Every finding on record at Quinton Mem HC & Rehab Center

Based on observations, staff and resident interviews, record review, and review of the License Practical Nurse and Registered Nurse (Charge Nurse) Job Descriptions, the facility failed to ensure residents received care in accordance with physician orders for one of 39 sampled residents (R) (R6). Specifically, the facility failed to ensure lab tests, and assessment of hemorrhoids were conducted as ordered by the physician. The deficient practice had the potential to place R6 at increased risk of adverse clinical outcomes related to blood loss.Findings include:Review of the facility's Licensed Practical Nurse (LPN) and Registered Nurse (RN) job descriptions documented, Reviews duties of collection of lab specimens and interpreting results. Maintain effective lines of communication with attending physicians. Charting of information regarding patient progress, ailments, medication symptoms, and observations. Addresses with supervising nursing staff, the progress of patients and how to proceed with care. They may be required to perform physical assessments of patients under the RN's direction. They may be required to draw blood and obtain fluids to submit for lab work.Review of the electronic health record (EHR) revealed R6 was admitted to the facility on [DATE] with diagnoses including, but not limited to, condition end stage renal disease, chronic obstructive pulmonary disorder (COPD) and dependency on renal dialysis.Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R6 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated severe cognitive impairment. Section I, Active Diagnoses, lists R6 primary medical condition as end stage renal disease, chronic obstructive pulmonary disorder (COPD) and dependency on renal dialysis.Review of the care plan revised 07/22/2025 revealed R6 had a Focus on anemia with a documented Goal, which was revised on 04/29/2026 and stated, Resident will remain free of signs and symptoms of complications related to anemia through review date. Interventions included, but not limited to, Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated.Review of the physician orders dated 05/08/2026 for R6 revealed the following:CBC & CMP {complete blood count test for anemia and complete metabolic panel test for overall body function status}Occult Stool {test for blood in the stool}Nursing to assess patient for external hemorrhoids and unusual bleeding.Review of the EHR, including the Lab Summary for R6 dated May 2026 revealed, there was no lab testing obtained as ordered on 05/08/2026.Review of the EHR revealed there was no documented assessment by nursing for R6 involving external hemorrhoids and bleeding as ordered on 05/08/2026.On 05/20/2026 at 3:50 PM, the Assistant Director of Nursing (ADON) confirmed that nurses are responsible for ensuring that orders and care plans are followed. She stated that it was her expectation that nursing staff were to receive and acknowledge orders from the nurse practitioner and medical director. The ADON stated the expectation was nurses were to perform orders, review findings and share with the medical team.Interview with the Nurse Practitioner (NP) on 05/21/2026 at 11:15 AM, the NP stated her expectation for performance of orders was that they were conducted with residents as ordered or NP was notified of delay reasons, unless the order was for a stat {immediate} lab. The NP stated typically they should be done within a few hours of order placement. She indicated that stool samples can take some time based on the resident's status. She added that she does a monthly check on those with chronic conditions, noting any changes of condition. The NP added that the medical team was made aware of delays or failures to collect labs as ordered. She stated she was aware of the situation with the orders for R6 and a review was being conducted.

Based on observations, record review, staff interviews, and review of facility's electronic Work Order system's cleaning schedule titled, Oxygen Concentrators: In-House Maintenance, the facility failed to ensure respiratory equipment was maintained in a clean and sanitary manner by not cleaning the oxygen concentrator filter for two of 30 residents (R)(R58 and R67), on respiratory care. This deficient practice had the potential to cause ineffective oxygen delivery, respiratory complications, and increased risk of infection.Findings Include:Record review of facility's electronic Work Order System's cleaning schedule titled, Oxygen Concentrators: In-House Maintenance, dated 05/15/2026 documented under section titled, Cleaning the Cabinet Filter - Risk of Damage: To avoid damage to the internal components of the unit: DO NOT operate the concentrator without the filter installed or with a dirty filter. 1. Remove the filter and clean as needed. 1. Environmental conditions that may require more frequent inspection and cleaning of the filter include, but are not limited to: high dust, air pollutants, etc.1. Record review of the Electronic Health Record (EHR) revealed R58 was admitted on [DATE] with diagnoses including, but not limited to, chronic diastolic (congestive) heart failure, chronic respiratory failure with hypercapnia obstructive sleep apnea (adult) (pediatric), pulmonary hypertension, unspecified, personal history of covid-19, essential (primary) hypertension, and paranoid schizophrenia.Record review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented R58 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated little to no cognitive impairment. The MDS further revealed the resident was dependent on staff for activities of daily living and received oxygen therapy services.Record review of physician orders dated 04/01/2025 revealed an active order for oxygen at 2 liters per minute via nasal cannula continuously, with additional orders to change oxygen tubing and nasal cannula or mask as needed.Record review of the resident's care plan revealed an active problem for oxygen use related to a focus of congestive heart failure and a risk for complications with interventions to administer oxygen per physician order.Initial screening observation on 05/19/2026 at 12:10 PM revealed R58's oxygen concentrator built-in filter dirty with significant amount of brown, fuzzy particulate matter.Observation on 05/20/2026 at 10:15 AM revealed the built-in filter on R58's oxygen concentrator was dirty with a significant amount of brown, fuzzy particulate matter.Observation on 05/20/2026 at 1:13 PM revealed the built-in filter on R58's oxygen concentrator was dirty with a significant amount of brown, fuzzy particulate matter.2. Record review of the EHR revealed R67 was admitted on [DATE] with diagnoses including, but not limited to, chronic respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic polyneuropathy, chronic obstructive pulmonary disease, unspecified, pulmonary hypertension, unspecified acute on chronic diastolic (congestive) heart failure, essential (primary) hypertension, chronic kidney disease, stage 3b.Record review of the Quarterly MDS dated [DATE] documented R67 had a BIMS score of 15, which indicated little to no cognitive impairment. The MDS further revealed the resident was dependent on staff for activities of daily living and received oxygen therapy services.Record review of physician orders dated 03/31/2025 revealed an active order for oxygen at 2 liters per minute via nasal cannula continuously, with additional orders to change oxygen tubing and nasal cannula or mask as needed.Record review of the resident's care plan documented an active problem for oxygen use related to a focus of congestive heart failure and a risk for complications with interventions to administer oxygen per physician order.Initial screening observation on 05/19/2026 at 10:46 AM revealed R67's oxygen concentrator's spongy foam intake filter was dirty with a significant amount of gray, fuzzy particulate matter.Observations on 05/20/2026 at 1:17 PM revealed R67's oxygen concentrator's spongy foam intake filter was dirty with a significant amount of gray, fuzzy particulate matter.Observation and interview on 05/20/2026 at 1:20 PM with Unit Manager/Licensed Practical Nurse (LPN)AA stated the nursing staff were responsible for changing out the oxygen tubing, nasal cannula, mask, and replacing equipment bags weekly. She stated they should check all other parts of the concentrator for cleaning purposes. She stated that all their residents should have a physician's orders stating to change oxygen tubing, nasal cannula, and mask every 30 days or as needed. She stated they kept a record of them completing the task on the residents' Medication Administration Record (MAR). She stated they clean the spongy style and/or built-in filters both with soap and water. LPN AA confirmed R58 and R67's oxygen concentrator filters were unclean with a thick gray, fuzzy particulate matter.Observation and interview on 05/20/2026 at 1:40 PM with Assistant Director of Nursing (ADON) confirmed R58 and R67's oxygen concentrator filters were unclean with a thick gray, fuzzy particulate matter. The ADON stated she was not for sure why LPN AA stated the nursing staff were responsible because she indicated the maintenance staff was responsible for cleaning the oxygen concentrators normally with a small portable vacuum cleaner. She stated the Maintenance Director (MD) could provide a routine cleaning schedule for the tasks that were recorded on their maintenance system called [name of electronic Work Order system.] Interview and observation on 05/20/2026 at 3:00 PM with MD mentioned there was a lot of patient care rounding being done at the same time as they are doing their routine cleaning. He stated the dirty equipment must have been an oversight that caused the residents' equipment routine cleaning to get missed.Interview 05/21/2026 at 12:52 PM with the Administrator revealed she was unaware that the oxygen concentrators' filters needed to be cleaned. She further provided an oxygen concentrator routine cleaning list from the electronic Work Order system, which indicated the task was completed by the MD on 05/15/2026.

Based on observations, resident and staff interviews, and review of the facility policies titled, HLTC Oxygen (O2) Administration and HTLC Administering Medications Through Nebulizer, the facility failed to bag and store unused O2 and nebulizer tubing, and cannulas/masks for four of 28 residents (R) (R52, R68, R39, and R287) receiving respiratory services . The deficient practice had the potential to allow unhealthy organisms to contact the equipment and of spreading infection in the facility. Findings include: Review of the facility policy titled HLTC Oxygen Administration revealed under Procedure: . 4. Maintenance, a. Replace oxygen tubing at least monthly and more often as needed for contamination, dysfunction, or visibly soiled tubing. Review of the facility policy titled HLTC Administering Medications Through Nebulizer revealed under Procedure: . 5. Cleaning, a. The facility will: i. Wipe machine with warm, soapy water and rinse or use an all-purpose disinfecting wipe according to the instructions on the label, and observing the appropriate kill time, at least once a week and as needed. ii. Clean humidifier weekly and air dry. iii. Rinse washable filter under running water once a week to remove dust and debris. Replace this filter at least once a year. iv. Clean masks, nasal pillows and tubing daily by cleaning with warm, soapy water. Rinse with warm water and allow it to dry between use. V. Clean headgear (strap) by washing with warm water and mild detergent as needed and allow to air dry. Review of the most recent quarterly Minimum Data Set (MDS) assessment for R52 dated 2/15/2025 Section I (Active Diagnoses) revealed but not limited to diabetes mellitus, malnutrition, Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive decline. During observation and interview on 3/11/2025 at 12:07 pm with R52 revealed unbagged O2 tubing with O2 concentrator in the corner on the floor. R52 said she recently moved into this room and this equipment was hers. During observation on 3/11/2025 at 4:30 pm of R52 revealed the same unbagged O2 tubing on the floor, unbagged, along with the O2 concentrator on the floor in the corner. During observation on 3/12/2025 at 9:05 am of R52 revealed O2 tubing remained on floor, unbagged, next to the O2 concentrator. Review of the most recent quarterly MDS assessment for R68 dated 12/14/2024 revealed diagnoses including but not limited to coronary artery disease, heart failure, respiratory insufficiency, hypertension, and dementia, Section C revealed a BIMS score of 15, indicating intact cognition. During an observation on 3/12/2025 at 11:06 am of R68 revealed the O2 concentrator filter had brownish-gray substance coating the machine filter cover. Review of the most recent quarterly MDS assessment for R39 dated 1/11/2025 revealed diagnoses including but not limited to anemia, heart failure, hypertension, hip fracture, Section C revealed a BIMS score of 15, indicating intact cognition. During an observation on 3/12/2025 at 10:45 am of R39 revealed nebulizer (machine to deliver breathing treatments) tubing and mask were noted to be unbagged and uncovered at the bedside. Review of the most recent quarterly MDS assessment for R287 dated 1/28/2025 revealed diagnoses including but not limited to anemia, heart failure, hypertension, hip fracture, Section C revealed a BIMS score of 9, indicating moderate cognition decline. During an observation on 3/13/2025 at 3:45 pm of R287 revealed nebulizer tubing and mask were noted to be unbagged and uncovered at the bedside in a room under Enhanced Barrier Precautions (EBP). During an interview on 3/12/2025 at 9:15 am with Certified Nursing Assistant (CNA) BB revealed when asked about the O2 equipment of R52's on the floor, uncovered and unmarked. CNA BB stated she was unsure why it was there, and that the resident had recently moved into the room and the O2 equipment came over with her. CNA BB stated she has not seen R52 use the equipment. During an interview on 3/12/2025 9:19 am with LPN AA regarding R52 O2 tubing lying on floor in the corner of R52's and R287's rooms, LPN AA stated she believed the policy was that the O2 equipment in this room and the nebulizer in R287 room should be placed in a bag when not in use. She further stated it was the duty of the night shift to take care of this equipment cleaning and storage. During an interview on 3/12/2025 at 11:30 am with the Infection Preventionist (IP) regarding respiratory infection prevention practices, she revealed she completed periodic spot checks on respiratory and O2 equipment during walk-arounds in the facility. She further revealed that the policy states the tubing and face masks/cannulas should be bagged when not in use and cleaning was to be done weekly by the evening shift staff. Review of in-service documentation from 2024 did not reveal any specific training on the infection prevention task as it related to respiratory equipment and tubing. Interview on 3/13/2025 at 3:50 pm with the Director of Nursing (DON) revealed the evening shift handled respiratory sanitization administration and control of O2 and nebulizer equipment and tubing. The DON stated tubes and cups should be bagged and dated when not in use and that cleaning should be done monthly according to policy. The DON confirmed with Registered Nurse (RN) EE that no logging was done when scheduled cleaning was performed.

