to determine if self-administration of medication was clinically appropriate. Resident #85 was observed to have medications in her hand and at bedside. This was evident during one of one observation of Resident #85. Finding included: Resident #85 was admitted to the facility on [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #85 ' s admission Minimum Data set (MDS) indicated her cognition was moderately impaired and she needed extensive one-person assist with her activities of daily living, however she could feed herself with set up help only. During an observation on 04/05/22 at 10:33 AM in Resident #85 was observed in her room holding a medication cup of pills. The medication cup included 2 pink pills, one yellow pill, one white pill and one clear capsule. There were 2 tubes of [MEDICATION(S)] ointment on the bedside table. During an interview with Resident #85 on 04/05/2022 at 10:40 AM Resident #85 indicated the nurses always left her medications with her because it took her a long time to take them. She indicated the nurses would tell her to take them all and she would respond Lord I got so many . Nurse #1 entered Resident #85 ' s room at 10:55 PM on 04/05/22 and indicated she had stepped out of the room to get the resident ' s inhaler. Nurse #1 stated Resident #85 had not been assessed for self-administration of her medication. Nurse #1 indicated she was not sure of the time that she gave Resident #85 her medication, but it was sometime after 10:00 am and it was her 9:00am scheduled medications. Nurse #1 indicated Resident #85 had not been assessed for self-administration. Review of Resident #85 ' s medical record did not reveal a physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the Administrator on 04/08/22 at 1:06 PM she stated it was her expectation for nurses to complete their medication pass and stay in the room with residents to ensure they took their medications.

Based on observation, record review, resident and staff interviews, the facility failed to provide a written order for treatment to open skin wounds to bilateral posterior legs for 1 of 2 residents (Resident #248) reviewed for wound care. Resident # 248 was admitted to the facility on [DATE] and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission minimum data set was not completed, however a review of Resident #248 ' s progress notes indicated her cognition was intact. A review of admission assessment dated [DATE] read in part skin turgor good, normal skin care required, including diabetic skin assessment, dry skin, bruises, abrasions. A review of weekly skin assessment dated [DATE] revealed existing skin conditions as follows: skin tear, resident has excoriated areas to lower back, left buttock, skin tear to rt inner lower leg. A care plan dated 4/1/22 revealed Resident #248 was at risk for pressure ulcer development due to decreased ability to assist with repositioning. Goal was to minimize risk for development of pressure ulcers through the interventions that were in place. Interventions included the use of devices to aid with positioning in bed to reduce friction/shearing. A review of the treatment record (TAR) for the month of April 2022 revealed treatment to cleanse sacral wounds with normal saline, pat dry, apply thick [MEDICATION(S)] barrier cream every other day. No order was noted for areas to lower back, left buttock, or rt inner lower leg. An interview was conducted on 4/5/22 at 12:18 pm and it was indicated Nursing Assistants (NA ' s) were instructed to provide wound care by mixing of a powder and a cream and applying it to the wounds. An interview was conducted on 4/5/22 at 12:18 pm with Resident #248 and it was indicated Nursing Assistants (NA ' s) were instructed to provide wound care by mixing of a powder and a cream and applying it to the wounds. On 4/6/22 an observation was made of NA #1 (Nurse #1 assisted) provide activities of daily living (ADL) care with Resident #248. NA #1 dried the resident ' s bottom area, she was in the process of applying a [MEDICATION(S)] powder to Resident #248, however Nurse #1 stopped NA #1 and stated a Nurse needed to do the wound treatment. On 4/6/22 at 11:12 am an interview was conducted with NA #1. She stated another Nurse had instructed her to apply the [MEDICATION(S)] powder to Resident #248 ' s wounds. NA #1 stated she could not recall the Nurses name who instructed her to apply the [MEDICATION(S)] powder. On 4/6/22 at 11:15 am an observation was made of Nurse #1 in the process of applying the [MEDICATION(S)] powder to Resident #248 ' s wounds and the surveyor noted the [MEDICATION(S)] prescription label had another person ' s name on it, not Resident #248 ' s. The surveyor stopped Nurse #1 due to the label on the powder having another person ' s name