Every finding on record at Pinnacle Health & Rehab at Sanford

Based on record review and interview, the facility failed to ensure a person-centered comprehensive care plan was developed in the area of Activities of Daily Living (ADL's) to meet the preferences and goals which included interventions for assistance needed for each resident to attaining or maintaining his or her highest practicable quality of life for 6 of 14 residents care plans reviewed. (Residents 6, 11, 21, 47, 55, 26, and 61) Findings: 1. Review of Resident #6's current ADL self-care performance deficit care plan lacked interventions which included the assistance needed for him/her in the area of eating, personal hygiene, transfers, lower body dressing, bathing, toileting, bed mobility and ambulating. 2. Review of Resident #11's current ADL self-care performance deficit care plan lacked interventions which included the assistance needed for him/her in the area of eating, personal hygiene, lower body dressing, bathing and oral hygiene. 3. Review of Resident #21's current ADL self-care performance deficit care plan lacked interventions which included the assistance needed for him/her in the area of eating, personal hygiene, transfers, lower body dressing, bathing, toileting, bed mobility and ambulating. 4. Review of Resident #47's current ADL self-care performance deficit care plan lacked interventions which included the assistance needed for him/her in the area of personal hygiene, lower body dressing, bathing, toileting hygiene and oral hygiene. On 2/11/25 at 1:49 p.m., during an interview, the Licensed Practical Nurse Manager for the first floor stated, in the beginning of the year the Minimum Data Set assessments for GG - Functional Abilities were changed, which also changed the residents care plans. This change failed to update the residents' care plan to include the personalization for the assistance needed for each resident to attain or maintain his/her functional abilities. 37015 5. Review of Resident #26's current ADL self-care performance deficit care plan lacked interventions which included the assistance needed for him/her in the area of personal hygiene, lower and upper body dressing, bathing and shower transfers. On 2/11/25 at 2:08 p.m., the finding was discussed with the Director of Nursing. 48648 6. Review of Resident #61's current ADL self-care performance deficit care plan lacked interventions which included the assistance needed for him/her in the area of eating, personal hygiene, transfers, lower body dressing, bathing, toileting and bed mobility. On 2/11/25 at approximately 2:00 p.m. a surveyor discussed the above findings with the Unit Director who confirmed that this information didn't automatically transfer with the new Electronic Medical Record system and would need to be added. 44049 Review of Resident #55s current ADL self-care performance deficit care plan lacked interventions which included the assistance needed for him/her in the area of personal hygiene, lower and upper body dressing, bathing and shower transfers. On 2/11/25 at approximately 3:00 p.m. the finding was discussed with the Director of Nursing

Based on record reviews, observations and interviews the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation by failing to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for multiple shifts, on 2 of 2 units reviewed. Findings: A review of the facility's Shift Count policy and procedure dated: 2/3/2000, stated under Procedure, 1. All schedule II-V medications will be counted at the change of each shift by the off-going and the on-coming nurse. 3. If the count is correct, the keys change hands and the shift count sheet is signed by both nurses. On 2/11/25 at 11:00 a.m., during a medication storage observation of the Second Floor Medication Room, a surveyor reviewed the Controlled Substance Books and Shift Counts which indicated the facility counts at the change of each shift, approximately 3 times a day. The person authorized to administer medications coming on duty or the person authorized to administer medications going off duty both failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was completed on multiple days. On 2/11/25 at 11:45 a.m., the surveyor confirmed the findings with the Unit Manager. On 2/11/25 at 3:30 p.m., the findiing was discussed the findings with the Administrator. On 2/11/25 at 4:00 p.m., during a medication storage observation of the First Floor Medication Room, a surveyor reviewed the Controlled Substance Books and Shift Counts. The person authorized to administer medications coming on duty or the person authorized to administer medications going off duty both failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was completed on multiple days. On 2/11/25 at 4:20 p.m., the surveyor confirmed the findings with the Charge Nurse. On 2/12/25 at 10:15 a.m., the surveyor discussed that multiple days on both units were missing staff signatures for verification and completion of the controlled medication count on the following dates: 6/16/24, 9/13/24, 10/2/24, 10/3/24, 11/3/24, 11/6/24, 11/16/24, 11/23/24, 12/2/24, 12/12/24, 12/29/24, 1/3/25, 1/18/25, 1/24/25, 1/25/25, 1/26/25 (both units), 1/27/25, 2/9/25, and 2/10/25.