Based on interviews, record review, and review of the facility policy titled Falls, the facility failed to provide the necessary supervision to prevent falls to the extent possible for one of three sampled residents (R) (R3) reviewed for falls. R3 sustained six falls at the facility from [DATE] through February 2024 when attempting to get out of bed unassisted and/or ambulating without assistance, with four of the first five falls resulting in injuries to the head. The facility documented contributing factors for the falls but failed to identify and address the need for increased supervision related to the resident's declining cognition and failed to conduct and document a root cause analysis for each fall to facilitate the ability to develop specific fall prevention interventions that would address the causative factors of the falls. Harm was identified to have occurred on [DATE], when R3 fell and was sent out to the hospital. The fall resulted in R3 sustaining a fractured ankle. The resident was hospitalized and diagnosed with a traumatic brain injury due to recurrent falls with multiple head injuries. Findings included: A facility policy titled Falls with a revised date of [DATE], revealed that the facility's management of falls focuses on resident-centered assessment to aid in the prevention of falls. The policy also specified that the care plan is used as the facility's resident-centered tool that lists the specific interventions that the IDT (interdisciplinary team) discussed and that adjustments can be made to interventions based on the effectiveness of these interventions. Interventions are based on each resident's needs. The policy indicated the facility interventions for fall risk or post-fall may include but were not limited to an IDT review and care plan review and revisions. A review of the Electronic Medical Record (EMR) revealed that R3 was admitted to the facility on [DATE] with diagnoses of mild cognitive impairment, insomnia, macular degeneration, peripheral vascular disease, age-related osteoporosis, an incomplete rotator cuff tear or rupture of an unspecified shoulder, and long-term use of anticoagulants. A review of the Significant Change Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], revealed that R3 presented with a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment; that R3 used a walker and wheelchair for mobility in the last seven days; that R3 required substantial/maximal assistance to move from a sitting to lying position and to move from a lying position to sitting on side of the bed; that R3 required partial/moderate assistance to move from a sitting to standing position, chair/bed-to-chair transfers, and toilet transfers; that R3 required supervision or touching assistance to walk 10 feet and that walking 50 or 150 feet was not attempted due to a medical condition or safety concerns; that R3 was frequently incontinent of urine and bowel; and that R3 had fallen in the last month, had fallen in the last two to six months prior to admission/reentry, but had not experienced falls since the prior assessment/reentry. A review of a nursing Progress Note dated [DATE] revealed the nurse heard yelling from R3's room and that R3 was found lying on the floor against the air-conditioner. A review of the Fall Event report dated [DATE] revealed that R3 sustained a fall while ambulating and was found on the floor on [DATE] at 9:30 pm. The report documented that the resident stated they were reaching for the bathroom door but could not get it to open, lost their balance, and hit their head on the air conditioning unit. According to the report, the contributing factors for the fall were Distractions. The report revealed R3 sustained a small, soft-tissue injury to the top of the head and an ice pack was applied. A review of the nursing Progress Notes dated [DATE] at 10:00 am revealed R3 had blue/purple bruising to the eyes, forehead, and the back of the head from the fall on [DATE]. The note documented that, per the resident's family member, the resident was having episodes of confusion. The note revealed new physician orders were obtained for a computed tomography (CT) scan and laboratory testing. A review of the ED [Emergency Department] Note dated [DATE] revealed that R3 had fallen from the standing position on [DATE]. Per the note, the resident hit their head, had bruising to the face, and had confusion after the fall. The note revealed during the ED visit, the resident complained of visual disturbances in the left eye and decreased hearing in the left ear with a roaring sensation and pain. The note revealed, per the resident's family, the previous CT scan was normal. According to the note, R3 had purplish facial bruising surrounding both eyes, the forehead, and the posterior occipital areas (back of the head). The notes revealed the resident was diagnosed with facial contusions and was transferred back to the facility. A review of the Fall Event report dated [DATE] revealed R3 fell from bed on [DATE] at 5:05 am. According to the report, a Certified Nursing Assistant (CNA) was called to R3's room, and the resident was found on the floor beside the bed. The report revealed that R3 stated they hit their head, arm, leg, and hip. The report documented a large baseball-sized bruise on the left side of the resident's forehead and that R3 was transferred to the ED. The report revealed the contributing factor to the fall was Action by Patient/Resident. The report revealed immediate actions included the implementation of fall prevention strategies, neurological checks, a referral to the ED, and Risk for falls noted on chart/care plan. The report did not specify what fall prevention strategies were implemented after this fall. A review of the hospital ED History and Physical Report dated [DATE] at 12:33 pm revealed R3 was being seen for a post-fall evaluation after the resident fell out of bed and hit their head. The report documented the resident had a hematoma to the forehead, bruising to the upper left arm, and bruising and a skin tear to the right shin. According to the History and Physical, it was reported the resident's feet got caught underneath their blankets and the resident fell out of bed hitting their head on a side table. According to the report, R3's family member reported the resident hit their head when they fell in [DATE] and since that time, the resident had rapidly declined in function and mentation and was much more confused. The report revealed the resident had also had recent dizziness that the resident described as the room spinning. A hospital Discharge Documentation form, dated [DATE], revealed that R3's discharge diagnoses included frequent falls and a closed head injury without concussion. A Fall Event, report dated [DATE] revealed at approximately 6:50 am, the nurse heard R3 yelling for help. According to the report, the resident fell from the bed. The report revealed R3 was found lying flat on their back to the left side of the bed, barefoot. The report documneted that R3 stated, Help when asked what happened. According to the report, the resident had a 1.5-inch skin tear on the left elbow and had bruising and an indention to the left cheekbone and was transferred to the ED. According to the report, the contributing factors to the fall were, Action by Patient/Resident and Confused/Disoriented. A review of the ED After Visit Summary dated [DATE], revealed R3 was diagnosed with a closed head injury. A review of the nursing Progress Notes dated [DATE] at midnight revealed R3 was yelling, and when staff entered the room, the resident was on their knees at the door wearing no socks. The report documented that R3 stated he was going to the bathroom and was using the rollator walker when they fell . A review of the nursing Progress Notes, dated [DATE] at 11:00 am revealed staff were following up on R3 after the unwitnessed fall. According to the notes, R3 had been more confused in the last two days. The notes documented that staff instructed the resident to use the call light if needed, the bed was in the lowest position, and staff placed the call light and bedside table within the resident's reach. A review of the physician's Office Visit note dated [DATE] revealed the resident had been confused the entire weekend with increased delusions and on this date, the resident had increased speech difficulty and was unable to keep their eyes open. The note revealed the physician explained to the family that this could be the progression of underlying dementia, which was now rapidly progressing since the resident's head injury in [DATE]. A review of the Fall Event report dated [DATE] revealed that R3 sustained another fall on [DATE] at 12:30 am while standing. The report revealed staff found the resident on the floor at the foot of the bed with the rollator walker at the resident's feet. According to the report, contributing factors included confusion/disorientation, current diagnosis/condition, inability to understand, lost/impaired balance, and mental status/capacity. The immediate actions listed on the report indicated the care plan was reviewed/revised, equipment was removed, fall prevention strategies were implemented, neurological checks, that the resident was assessed, the resident's representative was notified, and that the risk for falls was noted on the chart/care plan. The report did not specify what revisions were made to the care plan, what equipment was removed, or what fall prevention strategies were implemented as a result of this fall. A review of the nursing Progress Notes dated [DATE] revealed the resident's family did not want to send R3 to the ED for an evaluation. A review of the Fall Event report dated [DATE] documented that on [DATE] at 7:45 pm, staff found R3 on the floor, yelling that they had broken their foot. The report revealed R3 was holding the right foot in the air and telling staff not to touch the foot. The report documented the right ankle was swollen and the resident had a dislocation/fracture to the right ankle. According to the report, the resident fell from the bed and the contributing factors included confusion/disorientation, inability to understand, inadequate/improper footwear, and lost/impaired balance. Per the report, immediate actions included a care plan review/revision, fall prevention strategies, a footwear review, neurological checks, and a resident assessment. A review of the hospital history and physical report dated [DATE] at 12:33 am revealed the resident had been having repeated falls since [DATE] (approximately five to six) and the majority resulted in head injuries. The report revealed anticoagulation medications were discontinued on Tuesday of the previous week as a precaution and hospice was initiated earlier in the week. The report documented the resident had a closed, right ankle fracture from the fall from a bed at the facility. According to the report, the fracture was reduced and splinted. In addition, the report revealed the resident had a history of traumatic brain injury due to recurrent falls with multiple head injuries since [DATE], likely secondary to dementia. A review of the Discharge Summary dated [DATE] revealed the resident was deceased and the preliminary cause of death was cardiopulmonary arrest. A review of the [state] Death Certificate, dated [DATE], revealed that R3 expired on [DATE] at 12:25 pm. The death certificate documented the immediate causes of death were cardiopulmonary arrest, acute kidney injury on chronic kidney disease, acute delirium, and an ankle fracture. During an interview on [DATE] at 5:09 pm, CNA4 stated that R3 had dementia, and got up unassisted, and tried to walk without the rollator walker. The CNA stated she checked on the resident frequently, usually every hour, and the resident's room was close to the nurses' station. CNA4 stated R3 did not sustain any falls while she was working. During an interview on [DATE] at 2:27 pm, CNA5 stated that R3's health declined and that toward the end, the resident would get up unassisted. During an interview on [DATE] at 2:56 pm, Licensed Practical Nurse (LPN)6 stated that R3 had a strong will and was independent before declining. LPN6 indicated that R3 would get up unassisted, and before their health declined, the resident was using a rollator. LPN6 revealed that the resident would frequently walk without the rollator walker and that after each fall, interventions were put in place to prevent falls. During an interview on [DATE] at 9:30 am, the Rehabilitation (Rehab) Director stated that falls were discussed in morning meetings. She indicated that depending on the fall, the nurse manager completed a screening for the rehab department. The Rehab Director stated that R3 was seen by the physical therapy (PT) department from [DATE] through [DATE] for muscle weakness and balance issues. The Rehab Director indicated that R3 also had cognitive decline and confusion. According to the Rehab Director, R3 initially used a rollator walker but was no longer safe to use one and began using a wheelchair. During a telephone interview on [DATE] at 11:55 am, the Director of Hospice stated that R3 started receiving hospice services 48 hours before going to the hospital. She indicated that R3 was admitted to hospice for heart failure, had poor safety awareness, and was known to get up unassisted. She stated that the family revoked hospice when the resident went to the hospital in February 2024 and the resident had surgery on the ankle. During a telephone interview on [DATE] at 4:24 pm, Medical Director (MD)3 stated that R3 frequently forgot to use the walker and fell . MD3 revealed that he did not think an ankle fracture would be the cause of the resident's death unless it was an open fracture that caused an embolism (blood clot). MD3 stated the family chose hospice care for end-stage dementia with delirium, he believed the facility implemented interventions that included moving the resident closer to the nurse's station, and the CNAs checked the resident frequently. During an interview on [DATE] at 3:35 pm, the Director of Nursing (DON) stated that she expected resident falls to be minimized/reduced with the appropriate interventions. The DON stated that she expected a root cause analysis to be completed and that interventions to address falls be added to the care plan. During an interview on [DATE] at 11:37 am, the Administrator stated falls were discussed during daily morning meetings, but there was no written/documented information regarding the root cause for falls. During a follow-up interview on [DATE] at 3:40 pm, the Administrator stated she expected staff to assess the resident after a fall, implement necessary interventions, and put them on the care plan. The Administrator indicated that she expected a root cause analysis to be documented and that interventions to address the falls be documented on the care plan. The Administrator stated that this was discussed during the IDT meetings every morning.

