Every finding on record at S.P.J.S.T. Rest Home 3

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 4 medication cart (Medication Carts #1, #2 and #3) and 1 of 2 treatment carts (Treatment Cart #1) reviewed for medication storage. 1. The facility failed to ensure OTC medication stored in medication carts was labeled with the open date. 2. The facility failed to ensure wound care creams stored in the treatment cart were labeled with an open date. These deficient practices could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment. The findings include: Observation on 09/17/2025 at 11:10 a.m., of Medications Cart #1, #2 and #3 and Treatment Cart #1 with the DON, revealed the following: Medication Cart #1.Geri - Tussin, Robitussin oral solution, loosens and relieves chest congestion, did not have an open date. Medication Cart #2.Tylenol Extra strength 500mg, did not have an open date. Medication Cart #3.Vitamin D3 1000 [NAME] (25Mcg), did not have an open date.Refresh tear lubricant eye drop did not have an open date.Thera tears, therapy for your eyes, dry eye therapy, lubricant eye drops, did not have an open date. Treatment Cart #1Desenex, Antifungal foot powder with 2% Miconazole Nitrate, did not have an open date.Solosite wound gel, did not have an open date.Dermasil dry skin treatment, did not have an open date.SilvaKollagen Gel. Silver collagen wound Gel, did not have an open date.Hydrocortisone cream USP, 2.5%, did not have an open date.Coloplast, Triad Hydrophilic wound dressing, did not have an open date. Interview with MA A on 09/17/2025 at 11:30AM, MA A stated the OTC medication should have an open date written on them. She said they were still within the expiration date. She said that the medication aide and the nursing staff are responsible for ensuring all medications were labeled with an open date. She said it was important to write the open date to know for how long the bottle had been opened and may affect the health of the residents. This can put the residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment. Interview with the DON on 9/17/25 at 1:35 PM, the DON stated the OTCs should have an open date written on them. She said they were still within the expiration date. She said it was important to write the open date to know how long the bottle had been opened and avoid putting residents at risk for not receiving the therapeutic effects of the medication or treatment. The DON said nurses and medication aides were responsible for checking the medication bottles and writing an open date on them. Interview with LVN A, on 9/17/25 at 2:20 PM, LVN A stated the OTCs should have an open date written on them. She said they were still within the expiration date. She said when medications were not dated when opened, the effectiveness of the medication could be altered, and residents would not get the full benefit of the medication when administered. Record review of the facility's policy and procedure titled Medication Labeling and Storage revised in February 2023 revealed: Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.

Based on observation, interview and record review, the facility failed to ensure that, based on the comprehensive assessment of a resident, the facility must ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of two residents) Resident #4 reviewed for pressure sores.The facility failed to ensure Resident #4 received treatment for a pressure sore to the sacrum according to orders. This failure could place residents at risk for worsening of the pressure sore and for infection. Findings included: Record review of the admission Record for Resident #4 revealed an [AGE] year old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included, but were not limited to, protein-calorie malnutrition, weakness, and gastrostomy status (feeding tube). Record review of Resident #4's Physician's Order, dated 08/26/25, revealed Resident #4 had a Stage 2 pressure sore. The order reflected the wound was to be cleansed with Dakins solution, pat dry, have medihoney applied, followed by Calcium Alginate. The wound was to be covered with a bordered foam gauze. The treatment was to be provided every three days. Record review of Resident #4's Care Plan, dated 03/10/25, read, in part .Administer treatments as ordered and monitor for effectiveness. Observation on 09/16/25 at 12:55 p.m. revealed GVN B assisted Resident #4 onto his left side. GVN B loosened the resident's brief. The resident had a 4 x 4 inch bordered gauze dressing on his sacral area. The date on the dressing was 09/12 (2025). It appeared to reflect an initial of LVN E There was a second 4 x 4 inch bordered gauze dressing on the resident's left buttock. The date was reflected as 09/12 (2025) and an initial of LVN E. The date and the initials were verified by GVN B.In an interview on 09/16/25 at 1:01 p.m., ADON A said Resident #4 received Hospice Services, and the Hospice nurse provided the treatments. She said if the date on the sacral dressing was 09/12/25, it should have been changed on 09/15/25, the previous day. Observation on 09/16/25 at 1:14 p.m. revealed GVN B provided wound care for Resident #4, accompanied by CNA C,. ADON A was also present. When Resident #4 was turned onto his left side, the dates on the sacral and left buttock were visible. Both dressings were removed and discarded by GVN B. Observation revealed an open wound at the sacral area of approximately 1.5 cm diameter. There was yellow slough visible, making depth measurement unobtainable. Observation revealed an open area on the left buttock approximately 1.5 cm diameter, with superficial depth. Observation of wound care technique revealed no concern.In an interview on 09/16/25 at 3:50 p.m., ADON A said the initial documented on Resident #4's dressing would be for LVN E. ADON A said Hospice usually provided wound care for Resident #4, but the Hospice service was transitioning nurses, so the facility nurses were providing wound care. In an interview via telephone on 09/17/25 at 5:00 a.m., LVN D said she had not provided wound care for Resident #4 recently. She said when she worked on Sunday (09/14/25) she did not provide the scheduled wound care because it had been done PRN on 09/12/25. In an interview on 09/18/25 at 12:48 p.m., the DON said Hospice had been providing wound care for Resident #4. She said they did not use the communication book, but they would provide verbal report to the facility nurses. She said the dressing should have been changed on the routine day regardless of PRN treatments. She said going forward the facility nurses would be providing the treatments.Record review on 09/16/25 at 2:20 p.m. of Resident #4's September 2025 TAR revealed LVN D signed she provided the wound care on 09/14/25. LVN D's initial was not the initial documented on Resident #4's dressing. Record review of the facility's policy Wound Care (October 2010) read, in part .Documentation.2. The date and time the wound care was given.4. The name and title of the individual performing the wound care.