Based on observation, interviews, and the Centers for Disease Control (CDC) guidance, the facility failed to ensure vaccines were stored in a refrigerator without a freezer compartment for 1 of 3 medication storage refrigerators. Finding: A review of the United States (U.S.) Centers for Disease Control and Prevention: Vaccine Storage and Handling Toolkit dated 3/24/24 stated .Do not store any vaccine in a dormitory-style or bar-style combined refrigerator/freezer unit under any circumstances. On 2/11/25 at 4:00 p.m., during an observation of the First Floor Unit's Medication Room, a surveyor observed a dormitory style refrigerator (small combination refrigerator/freezer unit that is outfitted with one exterior door). The refrigerator contained several vials of purified protein derivative (for tuberculosis testing), and unit dose syringes of pneumococcal and influenza vaccines. On 2/11/25 at 4:20 p.m., the finding was confirmed by the charge nurse and the Infection Preventionist. On 2/12/25 at 10:15 a.m., the finding was discussed with the Administrator.

Based on observations and interviews, the facility failed to maintain a clean, comfortable and homelike environment on 2 of 2 units. Findings: On 2/12/25 at approximately 9:00 a.m. the following was observed on the First floor: -Resident room [ROOM NUMBER] - Wall behind chair in need of repair. -Many pieces of tape hanging from the ceiling in the main dining room -First floor common area has several dark spots on ceiling strapping -Unpainted repaired area on wall in Spa room. On 2/12/25 at approximately 9:30 a.m. the following was observed on the Second floor: -Stained ceiling tile just outside room [ROOM NUMBER] On 2/12/25 at approximately 10:00a.m. in an interview with the Administrator, the surveyor discussed the environmental observations.

Based on record reviews, interviews, and facility policy, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 5 residents records reviewed during complaint investigations (Resident 2). Findings: On 9/13/2024 at 10:19 a.m., the Department of Licensing received a complaint indicating ADL care was not being provided to Resident 2 as stated in the care plan. Review of facility policy Activities of Daily Living dated 1/1/95 states .Activities of daily living include bathing, dressing, ambulation and transfer, eating, and use of speech, language or other functional communication systems.the care plan will identify any unique needs or special treatment and services necessary to maintain or improve functional ability. Resident 2 was admitted on [DATE] and has diagnoses to include Parkinson's disease and is dependent on facility staff for all ADL needs. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident 2 had a Brief Interview for Mental Status (BIMS) of 11 of 15 indicating he/she has moderate cognitive impairment. Review of Resident 2's care plan, most recently updated on 8/27/24 revealed Problem: [Resident 2 has an ADL self-care performance deficit r/t Parkinson's with tremors and weakness. Goal: [Resident 2] and [his/her] family want [him/her] to maintain current level of function. Intervention: Staff assist with adls (Refer to tasks documentation); Oral hygiene and denture cleaning after each meal and bedtime; Toilet or change resident every 3-4 hours. Turn and reposition every two hours . Review of Resident 2's clinical record [task] lacked documented evidence Resident 2 was provide oral hygiene and denture cleaning as follows: after breakfast on 9/2/24, 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/8/24, 9/9/24, 9/10/24, 9/11/24, 9/12/24, 9/14/24, 9/15/24, 9/16/24, 9/17/24, 9/18/24, 9/19/24, 9/23/24, 9/27/24, 9/28/24, 9/29/24. After lunch on 9/7/24, 9/8/24, 9/9/24, 9/11/24, 9/13/24, 9/14/24, 9/16/24, 9/20/24, 9/21/24, 9/22/24, 9/23/24, 9/25/24, 9/26/24, 9/27/24, or 9/28/24. after dinner on 9/2/24, 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/7/24, 9/8/24, 9/9/24, 9/10/24, 9/11/24, 9/12/24, 9/13/24, 9/14/24, 9/15/24, 9/16/24, 9/17/24, 9/18/24, 9/22/24, 9/26/24, 9/27/24, or 9/28/24, and at bedtime on 9/2/24, 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/23/24, 9/25/24, 9/29/24, or 9/30/24. Review of Resident 2's clinical record [task] Toilet or change resident every 3-4 hours(total of 5-6 times daily) revealed Resident 2 was toileted 1 (one) time on 9/14, 2 (two) times on 9/2/24, 9/7/24, 9/8/24, 9/9/24, 9/11/24, 9/16/24, 9/23/24, 9/27/24, 9/28/24 and 9/30/24, and was toileted 3 (three) times on 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/10/24, 9/12/24, 9/13/24, 9/15/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/22/24, 9/24/24, 9/25/24, 9/26/24 and 9/29/24. Review of Resident 2's clinical record [task] Turn and Reposition (per care plan total of 12 times daily) revealed Resident 2 was turned/repositioned 1 (one) time on 9/14/24, 2 (two) times 9/7/24, 9/8/24, 9/9/24, 9/11/24, 9/16/24, 9/23/24, 9/27/24, 9/28/24 and 9/30/24. 2 (two) times on 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/10/24, 9/12/24, 9/13/24, 9/15/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/22/24, 9/24/24, 9/25/24, 9/29/24 and 9/26/24. During an interview on 10/2/24 at 12:14 a.m., Certified Nursing Assistant (CNA)1 indicated that Resident 2 needs total care with all ADL's. CNA1 further indicated Resident 2 doesn't really refuse much of anything, but if a resident refuses to do something, they should be reproached to try again at a later time, if they still refused, inform the nurse and document the refusal in clinical record. During a review of Resident 2's clinical record on 10/1/24 at 3:15 p.m., the Administrator confirmed above findings.