on it. Nurse #1 asked NA #1 where she got the powder from, and NA#1 stated she got it off the treatment cart. Nurse #1 left the room and returned with a bottle of [MEDICATION(S)] powder with Resident # 248 ' s name on the prescription label that read in part Nyamac ([MEDICATION(S)] topical powder 1000,000 USP units per gram 60 grams). Nurse #1 stated she needed to go check the order and again left the room. Nurse #1 returned to Resident #248 ' s room at 11:22 am and stated she was unable to find an order on the electronic medication record (EMAR), and she stated she was not sure if it was on the treatment administration record (TAR) because she was not able to access the TAR and maybe she wasn ' t able to access the TAR because she was from the Agency, she stated she would find out from the wound nurse and would wait to do the treatment. A review of Resident #248 ' s physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/6/22 at 11:47 am a follow-up interview was conducted with Nurse #1, and she stated she was from the Agency and had been at the facility for 3 days. Nurse #1 added she found the [MEDICATION(S)] powder on the treatment cart but could not find the order. She stated again maybe it was because she was from the agency. Nurse #1 indicated she informed the wound nurse the treatment needed to be done. On 4/06/22 at 3:11 pm an interview was conducted with the Director of Nursing (DON), and he stated they did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #248 was getting ([MEDICATION(S)] powder) in the hospital and that was why the powder was in the facility. He stated his expectation was any medication or treatment order for any treatment was to have an order and to be done as ordered. He also indicated Resident # 248 was alert and oriented and probably brought the medication from the hospital when she admitted to facility. On 4/7/22 at 2:00 pm an interview with the Wound Nurse was conducted and she stated she did not remember telling NA#1 or anyone else to get any medication off the treatment cart or to apply anything on Resident #248 ' s wounds. She stated there was no order for [MEDICATION(S)] powder because when Resident #248 came from hospital, the order was on the discharge (d/c) summary, but the doctor did not want it ordered at the time. The Wound Nurse stated, I never used [MEDICATION(S)] powder on resident because there was no order. A review of the d/c summary from the hospital dated 3/28/22 revealed medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/7/22 at 2:20 PM a telephone interview was conducted with pharmacy tech, and she stated the pharmacy received the d/c summary for Resident #248 with the medications list from the facility on 3/28/22 with the [MEDICATION(S)] powder listed and that was why the pharmacy sent the [MEDICATION(S)] powder. On 4/7/22 at 2:30 pm a follow up interview was conducted with the DON, and he indicated the discharge summary was sent to the pharmacy before the [MEDICATION(S)] powder was removed from the order list, and they did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and staff interview the facility failed to retain a minimum of 18 months of daily posted data that was complete and accurate. This was evident in 7 of 9 months of posted staffing data reviewed. (January, March, April, May, June, July and September 2021). Findings included: Review of the daily posted staffing forms revealed missing hours or missing posted staffing forms for the following dates: No LPN and unlicensed nursing staff hours were entered for January 30, 2021. Missing nursing hours for March 13, 2021. Daily staffing posted forms were missing for March 14, 2021 and March 15, 2021. Daily staffing posted form was missing for April 21, 2021. Daily staffing posted form was missing for May 10, 2021. Daily staffing posted forms were missing for June 8, 12 and 13, 2021. Daily staffing posted form was missing for July 15, 2021. Daily staffing posted form for July 24, 2021 had missing hours for all staff. Daily staffing posted form for September 5, 2021 was missing the facility census, number of hours of RN, LPN and unlicensed staff. Interview on 10/6/21 at 9:39 AM with the staff scheduler and the Director of Nurses (DON) was held. The DON stated the 3rd shift nurses were responsible for the staff posting, but no specific nurse was assigned. Continued interview with the DON stated he allowed the nurses on the 3rd shift to make the decision of who would post the staffing form. Interview on 10/6/2021 at 2 PM with the administrator stated she expected the staffing forms to be accurate (referring to the number of staff, hours, and census) and true. The administrator also stated she expected the facility to meet the requirements for retention of the posted staff forms.

