Every finding on record at Peak Resources-Outer Banks

Based on record reviews and staff interviews, the facility failed to develop a person-centered comprehensive care plan in the areas of anticoagulant medication use (Resident #5), and antidepressant medication use (Resident #8) for 2 of 20 residents whose care plans were reviewed.The findings included:1 Resident #5 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation.Resident #5 had a physician order dated 3/3/26 for Eliquis (anticoagulant medication) 5 milligrams (mg) one (1) tablet by mouth twice daily for atrial fibrillation.Review of Resident #5's June's 2026 Medication Administration Record (MAR) for the period of 6/1/26 through 6/30/26 revealed Resident #5 received Eliquis 5mg 1 tablet by mouth twice daily as prescribed.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was moderately cognitively impaired and was coded for anticoagulant medication use.Review of Resident #5's current comprehensive care plan last reviewed on 6/19/26, did not reveal a care plan focus area related to receiving an anticoagulant medication.An interview was completed with the MDS Nurse on 7/2/26 at 9:29am who revealed she was responsible for the development of resident care plans. The MDS Nurse stated Resident #5 should have an anticoagulant medication care plan with interventions in place. The MDS Nurse stated the missing care plan was due to an oversight.An interview was completed with the Administrator on 6/30/26 at 3:36pm. The Administrator revealed the MDS Nurse was responsible for reviewing and developing residents' comprehensive care plans. The Administrator stated the MDS Nurse was responsible for developing Resident #5's care plan for anticoagulant medication use. The Administrator revealed the care plan was missed due to an oversight by the MDS Nurse.2. Resident #8 was admitted to the facility on [DATE] with diagnoses that included insomnia.Resident #8 had a physician order dated 3/6/26 for Trazodone (antidepressant) 50mg 1 tablet by mouth at bedtime for insomnia. A quarterly MDS assessment dated [DATE] revealed Resident #8 was cognitively intact and was coded for antidepressant medication use.Review of Resident #8's June's 2026 Medication Administration Record (MAR) for the period of 6/1/26 through 6/30/26 revealed Resident #8 received Trazodone 50mg 1 tablet by mouth at bedtime as prescribed. Review of Resident #8's current comprehensive care plan last reviewed on 6/18/26, did not reveal a care plan focus area related to receiving an antidepressant medication.An interview was completed with the MDS Nurse on 7/2/26 at 9:29am who revealed she was responsible for the development of resident care plans. The MDS Nurse stated Resident #8 should have an antidepressant medication care plan with interventions in place. The MDS Nurse stated the missing care plan was due to an oversight.An interview was completed with the Administrator on 6/30/26 at 3:36pm. The Administrator revealed the MDS Nurse was responsible for reviewing and developing residents' comprehensive care plans. The Administrator stated the MDS Nurse was responsible for developing Resident #8's care plan for antidepressant medication use. The Administrator revealed the care plan was missed due to an oversight by the MDS Nurse.

Based on observation and staff interviews, the facility failed to maintain food service equipment free from debris and/or dried spills, failed to remove chipped dishes for safety, failed to maintain properly functioning walk-in freezer door, failed to keep walk-in cooler floor free from standing water, failed to discard expired food from walk-in freezer, failed to ensure dishware was air dried prior to stacking for use and free from dried debris. The facility also failed to remove dented cans from usable stock for 2 of 2 kitchen observations. These practices had the potential to affect food served to residents. Findings included: a. An initial observation of kitchen equipment on [DATE] at 09:33am revealed the steam table had orange reddish colored debris on the steam table glass, 1 steam table divider, and 3 steam table lids. [NAME] crumbs were observed on the shelf above the stove. The initial observation further revealed 1 of 3 cake plates had white and tan debris, 1 of 3 cake plates had white debris and 1 of 3 cake plates had a chip approximately 1 inch with a sharp edge. The cake plates were stored on the tray line ready to be used. There were also 15 of 32 dome lid plate covers that were stacked wet and ready for use on the tray line. An interview with the Regional Dietary Manager on [DATE] at 09:35am revealed breakfast had just been served, and staff must have missed the dirty areas on the glass, 1 steam table divider and 3 steam table lids as well as the shelf above the stove. The Regional Dietary Manager stated it was her expectation that the steam table be completely cleaned after each meal and that the shelf above the stove was cleaned. The Regional Dietary Manager also said the cake plates should be clean prior to being placed on the tray line for use, broken cake plates should be thrown in the trash and the dome tray lids should be completely dry prior to stacking and placing them on the tray line. A follow up observation and interview with the Certified Dietary Manager in the kitchen on [DATE] at 11:33am revealed 1 divided plate with red/brown debris that was on the tray line ready for use during lunch. An interview with the Certified Dietary Manager further revealed the expectation was all dishes be clean prior to placing them on the tray line for use and she removed the dish from the tray line. b. A continued initial observation and interview on [DATE] at 09:40am revealed the door to the walk-in freezer door was ajar and did not close when pressed. There was ice build-up around the top of the threshold that covered the thermostat, and the temperature of the walk-in freezer was not visible/readable. There was a puddle of water on the floor at the entrance of the walk-in freezer. The Certified Dietary Manager revealed the freezer needed to be repaired so that it could close. The Certified Dietary Manager also stated the water on the floor in front of the walk-in freezer was condensation. An observation and interview the Certified Dietary Manager of the kitchen on [DATE] at 11:37 am further revealed the freezer door closed properly but ice remained around the threshold covering the thermostat and the temperature remained not visible/readable and the puddle of water was gone from in front of the walk- in freezer door but was now inside the walk-in cooler on the hinged side of the cooler door, in front of the produce. An interview with the Certified Dietary Manager revealed she did not know what caused the ice around the threshold or covering the thermostat but stated the water was from condensation. An interview with the Regional Dietary Manager on [DATE] at 09:43am revealed the walk-in freezer had previously been repaired and said she would provide paperwork and put in a new work order to repair the door by the following day. c. An observation and interview took place on [DATE] at 09:45 with the Regional Dietary Manager. A frozen sealed plastic bag labeled Angel Food Cake that had a discard date of [DATE] was found in the freezer. The Regional Dietary Manager revealed the Angel Food Cake should have been discarded already and must have been missed with the last check which she stated should have occurred on [DATE]. d. An observation and interview with the Regional Dietary Manager and the Certified Dietary Manager took place on [DATE] at 09:50am of the dry food storage revealed one 7 pound can of original baked beans with 2-small, shallow linear dents at the top seal line and one 6.5 pound of canned sliced apples with one large, irregular, shallow dent along the seal line that was placed in the rack for use. An interview with both the Certified Dietary Manager and Regional Dietary Manager revealed the expectation was for dietary staff to remove dented cans from shelves and place dented cans on the bottom shelf for return. An interview with the Administrator and Director of Nursing on [DATE] at 1:15pm revealed the expectation was for kitchen staff to maintain clean food service equipment and follow all rules and regulations to maintain a safe and sanitary kitchen.

Based on record review, and resident and staff interviews, the facility failed to address repeat concerns and to communicate the facility's efforts to address concerns voiced by residents during Resident Council meetings for 2 of 4 months reviewed (November 2024 and February 2025). The findings included: The Resident Council meeting minutes were reviewed for November 2024. Under the heading New Business, the minutes noted resident complaints of medication not being administered in a timely manner. The Resident Council meeting minutes were completed by the Activity Director. The Resident Council meeting minutes were reviewed for December 2024. Under the heading Old Business, there was no documented follow-up for the November 2024 complaint related to medication not being administered in a timely manner. The Resident Council Meeting minutes were reviewed for January 2025. Under the heading New Business, the minutes noted resident complaints of nursing assistants often rushing out of resident rooms during mealtimes without checking if they need help with opening condiment packages or containers. The minutes also noted a repeat complaint of medication not being administered at the correct time. The Resident Council meeting minutes were completed by the Activity Director. In the February 2025 meeting minutes, under the heading Old Business, there was no documented follow-up for the complaints reported in January 2025 meeting related nursing assistants rushing out of resident rooms and medication not being administered at the correct time. Under the heading New Business, was the repeat complaint regarding medication administration. The Resident Council meeting minutes were completed by the Activity Director A Resident Council meeting was conducted on 3/26/25 at 1:32 PM with the following residents; Resident #83. Resident #19, Resident #53, Resident #25, Resident #66 Resident #40, Resident #35, Resident #11, Resident #69. During the meeting residents voiced on-going concerns of medication not being administered in a timely manner and they felt staff continued to rush out of resident rooms during mealtime without offering help. Residents in the meeting stated they did not know when/if their grievances were resolved, or the outcome of complaints/grievances voiced during Resident Council meetings without asking the Social Worker. An interview conducted with the Activity Director on 3/26/25 at 5:56 PM revealed that when a grievance was brought up in the Resident Council, she would write it down on the Resident Council minutes meeting form. In the morning meeting with the interdisciplinary team, she would let the interdisciplinary team know what the resident's concerns were in the Resident Council meeting. The Activity Director reported that the Corporate Administrator reviewed the Resident Council meeting minutes every month. The Activity Director explained she was informed of a new protocol by the Corporate Administrator in early March 2025 to present the completed grievances at next month's Resident Council meeting. She explained Resident Council for March was held on 3/24/25 and she had not had time to complete the March grievances. An interview conducted with the Social Worker (SW) on 3/27/25 at 8:33 AM revealed that if a resident brought up grievance in the Resident Council meeting, the Activity Director would let her know what concerns she (Social Worker) needed to address. The Social Worker stated she would inform the Activity Director verbally how the grievances were resolved for Resident Council and the Activity Director would go over the grievances from the previous month and inform the residents' how the grievances were resolved at the next Resident Council meeting. The Social Worker stated that she did not attend the Resident Council meetings. An interview conducted with the Administrator and Director of Nursing (DON) on 3/27/25 at 12:30 PM stated the Activity Director was responsible for verbally providing the resolutions to grievances/complaints reported during Resident Council meetings at the next Resident Council meeting the following month.

Based on staff interviews, resident representative interviews and record reviews, the facility failed to convey (transfer) funds within 30 days to the resident's representative for 1 of 1 resident (Resident #194) reviewed for refund of deposit. Findings included: Resident #194 was admitted to the facility on [DATE] for respite care. The resident had an unplanned discharge to the hospital on 12/23/24. Resident #194's medical record revealed there was no documentation of Resident #194's cognition. Review of a nursing note dated 12/27/24 written by Nurse # 2 revealed that all medication including narcotics and personal belongings were returned to Resident #194's resident representative and Resident #194 would be discharged from the hospital to home. On 3/25/25 at 03:45 PM an interview via telephone with Resident #194's representative occurred. The resident's representative explained her mother had been at the facility for respite care and she had submitted payment to the facility to cover the full duration of the planned stay for Resident #194. However, the resident's representative explained, the resident was discharged to the hospital, shortening the resident's stay at the facility, and then the resident was discharged from the hospital to home with the resident's representative. The resident's representative explained how she had expected a refund due to the resident's stay not being for the entire duration. She stated she called and talked to the Administrator the week of 3/17/25 about some other matters but the resident's representative had no recollection of the refund check being mentioned during the conversation with the Administrator. She stated she had still not received a refund from the facility. The Business Office Manager was interviewed on 03/26/25 11:02 AM. The Business Office Manager stated she had received payment for the intended full duration from Resident #194's resident representative and the funds were placed into a private pay account. The Business Office Manager stated she oversaw the refunds and had 30-60 days to refund the resident's money if a resident was discharged from the facility. The Business Office Manager stated she spoke with Resident #194's representative last week and she apologized to Resident #194's representative, because she had forgotten to take care of the refund after Resident #194 was discharged . The Business Office Manager stated the money for the refund was received from the corporate office late yesterday, 3/25/25. The Business Office Manager stated her plan was to call the resident's representative in the morning 3/26/25 to tell the resident's representative to come pick up her refund check. On 03/27/25 at 10:34 AM an interview occurred with the Administrator. She explained at the end of the month the facility sent a list of discharged residents sent to the corporate office. The list consisted of residents who were not expected to return and were due refunds. The Administrator stated upon receiving the check/funds from the corporate office, the Business Office Manager would then place a call to the resident or the resident's representative to pick up the refund. Pertaining to Resident # 194 the facility had documented the resident was coming back to the facility and the family chose to take the resident home from the hospital. When the facility realized the family was taking Resident #194 home, it was 15 days past the due date to provide the refund list to the corporate office.

