Every finding on record at Rice Estate Rehabilitation and Healthcare

Based on review of the facility policy, observations and interviews, the facility failed to ensure medications were accurately labeled and not expired in 4 of 4 medication carts and 1 of 3 medication storage rooms. Findings Include:Review of the facility policy titled, Medication Labeling and Storage last revised February 2023, states, Policy Interpretation and Implementation: Medication Storage: 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Medication Labeling: 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. Multi-dose vials that have been opened or accessed (e.g. needle Punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Review of the undated facility policy titled, Administering Medications, states, Medications are administered in a safe and timely manner, and as prescribed. 12. The expiration/beyond use date on the medication label is checked prior to administering, when opening a multi-dose container, the opened date is recorded on the container. An observation and interview on [DATE] at 08:20 AM of the [NAME] Hall revealed one vial of Tubersol 0.1 milliliters (mls) opened and undated. The Tubersol was received from the pharmacy on [DATE]. The opened and undated vial of Tubersol was confirmed by the Director of Nursing (DON) and removed from storage.An observation and interview on [DATE] at 02:15 PM, of Medication Cart 1 on Arbor Hall revealed the following:One 5 ml bottle of Brimonidine manufactured by [NAME], expired 01/2026. (Good for 28 days after opening).One opened undated 5 ml bottle of .1% Brimonidine manufactured by [NAME] with an expiration date of 08/28.One tube of Erythromycin 0.5% eye ointment; with an open date of [DATE] and an expiration date of 08/28 manufactured by Bausch and Lomb. (Good for 28-30 days after opening).One opened 2.5 m bottle of Latanoprost .005% 125 micrograms (mcgs) eye drops, manufactured by [NAME], with an expiration date of 02/27. (Good for 42 days after opening).One Breztri inhaler 160 mcg/9 mcg/4.8 mcg per inhalation; with no open date, Manufactured by AstraZeneca (Good for 90 days for 120 inhalations and 21 days for a pack with 28 inhalations).One bottle of Oxymetazoline nasal spray HCL .05%; with no open date, manufactured by Major Pharmaceuticals (Good for 3 days once opened).One bottle of Nasacort Allergy nasal spray, with no open date manufactured by Chathem (good for 60 days after opening).Three bottles of Fluticasone Propionate 50 mcg nasal spray with no open date Manufactured by Apolex (Good for 90 days after opening).The above out of date and unlabeled medications were confirmed by Licensed Practical Nurse (LPN)2 and removed from storage.An observation and interview on [DATE] at 03:14 PM, of Medication Cart 2 on Arbor Hall on revealed the following:One Iprotropium Bromide Albuterol inhaler 0.5/3mg/3mls with an open date of [DATE], Manufactured by Rite Dose noted with an expiration date of [DATE]. (Good for 7-14 days after opening).The unlabeled medications were confirmed by LPN3 on [DATE] at 03:37 PM and removed from storage.An observation and interview on [DATE] at 03:44 PM of the [NAME] House Medication Cart revealed one Albuterol inhaler 2.5 mg/3 mls with the foil pack was open and no open date, manufactured by Rite Dose is (Good for 2 weeks after foil pack is opened), confirmed by Registered Nurse (RN) 1 who then stated the package should have been dated.An observation and interview on [DATE] at 04:04 PM, of the Skilled Unit Medication Cart revealed the following:One Wixela inhaler 500/50 inhalation, manufactured by [NAME], with no open date and an expiration date of 06/2026 (Expires 30 days after opening).One Fluticasone Propionate and Salmeterol Inhalation Powder, manufactured by Hikma Pharmaceuticals, with an open date of [DATE] (Good for one month after opening).The unlabeled medications were confirmed by RN2 and removed from storage with other medications for resident use.

Based on review the facility policy, record reviews and interviews, the facility failed to ensure Resident (R)87 received a physician ordered medication for multiple days for 1 of 5 residents reviewed during medication administration. Based on review the facility policy, record reviews and interviews, the facility failed to ensure Resident (R)87 received a physician ordered medication for multiple days for 1 of 5 residents reviewed during medication administration. Findings Include: Review of the undated facility policy titled, Administering Medications states, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber's orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified.Review of R87's Face Sheet revealed the facility admitted R87 on 03/30/26 with diagnoses including but not limited to idiopathic pulmonary fibrosis.Review of R87's Medication Administration Record (MAR) revealed the following order: Nintedanib Esylate [used to slow lung function decline in idiopathic pulmonary fibrosis] 100 milligrams (mg) with instructions to give 1 capsule by mouth two times a day related to Idiopathic Pulmonary Fibrosis with a start date of 03/31/26. During an observation and interview of medication administration on 04/15/26 at 08:30 AM, Licensed Practical Nurse (LPN)1 stated R87 had not been receiving the medication, Nintedanib Esylate 100 mgs as ordered because the facility was waiting on the pharmacy to fill it and send the medication to the facility. Review of R87's Medication Administration Record (MAR) dated 03/30/26 and 03/31/26, revealed R87 did not receive the physician ordered medication of Nintedanib Esylate 100 milligrams on either day as ordered. Further review on 04/15/2026 of the April 26 MAR revealed the R87 received the medication on 04/01/26 at 8:00 AM and 5:00 PM, and again as ordered on 04/02/26 at 8:00 AM, but did not receive the 17:00 PM dose and likewise on 04/03/2026. R87 missed the 2 doses on 04/04/26, 04/05/26 and 04/06/26. R87 received a dose on 04/07/2026 but not the 5:00 PM dose and again on 04/09/26 R87 received the 8:00 AM dose but not the 17:00 PM dose. R87 did not receive any further doses through her discharge on [DATE]. No order to hold or to discontinue the medication was noted in the physician written orders. During an interview on 04/16/26 at 12:40 PM, the Director of Nursing (DON) stated that the Nintedanib Esylate 100 mg tablets were put on hold, surveyor noted the medication was not put on hold until 04/15/26 according to the physician's order.During an interview on 04/16/26 at 01:06 PM, the Pharmacist stated that if a medication is more than 500 dollars then they notify the DON to let her know so that she can notify the physician, or to see if the resident's family can bring the medication from home. The Pharmacist stated she would not know if the medication was put on hold and if it had been discontinued, the pharmacy would have gotten that order, so therefore the medication was not discontinued. The pharmacy received communication from the facility to refill the medication on 04/07/26, but the order was not filled due to cost.During an interview on 04/16/26 at 01:15 PM, the Attending Physician (AP) stated that he thought the medication was on hold. Surveyor then informed the AP that there was no order placed to hold the medication until 04/15/26 and that the documentation from the medical record to continue the Nintedanib Esylate. He went on to say that he was waiting for the pulmonologist to weigh in on the situation. He stated it was his intent to put it on hold when the resident was first admitted on [DATE].

