Every finding on record at Riverside Health & Rehab Cntr

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 35 current residents in the survey sample, Resident #128. The findings included: For Resident #128, the facility staff failed to obtain a stop date for the antibiotic medication, Macrobid which resulted in the medication being administered for greater than four (4) weeks. Resident #128's diagnosis list indicated diagnoses, which included, but not limited to Rheumatoid Arthritis, Essential Hypertension, Major Depressive Disorder, Atrial Fibrillation, and History of Falling. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/17/23 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating Resident #128 was cognitively intact. Resident #128's order history included an order dated 5/22/23 for Macrobid 100 mg by mouth two times a day for cellulitis related urinary tract infection. The Macrobid order did not include a duration or a stop date. Resident #128's clinical record included emergency department instructions dated 5/19/23 which included an order for Macrobid 100 mg by mouth every 12 hours for 7 days to treat a urinary tract infection. Resident #128's clinical record included a Consult Pharmacist Medication Regimen Review dated 5/23/23, the review was checked by the statement See report for any noted irregularities and/or recommendations. Upon review of Resident #128's clinical record on 9/01/23, surveyor was unable to locate the 5/23/23 drug regimen report completed by the pharmacist. On 9/01/23, surveyor spoke with the director of nursing (DON) and requested the 5/23/23 medication regimen review report for Resident #128. On 9/06/23 at 10:44 AM, the DON provided a copy of the 5/23/23 medication regimen review which in part recommended a stop date for Macrobid. The DON verified there was no evidence that the medication regimen review report was reviewed or addressed by the physician. Surveyor asked if the Macrobid was addressed when the pharmacist requested a stop date in May and the DON stated not that they could see from the clinical record. Resident #128 continued to receive the Macrobid until it was discontinued by the nurse practitioner (NP) on 6/22/23. The NP documented within the discontinuation order the reason for discontinuation as was only be [sic] for 5 days per dc [discharge] instructions - tx [treatment] UTI [urinary tract infection]. Surveyor requested and received the facility policy entitled, Medication Regimen Review which read in part .Resident-specific irregularities and/or clinically significant risks resulting from or associated with medication are documented in the resident's active record and reported to the Director of Nursing, Medical Director, and/or prescriber as appropriate .Recommendations are acted upon and documented by the facility staff and/or the prescriber . On 9/06/23 at 5:30 PM, the survey team met with the facility management team including the administrator and DON and discussed the concern of staff failing to obtain a stop date of the administration of Macrobid. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/07/23.

Based on observation, resident interview, staff interview, local ombudsman interview, clinical record review, and facility document review, the facility staff failed to provide care and services to meet the needs of the residents for 2 of 35 current residents in the survey sample, Resident #112 and #114. The findings included: 1. For Resident #112, the facility staff failed to administer the physician ordered antibiotic medication, Cephalexin to treat cellulitis and failed to address the wound specialist's recommendations for lab testing related to concern for cellulitis. Resident #112's diagnosis list indicated diagnoses, which included, but not limited to Hypocalcemia, Aortic Valve Stenosis, Essential Hypertension, Bilateral Open-Angle Glaucoma, Polyosteoarthritis, and Major Depressive Disorder. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 6/26/23 assigned the resident a Brief Interview for Mental Status (BIMS) summary score of 9 out of 15 indicating the resident was moderately cognitively impaired. Resident #112's clinical record included a physician's progress note dated 8/14/23 which documented in part .The patient is seen today at the request of nursing staff to evaluate the patient's left lower leg. The patient has skin tear to this leg, which one of the wound nurses is concerned has become infected .There is an area measuring 7 cm by 5 1/2 cm, superficial, no drainage, increased erythema extending out from the borders. No induration .Lower leg ulceration: Initially started as the skin tear, but not has developed cellulitis. Most likely Strep Infection. We will order Keflex . An 8/14/23 12:12 PM nursing progress note read in part LT [left] leg skin tear wound worsening, increasing in size and small amount of bloody drainage noted. Peri-wound is warm, red, and has scattered red, flat rash present to peri-wound. Dr. [name omitted] made aware. N.O. [new order] Cephalexin 250 mg Q [every] 8 hours x [times] 10 days for Cellulitis . Cephalexin is the generic name for the antibiotic Keflex. On 9/01/23, surveyor reviewed Resident #112's clinical record and was unable to locate evidence of the order being transcribed to the resident's orders or evidence that the resident received Cephalexin. Surveyor requested to speak with the author of the 8/14/23 12:12 PM nursing note, however, they were no longer employed by the facility. Resident #112 was seen by the wound specialist nurse practitioner (NP) on 8/28/23, the progress note read in part .Wound is closed however concerning for cellulitis. Recommend CBC [complete blood count], CRP [C-reactive protein], ESR [erythrocyte sedimentation rate], and culture . Resident #112 was again seen by the wound specialist NP on 9/04/23, the progress note read in part .Wound is closed however concerning for cellulitis. Recommend CBC, CRP, ESR, and culture . On 9/05/23, surveyor reviewed Resident #112's clinical record and was unable to locate evidence of the lab recommendations being addressed by the attending provider. On 9/05/23 at 3:25 PM, surveyor spoke with the wound specialist NP who stated they typically provided recommendations to the in-house provider, and they entered any orders. NP further stated if the provider was present in the facility, they spoke with them and if not, the facility wound nurse relayed the message/recommendations to the provider. NP stated they saw Resident #112 again on 9/04/23 and did not see the orders for their previous lab recommendations in the clinical record and recommended the orders again. NP stated upon assessment on 9/04/23, the area looked about the same as last week and they were still concerned because the area around the tissue was red. On 9/05/23 at 3:40 PM, the surveyor met with the administrator and director of nursing (DON) and discussed the concern of being unable to locate evidence of the resident receiving Cephalexin for cellulitis or the 8/28/23 wound specialist NP lab recommendations being addressed by the provider. Surveyor attempted to contact the medical director without success on 9/05/23 at 4:42 PM and 9/06/23 at 9:04 AM. Surveyor spoke with the DON on 9/06/23 at 9:06 AM and requested assistance in contacting the medical director, the DON stated they were unavailable today. On 9/06/23 at 9:25 AM, surveyor spoke with the Unit Manager (UM) who stated they spoke with the medical director yesterday and they approved the wound NP's lab recommendations but not the culture as there was no drainage to culture. On 9/06/23 at 10:48 AM, surveyor spoke with the DON who stated they believed the antibiotic was a recommendation from the wound NP and the facility nurse addressed it with the physician but failed to enter the actual order. The DON clarified that the physician initially ordered the antibiotic but when they spoke to the physician yesterday, they wanted to wait for the lab results to return before reordering the antibiotic at that time. On 9/06/23 at 10:55 AM, the surveyor and DON observed the area to Resident #112's left lower leg. The area appeared dry with no drainage present with a dry white center surrounded by multiple dark scabbed-like areas. Redness was present to the surrounding skin tissue. The DON felt the areas of redness and stated there was no increased warmth present when compared to the right lower leg. On 9/06/23 at 12:17 PM, surveyor spoke with licensed practical nurse (LPN) #4 who rounded with the wound specialist NP on 8/28/23 regarding the lab and wound culture recommendations. LPN #4 stated they were new in the position and thought the providers received a copy of the wound NP report and entered the orders themselves. On 9/06/23 at 5:30 PM, the survey team met with the facility management team including the administrator and DON and discussed the concern of Resident #112 not receiving an antibiotic as ordered and staff failing to address the wound NP's recommendations. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/07/23. 2. For Resident #114, the facility staff failed to follow-up with the nephrologist/urologist following an appointment in which the resident returned to the facility without the date of the next scheduled appointment resulting in a missed appointment. Resident #114's diagnosis list indicated diagnoses, which included, but not limited to Chronic Kidney Disease Stage 3B, Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis following Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Pseudobulbar Affect, and Polyneuropathy. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 6/13/23 assigned the resident a Brief Interview for Mental Status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. On 8/30/23 at 11:00 AM, surveyor met with the local ombudsman who stated Resident #114 returned from a nephrology/urology appointment with papers and an appointment card attached for a follow-up appointment which was given to a staff member, but the facility never scheduled transport for the appointment and the resident missed the appointment. On 8/30/23 at 4:04 PM, surveyor spoke with Resident #114 who stated they were worried about their kidneys. The resident stated they returned from a nephrology/urology appointment and gave the papers with an appointment card stapled to the front to (name omitted) but transport was not scheduled, and they missed the appointment, and the appointment could not be rescheduled until late September. Resident #114's current physician's orders included an order dated 4/04/23 for a nephrology consult. The resident's clinical record included a nursing progress note dated 5/18/23 5:51 PM which read in part Resident had an outside appt [appointment] at [name omitted] Nephrology .Several recommendations made by [name omitted] Nephrology, stop Amlodipine, consider lowering Lasix, start Losartan 25 mg daily, avoid NSAIDS [nonsteroidal anti-inflammatory drugs], IV contrast, renal panel after one month on Losartan and another renal panel one week before next visit (next visit not on consultation form . An 8/21/23 1:12 PM nursing progress note stated Resident and Family stated Resident has an Apt [appointment] with [name omitted] Urology today. Facility un-aware of apt at this time. Writer called [name omitted] Urology to verify apt. Resident does have an appointment schedule [sic] for today (8/21/23) at 1:45pm. Writer called and Rescheduled [sic] apt for (9/28/23) at 3:15pm D/t [due to] transportation hasn't been scheduled D/t facility not aware of apt. RP [responsible party] [name omitted] aware and apt time and date given to Transportation scheduler for transportation to be setup for apt on 9/28/23 at 3:15pm. On 9/05/23 at 5:07 PM, surveyor requested to speak with the writer of the 5/18/23 5:51 PM nursing note, however, they were off and unavailable. On 9/06/23 at 9:31 AM, surveyor spoke with the Unit Manager (UM) regarding Resident #114's missed nephrology/urology appointment and asked what their expectation was for the nurse present when the resident returned from the consult with no date for the follow-up appointment despite orders for labs one week prior to the next appointment. The UM stated the nurse on 5/18/23 should have called the office and asked about the follow-up appointment or passed it along in report for someone else to find out, UM stated they had no clue why the nurse did not do this. The UM further stated that no one had notified them of the resident returning from the appointment with no follow-up appointment date. Surveyor reviewed Resident #114's clinical record and was unable to locate documentation from the resident's 5/18/23 nephrology/urology appointment. On 9/06/23 at 5:30 PM, the survey team met with the facility management team including the administrator and director of nursing and discussed the concern of staff failing to contact the physician's office to inquire about the date of the follow-up appointment resulting in Resident #114 missing a nephrology/urology appointment. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/07/23.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure medical provider orders were obtained/provided to address the urinary catheter needs of 1 of 35 current residents in the survey sample, Resident #145. The findings included: For Resident #145, the facility staff failed to obtain provider orders for an indwelling urinary catheter present on readmission. Resident #145's diagnosis list indicated diagnoses, which included, but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, Dementia, Adult Failure to Thrive, and Unstageable Pressure Ulcer of the Right Buttocks. The most recent significant change minimum data set (MDS) with an assessment reference date (ARD) of 8/23/23 coded the resident as rarely/never understood and rarely never understanding others with short-term and long-term memory loss. Resident #145 was coded for the presence of an indwelling catheter. On 8/29/23 at approximately 3:15 PM, surveyor observed Resident #145 with an indwelling urinary catheter in place. Following the observation on 8/29/23, surveyor reviewed Resident #145's clinical record and was unable to locate a provider order for the indwelling urinary catheter or documentation of urinary catheter care. Resident #145's clinical record included an Admission/Readmission Nursing Collection Tool dated 8/20/23 documenting the resident was admitted to the facility on [DATE] with an indwelling catheter for prevention of contamination of a wound. On 9/05/23 at 1:05 PM, surveyor spoke with the Unit Manager (UM) who stated while in Resident #145's room, they noticed the resident had a catheter but there was no order. The UM stated at that time they obtained a provider order for the catheter. The UM stated staff did not obtain an order for the catheter when the resident was readmitted from the hospital. Surveyor asked if catheter care was being provided prior to the order being obtained and the UM stated the catheter did not look dirty but there was no order for catheter care. Resident had been at the facility for 11 days without orders for the indwelling catheter and catheter care. On 9/05/23 after speaking with the UM, the surveyor again reviewed Resident #145's clinical record and noted provider orders each dated 8/31/23 for a foley catheter and foley care every shift. Surveyor requested and received the facility policy entitled, Physician's Orders with an effective date of 3/24/20 which read in part . Admission orders should include .Foley catheter order if applicable. Size of foley/bulb and care instructions . On 9/05/23 at 5:45 PM, the survey team met with the facility management team including the administrator and Director of Nursing and discussed the concern of facility staff failing to ensure Resident #145 had provider orders in place for an indwelling urinary catheter and orders for the care of the catheter. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/07/23.