Based on record review, observations, staff resident, and Medical Director interviews, the facility failed to secure a tube of medicated arthritis gel that was observed left at bedside for 1 of 1 resident (Resident #68) reviewed for medication storage. Finding included: Resident # 68 was admitted to the facility on [DATE] with a diagnosis of other specified rheumatoid arthritis. The annual [NAME] Data Set (MDS) dated [DATE] revealed Resident # 68 was moderately cognitively impaired. A physician order dated 3/11/25 for Resident #68 specified for diclofenac sodium topical gel, for arthritis pain reliever to be applied on bilateral hands, neck, right hip, and back twice a day for pain. Observation conducted during medication pass on 03/26/2025 at 11:23AM with Nurse #1 revealed a tube of topical medicated pain relief gel was kept in Resident #68's room in her bedside table in the top drawer. The arthritis pain reliver gel was visible when Resident #68 opened the top drawer. An interview with Nurse #1 on 3/26/25 at 11:23AM revealed that Resident #68 kept the topical medicated arthritis pain relief gel at her bedside. Resident # 68 would call the nurse when she was ready to have the gel applied. Nurse #1 stated the previous shift nurse gave her report that Resident # 68 kept the topical medicated arthritis pain relief gel in her bedside table in the top drawer. Nurse #1 was unaware residents could not keep medication at their bedside. An interview and observation with Resident #68 on 3/26/25 at 11:42AM revealed Resident #68's family brought the topical medicated arthritis pain relief gel from a drug store. The observation revealed the topical medicated arthritis pain relief gel remained in the top drawer of Resident #68's bedside table. Interview with Nurse #3 on 03/26/25 07:46PM revealed there was tube of topical medicated arthritis pain relief gel in the medication cart for Resident #68 that was delivered by the pharmacy. An interview with the Administrator and Director of Nursing (DON) on 3/27/25 at 8:00AM revealed the family of Resident #68 had brought the topical medicated arthritis pain relief gel to the facility without informing staff. The DON and Administrator stated Nurse # 1 was a new nurse that just started at the facility within the last week and was unaware medications could not be left at the bedside. The DON and the Administrator stated medications should not be left at the bedside and staff should have removed the topical medicated arthritis pain relief gel from Resident #68's room. A phone interview on 3/27/25 at 11:58AM with the Medical Director revealed he did not write an order for Resident #68 to have medication left at her bedside.

Based on record review, staff, family, and resident interviews, the facility failed to protect a resident's bank card from being accessed and used without resident permission for 1 (Resident #3) of 2 residents reviewed for misappropriation of resident property. Findings included: Resident #3 was admitted to the facility on [DATE] with multiple diagnoses some of which included chronic congestive heart failure and diabetes. Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #3 was cognitively intact. Resident #3 was interviewed on 1/09/2025 at 8:45 AM and revealed the following information. A nurse aide (NA #2) had taken his bank card and used it at a local gas station in May 2024. The amount of money taken was approximately 30 to 35 dollars. The nurse aide was charged with theft, and the district attorney took the matter to court. The nurse aide no longer worked at the facility. Resident #3 indicated more information regarding the event could be obtained from his daughter, who was his power of attorney. The daughter of Resident #3 was interviewed on 1/09/2025 at 3:20 PM. The daughter explained the following events, detailing how she discovered Resident #3's missing bank card. The daughter stated she had her name on the bank account for Resident #3 and she handled his finances for him. The daughter of Resident #3 was alerted by the bank of two suspicious transactions on 5/29/2024, so she called Resident #3 to inquire if he used the bank card on those occasions. Resident #3 revealed to his daughter the bank card that he kept with his phone was missing. The daughter stated she immediately canceled the bank card and alerted the bank to the fraudulent charges, ordering Resident #3 a new bank card. The facility Administrator was interviewed on 1/09/2025 at 9:30 AM and provided the following information regarding the investigative steps and actions taken by the facility when it was brought to their attention Resident #3's bank card was missing. On 5/30/2024 at approximately noon, the Business Office Manager informed the Administrator that Resident #3 had told her his bank card was missing and had been used. Resident #3 had already left the facility for an appointment. The Administrator immediately contacted the daughter of Resident #3 and was informed the bank card of Resident #3 had been used two times at a local gas station on 5/29/2024 at 11:10 PM and 11:17 PM, the bank card was canceled, and another bank card was to be mailed to Resident #3. The family member revealed the last transaction made by Resident #3 with the missing bank card was on 5/28/2024. The local police department was called at approximately 12:30 PM on 5/30/2024 to file a report. A police officer arrived at the facility at 1:05 PM on 5/30/2024 to take a report but had to be informed Resident #3 was at an appointment and would be returning at 3:30 PM on that day. The responding police officer was provided photographs, of the fraudulent transactions made on Resident #3's bank card, which were provided to the facility by the daughter of Resident #3. On 5/31/2024 the facility interviewed all the cognitively intact residents residing in the same hallway as Resident #3, regarding any missing items, with no concerns voiced by the residents. On 5/31/2024 the Administrator spoke with a detective at the police department, who was working with the manager of the gas station where the fraudulent charges on the bank card of Resident #3 were made, to obtain video evidence to identify the suspect who used the bank card. Interviews with the facility staff were initiated on 5/31/2024 to inquire if anyone knew of the missing bank card of Resident #3, without any acknowledgment or awareness from any of the staff members. At approximately 11:30 AM on 5/31/2024, a facility housekeeper notified the Administrator the lost bank card was underneath the bed of Resident #3. The Administrator collected the bank card in a plastic bag to avoid getting fingerprints on it and notified the detective from the police department that the bank card of Resident #3 had been located. The Administrator notified the family member and Resident #3 that the bank card had been located. On 6/3/2024 the Administrator received a phone call from the detective revealing video evidence of the person using the bank card of Resident #3 was obtained from the local gas station. The Administrator received the image from the detective and identified the suspect using the debit card of Resident #3 as NA #2. On 6/3/2024 the detective came to the facility and was interviewed by the detective. NA #2 confessed to the crime and her employment was terminated with the facility. The Administrator provided the facility investigation file which included transaction details of a purchase made with Resident #3's debit card at a local gas station on 5/29/2024 at 11:10 PM and again at 11:17 PM in the amounts of $14.92 and another for $37.26. The investigation file provided by the Administrator also included the police report initiated on 5/30/2024 and completed on 6/4/2024. The police report included a supplemental narrative for the following events on 6/03/2024 at 3:00 PM. The detective interviewed NA #2 at the facility during which she was shown the photographs of herself at the local gas station on 5/29/2024 at 11:10 PM and 11:17 PM. NA #2 acknowledged that the person in the picture was her. The detective explained he was investigating the use of a stolen bank card that belonged to Resident #3. The detective told NA #2 that the photographs taken at the local gas station were of the person who used Resident #3's bank card to make purchases, explaining the bank notified Resident #3's family member of suspicious charges. At first, NA #2 denied she used Resident #3's bank card for the transactions for which she was pictured. The detective told her she was not being truthful because she was photographed at the local gas station, working in the facility the day the bank card went missing, and was assigned to the hallway where Resident #3 resided. NA #2 continued to deny she took the bank card from Resident #3 but told the detective she found the bank card in the hallway, used the bank card at the local gas station for food and then gas after the end of her nursing shift, and then returned the bank card to the hallway when she returned to work at the facility the next day. NA #2 denied she put the bank card under the bed of Resident #3 the next day despite being told of the improbability of that occurrence that someone else picked up the bank card from the hallway and put it under Resident #3's bed. NA #2 was informed by the detective that Resident #3 and a family member of Resident #3 were willing to press charges. The detective also told NA #2 he intended to seek a warrant for her arrest from the magistrate and contact her again after he had done so. The detective then went to inform the Administrator, Resident #3, and the daughter of Resident #3 of the results of the interview with NA #2. Current telephone contact information for NA #2 was not available at the time of the surveyor's investigation. The daughter of Resident #3 was interviewed on 1/9/2025 at 3:20 PM and provided the following additional information. The facility oversaw the entire investigation and made Resident #3 the priority. The bank reimbursed Resident #3 for the money charged to his bank card and acknowledged the charges made on 5/29/2024 at the local gas station were fraudulent. The District Attorney reached out to Resident #3 and with the assistance of his family member made a witness statement for the court. The case did go to court and NA #2 was given two years of probation because of her actions in fraudulently acquiring and using the bank card of Resident #3. The Administrator was interviewed again on 1/9/2025 at 1:02 PM and revealed the facility took immediate action when it was discovered Resident #3 had his bank card stolen. The proper reports to all entities required by policy and procedure, the investigation began, and interviews with 100 % of all cognitively intact residents were initiated on 5/31/2024. The QAPI (Quality Assurance and Performance Improvement) Committee met on 5/31/2024, and a Performance Improvement Plan (PIP) was implemented immediately. The facility provided the following corrective action plan with a completion date of 6/10/2024. Validation of the corrective action plan was completed on 1/10/2025. The facility's PIP for the problem area identified as Misappropriation of Property-Employee used resident's bank card for unapproved purchases initiated on 5/31/2024 was reviewed. On 5/31/2024 the bank card of Resident #3 was located. Law enforcement was notified by the administrator and law enforcement completed the investigation, substantiating the misappropriation of Resident #3's property. The facility Social Worker offered Resident #3 a lock box to contain valuables, including credit cards. On 6/10/2024 all residents/resident representatives were interviewed to determine if any other residents were affected. Residents were offered lock boxes for valuables. All cognitively impaired residents' family members/representatives were notified to retrieve valuables or obtain lock boxes from facility staff. The Administrator/designee educated staff on reporting misappropriation of property and offering lock boxes for resident valuables. This education was a part of the orientation process for newly hired staff. Beginning in July 2024 the Administrator/designee performed an audit of five residents monthly for 3 months ensuring that there had not been any misappropriation of resident property and lock boxes for valuables had been offered. The Administrator reported the results of these audits to the QAPI Committee monthly for three months for evaluation and further recommendations. Compliance date of 6/10/2024.

Based on record review and staff interviews, the facility failed to complete the Minimum Data Set (MDS) quarterly assessments at a minimum of every 3 months for 1 of 3 residents reviewed for MDS records over 120 days (Resident #65). The findings included: Resident #65 was admitted to the facility on [DATE]. Resident #65's Minimum Data Set (MDS) quarterly assessment with an Assessment Reference Date (ARD), (the last day of the 7-day lookback period) of 8/19/23 was observed in the electronic medical record as completed on 10/24/23. Resident #65's MDS quarterly assessment with an ARD of 11/10/23 was observed in the electronic medical record as completed on 1/18/24. A telephone interview was conducted on 1/25/24 at 8:18 am with the MDS Nurse #1 who revealed the MDS assessments were generally completed within a 14-day period. The MDS Nurse #1 stated there was a report that MDS ran sometimes which would list missed assessments that need to be completed and that would trigger them to complete those assessments that were late or missed. MDS Nurse #1 was unable to state why the MDS quarterly assessments were completed late for Resident #65. An interview was conducted on 1/25/24 at 9:24 am with the MDS Nurse #2 who confirmed Resident #65's MDS quarterly assessment completion dates for the 8/19/23 and 11/10/23 assessments were late based on the date and signatures on the assessments. The MDS Nurse #2 stated the quarterly assessments should have been completed within 14 days of the ARD. She stated she manually entered the dates for the assessments in the electronic medical record and then she would run the assessment report which would show when the assessments were due. The MDS Nurse #2 stated she must have just missed completing Resident #65's quarterly assessments; she further stated sometimes things were just missed. During an interview on 1/25/24 at 9:43 am with the Director of Nursing (DON) stated she was not certain of the time frame the assessments were to be completed. The DON revealed she did not normally monitor the MDS assessment for completion and she was unable to state how the MDS assessments for Resident #65 was completed late. An interview with the Administrator was conducted on 1/25/24 at 9:48 am who revealed the MDS Nurses were responsible for completing the MDS assessments on time.