Based on observation, staff interviews, record reviews , and facility policy review, the facility failed to implement pharmacy procedures for the reconciliation of controlled drugs on four (4) out of four (4) medication carts (Arbor Medication Cart Number One (#1), Arbor Medication Cart Number Two (#2), [NAME] Medication Cart, and [NAME] Medication Cart). Findings include: Review of the facility's policy titled, Controlled Substances, revised April 2019, revealed controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determines the count together. A review of the facility's documents titled Record of Narcotic and Medication Administration Record Review, and Change of Shift Controlled Medication Sheet, was identified by Licensed Practical Nurse (LPN)2, as the change of shift controlled drugs count sheets for March 2025, designated for the Arbor Medication Cart #2 The documents revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on 3/1/25, 3/2/25, and 3/3/25 to verify completion of the task to count the controlled drugs in the respective medication cart. Interview with LPN2, on 3/4/25, at approximately 11:40 a.m., he/she confirmed the observation and acknowledged that licensed nurses are expected to sign the count verification sheets at the change of shift. A review of the facility's document titled Shift-Change Controlled Substance Count Check, identified by Registered Nurse (RN)2 as the change of shift controlled count sheets for February through March 2025 for Arbor Medication Cart #1, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify completion of the task to count the controlled drugs in the respective medication cart 2/23/25, 2/24/25, and 2/26/25, and 3/1/25. Interview with RN2, on 3/4/25, at approximately 12:22 p.m., confirmed the observation and acknowledged the licensed nurses are expected to sign the count verification at change of shift. A review of a document titled Change of Shift Controlled Medication Sheet, identified by LPN5 as the change of shift controlled drugs count sheet for March 2025, for the [NAME] Medication Cart, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on 3/1/25 to verify completion of the task to count the controlled drugs in the respective medication cart. Interview with LPN5, on 3/4/25 at approximately 12:53 p.m., he/she confirmed the observation and acknowledged that licensed nurses are expected to sign the count verification at change of shift. A review of a document titled Record of Narcotic and Medication Administration Record Review, and Narcotic/Control Count, identified by LPN7, as the change of shift controlled drugs count sheets for January 2025, February 2025, and March 2025, for the [NAME] Medication Cart, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following dates to verify completion of the task to count the controlled drugs in the respective medication cart; 1/1/25, 1/5/25, 1/6/25, 1/20/25, 1/23/25, 1/27/25, 2/6/25, 2/16/25, 2/17/25, 2/22/25, and 3/1/25. During an interview with LPN7, on 3/4/25 at approximately 1:08 p.m., he/she confirmed the observation and acknowledged that licensed nurses are expected to sign the count verification at change of shift. A review of facility provided controlled drug count records titled, Record of Narcotic and Medication Administration Record Review, and Shift-Change Controlled Substance Count Check for January 2025 and February 2025 for the [NAME] Medication Cart, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change to verify completion of the task to count the controlled drugs on 1/3/25, 1/8/25, 1/9/25, and 1/10/25; and 2/25/25, 2/26/25, and 2/28/25. A continued review of facility provided controlled drug count records titled Record of Narcotic and Medication Administration Record Review, and Shift-Change Controlled Substance Count Check for January 2025 and February 2025, Arbor Medication Cart #1 revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify completion of the task to count the controlled drugs in the respective medication cart on 1/27/25, 2/4/25, 2/23/25, 2/24/25, and 2/26/25. A further review of facility provided controlled drug count records entitled Record of Narcotic and Medication Administration Record Review, and Shift-Change Controlled Substance Count Check for January 2025 and February 2025, for Arbor Medication Cart #2, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change to verify completion of the task to count the controlled drugs in the respective medication cart on 1/14/25, 1/27/25, 2/6/25, 2/14/25, 2/15/25, 2/25/25, 2/26/25, 2/27/25, and 2/28/25. During an interview, with the Director of Nursing (DON), on 3/5/25 at approximately 4:03 p.m., he/she confirmed that it was his/her expectation that nursing staff sign the Control Substance logs at change of shift to demonstrate that they have completed the count of the controlled drugs to identify any discrepancies. The DON further confirmed that the facility failed to implement pharmacy procedures for the reconciliation of controlled drugs.

Based on observation, interview, and review of facility policy, the facility failed to properly sanitize a meal thermometer in-between a tray line testing. Additionally, the facility failed to properly label and date items in the walk-in cooler and items in the freezer for 2 of 2 kitchens reviewed. Findings include: Review of the undated facility policy titled Food Preparation revealed, All foods are prepared in accordance with the Food and Drug Administration Food Code. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use. Review of facility policy titled Food Receiving and Storage last revised 10/31/17 revealed Food shall be receiving and stored in a manner that complies with safe food handling practices. Dry foods that are stored in bins will be removed from original packaging, labeled and dated use by date. Such foods will be rotated using a first-in-first-out system. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use-by) date. During an observation and interview of food temperature checks on 12/18/23 at 12:01 PM, of the Magnolia Kitchen, revealed the temping of 3 food items (scallop potatoes, broccoli, and carrots), without properly using sanitization methods before temping the next food item. An interview with the Head Chief revealed that staff are expected to sanitize in between temping food items. During an observation of the walk-in cooler of the Magnolia Kitchen on 12/18/23 at 12:15 PM, revealed the following items not properly labeled and dated after opening: cheddar cheese, apple juice, eggnog, turkey sausage, bacon, feta cheese, mashed potatoes, pepperoni, garlic bread, a bag of rolls/bread, a bag of hot dog buns, and pudding mix. During an observation on 12/19/23 at 12:23 of the Arbor Center Kitchen freezer revealed the following items not properly labeled and dated: frozen beans, frozen catfish nuggets, frozen onion rolls, and frozen pepperoni.

Based on review of facility policy, observation and interviews, the facility failed to inform residents of their resident's rights, rules and regulations governing resident conduct and responsibilities during resident's stay in the facility. Findings include: Review of the facility's policy revised February 2021, titled, Resident Council documented the facility supports resident's rights to organize and participate in the resident council. The purpose of the resident council is to provide a forum for: (a) residents, families, and resident representatives to have input in the operation of the facility; (b) discussion of concerns and suggestions for improvement; (c) consensus building and communication between residents and facility staff; and (d) disseminating information and gathering feedback from interested residents. Review of facility's policy revised December 2016, titled, Resident Rights documented (1.) Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident right to: (j) be informed about his or her rights and responsibilities. Review of facility's undated policy titled, Lutheran Homes of South Carolina Grievance Policy documented under Procedure (a) The facility will promote the grievance process throughout the organization. This includes notifying residents of their rights related to grievances as well as educating all those affected by potential grievances or concerns or the facility grievance processes; (c) the facility will inform residents orally and in writing of their right to make complaints and grievances and the process to do so during admission, and the care planning process. This notice shall include: (a) information on how to file a grievance or complaint (b) resident right to file grievances orally or in writing (c) resident right to file grievance anonymously (d) contact information of the facility designated grievance official (g) contact information of independent entities with who grievances may be filed. Review of Resident Council Visits for the month of September 2023, October 2023, and November 2023 revealed the [NAME] Unit, Rice Unit and Arbor unit resident council visits were documented to be held one-on-one with certain residents. Furthermore, the council visits outline general topic areas such as: management department, dietary, maintenance, environment, laundry, nursing, activities department concerns. Rights were not listed nor documented as discussed. During the Resident's Rights Council Certification Review meeting held on 12/20/23 at 2:30 PM, with four residents selected by the facility, revealed a consensus when asked about knowledge of resident's rights, how to file a grievance and how to contact the Ombudsman office, all the residents stated no one has spoken with them about their rights, they did not know how to file a grievance and did not know what the Ombudsman was. Furthermore, the residents stated they did not know where the Resident's Rights posting was in the facility. During an interview on 12/19/23 at 2:54 PM, the Activity Therapist revealed they review rights with the residents verbally during their visits. The Activity Therapist stated she did not have any documentation to present that resident rights are reviewed during visits. The Activity Therapist further stated Social Services review rights with the residents and may have documentation of the rights reviewed. During an interview on 12/19/23 at approximately 3:00 PM, the Social Worker (SW) revealed she visits the residents and asks them how they are doing and if they have any concerns. The SW stated she does document her visits with the residents, but she doesn't review residents' rights. During an interview on 12/20/23 at 11:10 AM, the Administrator stated his expectation is for rights to be reviewed during resident council meetings and the rights are posted on the walls in the facilities. After reviewing the Resident Council Visits provided to the survey team, he stated they have resident council meetings and the council minutes provided was perhaps an error in wording stating, Resident Council Visits.

