Every finding on record at Pruitthealth - Seaside

Based on observations, staff interview, and review of the facility's policy titled Labeling, Dating, and Storage, the facility failed to follow the proper procedures for labeling, dating, and storage to ensure proper food safety and to prevent foodborne illness. In addition, the facility failed to ensure the cleaning of appliances (stoves, ovens, fryers), countertops, food preparation areas, and the floor in the kitchen area. The deficient practice had the potential to affect 76 out of 79 residents receiving an oral diet from the kitchen.Findings include:Review of the facility policy titled, Labeling, Dating, and Storage dated 11/11/2022 under the Policy Statement: revealed, It is the policy of (Name of Organization) for all partners who assist in handling, preparing, serving and storing food and beverage items to follow the proper procedures for labeling, dating, and storage to ensure proper food safety. Under, Procedure: 1. Food and beverage items will have an identifying label as well as received date and opened date, as applicable; for items prepared onsite, a 'use by' date will also be indicated. 2. Foods will be stored in their original or approved container and, if opened, shall be wrapped tightly with film, foil, etc. 3. Bulk food dispensing utensils (scoops) shall be stored: (a): in a clean, protected location if the scoops are used only with a food that is not a time/temperature controlled for safety food. 4. Food and beverage items will be discarded according to guidance from a government agency such as the USDA and FDA; an example of approved guidance is attached to this policy.Observation during a tour of the kitchen on 9/3/2025 at 8:45 am with the Dietary Manager (DM) revealed the following:-In the walk-in pantry, there were containers of dried onions that had not been labeled.-In the walk-in freezer in the kitchen there were bags of cheese opened and not labeled, milk that had been expired and dated 4/8/2025, storage of employee's personal food and drink items.-In the sink, there was a bag of chicken sitting in water. -The oven had a buildup of dark, thick, greasy substances that coated the outside walls and oven doors. -The fryer was coated with the buildup of a dark brown greasy substance.The findings were confirmed by the DM at the time the observations were made. Interview on 9/3/2025 at 8:45 am with the DM revealed that they clean the kitchen weekly, daily, and monthly. And that he tries to come in on the weekends to do a deep cleaning of the kitchen. The DM revealed that he had asked the administration about replacing the stove. The DM stated that the whole kitchen needed to be renovated. The DM acknowledge that if things were not kept clean in the kitchen it could lead to food born illness, cross contamination, and all of the health issues for the residents. The DM revealed that he would educate his staff to make sure that things were done better in the kitchen.

Based on observations, staff interviews, and review of the facility's policy titled, Medication Storage in Healthcare Centers, the facility failed to ensure an expired bag of intravenous solutions was not stored in one of two medication rooms (located between 200-hall and 300-hall), failed to ensure for two of four medication carts (100-hall and 400-hall) did not have expired compounding cream and glucose gel, one loose pill, unboxed and illegible labels for respiratory inhalation solution vials. In addition, the facility failed to ensure that the treatment cart was not left unlocked and expired sterile supplies were removed for one of one treatment carts. This deficient practice has the potential to place residents at risk of receiving outdated medications and supplies.Findings include:Review of policy titled, Medication Storage in Healthcare Centers dated 11/1/2024 under the section titled, Policy Statement revealed, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel and pharmacy personnel. Under section titled Procedure: revealed, .2. Medication rooms, carts, and medication supplies are locked or attended by people with authorized access. 3. Nurses are required to check all medications for deterioration and expiration before administration and inspect medication storage areas and carts.Review of medication expiration dates reference sheet revealed that albuterol nebs and ipratropium nebs must remain in foil and outside of the foil expires in seven days.An observation and interview on 9/3/2025 at 9:33 am of the 100-hall medication cart revealed hydrocortisone 1% (percent)/nystatin/zinc oxide/lidocaine 2% compound cream that expired on 8/26/2025 and one loose pill in the bottom of the small top drawer of the medication cart. Further observation revealed, a box of ipratropium bromide 0.5 milligram (mg) with albuterol sulfate 3mg (respiratory inhalation solution) with an illegible label. In addition to illegible labels, there were inhalation vials that were unboxed and outside of foil packet. Interview conducted during this time with Registered Nurse (RN) FF confirmed that the compound cream was expired and that there was one loose pill in the bottom of the drawer. RN FF acknowledged that there should not be any loose pills on the medication cart. Further interview with RN FF revealed that she was unsure how long the inhalation vials were good for that was found outside of the foil packet and confirmed that the label was illegible.An observation and interview on 9/3/2025 at 10:27 am revealed sterile heel foam and sterile gauzes that was expired on the treatment cart that was left unsecured and unlocked. An interview with Wound Care Nurse confirmed that she left the treatment cart unlocked and unattended. She also confirmed that the gauze and heel foam was expired.An observation and interview on 9/3/2025 at 11:00 am on 400 hall revealed that the medication cart had diabetic oral glucose gel that expired on 5/31/2025. An interview with Licensed Practical Nurse (LPN) EE confirmed that the oral glucose gel was expired. An observation and interview on 9/3/2025 at 12:45 pm revealed that medication room located between 200-hall and 300-hall had one bag of dextrose 5% with 0.9% Sodium Chloride intravenous (IV) solution that expired on 6/2025. Interview with the Director of Health Services (DHS) confirmed that the IV solution was expired. She revealed that anything expired should be removed from the medication cart, medication room or treatment cart. She further revealed that nurses should check weekly for back stock and remove any expired items.An interview on 9/4/2025 at 12:44 pm with the Pharmacy Consultant revealed that on 9/2/2025 he was in the facility checking the four medication carts, two treatment carts, and two storage rooms. He revealed he was looking for expired medications and does not look for expired supplies. He verified that sterile items have expiration dates and that all items should have legible labels. He revealed that he did not recall any loose pills on the cart but confirmed there should not be any loose pills on the medication cart.An interview on 9/4/2025 at 12:12 pm with the Administrator revealed that the expectation was that the treatment and medication carts are kept locked when not in use.