Based on record reviews, interviews, and facility policy, the facility failed to implement interventions outlined in resident's care plan in the area of Activities of Daily Living (ADL) for 1 of 5 residents reviewed during complaint investigations. (Resident 2). Findings: On 9/13/2024 at 10:19 a.m., the Department of Licensing received a complaint indicating ADL care was not being provided to Resident 2 as stated in the care plan. Review of facility policy Comprehensive Care Plans dated 9/3/94 states It is the policy of Pinnacle Health & Rehab [NAME] to develop a comprehensive care plan for each resident, based on the needs identified in the comprehensive assessment .Each resident's plan of care describes the services being furnished to attain or maintain the resident's highest practical level of functioning . Resident 2 was admitted on [DATE] and has diagnoses to include Parkinsons disease and is dependent on facility staff for all ADL needs. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident 2 had a Brief Interview for Mental Status (BIMS) of 11 of 15 indicating he/she has moderate cognitive impairment Review of R2's care plan, most recently updated on 8/27/24 revealed Problem: [Resident 2 has an ADL self-care performance deficit r/t Parkinson's with tremors and weakness. Goal: [Resident 2] and [his/her] family want [him/her] to maintain current level of function. Intervention: Staff assist with adls (Refer to tasks documentation); Oral hygiene and denture cleaning after each meal and bedtime; Toilet or change resident every 3-4 hours. Turn and reposition every two hours . Further review of Resident 2's entire clinical record lacked evidence that the above interventions were completed as written. During an interview on 10/2/24 at 12:14 a.m., Certified Nursing Assistant (CNA)1 indicated that Resident 2 needs total care with all ADL's. CNA1 further indicated Resident 2 doesn't really refuse much of anything, but if a resident refuses to do something, they should be reapproached to try again at a later time, if they still refused, inform the nurse and document the refusal in clinical record. During a review of Resident 2's clinical record with a surveyor on 10/1/24 at 3:15 p.m., the Administrator confirmed above findings.

Based on observations, interviews, and policy review, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection on 1 of 2 rooms observed (room [ROOM NUMBER]). Findings: Review of facility policy Infection Prevention and Control dated 5/2023 states it is the policy of [Facility] to maintain and active infection prevention and control program (IPCP). The program is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection. Observation of shared sink in room [ROOM NUMBER] on 10/1/24 at 9:07 a.m., and 1:10 p.m., revealed the following items unlabeled and available for use: 2 deodorant bottles, 2- 8 ounce bottles of body wash, 1 bottle of mouthwash, 1 can of shaving cream. 1 opened can of ginger ale, 1 electric razor, approximately 8 razors held together with a rubber band, one small, soiled basin, and 1 white paper cup containing 1 toothbrush. During an interview on 10/1/24 at 9:20 a.m., Resident 3 confirmed his/her personal hygiene items are on the sink and he/she can independently use them, stating he/she just grabs what he/she needs and is unsure who it belongs to because they're not labeled. During an interview on 10/1/24 at 1:00 p.m., Resident 2 indicated that he/she does have personal items on the shared sink, but his/her family are the ones that retrieve it for him/her. During an interview on 10/1/24 at 1:10 p.m., Licensed Practical Nurse (LPN)1 and a surveyor entered room [ROOM NUMBER] and confirmed personal items were on shared sink, unlabeled and available for use. The above was discussed with Administrator on 10/1/24 at 3:10 p.m.