Based on observation, interview, and policy review, the facility failed to ensure staff wore the appropriate Personal Protective Equipment (PPE) on the COVID-19 Unit; ensure staff that worked the COVID-19 Unit doffed their PPE appropriately before and exited the COVID-19 Unit at the appropriate exit; ensured that laundry was delivered covered on the COVID-19 Unit; and ensure staff were consistently screened for COVID-19 prior to working. Findings include: Review of the facility policy titled, Infection Prevention and Control Program, with a revised date of October 2018 revealed, Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe and comfortable environment and to help prevent the development and transmission of communicable infections. Review of the facility policy titled, Coronavirus Disease (COVID-19) Prevention and Control, dated March 2020, Policy Statement: Facility leadership and clinical staff are implementing reasonable measures to protect the health and safety of residents and staff during the current outbreak of coronavirus disease (COVID-19) . During the entrance conference on 01/05/21 at 10:40 AM, the Administrator was asked what the appropriate PPE was to be worn on the COVID-19 Unit. The Administrator stated staff were expected to wear a gown, gloves, face shield, and KN-95 mask. 1. During observations on 01/05/22 at 12:55 PM, Licensed Practical Nurse (LPN)1 walked into the COVID-19 Unit wearing a surgical mask. LPN1 was observed on the Unit at the medication cart only wearing the surgical mask. The LPN was not wearing the KN-95 or a face shield. During an interview on 01/05/22 at 1:03 PM, LPN1 was asked about the PPE that should be worn on the COVID-19 Unit. LPN1 stated a gown, shield, and a mask. LPN1 was asked what kind of mask and shield. LPN1 stated she did not know about the mask and then reached in the clean area, grabbed a face shield, and put it on. LPN1 was asked if staff that worked the COVID -19 Unit should wear a KN-95 mask. LPN1 stated, No one told me, and I can't breathe wearing those masks. 2. During observation on 01/05/22 at 1:22 PM, Certified Nursing Assistant (CNA)2 was observed exiting the COVID-19 unit through the side door still donned in a mask, gown, and face shield. During an interview on 01/05/22 at 1:23 PM, CNA4 was asked what the procedure was to doff gowns and shield prior to leaving the unit. CNA4 stated this side door was the way to come in and out of the unit. CNA4 was asked about doffing PPE before leaving the unit. CNA4 stated, I throw my gown in the trash up by the double doors of the unit and then walk through the unit to leave. CNA4 was asked if gowns were to be worn in the halls of the unit. CNA4 stated, Yes, but there is no trash can at the door to throw the gown. During an interview on 01/05/22 at 3:00 PM, CNA2 was asked about exiting the side door with the gown on and face shield. CNA2 stated, There was no trash can. So, I went out that door and took the gown and shield off outside and threw them away in the trash on the other unit. When asked if that was appropriate, CNA2 stated, I'm confused because they say we can't use the double doors to get back on the other unit and we only have this door, but the trash can is kept up by the double doors. During an interview on 01/07/22 at 11:50 AM, LPN4 was asked how she entered and exited the unit. LPN4 stated, I use the same door to enter and exit the unit. No one has told me anything else. 3. Review of the facility policy titled, Laundry and Bedding, Soiled, revised October 2018, Policy Statement: Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. During an observation on 01/05/22 at 3:05 PM, CNA2 placed multiple uncovered clothing items on the sofa in the hall of the COVID-19 Unit. CNA4 then went back and forth from rooms delivering the clothes in resident rooms. During an interview on 01/05/22 at 3:28 PM, Vice President of Clinical Operations (VPCO RN) was asked what the staff were expected to wear on the COVID-19 Unit. VPCO RN stated, Full PPE should be worn that included gown, N-95 mask, gloves, and face shield or goggles. VPCO RN was asked about staff entering and exiting through the same door. VPCO RN stated, There is a separate door that staff are to use for exiting the unit. It is a little room with the trash can in it. It is closed off and should be the only exit from the unit. The VPCO RN added the staff have been educated to this. VPCO RN was asked how the laundry should be delivered on the COVID-19 Unit. VPCO RN stated the laundry should be covered and delivered to the residents' room. VPCO RN confirmed the clothing should not be laid on the sofa. 4. Review of the paper Coronavirus Disease 2019 (COVID-19) pandemic Prevention and Response Plan undated, provided by the facility indicated, This emergency response guide and plan is a guideline to establish the decision-making and coordinating structures for response to a COVID-19 pandemic; to delineate the actions needed for procedural implementation disease surveillance and staff education and training; internal and external communications; employee health . The essential components for responding to a COVID-19 outbreak included surveillance, command, control procedures, communication, care delivery, and service delivery. Review of the paper policy COVID-19 Staff Screening, undated, provided by the facility read in full, At the beginning and end of each shift staff will be screened for signs and symptoms of COVID-19: Signs and symptoms may include: -Fever or chills -Cough -Shortness of breath or difficulty breathing -Fatigue -Muscle or body aches -Headache -New loss of taste or smell -Sore throat -Congestion or runny nose -Nausea or vomiting -Diarrhea Any of these signs and symptoms should be reported to immediate supervisor. If symptoms are present prior to shift employee should call supervisor and notify. Follow CDC (Center for Disease Control) Guidance for exclusion and return to work recommendations. The details, such as who would take staffs' temperature, who would record it, and what occurred if there were any negative responses documented, were not included in the policy. During an interview on 01/07/22 at 10:29 AM, Unit Manager (UM)1 stated the staff screening location for the [NAME] building was in the foyer after entering the building from the main entry door; this area was separated from the [NAME] nursing home area with residents by a set of double doors which remained closed and required pushing a button to enter. In the foyer, UM1 showed the surveyor a scanner for staff to use to take their temperatures and a log on the credenza in which they were to document their name, date, temperature, and presence/absence of cough, chest pain, shortness of breath, and other. Staff were to answer the questions (cough, chest pain, SOB, and other) with a yes or no response prior to entering the [NAME] unit. UM1 stated staff were responsible to screen themselves as there was no staff person who manned the doors and screened staff. UM1 verified it was a small unit with few staff and a current resident census of 14 residents. UM1 stated anyone working in the building had to be screened. When asked about which staff member reviewed the logs for completion, she stated the Director of Nursing (DON) checked the logs. The DON was not present or available during the survey for interview. Observation of screening area at this time with UM1 revealed the scanner for taking temperatures and log for staff to complete were in place on the credenza in the foyer. a. Observation and interview on 01/06/22 revealed not all staff working in the [NAME] building had been screened prior to entering the unit and working: During an interview on 01/06/22 at 10:56 AM, the Environmental Services Aide stated he worked five to six days a week completing housekeeping duties on the [NAME] Unit. He was asked about employee screening. The Environmental Services Aide showed the surveyor his vaccination card indicating he received two COVID-19 vaccines and a booster. He stated, based on being vaccinated and being tested twice a week for COVID, he was not required to be screened prior to working on the unit. He verified he did not get screened prior to working on the unit. Review of the screening log Daily Temp & Symptoms Check form dated 01/06/22 revealed the Environmental Services Aide had not self-screened and signed in on 01/06/22 prior to working on the [NAME] unit. b. Observation and interview on 01/07/22 revealed not all staff working in the [NAME] building had been screened prior to entering the unit and working: An observation on 01/07/22 at 10:06 AM revealed the Environmental Services Aide was conducting housekeeping duties on the [NAME] unit. During an interview on 01/07/22 at 10:08 AM, Licensed Practical Nurse (LPN)3 stated she was the charge nurse working the 7:00 AM - 7:00 PM shift. She stated she was employed by a staffing agency and was not directly employed by the facility. LPN3 stated there were two Certified Nursing Assistants (CNAs) working with her currently on the [NAME] unit (CNA3 and CNA4). LPN3 stated staff came in the main door into the foyer area, took and recorded their temperatures prior to working on [NAME]. On 01/07/22 at 10:19 AM, observation of the Daily Temp & Symptoms Check dated 01/07/22 revealed the Environmental Services Aide, LPN3, and CNA3 had not signed in and self-screened for COVID-19 on the [NAME] unit. At this time LPN3 was interviewed and stated she had not screened herself or signed in today prior to working in the unit. Review of the Daily Temp & Symptoms Check forms dated 12/01/21 - 01/07/22 (at 10:08 AM) revealed the Environmental Services Aide had not self-screened for COVID-19. During an interview on 01/07/22 at 10:23 AM, CNA3 stated staff were supposed to self-screen in the foyer prior to entering the [NAME] unit to work. CNA3 verified she had not signed in on the Daily Temp & Symptoms Check form on this date; however, indicated she had taken her temperature. CNA3 verified she worked for a staffing agency and was not a direct employee of the facility. CNA3 stated she was supposed to write down the screening information on the form (Daily Temp & Symptoms Check). During an interview on 01/07/22 at 10:29 AM, UM1 stated if staff did not write down the screening information on the form (Daily Temp & Symptoms Check), then she viewed it as the staff not having self-screened. During an interview with the Director of Maintenance on 01/07/21 at 2:08 PM, he stated the Environmental Services Aide worked five days a week on the [NAME] unit and had been trained regarding self-screening. The Director of Maintenance reported the Environmental Services Aide should have been conducting self-screening and signing the log prior to working on the [NAME] unit. During an interview on 01/07/22 at 3:51 PM with the Vice President of Clinical Operations, Registered Nurse (VPCO RN) and Administrator, the VPCO RN indicated she was filling in for the DON in the role of Infection Preventionist while he was out of the facility. They stated all staff should have their temperatures taken and fill out the Daily Temp & Symptoms Check form prior to work. They stated if staff failed to document the screening process, it was unknown if they had been screened or were symptomatic. They verified the DON monitored the forms and maintained the logs, which included going through the forms and making sure everyone was screened. They verified the routine failure of the Environmental Services Aide to self-screen should have been identified. The Administrator stated, if an employee failed to self-screen, they should not be scheduled. The Administrator stated all staff and residents had been tested for COVID-19 this week with results noted on 01/06/22 for both residents and staff being negative for COVID-19.