Based on staff interviews, record review, and review of the facility's policy titled Advance Directives: Georgia the facility failed to ensure that the physicians orders was consistent with the Physician Order for Life-Sustaining Treatment (POLST) for one of 44 sampled residents (R) (R11) with an advance directive code status of Do Not Resuscitate (DNR). This deficient practice had the potential for the resident to receive an attempt of resuscitation from staff in the event of cardiopulmonary arrest. Findings include:Review of the facility policy titled Advance Directives: Georgia, dated [DATE], under the Policy statement revealed, The healthcare center recognizes the right of patients/ residents to control decisions related to their medical care. Advance Directives executed in accordance with state law will be honored by the healthcare center.Review of the electronic medical record for R11 revealed that she was admitted with diagnoses that included but was not limited to unspecified sequelae, depression, and generalized anxiety disorder.Review of the physician orders for R11 revealed, a code status of Full Code with a start date of [DATE] and end date of [DATE] (after discovery).Review of the care plan with problem start date of [DATE] for R11 revealed that she was a DNR with full treatment. The goal was noted that if her heart stops or if she stops breathing, then cardiopulmonary resuscitation (CPR) will not be initiated in honor of the DNR wishes.Review of the Physician Order for Life-Sustaining Treatment (POLST) for R11 dated [DATE] revealed, two physician signatures and an authorized person (resident's representative) signature that indicated R11's current medical condition and preference included but not limited to: Allow Natural Death and DNR in the event of cardiopulmonary arrest.Review of the meeting notes from the admission care plan conference on [DATE] revealed that DNR was chosen by the resident and a POLST form has been placed on file.An interview on [DATE] at 12:49 pm with Director of Health Services (DHS) revealed that staff were trained to follow the banner. She then stated that code status order was supposed to be updated to match the banner. She concluded that order and the banner were updated at the same time, and it was up to the unit manager to make that adjustment. She confirmed that the banner indicated R11 was a DNR and the order was Full code.An interview on [DATE] at 12:57 pm with Unit Manager (UM) BB revealed that he was responsible for updating code status after receiving and verifying the signed POLST. He then stated that if the resident was in cardiac arrest, the nurse would go by the banner and the POLST. He stated that Hospice must have sent the signed POLST late, and the order was not changed to reflect the DNR.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Care Plans, the facility failed to implement the care plan for one of 44 sampled residents (R) (R48). The deficient practice had the potential to place the resident at risk for falls and injury.Findings include:A review of facility's policy titled Care Plans, dated 7/27/2023 under the admission Comprehensive Plan of Care section revealed, 3.The comprehensive care plan should describe the following-The services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.A record review of the Quarterly Minimum Data Set (MDS) dated [DATE] for R48 revealed that section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 10 (indicating moderate impairment); Section GG (Functional Abilities and Goals) revealed that resident was dependent for transfers.Review of care plans dated 1/5/2025 for R48 revealed, a focus area that indicated R48 was at risk for falls related to a history of falls at home and on current antidepressant for poor appetite. Interventions included but limited to assist for toileting and transfer as needed with two to three staff for transfer via (by way of) mechanical lift.During an observation conducted on 9/4/2025 at 9:36 am revealed, R48 suspended in the air via a mechanical lift in the doorway of her room with Certified Nursing Assistant (CNA) DD attempting to transfer R48 to the shower bed that was located in front of the door. Further observation revealed, no other staff in the room with CNA DD during the transfer. Upon the discovery made by the surveyor, CNA DD then proceeded to ask the Medical Records Director for assistance with the transfer.An interview on 9/4/2025 at 4:00 pm with the Director of Health Services (DHS) revealed that the expectation was that staff follow the care plan and that the care plan should be updated in real time.

Based on observation, staff interviews, record review, review of the manufacturer instructions, and review of facility's policies titled, Medication Administration: Insulin injections, and Handling and/or Disposing of used Needles, the facility failed to prime a semaglutide injection pen (used to manage diabetes) and failed to dispose of the needle safely for one of six sampled residents (R) (R86) observed during medication administration. This deficient practice had the potential to place the resident at risk for medical complications and safety hazards.Findings include:Review of the facility's policy titled, Medication Administration: Insulin Injections, dated 7/28/2025 under the Policy Statement revealed, It is the policy of (Name of Organization) that the procedures outlined in this policy must be followed to aid oxidation and utilization of blood sugar by the tissues and to control the blood sugar levels in residents/patients with diabetes mellitus through the correct administration of insulin.Review of the facility's policy titled, Handling and/or Disposing of used Needles dated 10/17/2023 under the Purpose statement revealed, It is the policy of the (Name of Pharmacy Services) to provide guidelines for the handling and disposal of used needles. All used needles will be handled and disposed of in a safe manner by following the guidelines, to ensure the safety of the partner and patient/resident.Review of the (Brand Name) semaglutide injection manufacturer's instructions on page 11 revealed, Step 2. First Time Use for Each New Pen: Check (brand name) flow, before the first injection with each new pen only.Always make sure that a drop appears at the needle tip before you use a new pen for the first time. On page 12 revealed, Step 5. After your injection, Carefully remove the needle from the pen. Place the needle in sharps disposal container right away to reduce the risk of needle sticks.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for R86 under Section I (Active Diagnosis) revealed diagnoses that included, but not limited to, type 2 diabetes mellitus with hyperglycemia, chronic kidney disease type 2, hemiplegia and hemiparesis following a cerebral infarction.Review of the care plan dated 9/2/2025 revealed a focus area that indicated R86 was at risk for hyper/hypoglycemia related to diabetes mellitus with a goal to maintain his blood sugar over the next three months. Interventions included to administer medications as ordered, check blood sugar before meals and at bedtime, monitoring signs and symptoms of hyper or hypo glycemia and notifying the medical provider of abnormal results.An observation and interview on 9/3/2025 at 9:12am with Registered Nurse (RN) FF revealed that RN FF obtained a new semaglutide injection pen but turned the dial to the ordered dosage of medication without priming the pen and before administering the medication to R86. After administration was completed, RN FF proceeded to walk from room [ROOM NUMBER]-B with the exposed used needle pointed outward across the main hall to the 100-hall medication cart that was parked at the nursing station before disposing of the needle in a sharps container. During the interview with RN FF, she admitted that she did not prime the semaglutide injection pen. RN FF revealed that she forgot to prime the insulin injection pen and stated that it should be primmed every time. RN FF also admitted that she walked down the hall with an exposed used needle. She revealed that the policy was to pull the cart near the door and then throw the needle away in the sharps container. An interview on 9/4/2025 at 10:27 am with Infection Preventionist (IP)/Clinical Competency Coordinator revealed that staff was educated on insulin administration upon hire, annually, and during the year through computer education. She confirmed that insulin pens required priming. She revealed needles were to be disposed of in the sharps disposal container and that the medication cart should be at the doorway of the room so that the sharps container would be nearby.An interview on 9/4/2025 at 11:40 am with Director of Health Services (DHS) revealed that staff were expected to follow insulin policy and physician orders. She confirmed that insulin pens required priming and that this education was provided to nurses. She stated that the expectation was that directly after leaving a resident's room, the medication cart should be at the doorway and they should dispose of the needle in the sharps container. The DHS acknowledged that walking down the hallway with an exposed needle was dangerous.

Based on observations, staff interviews, record review, and a review of the facility procedure titled, Transferring a Resident Using a Mechanical Lift, the facility failed to ensure the safety of one of six sampled resident (R) (R48) during a transfer using the mechanical lift. The deficient practice had the potential to place residents that require a mechanical lift with transfers at risk for safety. Findings include:A review of the procedure guide revealed that on page two that the mechanical lift is a two-person device. One caregiver should not use the mechanical lift alone.A record review of the Quarterly Minimum Data Set (MDS) dated [DATE] for R48 revealed that section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 10 (indicating moderate impairment); Section GG (Functional Abilities and Goals) revealed that resident was dependent for transfers.Review of care plans dated 1/5/2025 for R48 revealed, a focus area that indicated R48 was at risk for falls related to a history of falls at home and on current antidepressant for poor appetite. Interventions included but limited to assist for toileting and transfer as needed with two to three staff for transfer via (by way of) mechanical lift.During an observation conducted on 9/4/2025 at 9:36 am revealed, R48 suspended in the air via a mechanical lift in the doorway of her room with Certified Nursing Assistant (CNA) DD attempting to transfer R48 to the shower bed that was located in front of the door. Further observation revealed, no other staff in the room with CNA DD during the transfer. Upon the discovery made by the surveyor, CNA DD then proceeded to ask the Medical Records Director for assistance with the transfer.An interview on 9/4/2025 at 9:41 am with Medical Record Director revealed that the CNA DD called her over for assistance. She admitted that she was three rooms down the hall from R48's room passing out supplies. She confirmed when transferring a resident using the mechanical lift, that it should be with two persons assisting and that the second person should be there the entire time the resident was on the mechanical lift. She revealed she only saw the nurse in the room passing medications to R48's roommate.An interview on 9/4/2025 at 9:44 am with Licensed Practical Nurse (LPN) AA revealed that she was in R48's room administering medication to her roommate. LPN AA revealed that she was only in the room administering medications and she did not assist CNA DD with using the mechanical lift. LPN AA revealed that she observed rolling R48 on the lift pad before leaving the room and confirmed that the CNA should have had another person assisting her when transferring a resident using a mechanical lift.An interview on 9/4/2025 at 10:22 am with CNA DD revealed that the nurse left the room after administering medications and confirmed that she was by herself transferring the R48. She verified that she called the Medical Record Director over to help with the transferring the resident over the doorway threshold. She confirmed that two people should assist with the transfer the entire time when using a mechanical lift.An interview on 9/4/2025 at 10:27 am with Infection Prevention Nurse/Clinical Competency Coordinator revealed that two people are required the entire time a resident is being transferred using a mechanical lift. She revealed that CNAs and nurses received training on mechanical lifts transfer at hire, annual skills fair, and through computer education.An interview on 9/4/2025 at 12:12 pm with Director of Health Services (DHS) revealed that expectation was for two people and no less than two people to transfer a resident using a mechanical lift. The DHS revealed that staff should be monitoring and assisting the resident while the resident was on the mechanical lift at all times.