Based on observations, interviews, and review of the facility's policies titled, Food Receiving and Storage, Preventing Foodborne Illness-Food Handling, and Food Brought by Family/Visitors, the facility failed to ensure opened food items in the kitchen were labeled and dated; failed to discard expired food items, failed to monitor refrigerator temperatures in two of two resident pantries, and failed to properly date and store food left for a resident. These deficiencies had the potential to affect 74 residents receiving an oral diet. The census was 74. Findings include: Review of the policy titled, Food Receiving and Storage issued [DATE] revealed the following: Purpose: Foods shall be received and stored in a manner that complies with safe food handling practices. 7. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). 12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Dietary Manager or designee and documented. A review of the policy titled, Preventing Foodborne Illness-Food Handling Issued [DATE] revealed the following: Purpose: Food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized. 5. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state-specific requirements. Federal standards require that refrigerated food be stored below 41 degrees F. and that freezers keep frozen foods solid. 8. Food that has been served to residents without temperature controls (e.g., trays, snacks, etc.) will be discarded if not eaten within two hours. A review of the policy titled, Foods Brought by Family/Visitors Issued [DATE] revealed the following: Purpose: Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. 2. Family/Visitors will be encouraged to date and store food that is left with the resident. 3. Staff will discard perishable foods as indicated. During an initial tour of the kitchen on [DATE] at 9:00 a.m. with the Assistant Dietary Manager (ADM) HH Storage issues were observed as follows: A bin of cornmeal labeled with expiration date of [DATE]. A bin of flour labeled with expiration of [DATE]. A bin of sugar labeled with expiration date of [DATE]. A bag of brown rice with no date opened or expiration date listed. A container of thickener with use by date of [DATE]. A container of parsley flakes without an open date. Interview [DATE] at 9:00 a.m. with ADM HH revealed the pantry items should all have a date and should have a newer label when the containers of cornmeal, sugar and flour were replaced. ADM HH also confirmed the brown rice should have a label and the thickener discarded when expired. Observation [DATE] at 9:22 a.m. revealed the snack refrigerators in the east and west wing pantries had temperature logs with missing temperature readings for several dates. There was a pizza box in the west wing pantry refrigerator with labeled [NAME] containing one slice of pizza with no date. Interview [DATE] at 9:23 a.m. with Certified Nursing Assistant (CNA) KK confirmed the box of pizza labeled [NAME] was not dated with date received or date to be discarded. She revealed she had no idea when it arrived or how long it had been in the refrigerator. Continued interview revealed it should have been labeled with date of receipt and date to be discarded. Further interview revealed she did not know who was supposed to be checking the refrigerator temperatures or who removes unlabeled or expired foods. Interview [DATE] at 9:25a.m. with Registered Nurse, (RN) II on the east wing revealed the night shift nursing staff was responsible for checking the pantry refrigerator temperatures and confirmed there were several missing dates on the log. Interview [DATE] at 9:29 a.m. with CNA JJ revealed it was night shifts responsibility for checking the refrigerator temperatures and all foods brought in by family members should be labeled and dated. Interview [DATE] at 9:31a.m. with RN II revealed it was the dietary department that is responsible for checking and recording the refrigerator temperature logs. Interview [DATE] at 9:40 a.m. with RD FF and RD GG revealed nursing was responsible for checking temperatures from the pantry refrigerators and recording on the temperature logs. They also revealed any food items brought in by family members should be labeled with their name when the item was brought in and discarded as identified by the facility policy. The RD's confirmed they had observed the out-of-date items in the kitchen and the bins had been emptied and thoroughly cleaned. They further revealed the additional out- of -date items had been discarded. The RD's additionally revealed the items without open dates had been discarded. RD FF revealed it is her expectation that all foods be labeled with the open date and the date to be discarded. Interview [DATE] at 9:47 a.m. with the Director of Nurses (DON) revealed the dietary department monitors the resident pantry refrigerator temperatures and items inside of them. Interview [DATE] at 12:30 p.m. with the Administrator revealed he is aware there is an issue with the pantry refrigerator temperatures not being recorded. Further interview revealed it is the responsibility of the dietary department for monitoring and recording the refrigerator temperatures. Interview [DATE] at 12:50 p.m. with RD FF revealed the policy regarding the monitoring of the pantry refrigerators had been changed recently and it had been pointed out to her that the dietary staff is responsible for monitoring the temperature logs and she was unaware of that change. Interview [DATE] at 10:00 a.m. with ADM HH revealed it was the responsibility of the nursing staff to monitor food brought in and stored in the food pantry refrigerators. Continued interview revealed the dietary department supplies snacks but does not check dates of food from outside sources. An interview [DATE] at 10:30 a.m. with the Administrator revealed foods brought in from outside by family should be labeled using supplied labels with the received date and date to be discarded. Continued interview revealed it is his expectation that all food items be labeled appropriately and discarded on discard date. Further interview revealed if a food item is found to be unlabeled it should be discarded by the person who discovers it.

Based on observations, staff interviews, review of the facility policy titled, [NAME] Long Term Care [HLTC] Non-Controlled and Controlled Medication Ordering, Receiving, and Storage, and review of the facility document titled, HLTC Medication Administration Competency Evaluation, the facility failed to ensure one of four medication carts were locked and secure when unattended that permitted only authorized personnel to have access on two occasions. The facility failed to ensure that narcotics were counted and documented at the beginning of each shift on two of four medications carts. In addition, the facility failed to ensure medications were stored with proper identification/labeling for three residents on one medication cart. These failures placed residents at risk of having their unsecured medications diverted and being administered incorrect medications. Findings include: Review of the policy titled, HLTC Non-Controlled and Controlled Medication Ordering, Receiving, and Storage, date of issue 10/1/2019 and revised on 7/7/2022, revealed that medications are dispensed by the pharmacy in unit dose packages, medications are required to be kept in secure location for storage, the licensed nurse will maintain keys to the medication cart and medication room during their assigned shift and the nursing staff will count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty will conduct the count together and sign the Controlled Medication Shift Count form. Review of the document titled, HLTC Medication Administration Competency and Evaluation revealed medications are administered as scheduled but no more that one hour before or after the scheduled time and the nurse administers medications by adhering to the five rights of medication administration: administer to the right resident, select the right medication, administer the right dose, administer at the right time, and administer via the right route. Review of the Controlled Medication Shift Count sheets for the month of February 2023 on two carts, one from the west long hall and one from the west short hall, revealed multiple missing signatures and multiple dates the form was not completed. The west short hall had missing signatures and/or the form was not completed on 2/8/2023, 2/9/2023, 2/10/2023, 2/11/2023, 2/13/2023, 2/14/2023, 2/15/2023, 2/15/2023, 2/16/2023, 2/17/2023, 2/18/2023, 2/19/2023, and 2/20/2023 and the west short hall had missing signatures and/or the form was not completed on 2/1/2023, 2/2/2023, 2/3/2023, 2/4/2023, 2/6/2023, 2/7/2023, 2/8/2023, 2/9/2023, 2/10/2023/2023/2023, 2/11/2023, 2/12/2023, 2/13/2023, 2/15/2023, 2/16/2023, 2/17/2023, 2/18/2023, 2/19/2023, 2/20/2023, 2/21/2023, and 2/22/2023. Observation on 2/22/2023 at 8:10 a.m. revealed Registered Nurse (RN) MM had previously prepared medication in small medication cups and placed them in her cart without labeling or any identification of the medications in the cups for three residents on the east hall. She stated she knew what was in each cup and whom it was for because she had prepared them. Interview on 2/22/2023 at 8:20 a.m. with the Director of Nursing (DON) revealed pre pulling medications is not the policy of the facility. The practice should be to pull/prepare medications just prior to giving the medication to each resident. The nurse should not prepare more than one resident's medication at a time and the medication should be given directly after preparation. Observation on 2/22/2023 at 9:28 a.m. of one medication cart on the east wing revealed the medication cart to be unlocked and unattended. The medication cart was located in front of the doorway to room [ROOM NUMBER] with the drawers facing the door and the door slightly ajar. RN MM approached the cart at 9:29 a.m. and confirmed she was across the hall from the medication cart in room [ROOM NUMBER] with the medication cart located in front of the slightly ajar door of room [ROOM NUMBER], that the cart drawers were facing the doorway of 105, and that the medication cart was unlocked. Observation on 2/22/2023 at 1:30 p.m. revealed of one medication carts on the east wing was observed to be unlocked and unattended. The medication cart was located in a common area and there were two residents in the immediate area sitting in wheelchairs. At 1:40 p.m. RN MM approached the cart and verified the cart to be unlocked and unattended. She revealed she had left it unlocked and unattended and thought she had locked it. Interview on 2/23/2023 at 11:00 a.m. with the DON revealed that the medication cart should be locked at all times unless the nurse is pulling medications for a resident. She stated when walking away from the medication cart for any length of time the cart should be locked first. She went on to reveal that narcotic count sheets should be signed by the nurse from each shift at every shift change. She stated the form should be filled out and signed.