Based on observation, interview, record review, and policy review, the facility failed to ensure the kitchenette in one of three buildings/units (the [NAME] unit) was maintained in a sanitary manner creating the risk for foodborne illness. Fourteen out of 75 total residents resided on the [NAME] unit. Findings include: Review of the paper Sanitization policy, undated, revealed, The food service area shall be maintained in a clean and sanitary manner . Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy . Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. During an observation on 01/05/22 at 12:26 PM, three staff were serving lunch to residents who resided on the [NAME] unit. Staff were observed to go into the kitchenette, scoop ice out of the ice machine into an ice bin, and then scoop ice from the ice bin into individual cups for residents' beverages. During an observation on 01/05/22 at 12:19 PM, the kitchenette on the [NAME] unit was inspected. The refrigerator/freezer (household type of refrigerator/freezer with the freezer on the top and refrigerator on the bottom) was evaluated. The bottom shelf of the freezer, on which foods were stored, was soiled with large food spills covering approximately 25% of the surface. There was a fast-food plastic cup with an orange beverage with a straw in it on the freezer shelf. The ice machine used earlier to obtain ice for residents' beverages was inspected. There was a plastic bar in the ice machine going from one side to the other, directly above the ice. The plastic bar had a black colored substance a quarter inch in width adhered to the plastic the entire length of the bar. This was located directly above the ice. Water was dripping in the ice machine from the top of the machine, near where the black substance was located. During an observation on 01/06/22 at 10:38 AM, the freezer in the [NAME] kitchenette was observed. The orange drink with the straw in it as well as the food spills remained in the freezer on the bottom shelf. In addition, the ice machine was in the same condition, with the black colored substance adhered to the plastic piece above the ice. Observation at this time revealed this was the only ice machine for the [NAME] building. On 01/06/22 at 11:55 AM the Certified Dietary Manager (CDM), accompanied the surveyor to the [NAME] kitchenette. The CDM stated the orange beverage with the straw in the fast-food cup in the freezer was a staff member's beverage. She stated staffs' food should be placed in the staff refrigerator in the other building (Arbor). The CDM stated the shelf with food spills needed to be cleaned. The CDM looked in the ice machine and stated the substance adhered to the plastic looked like mildew. The CDM stated the ice machine had been repaired recently due to dripping/leaking water. The CDM stated the facility had signed a contract to get the ice machines cleaned on a quarterly basis which would be implemented soon. The CDM instructed the housekeeper to clean out the ice machine and to dispose of the contents (ice). The CDM stated she would have the main kitchen provide ice to use for lunch. The CDM stated the dietary staff and housekeeping staff were responsible for keeping the kitchenette clean. During an interview on 01/06/22 at 12:31 PM, the CDM stated that the ice machine in the [NAME] unit had been fixed on 12/07/21 due to dripping and water leaking. The CDM stated the repair person would have observed the condition of the ice machine at that time, which led her to believe the black substance/mildew accumulated after that date. The CDM stated there were no other records of the ice machine having been cleaned or serviced. The CDM stated the housekeeper would be responsible for cleaning the kitchenette and ice machine going forward. During an interview on 01/07/22 at 10:06 AM, the Environmental Services Aide on the [NAME] unit stated he was told it was the kitchen staffs' responsibility to clean the kitchenette in the [NAME] unit; however, he would do it. During an interview on 01/07/22 at approximately 11:30 AM, the Director of Maintenance stated he supervised the housekeeping staff. The Director of Maintenance stated, We are now responsible for that kitchenette ([NAME]). The Director of Maintenance stated his staff had wiped and cleaned the refrigerator numerous times, indicating it could get bad in a brief period. He verified the facility now had a contract to get their ice machines cleaned and serviced by an outside vendor going forward.