Based on staff interview and clinical record review, facility staff failed to ensure that a resident diagnosed with dementia received the appropriate treatment and services by monitoring targeted behaviors associated with the use of an antipsychotic medication for 1 of 21 residents in the survey sample, Resident #75. The findings were: The facility staff failed to monitor behaviors for Resident #75 who had a dementia diagnosis. Resident #75's facesheet listed diagnoses which included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, epilepsy, stage 4 sacral pressure ulcer, dementia, adult failure to thrive, and bipolar disorder. The resident's minimum data set with an assessment reference date of 07/30/23 coded the resident's brief interview for mental status a 99 which indicated the resident was unable to complete the interview. The resident was coded to have both short and long-term memory problems and severely impaired cognitive skills for daily decision making. A provider order for Behaviors - monitor for the following: (specify) itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression [sic], refusing care was ordered on 01/12/23. Monitoring for behaviors was not noted on the resident's medication administration review (MAR), treatment administration review (TAR) or elsewhere within Resident #75's clinical record. On 09/06/23 at 1:20 p.m., the director of nursing (DON) acknowledged there was no evidence of behavior monitoring found for Resident #75. The DON reported her expectation was that behaviors monitoring would be evident in the MAR and signed off every shift as ordered. The policy titled, Behavioral Assessment/Behavior Monitor policy number 401 with an effective date of 03/28/23 read in part, Policy: Behaviors will be assessed and monitored. Factors influencing behaviors as well as management interventions will be evaluated and care planned. Procedure: 6. A licensed nurse will document targeted behaviors, side effects, and interventions in the clinical record. On 09/06/23 at 05:26 p.m. during a summary meeting with the assistant administrator, administrator, regional nurse consultant, and DON, the concern regarding there being no evidence of behavior monitoring for Resident #75 was discussed. No further information was provided prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the attending physician reviewed the pharmacists recommendations for 3 of 35 current sampled residents, Resident #57, 75, and 128. The findings include: For resident #57, the facility staff failed to ensure the physician reviewed the pharmacists recommendations for the months of May 2023 and July 2023. #57's diagnoses included but was not limited to the following; dementia, anxiety, major depressive disorder, post traumatic stress disorder, bipolar disorder and hypertension. The most recent minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/26/23, assigned resident #57 a brief interview for mental status (BIMS) score of 3, indicating severe cognitive impairment. The clinical record for resident #57 was reviewed 9/6/23. There was a Consultant Pharmacist Medication Regimen Review dated 5/31/23 that read in part, See report for any noted irregularities and/or recommendations. The surveyor was unable to locate the report in the clinical record. A Consultant Pharmacist Medication Regimen Review dated July 26, 2023 read in part, See report for any noted irregularities and/or recommendations. The surveyor was unable to locate the report in the clinical record. On 9/6/23 during an end of day meeting with the Director of Nursing (DON), Administrator, and Regional Director of Clinical Services, the surveyor asked for documentation that the physician had seen and addressed the pharmacist reports for May and July. The DON stated that they could print off the reports for the surveyor to review but they had not been addressed by the physician. On 9/7/23 the DON provided two documents entitled, Consultant Pharmacist Recommendation to Physician the first was dated 5/31/23. The document had no physician response or signature. The pharmacist recommendation was for a gradual dose reduction (GDR) of resident #57's antipsychotic medication. The second document was dated 7/26/23 and had no physician response or signature. The recommendation was for a GDR of the same antipsychotic medication. The DON confirmed that the physician had not seen the recommendations. They stated they had been in the position of DON two weeks and was not able to speak to the process that was in place in May and July of this year. The surveyor was provided with a Pharmacy policy entitled, Medication Regimen Review with an effective date of 8/2020. The policy read in part, 6. Resident specific irregularities and/or clinically significant risks resulting from or associated with medication are documented in the resident's active record and reported to the Director of Nursing, Medical Director, and/or prescriber as appropriate and, 7. Recommendations are acted upon and documented by the facility staff and/or the prescriber. The survey team met with the Administrator, DON and Regional Director of Clinical Services 9/7/23 at 1:45 PM and this concern was reviewed with them. No further information was presented to the survey team prior to the exit conference. 28169 2. The facility staff failed to ensure Resident #75's Medication Regimen Reviews (MRRs) were addressed by a medical provider for two of six months reviewed, April and June 2023. Resident #75's facesheet listed diagnoses which included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, epilepsy, stage 4 sacral pressure ulcer, dementia, adult failure to thrive, and bipolar disorder. The resident's minimum data set with an assessment reference date of 07/30/23 coded the resident's brief interview for mental status a 99 which indicated the resident was unable to complete the interview. The resident was coded to have both short and long-term memory problems and severely impaired cognitive skills for daily decision making. Resident #75's clinical documentation included a pharmacy review for 04/22/23 and 06/30/23 which both read to see the pharmacist's review for recommendations. On 09/06/23, the director of nursing (DON) provided a copy of the pharmacy recommendations for both review dates. The DON acknowledged the documents were not signed by the previous DON or the provider; no one's signature was present. The DON acknowledged the pharmacist's recommendations were not addressed (either accepted or declined) and reported having spoken to the psych nursing practitioner (NP) on 09/06/23 who stated she did not want to accept the gradual dose reduction (GDR) recommendation for either review. The practitioner told the DON the system the practitioner works within prompts its own GDRs therefore, the practitioner does not rely solely on the facility's pharmacy recommendation for GDRs. A pharmacy policy titled, Medication Regimen Review policy number 11.1 with an effective date of 08-2020, was reviewed and read in part, 7. Recommendations are acted upon and documented by the facility staff and/or the prescriber. a. The prescriber accepts and acts upon recommendation or rejects [sic] provides an explanation for disagreeing. On 09/06/23 at 05:26 p.m. during a summary meeting with the assistant administrator, administrator, regional nurse consultant, and DON, the concern regarding there being no evidence a provider reviewed the pharmacist's recommendations was discussed. No further information was provided prior to the exit conference. 42353 3. For Resident #128, the facility staff failed to provide evidence of the 5/23/23 and 7/26/23 medication regimen reviews being reported to and acted upon by the medical provider. Resident #128's diagnosis list indicated diagnoses, which included, but not limited to Rheumatoid Arthritis, Essential Hypertension, Major Depressive Disorder, Atrial Fibrillation, and History of Falling. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/17/23 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating Resident #128 was cognitively intact. Resident #128's clinical record included Consult Pharmacist Medication Regimen Reviews dated 5/23/23 and 7/26/23, each review was checked by the statement See report for any noted irregularities and/or recommendations. Upon review of Resident #128's clinical record on 9/01/23, surveyor was unable to locate the 5/23/23 and 7/26/23 medication regimen review reports completed by the pharmacist. On 9/01/23, surveyor spoke with the director of nursing (DON) and requested the 5/23/23 and 7/26/23 medication regimen review reports for Resident #128. On 9/06/23 at 10:44 AM, the DON provided copies of the 5/22/23 and 7/26/23 medication regimen review reports, the reports had not been addressed or signed by the provider. The DON verified there was no evidence of the medication regimen reviews being reviewed and addressed by the provider. The 5/22/23 Medication Regimen Review report recommended a diagnosis clarification for the use of the medication Amiodarone, a diagnosis for the medication Linzess, and a stop date for the antibiotic medication, Macrobid. The 7/26/23 Medication Regimen Review report read in part Resident currently has an order for: - Metoprolol succinate 25 mg: 1/2 T [tablet] PO [by mouth] BID [twice a day] for hypertension. Metoprolol is available in two different formulations, tartrate and succinate. Metoprolol tartrate is typically dosed every 12 hours. Metoprolol succinate is typically dosed every 24 hours. Can you please clarify which formulation this resident should be taking . Surveyor requested and received the facility policy entitled, Medication Regimen Review which read in part .Resident-specific irregularities and/or clinically significant risks resulting from or associated with medication are documented in the resident's active record and reported to the Director of Nursing, Medical Director, and/or prescriber as appropriate .Recommendations are acted upon and documented by the facility staff and/or the prescriber . On 9/06/23 at 5:30 PM, the survey team met with the facility management team including the administrator and DON and discussed the concern of Resident #128's medication regimen review reports not being reviewed and addressed by the provider. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/07/23.