Based on record review and staff interviews the facility failed to complete the Minimum Data Set (MDS) assessments for 2 of 3 residents reviewed for discharge (Resident #67 and Resident #5). Findings included: 1.Resident #67 was admitted to the facility on [DATE]. Review of Resident #67's medical record revealed the resident was discharged home on 9/12/23. There was no documentation in Resident #67's medical record that the discharge MDS assessment had been completed. During an interview with the MDS Nurse #2 on 1/25/24 at 9:24 AM she indicated Resident #67 should have had a discharge MDS completed. MDS Nurse #2 was unable to state why the discharge MDS assessment had not been completed for Resident #67. During an interview on 1/25/24 at 9:43 AM with the Director of Nursing (DON) stated she was not certain of the time frame the assessments were to be completed. The DON revealed she did not normally monitor the MDS assessment for completion and she was unable to state how the MDS assessment for Resident #67 was not completed. An interview with the Administrator was conducted on 1/25/24 at 9:48 am who revealed the MDS Nurses were responsible for completing the MDS assessments. 2. Resident #5 was admitted to the facility on [DATE]. Review of Resident # 5's discharge MDS assessment dated [DATE] was observed in the electronic medical record as completed but not transmitted until 1/18/23. During an interview on 1/25/24 at 9:43 am with the Director of Nursing (DON) stated she was not certain of the time frame the assessments were to be transmitted. The DON revealed she did not normally monitor the MDS assessment for completion or transmission and she was unable to state how the MDS assessment for Resident #5 was transmitted late. An interview with the Administrator was conducted on 1/25/24 at 9:48 am who revealed the MDS Nurses were responsible for completing and transmitting the MDS assessments.

Based on observation and staff interview, the facility failed to maintain privacy and confidentiality for 1 of 3 resident's medical records reviewed for privacy during medication administration. (Resident #5) The findings included: An observation was conducted of Nurse #2 on 10/12/22 at 9:40 AM. Nurse #2 walked away from the 100 Hall medication cart to go to another resident's room. Nurse # 2 left the computer screen open with Resident #5's information displayed. Staff and visitors passed by the cart while the resident's information was visible. Nurse #2 returned to the cart at 9:42 AM. An observation was conducted of Nurse #2 on 10/12/22 at 9:46 AM. Nurse #2 pulled Resident #5's medication and turned to walk in the room. Nurse #2 left Resident #5's information visible on the computer screen when she left the medication cart. Staff and visitors passed by the cart while the resident's information was visible. An interview was conducted with Nurse #2 on 10/12/22 at 10:00 PM. Nurse #2 stated that should have placed the computer screen on the step away feature to prevent the resident's information from being on the screen while she was away. Nurse #2 stated that when she used this feature it required her to sign back in. An interview was conducted with the Director of Nursing and the Administrator on 10/12/22 at 11:53 AM. The Administrator stated that each computer had a tab in the right upper corner for the nurse to tap to prevent resident information from being viewed while the nurse was away from the cart. The Administrator stated that Nurse #2 should have used the privacy feature when walking away from the cart.

Based on observation, record review, resident interview, staff and physician interviews, the facility failed to obtain a physician order for supplemental oxygen for 1 of 2 residents reviewed for oxygen (Resident #24). Findings included: Resident #24 admitted to the facility on [DATE] with diagnoses which included obstructive sleep apnea and respiratory failure. Record review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #24 was cognitively intact and was not coded for oxygen use. During observations on 10/12/22 at 3:34 pm and 10/13/22 at 9:10 am Resident #24 was observed with 2 liters (L) of oxygen via nasal canula (NC) in use. Record review of the active physician orders revealed no order for supplemental oxygen. During an interview on 10/13/22 at 9:10 am Resident #24 revealed he started using the oxygen a few days ago, but he was not sure why. Resident #24 stated he felt better with the oxygen in place. During an interview on 10/13/22 at 9:15 am Nurse #1 revealed Resident #24 had the oxygen in place for the two days she was assigned to his care. She stated Resident #24 had a history of respiratory distress and that may be the reason the oxygen was in use, but she was not certain. Nurse #1 stated she was not sure if it required a physician order. An attempt to interview Nurse #2, who was assigned to Resident #24 on 10/11/22 on the overnight shift, was unsuccessful. During an interview on 10/13/22 at 12:13 pm the Director of Nursing (DON) revealed a physician order was required for supplemental oxygen. She stated the nurse on the unit was required to enter a physician order for supplemental oxygen for Resident #24. The DON was not aware Resident #24 was on supplemental oxygen. During an interview on 10/13/22 at 12:40 the Medical Director revealed Resident #24's supplemental oxygen required an order and could be obtained from the on-call provider or himself when needed.

Based on observations, staff interviews, and record review the facility failed to promote dignity by placing signage in residents ' room which indicated residents had pressure ulcers and behaviors for 5 of 6 residents reviewed for dignity. (Resident #29, Resident #25, Resident #21, Resident #45, and Resident #34) Findings included: 1. A review of Resident #29 ' s minimum data set assessment dated [DATE] revealed she was assessed as severely cognitively impaired. She had no moods or behaviors. She required extensive assistance with bed mobility. Resident #29 was totally dependent on staff for transfers, locomotion on unit, dressing, eating toilet use, and personal hygiene. She was always incontinent of bowel and bladder. Her active [DIAGNOSES REDACTED]. A review of Resident #29 ' s care plan dated 2/15/21 revealed she was care planned to have a sacral pressure ulcer related to immobility and incomitance. The interventions included to assess the pressure ulcer for location, stage, size (length, width, and depth), presence/absence of granulation tissue, and epithelization weekly, provide incontinence care after each incontinent episode, and turn and reposition Resident #29 every 2 hours and as needed. During observation on 3/15/21 at 10:02 AM a sign was observed on the wall in the bedroom next to the door to the hall which read please turn or reposition resident every 2 hours secondary to current sacral pressure wound. Please do not leave resident in geri-chair longer than 2 hours. Please keep resident in the reclined position when not eating. During observation on 3/16/21 at 3:38 PM the sign was observed to still be in the resident ' s room. During observation on 3/17/21 at 10:32 AM the sign was observed to still be in the resident ' s room. During an interview on 3/17/21 at 10:05 AM Occupational Therapist #1 stated she and the wound care nurse who no longer worked at the facility would put signage up about what resident needs were in order to communicate to the nurse aides what care to do. She further stated she put the signage up in Resident #29 ' s room which indicated she had a pressure ulcer in order to communicate the need for repositioning to the nurse aides and the process worked well. During an interview on 3/17/21 at 10:48 AM the Director of Nursing stated signage was placed by therapy and they had to ask family or residents if it was okay to put signs up in the resident rooms. She further stated she was not aware of signage in the facility that identified wounds on the signage and there should be no signage that indicated if the resident had wounds. The Director of Nursing stated it would be a dignity concern for residents as it would not respect their privacy. Upon observing the signage, she concluded it should not have been posted in the room. 2. A review of Resident #25's minimum data set assessment dated [DATE] revealed she was assessed as severely cognitively impaired. She required extensive assistance with bed mobility and eating. She was totally dependent on staff for dressing toilet use, and personal hygiene. She was always incontinent of bowel and bladder. Resident #25's active [DIAGNOSES REDACTED]. A review of Resident #25's care plan dated 1/27/21 revealed she was care planned to require activities of daily living care. The interventions included to provide assistance with bed mobility and transfers. A review of Resident #25 ' s progress notes revealed her sacral pressure ulcer had resolved. During observation on 3/15/21 at 1:37 PM a sign above Resident #25 ' s bed read to increase skin integrity and promote healing of pressure ulcer please keep resident ' s head at 30 degrees or below when laying in bed, change position every 2 hours in bed, and change position every hour when in wheelchair. During observation on 3/16/21 at 8:50 AM the sign above Resident #25 ' s bed was still in place. During observation on 3/16/21 at 2:47 PM the sign above Resident #25 ' s bed was still in place. During observation on 3/17/21 at 10:33 AM the sign above Resident #25 ' s bed was still in place. During an interview on 3/17/21 at 10:05 AM Occupational Therapist #1 stated she and the wound care nurse who no longer worked at the facility would put signage up about what resident needs were in order to communicate to the nurse aides what care to do. She further stated she put the signage up in Resident #25 ' s room which indicated she had a pressure ulcer in order to communicate the need for repositioning to the nurse aides and the process worked well. During an interview on 3/17/21 at 10:48 AM the Director of Nursing stated signage was placed by therapy and they had to ask family or residents if it was okay to put signs up in the resident rooms. She further stated she was not aware of signage in the facility that identified wounds on the signage and there should be no signage that indicated if the resident had wounds. The Director of Nursing stated it would be a dignity concern for residents as it would not respect their privacy. Upon observing the signage, she concluded it should not have been posted in the room. 3. Resident # 45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum (MDS) data set [DATE] revealed Resident # 45 had short- and long-term memory problems and moderately impaired decision-making skills. He required total to extensive assistance with activities of daily living. He was assessed as having upper extremity impairment on one side and having lower extremity impairment on both sides. During an observation on 3/16/21 at 2:52 PM a sign above Resident # 45 ' s bed read please leave resident ' s feet uncovered or utilize foot tent! Thank you! OT. During an observation on 3/17/21 at 11:02 AM the sign above Resident #45 ' s bed was still in place. During an interview on 3/17/21 at 10:05 AM the Occupational Therapist #1 stated she and the wound nurse who no longer worked at the facility would put signage up about what residents needs were in order to communicate to the nurse aides what care to do. During an interview on 3/17/21 at 10:51 AM the Director of Nursing stated signage was placed by therapy and they had to ask family or residents if it was okay to put signs up in the resident rooms. She stated she was not aware that the Occupational Therapist had placed a sign in Resident #45 ' s room. 4. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #21 had significant cognitive impairment. She required extensive assist with 2-person physical assistance for her Activities of Daily Living (ADLs). During an observation on 03/15/21 at 11:13 AM, signage on the bathroom door indicated provide resident cat in order to increase sensory stimulation, decrease adverse behaviors and improve quality of life. The signage was visible from the hallway and had resident specific information that revealed Resident #21 had adverse behaviors. An interview on 03/17/21 at 8:45AM with the Occupational Therapist (OT) revealed she was familiar with Resident #21 and had provided therapy services for sensory integration, decrease adverse behaviors and coping strategies. OT further revealed they provided Resident #21 with a Twiddle-Cat to re-direct resident and reduce pinch and grab tendencies. OT revealed they had placed the signage in Resident#21's room. During an interview on 3/17/21 at 10:51AM the Director of Nursing stated signage was placed by therapy and they had to ask family or residents if it was okay to put signs up in the resident rooms. She stated she was not aware that the Occupational Therapist had placed a sign in Resident #21's room. The DON revealed Resident#21's Responsible Party had been notified of the signage and had given permission to place the signage. 5. A review of Resident #34's Annual MDS assessment dated [DATE] revealed he was assessed as moderately cognitively impaired. He required extensive assistance with one-person physical assistance with bed mobility, dressing and personal hygiene. Resident #34 was totally dependent on staff for transfers, bathing, and toilet use. A review of Resident #34's care plan last updated 3/9/2021 revealed she was care planned for pressure ulcer to sacrum related to immobility. The interventions included to turn and reposition Resident #34 every 2 hours as needed, apply house barrier cream to buttocks area after each incontinent episode. During an observation on 3/15/2021 at 2:19 PM a sign was observed on the wall above Resident #34's bed next to the door leading to the unit hallway. The note read; Pressure Ulcer Education and a yellow sticky note was attached that read I have a pressure injury, please be dear and place me in my side unless I am eating. During an observation on 3/16/2021 at 9:39 AM the sign was observed to still be in the resident's room. During the observation on 3/17/2021 at 10:28 AM the sign was observed to still be in the resident's room. During an interview on 3/17/2021 at 10:48 AM the Director of Nursing stated signage was placed by therapy and the wound nurse that was no longer there. The DON stated she was not aware of signage in the facility that identified wounds. The DON stated the signage would be a dignity concern for residents. The DON observed the signage and stated it should not have been posted in the room.