Based on observations, record reviews, and interviews, the facility failed to ensure proper medication and biological storage temperatures for 2 of 3 medication refrigerators in 1 of 2 medication storage rooms. Finding: On 11/14/2023 at 1:00 p.m., a surveyor observed the 2 medication refrigerators in the first-floor medication storage room. The upper refrigerator contained insulin, and 2 locked boxes for controlled liquid medications. The second refrigerator contained tuberculin purified protein derivative, influenza, and pneumococcal vaccines. Observation of the temperature logs for the medication refrigerators noted multiple shifts were lacking documentation. The Certified Nursing Assistant-Medications confirmed the finding. On 11/15/2023 at 9:50 a.m., a surveyor observed the first-floor medication room and refrigerator temperature logs with a Licensed Practical Nurse who stated the temperatures are to be checked and documented by a licensed nurse at every shift change. A review of the temperature logs lacked evidence of temperature monitoring of medication room refrigerators as follows: November 1-15, 2023, noted incomplete documentation for 5 of 43 shifts. October 1-15, 2023, noted incomplete documentation for 11 of 45 shifts. The facility did not provide evidence of temperatures being monitored from October 16-31, 2023. September 1-30, 2023, noted incomplete documentation for 27 of 90 shifts. August 1-31, 2023, noted incomplete documentation for 30 of 90 shifts. A review of the facility's Immunization Vaccine Storage and Handling Policy and Procedure, with a revision date of 7/2023, stated 6. Refrigerator/freezer temperatures are checked at the change of each shift by a licensed nurse, as part of the medication count process. Temperatures must be within the range of 36-46 degrees Fahrenheit. On 11/15/2023 at 10:30 a.m., the finding was confirmed by the Administrator.

Based on observations and interviews, the facility failed to adequately maintain maintenance services necessary to maintain in good repair and sanitary condition of arm rests of resident's wheelchair, ceiling tiles in hallways and common areas, and thresh-hold of elevator entrance. Findings: 1. On 11/13/2023, at 10:37a.m. surveyor observed wheelchair arms cracked for Resident #5, in room [ROOM NUMBER], creating an uncleanable surface. 2. On 11/14/2023 at 2:00p.m. during an environmental tour with Director of Facilities Management, the following were observed: First floor: Three stained ceiling tiles above the microwave area in the Main Dining Room Three stained ceiling tiles, just outside of the elevator on the first floor Second floor: Three stained ceiling tiles just outside the elevator in the main hallway Three stained ceiling tiles in the 300-wing hallway just outside of room [ROOM NUMBER] 3. On 11/14/2023 at approximately 3:00p.m. surveyor observed thresh-hold floor plate exiting the elevator was buckled in two different places allowing a gap and creating a trip hazard. On 11/14/2023 at approximately 3:05p.m. all the above were reported and confirmed with the Director of Facilities Management and Administrator.

Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition, on 2 of 2 floors (First and Second), and hallways, for 1 of 1 environmental tour. Findings: On 3/2/22 at 10:00 a.m., during the Environmental Tour with the Nurse Managers of the first and second floors, the following was observed: First-floor: The common hallways of the first-floor nursing unit were observed with a dark, dirty buildup along the edges and in the corners. The floors in rooms 131-138 have a dark, dirty buildup, in the corners, in the bathrooms around the toilet bases, and under the sinks. Room 132 - The wall to the left of the light switch, is noted to have ripped sheetrock on the corner. The sink vanity has a large light-colored stain. Room 133- At the entrance to the room, the rubber strip under the door is coming loose. The wall next to the door frame has peeling paint with exposed sheetrock, the sink vanity has four (4) rusted screw heads, creating an uncleanable surface. The area next to the closet is missing a board over the heater, where a cable wire is observed with a loose cover plate and exposed insulation. Room 135-B, the floor mat had exposed foam and the zipper tab is broken creating a sharp edge. Room 138-B, has a loose board on the edge of the closet over the heater. On 3/2/22 at 10:30 a.m. the surveyor confirmed the first-floor environmental observations with the Nurse Manager. Second-floor: The common hallways of the second-floor nursing unit are observed with a dark, dirty buildup along the edges and in the corners. The floors in rooms 231- 238 are observed to have a dark, dirty buildup, in the corners, in the bathrooms around the toilet bases, and under the sinks. Room 231-the sink vanity is observed with broken laminate edges, exposing the wood, creating an uncleanable surface with sharp edges. The heater is observed with areas of rust. Room 233-the sink vanity is observed with broken laminate edges, exposing the wood, creating an uncleanable surface with sharp edges. Room 236-the sink vanity is observed with broken laminate edges, exposing the wood, creating an uncleanable surface with sharp edges. The elevated surface of the Nurses' station is observed with three strips of duct type tape. The Nurse Manager stated that it had been that way for a while. In addition, the lower surface of the counter has strips of blue painter's type tape on the laminate edges, all creating an uncleanable surface. On 3/2/22 at 11:30 a.m. the surveyor confirmed the second-floor environmental observations with the Nurse Manager.

Based on record review and interview, the facility lacked evidence of a written transfer notice indicating rationale for a facility-initiated transfer for 3 of 3 residents reviewed for transfer (#7, #8 and #51). Findings: 1. Documentation in Resident #7's clinical record indicated that he/she was transferred to an acute care hospital on 12/14/21. Review of the clinical record lacked evidence of a transfer notice indicating rationale for the facility-initiated transfer. 2. Documentation in Resident #8's clinical record indicated that he/she was transferred to an acute care hospital on 12/10/21 and 12/12/21. Review of the clinical record lacked evidence of a transfer notice indicating rationale for the facility-initiated transfer. 3. Documentation in Resident #51's clinical record indicated that he/she was transferred to an acute care hospital on 1/4/22. Review of the clinical record lacked evidence of a transfer notice indicating rationale for the facility-initiated transfer. On 3/1/22 at 4:20 p.m., in an interview with a surveyor, the evening supervisor explained the transfer/discharge process. The facility's transfer form is used for communication to the receiving facility. On 3/2/22 at 9:50 a.m., in an interview with two surveyors, the facility's social worker stated the transfer notice mailed to the resident's representative is included in the discharge to home packet and is not given to residents who are transferred to the hospital or other facility. The social worker confirmed the facility's current forms do not meet the requirements of the regulations for transfer/discharge notices.

Based on record review and interview, the facility failed to issue a bed hold notice which included the daily bed hold cost, to a resident, known family member or legal representative for 3 of 3 sampled residents who had been transferred to the hospital (#7, #8 and #51). Findings: 1. Resident #7's clinical record revealed the resident was transferred to an acute care hospital on 12/14/21. The clinical record contained an incomplete bed-hold notice for the transfer, which did not include the daily bed hold cost. 2. Resident #8's clinical record revealed that the resident was transferred to the hospital on 12/10/21 and 12/12/21. The clinical record contained incomplete bed-hold notices for both transfers, which did not include the daily bed hold cost. 3. Resident #51's clinical record revealed that the resident was transferred to the hospital on 1/4/22. The clinical record contained an incomplete bed-hold notice for the transfer, which did not include the daily bed hold cost. On 3/2/22 at 9:50 a.m., in an interview with surveyors, the facility's social worker confirmed the facility's current forms do not meet the requirements of the regulation for bed hold notices, including information for daily bed hold costs and appeal rights.