Based on interviews, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure 1 of 6 sampled residents were promptly provided treatment to address a medical issue (Resident #6). There was a delay in Resident #6 receiving treatment for pneumonia. The findings include: Resident #6's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 3/23/21, was dated as completed on 3/30/21. Resident #6 was assessed as able to make self understood and as able to understand others. Resident #6's Brief Interview for Mental Status (BIMS) summary score was documented as a 7 out of 15, this indicated severe cognitive impairment. Resident #6 was documented as requiring assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #6's diagnoses included, but were not limited to: anemia, high blood pressure, kidney disease, diabetes, dementia, and seizure disorder. Resident #6's clinical record included chest x-ray results, with a reported date of 3/19/21 at 8:30 p.m., with the impression documented as Moderate scattered pneumonias in the lungs. No evidence of medical provider notification of these results were found in the resident's clinical documentation. No documented evidence of responsible party (RP) notification of the pneumonia was found until 3/27/21, when medications were ordered to address the pneumonia. The following information was found in a facility policy/procedure titled Significant Change of Condition (with an effective date of 11/1/19): - All staff members shall communicate any information about patient status change to appropriate licensed personnel immediately upon observation. - Notification of physician, time, and date (month, day and year) are to be documented in the Progress Notes. A licensed nurse must communicate directly to provider; you may not leave a message with an answering service or receptionist. Physician must respond back. - Notification of responsible party shall be documented in the Progress Notes including time and name of person informed. The following information was found in a facility policy/procedure titled Laboratory/Diagnostic Testing (with an effective date of 11/1/19): - A licensed nurse will monitor and track all physician or physician extender ordered laboratory, radiology, and other diagnostic tests; ensure that tests are complete [sic] as ordered and communicate results to the physician in a timely manner. - The physician or extender will be notified of the results as soon as possible by a licensed nurse of any results that fall outside of clinical reference range. - Once the physician or extender has been notified, the licensed nurses will document the date of notification, the method of notification as well as any other necessary information related to the lab, radiology, or other diagnostic testing results in the patient's medical record. Copies of results are placed in the patient's clinical record. Staff Member (SM) #6 (a nurse practitioner) was interviewed on 6/8/22 at 12:19 a.m. SM #6 was asked about medical provider notification of Resident #6's aforementioned chest x-ray results. After reviewing Resident #6's clinical documentation, SM #6 reported they could not find evidence of a medical provider being notified of the abnormal chest x-ray results. SM #6 stated facility staff should have called the on-call medical provider with the chest x-ray results. SM #6 reported they documented reviewing the chest x-ray results on 3/22/21 at 12:41 p.m. A medical provider progress note for Resident #6's, with a date of service (DOS) of 3/22/21, was obtained by the facility staff from the contracted medical provider group. This note indicated nursing staff reported the resident was coughing while eating. The respiratory assessment was documented as No upper respiratory infections, dyspnea, or wheezing. Resident #6 was documented as having a cough. The DIAGNOSIS AND ASSESSMENT section of this progress note indicated the resident had pneumonia. The plan for addressing the pneumonia included intravenous Rocephin and oral Zithromax and oral lactobacillus. (Rocephin and Zithromax are antibiotics; lactobacillus is a probiotic used to prevent diarrhea with antibiotic treatment.) Review of Resident #6's clinical record indicated the treatment for pneumonia was ordered on 3/27/21 to be started on 3/28/21. Resident #6's medication administration records (MARs) included documentation to indicate the Rocephin, Zithromax, and lactobacillus were started on 3/28/21. On 6/9/22 at 9:37 a.m., a survey team meeting was conducted with the facility's Administrator, Assistant Administrator, DON and Corporate Nurse Consultant. The delay in providing treatment for Resident #6's diagnosis of pneumonia was discussed for a final time. This is a complaint deficiency.

Based on interviews, clinical record review, facility document reviews, and in the course of a complaint investigation, the facility staff failed to maintain a complete and/or accurate clinical record for 1 of 6 sampled residents (Resident #6). The findings include: Resident #6's clinical record failed to include all the medical provider documentation. Resident #6's clinical record failed to include documents used for communication between facility nursing staff and medical providers. Resident #6's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 3/23/21, was dated as completed on 3/30/21. Resident #6 was assessed as able to make self understood and as able to understand others. Resident #6's Brief Interview for Mental Status (BIMS) summary score was documented as a 7 out of 15; this indicated severe cognitive impairment. Resident #6 was documented as requiring assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #6's diagnoses included, but were not limited to: anemia, high blood pressure, kidney disease, diabetes, dementia, and seizure disorder. h Staff Member (SM) #7 (a medical record staff member) was interviewed, on 6/8/22 at 12:54, about Resident #6's medical provider documentation. SM #7 confirmed Resident #6's clinical record, kept by the facility, did not include documentation of medical provider visits occurring on 3/22/21, 3/24/21, and 3/29/21. SM #7 was able to obtain the documentation from the medical provider group, with which the facility had a contract. A fourth medical provider document dated 3/19/21 was missing from Resident #6's medical record kept by the facility; SM #7 was able to obtain this document from the contracted medical provider group. On 6/8/22 at 12:19, Staff Member (SM) #6 was interviewed about Resident #6's documentation. SM #6 reported that communication does not always occur verbally between nursing staff and medical providers. SM #6 reported that at times facility nursing staff will enter information on to an Acute Concern Log form. On the morning of 6/9/22, SM #6 reported, after addressing concerns written on the Acute Concern Log form, they would dispose of the form. SM #6 confirmed the Acute Concern Log forms were not saved. On 6/8/22 at 12:19, SM #6 was interviewed about Resident #6's medical provider orders. SM #6 reported they did not enter orders into the facility's electronic system. SM #6 stated they would write the orders on the 'MD Communication Form,' place the form in a notebook at the nurse's desk, and the facility nursing staff would then enter the orders into the facility's electronic system. Resident #6's clinical records failed to include the 'MD Communication Forms' used to communicate orders to the facility's nursing staff. The following information was found in a facility policy/procedure titled Significant Change of Condition (with an effective date of 11/1/19): - All staff members shall communicate any information about patient status change to appropriate licensed personnel immediately upon observation. - Notification of physician, time, and date (month, day and year) are to be documented in the Progress Notes. A licensed nurse must communicate directly to provider; you may not leave a message with an answering service or receptionist. Physician must respond back. - Notification of responsible party shall be documented in the Progress Notes including time and name of person informed. On 6/8/22 at 3:00 p.m., a survey team meeting was held with the facility's Administrator, Assistant Administrator, Director of Nursing (DON), and Corporate Nurse Consultant (CNC). The failure of the facility staff to ensure Resident #6's clinical documentation included all medical provider progress notes, Acute Concern Log forms, and MD Communication Forms was discussed. It was reported the 'Acute Concern Log' and 'MD Communication Form' would not be maintained in residents' clinical records. It was reported these forms were used as communication tools between medical providers and nursing staff. The Administrator reported that multiple resident names were included on a single page of these forms therefore they could not become part of the residents' clinical records. Facility policies and procedure guiding the use of the 'Acute Concern Log' form and 'MD Communication Form' were requested; the CNC reported the facility did not have policies and procedures to guide the use of the two (2) aforementioned forms.

Based on interviews, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to promptly notify a medical provider and/or the responsible party of a need to alter the resident's treatment for 1 of 6 sampled residents (Resident #6). The facility staff failed to promptly notify a medical provider and/or the responsible party (RP) of Resident #6's chest x-ray results indicating the resident had pneumonia. The findings include: Resident #6's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 3/23/21, was dated as completed on 3/30/21. Resident #6 was assessed as able to make themselves understood and as able to understand others. Resident #6's Brief Interview for Mental Status (BIMS) summary score was documented as a 7 out of 15, this indicated severe cognitive impairment. Resident #6 was documented as requiring assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #6's diagnoses included, but were not limited to: anemia, high blood pressure, kidney disease, diabetes, dementia, and seizure disorder. Resident #6's clinical record included chest x-ray results, with a reported date of 3/19/21 at 8:30 p.m., with the impression documented as Moderate scattered pneumonias in the lungs. No evidence of medical provider notification of these results were found in the resident's clinical documentation. No documented evidence of responsible party (RP) notification of the pneumonia was found until 3/27/21, when medications were ordered to address the pneumonia. The following information was found in a facility policy/procedure titled Significant Change of Condition (with an effective date of 11/1/19): - All staff members shall communicate any information about patient status change to appropriate licensed personnel immediately upon observation. - Notification of physician, time, and date (month, day and year) are to be documented in the Progress Notes. A licensed nurse must communicate directly to provider; you may not leave a message with an answering service or receptionist. Physician must respond back. - Notification of responsible party shall be documented in the Progress Notes including time and name of person informed. The following information was found in a facility policy/procedure titled Laboratory/Diagnostic Testing (with an effective date of 11/1/19): - A licensed nurse will monitor and track all physician or physician extender ordered laboratory, radiology, and other diagnostic tests; ensure that tests are complete [sic] as ordered and communicate results to the physician in a timely manner. - The physician or extender will be notified of the results as soon as possible by a licensed nurse of any results that fall outside of clinical reference range. - Once the physician or extender has been notified, the licensed nurses will document the date of notification, the method of notification as well as any other necessary information related to the lab, radiology, or other diagnostic testing results in the patient's medical record. Copies of results are placed in the patient's clinical record. Staff Member (SM) #6 (a nurse practitioner) was interviewed on 6/8/22 at 12:19 a.m. SM #6 was asked about medical provider notification of Resident #6's aforementioned chest x-ray results. After reviewing Resident #6's clinical documentation, SM #6 reported they could not find evidence of a medical provider being notified of the abnormal chest x-ray results. SM #6 stated facility staff should have called the on-call medical provider with the chest x-ray results. SM #6 reported they documented reviewing the chest x-ray results on 3/22/21 at 12:41 p.m. On 6/9/22 at 8:21 a.m., the Director of Nursing (DON) reported the aforementioned x-ray report should have been reviewed, by facility staff, the morning after the results were received. On 6/8/22 at 3:00 p.m., the facility's Administrator, Assistant Administrator, DON, and Corporate Nurse Consultant was interviewed about Resident #6's responsible party notification of the abnormal chest x-ray results. On 6/9/22 at 8:21 a.m., the Director of Nursing (DON) reported Resident #6's family was contacted when the medical provider had given orders, on 3/27/21, to address Resident #6's chest x-ray findings. On 6/9/22 at 9:37 a.m., a survey team meeting was conducted with the facility's Administrator, Assistant Administrator, DON and Corporate Nurse Consultant. The delay in notifying Resident #6's medical provider and RP of the resident's aforementioned abnormal chest x-ray report was discussed for a final time. This is a complaint deficiency.