Based on observation, record review, staff interviews, and review of the facility's policy titled, Oxygen Administration, the facility failed to follow physician orders for one of one residents (R) (R47) reviewed for oxygen therapy.Findings include:Review of the facility's policy titled Oxygen Administration dated 8/2/2023 under the Procedure section revealed, Oxygen will be administered by licensed personnel only when ordered by the physician, PA or NP. The physician order may be written PRN for comfort/dyspnea or may specify the number of liters, method of administration and length of time the oxygen is to be administered. Oxygen ordered PRN for comfort/dyspnea will be based upon the physician/licensed nurse assessment of the patient/resident's condition including oxygen saturation levels, respiratory rate, effort used by patient/resident to breath, shortness of breath presents, and respiratory distress. Use of oxygen will be based in the patient/resident's clinical condition, comfort level, and the patient/resident/family desire for oxygen therapy. Patient/residents/families have the right to refuse to use oxygen.Review of the clinical record for R47 revealed the resident was admitted to the facility with diagnoses of but not limited to acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease.Review of most recent Annual Minimum Data Set (MDS) dated [DATE] for R47 revealed, Section C (Cognitive Pattern) a Brief Interview for Mental Status (BIMS) score of 14, which indicated little to no cognitive impairment; Section O (Special Treatments, Procedures, Programs) revealed the resident required oxygen therapy. Review of the physician orders revealed an order for oxygen at 4 liters per minute (LPM) per nasal cannula at 9 pm with a start date of 1/17/2022.Observation on 9/2/2025 at 2:15 pm revealed that R47 was receiving oxygen at 3.5 LPM per nasal cannula.Observation on 9/2/2025 at 4:30 pm revealed that R47 was receiving oxygen at 3.5 LPM per nasal cannula.Observation on 9/3/2025 at 11:15 am revealed that R47 was receiving oxygen at 3.5 LPM per nasal cannula.During an observation and interview on 9/3/2025 at 11:15 pm with the Director of Nursing (DON) confirmed R47's oxygen was set on 3.5 LPM but should have been set on 4 LPM after checking R47's medical record. The DON revealed that all nurses should follow the orders and that oxygen levels should be checked several times a day to ensure that the residents were receiving the correct amount of oxygen. The DON revealed that the CNAs do not change the oxygen levels and if they see a resident who uses oxygen struggling, that they were instructed to let the nurse know.

Based on observations, resident and staff interviews, and review of the facility's temperature logs, the facility failed to ensure that heat/air-conditioning systems located throughout the facility were in working order and in good repair. The deficient practice had the potential to affect the safety, functional, and comfortable conditions for all residents in the facility. Findings include: Observations upon entrance to the facility on 5/22/2025 at 9:00 am revealed several portable Air Conditioning (AC) units located throughout the facility. There was one portable AC unit in the front lobby/main entrance, three portable AC units on the 100, 400, and 500 Halls, two portable AC units on the 200 Hall, one portable AC unit in the dining room, sitting area, activity room, and one portable AC unit outside the kitchen near the Director of Health Services (DHS) office. The temperatures on the portable AC units ranged between 70 and 77 degrees Fahrenheit (F), and the hallway temperatures ranged between 75 and 81 degrees F. Interviews conducted during the survey with residents with a Brief Interview for Mental Status (BIMS) score of 12 (indicating little to no cognitive impairment) or higher revealed that there were no residents who complained of high temperatures. Observations of residents revealed that some residents were observed in their rooms with blankets over them, and some residents were observed with personal fans. Residents stated that the temperatures were fine, and they were not hot. Review of the March 2025 Resident Council minutes revealed that the residents asked if the AC would be working during the summer. Review of temperature logs provided by the Maintenance Director revealed the following dates with temperatures over 81 degrees F: 5/22/2025 at 9:00 pm temperature 81.3 to 85.6 degrees F. 5/23/2025 at 12:00 am temperature 81.2 to 82.5 degrees F. 5/24/2025 at 8:00 am 84 degrees F. In an interview on 5/22/2025 at 9:15 am, the Administrator stated that she was notified of the high temperatures in the building on 5/16/2025. She stated that she contacted the corporate office, and she was waiting for approval for new AC units. She stated that a family member had complained of high temperatures, and no residents had complained about the temperature. The Administrator stated that there had been no hospital admissions related to high temperatures in the facility. She stated that they had moved one resident to another room until the temperature in the room was back within regulatory range. In an interview on 5/22/2025 at 9:53 am, the Maintenance Director stated that the facility was waiting on parts and new AC units. He stated that he checked the temperatures in the rooms and down the halls throughout the day, and the night shift nurses were responsible for checking the temperatures at night. He further stated that he had provided an in-service to the staff on how to use the thermometer and properly check the temperatures in the rooms and halls. In an interview on 5/22/2025 at 12:00 pm, the Ombudsman revealed she discussed the AC not working properly with the former Administrator two summers ago. She stated that residents had informed her they were upset and tired of the heat every summer. She stated that the facility had portable AC units last summer. The Ombudsman further stated she was in the facility on 5/16/2025, and the temperature in the building felt hot to her. In an interview on 5/27/2025 at 9:30 am, the Administrator stated that the facility was providing extra hydration to residents. She stated that no resident had complained of being hot. She further stated that residents' temperatures were taken daily. The Administrator stated that she had received approval from the corporate office to replace two Heating, Ventilation, and Air Conditioning (HVAC) units and received a quote on 5/27/2025, and it would take about two weeks for the units to arrive. In an interview on 5/29/2025 at 2:55 pm, a representative from the local Department of Public Health Emergency Management stated the facility's Administrator had reached out to him and informed him of the issues with the AC unit at the facility, and had not asked for assistance In an interview on 5/29/2025 at 3:30 pm, the Administrator stated that she rented portable AC units in April 2025 to try to stay ahead, just in case they were needed. She stated that once the temperatures went up, she had to rent additional units. In an interview on 6/4/2025 at 1:15 pm, the Director of Health Services (DHS) stated that there were new issues with the AC every year. She stated that they would fix the issues, and the next summer, there would be another issue.