Based on record review and staff interviews the facility failed to develop an individualized and person-centered care plan that addressed discharge plans for 3 of 3 residents (Resident #3, Resident #6 and Resident #7) reviewed for safe and orderly discharge. Findings included: 1.Resident #3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was severely cognitively impaired and required extensive assistance with one person for bed mobility, dressing, toileting and personal hygiene and extensive assistance with 2 people for transfers. Resident #3's care plan dated 7-14-20 revealed no goals or interventions for discharge. During an interview with the MDS/nurse supervisor on 11-13-20 at 10:15am, the nurse stated she was new to the MDS role and was not aware the resident person-centered comprehensive care plans needed to contain a discharge goal and interventions. She explained, when a resident was discharged , they were provided with a discharge summary that included their medications and follow up appointments. The Director of Nursing was interviewed on 12-13-20 at 12:00pm. The DON stated she was not aware there were not discharge goals or interventions in the resident's person-centered care plan. 2. Resident #6 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 was cognitively intact and required extensive assistance with 2 people for bed mobility and transfers, extensive assistance with one person for toileting, dressing and personal hygiene. Resident #6's care plan dated 7-1-20 revealed no goals or interventions for discharge. During an interview with the MDS/nurse supervisor on 11-13-20 at 10:15am, the nurse stated she was new to the MDS role and was not aware the resident person-centered comprehensive care plans needed to contain a discharge goal and interventions. She explained, when a resident was discharged , they were provided with a discharge summary that included their medications and follow up appointments. The Director of Nursing was interviewed on 12-13-20 at 12:00pm. The DON stated she was not aware there were not discharge goals or interventions in the resident's person-centered care plan. 3. Resident #7 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 was moderately cognitively impaired and required extensive assistance with one person for bed mobility, dressing, toileting and personal hygiene and limited assistance with one person for transfers. Resident #7's care plan dated 6-9-20 revealed no goals or interventions for discharge. During an interview with the nursing supervisor on 11-12-20 at 1:10pm, the nurse stated when a resident was discharged , they were provided with a discharge packet that included their medications and follow up instructions. The MDS/nurse supervisor was interviewed on 11-13-20 at 10:15am. The nurse stated she was new to the MDS role and as not aware the resident person-centered comprehensive care plans needed to contain a discharge goal and interventions. The Director of Nursing was interviewed on 12-13-20 at 12:00pm. The DON stated she was not aware there were not discharge goals or interventions in the resident's person-centered care plan.

Based on record reviews, interviews with the legal representative, nurse practitioner interview and staff interview the facility failed to include or inform the legal representative of Resident #117 in a decision to begin the use of an antipsychotic medication for 1 of 1 resident reviewed for medical decision making. Findings included: Resident #117 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set assessment dated [DATE] coded the resident as being severely cognitively impaired. Review of the computerized admission packet revealed the Marketing Director completed Resident #117 admission to the facility. Review of the mental health Nurse Practitioner 's (NP) initial evaluation dated 8/2/19. This evaluation in part revealed Resident #117 had episodes of crying, hallucinating, and anxiety as evidenced by looking for people who aren't there. After this evaluation, the NP ordered on [DATE] [MEDICATION NAME] Tablet (a antipsychotic drug) 12.5 milligrams (mg) by mouth (po)two times a day. Record review revealed the legal representative had not been consulted or informed about the [MEDICATION NAME] order on 8/2/19 by Nurse #4 (who transcribed the order). Review of the Medication Administration Record [REDACTED]. Review of the progress notes dated 8/5/19 at 5:20 PM revealed the legal representative was notified about the medication change (3 days post the [MEDICATION NAME] order) On 8/7/19 at 10:30 AM a care conference was held and attended by the interdisciplinary team, Resident #117's legal representative for healthcare and family member. The care conference summarize updates/changes made in response to the [MEDICATION NAME] medication and the facility not notifying the legal representative and didn't