Based on a review of the United States Centers for Disease Control and Prevention (CDC) guidelines, facility policy review, and staff interviews, the facility failed to screen staff and ensure documenting the results [of the screenings] for Coronavirus Disease -19 (COVID-19) in accordance with CDC guidelines and in accordance with facility policy and procedure for 2 of 11 facility staff interviewed (the Infection Preventionist, Maintenance Assistant #1) . Findings: A review of the United States Centers for Disease Control and Prevention, Preparing for COVID-19 in Nursing Homes, updated June 25, 2020 notes the following: Screen all Health Care Personnel(HCP) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. A review of Center for Disease Control (CDC) guidance Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated March 29, 2021 Recommends the following: Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19: ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19. A review of the facility policy, Surveillance of Communicable Employee Diseases, revised 7/2021, noted the following, When indicated, all staff as well as essential non-employees (including volunteers, vendors, student nurses, and student nurse aids) will be actively screened for fever or other signs of infection prior to the start of each shift or upon entering the building. This screening will be completed and documented when indicated based on current CDC guidance. Copies of completed screening forms will be kept in the Infection Preventionist office for reference as needed. A review of the record of staff screening for 8/27/21 noted that it lacked evidence that Maintenance Assistant #1, had been screened when reporting to work on 8/27/21 and prior to testing positive for COVID-19 on 8/30/21. A review of the record of staff screening on 9/02/21 noted that it lacked evidence that the Infection Preventionist was screened when she entered the facility. On 9/20/21 at 11:00 a.m. during an interview, the Infection Preventionist stated that on 9/02/21, upon arriving at the facility, she screened herself, conducted a rapid [MEDICATION(S)] test for COVID-19 on herself, and entered the facility wearing the recommended source control. The IP confirmed that the screening record dated 9/2/21 lacked documentation of her screening of symptoms, and lacked the results of her rapid [MEDICATION(S)] test. On 9/20/21 at 1:30 p.m. during an interview, Maintenance Assistant #1 stated the following: I take my temperature every day. But I don't write it down. I report it to the Environmental Services Supervisor, and tell him if I have any symptoms. I come in and get busy with work right away. I don't go upstairs to be screened. On 9/20/21 at 11:10 a.m. the IP confirmed that the screening record dated 8/27/21 lacked evidence that Maintenance Assistant #1 was screened prior to entry into the facility. On 9/20/21 at 3:15 p.m., during an interview, the Administrator confirmed that the facility was not consistently following their Surveillance of Communicable Employee Diseases policy for screening of facility staff for COVID-19 when staff report to work.

Based on record review and interview, the facility failed to ensure that a urinary catheter care plan was developed for 1 of 2 residents reviewed with a urinary catheter (Resident #71). Finding: Documentation on Resident #71's Minimum Data Set (MDS) Admission Assessment, dated 8/8/19, indicated the Resident had an indwelling catheter. During an interview on 9/16/19 at 11:34 a.m., Resident #71 stated he/she has a catheter. On review of the resident's comprehensive care plan, dated 8/2/19, the surveyor noted, (Resident #71) has an ADL (Activities of Daily Living) self-care performance deficit with an approach, ADL - Toilet Use, Indwelling Catheter. The surveyor could not locate any further directions on the care of the catheter. On 9/17/19 at 12:03 p.m., in an interview with the the MDS Coordinator, the surveyor confirmed the care plan did not reflect the care of a urinary catheter.

Based on record review and interview, the facility failed to ensure that a care plan was updated to reflect the resident's current diet for dysphagia in 1 of 3 resident care plans reviewed for nutrition (Resident #52). Finding: On 9/18/19 at 11:00 a.m., Resident #52's clinical record review revealed that on 8/19/19 the Speech Therapist recommended, from the previous MBS (Modified [MEDICATION NAME] Swallow) dated 2/28/19, a Level 1 (pureed) diet and honey thick liquids. On 8/22/19 the physician signed orders for the Level 1 dysphagia (pureed) diet. In review of Resident #52's care plan, the surveyor noted the care plan indicated Regular diet, Regular texture, Honey consistency for all meals. On 9/18/19 at 11:55 a.m. during an interview with the Director of Nursing, the surveyor confirmed that the care plan had not been revised/updated to reflect the current physician orders [REDACTED].