Based on interview, record review, and policy review, the facility failed to ensure the care plan was revised when a change in resuscitation status was made for one (Resident (R)33) of 10 reviewed for advanced directives in a total sample of 24 residents. R33's care plan documented he was designated as both full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) and Do Not Resuscitate (DNR). Findings include: Review of the paper Care Plans Comprehensive Person-Centered policy dated 2016, provided by the facility, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The care planning process will . reflect the resident's expressed wishes regarding care and treatment goals; The interdisciplinary team must review and update the care plan: a. when there has been a significant change in the resident's condition. Review of the Clinical tab, undated, in the Electronic Medical Record (EMR) revealed R33 was admitted to the facility on [DATE]. Review of the Diagnoses/Surgical Procedures tab, undated, in the EMR revealed R33's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/10/21, in the EMR under the MDS tab, revealed R33 was moderately impaired in cognition with a Brief Interview for Mental Status score (BIMS) of eight (score of eight - 12 indicates moderate cognitive impairment). R33 required extensive assistance of one staff for activities of daily living (ADLs) including bed mobility and personal hygiene; he was dependent on one staff member for toilet use and dressing. R33 had experienced a fall within the previous two to six months with a fracture occurring. Both the resident and family participated in the assessment. The resident was expected to remain in the facility. Review of the Home tab, undated, in the EMR revealed R33's status was DNR. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Emergency Services Do Not Resuscitate Order dated 08/10/21, in the EMR under the Attachments tab, revealed two physicians and R33's family member signed the document indicating R33 was not to be resuscitated in the event his heart stopped beating (coded). Review of the Care Plan Report dated 08/03/21 (initiation date), in the EMR, under the Care Plan tab, under the heading of Advanced Directives indicated Full code, Do Not Resuscitate. The Care Plan Report did not include any additional information related to advanced directives and whether full code or DNR should be enacted in the event the resident coded. During an interview on 01/07/22 at 8:52 AM, the Director of Social Services stated R33's family member made health care decisions for R33. The Director of Social Services reviewed the care plan in the EMR and verified the care plan documented both full code and DNR, which were opposite of each other. The Director of Social Services stated the care plan should document DNR only and showed the surveyor the current Emergency Services Do Not Resuscitate Order dated 08/10/21. The Director of Social Services stated when residents were admitted to the facility, their status was usually full code until the advanced directives could be completed. The Director of Social Services verified R33's status was initially full code when he was admitted . She stated she was not sure why the Full Code did not get deleted when DNR was added to the care plan. During an interview on 01/07/22 at 9:09 AM, the MDS Coordinator stated her responsibilities included care planning. She reviewed R33's care plan and stated she had not known R33's care plan documented both DNR and full code. She stated the Advanced Directives heading auto populated from the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator stated R33's initial order dated 08/03/21 documented full code and it was changed on 8/10/21 to DNR per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 01/07/22 at 10:55 AM, Unit Manager (UM)1 stated R33's status was DNR, and not full code based on documentation in the EMR and on the 24-Hour report. She indicated she would look on the initial screen in the EMR to determine whether to resuscitate a resident, which indicated DNR.

Based on record review, interview, and facility policy review, the facility failed to notify in writing the resident's representative and the Ombudsman of transfer to the hospital for one (R80) of three reviewed for hospitalization in a total sample of 24 residents. Findings include: Review of the facility's policy, Transfer or Discharge Notice, revised 03/21 stated, Policy Interpretation and Implementation .4. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: .d. An immediate transfer or discharge is required by the resident's urgent medical needs .5. The resident and representative are notified in writing of the following information: a. The specific reason for the transfer; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged .e. The facility bed hold policy; f. The name, address, and telephone number of the office of the State Long-term Care Ombudsman .6. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Review of the electronic medical record (EMR) under the Census tab revealed R80 was admitted to the facility on [DATE]. Review of R80's EMR under the Clinical notes tab, revealed R80 was admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R80's EMR under the Clinical Notes tab revealed a progress note dated 11/22/21 which revealed the resident was found by facility staff having emesis. The physician was notified, and orders were received to transfer R80 to the hospital for evaluation. The responsible party was notified via phone of the transfer. There was no documentation in the EMR of written notification regarding R80's transfer to R80's representative and/or the Ombudsman. During an interview on 01/07/22 at 7:55 PM, the Vice President of Clinical Operations, Registered Nurse (VPCORN) stated she was unable to locate written notification regarding R80's transfer to the hospital being provided to R80's representative and the Ombudsman. VPCORN said at the time of R80's transfer, the staff member who made the transfer notifications thought she did not need to provide the written notification due to an 1135 waiver, a result of the Coronavirus Disease 2019 (COVID-19) pandemic. The VPCORN stated during December 2021 she realized the notifications to the Ombudsman were not being made and instructed staff to re-start the resident's representative and Ombudsman notification process upon transfer.

Based on record review, interview, and facility policy review, the facility failed to provide written information regarding the facility's bed hold policy to the resident and the resident's representative at the time of transfer or within 24 hours of the transfer for one (Resident (R)80) of three reviewed for hospitalization in a total sample of 24 residents. Findings include: Review of the facility's policy, Transfer or Discharge Notice, revised 03/21 stated, .5. The resident and representative are notified in writing of the following information: .e. The facility bed hold policy Review of the electronic medical record (EMR) under the Census tab revealed R80 was admitted to the facility on [DATE]. Review of R80's EMR under the Clinical notes tab, revealed R80 was admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R80's EMR under the Clinical Notes tab revealed a progress note dated 11/22/21 which documented the resident was found by facility staff having emesis. The physician was notified, and orders were received to transfer R80 to the hospital for evaluation. The responsible party was notified via phone of the transfer. There was no documentation, located in the EMR, of written notice regarding the facility's bed hold policy being provided to R80 and/or their representative. During an interview on 01/07/22 at 7:55 PM the Vice President of Clinical Operations, Registered Nurse (VPCORN) stated she was unable to locate written notification provided to R80 and/or their representative explaining the facility's bed hold policy. The VPCORN said at the time of R80's transfer to the hospital the staff member who should have provided the bed hold information thought it was not required due to an 1135 waiver, a result of the Coronavirus Disease 2019 (COVID-19) pandemic. The VPCORN stated during December 2021 she realized the information was not being provided and instructed staff to re-start the process.

Based on observations, interview and record reviews the facility failed to assure that a staff member observed proper placement of a facemask in relation to COVID-19 infection control guidelines during 1 of 5 staff observed during medication pass observations in the Arbor resident care building. The findings include: During medication pass observations, on 8/18/20 at 9:42 AM outside Arbor room [ROOM NUMBER], LPN (Licensed Practical Nurse) # 1 walked down hallway to the medication cart with entire mask hanging beneath his/her chin, not covering mouth or nose, as he/she peeled and ate a banana. The banana skin was placed in the medication cart waste bin as LPN # 1 carried on a conversation with LPN # 2 who was in the process of passing medications. He/she then walked away with the mask hanging beneath his/her neck. On 8/18/20 at approximately 11:30 AM the DON (Director of Nursing) stated that this was contrary to the Center for Disease Control and Center for Medicare & Medicaid Services Guidance for Wearing Masks-COVID-19 which the facility had adopted as policy. The DON stated that a facemask must be worn at all times over the nose and under the chin and that food is not allowed in the hallways, nursing station or on medication carts.