Based on staff interviews, record review, and review of the facility policy titled Physician Orders, the facility failed to ensure a telephone order for one of 25 sampled residents (R) (R72) was transcribed into the Electronic Medical Record (EMR) system. This failure had the potential to not identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that would meet the resident's physical, mental, and psychosocial needs. Findings include: Review of the facility policy titled Physician Orders dated 7/19/2023, revealed the Policy Statement of: Physician orders must be complete and legible when written by the physician, physician extender or transcribed by the licensed professional. Written orders for medications may be transcribed by a licensed professional nurse or licensed pharmacist. Faxed orders are considered to be original physician's order. The Procedures section titled Verbal and Telephone Orders revealed line numbered 1 stated: All verbal and telephone orders will be immediately transcribed in the medical record by the licensed professional taking the order. Review of R72's Face Sheet, located in the EMR, revealed diagnoses that included constipation, dementia, spondylosis, and other reduced mobility. Review of R72's Progress Note, located in the EMR, dated 11/2/2023 at 8:28 am revealed [Resident Name] KUB (Kidney, Ureter, and Bladder) shows moderate distention and diffuse fecal retention suggesting constipation and lumbar spine x-ray demonstrate mild to moderate degenerative changes of lumbar spine and compression fractures to L (lumbar)1 and L3 of uncertain age. [name of provider], NP (Nurse Practitioner) notified and new order received for Lactulose 15ML (milliliter) PO (by mouth) QD (everyday) for constipation with no additional orders received. Order transcribed and family notified. Review of R72's Resident Census revealed she was discharged from the facility on 11/2/2023 at 11:32 am. Review of the R72's Order History, located in the EMR, from 10/19/2023 through 11/2/2023 revealed no current or discontinued orders for Lactulose 15 ml PO QD. Interview conducted on 1/7/2024 at 8:05 am with Unit Manager (UM) AA stated she had worked at the facility for seven years. She stated she was not the UM for R72 while at the facility. UM stated the nurse who received the order for Lactulose and wrote the progress note no longer worked at the facility. She stated the process for receiving orders would be to write the orders as prescribed and notify the family. UM AA acknowledged the progress note written on 11/2/2023 indicated Lactulose had been transcribed. The Director of Health Services (DHS) joined the interview at 8:08 am and acknowledged the progress note indicated Lactulose had been transcribed. Both the UM AA and DHS confirmed there was not an order in the EMR for the Lactulose. DHS stated she was not sure why the order had not been completed and that R72 had no additional records that needed to be scanned into the EMR system. She stated if it was not there, it was not done. DHS stated her expectation of nurses was for them to transcribe orders when received, put them in the EMR system and implement the orders as indicated.

Based on observation, record review, resident and staff interview, and review of the facility policy titled Procedure: Indwelling Urinary Catheter, the facility failed to secure the catheter tubing to prevent tension on the urethra for two residents (R#34 and R#17), failed to obtain a Physician's Order to flush the catheter for one resident (R#34); failed to follow the Physician's Order for a follow up appointment with a Urologist and failed to have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. Review of R #34's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score of 15 indicates no cognitive impairment), and an indwelling catheter. Observation and interview on 4/19/22 at 11:48 a.m. revealed R#34 has had a catheter since September. Resident #34 stated that the catheter is uncomfortable, and it hurts his penis. He stated pain killers get rid of his pain quick. The resident pulled back covers to show surveyor his catheter tubing. The catheter tubing was not secured to his leg. Observation on 4/19/22 at 3:29 p.m. revealed R#34 lying in bed with right leg exposed. The resident did not have a catheter strap in place. During an observation and interview on 4/19/22 at 3:43 p.m., Certified Nursing Assistant (CNA) AA confirmed R#34 did not have a securing device in place for the catheter tubing. CNA AA stated she worked with him Saturday (4/16/22) and Sunday (4/17/22) and she does not remember seeing a securing device in place. During an observation and interview on 4/20/22 at 9:22 a.m. Licensed Practical Nurse (LPN) II verified that R#34 did not have a leg strap or securing device in place to secure the catheter to reduce tension on the [CONDITION(S)] meatus. LPN II stated that she is aware that residents with Foley catheters are supposed to have a securing device in place to secure the catheter. LPN II stated that she had placed a securing device on R#34 when she worked Monday 4/18/22. Review of Progress Note dated 4/2/22 at 4:54 p.m. revealed R#34 complained of abdominal pain and bladder was distended. Attempted to flush Foley x2 (twice) but was unable to do so. Changed to 16F (16 French) Foley. Tolerated well. Draining clear, yellow urine. Responsible Party and Physician were notified. Further review of the clinical record revealed no evidence of that an order was obtained to flush Foley catheter or that the physician was notified prior to flushing the catheter. Review of clinical record revealed R#34 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Regional Senior Nurse Consultant (RSNC) on 4/20/22 at 10:04 a.m. revealed the facility does not have a policy for flushing Foley catheters, but the nurses should obtain a physician's order prior to flushing a catheter or sometimes the physician will just give orders to change the catheter. RSNC CC further stated that the facility's nursing staff received education on indwelling catheter care and maintenance of the catheter on 11/30/2021 through a training video and at the Annual Skills Fair which was conducted for nurses and CNA's on 2/17/22, 3/30/22, 4/01/22, 4/14/22, and 4/15/22. 2. Observation on 4/20/22 at 9:27 with the Director of Health Services (DHS) and CNA FF performing ADL care for R#17 revealed the resident had a Foley catheter with the catheter tubing not secured. Resident #17 stated that she does not ever remember the catheter being secured with tape, strap, or securing devices. CNA FF and DHS verified that the catheter is not secured. Interview with DHS at this time revealed that nurses and CNAs are aware that Foley catheters must be secured with a leg strap or securing device. Review of facility policy titled Procedure: Indwelling Urinary Catheter dated 2019 under #21 revealed: secure with catheter securement device if available -tape the catheter, use an adhesive catheter holder, or apply a Velcro leg strap to secure the catheter - Do not leave the room until the catheter is secured. The mechanical irritation caused by a catheter can cause complications. 3. Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was not a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#17's Quarterly Minimum Data Set (MDS) dated [DATE] indicated Section C-Cognition: Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive loss; Section G-Functional Status-resident required extensive assistance with bed mobility, dressing, toileting, and personal hygiene; Section H-Bowel and Bladder: resident had a urinary indwelling catheter. Review of R#17's Physicians Progress Note dated 12/1/21 revealed recommendation to obtain a urology follow-up for removal of catheter. Review of R#17's Nurses Notes/Progress Notes dated between 11/24/21 and 4/20/22 did not indicate any attempt to arrange for a follow-up appointment with a Urologist. Observation and interview with R#17 on 4/19/22 at 11:30 a.m. revealed the resident had an indwelling catheter and the resident indicated she did not know why she still has the catheter. An observation of R#17 on 4/20/22 at 8:00 a.m. revealed resident in her bed, sitting up, eating breakfast. She had a catheter, attached to leg by a catheter strap and was attached to side of bed in a privacy bag below the level of her bladder. She indicated again she was not sure why she has the catheter. An observation of R#17 on 4/21/22 at 7:56 a.m. revealed resident still had the catheter. An interview on 4/20/22 at 1:34 p.m. with the DHS revealed the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She verified a follow-up appointment with the urologist was not made. She indicated it was due to COVID and doctors not taking appointments. The DHS indicated she found no documentation related to making an appointment with the Urologist. Review of the catheter order with the DHS revealed the catheter order did not include a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 4/21/22 at 2:00 p.m. with the Licensed Practical Nurse (LPN) Unit Manager (UM) LPN/UM II revealed the resident has a catheter, they had attempted to get her an appointment with a Urologist a few months ago but was unable do to get an appointment due to COVID. She indicated they have not tried a trial removal of the catheter. They change the catheter monthly and as needed. She indicated she did not see any documentation indicating the attempt to make an appointment. An interview on 4/21/22 at 9:31 a.m. with the Administrator revealed she would expect a resident who has a catheter should have a proper diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, staff interview and the review of the facility policy titled COVID -19 Isolation and Cohorting Process the facility failed to appropriately wear and doff personal protective equipment (PPE) on the COVID-19 isolation unit. The deficient practice had the potential to spread of COVID-19 virus to other residents in the facility. The census was 65. Findings include: Observation on 4/19/22 at 8:30 a.m. of the COVID-19 isolation unit revealed no biohazard container available at the door before exiting the COVID-19 isolation unit. There were nine residents inside the COVID-19 isolation unit including two with active symptoms. Biohazard containers were observed only outside of rooms 206, 207, 209, and 210. During an interview on 4/19/22 at 8:45 am about the doffing container, Licensed Practical Nurse (LPN) DD said, I don't know and kept on doing his work. There was also no shoe protector available for the staff. Observation on 4/20/22 at 10:30 a.m. of the COVID-19 isolation unit revealed no biohazard container available at the door before exiting the COVID-19 isolation unit. There was a trash can with a broken lid available for doffing outside the COVID-19 unit very near the donning station with clean personal protective equipment (PPE) outside the door. During an observation on 4/20/22 at 2:00 p.m. Certified Nursing Assistant (CNA) HH took her used PPE off inside a resident's room in the COVID-19 isolation unit. Her mask was on her chin not covering the nose or mouth. She was also missing the face shield/ goggles inside the COVID- 19 isolation unit while caring for the positive residents. During an interview on 4/21/22 at 9:54 a.m., COVID-19 Isolation Unit Manager LPN II confirmed there was no biohazard container available at the exit door of the isolation unit since it was set up. She stated it was the infection control nurse's responsibility and that nurse is on leave. A biohazard contained was placed on 4/21/22 when the medical director made an inquiry. Interview on 4/21/22 at 9:30 a.m. with Director of Health Services (DHS) revealed that staff should discard the used gown and mask inside the isolation unit by doffing it in the biohazard container before exiting the door, but she wasn't aware there was no container. She stated that unit manager from isolation unit should have checked it as a part of her job duty. The DHS expected the staff to follow the facility policy and procedure for appropriate donning/doffing of PPE. Interview on 4/21/22 at 10:00 a.m. with Administrator revealed that her expectations are to prevent infection to all residents who are at the facility under her care. She was dependent on her Infection Preventionist who was out on leave. She expected the staff to follow Center for Disease Control's (CDC) guidelines. She also expected the staff to follow the policies for wearing PPE on the isolation unit. Review of the facility Policy titled COVID -19 Isolation and Cohorting Process with a reviewed date of 2/9/22 under Level I Positive COVID-19 Isolation Unit #4 on page 6 #5 documented that PPE to be used by all partners on the unit to include: KN95 mask in contingent or crisis capacity and eye protection (face shield, googles, etc.)