Based on observation, interviews and record review, the facility failed to provide respiratory care and services to 1 of 3 residents reviewed for respiratory care (Resident #19). Finding: On 9/16/19 at 9:18 a.m., a surveyor observed Resident #19's oxygen (O2) tubing with no date on the tubing connected to a nasal cannula with darkened yellowish nasal prongs. The resident stated at this time that he/she uses oxygen every night and didn't know when the tubing was last changed. On review of the resident's medical record, the surveyor noted physician's orders [REDACTED]. The (MONTH) 2019 electronic Treatment Administration Record (eTAR) indicated O2 sats are documented every shift. On 9/17/19 at 1:47 p.m., the Minimum Data Set - Coordinator (MDS-C) confirmed in an interview that the TAR on Resident #19 does not reflect weekly tubing changes nor the amount of O2 to use, or the delivery system, when the resident does receive oxygen. On 9/18/19 at 6:14 a.m., the night shift Licensed Practical Nurse (LPN) stated in an interview with the surveyor that the oxygen tubing is changed as directed in the eTAR and it is done weekly. The LPN stated that the oxygen tubing is labeled with the date when it is changed. The LPN also confirmed that Resident #19 frequently uses oxygen during the night shift. On 9/18/19 at 7:45 a.m., in an interview with the Director of Nursing, the surveyor confirmed that Resident #19's oxygen orders do not specify how much oxygen to use, when oxygen is needed or the system to use for delivery of the oxygen. The surveyor also confirmed the clinical record did not reflect the maintenance of the system to prevent to transmission of infections.

Based on record review and interview, the facility failed to obtain consent for 3 of 35 sampled residents related to a care plan video monitoring intervention. ( #37, #89, #77) Findings: 1. On 6/20/17 at 1:24 p.m. a surveyor observed an camera in a residents room. The camera was placed on a shelf that was above Residents #37's head of bed and facing down toward bed. On 6/21/17 at 8:53 a.m. a surveyor observed a camera in residents room sitting on nightstand beside the bed facing towards residents bed. Residents #37's care plan for the problem history of falls included an intervention that indicated camera in place for safety, prn (as needed). During a medical record review, the medical record lacked evidence of a consent for use of a camera in a resident room. On 6/20/17 at 2:04 p.m. in an interview with the Director of Nurses (DON) and the MDS (Minimum Data Set) Coordinator, the DON confirmed they have no documented consent for use of the cameras and that they use the cameras for falls. 2. Resident #89 was admitted to the facility in February 2017. Review of the care plan reveals on 2/24/17 the following intervention was intiated use video monitor as indicated for safety. On 6/21/17 at 2:00 p.m., a surveyor observed the camera on the bedside table in the resident's room. On 6/21/17 at 2:10 p.m., in an interview with the Charge Nurse, he/she indicates the camera is used when Resident # 89 is in the bedroom . On 06/22/17 at 8:17 a.m., the Nurse Manager indicated, the cameras are in the rooms as needed , this is a nurses judgment and we have always done this when safety is of high concern. the Nurse Manager further indicated, the family of Resident #89 is aware that camera use is in place; however; confirmed there is not a documented consent. 3. Resident #77 was admitted to the facility in April 2017. Review of the care plan reveals on 4/13/17 the following intervention was intiated use video camera PRN. On 6/21/17 at 2:00 p.m., the surveyor observed the camera in the resident's room. On 6/21/17 at 2:10 p.m., in an interview with the Charge Nurse, he/she indicates the camera is in use when Resident #77 is in the bedroom On 06/22/17 8:17 a.m., the Nurse Manager indicated,the cameras are in the rooms as needed , this is a nurses judgment and we have always done this when safety is of high concern. The Nurse Manager further indicated, the family of Resident #77 is aware that the camera is in place; however confirmed there is not a documented consent. On 6/22/17 at 9:15 a.m., the Administrator provided an Accident/Incident CQI Reporting Form stating that on 4/12/17 the responsible party was notified of a video camera placed at bedside for use. From 4/13/17 until 6/22/17, 70 days there was not a documented consent.