want the [MEDICATION NAME] initiated and requested the drug be stopped. Further review of the MAR indicated [REDACTED]. These hold dates were 8/5/19 at 9 PM and 8/6/19 at 9 AM to 08/08/2019 at 9 AM. Continued review of the MAR (after the care conference) revealed the 9 PM dose of [MEDICATION NAME] on 8/8/19 and the 9 am and 9 PM doses on 8/9/19 were administered to the resident. Another review of the physician orders [REDACTED]. An interview via the phone with the legal representative on 10/15/19 at 1:28 PM stated he was the legal representative for healthcare decisions and expressed on admission to the Admissions Coordinator that he did not want any medications prescribed during Resident #117 stay at the facility unless prior approval was provided. Interview via the phone on 10/15/19 at 3:44 PM with Marketing Director stated she could not remember Resident #117 and would have communicated with the Director of Nurses (DON) for any medical needs (such as medications). A second telephone interview with the legal representative was conducted on 10/16/19 at 2:59 PM stated no facility staff called to inform him that [MEDICATION NAME] had been prescribed. I wanted to be informed about any changes in Resident #117's care. Additionally, the legal representative stated a meeting on 8/7/19 at the facility was held to let the staff know Resident #117 was drowsy, and I did not want her to be administered the drug [MEDICATION NAME]. However, the facility continued to give her [MEDICATION NAME]. Interview with the DON on 10/16/19 at 3:30 PM revealed she was unaware of the resident's order for [MEDICATION NAME]. The DON stated normally, she would have follow-up on any orders for antipsychotics and she called the legal representative on 8/5/19 to obtain a written consent for the use of an antipsychotic. The DON expected her nurses to notify family members and or legal representative of medical changes, Interview on 10/16/19 at 3:54 PM with Nurse #4 stated [MEDICATION NAME] was a new order. Usually with a new order or medication change I would notify the responsible party/legal representative, but I did not this time and not sure why I did not. Interview on 10/17/19 at 10:21 AM with the NP (who prescribed [MEDICATION NAME]) via telephone was conducted. The NP stated a referral to see the resident was in the physician's communication book and was unaware of the legal representative request to not start the [MEDICATION NAME]. Continued interview with the NP stated a mistake was made to order and to continue the administration of the [MEDICATION NAME]. I did not notify the RP as I usually would do. Unable to interview the nurse who administered the [MEDICATION NAME] on 8/8/19. Interview on 10/17/19 at 3:47 PM Nurse #5 (nurse who administered the [MEDICATION NAME] on 8/9/19 at 09 AM after the care plan meeting) was conducted. Nurse #5 stated [MEDICATION NAME] was administered because there was no hold on the administration, and I received a pop-up message in the Electronic MAR indicated [REDACTED]

Based on record review and staff interview the facility failed to accurately code the minimum data set (MDS) assessment for the areas of special treatments and [DIAGNOSES REDACTED].#57 and #28). Findings included: 1. Resident #57 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. Resident #57's Care plan dated 9/8/19 revealed resident was to receive [MEDICAL TREATMENT] 3 times per week due to [MEDICAL CONDITION] The Admission MDS assessment for Minimum data set ((MDS) dated [DATE] identified resident did not receive [MEDICAL TREATMENT] during the 7 day look back period. An interview was conducted with Nurse #1 on 10/17/19 at 1:30 pm and she stated she has worked in the facility for 5 months and works with Resident #57 and he goes to [MEDICAL TREATMENT] 3 times a week. During an interview on 10/17/19 at 5:53 pm with the with MDS Coordinator revealed the special treatments (section O) on Resident #57's 09/14/19 MDS should have been coded for [MEDICAL TREATMENT] and she was not sure why it was not coded correctly. On 10/17/19 at 7:10 pm an interview was conducted with the Administrator and he stated he expected the MDS to be completed accurately. 2. Resident #28 was admitted to facility on 7/24/19 and [DIAGNOSES REDACTED]. An admission minimum data set (MDS) assessment dated [DATE] for Resident #28 did not identify [MEDICAL CONDITION], congested heart failure, and major [MEDICAL CONDITION] as active diagnoses. An interview conducted on 10/17/19 at 6:08 pm with MDS Coordinator and she confirmed that the active [DIAGNOSES REDACTED].#28's MDS assessment of 7/31/19, did not include [MEDICAL CONDITION], congested heart failure, and major [MEDICAL CONDITION] as active diagnoses. On 10/17/19 at 7:10 pm an interview with the Administrator was conducted and he stated he expected the MDS assessments to be coded accurately.