Based on observation, record review, and interview, the facility failed to maintain medical records on each resident that were complete and accurately documented. Resident #25 and Resident #10 were enrolled in Programs of All-Inclusive Care for the Elderly (PACE). During the days of survey, the facility failed to maintain in the residents medical record documentation of Resident #25 and Resident #10's Physical Therapy and Occupational Therapy notes from the PACE program (2 of 2 sampled residents reviewed for positioning/mobility). The facility failed to document constipation interventions for Resident #20 (1 of 1 reviewed for hospice). The facility failed to document tube feeding assessment following emesis for Resident #31 (1 of 1 reviewed for change of condition). The findings included: The facility admitted Resident #25 with [DIAGNOSES REDACTED]. Review of the 11/28/18 Quarterly Minimum Data Set (MDS) Assessment on 1/15/19 at 7:34 PM revealed that the resident had impaired functional Range of Motion (ROM) in both lower extremities. Further record review revealed no evidence of routine provision of services to prevent further decline. During an interview on 1/17/19 at 8:54 AM, when asked what was being done to prevent further decline for this resident with functional impairment in both lower extremities, Licensed Practical Nurse (LPN) #1 stated, CNAs (Certified Nursing Assistants) do ROM with daily care. When asked where this was documented, the LPN did not know. During an interview on 1/17/19 at 1:37 PM, the Director of Nurses also stated that CNAs provided ROM with daily care but that it was not documented anywhere. S/he stated the facility had no restorative program. Review of the Care Plan on 1/15/19 at 3:49 PM revealed no reference to limitations in ROM or interventions to prevent further decline. During an interview on 1/17/19 at 4:43 PM, Registered Nurse (RN) #1 reviewed the care plan and stated s/he saw nothing in the care plan on ROM limitation and no planned interventions to prevent further decline. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Observation of Resident #10 and interview with CNA #2 on 01-15-19 at 8:50 AM revealed that s/he could not straighten his/her knees bilaterally. CNA #2 confirmed this by demonstrating an attempt to straighten the resident's legs. Review of the 07-21-18 Quarterly and 10-15-18 Annual MDS assessments revealed that the upper and lower extremity on one side were coded as having impaired ROM. Review of the Plan of Care revealed that there was a splint provided for the left upper extremity, but no interventions planned for the lower extremities. Review of the 01-17-18 Occupational Therapy note on 01-16-19 at 11:26 AM revealed that the resident's right lower extremity had limited knee extension of approximately negative (-) 45 degrees. The left lower extremity had limited extension of approximately 35 degrees. During an interview on 01-17-19, the Director of Nursing (DON) stated that ROM was done when the aides were giving care. S/he stated that ROM was not documented anywhere and there was no restorative program. Additional information was provided by the facility on 2/2/19 for Resident #25 and Resident #10. This information revealed that Resident #25 and Resident #10 are enrolled in the PACE program where they are assessed for Physical/Occupational Therapy needs and services are provided as needed. During the days of survey PACE documentation was not maintained in the residents medical record and not available for the surveyors to review. Resident #20 was admitted to the facility with [DIAGNOSES REDACTED]., and [MEDICAL CONDITION]. On 1/14/19, during a telephone interview with Resident #20's responsible party, s/he expressed a concern regarding the residents bowel movements and the possibly of pain from constipation. Observations and review of the resident's medical record and CNA flowsheet on 1/16/19 at 11:55 AM revealed the resident had multiple entries of no documented bowel movements. During an interview with the DON on 1/16/19, s/he confirmed there had been multiple days of no documentation of the resident having bowel movements. The facility admitted Resident #31 with [DIAGNOSES REDACTED]. Observations and review of the 12-7-18 Annual Minimum Data Set on 1/16/19 at 10:56 AM revealed the resident was totally dependent for all activities of daily living and was fed via gastrostomy (G-) tube. Record review on 1/14/19 at 3:45 PM revealed a 11/24/18 Clinical Note which stated: Rectal exam provided d/t (due to) resident having loose stools and per staff vomited x 1 yesterday. Rectal vault clean. No hardstool or impaction noted. Abdomen is soft and non-distended with active BS (bowel sounds) x 4. She (He) tolerated water flushes and bolus today without difficulty . Further review on 1/16/19 at 11:12 AM revealed there were no vital signs recorded between 11/19/18 and 11/25/18. There were no assessments of the lungs related to possible aspiration. The next clinical (nursing) note was not entered until 11-29-18, five days later. During an interview on 1/16/19 at 1:27 PM, LPN #1 stated, There should be an order to check for aspiration every shift. S/he reviewed the e-chart and found none. When questioned about the lack of subsequent assessment, the LPN looked in the acute charting book and confirmed that the resident's name had not been entered to do 3 day follow-up charting.

Based on observation, record review, and interview, the facility failed to ensure care plans were attended by all required disciplines and/or were reviewed and revised as needed for 7 of 21 sampled residents reviewed for care plans (Residents #39, #44, #274, #25, #31, #19, #10). Findings: Resident #39 was admitted with [DIAGNOSES REDACTED]. Review of the care plan on 1/15/19 at 5:26 PM revealed that on 11/21/18 the facility conducted a care plan; however, not all required interdisciplinary team members participated including nutrition, social, therapy, and activities/life enrichment services. During an interview with the Director of Nursing (DON) on 1/17/19 at 4:52 PM, s/he confirmed these findings. Resident #44 12/10/18 was admitted with [DIAGNOSES REDACTED]. Review of the care plan on 1/16/19 at 7:13 PM revealed that on 12/18/18 the facility conducted a care plan; however, not all required interdisciplinary team members participated including the nursing assistant, nutrition, social, therapy, and activities/life enrichment services. During an interview with the DON on 1/17/19 at 4:52 PM, s/he confirmed these findings. Resident #274 was admitted with [DIAGNOSES REDACTED]. Review of the resident's medical on 1/17/19 at 8:02 AM revealed that on 10/7/18 the nursing assistant providing care to the resident observed and reported bruising and swelling of the ring finger and restless behavior. On 10/8/18, x-ray revealed a [MEDICAL CONDITION] finger. According to the nurse's notes, the physician ordered to discontinue the anticoagulant ([MEDICATION NAME]) and antacid ([MEDICATION NAME]), and to start a diuretic ([MEDICATION NAME]), and to place a splint to the finger. On 10/9/18, the nursing assistant providing care said that the resident's little toenail was utterly dislodged. The nurse assessed and treated the resident. On 10/19/18, the nursing assistant reported a new bruise to the left 2nd toe and back of the left ankle. The physician evaluated and sent the resident to the emergency room for evaluation and treatment. The resident returned to the facility on [DATE] diagnosed with [REDACTED]. On 11/3/18, the nursing assistant said that s/he found the resident on the floor of his/her room with a gash on his/her forehead and under the corner of his/her right eye. The nursing assistant reported that the resident stated s/he was reaching for his/her sibling. According to the nurse's notes, the resident's health continued to decline with personality changes, increased fatigue, poor appetite, decreased verbal response, urine changes, and high sodium levels despite all medical interventions. On 11/19/18, the physician ordered to discontinue all medication and start the resident on [MEDICATION NAME] and hospice services. On 11/21/18, the resident passed with his/her son and daughter at her/his bedside. Review of the care plan on 1/17/18 at approximately 9:45 AM revealed that the facility did not update the care plan regarding fracture, hospitalization , falls, behavior, total health decline, and hospice services. In addition, the care plan conducted on 7/25/18 did not include the Certified Nursing Assistant (CNA) and therapy. During an interview with the administration and the DON on 10/17/19 at approximately 6:35 PM, both acknowledged these findings. The facility admitted Resident #25 with [DIAGNOSES REDACTED]. During observations on 01/15/19 at 8:47 AM and on 1/16/19 at 1:00 PM, a pressure pad bed alarm was noted on Resident #25's bed. During an interview on 01/17/19 at 8:54 AM, Licensed Practical Nurse (LPN) #1 spoke with CNA #1 who confirmed they had been using a bed alarm on the resident. S/he reviewed the record and verified there was no care plan for use of the alarm. Review of the Care Plan on 1/15/19 at 3:49 PM revealed that the resident was supposed to have a Concave mattress for positioning. Observations throughout the survey revealed that the resident did not have it in place. During an interview on 1/16/19 at 1:00 PM, LPN #1 verified that the Care Plan had not been updated. S/he stated that Resident #25 did not have a concave mattress. Review of the 11/28/18 Quarterly Minimum Data Set Assessment on 1/15/19 at 7:34 PM revealed that the resident had impaired functional range of motion (ROM) in both lower extremities. Further record review revealed no evidence of routine provision of services to prevent further decline. Review of the Care Plan on 1/15/19 at 3:49 PM revealed that the care plan had not been updated to include the resident's limitations in ROM or interventions to prevent further decline. During an interview on 1/17/19 at 4:43 PM, Registered Nurse (RN) #1 reviewed the care plan and stated s/he saw nothing in the care plan on ROM limitation and no planned interventions to prevent further decline. The facility admitted Resident #31 with [DIAGNOSES REDACTED]. Observations and review of the 12-7-18 Annual Minimum Data Set on 1/16/19 at 10:56 AM revealed the resident was fed via gastrostomy (G-) tube. Record review on 1/14/19 at 3:45 PM revealed a 11/24/18 Clinical Note which stated: Rectal exam provided d/t (due to) resident having loose stools and per staff vomited x 1 yesterday. Rectal vault clean. No hardstool or impaction noted. Abdomen is soft and non-distended with active BS (bowel sounds) x 4. She (He) tolerated water flushes and bolus today without difficulty . Further review on 1/16/19 at 11:12 AM revealed there were no vital signs recorded between 11/19/18 and 11/25/18. There were no assessments of the lungs related to possible aspiration. The next clinical (nursing) note was not entered until 11-29-18, five days later. During an interview on 1/16/19 at 1:27 PM, Licensed Practical Nurse #1 stated, There should be an order to check for aspiration every shift. S/he reviewed the e-chart and found none. Review of the Care Plan for tube feeding on 1/16/19 at 11:21 AM revealed that it did not include an intervention to monitor for aspiration. During an interview on 1/17/19 at 4:58 PM, RN #1 reviewed and confirmed that the care plan for provision of tube feeding had not been updated to include monitoring for signs and symptoms of aspiration. The facility admitted Resident #19 with [DIAGNOSES REDACTED]. Record review on 01-17-19 at 10:42 AM revealed that [MEDICATION NAME] had been discontinued on 11-20-18. A review of the Plan of Care revealed that Resident #19 was at risk for fall related to [DIAGNOSES REDACTED]. Takes [MEDICAL CONDITION] medications as ordered. During an interview on 01-17-18 at 06:35 PM, RN #1 reviewed the physician's orders [REDACTED]. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Observation of Resident #10 and interview with CNA #2 on 01-15-19 at 8:50 AM revealed that s/he could not straighten his/her knees bilaterally. CNA #2 confirmed this by demonstrating an attempt to straighten the resident's legs. Review of the 01-17-18 Occupational Therapy note on 01-16-19 at 11:26 AM revealed that the resident's right lower extremity had limited knee extension of approximately negative (-) 45 degrees. The left lower extremity had limited extension of approximately 35 degrees. Review of the 07-21-18 Quarterly and 10-15-18 Annual MDS assessments revealed that the upper and lower extremity on one side were coded as having impaired ROM. Review of Resident #10's Plan of Care revealed that there was a splint provided for the left upper extremity, but no interventions planned for the lower extremities.