Based on observations, interviews, and facility documentation review it was determined the facility staff failed to ensure their infection control plan was fully implemented in an effort to prevent the spread of COVID-19 on one of three units (North Unit). The findings were: The facility staffed failed to maintain an infection prevention and control program by not ensuring that all employees donned eye protection when entering a resident's room labeled as being on Enhanced Droplet-Contact precautions. The surveyor toured the facility making observations on all of the resident units. The director of nursing (DON) explained residents were admitted to their north unit and had either been tested for COVID-19 at the hospital prior to admission or if the resident was admitted from home, they were tested at the facility prior to admission. On 08/03/21 at approximately 2:40 p.m. an employee (CNA#1 - certified nursing assistant) wearing a face mask was observed donning a gown and gloves prior to entering room [ROOM NUMBER] on the north unit. A sign hanging on that door read Enhanced Droplet-Contact Precautions and listed seven instructions which included: 1. Perform hand hygiene 2. N-95 or surgical mask when entering room 3. Eye protection (goggles or face shield) when entering room 4. Gown when entering room 5. Gloves when entering room 6. Keep door closed 7. Remove PPE (personal protective equipment) and perform hand hygiene before exiting room. At 2:44 p.m. upon exiting the room, CNA#1 was interviewed about PPE requirements. The CNA reported their understanding was to don N-95 masks, a gown and gloves when entering a room with enhanced droplet-contact precaution and the eye goggles or face shield was only expected if the resident was actually COVID-19 positive. At approximately 2:50 p.m., the administrator, DON, and infection preventionist (IP) was informed of the PPE observation and CNA#1's interview. The DON stated the expectation was for staff to don PPE as listed on the door sign for Enhanced Droplet-Contact precautions to include eye protection. On 08/11/21 at 2:00 p.m. the facility's local epidemiologist was contacted by phone. The epidemiologist reported it was best practice to wear eye protection when N-95 masks were necessary. The facility's DON and IP were contacted by phone on 08/11/21 at 3:35 p.m. Both reported their expectation for PPE in an Enhanced Droplet-Contact Precaution room had not changed since the onsite focused infection control survey. The IP reported there were currently no COVID-19 positive residents or staff at the facility. Policy #2202 titled, COVID-19 read in part, Procedure: 5. New Admissions/Readmissions/Return to Center from outside visits (including hemodialysis patients): · Unvaccinated new admissions will be cared for using recommended personal protective equipment and placed on Enhanced Droplet-Contact Precautions. Monitor for signs and symptoms of COVID-19 every day for fourteen (14) days. If no symptoms appear, the patient may be moved out of this designated area and precautions discontinued on day fifteen (15). No further information was provided prior to the exit conference via phone with the administrator and DON on 8/12/21 at 2:10 p.m.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to consistently document in the resident's clinical records that COVID-19 testing was offered, completed (as appropriate to the resident's testing status), and the results of each test for 26 residents. The findings included: The facility staff failed to consistently document that COVID-19 testing was offered to the residents of the facility and failed to document the results of each test in the resident's clinical records. During the record reviews, the survey team were unable to locate results of COVID-19 tests for negative residents. On 03/11/2021 at 1:45 p.m., the administrator, (DON) director of nursing, and (RNC) regional nurse consultant were interviewed regarding the missing COVID-19 testing results. The DON stated they printed off the facility census, identified if anyone was positive and that was marked on the census. They did not mark the negative test results on this census and only documented in the clinical record if the resident was positive. The DON stated they charted by exception. The facility provided the survey team with a copy of their policy titled, Documentation Summary with an effective date of 11/01/2019. This policy read in part, Licensed Nurses .will document all pertinent nursing assessments, care interventions .Document all of the facts and pertinent information related to an event, course of treatment, patient condition . No further information regarding the documentation of negative COVID-19 testing results in regards to the residents of the facility was provided to the survey team prior to the exit conference.

Based on interviews and the review of documents, it was determined the facility staff failed to follow medical provider orders for treatment and/or care for two (2) of 28 sampled residents (Resident #65 and Resident #83). The findings include: 1. The facility staff failed to ensure Resident #83's blood glucose levels were monitored according to medical provider orders. Resident #83's minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/3/21 had the resident assessed as able to make self understood and as able to understand others. Resident #83's Brief Interview for Mental Status (BIMS) summary score was documented as 13 out of 15. Resident #83 was documented as requiring assistance with bed mobility, dressing, toilet use, personal hygiene, and eating. Resident #83 was assessed as having an indwelling urinary catheter. Resident #83's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #83's clinical record revealed an order dated 1/29/21 for the resident's blood glucose (finger stick blood sugar) to be checked daily before meals and at bedtime. Review of Resident #83's MARs (medication administration records) and TARs (treatment administration records) failed to provide evidence this order had been implemented. On 3/11/21 at 10:18 a.m., Licensed Practical Nurse (LPN) #21 was interviewed about Resident #83's aforementioned finger stick blood sugar order. LPN #21 confirmed the order had been entered into Resident #83's electronic clinical record. LPN #21 reported the order had been enter in a manner that resulted in the order not appearing on the Resident #83's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The following information was found in a facility policy and procedure titled Monitoring related to blood testing (with an effective date of 11/1/19): Licensed nurses will complete blood glucose monitoring as ordered by the physician or when emergency situations indicate the need . Blood glucose checks will be document on the eMAR (electronic MAR) . The failure of facility staff to ensure Resident #83's blood sugar levels were monitored as ordered by the medical provider was shared with the facility's Administrator, Director of Nursing, and Nursing Consultant during a survey team meeting on 3/11/21 at 4:45 p.m. 2. For Resident #65, facility staff failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #65's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS (minimum data set) with an ARD (assessment reference date) of 1/22/21 assigned the resident a BIMS (brief interview for mental status) score of 13 out of 15 in section C, Cognitive Patterns. Resident #65 is also coded as having an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #65's clinical record revealed an active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed Resident #65's January 2021 through March 2021 MARs (medication administration records) and TARs (treatment administration records) and was unable to locate blood sugar monitoring results obtained before meals or at bedtime. On 3/10/21 at approximately 7:50 am, surveyor spoke with the DON (director of nursing) and asked where were blood sugar results documented and the DON stated on the TARs. On 3/11/21 at 12:25 pm, surveyor spoke with LPN (licensed practical nurse) #1 and asked how often is Resident #65's blood sugar being checked and LPN #1 stated I check it once. LPN #1 then reviewed Resident #65's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 stated they would update the order so it will pop up. On 3/11/21 at 4:55 pm, surveyor notified the administrator, DON, and the Regional Nurse Consultant of Resident #65's blood sugars not being obtained as ordered. No further information regarding this issue was presented to the survey team prior to the exit conference on 3/11/21.

Based on observations, interviews, and the review of documents, it was determined the facility staff failed to develop a base-line care plan to address indwelling urinary catheter needs at the time of admission for one (1) of 28 sampled residents (Resident #83). The findings include: The facility staff failed to develop a base-line care plan, within 48 hours of the resident's admission, to address Resident #83's indwelling urinary catheter. Resident #83 was admitted to the facility with an indwelling urinary catheter in place. Resident #83's minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/3/21 had the resident assessed as able to make self understood and as able to understand others. Resident #83's Brief Interview for Mental Status (BIMS) summary score was documented as 13 out of 15. Resident #83 was documented as requiring assistance with bed mobility, dressing, toilet use, personal hygiene, and eating. Resident #83 was assessed as having an indwelling urinary catheter. Resident #83's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #83's clinical record included an Admission Assessment/Screening form that indicated the resident had an indwelling urinary catheter at the time of admission. Resident #83's care plan was reviewed with Licensed Practical Nurse (LPN) #21 on the morning of 3/11/21. LPN #21 confirmed Resident #83's indwelling urinary catheter care plan had not been developed until 10 days after the resident's admission. The facility policy and procedure titled Catheterizations (with an effective date of 11/1/19) did not provide guidance on the development of resident care plans related to the use of indwelling urinary catheters. The failure of facility staff to ensure Resident #83's base-line care plan addressed the resident's indwelling urinary catheter needs was shared with the facility's Administrator, Director of Nursing, and Nursing Consultant during a survey team meeting on 3/11/21 at 4:45 p.m.

Based on observations, interviews, and the review of documents, it was determined the facility staff failed to ensure medical provider orders were obtained/provided to address the urinary catheter needs of one (1) of 28 sampled residents (Resident #83). The findings include: Facility staff members failed to ensure Resident #83's clinical record included medical provider orders for an indwelling urinary catheter and medical provider orders for the care of an indwelling urinary catheter. Resident #83's minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/3/21 had the resident assessed as able to make self understood and as able to understand others. Resident #83's Brief Interview for Mental Status (BIMS) summary score was documented as 13 out of 15. Resident #83 was documented as requiring assistance with bed mobility, dressing, toilet use, personal hygiene, and eating. Resident #83 was assessed as having an indwelling urinary catheter. Resident #83's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/10/21 at 8:42 a.m., Resident #83 was noted to have an indwelling urinary catheter in use. Review of Resident #83's clinical record failed to reveal a provider order for the indwelling urinary catheter. Review of Resident #83's clinical record failed to reveal evidence of consistent indwelling urinary catheter care. Resident #83 had been at the facility for greater than four (4) weeks without the aforementioned orders. On 3/11/21 at 10:20 a.m., a Registered Nurse (RN) Unit Manager (RN #21) was interviewed about Resident #83's indwelling urinary catheter. RN #21 confirmed that Resident #83 did not have orders for an indwelling urinary catheter and did not have orders for indwelling urinary catheter care. Resident #83's care plan for indwelling urinary catheter for urinary retention included the intervention of Care as ordered and as needed. On 8/11/21 at 10:35 a.m., a Licensed Practical Nurse (LPN) (LPN #21) was observed to call Resident #83's medical provider and obtain orders for an indwelling urinary catheter and orders for indwelling urinary catheter care. The following orders for Resident #83, dated 3/11/21 at 10:52 a.m., were provided to the survey team: - Foley (catheter) (16F/10ml) (A 'foley' is an indwelling urinary catheter.) - Foley care (every) shift - Change Foley (catheter) (as needed) for clinical indications such as infection, obstruction, or when the closed system is compromised. The following information was found in a facility policy and procedure titled Catheterizations (with an effective date of 11/1/19): POLICY: Licensed nurses may perform indwelling, in and out catheterization, removal of urinary catheters and application of External Catheters with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A licensed nurse will ensure that appropriate medical justification is documented . 3. Licensed nurses will follow manufacturer's guidelines when preparing and maintaining urinary catheter insertion . The following information was found in a facility policy and procedure titled Documentation Summary (with an effective date of 11/1/19): Document all of the facts and pertinent information related to an event, course of treatment, patient condition, response to care, and deviations from standard treatment along with the reason for the deviation. The failure of facility staff to ensure Resident #83 had orders for an indwelling urinary catheter and orders for the care of an indwelling urinary catheter was shared with the facility's Administrator, Director of Nursing, and Nursing Consultant during a survey team meeting on 3/11/21 at 4:45 p.m.