Based on observations, record review, staff interviews, and review of facility policy titled, HLTC [[NAME] Long Term Care] Restorative Nursing Policy, the facility failed to provide restorative services as related to range of motion exercises for one resident (R) #13 of 31 sampled residents and related to splint use and contracture management for three residents (R#73, R#60, and R#57) of 31 sampled residents. These failures had the potential to cause a decline in R#13, R#73, R#60, and R#57's functional abilities. Findings: Review of the policy titled, HLTC Restorative Nursing Policy, dated 1/1/2019, revealed that the purpose of the program is that the facility shall provide a restorative program to ensure residents receive restorative nursing care as needed to promote the resident's ability to adapt and adjust to living as independently and safely as possible. The Restorative programs may include the following, but not limited to active range of motion (AROM), splint or brace assistance, transfer, walking, dressing, and grooming. 1. Review of the electronic medical record (EMR) for R#13 revealed that she had diagnoses that include but are not limited to depression, anxiety, need for assistance with personal care, history of transit ischemic attack (TIA) and a cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Alzheimer's disease with late onset. Review of the quarterly minimum data set (MDS) dated [DATE], revealed that R#13 had a brief interview of mental status (BIMS) score of 8, indicating moderate cognitive impairment. It also revealed that she needed some assistance with personal hygiene, ambulation, and transfers. Review of the care plan for R#13, initiated on 8/25/2020, and revised on 2/22/2023, revealed that R#13 fluctuates at times in the amount of assistance needed. She is independent most of the time with activities of daily living (ADL) but at times she does need some staff assistance. She had right sided hemiplegia following a cardiovascular accident and had contracture of her right upper extremity. She is at risk for decline in ADL status related to weakness, debility, dementia, and Alzheimer's disease. The care plan also revealed that R#13 preferred not wearing a splint on her left upper extremity that was initiated on 2/22/2023. Review of the functional program that was initiated on 7/25/2022, R#13 was to have active range of motion (AROM), seated knee extensions, marches, hip abduction, and sit to stand, 10 repetitions for 3 sets. Ambulation of 50 feet for 2 sets with use of quad cane and wheelchair to follow, was also recommended to be completed. During the last three months the AROM was documented that it was completed only eight times. Interview on 2/22/2023 at 10:00 a.m. with the Director of Rehabilitation revealed there is a restorative nursing program for the east and west wing nursing units. She confirmed there was a document titled, Functional Program located under the miscellaneous tab of R#57's EMR completed by OT with a start date of 1/9/2023 and a document titled, In-service Training Report located under the miscellaneous tab documenting training of six CNA's regarding R#57's restorative care. She confirmed the document titled, Restorative Intervention Plan only had documented restorative care done on 2/8/2023, 2/15/2023, and 2/18/2023 and stated that this was correct. An interview on 2/23/2023 at 10:29 a.m. with the Director of Nursing (DON) revealed there is no restorative program at this time. She stated that the previous DON had restorative in place but did not manage the program and due to staffing issues, it was not continued. 2. Review of the EMR for R#73 revealed diagnoses that include but are not limited to cerebral infarction, gastrostomy tube, dysphagia, hemiplegia affecting left non-dominant side, need for assistance with personal care, cognitive communication deficit, depression, and diastolic congestive heart failure. Review of the quarterly MDS dated [DATE] revealed that R#73 was totally dependent with transfers and dressing, required extensive assistance with toileting and personal care, and had impairment on both sides of his upper extremities and one side of his lower extremities. It also revealed that he had a BIMS score of 15, indicating he was cognitively intact. Review of the care plan initiated on 10/5/2022 revealed that he was at risk for ongoing changes, fluctuations, and decline in ADL's related to muscle weakness, decreased mobility, potential medication side effects, pain, CVA, left sided weakness, and contractures to fingers on left hand. The only intervention that was noted was to provide range of motion (ROM) and a referral to restorative nursing as needed. Review of the physician's orders for R#73 revealed an order on 2/23/2023 that a left functional hand splint was to be applied daily as clinically indicated and tolerated by the resident. Left shoulder brace was to be always worn when out of bed to prevent shoulder subluxation [dislocation]. Braces to be worn as clinically indicated and tolerated by the resident. Review of the document titled; HLTC Functional Program dated 1/16/2023 revealed that staff was to assist R#73 in wearing a left hand brace. It was also revealed that R#73 was to wear a left hand brace for 6 hours daily. There were only seven days of documentation for R#73 since the start of the program on 1/16/2023. 3. Review of the EMR for R#60 revealed diagnoses including muscle weakness, contracture of left hand, contracture of left knee, and unspecified dementia. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 10, indicating that R#60 had moderate cognitive impairment. The MDS also revealed she required extensive assistance of two plus persons for bed mobility, transfers, dressing, toileting and required extensive assistance of one person for personal hygiene. Further review revealed R#60 did not receive restorative nursing during the assessment period. Review of the care plan updated 5/22/2021 and revised 12/29/2022 revealed ADL deficit due to weakness and left-hand contracture with interventions that include restorative nursing as ordered and splint to left lower arm. Review of the documentation book titled, Restorative located at the west wing nurse's unit revealed a functional program plan dated 12/20/2023 for R#60 to include: 1. Perform gentle passive range of motion exercise to left arm and hand on all planes. 2. Have patient wear left hand brace for six hours every day. There was no form for documentation of services being provided. Review of the documentation book titled, Education, located at the west wing nursing unit, revealed no documented education for restorative services or splinting for R#60. Review of the book titled, Restorative, located at the west wing nursing unit, revealed no functional program plan or documentation for restorative services including splints or braces for R#60. Observations on 2/21/2023 at 11:15 a.m. and 2/22/2023 at 8:15 a.m. of R#60, revealed her to be in bed without a splint on her left hand. Her left hand was observed to be contracted with her fingertips turned inward to the palm of her hand. A hand splint was observed lying on her bedside table. R#60 revealed she did not know when the left-hand splint had last been applied. R#60 further revealed she was unable to apply the splint without assistance. She revealed she exercises her left hand with her right hand and was unsure when staff had last exercised her left hand. Observation on 2/23/2023 at 9:30 a.m. of R#60 revealed a splint on her left hand. R#60 revealed her hand felt better while the splint was on and that she hoped it would be applied daily. Interview on 2/22/2023 at 9:40 a.m. with the Director of Rehabilitation verified that R#60 did not have a form for documentation in the Restorative book located at the West Wing and revealed she should have one. Interview on 2/22/2023 at 10:40 a.m. with RN AA revealed the therapy department and the CNA's are responsible for restorative nursing and splint applications. She revealed she was aware R#60 had a hand splint in her room. Interview on 2/22/2023 at 4:15 p.m. with the DON revealed it was her expectations for residents with splints to have the splints applied as ordered and to be documented as provided and verified there was no documentation for splint application for R#60. Interview on 2/23/2023 at 11:15 a.m. with MDS-RN EE verified that R#60's care plan included restorative nursing as indicated and splint to lower left arm. 4. Review of the EMR revealed R#57 with diagnoses of but not limited to dementia, type 2 diabetes mellitus (DM), depression, dysphagia, lack of coordination, muscle weakness, reduced mobility, needs assistance with personal care. Review of Physician's Orders revealed an order with no start date and a revision date of 2/22/2023 for a left hand brace to be applied daily. Review of the quarterly MDS assessment completed on 11/24/2022 revealed a BIMS of 99, indicating severe cognitive impairment and functional status of extensive assistance with ADL's with two or more person assistance required. Review of the care plan dated 11/30/2022 with revision 12/2/2022 included focus related to but not limited to risk for limited physical mobility with a goal to remain free of complications related to immobility and contractures, with interventions of gentle ROM as tolerated and PT and OT referrals as ordered and as needed. Review of the document titled, Restorative Intervention Plan for February 2023 revealed restorative care was documented only on 2/8/2023, 2/15/2023, and 2/18/2023. Review of document titled, [NAME] Long Term Care Functional Program revealed R#57 was to have PROM and assistance with brace placement to right hand starting on 1/9/2023. She was to receive this care seven times a week. Observation on 2/21/2023 at 12:58 p.m. revealed signage on R#57's wall above the head of her bed regarding application of right-hand brace. R#57 was in the common area in a Broda chair [adjustable reclining chair] without a brace/splint on her right hand. Observation on 2/22/2023 at 9:15 a.m. of R#57 in the common area sitting in a Broda chair without a brace/splint on her right hand. Interview on 2/22/2023 at 12:00 p.m. with RN EE confirmed that the restorative care for R#57 was not listed on her care plan. She stated that she did not believe there was a restorative program in the facility prior to 2/17/2023 when the facility re-started the program. Interview on 2/23/2023 at 11:02 a.m. with the DON revealed she started working in this facility five weeks ago and since taking this position she discovered the restorative nursing program was not running and was broken. 46691 47146