Based on record review and staff interviews, the facility failed to ensure one resident (R) (R#66) that transferred to the hospital was permitted to return to the facility of three residents reviewed for transfer and/or discharge. Findings include: Review of R66's medical record revealed an admitted [DATE] at 4:23 p.m. with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was sent back to the hospital on 3/30/22 at 10:00 p.m. The resident was admitted with the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Progress Note dated 3/30/22 at 4:46 p.m. revealed that resident was agitated and expressing extreme paranoia and says she hears voices. Review of R66's Progress Note dated 3/30/22 at 8:02 p.m. revealed R#66 was transferred to the hospital after the nurse went into resident's room to perform [MEDICATION(S)] skin test and R#66 became very agitated very quickly and began yelling and cursing. R#66 said, Ain't nobody [OBSCENITY] ing sticking me. Nurse tried to calm resident down, but she became increasingly more agitated. R#66 yelled at nurse and then spit in her face. Nurse went and got another nurse for assistance and R#66 continued to be combative. Two more nurses came into room to assist, and R#66 continued to scream and curse at staff. DON gave order to 1013 resident (to receive mental health treatment in an emergency). Resident said, Call the damn police and get me the hell out of here. I want to go home. Called Central EMS (emergency medical services) for pickup and to take her to (hospital) for psych evaluation. Record review revealed that nurse from the hospital called the facility on 3/31/22 at 12:00 a.m. stating that R#66 was being sent back to facility and that the emergency room (ER) Physician did not have a reason to admit R#66 into the hospital. Facility nurse informed ER nurse that the Administrator stated that facility is not equipped to handle the residents needs and R#66 could not return to facility. Further review of the clinical record for R66 revealed no valid basis for discharge, which shows why the facility can no longer care for the resident. Interview with Social Service Director (SSD) 4/21/22 at 8:43 a.m. revealed she did not play an active role in the discharge of the resident. SSD stated that she did not call the hospital to check the status of the resident when she learned of the resident's discharge back to the hospital and she had no idea as to if the resident was admitted to the hospital or discharged someplace else. Interview with Administrator on 4/21/22 at 8:48 a.m. revealed the staff reported to her that the resident was spitting, kicking, and screaming at staff and that the staff was not able to redirect resident. At this point the resident was sent back to the hospital because she did not feel the facility could meet the needs of the resident. Administrator also stated that she had heard that R#66 family did not want her to return to their home. She further stated that R#66 was her own responsible party, so the facility did not have to notify family of the transfer. Telephone interview with Regional Nurse Liaison (RNL) on 4/21/22 at 8:56 a.m. revealed that when she spoke with the case manager at the hospital, R#66 did not exhibit any behaviors while there prior to discharge or upon return. She further stated that she is not sure where R#66 was discharged to after leaving the hospital.

Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) to reflect Preadmission Screening and Resident Review (PASRR) Level II status for two residents (R) (#44 and #46) of 32 sampled residents. Findings include: 1. A review R# 44's Annual MDS assessment dated [DATE] documented that R#44 did not have a serious mental illness with no PASSAR level II documented on the MDS. A review of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The PASSAR level II for R#44 revealed an assessment date of 3/4/22 and that the end date for services would be 12/31/2299 (sic). There were documented recommendations for behavioral health assessment, ongoing psychiatric care, and individual counseling. A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. A review of R#49's Annual MDS assessment dated [DATE] documented that R#49 did not have a serious mental illness with no PASSAR level II documented on the MDS. A review of R#49's revealed the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The PASSAR level II for R#49 revealed and assessment date of 4/28/20 and that the end date for services would be 12/31/2299 (sic). There were documented recommendations for behavioral health assessment, ongoing psychiatric care, and individual counseling. A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 4/20/22 at 2:10 p.m. with the Social Services Director she confirmed both residents had a PASARR Level II and received psychotherapy monthly. Further review revealed she does not fill out section A of the MDS. She stated the MDS Coordinator fills out that section. Interview on 4/21/22 at 8:33 a.m. with the MDS Coordinator revealed she was aware R#49 had a PASSAR level II but was unaware of R#44's PASSAR status. She confirmed both MDS assessments were coded in error.

Based on observation, record reviews, staff interviews, and policy review, the facility failed to assist one resident (R) (R#19) with necessary arrangements to obtain routine dental services of 32 sampled residents. Findings include: Observation on 4/21/22 at 8:15 a.m. revealed R#19 sitting up in bed with breakfast in front of him not eating. Surveyor asked if he was going to eat, R#19 shook his head no and pointed to his mouth and responded my teeth hurt. Resident #19 opened his mouth at this time, surveyor observed resident to have several teeth on the right side of his mouth broken off to the gumline. Gums appears red and swollen. Surveyor asked R#19 had he reported his mouth pain to anyone, he shook his head no. Approximately 20% of meal had been eaten at this time. Record review revealed R#19 was admitted to the facility on [DATE]. The resident had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed that on 4/13/22 at 1:48 p.m. R#19 met with Minimum Data Set (MDS) Coordinator, Activities Director, Social Service Director (SSD), and R#19's sister (via phone) for a care plan meeting. R#19's sister stated that one of her biggest concerns were that R#19's dental issues be addressed. Interview 4/21/22 at 8:36 a.m. with SSD revealed that R#19's sister met with her and discussed her concerns about dental care and wanted him to be seen by a dentist. SSD further stated that R#19's sister did not want to pay a copay for him to be seen by the provider that comes to the facility. SSD stated she later learned that R#19 in the past had received dental care at (name). SSD further stated that scheduling the appointment is on her radar, but she has not gotten around to scheduling the appointment. SSD also stated that she was aware that R#19 was experiencing mouth pain and that it was her responsibility to schedule the dental appointment. Interview 4/21/22 at 9:50 a.m. with the Administrator revealed that it is her expectation that the SSD will call a provider and schedule dental appointments for residents in need of dental care. She further stated that the appointments are scheduled based on availability and the resident's source of income. Review of facility's policy titled Specialty Services: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health revised 11/21/16 revealed that It shall be the responsibility of this healthcare center to obtain regular and emergency specialty services for each patient/resident to ensure the highest well-being of the residents.