Based on observation, interview and record review, the facility failed to ensure the personal privacy of 3of 35 sampled residents through the use of video monitoring for safety. ( #37, #89, #77) Findings: 1. During a review of Resident #37's medical record, Progress notes dated 5/22/17 indicated Resident #37 stated he/she wanted to commit suicide. The facility initiated the suicide prevention protocol, placed resident on 15 minute check and removed potential harm. In addition, Progress Notes dated 5/22/17 indicated resident does have a camera and this was placed out of reach behind his bed aimed at him/her. On 6/20/17 at 1:24 p.m. a surveyor observed an observation camera in a residents room. The camera was placed on a shelf that was above the Residents #37's head of bed and was facing towards bed. On 6/21/17 at 8:53 a.m. a surveyor observed a camera in the residents room sitting on nightstand beside the bed which was facing towards residents bed. Residents #37's care plan for the problem history of falls consisted of an intervention that indicated camera in place for safety, prn. During a medical record review, the medical record lacked evidence of a consent for use of a camera in a resident room. On 6/20/17 at 2:04 p.m. the finding was confirmed in an interivew with the Director of Nurses (DON) and the MDS Coordinator, the DON confirmed they use the cameras for falls. 2. In review of Resident #89's care plan, there is an intervention initiated on 2/24/17 that states use video monitor as indicated for safety. On 6/21/17 at 2:00 p.m., a surveyor observed the resident's room that contained a camera on the bedside table. On 6/21/17 at 2:10 p.m., in an interview with the Charge Nurse, he/she indicates the camera is used when Resident # 89 is in the bedroom . On 06/22/17 at 8:17 a.m., in an interview with a surveyor the Nurse Manager confirmed, the cameras are in the rooms as needed , this is a nurses judgment and we have always done this when safety is of high concern. 3. In review of Resident #77's care plan, there is an intervention initiated on 4/13/17 that indicates use video camera PRN. On 6/21/17 at 2:00 p.m., the surveyor observed the camera in the resident's room. On 6/21/17 at 2:10 p.m., in an interview with the Charge Nurse, he/she indicates the camera is in use when Resident #77 is in the bedroom On 06/22/17 8:17 a.m., in an interview with a surveyor the Nurse Manager confirmed,the cameras are in the rooms as needed , this is a nurses judgment and we have always done this when safety is of high concern.

Based on observations and interviews the facility failed to ensure that hot water temperatures accessible to residents did not exceed 120 degrees Fahrenheit during 1 of 4 days of survey on all resident wings of the facility. Finding: On 6/19/17 between 2:45 p.m. and 3:15 p.m., 4 surveyors observed the following hot water temperature readings: In Resident Room 111, 126.6 degrees Fahrenheit; In Resident Room 116, 122.9 degrees Fahrenheit; In Resident Room 118, 122 degrees Fahrenheit; In Resident Room 122, 125.7 degrees Fahrenheit; In Resident Room 132, 123 degrees Fahrenheit; In Resident Room 215, 124 degrees Fahrenheit; In Resident Room 218, 121 degrees Fahrenheit; In Resident Room 222, 125.4 degrees Fahrenheit; In Resident Room 226, 120.4 degrees Fahrenheit; In Resident Room 231, 126 degrees Fahrenheit; and In Resident Room 236, 125.4 degrees Fahrenheit. On 6/19/17 at 3:05 p.m., the surveyor discussed the temperature readings with the administrator, who confirmed the readings exceeded 120 degrees. On 6/19/17 at 3:18 p.m., the Environmental Services Director confirmed in an interview with the surveyors the high hot water temperature readings. Interviews with staff and residents indicated no prior awareness of hot water temperatures.

Based on medical record review and interview the facility failed to follow doctors orders for obtaining lab levels for use of [MEDICATION NAME] for 1 of 5 residents reviewed for unnecessary medications. (#37) Finding: During a review of Resident #37 medical record, Doctors Order Sheet dated 3/30/17 indicated continue same dose [MEDICATION NAME] 5 mg (milligram) alt (alternate) with 4.5 mg [MEDICATION NAME]. Repeat INR (International Normalized Ratio) in 1 week (6 [DATE]). Residents [MEDICATION NAME] Flow Sheet and medical record lacks evidence of an INR level was completed on 4/6/17. The Medication Administration Record [REDACTED]. The [MEDICATION NAME] Flow Sheet revealed that there was no INR levels documented as being drawn between 3/30/17 and 5/24/17. The [MEDICATION NAME] Flow Sheet confirmed that between the December 2016 and March 2017 resident previously was having INR levels drawn 4 -5 times monthly On 6/21/17 at 2:24 p.m. in an interview with the Director Of Nurses (DON), the DON confirmed that she did pick up that the INR lab was not completed and had was obtained on 5/24/17.