Based on observation, Resident interview, staff interview and clinical record review the facility staff failed to provide ADL (activities of daily living) care for dependent residents for 2 of 28 residents, Resident #49 and Resident #144. The findings included: 1. For Resident #49 the facility staff failed to provide assistance with oral care. Resident #49's face sheet listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #49's admission MDS (minimum data set), with an ARD (assessment reference date) of 01/09/21 assigned the resident a BIMS (brief interview for mental status) score of 15 of 15 in section C, cognitive patterns. Section G, functional status, coded the resident as needing extensive assistance of one person physical assist in the area of personal hygiene. Personal hygiene is listed as combing hair, brushing teeth, shaving, applying make-up, and washing/drying face and hands. Resident #49's CCP (comprehensive care plan) was reviewed and contained a care plan for the resident has an ADL self-care performance deficit r/t (related to) activity intolerance, weakness, decreased balance/mobility/ ROM (range of motion) to bilateral upper extremities, pain, occasional incontinence, meds, dx (diagnosis) right scapula fx (fracture), multiple falls, hx (history) shoulder replacements. Interventions for this care plan included Personal hygiene/oral care: Assist with all hygiene needs. Surveyor spoke with Resident #49 on 03/09/21 at approximately 5:20 pm. Resident stated she hasn't had her teeth brushed in two weeks. Also stated that she discussed this with the nurse earlier today, but cannot recall which nurse. Also stated that she is unable to brush her own teeth due to having radial nerve damage in her left arm and right arm being injured from previous fall. Surveyor observed right arm wrapped in bandage and ace wrap, with significant [CONDITION(S)]. Surveyor spoke with Resident #49 on 03/10/21 at approximately 11:00 AM. Resident stated she had a shower this morning, but still has not had teeth brushed. Surveyor spoke with CNA (certified nurse's assistant) #1 on 03/10/21 at approximately 02:57 PM regarding Resident #49. Surveyor asked CNA #1 if they brush residents' teeth when providing resident care and CNA #1 stated sometimes. Surveyor asked CNA #1 specifically about Resident #49 and CNA #1 stated She can probably brush her own teeth since she has the one good hand. Surveyor asked CNA #1 if they ever asked Resident #49 if she needed help and CNA #1 stated no. Surveyor spoke with CNA #2 on 03/11/21 at approximately 09:40 AM. CNA #2 stated that if residents need help brushing their teeth, they do so, but try to let them do as much as possible for themselves. CNA #2 stated they provide oral care for residents daily. Surveyor asked CNA #2 if they worked with Resident #49 and CNA #2 stated that they did not. Surveyor spoke with UM (unit manager) on 03/11/21 at approximately 09:50 AM regarding residents oral care. UM stated that they would expect the CNA's to provide oral care for each resident they are providing daily grooming for. UM also stated that they had spoken with Resident #49 on 03/10/21 regarding her oral care, and they were trying to track down which CNA's have been working with the resident. On 03/11/21 at approximately 10:30 AM, Resident #49 stated her teeth have still not been brushed. Surveyor spoke with CNA #3 on 03/11/21 at approximately 10:40 AM. CNA #3 stated they have not brushed Resident #49's teeth. Surveyor asked CNA #3 if they had asked Resident #49 if she wanted her teeth brushed and they stated that they had not, and that Resident #49 normally tells you everything she wants done for her. On 03/11/21 at approximately 01:30 PM, Resident #49 stated her teeth have now been brushed. Resident also stated that CNA told her that if she wanted her teeth brushed she should have asked. Resident also stated to surveyor that she thought that was just part of personal hygiene and that she shouldn't have to ask. The concern of not assisting Resident #49 with oral hygiene was discussed with the administrative team (administrator, DON [director of nursing], and RNC [regional nurse consultant]) during a meeting on 03/11/21 at approximately 4:45 pm. No further information was provided prior to exit. 2. For Resident #144 the facility staff failed to provide nail care. Resident #144's face sheet listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #144's most recent annual MDS (minimum data set) with an ARD (assessment reference date) of 02/24/21 assigned the resident a BIMS (brief interview for mental status) of 3 out of 15 in section C, cognitive patterns. Section G, functional status coded the resident as needing extensive assistance of one person physical assist in the area of personal hygiene. Personal hygiene is listed as combing hair, brushing teeth, shaving, applying make-up, and washing/drying face and hands. Resident #144's CCP (comprehensive care plan) was reviewed and contained a care plan for the resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) Deconditioning, Gait/balance problems, kyphosis, poor safety awareness, incontinence, combative behaviors, cognitive/vision/communication impairments, meds DX (diagnosis): NSTEMI (non-ST segment elevation [CONDITION(S)] [type of heart attack]), dementia, [CONDITION(S)], DM (diabetes mellitus), [CONDITION(S)] (hypertension), [CONDITION(S)], depression, anxiety, [CONDITION(S)], hx (history); [CONDITION(S)] ([CONDITION(S)]). Interventions for this care plan include personal hygiene/oral care: Provide assist w (with)/oral care, nail care, personal hygiene & grooming needs. Surveyor observed Resident #144 on 0310/21 at approximately 11:08 am. Surveyor noted that residents fingernail were extremely long and ragged in appearance. Surveyor attempted to ask resident about fingernails, but due to cognitive impairment, resident was unable to answer surveyor's questions. Surveyor spoke with UM (unit manager) on 03/11/21 at approximately 9:50 am regarding nail care for residents. UM stated that CNA's (certified nurse's aide) are responsible for maintaining nail care. UM also stated, I'm supposed to do that as well. UM also stated that they check resident nails while making rounds. Surveyor asked UM specifically about Resident #144's nails, and UM stated they had checked Resident #144's nails last week. Surveyor asked UM if they knew that the resident's nails were extremely long, and UM stated, I'll take care of that right now. Surveyor observed Resident #144's nails on 03/11/21 at approximately 10:30 am, 1:30 pm, and 3:55 pm. Resident's nails had not been trimmed and were still long and ragged. The concern of facility staff not providing nail care for Resident #144 was discussed with the administrative team (administrator, DON [director of nursing], and RNC [regional nurse consultant]) during a meeting on 03/11/21 at approximately 4:45 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation. The facility staff failed to protect the personal privacy and confidentiality of the residents personal account information for 3 of 6 Residents, Residents #2, #5, and #6. The findings included: The facility staff sent a copy of checks that were made payable to the facility to the family member of Resident #3. These checks included the residents name, account number, bank account number, and the name of the banking institution. Resident #3's clinical record included the diagnoses dementia, chronic pain, chronic kidney disease, and depressive disorder. Section C (cognitive patterns) of the residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/28/2019 included a BIMS (brief interview for mental status) summary score of 9 out of a possible 15 points. The residents comprehensive care plan included the focus area alteration of prior leisure activities and at risk for falls. On 01/05/2021 at 11:55 a.m., the administrator verbalized to the surveyor that copies of three checks were sent out by mistake that they had got caught up in the billing cycle and attached to Resident #3's statement. The administrator stated the appropriate parties were notified and provided the surveyor with copies of these three checks. Check #1 included Resident #2's name, bank account number, and bank name. Check #2 included Resident #5's name and account number written on the left hand bottom of the check. Check #3 included Resident #6's name, bank account number, and bank name. On 01/05/2021 at 12:30 p.m., the surveyor interviewed the BOM (business office manager). The BOM verbalized to the surveyor that the receptionist accidentally picked up the copies and placed them with other paperwork. The administrator stated it was a clerical error. On 01/06/2021 at 9:03 a.m., the DON (director of nursing) identified this staff person as CNA (certified nursing assistant) #4 and stated this staff was no longer in a clerical role. The facility provided the surveyor with a copy of an EMPLOYEE CORRECTIVE ACTION. This document was identified as a first written warning. This document read in part, Received notification on 4-22-019 from _____ POA (power of attorney) for Resident #3 that a copy of three resident checks (________________) had been included in the monthly invoice sent to her for Resident #3's March 2019. Failure to maintain confidentiality of confidential information of patients. Describe the impact the infraction had on the patient, customer, or business: Release of confidential and/or protected information impacts our residents, family members and employees confidence in the facility's ability to maintain their personal information securely. In addition this is a HIPAA violation. This document had been signed by CNA #4 and the BOM on 04/24/2019. On 01/06/2021 at 9:10 a.m., during an interview with the BOM the BOM verbalized to the surveyor that no resident information was given and it was simply a clerical error. On 01/06/2021 at 9:15 a.m., the surveyor spoke with CNA #4 via phone. CNA #4 stated they she remembered the incident briefly and that it had been so long ago. CNA #4 stated they had everything laid out on the desk and the papers had gotten stuck together. On 01/11/2021 at 8:35 a.m., the surveyor called the facility, attempted to speak with the BOM, and was told by the receptionist and the administrator that they were not working today. The administrator was notified that the copies of checks provided to the surveyor did contain confidential information in regards to resident names, account numbers, and names of banking institutions. The administrator verbalized to the surveyor that they had sent out HIPAA forms to all the families involved. No further information was provided to the surveyor at that time. This is a complaint deficiency.