Based on observations, record review, and staff interviews, the facility failed to provide supervision and monitoring to prevent the elopement of one resident (R) (#2) from a sample of nine residents identified by the facility to be at high risk for elopement. The facility failed to ensure areas under construction/ renovation remained locked and inaccessible to residents. Findings include: Review of a facility document titled Safe Support for Someone at Risk for Elopement dated 2016 revealed environmental considerations: Where do exit doors lead? Environmental Interventions included to regularly check that doors and gates are securely locked. R#2 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, repeated falls, major depressive disorder, generalized anxiety disorder and hallucinations. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] revealed R#2 with a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Section E - Behavior documented no behaviors and no wandering. Review of the medical record revealed that on 11/21/2020 at 6:30 p.m., R#2 was missing from her room and could not be found in the facility. R#2 had taken her pillows and stuffed under the sheets in the form of a body. Nurse announced Code Pink missing resident and staff began to search the facility and its surroundings. The police and responsible party were notified. On 11/21/20 at 9:21 p.m., resident was located and transported to the hospital ER (emergency room ) for further evaluation. The ER visit report dated 11/21/2020 revealed the chief complaint for R#2 was cold exposure. No other abnormalities were revealed on the hospital ER visit report. Review of Progress Note dated 11/22/2020 at 1:00 a.m., revealed R#2 returned to facility with no injuries. During an interview 5/4/2021 at 11:15 a.m., Construction Superintendent (CS) reported he was informed that R#2 got past the temporary wall on Unit 500, walked down the hallway and out the back door facing the street. He reported R#2 passed through a portion of the chain link fence that had been intentionally cut by the construction crew to get their supplies inside the building. He reported there were no lights working on Unit 500 at that time, due to replacing electrical wiring. Interview 5/4/2021 at 4:25 p.m., Administrator reported no one witnessed R#2 leaving the building on 11/21/2020, but the resident was able to show her how she got out of the facility. Interview on 5/6/2021 at 11:00 a.m., Maintenance Director (MD) reported when R#2 eloped on 11/21/2020, she eloped from Unit 500. He reported that unit was under construction/renovation at that time and the construction crew had detached the maglock from the exit door for easier access to get their construction supplies in the building. He reported on 11/21/2020, on Unit 500, R#2 would have exited through the back door of that unit, through the construction area. He reported the door on the temporary wall leading into the construction area had to have been left unlocked. Review of the MDS Quarterly assessment dated [DATE] revealed R#2 with a BIMS score of 8, indicating moderate cognitive impairment. Section E - Behavior documented wandering occurred daily. Progress Note dated 2/02/2021 at 12:58 p.m., revealed R#2 eloped a second time from an area of the facility under construction (Unit 200), due to the door on the temporary wall was unlocked leading through the side door of that unit. Resident eloped from facility through the construction side of the building. Resident was seen by construction workers and staff was outside and quickly noticed resident and she came back with resistance. Review of the medical record for R#2 revealed a care plan for behavioral symptoms of wandering with elopement attempts on 11/21/2020 and 2/2/2021. The care plan was updated on 11/22/2020 to include elopement protocol for facility and psych evaluation. The care plan was also updated on 2/2/2021 to include frequent visual checks and constant observation, referrals were made for a locked memory care unit. Further review of the clinical record revealed R#2 discharged on [DATE] to another facility for memory care unit needs. Random observations on 5/4/2021 revealed construction taking place on Unit 300. The Unit 300 hall leading to the back of the building and to the laundry building had a door erected on a temporary wall for the construction areas that was unlocked. There was no access to the outside of the building. However, it was observed to have had hazardous materials on the floor, exposed wires from the ceiling and metal framing exposed from the walls. Further observations on 5/5/2021 at 9:35 a.m. revealed entrance door to Unit 300 locked and on 5/6/2021 at 3:00 p.m., all exit doors are locked and require a badge, a key, or a code to exit.

Based on record review, staff interviews, and review of the facility policy titled, Errors, Omissions & Late Entries, the facility failed to maintain accurate clinical records for one resident (R) (#1) of four sampled residents. Findings include: Review of the facility policy titled, Errors, Omissions and Late Entries revised 7/27/2015 revealed under the section Errors in Documentation in the Clinical Record: Never document for someone else. Review of document titled, Nursing Assignment dated 3/19/2021 and 3/20/2021 revealed Licensed Practical Nurse (LPN) EE was listed on the schedule. The Director of Nursing (DON) was not on the schedule. Review of document titled, Medications Administration History for 3/20/2021 through 3/31/2021 for R#1 revealed initials of the DON on the record for administering medication and monitoring of resident whereabouts on the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/4/2021 at 2:41 p.m., the DON confirmed she did give her login information to LPN EE to have access to the system. She reported this covered medication administration, progress notes and any documentation needed for resident care. She reported LPN EE did receive a login, but the login was not working. She reported she has no excuse for why it took from 12/28/2020 until 3/26/2021 for LPN EE to get her login to work. During an interview on 5/11/2021 at 1:09 p.m., LPN EE confirmed she worked 3/19/2021 and 3/20/2021 and documented under the login of the DON. LPN EE reported she was hired on 12/28/2020, and she did not have access to a login to the electronic health record with her own working login until 3/26/2021. She reported she was told by the DON to login under her (DON's) name to document. She reported that included medication administration, progress notes and anything she had to document on the system related to resident care and her job duties. She stated she did receive a login password on 1/4/2021, but it did not work for the system. She stated she did not get her working password for the system until 3/26/21.