Based on observation and staff and resident interviews, the facility failed to post the required posting of a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, or a statement the resident may file a complaint with the State Survey Agency. Findings included: During a resident council meeting on 3/17/21 at 9:55AM, the 5 resident council members that attended the meeting, revealed there was no signage in the facility with State agency information. The 5 residents revealed they were not aware they could file a complaint with the State Survey Agency nor how to file a complaint. An interview with the Social Worker on 3/17/21 at 10:36AM revealed she provided signage on grievances and the Ombudsman contact information, which was located outside her office. An observation of the posting outside the Social Worker's office on 3/17/21 at 10:37AM revealed posting of Resident Right information with the contact information for the Ombudsman and a posting on the grievance policy and how to file a grievance. The posting was visible to staff and residents. A tour of the facility, with the Administrator, on 3/17/21 at 10:45AM, revealed no signage on State Agency contact information was posted in the facility. During the tour of the facility, postings for the local Nursing Home Community Advisory Committee were observed. These posting were visible and accessible to residents and staff. An interview with the Administrator on 3/17/21 at 10:50AM, revealed signage with State Agencies contact information should be posted and visible. The Administrator stated the signage must have been removed during COVID Outbreaks.

Based on observation and staff interview the facility failed to date an opened bottle of [MEDICATION NAME] in the medication refrigerator for 1 of 1 medication storage room reviewed. The facility failed to label medications with an open date on 2 of 2 medication carts reviewed for medication storage. (400-Hall and 100-Hall) The findings included: An observation was conducted of medication storage room [ROOM NUMBER] on 3/17/2021 at 8:39 AM. A bottle of opened [MEDICATION NAME] 5TU/0.1ml was found in the medication refrigerator without an open date. The [MEDICATION NAME] bottle read discard product 30 days after opening. An interview with the Director of Nursing (DON) on 3/17/2021 at 8:44 AM revealed that the medication bottle should have had an open date. During an observation of the 400-hall medication cart on 3/17/2021 at 1:53 PM 1 opened bottle of [MEDICATION NAME] (for [MEDICAL CONDITION]) with no open date and 1 opened bottle of Travoprost 0.0004% (for [MEDICAL CONDITION]) with no open date for Resident # 5. An interview conducted with Nurse #3 on 3/17/2021 at 2:03 PM revealed there should be an open date on all eye drops because some expire in 2 weeks and others in 6 weeks. During an observation of the 100-hall medication cart on 3/17/2021 at 2:08 PM 1 opened bottle of Oloptadine HCL 0.1% with no open date for Resident # 51 (for itchy eyes) and 1 opened bottle of Children's Alaway with no open date for Resident #50. An interview conducted with Nurse #1 on 3/17/2021 at 2:16 PM revealed that opened eye drops could be used until the expiration date on the bottle. An interview with the DON on 3/17/2021 at 2:28 PM revealed that eye drops are to have an opened date when seal is broken.

Based on observations and staff interviews the facility failed to maintain kitchen equipment clean and in a sanitary condition by failing to clean six of six baking sheets, four of four half size steam table pans, three of three full size steam table pans and by failing to clean 2 of 2 convection ovens. The findings included: A review of the undated Area and Equipment Cleaning Frequency, Kitchen Area Policy, under Equipment/ Area/Tasks/ Comments, read as: Ovens-Outside- Clean and Sanitize-Daily. Ovens Inside- Clean and Sanitize Daily. Ovens-Inside-Clean and Sanitize-Weekly. During the initial tour on 3/15/2021 at 10:55 AM the dish room drying rack was observed. Six baking sheets were observed stacked on the drying rack ready for use. The six baking sheets were observed to have 1/8-inch to ¼-inch of black food residue one inch wide under the rim. Stacked on the drying rack ready for use, 4 of 4 half size steam table pans and 3 of 3 full size steam table pans were observed with black food residue under the rim of the pans. Two of the two convection ovens were observed with black charred food particles on the bottom of the ovens and the inner rim of the convection ovens doors were observed with black grease build up. A second observation of the kitchen on 3/16/2021 at 2:34 PM revealed the convection ovens were in the same condition. The drying rack was observed to have 3 of 3 full size steam table pans, and 3 of 3 half size steam table pans were observed with black food residue under the rim of the pans and 4 of 4 baking sheets with 1/8-inch to ¼-inch of black food residue one inch wide under the rim. A third observation of the kitchen on 3/17/2021 at 1:26 PM revealed the convection ovens and steam table pans were in the same condition. In an interview on 3/17/21 at 1:28 PM the day cook stated the convection oven was cleaned weekly, but another worker had spilled something in the oven and did not clean it up. The day cook indicated the ovens should be wiped out daily. In an interview on 3/17/21 at 1:33 PM the District Dietary Supervisor stated the convection ovens should be cleaned after any spill. She stated the baking sheets and steam table pans could be cleaned with a degreaser and staff would clean them that day. On 3/17/21 at 2:59 PM the Administrator stated she would expect the kitchen to be clean.

Based on observations, record review and resident and staff interviews, the facility failed to screen a vendor upon entrance, and implement their infection control policies and the Centers for Disease Control and Prevention (CDC) guidelines for the use of Personal Protective Equipment (PPE) when Nurse Aide #1 entered resident room without wearing gloves for 1 of 1 resident with transmission-based precautions (Resident #169) and Nurse #3 administered medications to a resident with her face mask below her nose (Resident #54) for two of two staff members observed for infection control practices. In addition, the facility failed to offer hand hygiene prior to meals for 2 of 2 residents observed during meal tray delivery (Resident #59 & Resident #61). This failure occurred during the COVID19 pandemic. Findings included: 1. Review of the facility's COVID-19 Employee/Visitor Screening Form Guidelines, no date, revealed anyone entering the facility will complete the appropriate screening form based on the reason for entering the facility. An observation on 3/15/21 at 12:45PM revealed Maintenance Staff #1 opened the dining room entrance and permitted a vendor into the facility. It was further observed that 7 residents were participating in an activity in the dining room. The residents were eating and had no masks on when the vendor was permitted access into the dining room. The vendor was observed wearing a mask. The vendor walked within 6 feet of the residents participating in the activity. An interview with Maintenance Staff #1 on 3/18/21 at 4:08PM, revealed he had unlocked the dining room door for the vendor. He further stated all vendors were to be screened at the main entrance to include a temperature check and questionnaire. The Maintenance Staff #1 revealed he had been instructed by the Maintenance Supervisor to open the door and allow the vendor into the building. He further stated the Maintenance Supervisor was with the vendor when he opened the door. The Maintenance Staff #1 stated he was trained that all vendors were required to complete a screening at the main entrance prior to access to the facility. During an interview with the Receptionist on 3/15/21 at 1:00PM, it was revealed no screenings had been completed on vendors on this date. The Receptionist further stated all staff, visitors, and vendors were required to enter through the main entrance. She indicated vendors were required to be screened prior to being permitted access into the facility. An interview with the Maintenance Supervisor on 3/15/21 at 1:05PM revealed vendors were to be screened prior to entrance into the building. He further stated the vendor should not have been allowed entrance through the dining room door. An interview with the Infection Preventionist on 3/15/21 at 2:12PM revealed COVID19 screening was performed at the main entrance into the facility. She stated all staff, visitors and vendors must be screened. She further revealed training was conducted on 9/4/20 to include how, when and where screening of staff, visitors and vendors occurred. All staff members were part of this training, including the maintenance staff. During an interview with the Director of Nursing on 3/17/21 at 2:12PM, she stated when a vendor came into the building, they were to be screened. She indicated screening occurred at the main entrance into the facility. The DON further stated staff were not permitted to allow vendors entrance through a side door. 2.a. Review of the PPE Use Guidelines during COVID Pandemic revised 2/13/21 revealed the facility followed all current guidelines for infection control and prevention. Resident #169 was admitted to the facility on [DATE] from the hospital and was placed on Enhanced Droplet Precautions for the 14-day quarantine period. Review of the Enhanced Droplet Isolation signage on Resident #169's door revealed before entering this room, follow the instructions below. The instructions stated staff should don a mask, eye protection, gown, and gloves prior to entering the resident room. An observation on 3/15/21 at 12:20PM revealed NA #1 entered Resident #169's room to deliver a meal tray. NA #1 was wearing a mask, donned a gown, entered the resident room and delivered the lunch meal. NA #1 doffed the gown prior to exiting Resident #169's room. NA #1 applied Alcohol Based Hand Rub (ABHR) after exiting the resident room. During an interview on 3/15/21 at 12:22PM with NA #1, she stated she was not required to wear gloves when providing a meal tray for residents on Enhanced Droplet Precautions (EDP). An interview with Nurse #1 on 3/15/21 at 12:40PM revealed staff were to don Personal Protective Equipment (PPE) each time staff entered a resident room who was on EDP. She further revealed PPE included a mask, gown, and gloves. Nurse #1 stated staff were trained to wear gloves when entering resident rooms on EDP. She further stated the NA was trained to wear gloves when passing trays. During an interview with the Director of Nursing (DON), she stated staff were to don PPE which included a mask, gown, and gloves each time they entered a resident room who was on EDP. She further stated staff should doff the PPE in the resident room and then apply Alcohol Based Hand Rub (ABHR). The DON stated NA #1 was educated on how to pass trays for residents on EDP, which included donning gloves. 3. During observation on 3/15/21 at 12:44 PM Nurse #1 was observed to enter Resident #59 ' s room and provide the resident their meal tray. She set up the food tray for the resident and left the room. She did not offer hand hygiene to the resident. The resident began to eat without performing hand hygiene. During an interview on 3/15/21 at 12:47 PM Nurse #1 stated she would help with passing meal trays when it was needed. She further stated she did not think to offer hand hygiene to the residents prior to passing trays but understood it was important and she would begin to do so. During an interview on 3/16/21 at 8:24 AM the Director of Nursing stated residents should be offered hand hygiene for infection control purposes before eating. 4. During observation on 3/15/21 at 12:31 PM Nurse #1 was observed to assist passing meal trays. She was observed to enter Resident #61 ' s room with his meal tray. She set the meal tray down and asked if the resident needed to sit up, and he indicated he did. She requested Nurse Aide #1, who was passing by in the hall, assist her with the resident. They assisted the resident up and Nurse #1 and Nurse Aide #1 exited the resident ' s room without offering the resident hand hygiene. Resident #61 began to eat without performing hand hygiene. During an interview on 3/15/21 at 12:34 PM Nurse Aide #1 stated staff were to offer hand hygiene to residents before meals. She concluded she was not aware Nurse #1 had not offered hand hygiene to the resident before she had entered the room to assist with positioning. During an interview on 3/15/21 at 12:47 PM Nurse #1 stated she would help with passing meal trays when it was needed. She further stated she did not think to offer hand hygiene to the residents prior to passing trays but understood it was important and she would begin to do so. During an interview on 3/16/21 at 8:24 AM the Director of Nursing stated residents should be offered hand hygiene for infection control purposes before eating. 2b. Review of the facility's policy Personal Protective Equipment (PPE) Use During COVID Pandemic last revised 2/13/2021 read in part: A well-fitting facemask would be worn by healthcare professionals for source control while in the facility and for protection during patient care encounters. During an observation on 3/17/21 at 8:08 AM Nurse #3 was observed at the 100 Hall medication cart preparing medication for Resident #3. The nurse's face mask was observed to be resting below her nose. An interview was conducted with Nurse #3 at 8:12 AM. The nurse pulled the mask up to cover her nose and stated that the mask was always to be worn over her nose and mouth while in the facility. During an observation of 3/17/21 at 10:34 AM Nurse #3 was observed at the 100 Hall medication cart preparing medication for Resident #54 with the mask resting below her nose. The nurse left the medication cart and entered into Resident #54's room. The nurse administered resident's medication with mask below her nose. The nurse washed her hands and returned to the medication cart with mask resting below her nose. An interview on 3/17/21 at 10:41 AM with the Director of Nursing revealed that staff should always wear their mask while in the facility.