Based on observation, staff interviews, interviews with local health department staff, review of facility documents, and clinical record reviews, the facility staff failed to maintain an infection prevention program for preventing and controlling infection and communicable diseases during an identified outbreak of COVID-19 for 2 of 12 residents in the survey sample (Resident #1 and Resident #4). Facility staff failed to follow facility policy and procedure; CMS (Centers for Medicare and Medicaid) and CDC (Centers for Disease Control and Prevention) guidance related to cohorting COVID-19 positive and negative residents together when vacant rooms were available creating the likelihood of residents being exposed to and contracting COVID-19 for Residents #1 and #4. Facility staff failed to maintain droplet precautions and ensure social distancing between a COVID-19 positive and negative resident residing in the same room increasing the likelihood of Resident #1 being exposed to and contracting COVID -19. At the time of the survey, there was a cumulative total of 71 COVID-19 positive residents with 14 deaths. Surveyors informed the administrator, assistant director of nursing, and the regional nurse consultant on 9/21/20 at 6:40pm of the Immediate Jeopardy situation. The scope and severity was originally cited at Level IV, Isolated. On 9/22/20 at 4:48pm, the Immediate Jeopardy was abated and lowered to a Level II, Isolated. The findings included: On 9/16/20 at 10:00am, a telephone interview was conducted with the facility IP (Infection Preventionist) and the IP trainee. IP stated that the local health department was in the facility yesterday and directed facility to transition COVID-19 positive residents that are 20 plus days past their COVID-19 positive test and asymptomatic be moved from West Unit to South Unit and any COVID-19 positive residents residing on South be moved to West. IP stated the room moves are starting today. The surveyor asked if there were any COVID-19 positive and negative residents in a room together and the IP stated no. On 9/17/20, a remote review of the facility's line listing for COVID-19 and Resident Daily Census report revealed there were four separate resident rooms in which a COVID-19 positive resident resided with a COVID-19 negative resident. Residents #1, #2, #3, #4, #5, #6, #7, and #8. On 9/17/20 at 11:45am surveyor interviewed the district epidemiologist with the local health district and asked if they were aware of the four rooms in the facility with a COVID-19 positive and negative resident residing together. Epidemiologist stated they were unaware but either way the negative resident has been exposed and may be in their pre-symptomatic infectious window and cohorting would be acceptable if there were nowhere else to move them. On 9/17/20 at 1:30pm, surveyor interviewed the ADON (assistant director of nursing) by phone and asked about the four resident rooms with a COVID-19 positive and negative resident residing together. The ADON stated they received guidance from the health department initially that when someone becomes positive, they leave the roommate in the room. ADON stated they talked to the epidemiologist today and have developed a plan, the negative roommates will be tested today and again in 24 hours and after two negative PCR tests are received, the residents will be moved to South (Warm Unit) and South will be a warm unit. ADON stated all COVID-19 positive residents have been moved to West (COVID unit) and they are in the process of moving recovered residents from West to South (warm unit). ADON stated one of the negative roommates is showing symptoms today. On 9/18/20 at 2:08pm, surveyor spoke with the administrator, ADON, and RNC (regional nurse consultant) by phone and discussed concern of cohorting COVID-19 positive residents and negative residents in the same room. Surveyor requested the CMS and/or CDC guidance used by the facility for cohorting COVID-19 positive and negative residents. The regional nurse consultant stated the health department's direction was to keep residents where they were up until now, the epidemiologist will document this, and facility will provide to the surveyor. On 9/19/20 at 12:19pm, surveyor received an email from the epidemiologist stating in part, There is no official guidance stating a negative individual should ever be cohorted with a positive case. With regards to the (name omitted) facility we recently discussed, there were four non-ill individuals (that you were kind enough to bring to my attention 09/17) in the same rooms as other positive cases on the Western unit of the facility. As these four individuals are considered exposed and potential carriers of COVID, I advised they remain where they were until such time that quarantine measures could be made available on Southern unit, and then be moved to quarantine and be tested with the facility's rapid [MEDICATION NAME] test available to them via the new CMS testing requirements as a screening precaution. As rapid [MEDICATION NAME] tests are not as reliable as molecular PCR tests, I advised the facility to pursue two negative tests back-to-back in addition to the 14-day quarantine. Two of these individuals have since tested positive and the other two are under a 14-day quarantine on South Ward with negative results. On 9/21/20 at approximately 1:20pm, the onsite surveyor and the remote surveyor present via phone met with the administrator, ADON, and the RNC and was informed that Resident #7 (COVID-19 positive) has been assessed as recovered from COVID-19 and moved to the South (warm) unit and Resident #8 (COVID-19 negative) was also moved to the South (warm) unit and both residents are residing in the same room. Resident #6 (COVID-19 negative) was moved from the room shared with Resident #5 (COVID positive) to the South (warm) Unit and placed in a room alone on enhanced droplet precautions. The ADON stated Resident #1 (COVID negative) was not moved due to nausea and projectile vomiting and was now considered symptomatic. ADON stated that Resident #4 is also symptomatic with a temperature and was not moved. ADON stated the NP (nurse practitioner) has seen Resident #1 and Resident #4 but was not sure it is documented. Surveyor asked if there were any rooms available on South and was informed that yes there were rooms available. During the meeting, the administrator asked the surveyors what regulation in the big red book was in question. Surveyors explained they were conducting a focused infection control survey. On 9/21/20 at approximately 1:40pm, the surveyor, accompanied by the RNC, observed Resident #3, who tested positive for COVID-19 on 9/11/20, in bed with the privacy curtain fully pulled separating them from their COVID-19 negative roommate, Resident #4. Resident #4 was sitting in a wheelchair on the other side of the room next to the window. The door was closed and there was a sign on the door for Enhanced Droplet Precautions with a PPE caddy at the door. Resident #3 was tested for COVID-19 on 9/11/20 at 12:00pm and the positive result was called to the administrator on 9/12/20 at 8:41am by the lab. Resident #4 was tested for COVID-19 on 9/14/20 at 11:02am with the final negative result reported on 9/16/20 at 8:01am. The facility reported a rapid point of care COVID-19 test was obtained on 9/18/20 with negative results. Facility also reported additional COVID-19 test was obtained on 9/18/20 and the results were pending at the time of the observation. Resident #4's [DIAGNOSES REDACTED]. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 8/26/20 assigned the Resident #4 a BIMS (brief interview for mental status) score of 11 out of 15 in section C, Cognitive Patterns. Resident #4 was also coded as requiring limited assistance for transfers, dressing, and toilet use and supervision only for bed mobility and personal hygiene. On 9/21/20 at approximately 1:45pm, the surveyor, accompanied by the RNC, observed Resident #1, who is COVID-19 negative, standing at the foot of Resident #2's bed, who tested positive for COVID-19 on 9/14/20, going through and touching the personal belongings of Resident #2. At the time, Resident #2 was sitting in a wheelchair positioned at the middle of the right side of the bed, approximately 3 feet from Resident #1, also touching the belongings. Neither resident was wearing a face covering. Resident #1 and Resident #2 reside in the same room. Upon observation, the door was closed with a sign on the door for Enhanced Droplet Precautions and a PPE caddy hanging on the door. In the residents' room, the privacy curtain separating the two beds was open allowing full visualization of both residents from the doorway. Resident #2 was tested for COVID-19 on 9/14/20 at 11:04am with a final positive result reported on 9/16/20 at 8:34am. Resident # 1 was tested for COVID-19 on 9/14/20 at 11:03am with the final negative result dated 9/16/20 at 7:58am. The facility reported a rapid point of care COVID-19 test was obtained on 9/18/20 with negative results. Facility also reported an additional COVID-19 test was obtained on 9/18/20 and the results were pending at the time of observation. Resident #1's [DIAGNOSES REDACTED]. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 8/19/20 assigned the resident a BIMS (brief interview for mental status) score of 13 out of 15 in section C, Cognitive Patterns. Resident #1 is also coded as requiring supervision only for bed mobility, transfers, walking in room, and toilet use and limited assistance with dressing and personal hygiene. On 9/21/20 at approximately 3:40pm, the onsite surveyor and the remote surveyor present via phone informed the administrator, ADON (assistant director of nursing), IP, and the IP trainee of the observations for Residents #1, #2, #3, and #4. The RNC acknowledged the observations. The ADON stated Resident #1 and Resident #4 were not separated from their COVID-19 positive roommates because both residents were symptomatic and exposed and would be left in their current rooms until proven differently. Administration stated this was to mitigate risk to other residents. Surveyor asked if there were any vacant rooms on West as of Friday, ADON stated they did not believe so. The administrator stated they could have told the surveyors this on Friday but was not sure now, also stated that the facility does not have private rooms. ADON stated Resident #1 was symptomatic due to projectile vomiting. Surveyor requested any supporting documentation of Resident #1's symptom of vomiting. Facility provided surveyor with only a physician's orders [REDACTED]. Review of the September 2020 MAR (Medication Administration Record) revealed the [MEDICATION NAME] had not been administered. ADON stated Resident #4 was symptomatic due to an increased temperature. Surveyor requested supporting documentation of the increased temperature. Facility provided surveyor with only a printed Temperature Summary for Resident #4. The Temperature Summary revealed in part, the following temperatures: 9/18/20 2:59pm 99.1 F, 9/18/20 10:59pm 97 F, 9/20/20 6:28am 98 F, and 9/21/20 1:05am 97.8 F. Resident #4's Order Summary Report included an order dated 8/26/20 for [MEDICATION NAME] Tablet give 650 mg enterally (sic) every 6 hours as needed for fever. A review of Resident #4's September 2020 MAR (medication administration record) on 9/21/20 revealed [MEDICATION NAME] was not administered during September 2020. The ADON stated the temperature of 99.1 F obtained on 9/18/20 was an increase from the resident's baseline temperature. On 9/21/20 at 5:40pm, a conference call was completed with two LTC (long-term care) supervisors and the survey team. It was determined that the facility's failure to maintain an infection prevention program for preventing and controlling infections and communicable disease (COVID-19) resulted in a situation of IJ (immediate jeopardy). On 9/21/20 at 6:40pm, the onsite surveyor and the remote surveyor informed the administrator, ADON, and RNC that immediate jeopardy was identified due to cohorting and lack of social distancing, completed IJ template was provided to the administrator. Surveyors discussed the guidance available from the CDC dated 4/30/20 related to cohorting. Administrator stated they have never been cited from the CDC and not the regulations and told the surveyors that they work for the state and do CMS surveys, not the CDC. The administrator questioned the relevance of any CDC guidance from as long as April 2020. Given that the administrator questioned the relevance of CDC guidance during this public health pandemic, the following information is provided: CMS QSO-20-14-NH DATE: March 13, 2020 documents in part, Guidance-Facility staff should regularly monitor the CDC website for information and resources. (https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and/qso-20-14-nh.pdf) QSO-20-20-All March 23, 2020 On Friday, March 13, 2020, the President declared a national emergency, which triggers the Secretary's ability to authorize waivers or modifications of certain requirements pursuant to section 1135 of the Social Security Act (the Act). Under section 1135(b)(5) of the Act. (https://www.cms.gov/files/document/qso-20-20-all.pdf) Current emergencies notice from the CMS website contains information stating that Secretary Azar used his authority in the Public Health Service Act to declare a public health emergency (PHE) in the entire United States on January 31, 2020 giving them the flexibility to support their beneficiaries, effective January 27, 2020. The PHE was renewed on April 21, 2020, July 23, 2020, and October 2, 2020, effective October 23, 2020. (https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page) On 9/22/20 at 12:10pm, the onsite surveyor was provided with the four following late entry progress notes: (1) Health Status Note with an effective date of 9/17/20 4:15am and created date of 9/21/20 4:31pm stating in part called on call clinician (name omitted) NP in regards to resident reporting nausea and vomiting x 1. On call then ordered [MEDICATION NAME] 4mg PRN (as needed) q (every) 8 hours x 14 days. RP (name omitted) made aware. [MEDICATION NAME] not given due to the resident denying feeling nauseated post speaking to the on call . (2) Health Status Note with an effective date of 9/17/20 4:18am and created date of 9/22/20 8:20am stating Oral T (temperature): 97.2 P (pulse): 86 R (respirations): 18 BP (blood pressure): 114/84 O2 (oxygen saturation): 97% on RA (room air). (3) Health Status Note with an effective date of 9/17/20 1:30pm and created date of 9/21/20 2:24pm stating (name omitted) NP in facility & did not want resident to have a covid swab done due to episode of vomiting & preferred to have resident swabbed on 9/21/20 with regular scheduled testing. (4) Encounter Note by the NP with an effective date of 9/16/20 11:00pm and Date of Service of 9/17/20 stating in part, The patient is being evaluated today at nursing request for episodes of nausea and vomiting overnight. The patient had an acute episode of nausea and vomiting overnight last night and [MEDICATION NAME] was ordered by the on call. The patient reports symptoms started after dinner last night and persisted into the night. She feels that nausea is from the greenbeans she ate. She reports she did feel some improvement after vomiting. She denies abdominal pain, diarrhea/constipation, or blood in vomit or stool. She denies any fever or chills. The patient has been exposed to COVID although previous COVID test was negative. She denies any other signs and symptoms including sore throat, cough, headache, dyspnea, chest pain, muscle aches, and change in taste and smell. She has been afebrile on chart review and As (he/she) remains afebrile and is otherwise asymptomatic, repeat testing is not warranted at this time. Note was signed by the NP on 9/22/20 11:11am. On 9/22/20 at 12:30pm, at the request of the administrator, the surveyors attended a conference call with the administrator, ADON, RNC, IP, IP trainee and the local epidemiologist. Administrator informed the epidemiologist that they have made 32 room moves since last week and were told that negative symptomatic residents should stay with their positive roommate. Epidemiologist replied no, a negative symptomatic resident should still be moved from a room with a confirmed positive. Epidemiologist further stated that with an exposed resident it is likely they will become positive; however, you have to go with the benefit of the doubt and separate negative from positive residents. Administrator stated to the epidemiologist that they have had calls with them where the opposite was said to the facility. Epidemiologist stated there is a need for a written plan to avoid future pitfalls and stated willingness to help the facility with the plan of correction. Prior to the call ending the administration stated to the epidemiologist if the facility needs their help, they will call. Administrator provided a copy of a hand written note dated 9/18/20 stating in part, Call with (epidemiologist name omitted) for follow up. 4 residents negative in rooms with positive residents after PPS. Move all 4 if possible, 2 moved to South with (no) symptoms (negative) POC test. 2 remain with symptoms. Get 2 (negative) tests prior to move. POC ok, PCR done. Waiting for results to move. Put in 14 day quarantine on South if both negative. The administration stated to the surveyors that they do not agree with the IJ as they were under the direction of the health department. Administrator further stated, I'll fight this as far as I can. A review of the facility's Daily Census reports for 9/18/20, 9/19/20, and 9/20/20 revealed there was one vacant semi-private room on West (COVID unit) and eight vacant semi-private rooms on South (warm unit) available for use each day. Surveyor requested and received the facility's COVID-19 policy, entitled COVID-19 which states in part: 2. Transmission a) The primary route of transmission is by close person to person contact (within 6 feet). b) [MEDICAL CONDITION] is thought to be transmitted most readily by respiratory droplets produced when an infected person coughs or sneezes. The droplets from the cough or sneeze of an infected person are propelled through the air and deposited on the mucous membranes of the mouth, nose, or eyes of persons who are nearby. c) It may be possible for transmission to occur when a person touches a surface or object contaminated with infectious droplets and then touches his or her mouth, nose, or eyes. 11. Containment/Management a) Implement Enhanced Droplet Contact Precautions while patient is in the Center b) Contain the area of potential contamination. Do not use the room for another patient until terminal cleaning has occurred. c) Cohort like patients in a designated area (i.e. a close group of rooms on a certain hall). d) Place patient in a private room and keep the door closed. The facility failed to follow their COVID-19 policy by cohorting COVID-19 positive and negative residents together. Transmission Based Precautions-General Practice Policy and Procedure Surveyor requested and received the policy and procedure for Transmission Based Precautions (TBPs) entitled, Transmission Based Precautions-General Practice which states in part: 2. Droplet Precautions a) Patient Placement Place patient in a room with a patient(s) who has active infection with the same microorganism, but with no other infection (cohorting). When cohorting is not possible consider placing in a private room, if available or consider placing in a room with a patient considered to be low risk (no open access sites, wounds, IVs, or tubes) while maintaining a spatial separation of at least 3 feet between the infected patients and other patients and visitors. Special air handling and ventilation are not necessary and the door may remain open. The facility failed to follow the provided Transmission Based Precautions-General Practice policy by cohorting COVID-19 positive and negative residents together when vacant rooms were available. COVID-19 Long-Term Care Facility Guidance dated April 2, 2020 from the Centers for Medicare and Medicaid contained the following directive to long-term care facilities: Nursing Homes should immediately ensure that they are complying with all CMS and CDC guidance related to infection control. This CMS document also includes, but is not limited to the following statement where Long-term care facilities should separate patients and residents who have COVID-19 from patients and residents who do not, or have an unknown status. (https://www.cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf) Responding to Coronavirus (COVID-19) in Nursing Homes CDC guidance updated 4/30/20 included information reflecting that If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. The guidance further states that roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible,should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Also, exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) On 9/22/20 at approximately 12:25pm, the administrator presented the following immediate jeopardy abatement plan: 1. Roommates to resident (name omitted) and (name omitted) were moved into a room together creating a + COVID room. Residents (name omitted) and (name omitted) were left in their rooms due to being symptomatic and waiting for PCR test results. -----September 21, 2020 2. Current residents that are COVID + were assessed for appropriate roommates to assure that no negative resident is in a room with a positive resident by the ADON. ----- September 20, 2020 3. Nursing Administration was educated to notify the Administrator if a resident test positive and status of roommate for bed management and movement of resident as needed by ADON. ----- September 21, 2020 4. Nursing Administration was educated on monitoring documentation of signs and symptoms residents are exhibiting and appropriate follow up to assure precautions are put in place in a timely manner by the SDC by September 22, 2020. 5. DON/designee will review current residents that are positive in daily stand up meeting at least 5 times per week to monitor symptoms and COVID status and status of roommates. 6. DON/Administrator will work with Housekeeping staff to assure room moves are completed as soon as possible at time of identification. 7. Any non-compliance will be reported to the QA committee for tracking and trending. On 9/22/20 at approximately 2:15pm, the survey team informed the administrator, ADON, and RNC that the facility's plan of correction was accepted. The facility presented credible evidence that the plan of correction had been implemented, including evidence of nurse education as outlined in the POC (plan of correction), audit of the cohorting of residents with an attestation by the ADON stating all positives cohorted appropriately, and staff email confirmations of a QA Zoom meeting held on 9/22/20 at 9:30am. On 9/22/20 at 3:13pm, surveyor observed Resident #2 (COVID-19 positive) and Resident #3 (COVID-19 positive) residing in a room together on West Unit. An Enhanced Droplet Precautions sign and PPE caddy was present on the door, the door was closed. At 3:16pm, surveyor observed Resident #1 (COVID-19 negative) in a semi-private room alone on West Unit. An Enhanced Droplet Precautions sign and PPE caddy was present on the door, the door was closed. At 3:23pm, surveyor observed Resident #4 (COVID-19 negative) in a semi-private room alone on West Unit. An Enhanced Droplet Precautions sign and PPE caddy was present on the door, the door was closed. Surveyor reviewed the facility's COVID-19 positive line listing and Daily Census Report for 9/22/20 and verified there were no COVID-19 positive and negative residents residing together in the same room. Surveyor also verified inservice training for the nursing administration through comparison of the list of active nurses with the inservice sign-in sheets. Interviews were conducted onsite with LPN (licensed practical nurse) #1, #2, and #5 and Unit Managers #3 and #4; each voiced they would notify the administration for a room change when a resident tested positive for COVID-19 and their roommate was negative. Each nurse also voiced that resident signs and symptoms are to be documented in the medical record. On 9/22/20 at 4:48pm, the surveyors notified the administrator, ADON, and RNC that the Immediate Jeopardy was abated. No further information regarding this issue was presented to the survey team prior to the remote exit conference on 9/23/20.