Based on observations, staff interviews, record review, and review of the facility policy titled, HLTC [[NAME] Long Term Care] Care Planning, the facility failed to follow the care plan for splint application for one resident (R) (R#60), failed to develop a care plan for splint application and passive range of motion (PROM) for one resident (R#57), and failed to develop a care plan for splinting for one resident (R#73). This deficient practice had the potential to affect the delivery of the proper care and services provided to R#60, R#57, and R#73. The sample size was 31. Findings include: Review of the policy titled, HLTC Care Planning dated 11/1/2019 revealed the policy was for each resident to have a baseline and comprehensive care plan that reflects resident centered care and services and in effort to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The Baseline Care Plan section line numbered 7 revealed: The facility will develop and implement a comprehensive, resident centered care plan within Point Click Care (PCC) [electronic medical records system] for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. Review of the current care plan for R#60 revealed an intervention initiated on 9/5/2020 for restorative nursing as indicated. Interview on 2/22/2023 at 4:15 p.m. with the Director of Nursing (DON) revealed it was her expectation that care plans were followed. 2. Review of the care plan dated 11/30/2022 with revision 12/2/2022 for R#57 included intervention for daily range of motion exercises as tolerated. Interview on 2/22/2023 at 12:00 p.m. with Registered Nurse RN EE she confirmed that the restorative care for R#57 was not listed on her care plan. 3. Review of the care plan for R#73 that was initiated on 10/5/2022, revealed an intervention noted to provide ROM and a referral to restorative nursing as needed. An interview on 2/23/2023 at 10:29 a.m. with the DON revealed that there was no restorative program at this time. Cross reference F688 46691 47146

Based on record review, staff interviews, and review of the facility's policy Advanced Directives, the facility failed to ensure that the Do Not Resuscitate (DNR) document was signed by a physician for one resident (R) (R#52) of 31 sampled residents reviewed for advanced directives. Findings include: Review of the policy titled, Advanced Directives, date of issue 1/1/2019, revealed online item # 6. The facility will inform the Directive resident's physician of any advanced directives to ensure appropriate orders are obtained when indicated. Review of the electronic medical record (EMR) for (R) #52 revealed diagnoses that included but not limited to chronic obstructive pulmonary disease, anemia, dysphagia, paroxysmal atrial fibrillation, and hypertension. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed R#52 had a Brief Interview for Mental Status (BIMS) of 15 which indicates resident was cognitively intact. Review of the EMR revealed R#52 signed a document titled Do Not Resuscitate Order for Resident with Decision Making Capacity on 12/22/2020 and the area that indicated a physicians signature had a blank line without a signature. Review of the physician's order dated 12/4/2021 revealed an order for do not resuscitate (DNR). Interview on 2/22/2023 at 10:48 a.m. with the Social Service Director (SSD) revealed R#52 had agreed to a DNR code status and had signed the form. The SSD stated she acknowledged that the form was not signed by a physician, and she would get the physician to sign the form today to prevent the form from being invalid. The SSD was unable to locate the DNR form that was signed by the physician. Interview with DON on 2/23/2023 at 9:34 a.m. revealed that all DNR forms should be signed by the physician as a part of the medical chart. The DON further revealed that the SSD had the responsibility of ensuring the DNR forms were signed by the physician upon placing in the resident's medical record.

Based on observations, resident and staff interviews, record review, and review of the facility's policies titled, Medication Self-Administration Medications and Medication Administration-General, the facility failed to assess one resident (R) (R#51) of 31 sampled for the ability to self-administer medications prior to leaving medications at the bedside. This deficient practice had the potential to adversely affect the safety of R#51 and other residents in the facility. Findings include: Review of the policy titled, Resident Self-Administration Medications dated 10/1/2019 revealed: Policy: 1. Each resident who desires to self-administer medications is permitted to do so if the interdisciplinary team has determined that the practice would be safe for the resident and other residents in the facility. 2. The resident must be deemed competent to accurately self-administer medications prior to self-administering medications. 3. A physician's order is required for residents to self-administer medication and store medication at bedside. Review of the policy titled, Medication Administration-General dated 10/1/2019 and revised on 12/1/2019 and 6/23/2022 revealed policy and interpretation line numbered 5. Residents may self-administer their medications in accordance with the Resident Self-Administration Medication policy. Record review of the electronic medical record (EMR) for R#51 revealed diagnosis including anxiety disorder, end stage renal disease, heart failure, unspecified lack of coordination. Review of the quarterly minimum data set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating R#51 was cognitively intact, was independent with activities of daily living (ADLS), and received an antidepressant seven of seven days. Review of the physician's orders revealed medication orders to include: Sevelamer hydrochloride tablet 800 milligrams (mg) give three tablets by mouth with meals for phosphate binder, start date 7/21/2023 and revised 12/12/2022, trazodone hydrochloride 50 mg tablet give 0.5 tablet by mouth at bedtime for insomnia, start date 7/25/2022, duloxetine hydrochloride capsule delayed release particles 60 mg give one capsule by mouth one time a day for mood, start date 7/22/2022. There was not a physician's order for the Lidocaine 2.5% and Prilocaine 2.5% cream 30 grams (g). Review of the care plan dated 4/19/2022 and revised on 10/25/2022 revealed a focus area that resident was at risk for cognitive loss and dementia related to diagnoses of end stage renal disease, heart failure, and anxiety disorder. Interventions included: administer medications as ordered and monitor for side effects and effectiveness; cue, reorient, and supervise as needed; ask yes/no questions in order to determine needs. Review of the medication administration record (MAR) dated February 2023 revealed medications documented as given as ordered. Lidocaine 2.5% and Prilocaine 2.5% cream 30 g were not on the MAR. Review of the clinical record revealed there was no assessment for medication self-administration. Observation on 2/21/2023 at 10:45 a.m. of R#51's room revealed one 30 milliliter (ml) medication cup sitting on the bedside table and containing two white oblong shaped tablets. An interview with R#51 revealed the nurse normally leaves the medication for her to take when she desires. Observation on 2/22/2023 at 8:35 a.m. of R#51's room revealed one container of Lidocaine 2.5% and Prilocaine 2.5% cream 30 g lying on her bed. She revealed she applied it to her port site prior to going to dialysis three days per week. She revealed the nurses were aware she had it in her room. Interview on 2/22/2023 at 8:55 a.m. with Registered Nurse (RN) AA revealed she was aware of the medication cup containing two white tablets sitting on R#51's bedside table on 2/21/2022 and that the previous shift must have left them for her to take. She revealed she did not remove the medication from the resident's room and revealed she should have removed them. Observation on 2/22/2023 at 8:58 a.m. of R#51's room with RN AA verified the container of Lidocaine 2.5% and Prilocaine 2.5% cream 30 g lying on her bed. RN AA removed the medication and explained to R#51 the medication would be kept in the medication cart and given as ordered by her physician. She verified all medications should be kept in the medication cart and given as prescribed by the physician. RN AA verified there was not a physician's order for the Lidocaine 2.5% and Prilocaine 2.5% cream and revealed she would contact the physician about the medication and the resident should not have or receive the medication without a physician's order. She revealed a self-administration assessment must be completed prior to a resident being allowed to have medications at their bedside. On 2/22/2023 at 9:05 a.m. an interview with the Director of Nursing (DON) revealed her expectations are for medications to be kept secured in the medication carts and not be left in a resident's room unless the resident had been assessed for self-administration of the medication, approved by the interdisciplinary team, had a physician's order for self-administration of medication, and appropriate training was provided to the resident. She revealed her expectation is for medications to only be administered with a physician's order. She verified that R#51 did not have a medication self-administration assessment for any medications and did not have a physician's order for the Lidocaine 2.5% and Prilocaine 2.5% cream.

Based on observations, record review, resident and staff interviews, and review of the facility policy titled Oxygen Administration, the facility failed to ensure three of 11 sampled residents (R) R#172, R#8, and R#68 were administered Oxygen according to Physician orders. Specifically, R#8 and R#68 were observed with an incorrect Oxygen flow rate and R#172 was observed with no Oxygen use when ordered for continuous Oxygen therapy. Findings include: Review of the facility policy titled Oxygen Administration with issue date of 1/1/2019, revealed the purpose is to provide guidelines for safe Oxygen administration. Procedure A. 1. Review the physician's orders or facility protocol for oxygen administration. Procedure D. 4. Turn on the oxygen. Adjust flow to the ordered rate. Review of the Oxygen flowmeter User Manual No. ANA 001 Issue 2, page 6, section Adjust the Oxygen flow rate, revealed to turn the flowmeter control knob anti-clockwise until the center of the ball corresponds with the line indicating the required flow rate. 1. Review of the clinical record for R#172 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Section O revealed the use of Oxygen. Review of the care plan for R#172, initiated 8/11/2021, revealed resident has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions include Oxygen settings at 2 Liters Per Minute (LPM), continuously, via nasal cannula (NC). Review of Physician Orders (PO) for R#172 dated 4/13/2021 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 8/11/2021 at 1:20 p.m. revealed resident was alert and oriented and not wearing her Oxygen, as ordered. Observation on 8/12/2021 at 10:35 a.m. revealed resident was not wearing her Oxygen, as ordered. Interview on 8/12/2021 at 10:40 a.m. with Certified Nursing Assistant (CNA) JJ, stated she was taking R#172 for a shower. She stated she had not noted any signs of respiratory distress when caring for R#172. 2. Review of the clinical record for R#8 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent quarterly MDS dated [DATE], revealed a BIMS score of 13, which indicated no cognitive impairment. Section G revealed she required extensive assistance for all activities of daily living (ADLs) except supervision for eating and total dependence for bathing. Section O did not reveal the use of Oxygen. Review of the care plan for R#8, revised 7/31/2021, revealed resident has potential for SOB, chest pain, [CONDITION(S)], and high blood pressure (BP) due to congestive heart failure (CHF) with history of exacerbations. Interventions included notify Physician/Nurse Practitioner if [CONDITION(S)], chest pain, elevated BP, or SOB occurs. There was no indication that resident had Oxygen use for [CONDITION(S)]. Review of the PO for R#8 dated 11/20/2020 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 8/11/2021 at 1:30 p.m. revealed the resident was using her Oxygen and the flow rate was set at 2.75 LPM. Observation on 8/12/2021 at 10:45 a.m. revealed the resident was using her Oxygen and the flow rate was set at 2.5 LPM. 3. Review of the clinical record for R#68 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent MDS (PPS 5-day) dated 7/26/2021, revealed a BIMS score of 15, which indicated no cognitive impairment. Section G revealed she required extensive assistance to total dependence for all ADLs except supervision for eating and limited assistance for personal hygiene. Section O did not reveal the use of Oxygen. Review of the care plan for R#68 revised 6/14/2021, revealed resident was at risk for SOB, changes in respiratory status and/or re-hospitalization related to history of COVID-19, [CONDITION(S)], and sleep apnea. Interventions included Oxygen as ordered and assist resident with replacing Oxygen tubing when/if she removes it. Review of the PO for R#68 dated 7/20/2021 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 8/11/2021 at 1:40 p.m. revealed the resident was using her Oxygen and the flow rate was set at 3 LPM. Observation on 8/12/2021 at 10:55 a.m. revealed the resident was using her Oxygen and the flow rate remained set at 3 LPM. Observation on 8/12/2021 beginning at 11:55 a.m. with the Director of Nursing (DON) confirmed R#172 was not wearing Oxygen as ordered, and the Oxygen flow rates for R#8 and R#68 were set at incorrect flow rates. During the observation, she adjusted the Oxygen flow rates to reflect the physician orders. Interview on 8/11/2021 at 1:50 p.m. with Licensed Practical Nurse (LPN) AA, stated the Oxygen flowmeter setting was determined by the position of the indicator ball below the desired flow rate. She stated the facility's respiratory education did not include instructions on how to determine accurate Oxygen flow rate. In an interview with LPN HH on 8/11/2021 at 2:00 p.m., she stated accurate Oxygen flow rate was determined by reading the center of the indicator ball. She further stated a person must look at the flowmeter at eye-level to set the ball correctly. She stated Oxygen in-services did not include instructions on how to accurately set Oxygen flow rate. In an interview with LPN GG on 8/11/2021 at 2:10 p.m., she stated the Oxygen indicator ball should be above the selected flow rate. She stated facility education on Oxygen administration did not include how to read the indicator ball. Interview on 8/12/2021 11:55 a.m. with the DON, stated she would contact the Physician for R#172 regarding her Oxygen orders. She stated she provided in-services and competency checks for nurses on Oxygen administration but was not certain how to accurately set the Oxygen flow rates was included in the in-service.