Based on record review and staff interviews the facility failed to develop a Care plan for oral care for one of one residents reviewed for dental care (Resident # 45) and failed to provide restorative therapy according to the plan of care for 1 of 2 residents reviewed for range of motion. (Resident #35). The findings included: 1. Resident # 45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum (MDS) data set [DATE] revealed Resident # 45 had short- and long-term memory problems and moderately impaired decision-making skills. He required total to extensive assistance with activities of daily living and was coded for obvious or likely cavity or broken natural teeth. He was assessed as having upper extremity impairment on one side. Review of Resident # 45 ' s care plan dated 11/19/18 and last updated on 5/23/2021 revealed the resident had a care plan for nutritional status. Interventions included encourage drinks in two handle cups, encourage fluids, RD/dietary consult as needed, diet; likes finger foods, encourage weight as ordered, record meal and fluid intake every shift. Review of Resident # 45 ' s care plan dated 12/07/18 and last updated on 5/23/21 revealed the resident had a care plan for behavioral symptoms. Interventions included approach resident in calm manner, monitor behaviors frequently and refer to psychiatrist as needed. Review of the residents Comprehensive Care Plan dated 11/19/18 and last revised on 5/23/21 contained no information or interventions regarding oral care. During an observation on 3/15/21 at 12:25 PM Resident # 45 was observed eating lunch in his room. His right upper and lower jaw were observed to have black jagged teeth and he was missing teeth on both his upper and lower jaws. During an observation on 3/15/21 at 3:20 PM Resident # 45 was observed sitting up in bed. His right upper and lower jaw were observed with black jagged teeth and he was missing teeth on both his upper and lower jaws. In an interview on 3/17/21 at 9:37 AM nursing assistant (NA) # 5 stated Resident # 45 would not let staff brush his teeth or use a sponge swab to clean his teeth. In an interview on 3/17/21 at 10:32 AM NA # 6 stated the resident refused ADL care and all oral care. She stated the resident did not like to have his face washed or his teeth brushed. The NA stated staff tried to provide oral care, but the resident would not allow them to brush his teeth. During an interview on 3/17/21 at 11:40 AM the MDS Nurse stated she did not see a care plan for oral care for the resident. The MDS nurse indicated Resident # 45 had behaviors and she had care planed his refusal of laboratory test and weights under behaviors. She stated she could have care planed his oral care under the behaviors as well. 2. Resident #35 was admitted to the facility on [DATE]. A review of Resident #35's Minimum Data Set assessment dated [DATE] revealed she was assessed as moderately cognitively impaired. She had no moods and no behaviors. Resident #35 required extensive assistance with personal hygiene, eating, and bed mobility. She was totally dependent on staff for transfers, locomotion on and off unit, dressing, and toilet use. Her active [DIAGNOSES REDACTED]. A review of Resident #35's care plan dated 1/25/21 revealed she was care planned to receive restorative active range of motion. This intervention was initiated on 5/9/19. The interventions included to have Resident #35 lift bilateral knees 10 times, have resident bend, and straighten bilateral knees 10 times, and have resident move bilateral ankles up and down 10 times. A review of Resident #35's restorative nursing range of motion charting from 3/11/21 through 3/16/21 revealed on 3/12/21 she received 15 minutes of active range of motion. It was not documented that she received any other restorative active range of motion during that time. During an interview on 3/16/21 at 4:39 PM Nurse Aide #2 stated the floor nurse aides do not perform restorative care for residents. She concluded she did not know if the facility had a restorative program and she had not performed restorative therapy to Resident #35. During an interview on 3/17/21 at 7:48 AM Nurse Aide #3 stated she did not know if there was a restorative nurse aide, however she stated she did not perform restorative therapy with the residents including Resident #35. During an interview on 3/17/21 at 7:53 AM Nurse Aide #4 stated the floor nurse aides do not perform active range of motion or restorative therapy. She further stated there was a restorative aide sometimes but to her knowledge there was not a restorative aide in the facility this week. She concluded she did not perform any restorative active range of motion with Resident #35. During an interview on 3/17/21 at 8:09 AM Nurse #2 stated the nurses did not perform any restorative therapy with any of the residents including Resident #35. During an interview on 3/17/21 at 8:11 AM the Director of Nursing stated that currently floor nurse aides were to do the restorative therapy as the restorative nurse aide had begun to work only part time. She further stated if restorative range of motion was in Resident #35's plan of care and the nurse aides were supposed perform active range of motion with Resident #35. She concluded she was not aware the nurse aides did not know they were to perform restorative care and it was not done as it should have been for Resident #35. During an interview on 3/17/21 at 10:05 AM Occupational Therapist #1 stated it was an expectation that when a resident is put on restorative therapy upon discharge that it would be carried out by the nursing aide staff or the restorative team if there was one.

Based on observation and staff interviews the facility failed to provide privacy curtains in resident rooms to provide full visual privacy for three of six rooms observed on the 100 hall (Room # ' s 102, 105, 111). The findings included: 1. During an observation on 3/16/2021 at 2:51 PM, revealed there were no privacy curtains hung in room [ROOM NUMBER], to provide privacy for either resident in Bed A or Bed B. Observation on 3/16/2021 at 2:55 PM in room [ROOM NUMBER] revealed there was no privacy curtain for Bed A. 2. Observation on 3/17/21 at 10:34 AM revealed there were no privacy curtains hung in room [ROOM NUMBER], to provide privacy for either resident in Bed A or Bed B. Observation on 3/17/21 at 10:36 AM in room [ROOM NUMBER] revealed there was no privacy curtain for Bed A. Observation on 3/17/21 at 2:06 PM in room [ROOM NUMBER] revealed there was no privacy curtain for Bed A. In an interview on 3/17/2021 at 2:11 PM the Housekeeping manager revealed if staff saw any dirty, torn or missing privacy curtains they should notify him, and he would take care of it right away. On 3/17/21 at 2:53 PM the Administrator stated she would expect all residents to have privacy curtains. She indicated housekeeping staff should have reported the curtains were missing.

Based on observations and staff interviews the facility failed to lock an unattended medication cart and failed to secure an open computer medication screen from view on the 400-hallway for 1 of 2 medication carts observed. The findings included: During a tour of the facility on 02/09/2021 at 9:27 AM, Nurse #1 was observed to leave her medication cart across the hallway from room [ROOM NUMBER]. The nurse walked across the hall and entered room [ROOM NUMBER] with medications in her hand and shut the door. The medication cart lock was observed to be sticking out from the cart in the unlocked position. A computer with an open screen on top of the medication cart was in full view with information for a resident in room [ROOM NUMBER]. At 9:29 AM, Certified Nurse Assistant (CNA) #1 entered the hallway and walked down the hallway past the unsecured medication cart. At 9:30 AM, Nurse #1 exited room [ROOM NUMBER] and opened the bottom drawer without having to unlock the medication cart. An interview was conducted with Nurse #1 on 02/09/2021 at 9:30 AM immediately following the observation. The nurse stated she normally kept her medication cart locked and must have forgotten to lock it before going into room [ROOM NUMBER]. The nurse stated she normally kept her computer screen open to the resident information when she was working but had been in-serviced to lock her medication cart and log out of the computer every time she left her cart. On 02/10/2021 at 1:28 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she expected nurses to lock their medication cart every time they were not in front of it. The DON stated staff should click the walk-away button, which closed the computer screen, or should log out of the computer when they were not at the cart. The DON stated all staff had been instructed on these procedures during orientation.