Based on staff interviews, review of facility documents, and clinical record reviews, the facility staff failed to ensure complete and accurately documented clinical records for 2 of 12 residents in the survey sample (Resident #1 and Resident #4). The findings included: 1. For Resident #1, facility staff failed to contemporaneously document an episode of nausea and vomiting and subsequent physician notification of the change in resident condition occurring on 9/17/20. Resident #1's [DIAGNOSES REDACTED]. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 8/19/20 assigned the resident a BIMS (brief interview for mental status) score of 13 out of 15 in section C, Cognitive Patterns. Resident #1 is also coded as requiring supervision only for bed mobility, transfers, walking in room, and toilet use and limited assistance with dressing and personal hygiene. A review of the medical record revealed the following documentation: A physician's orders [REDACTED]. [MEDICATION NAME] is in a class of medications called serotonin 5-HT3 receptor antagonists that works by blocking the action of serotonin, a natural substance that may cause nausea and vomiting. A review of Resident #1's September 2020 MAR (medication administration record) revealed the [MEDICATION NAME] had not been administered. On 9/21/20 at approximately 12:30pm, surveyor reviewed Resident #1 nursing progress notes and was unable to locate documentation related to nausea and/or vomiting or resident change in condition leading to the new physician's orders [REDACTED]. On 9/21/20 at 1:15pm, the onsite surveyor and the remote surveyor present via phone met with the administrator, ADON (assistant director of nursing) and the RNC (regional nurse consultant) and discussed Resident #1 and the lack of documentation of the resident's change in condition leading to the new physician's orders [REDACTED].#1 is negative for COVID-19 and residing in a room with a COVID-19 positive roommate. The ADON stated Resident #1 was symptomatic for COVID-19 and had projectile vomiting and resident could not be swabbed for PCR COVID-19 test on 9/17/20. ADON stated the NP (nurse practitioner) had seen Resident #1 but was not sure if it was documented. Surveyor requested any documentation related to Resident #1's symptoms of nausea and vomiting. At approximately 2:05pm, surveyor received a copy of the physician's orders [REDACTED]. On 9/21/20 at 4:47pm, the surveyor was provided with a copy of a late entry progress note with the effective date of 9/17/20 1:30pm stating (name omitted) NP (nurse practitioner) in facility & did not want resident to have a covid swab done due to episode of vomiting & preferred to have resident swabbed on 9/21/20 with regular scheduled testing. Surveyor requested created date for the late entry progress note and the facility policy and procedure related to monitoring and documentation of resident symptoms. On 9/22/20 at 12:10pm, surveyor was provided with the four following late entry progress notes for Resident #1: (1) Health Status Note with an effective date of 9/17/20 4:15am and created date of 9/21/20 4:31pm stating in part called on call clinician (name omitted), NP in regards to resident reporting nausea and vomiting x 1. On call then ordered [MEDICATION NAME] 4mg PRN (as needed) q (every) 8 hours x 14 days. RP (name omitted) made aware. [MEDICATION NAME] not given due to the resident denying feeling nauseated post speaking to the on call. Will continue to monitor. (2) Health Status Note with an effective date of 9/17/20 4:18am and created date of 9/22/20 8:20am stating Oral T (temperature): 97.2 P (pulse): 86 R (respirations): 18 BP (blood pressure): 114/84 O2 (oxygen saturation): 97% on RA (room air). (3) Health Status Note with an effective date of 9/17/20 1:30pm and created date of 9/21/20 2:24pm stating (name omitted) NP in facility & did not want resident to have a covid swab done due to episode of vomiting & preferred to have resident swabbed on 9/21/20 with regular scheduled testing. (4) Encounter Note by the NP with an effective date of 9/16/20 11:00pm and Date of Service of 9/17/20 stating in part, The patient is being evaluated today at nursing request for episodes of nausea and vomiting overnight. The patient had an acute episode of nausea and vomiting overnight last night and [MEDICATION NAME] was ordered by the on call. The patient reports symptoms started after dinner last night and persisted into the night. She feels that nausea is from the greenbeans she ate. She reports she did feel some improvement after vomiting. She denies abdominal pain, diarrhea/constipation, or blood in vomit or stool. She denies any fever or chills. The patient has been exposed to COVID although previous COVID test was negative. She denies any other signs and symptoms including sore throat, cough, headache, dyspnea, chest pain, muscle aches, and change in taste and smell. She has been afebrile on chart review. Note was signed by the NP on 9/22/20 11:11am. On 9/22/20 at 12:10pm, the administrator provided the policy Significant Change in Condition which stated in part: 11. Each change of condition shall be documented in the Progress Notes and Shift Report. No further information regarding this issue was presented to the survey team prior to the exit conference on 9/23/20. 2. For Resident #4, the facility staff failed to document an assessment and physician notification following an identified increased temperature on 9/18/20. Resident #4's [DIAGNOSES REDACTED]. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 8/26/20 assigned the resident a BIMS (brief interview for mental status) score of 11 out of 15 in section C, Cognitive Patterns. Resident #4 is also coded as requiring limited assistance for transfers, dressing, and toilet use and supervision only for bed mobility and personal hygiene. On 9/21/20 at 1:15pm, the onsite surveyor and the remote surveyor present via phone met with the administrator, ADON (assistant director of nursing) and the RNC (regional nurse consultant) and discussed Resident #4. The ADON stated Resident #4, who is COVID-19 negative, is residing in a room with a COVID-19 positive roommate due to Resident #4 being symptomatic for COVID-19 due to a recent temperature. Surveyor informed the facility they were unable to locate documentation in the progress notes concerning an increased temperature. Surveyor requested any documentation reflecting Resident #4's symptom of an elevated temperature. On 9/21/20 at approximately 2:05pm, surveyor received a copy of Resident #4's Temperature Summary log. Resident #4's Temperature Summary revealed the following temperatures: 9/18/20 3:01am 97.6 F, 9/18/20 2:59pm 99.1 F, 9/18/20 10:59pm 97.0 F, 9/20/20 6:28am 98.0 F, and 9/21/20 1:05am 97.8. No additional documentation related to an increased temperature was provided to the surveyor. A review of Resident #4's medical record did not reveal any additional documentation related to the temperature of 99.1 F obtained on 9/18/20. Resident #4's Order Summary Report included an order dated 8/26/20 for [MEDICATION NAME] Tablet give 650 mg enterally (sic) every 6 hours as needed for fever. A review of Resident #4's September 2020 MAR (medication administration record) on 9/21/20 revealed [MEDICATION NAME] was not administered during September 2020. On 9/22/20 at 12:10pm, the administrator provided the policy Significant Change in Condition which stated in part: 11. Each change of condition shall be documented in the Progress Notes and Shift Report. No further information regarding this issue was presented to the survey team prior to the exit conference on 9/23/20.