Based on observation and interview, the facility failed to provide needed maintenance repairs as required. There was damage noted to walls, doors, and furniture in 2 of 3 buildings. The findings included: The following concerns were identified during the Initial Pool Process on 1/14/19 and 1/15/19 and confirmed during the environmental tour with the Maintenance Supervisor on 01/17/19 at 3:09 PM: Arbor Center (1) room [ROOM NUMBER] had an overbed table with 2 edges damaged and top peeling back and with particleboard exposed. (2) room [ROOM NUMBER] had wall damage near the sink and dark scuffs along the wall 2' from the floor. Rice (1) room [ROOM NUMBER] - The inside of the bathroom door was gouged out ~ 2' from the floor. The sink bib was peeling along the bottom edge. The side of the sink cabinet had the bottom broken off and was peeling near the floor. (2) room [ROOM NUMBER] - The side of the sink cabinet had the veneer peeling off. (3) room [ROOM NUMBER] - Both closet doors and the bathroom door and frame were damaged with paint peeling on the lower half of the doors. The bathroom wall was gouged between the sink and toilet and the toilet paper holder was broken. (4) room [ROOM NUMBER] had a knob missing on the bedside stand. (5) Dining/Day Room - The walls under the windows on the left side of the exit door and to the right of the TV were damaged. (6) There was wall damage near the baseboard in the hall between Rooms 302 & 303. During an interview at 8:15 AM on 1/17/19, the Maintenance Supervisor stated s/he had only 2 work orders, none on the skilled units.

Based on record review and interview, the facility failed to complete accurate Minimum Data Set (MDS) assessments for 1 of 2 sampled residents reviewed for tube feeding (Resident #10), 1 of 1 sampled residents reviewed for hospice (Resident #20), and 1 of 1 sampled residents reviewed for physical restraints (Resident #4). The findings included: Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record on 1/16/19 indicated the Resident had been admitted to Hospice services on 5/8/2018 with a [DIAGNOSES REDACTED]. Further review of the MDS assessments revealed two quarterly assessment had been completed on 8/17/18 and 11/13/18. These assessments did not indicate J1400 as being accurate either. During an interview with the MDS Registered Nurse (RN) on 1/17/19, s/he indicated the assessments were not completed accurately. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the 10-8-18 Annual MDS Assessment on 1/16/19 at 5:12 PM revealed that Resident #4 had been assessed with [REDACTED]. Section C0100 was answered No, indicating the Brief Interview for Mental Status (BIMS) should not be conducted because the resident was rarely/never understood. This coding was not consistent with the response to B700 and the interview should have been attempted. During an interview on 1/17/19 at 4:34 PM, RN #1 stated that C0100 should have been answered yes and the BIMS should have been attempted. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Review of the 07-21-18 Quarterly MDS assessment on 01-16-19 at 11:26 AM revealed that under Section G Functional Status, eating was coded 8 for self-performance and 8 for Activity of Daily Living (ADL) support provided, indicating the activity did not occur. During an interview on 01-17-19 at 06:28 PM, RN #1 reviewed the assessment and verified that it had been coded wrong.

Based on record review and interview, the facility failed to conduct a quarterly Minimum Data Set (MDS) assessment for Resident #274 (1 of 1 reviewed for injury of unknown origin). The findings included: The facility admitted Resident #274 with [DIAGNOSES REDACTED]. According to the resident's record reviewed on 1/16/19 at approximately 3:45 PM, the facility completed the first quarterly MDS assessment on 4/24/18 and a second quarterly assessment on 7/17/18; however, the third quarterly MDS assessment, which should have been conducted in October, was not in the resident's medical record and the facility was unable to provide documentation to indicate that the assessment had been conducted. In an interview with the administrator and the director of nursing on 1/17/19 at 4:52 PM, both acknowledged the assessment should have been conducted. They also stated that the (MONTH) quarterly MDS did not show up in the facility computer system as missing and that it did not trigger on the CMS transmittal report.

Based on record review and interview, the facility failed to notify the physician and/or family of changes in the resident's condition, potentially requiring medical intervention for two of two sampled residents reviewed for notification. The family was not notified when Resident #25 developed a new pressure ulcer. For Resident #273, the physician and family were not notified of blood pressures outside acceptable parameters. The findings included: The facility admitted Resident #25 with [DIAGNOSES REDACTED]. Review of weekly Body Audits on 01/15/19 at approximately 3 PM revealed that a right inner knee pressure ulcer was first noted on 10-2-18. There was no note on the form regarding family notification. Review of Nurses Notes on 01/15/19 at 3:21 PM also revealed no reference to family notification of the resident's change in condition. During an interview on 1/16/19 at 12:32 PM, Licensed Practical Nurse (LPN) #1 reviewed and verified the 10-2-18 body audit. S/he reviewed Nurses Notes and was unable to locate family notification of the new wound. The LPN stated the family had been notified of an order for [REDACTED]. The facility admitted Resident #273 for reconditioning and strengthening with [DIAGNOSES REDACTED]. Review of the Resident Vital Sign Report on 1/17/19 revealed the following recorded blood pressures (BPs) : -4/1/18 @ 12:08 PM =78/38 -4/9/18 @ 9:06 AM = 190/73 -4/10/18 @ 8:49 AM = 198/76 Computerized program alerts noted when the systolic BP was less than 91 or greater than 189 and when the diastolic BP was less than 51 or greater than 89. Continued review revealed no evidence of physician or family notification of BPs outside acceptable parameters. There was no Clinical Notes Report for 4-1-18. Clinical Notes Reports for 4-9-18 and 4-10-18 did not include any mention of the BP or physician notification. During an interview on 01/17/19 at 5:32 PM, the Director of Nurses (DON) reviewed the vital signs and Nurses Notes. S/he was unable to locate evidence of physician notification of the noted BP results. When asked about written policies regarding physician notification of change of condition, the DON stated the facility had no written policies and This should be nursing judgement. When asked if s/he would have notified the physician with the above BPs, s/he stated, Yes.