Based on record review, staff interview, and the facility policy titled Maintenance of Medical Record the facility failed to have access and availability from the former operator the previous medical records for continuity of care for active remaining facility Residents(R) who were residents prior to (MONTH) 1, (YEAR), and two (2) closed record for discharged residents, (R) R#235's Advance Beneficiary Notice (ABN) documents and R#79 's record files. Other missing files included Grievance Logs and Resident Council Meeting Minutes prior to (MONTH) 1, (YEAR) . The sample size was 34 and the facility census was 83 residents. Findings include: 1. Review of the medical record for active resident revealed that all active residents admitted prior to (MONTH) (YEAR) who remained the facility were affected by the non-availability of their previous medical records. Thereby, the continuity of care was flawed by the incomplete records. 2. Record review of Advance Beneficiary Notice for R#235, revealed that R#235 had been discharged from the facility on under Medicare part A. on 7/20/18. There was no closed record to review. R#235 was discharged from services on 7/20/18 and was discharged home last date 7/19/18 and no record to show resident received notifications Form CMS - SNFABN (Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage) missing 3. Record review of Discharge Record for R#79 revealed that R#79 had been discharged from the facility on. There was no hard copy closed record to review nor electronic file record readily accessible to facility staff and the surveyor. Interview on 12/23/18 at 12:55 p.m., the Administrator (ADM) stated that the previous owners/operator of the facility had removed all residents upon their departure. Reported that new Corporate office/owners and himself were aware that certain pertain information was missing from the resident 's complete record. He further stated the facility staff did not have access to pertinent resident 's records files that were in the former electronic filing system (Point Click Care) used by the facility staff prior to (MONTH) 1, (YEAR). Interview on 12/3/18 at 2:33 p.m., with the Director of Nursing (DON) verified that all nursing notes and other pertinent resident information were in Point Click Care, and her nursing staff no longer have access to this electronic filing system. She verified that this was a previous identified problem prior to the survey as it relates to active enrolled residents who remained in the facility and the corporate office was aware of the problem. She further stated that all only had resident hard copy medical record information in the facility that was after 10/1/18. Interview on 12/4/18 at 10:21 a.m., the Administrator (ADM) revealed that Health Management took the minutes for the Resident Council Minutes. Later the next day, Resident Council President was able to provide some of her written notes but the facility did not still have an actual attendance sheet for the meetings and actual minutes that captures all the actual events and reviews of each meeting. Interview on 12/4/18 at 4:58 p.m., with the DON revealed that she did not have a chart R#79 for a closed record to provide for a review. Interview on 12/6/18 at 8:50 a.m. with the Financial Counselor revealed that Advance Beneficiary Notice was obtained on(NAME)Burcham at the time Medicare A services ended. However, the financial charts were not kept in the facility when change of ownership took place (MONTH) 1. (YEAR) so copies of the signed documents cannot be produced at this time. Review of policy titled Maintenance of Medical Record the Policy Statement stated the following It is the policy of(NAME)Health and its affiliated entities (collectively, the Organization :) to maintain a medical record for each patient /resident in the healthcare center/agency that is to be accurate, complete and systematically organized. 11. All active medical records will be maintained at a designated location and readily accessible to all authorized personnel. Purpose: Since it is a requirement that a medical record will be maintained for each patient /resident in the healthcare center/agency, preventive measures must be in place to assure the safekeeping of all medical records to protect them against theft, loss or destruction. Interview with the Activity Director on 12/04/2018 at 8:58 a.m. revealed she was unable to locate any of the resident council meeting notes. She stated the previous company, Health Management, took the notes. She does not know if copies were made prior to the previous company leaving. Interview with the Administrator on 12/4/2018 at 8:58 a.m. confirmed the resident counsel meeting notes were taken by the prior company, Health Management, and no copies were available for review. Review of the policy titled Patient/Resident Council dated reviewed 10/19/18 revealed the Minutes of the Council will contain an accurate and complete record of all Council activities and discussion to include, but not limited to: kind of meeting, name of presiding member, members present, others in attendance and for what purpose, date, time and place of meeting, a complete record of items of business (old and new) discussed with the suggested actions, who will do what, and any other pertinent information relating to appropriate follow through, signed and dated by the presiding officer of the council and the recorder. Minutes will be documented using Patient/Resident Council Minutes Report Form. The Patient/Resident Council Minutes/Report Form, complaints, and responses to the complaints will be maintained in a notebook, using tabs to indicate the months, and will be maintained for one year. After a year, the old minutes will be kept in a separate binder or notebook for a period of five years.

Based on the policy titled Patient/Resident Council reviewed 10/19/2018 and resident and staff interviews, and observations, it was determined the facility failed to ensure the Resident Council Meetings remained free of staff interruptions, held in a private location and ensured resident grievances were addressed monthly. The facility census was 83 residents. Findings include: Review of the policy titled Patient/Resident Council dated reviewed 10/19/2018 revealed the Council will meet in a private place. The Minutes of the Council will contain an accurate and complete record of all Council activities and discussion to include, but not limited to: kind of meeting, name of presiding member, members present, others in attendance and for what purpose, date, time and place of meeting, a complete record of items of business (old and new) discussed with the suggested actions, who will do what, and any other pertinent information relating to appropriate follow through, signed and dated by the presiding officer of the council and the recorder. Minutes will be documented using Patient/Resident Council Minutes Report Form. The Patient/Resident Council Minutes/Report Form, complaints, and responses to the complaints will be maintained in a notebook, using tabs to indicate the months, and will be maintained for one year. After a year, the old minutes will be kept in a separate binder or notebook for a period of five years. An interview held on 12/04/2018 at 8:58 a.m. with the Activity Director (AD) revealed she was unable to locate the resident council meeting notebook with the meetings minutes and attendance sheets. She stated the previous company, Health Management, took the notebook. She does not know if copies were made prior to the previous company leaving and the new company began services. Further interview held on 12/06/2018 at 9:48 a.m. with the Activity Director revealed she has been at this facility eight days. She has not had an official resident counsel meeting with the residents. She revealed the Resident Council usually meet in the dining room. The dining room does not have a door to close off the room. An interview held on 12/4/2018 at 8:58 a.m. with the Administrator confirmed the resident council meeting notebook with the meetings minutes and attendance sheets is no longer in the facility and was taken by the prior company. Further interview held on 12/06/2018 at 8:00 a.m. with the facility Administrator revealed they have been without a Social Worker (SW) since 10/24/2018. The Administrator, the Business Office Manager (BOM) and Director of Nursing (DON) have been fulfilling the duties of the SW. The Administrator has hired a new SW that is due to start at the first of the year. A temporary SW is starting next week. Further interview with the Administrator on 12/06/2018 at 11:48 a.m. revealed the Resident Council usually meets in the Dining Room, he agrees it is not private and does not have a door. The Resident Council President, Resident (R) R#13, has hand written notes on sheets of paper from some of the previous meetings and the AD took the notes and typed them up according to her notes. The Resident Council President did not keep an attendance sheet. An observation made on 12/06/2018 at 10:22 a.m. of dining room revealed the room had an open entry way without a door. A Resident Council meeting was held on 12/4/2018 at 11:00 a.m. The meeting was held in an open area located at the end of the hall. The area did not have a door and was not private. The Resident Council President R#13 was in attendance along with eight other residents. The council had the following concerns: 1. No SW is available at this time. They like it when there is a SW so they can bring concerns to them. 2. Staffing 3. Residents are concerned they can not get coffee or tea when ever they want. They are told by the kitchen staff they have to ask a nurse to get it for them. 4. Residents stated they know how to file a grievance but they are not usually acted upon in a timely manner, if at all. 5. They are concerned they are not able to go out for activities because they do not have a van any more. They had a van with the prior company but do not have the van any more. 6. Have to wait a long time for care. 8. One of the shower rooms doesn't have any heat so they can't use it. (C-Hall) 9. Snacks are offered but tends to be all bread and not much meat. They do get peanut butter and jelly or pimento cheese sandwiches that are more substantial. 10. Concern anyone can come into the building at anytime of the night. 11. Concerned their checks come in but don't get to see it or sign it.