Based on observations, record review, resident and staff interview the facility failed to ensure that a low potassium, fluid restricted diet was followed per the physician's orders [REDACTED].#25) and failed to provide follow-up for a nutritional recommendation from the Registered Dietitian for 1 of 4 residents reviewed for nutrition (Resident #30). Findings Included: A facility policy titled [MEDICAL TREATMENT] Protocol dated 1/2010 identified under Protocol #4 If the resident required fluid restrictions, intake and output records must be maintained. Fluid restrictions must be care planned to notify staff of how much intake was allowed on each shift and staff should also monitor for signs of fluid imbalances. 1. Resident #25 was admitted to the facility on [DATE] and his [DIAGNOSES REDACTED]. Review of the physician's order [REDACTED]. The meal tray card for Resident #25 was provided by the Dietary Manager (DM) and identified his diet as cardiac, low potassium, 1000 ml fluid restriction. 240 ml of coffee and 120 ml of juice was provided at breakfast and 240 ml of tea was provided at lunch and dinner. A care plan dated 3/4/19 for Resident #25 stated he was on a fluid restriction of 1000 ml per day 850 ml from dietary and 150 ml from nursing. Interventions included to educate resident, family and visitors on fluid restriction and monitor resident for signs / symptoms of fluid overload. A quarterly minimum data set ((MDS) dated [DATE] for Resident #25 identified he received [MEDICAL TREATMENT], received a therapeutic diet, was independent with set-up for eating and his cognition was intact. A dietitian note for Resident #25 dated 8/15/19 stated current body weight was 133.7 pounds (lbs.) with weight fluctuations related to [MEDICAL TREATMENT]. Weight was overall stable. Receiving a low potassium, cardiac, regular texture diet with a 1000 ml fluid restriction. Meal intakes were optimal. [MEDICATION NAME] (a [MEDICATION NAME] binder) with meals. Nutritional needs likely met and continue to monitor. Review of a [MEDICAL TREATMENT] report for Resident #25 dated 9/30/19 identified potassium level was 6.1 milliequivalents per liter (mEq/L) and above the goal of 5.5 mEq/L). The meal intake record for Resident #25 for 10/3/19 through 10/15/19 identified 1360 ml fluid intake on 10/5/19, 1440 ml fluid intake on 10/6/19 and 1240 ml fluid intake on 10/7/19. The record revealed multiple days were blank. The (MONTH) 2019 medication administration record (MAR) for Resident #25 revealed an order for [REDACTED]. The MAR identified to give 50 ml on the 7:00 am to 3:00 pm shift, 50 ml on the 3:00 pm to 11:00 pm shift and 50 ml on the 11:00 pm to 7:00 am shift. Review of the documented fluid intakes were as follows: 10/1/19 - 220 ml, 10/2/19 - 340 ml, 10/3/19 - 80 ml, 10/4/19 - 150 ml, 10/5/19 - 350 ml, 10/6/19 - 290 ml, 10/7/19 - 170 ml, 10/8/19 - 220 ml, 10/9/19 - 230 ml, 10/10/19 - 340 ml, 10/11/19 - 220 ml, 10/12/19 - 130 ml, 10/13/19 - 160 ml, 10/14/19 - 220 ml and 10/15/19 - 160 ml. An observation on 10/16/19 of Resident #25 ' s room revealed a 4-ounce (oz) container of orange juice and a 4oz container of cranberry juice were on his bedside table. There were 5 - 4oz containers of orange juice, 3 - 4oz containers of cranberry juice and 10 - 8oz cans of soda on the resident ' s dresser. The resident was not present in his room. An observation and partial interview was conducted with Resident #25 on 10/17/19 at 9:44 am. The resident was Spanish speaking and couldn ' t understand all the questions asked. He did state he went to [MEDICAL TREATMENT] yesterday and would go again tomorrow. He pointed to the juice present in his room and stated he did drink these. An interview on 10/17/19 at 10:27 am with Nursing Assistant (NA) #3 revealed she worked with Resident #25 and overall, he was very independent with his care. She stated the resident was on a fluid restriction and she believed this was because he went to [MEDICAL TREATMENT]. NA #3 explained the nurse would notify the NAs if a resident was on a fluid restriction and it was also listed on their tablets where they obtained and entered information about the residents. She added dietary and nursing each got so much fluid per day to provide to the resident. NA #3 stated she believed residents on fluid restrictions could have a water pitcher in their room, but with a specific amount of fluid. She added she did not know why Resident #25 had so many extra juices and sodas in his room. An interview on 10/17/19 at 11:00 am with Nurse #3 revealed she was the nurse for Resident #25. She stated the resident was on a fluid restriction and the nurses had a specific amount they could give him with his medications on each shift and dietary had a certain amount they provided with his meals. Nurse #3 explained the nurses documented how much fluid they provided per shift on the MAR and the NAs documented how much fluid he consumed with his meals on his meal intake record. She added she was not sure if there was