Based on observation and staff interview the facility staff failed to prepare, distribute and serve food in accordance with professional standards for food service safety. Findings: On 2/19/19 at 4:15 PM the surveyor observed Cook I taking the trayline temperatures on the kitchen. The DM (dietary manager) was assisting by wiping the thermometer hub with an alcohol wipe between dishes. Cook I was observed to take the temperatures in two separate chicken dishes by inserting the hub of the thermometer down into the juices beside the whole pieces of the chicken in the pan. The thermometer hub was not inserted into the deepest portion of the meat to obtain the temperature. The surveyor asked if this was the usual manner to to check the juices in the pan rather than check the actual internal meat temperature. The DM said NO they always checked the inside of the meat and took the thermometer from Cook I and inserted it into a chicken thigh. The DM did not have on gloves and she fumbled with the greasy thermometer and her right knuckle slipped onto the surface of the chicken. The surveyor asked why she was not wearing gloves when she attempted to take the temperature ( which was 170 degrees) and the DM denied her finger had slipped into the chicken. On 2/19/19 at 4:55 PM the surveyor was watching the staff serving drinks to the resident in the dining room in preparation for the evening meal. CNA I was using a scoop to remove ice from an ice chest into glasses with her bare hands and dropped the scoop back into the ice chest on top of ice. CNA II followed up, scooping ice into glasses in the same manner with no gloves and dropped the scoop back into the chest on top of the ice. The DM came out of kitchen and told them to always put ice scoop back into holder and not leave it in the ice. On 2/20/19 at 3:00 PM the administrator and ADON were informed of the surveyor's findings. The administrator provided the surveyor with a food policy for taking safe food temperatures. It included: .Cook hot foods to the minimum end-point temperature or higher as indicated on the following table Use a calibrated thermometer to check product temperature in the thickest portion of the meat .Poultry 165 degrees for 15 seconds The surveyor did not receive a policy concerning donning gloves prior to touching prepared foods or the proper storage of ice scoops. No additional information was provided prior to the survey team exit.

Based on staff interview and clinical record review, the facility staff failed to accurately complete a DDNR (durable do not resuscitate) order form for one of 37 Residents, Residents #142. The findings included: The facility staff failed to accurately complete the Residents DDNR. The boxes on this form had been left unchecked. The clinical record review revealed that Resident #142 had been admitted to the facility 10/26/18. [DIAGNOSES REDACTED]. Section C of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/02/19 included a BIMS (brief interview for mental status) summary score of 3 out of a possible 15 points. The Residents clinical record included a physicians order indicating the Residents code status was a DNR (do not resuscitate). On 02/19/19 at 3:13 p.m., the unit manager provided the surveyor with a DDNR order form from the Virginia Department of Health that had been signed by the Residents physician and authorized representative. This DDNR read in part. Under section 1 I further certify (must check 1 or 2): 1. The patient is CAPABLE of making an informed decision . 2. The patient is INCAPABLE of making an informed decision . Neither box had been checked. Section 2 read, If you checked 2 above, check A, B, or C below . All three boxes had been left blank. The administrative staff were notified of the incomplete DDNR order form during a meeting with the survey team on 02/20/19 at 4:34 p.m. and again on 02/21/19 at 1:00 p.m. No further information regarding the DDNR was provided to the survey team prior to the exit conference.

Based on staff interview and facility document review, the facility staff failed to ensure that employee background checks were obtained within a timely manner upon hire to the facility for 2 of 25 newly hired employees. The findings included: The facility staff failed to ensure that employee background checks were completed within 30 days of hire for 2 newly hired employees. On 2/20/19 at 1:32 pm, the surveyor reviewed employee records for 25 newly hired employees. During the employee record review, the surveyor observed that Employee # 1 had a hire date of 3/6/18 and criminal background check was completed on 2/19/19. Employee # 2 had a hire date of 2/20/18 and criminal background check was completed on 10/26/18. On 2/20/19 at 2:00 pm, the surveyor spoke with the facility human resources manager. The surveyor asked the facility human resources manager to verify the dates of hire and employee background checks for Employee # 1 and Employee # 2. On 2/20/19 at 2:15 pm, the facility human resources verified that the hire dates and criminal background check dates for Employee # 1 and Employee # 2 were correct as stated as stated above. The surveyor asked the facility human resources manager why the criminal background checks for Employee # 1 and Employee # 2 had not been completed within 30 days. The facility human resources manager informed the surveyor that Employee # 1 and Employee # 2 were hired prior to her being hired at the facility and she could not answer as to why the criminal background checks had not been completed within 30 days. On 2/20/19 at 4:33 pm, the administrative team was made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 2/21/19.