Based on observation, record review, staff interviews and review of the facility policies titled Skin, Wound and Pressure Ulcer Treatment-Overview and Skin Integrity Overview, the facility failed to maintain appropriate infection control practices during wound care observation for one Resident (R) R#271 of 38 sampled residents. Findings Include: Review of the facility policy titled Skin Integrity Overview dated March 1, 2020, revealed the purpose of the policy is to promote resident care and services in an environment where residents will not develop wounds and/or pressure ulcers, unless clinically unavoidable. 2. The facility will provide skin care and treatments consistent with professional standards of practice, to a resident who has wounds/pressure ulcers, to promote healing, prevent infection and prevent new wounds/pressure ulcers from developing, unless clinically unavoidable. Review of the facility policy titled Skin, Wound and Pressure Ulcer Treatment-Overview dated March 1, 2020, revealed the purpose of the policy is to promote skin, wound and pressure ulcer healing. 4. Application of treatments will follow professional standards of practice of wound care and infection control, as outlined in the Lippincott Manual of Nursing Practice. Review of the clinical record for R#271 revealed she was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Section G revealed resident requires extensive 2+ person assist with all Activities of Daily Living (ADL). Section (M) Skin Conditions revealed she is at risk for pressure ulcers. Review of the Care Plan for R#271, dated 7/30/2021, revealed resident is at risk for pressure ulcers related to reduced mobility, incontinence, and obesity with open areas to inner knee folds, open areas to posterior left thigh, redness to bilateral breast folds, and redness to armpits, all present on admission. Interventions include avoid scratching and keep hands and body parts from excessive moisture; keep fingernails short; cleanse inner knee folds as needed and pat dry with gauze, place [MEDICATION(S)]/[MEDICATION(S)] cream to edges of open areas to inner folds behind knees every day shift; cleanse open areas to posterior left thigh as needed and pat peri-wound areas dry with gauze; Place [MEDICATION(S)]/[MEDICATION(S)] cream to edges of open areas; place collagen powder to wound bed, and cover with Abdominal (ABD) pad and secure with paper tape every day shift every Monday, Wednesday, and Friday for abrasions; cleanse reddened areas of armpits as needed and pat dry well, place antifungal powder to skin folds every day shift for redness/irritation; cleanse redness to bilateral breast folds as needed and pat dry well; place inter dry sheets in skin folds as needed for soilage/displacement; encourage good nutrition and hydration in order to promote healthier skin; follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Skin Evaluation dated 7/21/2021 revealed five open areas to posterior left thigh, creases to bilateral inner knees open; redness to bilateral breast folds, and redness to armpits observed. Review of Physician Order (PO) dated 7/22/2021 revealed a verbal order for treatment to open areas to posterior left thigh: cleanse areas as needed and pat peri-wound areas dry with gauze. Place [MEDICATION(S)]/[MEDICATION(S)] (ex. Triad) cream to edges of open areas, place collagen powder to wound bed, and cover with ABD pad and secure with paper tape every day shift every Monday, Wednesday, Friday for abrasions AND as needed for saturation/displacement. Review of the Wound Dressing Application Competency Evaluation dated 6/23/2021, for LPN AA, revealed competency skills include, but not limited to: Organize equipment and supplies on a clean surface, arranging them according to the order of use. Place a fluid-impermeable pad between the environment and equipment, if necessary. Place a waterproof trash bag within reach. Perform hand hygiene. Put on gloves and as needed, other personal protective equipment. Discard the soiled dressing in the waterproof trash bag. Remove and discard your soiled gloves. Perform hand hygiene. Put on new gloves. Clean the wound with prescribed cleanser or saline moistened gauze pads. Discard the soiled gauze in the sealable waterproof trash bag. Remove and discard your soiled gloves. Perform hand hygiene. Put on new gloves. Pat the surrounding skin dry with a gauze pad. Seal the waterproof trash bag, and discard used supplies in the appropriate receptacles. Remove and discard your gloves and, if worn, other personal protective equipment. Perform hand hygiene. Further review of the checklist revealed LPN AA was verified as competent by LPN LL. Observation on 8/10/2021 at 10:02 a.m. of Certified Nursing Assistant (CNA) EE and Temporary Nurse Aid (TNA) FF, with the assistance of the Physical Therapy Director, provide incontinence care to R#271 revealed a dressing on the back side of R#271's left upper leg with a brown substance on the dressing and the dressing was noted to be pulling away from the skin. There was red drainage observed coming from the underside of the bandage. Licensed Practical Nurse (LPN) AA entered R#271 room with a tray of supplies for a dressing change. LPN AA sat the tray with the dressing supplies on the bedside table without cleaning the table, placing a barrier, or removing residents' personal items. She washed her hands and donned gloves. R#271's left leg was lifted making the wound easily accessible. LPN AA removed the current dressing dated 8/10/2021 and placed it on the bedside table up against the resident's water cup. Without changing her gloves, LPN AA took a damp 4 x 4' s' from the tray of supplies and cleaned the wound area from the inside outward and discarded the soiled 4 x 4' s' on the bedside table next to the soiled bandage. She repeated the process one more time without changing her gloves or sanitizing her hands. Without removing her soiled gloves, LPN AA took a dry 4 x 4' s' and dried the area and discarded the soiled 4 x 4' s' on the bedside table with the other soiled supplies. LPN AA then doffed her gloves, washed her hands, donned clean gloves, and placed a new clean dressing over the wound area, labeled it with the date and her initials. LPN AA doffed her gloves and placed them on the bedside table, with the other soiled supplies. With her bare hands, LPN AA picked the soiled gloves and 4 x 4' s' from the bedside table and placed them on top of the discarded soiled dressing. She then washed her hands, donned gloves, and retrieved the soiled dressing change items from the bedside table and discarded them in the garbage. LPN AA did not clean the bedside table or place a barrier on the table before placing the tray with supplies on the table or after discarding the soiled items and removing the tray. Interview on 8/11/2021 at 9:55 a.m. with LPN AA, revealed she received training related to infection control practices on hire, which was approximately 8 months ago. She stated she cannot recall if she received education specifically as it relates to infection control practices during wound care. She revealed that on the morning of 8/10/2021, she observed the Wound Care Nurse (WCN) provide wound care for R#271 and was educated at that time on how to provide wound care. During further interview, LPN AA added that, on the weekends, it is the nurse caring for the resident responsibility to provide the wound care, and when the WCN is not available during the week, it is the responsibility of the nurse to do the wound care. Interview on 8/11/2021 at 10:10 a.m. with the WCN, revealed she has new nurses observe wound care to educate them on how to provide wound care. She revealed when a nurse is hired, they are trained on standard infection control practices that covers a lot of different areas and then are checked off on what they have learned. The WCN revealed there are certain infection control practices that are important to know and to do during wound care to prevent wound infections. Interview on 8/11/2021 at 11:30 a.m. with the Director of Nursing (DON) revealed there are competency checkoffs for all nursing staff related to wound care and infection control practices. During further interview, she stated standard infection control education is provided on hire and periodically throughout the year. The DON revealed she will begin education today related to infection control as it specifically relates to wound care.

Based on record review, interviews and review of the facility policy titled Discharge Summary, the facility failed to provide one resident (R) R A or his responsible party, written notification for discharge from the facility, failed to complete the Recapitulation of Residents Stay to include post discharge plans and instructions for who will be responsible for the resident and failed to notify Ombudsman of R A discharge. Findings include: Review of the facility policy titled Discharge Summary dated 11/1/2019, revealed the purpose is to ensure the facility communicates necessary information to the resident, continuing care provider and other authorized persons at the time of anticipated discharge. An anticipated discharge is defined as a discharge that is planned and not due to the resident's death, or an emergency. Further review of the policy revealed at the time the resident leaves the facility, the facility will provide a copy of the discharge summary, final summary of resident's status and post discharge plan to the continuing care provider. Review of the facility document titled Discharge Summary for R A dated 5/11/2021 revealed section V11. Post Discharge Plan and Instructions Provided, Section C lacked information for the caregiver responsible for the resident after discharge. Review of the facility document titled Transfer/Discharge Report for R A dated 5/14/2021 revealed the primary contact listed was R A son. There was no evidence on the report that the son was notified of the resident's discharge. Interview on 8/12/2021 at 1:10 p.m. with Social Worker (SW) revealed she informed R A he was being discharged from the facility because the facility could no longer meet his needs. She stated that R A informed her he could not afford to stay at the facility as private pay but had nowhere to live. She stated she called R A son, who agreed to pick him up and take him home. The SW continued to state she gave R A discharge instructions to him on 5/14/2021. She confirmed she did not discuss with R A or his family representative of their right to appeal the discharge. Phone interview on 8/12/2021 at 3:00 p.m. with the family of R A, revealed he spoke with the SW from the facility regarding R A stay. He stated he could not remember the date that he spoke with her, but stated he was told that he had until Friday, May 14, 2021, to pick R A up from the facility. Interview on 8/12/2021 at 4:15 p.m. with Licensed Practical Nurse (LPN) CC revealed that R A son never showed up to take resident home. During further interview, she stated R A called his brother, who came to take him home. She stated that she gave R A brother the discharge instructions and explained to his brother about his medications, the day he was discharged home. She stated that she got a verbal order from the on-call Physician to discharge R A but stated she could not locate the documentation in the EMR for the verbal order. On 8/12/2021, an attempt to obtain phone interview with on-call Physician KK, was unsuccessful, with the Physician stating they were on vacation and did not want to be disturbed.