Based on record review, staff interview, nurse practitioner interview, and physician interview the facility treated urinary tract infections and a sinus infection with antibiotics without a clear indication for use for 1 (Resident # 2) of 3 residents reviewed for antibiotic use. Resident #2 was treated with antibiotics 10 times at the facility in 2019-2020 for urinary tract infection and a sinus infection. Findings include: Resident #2 was admitted to the facility on [DATE] and had cumulative [DIAGNOSES REDACTED]. Documentation on the quarterly minimum data set (MDS) assessment dated [DATE] coded Resident #2 as having memory problems, no mood, or behavior problems. Resident #2 was coded as having no ability to speak, was rarely/never understood and rarely/never understood others. Documentation on the same MDS assessment coded Resident #2 as dependent for activity of daily living care, always incontinent of bowel and bladder, on antibiotics for 5 days of the assessment period, and having urinary tract infections in the last 30 days. Documentation on the care plan revealed Resident #2 had a focus area, last reviewed or revised on 10/23/20, for dehydration/fluid maintenance. One of the interventions under this focus area was to assess for dehydration such as fever, infection, or electrolyte imbalance. Documentation on the care plan revealed an additional focus area, last reviewed or revised on 9/11/20, for Resident #2 for bladder incontinence. The goal of the bladder incontinence focus area was to minimize risk of skin breakdown and urinary tract infections through the next review. One of the interventions under this focus area was to report signs of urinary tract infections such as acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back pain/flank pain, malaise, foul odor, concentrated urine, and/or blood in urine. A. Documentation in a nursing note for Resident #2 dated 7/24/19 stated, Blood obtained and awaiting pickup. Labs for urinalysis arrived, (name of on-call physician) notified. (Stated) would like to wait for urine culture before treatment started. Pt (patient) is asymptomatic at this time. Documentation in a nursing note dated 7/25/19 at 3:56 AM revealed Resident #2 was difficult to awaken for medication administration. Documentation in a nursing note dated 7/25/19 at 1:04 PM indicated the RP (responsible party) of Resident #2 was notified of the urinalysis results and [MEDICATION NAME] (antibiotic) was started. Documentation in a progress note by NP #1 dated 7/25/19 under history of present illness stated, Resident seen today for follow-up. She was seen on Tuesday for a change in condition. Labs were drawn at that time. Her urinalysis did come back positive for urinary tract infection with greater than 100,000 colony-forming units of E. Coli. Susceptibility is not yet available. Past medical history reviewed. She remains (with out a fever) with stable vital signs. Documentation under the [DIAGNOSES REDACTED]. Documentation in the physician orders [REDACTED].#2 to be administered a [MEDICATION NAME] (antibiotic) 100 mg (milligram) tablet orally twice a day from 7/25/19 to 7/31/19. Documentation on the Medication Administration Record [REDACTED]. Documentation on an Event Report for suspected infection/antibiotic use, dated as initiated on 7/25/19, revealed Resident #2 had an altered mental status from baseline with clear urine with a positive UA (urinalysis). The documentation stated that the McGeer criteria were not met but antibiotics were initiated. (The McGeer criteria is used for infection surveillance to define infections.) B. Documentation in a progress note by NP #1 dated 8/2/20 revealed Resident #2 was seen for a follow up to a fever on 8/1/20. Documentation under the history of the present illness revealed vital signs were stable, the fever was well controlled, became more alert with administration of IV (intravenous) fluids, and ate breakfast with her husband. Documentation under the [DIAGNOSES REDACTED]. Documentation in a nursing progress note dated 8/4/20 at 3:36 AM revealed, Resident is s/p (status [REDACTED]. No adverse reactions noted. Resident had had one injection of [MEDICATION NAME] ([MEDICATION NAME]) IM (intramuscularly) and continues with the injections once daily for a UTI. No adverse reactions noted during this shift. Documentation in the physician orders [REDACTED]. Documentation on the MAR indicated [REDACTED]. Documentation on an Event Report for suspected infection/antibiotic use, dated as initiated on 8/2/19, revealed Resident #2 had the signs and symptoms of a fever of 101.8 degrees F (Fahrenheit) and lethargy along with a positive UA. A BMP (basic metabolic panel), CBC (complete blood count), UA C&S (urinalysis culture and sensitivity), and chest x-ray was ordered by NP #1. The documentation on the event report stated antibiotics were initiated, chest x-ray was negative, and the McGeer criteria were not met. C. Documentation in the nursing notes for Resident #2 dated 4/28/20 revealed, (NP #1) rounded on resident, and new order for UA/CS (urinalysis/culture and sensitivity) given due to resident seeming off her normal baseline. RP (responsible party) in agreement. Documentation in the nursing notes for Resident #2 dated 4/30/20 revealed the UA and C&S was obtained through a sterile catheter with the resident tolerating the procedure well. There was no documentation of new or worsening urgency, fever, increased frequency, suprapubic pain, gross hematuria, flank pain, or shaking chills. Documentation in the nursing notes for Resident #2 dated 5/4/20 revealed, UA C&S resulted and noted per (NP #1). Resident has a UTI per (NP #1) start [MEDICATION NAME] 100 mg (milligrams) x 7 days and [MEDICATION NAME] x 7 days. Documentation in physician orders [REDACTED]. Documentation on the MAR indicated [REDACTED]. Documentation on an Event Report dated as initiated on 5/4/20 revealed Resident #2 had altered mental status and a positive urinalysis with clear colored urine. The documentation on the event report stated antibiotics were initiated and the McGeer criteria were not met. Documentation in the nursing notes dated 5/5/20 at 11:29 AM for Resident #2 revealed Resident #2 had a temperature of 102.8 degrees (F). The nurse administered Tylenol, a cold cloth to the resident's head, and cold packs to the sides of the resident's arms to help lower her temperature. NP #1 ordered IM (intermuscular) [MEDICATION NAME] (antibiotic) for three days. Documentation in the physician orders [REDACTED]. Documentation on the MAR indicated [REDACTED]. Documentation on in a progress note by NP #1 dated 5/5/20 at 4:22 PM revealed in the plan portion of the note that the plan was discussed in detail with the RP (responsible party) to monitor closely, vital signs every shift, 1 gram of [MEDICATION NAME] IM (intramuscularly) for 3 days, continuation of [MEDICATION NAME] 100 mg twice daily, push fluids by mouth, Tylenol when necessary, and notification of physician on call if condition worsened. Documentation in the same progress note also revealed later in the afternoon the resident's overall appearance and vital signs improved. Documentation in the nursing notes dated 5/5/20 at 8:06 PM revealed Resident #2 continued to have a high temperature and new orders were received to send the resident to the hospital. D. Documentation in a nursing note dated 5/8/20 revealed Resident #2 returned from the hospital with a new order for [MEDICATION NAME] (antibiotic) 875-125 mg tablet twice a day for 3 days for treatment of [REDACTED]. Documentation in a physician orders [REDACTED]. Documentation on the MAR indicated [REDACTED]. Documentation on an Event Report for an infection control report dated as initiated on 5/8/20 revealed Resident #2 completed antibiotic therapy and the McGeer criteria were not met. E. Documentation in the nursing notes dated 5/25/20 revealed a CBC and a UA C&S was ordered. Documentation in the nursing notes dated 5/26/20 revealed the UA C&S was obtained via an in and out catherization with the urine described as clear yellow, with a slight order. There was no documentation of new or worsening urgency, fever, increased frequency, suprapubic pain, gross hematuria, flank pain, or shaking chills. Documentation in a progress note dated 5/29/20 by NP #1 revealed Resident #2 was seen for a follow up to laboratory results that were ordered on [DATE]. The documentation in the progress note explained under history of present illness, Resident #2 had been admitted to the hospital from 5/6/20 to 5/8/20 for treatment of [REDACTED]. The documentation under the plan portion of the note revealed Resident #2 was to be started on Bactrim DS (antibiotic) by mouth twice a day empirically until sensitivity reports became available. Documentation in the physician orders [REDACTED]. Documentation on the MAR indicated [REDACTED]. Documentation in the nursing notes on 6/1/20 revealed Bactrim DS was discontinued for Resident #2 due to an adverse reaction of swollen lips and a red neck. Bactrim was added to the list of the resident's allergies and [MEDICATION NAME] 1-gram IM was to be administered every 12 hours for 10 days. Documentation in the physician orders [REDACTED]. Documentation on the MAR indicated [REDACTED]. Documentation on an Event Report for suspected infection/antibiotic use dated 5/29/20 revealed Resident #2 had altered mental status and a positive uranalysis result. The documentation on the event report stated antibiotics were initiated and the McGeer criteria were not met. F. Documentation in a nursing note dated 6/13/20 revealed Resident #2 had a [MEDICAL CONDITION] witnessed by the nurse, the on-call physician was notified, and laboratory values were ordered, one of which included a UA C&S via a straight catherization. Documentation in a nursing note dated 6/17/20 revealed the on-call NP was notified of a positive urine culture. The documentation in the note further revealed the on-call NP requested the facility provider address the urine culture results because the resident was asymptomatic. Documentation in a progress note by NP #1 dated 6/22/20 revealed under the history of the present illness Resident #2 was seen for a follow up to a urinalysis. Documentation under the plan in the note revealed, Resident asymptomatic, without fever or other overt symptom, and colony count was low, therefore we will repeat UA C&S as this could be containment. Documentation in the nursing notes on 7/7/20 for Resident #2 revealed a verbal order was given by NP #1 for a repeat UA C&S. Documentation in a progress note by NP #1 dated 7/10/20 revealed under the history of the present illness Resident #2 was seen for a follow-up to urinalysis, she was asymptomatic and without fever. The documentation revealed the resident was diagnosed with [REDACTED]. Documentation in the physician orders [REDACTED]. Documentation in the physician orders [REDACTED]. Documentation in the physician orders [REDACTED].#2 was ordered to receive [MEDICATION NAME] 875-125 mg one tablet by mouth twice a day with the instructions to give two doses to complete the antibiotic dosing for the urinary tract infection on 7/17/20 to 7/18/20. Documentation on the MAR indicated [REDACTED]. Documentation on the MAR indicated [REDACTED]. Documentation on the MAR indicated [REDACTED]. Documentation in an Event Report initiated on 7/10/20 revealed Resident #2 had no signs or symptoms of a UTI. The documentation stated, Did not meet (Mc Geer) criteria. No supporting documentation of UTI noted. (Antibiotic) ordered by NP #1. G. Documentation in a nursing note dated 8/16/20 at 5:24 PM for Resident #2 revealed, Resident slept (half) way through lunch and slept through dinner. Resident arouses when shaken but falls asleep fast. Did not push feeding dinner due to possibility of aspiration while resident so somnolent. Documentation in a nursing note dated 8/17/20 revealed a UA C&S was obtained via a straight catheter per a physician's orders [REDACTED]. Documentation in a progress note by NP #1 dated 8/21/20 for Resident #2 revealed in the history of present illness, UA, C&S, CBC and BMP were ordered to evaluate a subtle change from baseline. She had not consumed usual amount of dinner x 2 over the weekend. She has profound dementia that renders her unable to express basic needs. Her appetite is usually very stable with 75-100% meal consumption. Per nursing, she has remained afebrile (without fever) with stable (vital signs) and has resumed usual eating pattern, etc. Documentation in the plan portion of the note revealed the nursing staff was ordered to look for the final result of the urine C&S for the final result every shift and notify the on-call provider of results so the results could be addressed further if needed. Documentation in a follow up progress note by NP #1 dated 8/24/20 stated Resident #2 was suspected to have a UTI. Documentation in the plan portion of the note revealed, Husband aware threshold for aggressive (antibiotic therapy) low in this resident as she has been hospitalized for [REDACTED]. Documentation in the physician orders [REDACTED]. Documentation on the MAR indicated [REDACTED]. Documentation in the physician orders [REDACTED]. Documentation in the physician orders [REDACTED]. Documentation on the MAR indicated [REDACTED]. Documentation in the physician orders [REDACTED]. Documentation on the MAR indicated [REDACTED]. Documentation on an Event Report dated as initiated on 8/24/20 revealed Resident #2 had altered mental status, decreased appetite and was started on [MEDICATION NAME] twice a day until [MEDICATION NAME] IV arrived from the pharmacy. Documentation in the evaluation notes stated, Resident had (Altered Mental Status), did not have greater than 100,000 cf/u (colony forming unit). Ordered by (NP #1). No leukocytes noted. Resident had fever x 1. Resident did not meet criteria. No increased incontinence, urgency, or frequency noted. The documentation on the event report stated antibiotics were initiated and the McGeer criteria were not met. H. Documentation in the nursing notes on 8/25/20 beginning at 12:56 PM revealed Resident #2 went to the dentist and returned lethargic with a temperature of 101.8 degrees F. Tylenol and IV (intravenous) hydration was administered. At 2:53 PM the resident's temperature was 98 degrees F. At 3:40 PM NP #1 and the responsible party for Resident #2 agreed to send Resident #2 to the emergency room for evaluation. Documentation in a nursing note on 8/26/20 at 6:05 PM stated, Report received from (hospital) stating that resident will be returning to the facility tonight. (Diagnosis) of UTI, mild dehydration. Documentation in physician orders [REDACTED]. Documentation on the MAR indicated [REDACTED]. Documentation in a regulatory progress note by the Medical Director dated 9/9/20 stated that Resident #2 was sent to the emergency roiagnom on [DATE], treated with [MEDICATION NAME] and IV hydration with good results. The documentation also revealed a head CT (x-ray of the head) was performed in the hospital indicating the resident had a chronic sinus infection fungal in nature, a specialist consulted, and no further treatment was warranted at that time. The Medical Director stated in the plan portion of the progress note under recurrent urinary tract infections, May consider [MEDICATION NAME] antibiotic regimen if increased frequency of recurrence. I. Documentation in the nursing notes on 9/12/20 at 7:10 PM revealed Resident #2 slept through dinner, was difficult to arouse, appeared pale, had a temperature of 102 degrees F, and was transferred to the emergency room . Documentation in the nursing notes on 9/12/20 at 10:30 PM revealed Resident #2 returned from the hospital after receiving medication for [MEDICAL CONDITION]. Documentation in the nursing notes on 9/15/20 at 3:15 PM revealed Resident #2 had emesis of 100 ml (milliliters) of undigested food. Documentation in the nursing notes on 9/15/20 at 5:24 PM revealed Resident #2 was pale, had a distorted face, and was difficult to wake up. Resident #2 was sent to the hospital. Documentation in the nursing notes on 9/16/20 at 3:23 AM revealed Resident #2 returned from the hospital with a [DIAGNOSES REDACTED]. Documentation in the nursing notes on 9/16/20 at 12:30 PM revealed, (RP) called with concerns about resident going out to hospital. Reviewed ER reports with him. Spoke to (Medical Director) about ER notes and tests. Informed (RP) that (Medical Director) wanted to stop [MEDICATION NAME] (antibiotic) because the results didn't show a UTI. CT showed questionable sinus infection per (Medical Director). Orders received for [MEDICATION NAME] 875/125 mg daily x 7 days and [MEDICATION NAME] x 7 days. (RP) notified about treatment plan. Documentation in the physician orders [REDACTED]. Documentation on the MAR indicated [REDACTED]. Documentation in the physician orders [REDACTED]. Documentation on the MAR indicated [REDACTED]. Documentation in a follow up progress note by NP # 1 dated 9/17/20 stated in part under history of present illness, (Resident #2) was apparently seen at the ER again on 9/15, dx with a UTI, given [MEDICATION NAME] dose in ER 1G IV and returned to the facility with [MEDICATION NAME] orders. (Medical Director) in house yesterday and was given records - specifically UA results - to review and she discontinued that (antibiotic) as labs did not support UTI (diagnosis) at (that time) or warranted (antibiotics) (treatment) at that time. She subsequently started her on [MEDICATION NAME] for a possible sinus infection noted on CT during last in-patient hospitalization - Unfortunately she has been experiencing (nausea/vomiting/diarrhea) for which she is being evaluated today for. Documentation under the assessment portion of the progress note revealed a [DIAGNOSES REDACTED]. Documentation under the plan portion of the progress note revealed in part, Due to the resident's adverse (symptoms) from [MEDICATION NAME] most likely to include (nausea/vomiting/diarrhea), and considering sinus issue likely chronic and not likely to cause systemic issues, and appears it may actually be fungal in nature, medical director, myself and RP all in agreement to (discontinue) [MEDICATION NAME] at this time. Documentation on the Event Report for antibiotic use dated as initiated on 9/16/20 revealed under the evaluation notes, Resident (#2) sent out for paleness, difficult to arouse, resident returned back to the facility with dx (diagnosis) of UTI and CT results stated sinus infection. Resident does not meet criteria. (Medical Director) ordered (antibiotic) for sinus infection. The Event report indicated antibiotics were initiated and the J. Documentation in a nursing note dated 10/17/20 revealed nursing was unable to keep Resident #2 awake long enough to feed her dinner. There was no documentation of a fever, new or worsening urgency, increased frequency, suprapubic pain, gross hematuria, flank pain, or shaking chills. Documentation in a nursing note dated 10/19/20 revealed NP #1 was into see Resident #2 and a UA C&S, CBC, and BMP were ordered. Documentation in the physician orders [REDACTED]. Documentation on the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Documentation on an Event Report dated as initiated on 10/22/20 revealed the resident had altered mental status, a positive UA. The Report had not been completed yet and the event was still open. The infection control preventionist (ICP) was interviewed on 10/22/20 at 4:00 PM. The ICP nurse revealed that the facility policy for infection control antibiotic stewardship was to follow the McGeer criteria for administration of antibiotics. ICP nurse stated that each time an antibiotic was prescribed for a resident the facility completed an Event Report for a suspected infection/antibiotic use. The ICP nurse explained that the Event Report for suspected infection/antibiotic use required three or more of the symptoms of the UTI (urinary tract infection) without a catheter in order to meet the criteria for antibiotic use. The ICP nurse provided the facility policy entitled, Revised McGeer criteria for infection surveillance checklist dated 11/28/17. The ICP nurse explained that on Table 1 of the criteria for infection the resident must have fever, leukocytosis, acute mental status change, and acute functional decline. The ICP nurse explained that on Table 2 of the McGeer criteria the urinary tract infection surveillance definitions listed the criteria for the treatment of [REDACTED]. The ICP nurse revealed that the facility had the expectation that NP (Nurse Practitioner) #1 and the Medical Director follow these criteria listed on the facility policy. The ICP nurse provided documentation of antibiotic stewardship and the McGeer criteria training provided to the NP #1 and the Medical Director on 7/28/20. The ICP nurse indicated that many elderly female residents in long term care have a positive urinalysis without any symptoms of a UTI, therefore not requiring antibiotic therapy. Nurse #1 was interviewed on 10/22/20 at 12:26 PM. Nurse #1 stated Resident #2 had a history of [REDACTED].#1 stated the facility treated the urinary tract infections very aggressively with antibiotics and IV hydration because the resident declined rapidly when she had a UTI. Nurse #1 stated Resident #2 usually ate and drank 100% of what was given to her and the nurse aides would report to her if Resident #2 was not eating or drinking. Nurse #1 did not know why Resident #2 had frequent UTIs, stating that it could be her immobility or a decline in overall health. NP #1 was interviewed on 10/23/20 at 12:46 PM. NP #1 stated that Resident #2 had been her patient for 2 years and Resident #2 had a very involved RP (responsible party). NP #1 stated that Resident #2 has subtle changes and she decompensates quickly. NP #1 stated she was able to notice these subtle changes in her condition and when she talked to the RP it was always agreed upon to do a urinalysis. NP #1 further added that Resident #2 was treated with antibiotics and she always improved. NP #1 explained that Resident #2 could not met the McGeer criteria because she was verbally unable to say she had a feeling of urgency, suprapubic pain, or increased incontinence. NP #1 explained that as a clinician she had to go by the body language and the clinical signs of a UTI, reiterating that Resident #2 always improved with antibiotic treatment. NP #1 stated that the use of antibiotics without the use of the McGeer criteria for Resident #2 was justified due to her dementia and nonverbal status. NP #1 stated that since Resident #2 could not vocalize how she was feeling, and if the facility waited to meet the McGeer criteria such as a fever along with not eating and lethargy, it would mean Resident #2 would be sent out to the hospital. NP #1 indicated that sending the Resident to the hospital was something both she and the RP would like to avoid. NP #1 revealed that on 10/22/20 she started [MEDICATION NAME] right away because the longer the length of time she waited to start the antibiotics the greater the chance Resident #2 will get a fever and be subsequently sent to the hospital. NP #1 indicated that a hospital admission was distressing for Resident #2 as a resident with dementia. NP #1 stated she would change the antibiotic once she has the culture and sensitivity results. Np #1 noted that hospitalization of Resident #2 in May 2020 with urosepsis was the first hospitalization the resident had in the two years she had been a provider at the facility. The facility Director of Nursing (DON) was interviewed on 10/23/20 at 3:22 PM. The DON indicated that it was a fine line between to treating Resident #2 with an antibiotic and waiting for more symptoms to appear. The DON stated she understood the concerns of NP #1 and the RP in wanting to treat the UTI before the resident decompensated quickly. The facility Administrator was interviewed on 10/23/20 at 12:04 PM. The Administrator stated that Resident #2 ate and drank everything offered to her. The Administrator stated that the increased sleepiness of Resident #2 could be normal aging or dementia. The Administrator stated that the facility did have an antibiotic stewardship program but that attempts were being made to appease the family of Resident #2 despite her asymptomatic UTIs. The facility Medical Director was interviewed on 10/23/20 at 3:37 PM. The facility Medical Director stated that she had discussed the use of antibiotics to treat asymptomatic UTIs for Resident #2 with NP #1. The Medical Director stated she trusted the judgement of NP #1 and she agreed Resident #2 would have a hard time meeting the McGeer criteria for antibiotic use due to the resident's cognition. The Medical Director agreed with the use of antibiotics for Resident #2 to help prevent urosepsis and a hospitalization . The Medical Director confirmed she thought NP #1 was treating Resident #2 appropriately with antibiotics despite not meeting the McGeer criteria.