Based on record review, and review of the policy, Care Plans as well as interviews the facility failed to ensure the resident and/or the family representative received a copy of the Baseline Care Plan that includes instructions needed to provide effective and person-centered care of the resident, and to meet professional standards of quality of care. This system failure affected residents, Resident #73 (R#73), R#61, R# 72 and R#229 out of a sample of 34 residents. The census was 83. Findings include: 1. Resident #73 was admitted to the facility on [DATE]. He entered the facility after an amputation of his left foot. He presented with [DIAGNOSES REDACTED]. Review of the nursing notes and care plan documentation revealed no documentation to indicate the family or the family representative received a copy of the Baseline Care Plan after admission to the facility. Review of the facility policy, Care Plans revealed under Scope, Baseline Care Plan - Must include the minimum healthcare information necessary to properly care for each patient/resident immediately upon their admission, which would address specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions and assistance with activities of daily living, as necessary. Under Procedure: New Admission Baseline Plan of Care, Number one (1) .a baseline care plan will be developed by the admitting nurse/nurses in conjunction with other IDT, the patient/resident and/or patient/resident representative. Number three (3), .A copy of the Baseline Care Plan form and Admission Physician order for [REDACTED]. During an interview with the Case Mix Director on 12/4/18 at 11:09 a.m., she revealed the Unit Managers are responsible for the Baseline Care Plan and ensuring the resident and/or the family representative receive a copy of that information. During an interview with the Unit Manager BB on 12/4/18 at 11:14 a.m., she revealed that a baseline care plan was created for this resident but the resident and/or the resident representative did not receive a copy of that information. She stated that since (MONTH) (YEAR) staff are working on a new computer system and that there was not a place for that information in the new system. She stated they have not been giving a copy of the baseline care plan to the resident and/or resident representative since the new system came into being. During an interview with the Director of Nursing (DON) on 12/6/18 at 8:38 a.m., she stated that she expected the Baseline Care Plan to be complete within 48 hours, and when the nurse signs and completes it they conduct a Five (5) Day Meeting with the interdisciplinary team (IDT), family and resident to discuss all the care concerns for the resident. There is a sign-in sheet and if the family is unable to attend they will be called and that information will be documented. 2. Resident (R)#61 was admitted to the facility with the following [DIAGNOSES REDACTED]. Further review of the facility nursing notes and care plan documentation for R#61 revealed no documentation to indicate the resident or the family representative received a copy of the Baseline Care Plan (dated 11/8/18) after admission to the facility. Interview with the Case Mix Director on 12/4/18 at 11:01 a.m., revealed that R#61 and other admission residents within the last 30 days was not provided with a copy of the baseline care plan. Interview on 12/5/18 at 10:03 a.m. with the Family Member of R#61, revealed her relationship as Power of Attorney (POA) for R#61. POA verified not receiving a copy of the baseline care plan and that also that another relative who was also listed as a Responsible Party and contact person for R#61 did not received a copy of baseline care plan. POA further stated that she and the responsible party visited the nursing home daily and had several contacts with the Director of Nursing(DON) and other administrative staff daily. POA stated being unaware about the type of medical care R#61 was receiving on a daily basis and this was confusion and disturbing. She stated that she had informed the DON that she was the POA at the time of R#61 admission to the facility. She stated that the DON was often rude during telephone contact whenever she called or inquired about R#61 's plan of care. 3. Resident #72 was admitted to the facility on [DATE]. She entered the facility after a hospital stay for an acute exacerbation of [MEDICAL CONDITIONS] and [MEDICAL CONDITION] hypertension. She presented with [DIAGNOSES REDACTED]. R#72 is alert and oriented to person, place, time and situation. She makes her own decisions and is able to make her needs known. Review of the nursing notes and care plan documentation revealed no documentation to indicate the resident or the family representative received a copy of the Baseline Care Plan (dated 11/8/18) after admission to the facility. Review of the facility policy, Care Plans revealed under Scope, Baseline Care Plan - Must include the minimum healthcare information necessary to properly care for each patient/resident immediately upon their admission, which would address specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions and assistance with activities of daily living, as necessary. Under Procedure: New Admission Baseline Plan of Care, Number one (1) .a baseline care plan will be developed by the admitting nurse/nurses in conjunction with other IDT, the patient/resident and/or patient/resident representative. Number three (3), .A copy of the Baseline Care Plan form and Admission Physician order for [REDACTED]. During an interview with R#72 conducted on 12/4/18 at 8:49 a.m., stated the staff did not discuss her goals or plan of care with her at the time of admission nor did they provide her a copy of the care plan. During an interview with the Unit Manager on 12/5/18 at 1:10 p.m., she revealed that a baseline care plan was created for R#72, but the resident and or the resident representative did not receive a copy of that information. She stated that since (MONTH) (YEAR) staff are working on a new computer system and that there was not a place for that information in the new system. She stated they have not been giving a copy of the baseline care plan to the resident and/or resident representative since the new system came into being. An interview with the DON on 12/6/18 at 8:30 a.m. confirmed that she expects the staff to complete and initial care plan for the resident within 48 hours. She also stated that the resident and/or family should be involved and they should sign the care plan as well. She also stated that the responsibility for the completion of the care plan was delegated to the MDS Coordinator and the Social Worker, but that the position is currently vacant. 4. Resident #229 was admitted to the facility on [DATE] after a lengthy hospitalized from [DATE] through 11/29/18. He was admitted from the community to the hospital in acute [MEDICAL CONDITION], was on a ventilator with a [MEDICAL CONDITION] ; he developed a community acquired pneumonia and had comorbidities of [MEDICAL CONDITION] and [MEDICAL CONDITION]. R#229 reports he lost over 100 pounds during his hospital stay. He was unable to ambulate due to muscle weakness and deconditioning and required rehabilitative therapy to aid in his eventual return to home. R#229 is alert and oriented to person, place, time and situation. He makes his own decisions and is able to make his needs known. Review of the nursing notes and care plan documentation revealed no documentation to indicate the resident received a copy of the Baseline Care Plan (dated 11/30/18) after admission to the facility. Review of the facility policy, Care Plans revealed under Scope, Baseline Care Plan - Must include the minimum healthcare information necessary to properly care for each patient/resident immediately upon their admission, which would address specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions and assistance with activities of daily living, as necessary. Under Procedure: New Admission Baseline Plan of Care, Number one (1) .a baseline care plan will be developed by the admitting nurse/nurses in conjunction with other IDT, the patient/resident and/or patient/resident representative. Number three (3), .A copy of the Baseline Care Plan form and Admission Physician order for [REDACTED]. During an interview with the Unit Manager on 12/5/18 at 1:10 p.m., she revealed that a baseline care plan was created for R#229, but the resident and or the resident representative did not receive a copy of that information. She stated that since (MONTH) (YEAR) staff are working on a new computer system and that there was not a place for that information in the new system. She stated they have not been giving a copy of the baseline care plan to the resident and/or resident representative since the new system came into being. An interview with the DON on 12/6/18 at 8:30 a.m., confirmed that she expects the staff to complete and initial care plan for the resident within 48 hours. She also stated that the resident and/or family should be involved and they should sign the care plan as well. She also stated that the responsibility for the completion of the care plan was delegated to the MDS Coordinator and the Social Worker, but that the position is currently vacant.

Based on observation, interview and review of a facility policy entitled Labeling, Dating, and Storage dated [DATE], the facility failed to store pre-poured thickened beverages in the cooler with a use by date and failed to dispose of an expired spice in the kitchen. The pre-poured thickened beverages had the potential to affect five of five residents with physician's orders [REDACTED]. Findings include: During the initial tour of the kitchen conducted on [DATE] at 11:10 a.m., a tray containing six glasses of ready to drink thickened liquids were noted in the cooler with lids on them and the date of ,[DATE] marked on the lids. Also, during the initial tour of the kitchen conducted on [DATE] at 11:10 a.m., a plastic container of ginger (spice) was noted as labeled with date opened ,[DATE] and date expires [DATE]. The container was sitting on a shelf above a food prep area with other spices within easy reach of staff. During an interview with the Food Service Director (FSD) conducted on [DATE] during the initial tour at 11:10 a.m., she stated that the date of ,[DATE] noted on the lids of the thickened liquids was the date the liquids were poured into the glasses and placed in the cooler. She stated they are good for 48 hours; the FSD disposed of the six glasses of beverages. The FSD confirmed the container of ginger (spice) should have been discarded by the expiration date listed on the label, [DATE]; she disposed of the container Review of a facility policy entitled Labeling, Dating, and Storage dated [DATE] provided by the FSD, states: 1. Food and/or beverage items will be properly labeled with the name of the item, and a use by date. 2. Foods will be stored in their original containers or in an approved container or wrapped tightly with film, foil, etc and clearly labeled with the name of the item and the use by date. Review of product information listed on the label of(NAME)Ready Care (nectar thickened lemon flavored water), notes the following: Shelf Life: 7 months from date of manufacture. Refrigerate after opening and use within 7 days. The product label does not provide any guidance regarding expiration date of the product once it is poured out of the manufacturer's container.