Based on interviews, record reviews, facility policy reviews, and review of the Center for Disease Control and Prevention (CDC) resources, the facility failed to have an effective immunization program in place to ensure residents were offered pneumococcal vaccinations per the CDCs recommendation for residents over the age of 65 for two of seven residents (R) (R#1 and R#7) sampled for immunizations. Findings include: 1. Review of R#1's undated Admission Record, located in the resident's Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the resident's admission record revealed the resident was [AGE] years old at time of survey. Review of R#1's Immunization Record, provided by the facility revealed on 06/10/15 R#1 had received PPSV23. There was no documentation the resident had received the one final dose of PPSV23 at least five years after the prior dose of PPSV23. 2. Review of R#7's undated Admission Record, located in the resident's Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the resident's admission record revealed the resident was [AGE] years old at time of survey. Review of R#7's Immunization Audit Report, provided by the facility revealed, on 03/16/16 R#7 had received PCV13. There was no documentation the resident had received the dose of PPSV23 one year later. During an interview on 01/12/21 at 5:55 p.m. the Resident Care Coordinator (RCC) for the West Wing revealed both R#2 and R#7 should have been offered the follow up doses of the pneumonia vaccine and educated on the risks verses the benefit of the vaccine. The RCC stated, Usually the Infection Preventionist (IP) takes care of following up on the immunizations. During an interview on 01/12/21 at 7:04 p.m. with the Director of Nursing (DON), the DON revealed she was unaware that R#2 and R#7 had not received the follow up doses of the pneumonia vaccine. When asked if she had a system for tracking when immunizations were due the DON stated, The IP likely does, but she is currently off work with COVID-19. I cannot find anything in her office that tracks when immunizations are due at this time. During an interview on 01/12/21 at 7:28 p.m. the Medical Director revealed it was his expectation residents would be up to date on immunizations. The Medical Director stated, It is likely the IP has the records, but we are at fault for not having a designee during her absence. We will have to correct this. Review of the Centers for Disease Control and Prevention (CDC) website titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, revealed There are 2 types of pneumococcal vaccines available in the United States: Pneumococcal conjugate vaccine (PCV13 or Prevnar13®) and Pneumococcal [MEDICATION NAME] vaccine (PPSV23 or [MEDICATION NAME]®).CDC recommends pneumococcal vaccination for adults 19 through [AGE] years old who have certain medical conditions or who smoke.CDC recommends you: Give 1 dose of PCV13 and 1 dose of PPSV23. Administer PCV13 first, then give the PPSV23 dose at least 8 weeks later . For anyone with any of the conditions listed below who has not previously received the recommended pneumococcal vaccine: Alcoholism, Chronic [MEDICAL CONDITION], Chronic liver disease, [MEDICAL CONDITION], including [MEDICAL CONDITIONS], and asthma, Diabetes mellitus CDC recommends you: Give 1 dose of PPSV23 .CDC recommends pneumococcal vaccination for all adults [AGE] years or older.All adults [AGE] years or older should receive 1 dose of PPSV23. For adults [AGE] years or older who. want to receive PCV13 AND PPSV23: Administer 1 dose of PCV13 first then give 1 dose of PPSV23 at least 1 year later .If the patient already received PPSV23, give the dose of PCV13 at least 1 year after they received the most recent dose . The following adults aged [AGE] years are potentially at increased risk of exposure to PCV13 serotypes may consider regularly offering PCV13 to their patients aged [AGE] years who have not previously received PCV13: Persons residing in nursing homes or other long-term care facilities . https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html Review of the Center for Disease Control and Prevention website titled, Pneumonia Can Be Prevented-Vaccines Can Help, revealed, CDC data showed that in the United States during 2017: 3 million people were diagnosed with [REDACTED].

Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessment were transmitted within 14 days of completion to Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for one resident (R) #35 out of two reviewed. The sample size was 54 residents. Findings Included: Resident#35 admitted on [DATE] readmitted on [DATE]. Review of a listing of R#35's completed and transmitted MDS revealed annual assessment dated [DATE] was the last assessment transmitted for R#35. An interview was conducted on 09/18/18 at 2:29 p.m. with AA Resident Assessment Instrument (RAI) Director responsible for MDS and care plans for the facility regarding R#35 MDS assessment. The RAI Director revealed that R#35 quarterly assessment dated [DATE] was completed and closed has not been transmitted to the QIES ASAP System. Review of the facility's MDS 3.0 Nursing Home (NH) Final Validation Report (report to verify assessment submitted into the QIES ASAP System) dated 8/31/18 R#35 was not listed in the report. Review of the facility's MDS 3.0 NH Final Validation Report dated 9/7/18 R#35 was not listed in the report. An interview was conducted on 09/18/18 at 3:19 p.m. with the Director of Nursing (DON) regarding transmitting of MDS assessments timely. DON revealed her expectation is that all MDS assessments are complete and transmitted on time. DON revealed she currently does not have an audit in place to ensure MDS accuracy, completion, and transmission. An Interview was conducted on 9/20/18 at 3:15 p.m. with the Administrator regarding transmitting of MDS assessments timely. The Administrator revealed expectation all scheduled MDS assessment should be transmitted on time. The Administrator revealed that transmission of the completed assessment became the facilities responsibility 8/3/18 and there was no audit in place to ensure MDS accuracy, completion, and transmission. The Administrator revealed an audit has been completed on 9/19/18 to ensure assessment have been completed and transmitted as required.

Based on record review, staff interview, Hospice Clincal Manager Interview, and review of the Hospice and Respite Service Agreement the facility failed to have a physician order [REDACTED]. Finding included: Resident #42 was admitted to the facility on [DATE] [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Section O- Special Treatments and Programs 0100 K. Hospice Care- while a resident. Review of R#42 medical record the following required documentation was not located in the medical record: physician order [REDACTED]. Review of the Hospice and Respite Service Agreement dated 8/26/13 revealed: 3.1 B. Physician Orders: Verbal physician orders [REDACTED]. Hospice will provide the nursing center with the hospice election form. An interview was conducted on 9/20/18 at 10:08 a.m. with the Assistant Director of Nursing (ADON) regarding a signed attending physician order [REDACTED]. An interview was conducted on 9/20/18 at 12:03 p.m. with Licensed Practical Nurse (LPN) EE hospice staff regarding an attending physician order [REDACTED].#42 facility medical record. An interview was conducted on 9/20/18 at 12:05 p.m. the Hospice Clinical Manager DD regarding an attending physician order [REDACTED]. The Hospice Clinical Manager revealed the signed required documents by the resident/family should be in the resident facility medical record. An order must obtain from the attending physician to admit to hospice along with a qualifying diagnosis. The above stated document must be on the resident's medical record chart within 48 hours of admission to hospice service. The Clinical Manager confirmed that there was not an attending physician order [REDACTED]. An interview was conducted on 9/20/18 at 3:35 p.m. with the Administrator regarding hospice services. The Administrator revealed he was not aware that the R#42 was receiving hospice service without an attending physician order [REDACTED].

Based on record review, staff interview, Pharmacy consultant interview, the facility policy, and review of the pharmacy consultant duties, the facility failed to account for disposition of control medication. The Certificate of Inventory And Destruction record of controlled medications did not include the involved facility staff and pharmacy consultant. The records of controlled medication destruction were not readily accessible for review. The sample size was 54 residents. Findings Included: Review of the medication destruction sheets that were provided to the surveyor from the Director of Nursing ( DON) for the month of (MONTH) (YEAR) revealed two signatures. The Certificate of Inventory And Destruction record dated 9/11/8 revealed the signature of the Assistant Director of Nursing (ADON) and the DON. No other signature was noted on 3 out of 3 sheets. An Interview was conducted on 9/19/18 at 6:15 p.m. with the DON regarding controlled medication destruction. The controlled medication and the controlled drug record are kept in a double lock gun case until ready for destruction. The DON revealed medication destruction takes place monthly with two nursing staff and the pharmacy consultant. The Certificate of Inventory And Destruction record is signed by two nurses and the consultant on the day of destruction. Request for a years' worth of The Certificate of Inventory And Destruction record. The DON revealed that the destruction records are Kept by the medical records person who has left for today and she had no assess to the office. An Interview was conducted on 9/19/18 at 6:30 p.m. with the Pharmacy consultant regarding controlled medication destruction. The Pharmacy Consultant revealed that medication destruction is completed based on the number of narcotics in the facility. Medication destruction is done at least every other month. The Pharmacy consulted confirmed that Certificate of Inventory And Destruction record should be signed at the time of controlled medication destruction by the consultant and two nurses. The Pharmacy Consultant stated a controlled medication destruction was completed on 9/11/18 but he forgot to sign and date the destruction sheet prior to leaving the facility. The Pharmacy Consultant revealed he is not required to document the medication destruction on the Monthly Consultant Pharmacist Report. An interview was conducted on 9/20/18 at 2:30 p.m. with the DON regarding Monthly Consultant Pharmacist Report for 9/11/2018. The DON revealed that she did not have a report for (MONTH) (YEAR) because the Pharmacy Consultant comes at the end of the month. Review of the Consulting Pharmacist Retainer agreement dated 4/1/17 signed by the administrator and DD the pharmacy consultant revealed: the consultant duties 2. Provide and maintain complete documentation of all activities is required. 8. Assist in the accounting, destruction and reconciliation of unused drugs as prescribe by law, rule and/or regulation. 19. Consultant activity reports to include 19.10 Drug destruction confirmation. Review of the facility policy on Medication Destruction-Traditional Method Controlled Substance (CII-CV Medications) dated 12/2017 revealed the Certificate of Inventory And Destruction must be completed in its entirety. Three witnesses' signatures are needed. An Interview was conducted on 9/20/18 at 3:30 with the Administrator regarding controlled medication destruction. The Administrator revealed the pharmacy consultant not signing the Certificate of Inventory And Destruction is due to the consultant indolence.