Based on observations and staff interviews the facility failed to keep a cognitively impaired resident's catheter bag covered and urine out of view of the hall for 1 of 2 residents reviewed for catheter care. (Resident #134) Findings included: Resident #134 was admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. Review of Resident #134's orders revealed on 3/23/19 the resident was ordered to have a catheter. During observation on 4/1/19 at 3:26 PM Resident #134 was observed in bed. The resident's catheter bag was observed uncovered, facing the door to the room, and Resident #134's urine was visible from the hallway. During observation on 4/2/19 at 8:51 AM Resident #134 was observed in bed. The resident's catheter bag was still uncovered and facing the door. Resident #134's urine in the catheter bag was visible in the hall. During an interview on 4/2/19 at 9:00 AM Nurse #1 stated Resident #134 just came back from the hospital a week or so ago and her catheter bag was from the hospital which did not have privacy covers. She further stated when residents returned from the hospital to the facility, the facility had black privacy bags to place on the hospital catheter bags in. The facility did this for the dignity of the residents. The nurse concluded she did not know why one had not been put in place for Resident #134. During an interview on 4/2/19 at 9:09 AM the Director of Nursing stated when residents came to the facility from the hospital with catheters, the catheter bag itself would be changed to a facility supplied catheter collection bag, which had a privacy cover. She stated this change was to be done within the first day or two of resident arrival to insure dignity. She further stated Resident #134's came to the facility on [DATE] after a quick stay in the hospital. The Director of Nursing stated the catheter bag was uncovered and visible from the hall and the resident's urine could be seen in the hallway. She further stated for dignity reasons the catheter bag should have been replaced and it had not been done. She further stated she did know why the catheter bag had not been replaced and she would replace the catheter bag immediately following the interview.

Based on observations, record review, physicians, and staff interview, the facility neglected to identify and remove wound packing left inside a sacral pressure ulcer for 1 of 6 residents (Resident #11) investigated for wound care which resulted in the decline of the sacral pressure ulcer and development of an abscess. Findings included: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's care plan initiated 4/29/16 revealed the resident was care planned for a pressure ulcer on the sacral area. The goal was that the resident's pressure ulcer would decrease in size by next review. The interventions were to measure and record descriptions of the area, location, and size weekly, and to treat the area per physician orders. Review of the resident's quarterly minimum (MDS) data set [DATE] revealed the resident was assessed as having an unstageable pressure ulcer. The measurements of the pressure ulcer were 2.5 centimeters by 2.0 centimeters. Review of a physician's orders [REDACTED]. Record review of the resident's Treatments Administration History for the dates of 7/18/16 - 7/22/16 revealed Resident #11 was documented to have received sacral wound care. According the documentation, the wound was packed with a fine mesh gauze, soaked with normal saline, covered with dry dressing, and secured with tape on 7/18/16, 7/19/16, 7/20/16, and 7/21/16 by Treatment Nurse #1 per physician's orders [REDACTED]. Review of the weekly pressure ulcer documentation dated 7/21/16 at 3:23 PM signed by Treatment Nurse #1 revealed the sacral pressure ulcer was recorded as an unstageable pressure ulcer, 0.8 centimeters by 0.8 centimeters by 0.1 centimeters. Undermining (meaning the wound continued under intact skin) was noted at 12 o'clock 1.5 centimeters, 3 o'clock 0.5 centimeters, 6 o'clock 0.5 centimeters, and 9 o'clock 0.5 centimeters. 100% of the wound bed was documented to be granulation tissue (new healthy tissue growth that occurs during the wound healing process). Pressure ulcer care was documented as performed. Review of a physician's orders [REDACTED]. The order to pack the wound with normal saline soaked fine mesh gauze was discontinued on this date. Review of the weekly pressure ulcer check dated 7/27/16 revealed the wound was documented to be an unstageable pressure ulcer, 0.8 centimeters by 0.8 centimeters by 0.1 centimeters. Undermining was noted at 12 o'clock 1.5 centimeters, 3 o'clock 0.5 centimeters, 6 o'clock 0.5 centimeters, and 9 o'clock 0.5 centimeters. The wound was 100% granulation tissue. There was no documentation of fine mesh gauze observed in the wound. Review of the weekly pressure ulcer check dated 8/4/16 revealed the wound was documented to be an unstageable pressure ulcer, 1.0 centimeters by 1.0 centimeters with no depth. Undermining was noted at 12 o'clock 1.0 centimeters, 3 o'clock 2.0 centimeters, 6 o'clock 1.0 centimeters, and 9 o'clock 0.5 centimeters. The wound was 100% granulation tissue. There was no documentation of fine mesh gauze observed in the wound. Review of a wound care physician's consult note dated 8/11/16 revealed the resident was assessed at a doctor's office by Physician #1. Physician #1 discussed options with the family for continued treatment. The order for the [MEDICATION NAME] dressing was continued as a result of the consult. There was no documentation of fine mesh gauze observed in the wound. Review of the resident's quarterly minimum (MDS) data set [DATE] revealed the resident was assessed as having an unstageable pressure ulcer. The measurements of the pressure ulcer were 1.5 centimeters by 1.5 centimeters with no depth. There was no documentation of fine mesh gauze observed in the wound. Review of the weekly pressure ulcer check dated 8/19/16 revealed the wound was documented to be an unstageable pressure ulcer, 0.5 centimeters by 0.5 centimeters with no depth. The wound was 100% granulation tissue. There was no documentation of fine mesh gauze observed in the wound. Review of the weekly pressure ulcer check dated 8/25/16 revealed the wound was documented to be an unstageable pressure ulcer, 0.3 centimeters by 0.3 centimeters with no depth. The wound was 100% granulation tissue. There was no documentation of fine mesh gauze observed in the wound. Review of the weekly pressure ulcer check dated 8/29/16 revealed the wound was documented to be an unstageable pressure ulcer, 0.5 centimeters by 0.5 centimeters with no depth. The wound was 100% [MEDICATION NAME] tissue. There was no documentation of fine mesh gauze observed in the wound. Review of the weekly pressure ulcer check dated 9/5/16 revealed the wound was documented to be a stage II pressure ulcer, 0.3 centimeters by 0.3 centimeters with no depth. The wound was 100% [MEDICATION NAME] tissue. There was no documentation of fine mesh gauze observed in the wound. Review of the weekly pressure ulcer check dated 9/13/16 revealed the wound was documented to be a stage II pressure ulcer, 0.2 centimeters by 0.2 centimeters with no depth. The wound was 100% [MEDICATION NAME] tissue. There was no documentation of fine mesh gauze observed in the wound. Review of the weekly pressure ulcer check dated 9/26/16 revealed the wound was documented to be a stage I pressure ulcer, 0.5 centimeters by 0.5 centimeters with no depth. The wound was 100% [MEDICATION NAME] tissue. There was no documentation of fine mesh gauze observed in the wound. Review of Resident #11's progress note dated 10/5/16 revealed during the routine dressing change to sacral pressure ulcer, Treatment Nurse #2 noted a large 6 centimeters by 6 centimeters soft fluid-filled packet at the wound. The skin color at the wound was noted to be red. Treatment Nurse #2 notified the Medical Director and an appointment was scheduled with Physician #1 the next day. Review of a wound care physician's consult note dated 10/6/16 revealed Physician #1 assessed Resident #11's pressure ulcer at his doctor's office. The assessment revealed the sacral ulcer had increased pain and redness. A large abscess was noted to be 12 centimeters by 12 centimeters by 5 centimeters on the resident's sacrum. Physician #1 performed an incision and drainage of the abscess and discovered 6 inches of fine mesh gauze in the subcutaneous tissue. Review of Resident #11's most recent Minimum (MDS) data set [DATE] revealed the resident had a stage III pressure ulcer. Review of Resident #11's most recent weekly pressure ulcer check dated 11/28/16 revealed the resident's sacral pressure ulcer measurements were 2.5 centimeters by 1.5 centimeters by 0.7 centimeters. Review of the resident's active [DIAGNOSES REDACTED]. During a telephone interview on 11/30/16 at 12:20 PM, Physician #1 stated when he observed Resident #11 on 8/11/16 he did not observe any fine mesh gauze in the wound. He further stated he only continued the ordered [MEDICATION NAME] dressing following this visit. Physician #1 stated that the facility placed a fine mesh gauze in the pressure ulcer on the sacrum intentionally or unintentionally at some point while the wound was still open. He further stated the gauze was either lost or forgotten about and the wound healed over the gauze. Physician #1 further stated that he had no doubt the gauze was the cause of the abscess that Resident #11 developed and he treated on 10/6/16. Physician #1 stated that someone in the facility's staff had made a mistake and either not followed the order correctly or had lost a gauze in the wound somehow. He further stated that the fine mesh gauze should not have been left in the wound. During an interview on 11/30/16 at 2:45 PM Treatment Nurse #2 stated Resident #11's sacral pressure ulcer was first identified on 4/27/16. Treatment Nurse #2 stated that she was not the wound care nurse at that time. She stated that when she began care of Resident #11's sacral pressure ulcer, the skin was healing and intact. She stated that the wound care orders at that time were for [MEDICATION NAME] dressing changed every three days and as needed. She further stated she had never packed the wound prior to it being reopened 10/6/16. Treatment Nurse #2 stated that she felt the resident had progressed well and she believed care was about to be discontinued, but on 10/5/16 she changed the resident's dressing and observed a fluid pack around the wound. She stated she alerted the medical director and the resident was sent to Physician #1's office the next day for wound care. She added a piece of wound packing in the resident's pressure ulcer was found by Physician #1. Treatment Nurse #2 stated that when changing a [MEDICATION NAME] dressing, she would inspect the wound for healing and make measurements. She further stated that when she began to care for the resident's wound full time, the wound had already closed and the skin was intact so she was unable to inspect inside the wound. During an interview on 11/30/16 at 5:22 PM the Director of Nursing (DON) stated she that she expected the wound would be inspected by the wound care nurse upon return to the facility from the doctor's visit with new orders. She further stated her expectation was anything noted foreign or unusual in the wound during the assessment to be documented and reported. The Director of Nursing stated the nurses informed her of the abscess found on 10/6/16. The DON stated she believed the abscess could have caused harm to the resident, but did not know if the abscess was a result of the gauze being left in the resident. During an interview on 11/30/16 on 5:57 PM Treatment Nurse #2 stated she covered the Treatment Nurse #1's shift on 7/15/16 and then again on 7/23/16. During these dates the [MEDICATION NAME] dressing was ordered. She stated she did not remember ever placing fine mesh gauze in the resident's wound and that she checked the dressing each day and performed the weekly wound assessments as ordered. She further stated that due to the abscess Resident #11 had developed, the resident had increased reports of pain to the area. She stated that the resident was receiving pain medications for the increased pain. Treatment Nurse #1 no longer worked for the facility. Attempts were made to interview Treatment Nurse #1 with no return calls received.