Based on record review and interview, the facility failed to ensure that each individual who completed a portion of the Minimum Data Set (MDS) assessment signed and certified the accuracy of that portion of the quarterly and comprehensive MDS assessments for one of five residents reviewed for unnecessary medications. The sections E and F were not signed and certified as accurate by the individual(s) who completed those sections on the comprehensive MDS assessment with Assessment Reference Date (ARD) of 8/11/17 for Resident #69 as required. The section M was not signed and certified by the individual(s) who completed that section on the quarterly MDS assessment with ARD of 11/11/17. The findings included: The medical record review conducted on 12/6/17 at 1:45 PM revealed that the facility admitted resident #69 with the [DIAGNOSES REDACTED]. Record review on 12/6/17 at 3:30 PM of Resident #69's Annual Comprehensive Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 8/11/17 revealed that there were no electronic signatures in section Z0400 that reflected sections E and F were completed, and certified as accurate by an individual. Further review revealed that Z0500 A&B were signed by the Registered Nurse and dated 8/28/17 to reflect that the assessment was complete. Additional review of Resident #69's Quarterly MDS assessment with ARD of 11/11/17 revealed that there was no electronic signature in section Z0400 that reflected section M was completed, and certified as accurate by an individual. Ongoing review revealed that Z0500 A&B were signed by the Register Nurse and dated 11/20/17 to reflect that the assessment was complete. During interview with MDS Nurse #1 on 12/7/17 at 2:00 PM, s/he verified that there were no signatures to reflect that sections E and F were completed and certified as accurate by an individual on the comprehensive MDS assessment with ARD of 8/11/17, and that there was no signature to reflect that section M was completed and certified as accurate by an individual on the quarterly MDS assessment with ARD of 11/11/17.

Based on observation, limited record review and interview, the facility failed to assure that 1 of 16 residents screened during initial pool process, and 1 of 5 residents reviewed for unnecessary medications received accurate assessments. The findings included: The limited medical record review conducted on 12/5/17 at 11:00 AM revealed that the facility admitted Resident #17 with the [DIAGNOSES REDACTED]. Resident #17 was observed to be incontinent of bowel and bladder during initial pool screening process on 12/4/17 and 12/5/17. Record Review of Resident #17's Annual Comprehensive Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 9/18/17 on 12/5/17 15 11:00 AM revealed Section H (Bladder and Bowel) item H0400 was coded as 0=always continent of bowel. Further review of medical record on 12/6/17 at 12:30 PM revealed that on the printed report entitled Lowman B&B Continence with print date 12/6/17 at 8:56 AM, that resident #17 was incontinent of bowel 9 times during the assessment window of 9/12/17-9/18/17 with no episodes of continent bowel movement recorded during that same time frame. During interview with MDS Nurse #1 on 12/7/17 at 3:09 PM, s/he verified that H0400 was incorrectly coded as 0=always continent of bowel and that Resident #17 should have been coded as 3=always incontinent of bowel. The medical record review conducted on 12/6/17 at 1:45 PM revealed that the facility admitted resident #69 with the [DIAGNOSES REDACTED]. Resident #69 was observed without the use of a hearing aid during each of multiple observations and to be incontinent of bowel and bladder during initial pool screening process on 12/4/17 and 12/5/17. Record review of Resident #69's Annual Comprehensive Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 8/11/17 revealed Section B Hearing, Speech, and Vision item B0300 was coded 1=hearing aid or other hearing appliance used in completing B0200, Hearing. Further review revealed that section H (Bladder and Bowel) item H0400 was coded as 2=frequently incontinent-2 or more episodes of bowel incontinence, but at least one continent bowel movement. Further review of medical record on 12/7/17 at 12:15 PM, revealed that on the printed report entitled Lowman B&B Continence with print date of 12/7/17 at 7:42 AM, that resident #69 was incontinent of bowel 6 times during the assessment window of 8/5/17-8/11/17, with no episodes of continent bowel movement recorded during the same time frame. Review of the nursing notes for that time frame also revealed that there were no episodes of documented continent bowel movements during the dates 8/5/17-8/11/17. Additional record review of Resident #69's Quarterly MDS assessment with ARD of 11/11/17 revealed Section B Hearing, Speech, and Vision item B0300 was coded 1=hearing aid or other hearing appliance used in completing B0200, Hearing. Further review revealed that section H (Bladder and Bowel) item H0400 was coded as 2=frequently incontinent-2 or more episodes of bowel incontinence, but at least one continent bowel movement. Ongoing review of Section J Health Conditions item J1900B was coded as 0 (none)=number of falls since prior assessment with injury (except major)-skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the resident to complaint of pain. Further review of medical record on 12/7/17 at 12:15 PM, revealed that on the printed report entitled Lowman B&B Continence with print date of 12/7/17 at 7:43 AM, that resident #69 was incontinent of bowel 6 times during the assessment window of 11/5/17-11/11/17, with no episodes of continent bowel movement recorded during the same time frame. Review of the nursing notes for that time frame also revealed that there were no episodes of documented continent bowel movements during the dates 11/5/17-11/11/17. Finally, on 12/7/17, review of Occurrence report for incident that occurred on 10/31/17 at 1:15 PM revealed that Resident #69 sustained a fall resulting in a 0.5 cm skin tear/laceration to right side of forehead, 2 cm skin tear to right elbow and 1 cm skin tear to right hand. MDS Nurse #1 verified during interview on 12/7/17 at 2:00 PM that items B0300 and H0400 were incorrectly coded on both the annual comprehensive MDS assessment with ARD of 8/11/17 and quarterly MDS assessment with ARD of 11/11/17. S/he further verified that on the quarterly MDS assessment with ARD of 11/11/17, that item J1900B was incorrectly coded.

Based on observations, record reviews, interviews, and review of the facility policy's, the facility failed to ensure that standards of clinical practice were followed related to drug administration for 1 of 4 units reviewed for professional standards. Registered Nurse #1 did not ensure safe medication administration practices. The findings included: The facility admitted Resident #482 with a [DIAGNOSES REDACTED]. On 12/06/17 at approximately 6:50 AM, during an observation of Resident #482's medication administration on the Arbor Unit (side #2), Registered Nurse (RN) #1 entered Resident #482's room and walked over to the residents tray table next to the bed where a medication cup with approximately 15 milliliters (ml's) of a red liquid was observed. RN #1 verified that the liquid in the medicine cup was cough medication that was given to Resident #482's the night before. Also, Resident #482's nebulizer cup was ½ full of a clear liquid. RN #1 verified the liquid in the nebulizer cup was medication from a treatment the resident was to receive through the night, but did not receive. RN #1 stated s/he did not wait till the resident took the medication before leaving the room and indicated that s/he should not have left medication at bedside or in the nebulizer cup. On 12/6/17 at 1:00 PM, a review of Resident #482's assessment Self Administration of Medication and/or Treatments indicated the resident was not authorized to self-administer medications. Also, review of Resident #482's physicians orders revealed no order stating that Resident #482 could self-administer medications. On 12/6/17 at 1:20 PM, a review of the facility policy entitled, Medication Administration General Guidelines section (7.1) states under procedure (15.) Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications and state regulations. Also, procedure (20.) states, The resident is always observed after administration to ensure that the dose was completely ingested, this is noted on the MAR, and action is taken as appropriate.