Based on record review and staff interview, it was determined the facility failed to complete and sign the quarterly Minimum Data Set (MDS) assessment every 90 days for one resident (R #1) one out of two reviewed. The sample size was 54 residents. Facility Finding Included: Resident #1 was admitted on [DATE] Admission assessment dated [DATE] was completed and transmitted. Further review revealed a quarterly assessment was not completed. An interview was conducted on 09/18/18 at 2:34 p.m. with AA Resident Assessment Instrument (RAI) Director who is responsible for MDS and care plans for the facility . The RAI Director confirmed that 5/17/18 was the last completed assessment for R#1. An interview was conducted on 09/18/18 at 3:19 p.m. with the Director of Nursing (DON) regarding completing of MDS assessments timely. DON revealed her expectation is that all MDS assessments are complete and transmitted on time. DON revealed she currently does not have an audit in place to ensure MDS accuracy, completion, and transmission. An Interview was conducted on 9/20/18 at 3:15 p.m. with the Administrator regarding completing MDS assessments timely. The Administrator revealed the expectation all scheduled MDS assessment should be completed on time. Review of the Center for Medicare/Medicaid Services (CMS) RAI Version 3.0 Manual, page 5-4 dated (MONTH) (YEAR) revealed: Assessment Schedule: An Omnibus Budget Reconciliation Act (OBRA) assessment (comprehensive or Quarterly) is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between OBRA assessments. The facility failed to complete and sign quarterly MDS assessments every 92 days as required for R#1.

Based on medical record review, interview, and a review of policy, the facility failed to develop a comprehensive Resident Care Plan for 2 of 5 residents (R41 and R43) reviewed for unnecessary drugs. The facility also failed to develop a care plan for for the care required for an indwelling urinary catheter for 1 resident (R111) and care plan the assistance required to complete the activities of daily living (ADL) for 1 (R143). 30 residents were reviewed in Stage 2. Findings include: 1. Review of the medical record revealed R41's [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set-an assessment tool used by an interdisciplinary team (IDT) to determine what care and services the resident needs) dated 10/9/15, identified the resident as being moderately cognitively impaired, exhibited physical behavioral symptoms directed toward staff or others, and required extensive assistance from others for activities of daily living (ADL). Review of physician orders dated 3/11/16 identified that the resident received the antipsychotic medication [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg (milligram) daily for major [MEDICAL CONDITION] with psychoses. A Behavioral Health Consult dated 10/2/15 recommended the use of the [MEDICATION NAME] 0.25mg daily in the morning for specific paranoid behaviors that included staff trying to poison her, trying to take her fingerprints, and trying to beat her up. An interview with the Assistant Director of Nursing (ADON) on 4/5/16 at 11:00 a.m. revealed that the facility policy for documenting target behaviors for residents receiving antipsychotic was to put the behaviors in the Medication Administration Record (MAR) and document the presence or absence of them every shift. A review of the current MAR for April 2016 lacked any documented evidence of the presence or absence of paranoid behaviors. The comprehensive care plan failed to include an identified problem of antipsychotic medication usage and the monitoring of target behaviors. 2. Review of the medical record revealed R43 was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] revealed the resident was moderately cognitively impaired and had no behavioral disturbances. The current physician orders dated 4/6/16 revealed the resident was receiving [MEDICATION NAME] ( an antipsychotic) 25mg twice daily for a major [MEDICAL CONDITION] with psychotic symptoms. The resident care plan dated 3/31/16 lacked a problem of antipsychotic medication usage and monitoring of target symptoms. A review of the Behavioral Health notes dated 4/3/15 revealed a recommendation to start [MEDICATION NAME] 25mg twice daily for paranoia and added the [DIAGNOSES REDACTED]. A review of the facility policy Monitoring of Antipsychotics reviewed and updated January 2016, indicated the resident was to be monitored quantitatively and qualitatively to determine the effectiveness of the medication by documenting the evidence of the target behaviors per shift per day. A review of the MAR indicated [REDACTED]. The current MAR for April 2016 identified only a target behavior of refusal of care. 3. Observation of R111 on 4/4/16 at 1:43 p.m. revealed a urinary drainage bag hanging on the frame of his wheelchair. Numerous observations from 4/4/16 - 4/7/16 during the survey process revealed the urinary drainage bag was either on the wheelchair or the bed. In an interview on 4/4/16 at 1:35 p.m., Licensed Practical Nurse (LPN) 15 stated that R111 had an indwelling Foley urinary catheter. A review of the Client [DIAGNOSES REDACTED]. A review of R111's medical record, Physician Order section, revealed a faxed order dated 1/31/16 to place foley (sic) to obtain UA (urinalysis) and to keep wound dry Review of R111's plan of care dated 8/8/14, revealed a problem/strength, Requires assistance with ADLs (activities of daily living) R/T (related to) disease process Dx (diagnosis) Dementia. Strengths: Continent B&B, (Bowel and Bladder) Steady gait, Ambulates with no assistance. There was no other documentation related to bowel and bladder or the use of an indwelling urinary catheter. A review of R111's quarterly MDS dated [DATE] revealed, Section H - Bowel and Bladder was not coded for an indwelling urinary catheter. A review of the significant change MDS dated [DATE] Section H - Bowel and Bladder was coded for use of an indwelling urinary catheter. In an interview on 4/7/16 at 6:37 p.m., MDS Coordinator RN (Registered Nurse) 11 stated R111 had a significant change MDS in February and I just didn't update his care plan. RN11 also stated that normally, catheters would be care planned. A review of the facility policy Patient's Plan of Care reviewed and updated for release September 2015, indicated: Intent: It is the intent of this center to develop and maintain an individualized plan of care for each patient.Under Procedural Guidelines the policy stated, The care plan is developed from the patient assessment (MDS) and in coordination with the attending physician's regiment of care. All professional personnel involved in the care of the patient review the care plan as necessary, but at least quarterly 4. Observations of R143 on 4/4/16 and 4/5/16, during stage 1 of the survey process, revealed R143 was in his room or hallway in a wheelchair. A review of the Client [DIAGNOSES REDACTED]. the tissue) affecting right dominant side; paralytic gait; muscle weakness (generalized); dysphagia (difficulty or discomfort in swallowing, as a symptom of disease); dysarthria (difficult or unclear articulation of speech that is otherwise linguistically normal) following cerebral infarction; and [MEDICAL CONDITION] (loss of ability to understand or express speech, caused by brain damage) following cerebral infarction. On 4/7/16, at 9:30 a.m., the Physical Therapist (PT) was observed to propel R143's wheelchair to the therapy room. Observation of the therapy session revealed R143 had difficulty standing up from the wheelchair without physical assistance from the therapist and later, ambulated with the therapist holding on to the gait belt and a second therapist following R143 with the wheelchair. A review of R143's plan of care dated 11/5/15 revealed a Problem/Strength, Requires assistance with ADLs that had a goal with the same date of Resident will continue to assist staff with dressing. Interventions included Encourage participation in ADL care. Assist with ADLs as needed. Call light within reach. Verbal cues as needed. Praise efforts and accomplishments. Assistive devices as needed. Staff will set up meal tray during meal times. Thickened liquids as ordered. Resident's personal items will be kept within resident's reach to allow him to groom self daily. The care plan noted a Problem/Strength of Occasional incontinence of bladder and usually continent of bowels. and had an intervention of Offer assistance to bathroom. Further review of the plan of care revealed no documented evidence of R143's bed mobility capabilities; transfer methods from bed to wheelchair or wheelchair to toilet; capabilities of oral care; capabilities of locomotion in the room or hallways to meals or activities; or how much assistance R143 required to get dressed/undressed. A review of R143's medical record revealed a 7-Day ADL Coding Summary for 1/13/16 - 1/19/16, printed by MDS Coordinator RN11 on 1/28/16 that revealed computerized charting for Bed Mobility, Transfers, Eating and Toilet Use. There was no documentation related to walking in the room and/or corridor; locomotion on and/or off the unit; dressing, personal hygiene or bathing. A handwritten note on the bottom of the sheet, signed by RN11, stated Clarifications: Pressure reducing device to bed and chair. Pt (patient) has dx [MEDICAL CONDITION] which effects his ® (right) side. He requires extensive assistance with 1 staff member (2 when more tired) for mobilities and transfers. Pt is able to use unaffected side to feed self after tray set up. In an interview on 4/7/16 at 4:15 p.m., RN11 stated We don't care plan every little thing - we just put in extensive assist and if you want to know how the resident does something, you ask staff. In an interview on 4/7/16 at 4:40 p.m., the Regional Nurse stated We don't care plan that stuff - we normally don ' t even care plan limited or extensive (assist) because it changes. In the same interview, MDS Coordinator (RN10) stated If you ' re working the floor and somebody has to go to the bathroom, you just go ask someone how to help them. A review of the facility policy Patient's Plan of Care (reviewed and updated for release September 2015) revealed: Intent: It is the intent of this center to develop and maintain an individualized plan of care for each patient. In the Procedural Guidelines section it stated: 3. The care plan is available for use by all personnel providing care/services to/for the patient. It includes, but is not limited to: A. Incorporate identified problem areas; B. Incorporate risk factor(s) associated with the identified problem(s): C. Build on the patient ' s strength; D. Reflect treatment goals and objectives in measurable goals; E. Identify the professional services that are responsible for each element of care; F. Prevent declines in the patients functional status and/or functional levels; and F. Enhance the optimal functioning of the patient by focusing on a rehabilitative program. 5. Care plans are revised as changes in the patient ' s condition dictates.

Based on observation and interview, the facility failed to ensure dietary staff honored food preferences for 1 of 30 residents (R154) reviewed in Stage 2. Findings include: Observation on 4/4/16 at 1:00 p.m. revealed R154 received steamed cabbage on his lunch tray. Further observation revealed that the resident refused the cabbage and gave it to the Certified Nursing Assistant (CNA) 19. During an interview at 1:00 p.m. on 4/4/16, CNA19 stated Cabbage is listed as a dislike on his tray ticket but it was on his tray. The resident told me to take it away. He refused a substitute. In an interview at 1:00 p.m. on 4/4/16, R154 stated Cooked cabbage gives me diarrhea but they (the dietary staff) always give it to me. I am used to it. This happens all the time. I have told them many times and nothing changes. Observation of the tray ticket also indicated that R154 was to receive double portions; however, no double portions were provided during that lunch service. Observation of lunch on 4/5/16 at 12:30 p.m. revealed R154 was served collard greens. The resident sent the collard greens back and the dietary staff sent out stewed tomatoes. R154 refused the tomatoes. Review of the tray ticket revealed tomatoes were listed on the tray ticket as a dislike. Further observation of the resident's lunch revealed no double portions. Interview with the Dietary Manager (DM) 4 at 12:05 p.m. on 4/6/16 revealed that she had reviewed food preferences with the resident about 2 weeks ago and stated What is listed on the tray ticket is correct. I am aware of the errors made and I apologized to the resident yesterday.