Based on observations, record review, physicians, and staff interview, the facility failed to remove wound packing from a sacral pressure ulcer for 1 of 6 residents (Resident #11) investigated for wound care which resulted in the decline of the sacral pressure ulcer and development of an abscess. Findings included: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's care plan initiated 4/29/16 revealed the resident was care planned for a pressure ulcer on the sacral area. The goal was that the resident's pressure ulcer would decrease in size by next review. The interventions were to measure and record descriptions of the area, location, and size weekly, and to treat the area per physician orders. Review of the resident's quarterly minimum (MDS) data set [DATE] revealed the resident was assessed as having an unstageable pressure ulcer. The measurements of the pressure ulcer were 2.5 centimeters by 2.0 centimeters. Review of a physician's orders [REDACTED]. Record review of the resident's Treatments Administration History for the dates of 7/18/16 - 7/22/16 revealed Resident #11 was documented to have received sacral wound care. According the documentation, the wound was packed with a fine mesh gauze, soaked with normal saline, covered with dry dressing, and secured with tape on 7/18/16, 7/19/16, 7/20/16, and 7/21/16 by Treatment Nurse #1 per physician's orders [REDACTED]. Review of the weekly pressure ulcer documentation dated 7/21/16 at 3:23 PM signed by Treatment Nurse #1 revealed the sacral pressure ulcer was recorded as an unstageable pressure ulcer, 0.8 centimeters by 0.8 centimeters by 0.1 centimeters. Undermining (meaning the wound continued under intact skin) was noted at 12 o'clock 1.5 centimeters, 3 o'clock 0.5 centimeters, 6 o'clock 0.5 centimeters, and 9 o'clock 0.5 centimeters. 100% of the wound bed was documented to be granulation tissue (new healthy tissue growth that occurs during the wound healing process). Pressure ulcer care was documented as performed. Review of a physician's orders [REDACTED]. The order to pack the wound with normal saline soaked fine mesh gauze was discontinued on this date. Review of the weekly pressure ulcer check dated 7/27/16 revealed the wound was documented to be an unstageable pressure ulcer, 0.8 centimeters by 0.8 centimeters by 0.1 centimeters. Undermining was noted at 12 o'clock 1.5 centimeters, 3 o'clock 0.5 centimeters, 6 o'clock 0.5 centimeters, and 9 o'clock 0.5 centimeters. The wound was 100% granulation tissue. Review of the weekly pressure ulcer check dated 8/4/16 revealed the wound was documented to be an unstageable pressure ulcer, 1.0 centimeters by 1.0 centimeters with no depth. Undermining was noted at 12 o'clock 1.0 centimeters, 3 o'clock 2.0 centimeters, 6 o'clock 1.0 centimeters, and 9 o'clock 0.5 centimeters. The wound was 100% granulation tissue. Review of a wound care physician's consult note dated 8/11/16 revealed the resident was assessed at a doctor's office by Physician #1. Physician #1 discussed options with the family for continued treatment. The order for the [MEDICATION NAME] dressing was continued as a result of the consult. Review of the resident's quarterly minimum (MDS) data set [DATE] revealed the resident was assessed as having an unstageable pressure ulcer. The measurements of the pressure ulcer were 1.5 centimeters by 1.5 centimeters with no depth. Review of the weekly pressure ulcer check dated 8/19/16 revealed the wound was documented to be an unstageable pressure ulcer, 0.5 centimeters by 0.5 centimeters with no depth. The wound was 100% granulation tissue. Review of the weekly pressure ulcer check dated 8/25/16 revealed the wound was documented to be an unstageable pressure ulcer, 0.3 centimeters by 0.3 centimeters with no depth. The wound was 100% granulation tissue. Review of the weekly pressure ulcer check dated 8/29/16 revealed the wound was documented to be an unstageable pressure ulcer, 0.5 centimeters by 0.5 centimeters with no depth. The wound was 100% [MEDICATION NAME] tissue. Review of the weekly pressure ulcer check dated 9/5/16 revealed the wound was documented to be a stage II pressure ulcer, 0.3 centimeters by 0.3 centimeters with no depth. The wound was 100% [MEDICATION NAME] tissue. Review of the weekly pressure ulcer check dated 9/13/16 revealed the wound was documented to be a stage II pressure ulcer, 0.2 centimeters by 0.2 centimeters with no depth. The wound was 100% [MEDICATION NAME] tissue. Review of the weekly pressure ulcer check dated 9/26/16 revealed the wound was documented to be a stage I pressure ulcer, 0.5 centimeters by 0.5 centimeters with no depth. The wound was 100% [MEDICATION NAME] tissue. Review of Resident #11's progress note dated 10/5/16 revealed during the routine dressing change to sacral pressure ulcer, Treatment Nurse #2 noted a large 6 centimeters by 6 centimeters soft fluid-filled packet at the wound. The skin color at the wound was noted to be red. Treatment Nurse #2 notified the Medical Director and an appointment was scheduled with Physician #1 the next day. Review of a wound care physician's consult note dated 10/6/16 revealed Physician #1 assessed Resident #11's pressure ulcer at his doctor's office. The assessment revealed the sacral ulcer had increased pain and redness. A large abscess was noted to be 12 centimeters by 12 centimeters by 5 centimeters on the resident's sacrum. Physician #1 performed an incision and drainage of the abscess and discovered 6 inches of fine mesh gauze in the subcutaneous tissue. Review of Resident #11's most recent Minimum (MDS) data set [DATE] revealed the resident had a stage III pressure ulcer. Review of Resident #11's most recent weekly pressure ulcer check dated 11/28/16 revealed the resident's sacral pressure ulcer measurements were 2.5 centimeters by 1.5 centimeters by 0.7 centimeters. Review of the resident's active [DIAGNOSES REDACTED]. During a telephone interview on 11/30/16 at 12:20 PM, Physician #1 stated when he observed Resident #11 on 8/11/16 he did not observe any fine mesh gauze in the wound. He further stated he only continued the ordered [MEDICATION NAME] dressing following this visit. Physician #1 stated that the facility placed a fine mesh gauze in the pressure ulcer on the sacrum intentionally or unintentionally at some point while the wound was still open. He further stated the gauze was either lost or forgotten about and the wound healed over the gauze. Physician #1 further stated that he had no doubt the gauze was the cause of the abscess that Resident #11 developed and he treated on 10/6/16. Physician #1 stated that someone in the facility's staff had made a mistake and either not followed the order correctly or had lost a gauze in the wound somehow. He further stated that the fine mesh gauze should not have been left in the wound. During an interview on 11/30/16 at 2:45 PM Treatment Nurse #2 stated Resident #11's sacral pressure ulcer was first identified on 4/27/16. Treatment Nurse #2 stated that she was not the wound care nurse at that time. She stated that when she began care of Resident #11's sacral pressure ulcer, the skin was healing and intact. She stated that the wound care orders at that time were for [MEDICATION NAME] dressing changed every three days and as needed. She further stated she had never packed the wound prior to it being reopened 10/6/16. Treatment Nurse #2 stated that she felt the resident had progressed well and she believed care was about to be discontinued, but on 10/5/16 she changed the resident's dressing and observed a fluid pack around the wound. She stated she alerted the medical director and the resident was sent to Physician #1's office the next day for wound care. She added a piece of wound packing in the resident's pressure ulcer was found by Physician #1. She further stated that when she placed fine mesh gauze in a wound no more than one continuous length of fine gauze should be placed and there should be enough fine mesh gauze in the wound to be observed and taken hold of to be removed. Treatment Nurse #2 stated that when changing a [MEDICATION NAME] dressing, she would inspect the wound for healing and make measurements. She further stated that when she began to care for the resident's wound full time, the wound had already closed and the skin was intact so she was unable to inspect inside the wound. During observation on 11/30/16 at 2:52 Treatment Nurse #2 provided wound care to Resident #11's sacral pressure ulcer. The resident's wound was observed to have an opening approximately 2.0 centimeters by 1.5 centimeters by 0.7 centimeters with 3 centimeters of undermining from 1 o'clock to 7 o'clock. The wound care nurse provided wound care according to the physician's order [REDACTED]. During an interview on 11/30/16 at 5:22 PM the Director of Nursing (DON) stated it was her expectation that wound care with nu-gauze be provided according to the doctor's orders. She further stated that she expected the wound would be inspected by the wound care nurse upon return to the facility from the doctor's visit with new orders. She further stated her expectation was anything noted foreign or unusual in the wound during the assessment to be documented and reported. The Director of Nursing stated the nurses informed her of the abscess found on 10/6/16. The DON stated she believed the abscess could have caused harm to the resident, but did not know if the abscess was a result of the gauze being left in the resident. During an interview on 11/30/16 on 5:57 PM Treatment Nurse #2 stated that after the abscess had been found on 10/6/16 she reported it to the charge nurse and the DON. She stated she covered the Treatment Nurse #1's shift on 7/15/16 and then again on 7/23/16. During these dates the [MEDICATION NAME] dressing was ordered. She stated she did not remember ever placing fine mesh gauze in the resident's wound and that she checked the dressing each day and performed the weekly wound assessments as ordered. She further stated that due to the abscess Resident #11 had developed, the resident had increased reports of pain to the area. She stated that the resident was receiving pain medications for the increased pain. Treatment Nurse #1 no longer worked for the facility. Attempts were made to interview Treatment Nurse #1 with no return calls received.