a cumulative total of the fluids he consumed per day. Nurse #3 stated typically fluids weren ' t kept in a resident ' s room if they were on a fluid restriction. She added she had observed Resident #25 had multiple containers of juice and sodas in his room and these were the brands the facility used. Nurse #3 indicated the extra fluids in his room needed to be removed. A phone interview on 10/17/19 at 1:27 pm with the Registered Dietitian (RD) revealed Resident #25 was on a low potassium, fluid restricted diet. She stated she was not sure if the facility kept a cumulative total of fluids per day that the resident consumed. She added she would only monitor if dietary was following their portion of the fluid restrictions correctly. The RD explained she was not aware that Resident #25 had an accumulation of extra fluids, including orange juice, in his room. She stated the resident received [MEDICATION NAME] but was not aware of his elevated potassium level. The RD added she had not spoken to the [MEDICAL TREATMENT] RD about the resident. An interview on 10/17/19 at 3:00 pm with the Director of Nursing (DON) revealed the facility would define what fluids were provided from dietary and nursing for fluid restrictions. She stated the nurses documented how much fluid the resident drank per shift on the MAR. She added if she was the residents nurse, she would ask the NAs how much fluid the resident drank and put the total fluid consumed that shift on the MAR. The DON explained it didn ' t look like the nurses were documenting this and there was not a cumulative 24-hour total of the resident ' s fluid consumption. She added this should have been completed per the facility protocol for fluid restrictions. The DON explained she was not aware Resident #25 had multiple containers of fluids in his room and he should not be provided with orange juice. 2. Resident #30 was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. A quarterly minimum data set ((MDS) dated [DATE] for Resident #30 identified she was on a therapeutic diet, required extensive one-person assist with eating and her cognition was intact. Review of the physician's order [REDACTED]. The meal tray card for Resident #30 was provided by the Dietary Manager (DM) indicated she was on a low potassium diet. It noted for lunch and supper meals to not provide beans, legumes or potatoes. A dietitian note dated 8/15/19 for Resident #30 stated her current body weight was 129.8 pounds (lbs.) and BMI was 23.7 indicating normal weight status. Weight fluctuated related to ascites and diuretic therapy. Patient was receiving a low potassium diet and meal intakes were 26 to 100%. Labs reviewed from 6/17/19 revealed [MEDICATION NAME] was low, and potassium was within normal limits. Recommended to remove low potassium restriction. An interview on 10/14/19 at 10:58 am with Resident #30 revealed she often had the same food items and they would not allow her to have any creamed potatoes. She stated no one told her why she couldn ' t have them. Resident #30 added she used to be on [MEDICAL TREATMENT], but she no longer had to go. An observation on 10/14/19 of Resident #30 revealed she was eating her lunch meal in her room. She had received a low potassium diet. An interview on 10/17/19 at 10:20 am with Resident #30 revealed she would like to have some potatoes and she didn ' t understand why she was still receiving a low potassium diet when she was no longer receiving [MEDICAL TREATMENT]. An interview on 10/17/19 at 10:47 am with Nursing Assistant (NA) #3 revealed she worked with Resident #30. She stated the resident ' s meal intake fluctuated depending on what she was served. A phone interview on 10/17/19 at 1:35 pm with the Registered Dietitian (RD) revealed if she had a recommendation for a resident, she documented it on a recommendation sheet and provided a copy to the Director of Nursing (DON), the Unit Manager and the DM. She explained nursing would provide her recommendations to the resident ' s physician. The RD stated she didn ' t know for sure why her recommendation to discontinue Resident #30 ' s potassium restriction was not done. She added there was currently not a system in place to notify her if the recommendations were not approved by the physician or to follow-up that the recommendations were addressed. She added she was not aware Resident #30 was concerned about not receiving potatoes because she was on a low potassium diet. An interview on 10/17/19 at 2:50 pm with the DON revealed the RD either emailed or provided her with a hard copy of any nutritional recommendations she had. She explained the RD ' s recommendations were provided to the resident ' s physician for follow-up right away and she would expect a response within 24 hours. The DON reviewed the RD recommendation form and was unable to locate any information about discontinuing the potassium restriction for Resident #30. She stated she was not sure why this was not completed or if the recommendation had been processed.