Based on video observation, interviews, and record review, the facility failed to maintain implement and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for 1 (Resident # 1) of 5 resident reviewed for infection control.The facility failed to ensure LVN A used gloves and performed hand hygiene during Resident # 1's care tasks, including wound care and injection administration.This facility failure could place residents at increased risk for cross-transmission of infectious organisms. Record review of Resident #1's Facesheet dated 08/01/2025 revealed resident was originally admitted to the facility on [DATE], and readmitted on [DATE], age [AGE] years old. Resident #1's Primary Admitting diagnosis of Hemiplegia and Hemiparesis Following Cerebral Infarction, Affecting Left Non-Dominant Side (indicating paralysis or weakness on the left side of the body due to a stroke), secondary diagnosis documented with history of a Sacral Region Stage 2, Pressure Ulcer (characterized by partial-thickness skin loss, shallow with a pink to red base. Stage 2 also includes intact or partially ruptured blisters secondary to pressure).Record review of Resident #1's MDS dated [DATE] Resident#1 had a BIMS (Brief Interview for Mental Status) score of 07, which indicated severe cognitive impairment. The MDS indicated a need for comprehensive assistance and specialized care approaches.Record review of Resident # 1's Care Plan dated 08/01/2025 revealed, Focus area: Resident #1 had potential for pressure ulcer development related to dehydration, nutritional deficiencies, disease process, immobility, diabetes mellitus and her decision to stay up in wheelchair without off-loading time for long periods of time: 11/04/22- stage II to sacral area-resolved; 12/30/23 reopened stage II to sacral area;- resolved; 05/23/24 reopened Stage II to sacral area. Goal: Resident #1 will have intact skin, free of redness, blisters or discoloration by Intervention: Follow facility policies/protocols for the prevention/treatment of skin breakdown or pressure areas.Record review of Resident #1's Clinical physician order, with start date of 05/29/2024 and discontinued date 10/25/2025, revealed Cleanse the sacral area with Anasept (used to treat or prevent infections), pat dry, apply collagen powder, and cover with bordered dressing daily every evening shift for prevention.Video observation review provided by complainant, dated 09/24/2024, revealed care provided to Resident #1. In the video: CNA A and CNA B were shown providing incontinence care. Both CNAs positioned Resident #1 while LVN A applied a dressing to Resident #1 buttocks without wearing gloves. Upon completing the dressing application, LVN A obtained an injection syringe and supplies from bedside table and administered an injection to the resident's right arm. LVN A did not perform hand hygiene between the dressing application and injection administration.Interview attempted with Resident #1 on 08/01/2025 between the hours of 9:00am 12:00pm were unsuccessful, as Resident #1 had a scheduled procedure the morning of surveyor's visit.Interview with ADON M, on 08/01/2025 at 10:33am, ADON M confirmed that the facility had provided infection control training to all staff. ADON M stated proper hand hygiene should be implemented before and after all patient care tasks. ADON M confirmed the name of the three staff shown in the video. ADON M identified LVN A as the staff who implemented the dressing application and then administered an injection. After viewing the video, ADON M confirmed LVN A did not perform hand hygiene between the wound care dressing application and injection administration. She stated according to facility policy and CDC guidelines, staff must perform hand hygiene, before and after wound dressing application, incontinence care, and before performing another clean or invasive task like an injection to prevent cross-contamination.Interview with the Administrator on 08/01/2025 at 4:30 PM, the Administrator stated that the facility's Director of Nursing (DON), who also served as the Infection Preventionist, was out of the facility on vacation. The Administrator indicated that she was the designated backup Infection Preventionist while the DON was out. The Administrator stated the facility had not received information regarding LVN A not wearing gloves during the wound care dressing change for Resident #1. She stated if the information had been emailed, it was possible that it had been overlooked due to the large number of emails from the family, despite being advised about the importance of following the grievance process to ensure concerns related to Resident #1 were thoroughly investigated and appropriate interventions were implemented to ensure the safety and well-being of each resident. The Administrator affirmed that all staff were expected to adhere to the facility's infection control policy. She stated standard precautions such as hand hygiene should always be implemented before and after staff tasks such as administering an injection or applying wound dressing. She stated the shortcoming of LVN A not wearing gloves was a breakdown in staff adherence to infection control training and could have placed both staff and residents at an increased risk for cross-transmission and infection. The Administrator stated the facility had provided ongoing infection control training to all staff to prevent such action. She stated the most recent training was conducted in 07/2025. She stated the DON, Administrator, and ADON was responsible for ensuring staff implemented infection prevention measure. She stated compliance is assessed during facility environmental and safety rounds. Interview with the CNA A on 08/01/2025 at 6:30 PM, she stated the facility had provided infection control training, including prior hand hygiene. CNA A recalled the occurrence depicted in the video but could not recall the specific date, time, and details of the occurrence. CNA A confirmed she was one of the two CNAs observed in the video. She stated LVN A did not wear gloves, did not perform hand hygiene between the dressing application and injection administration and did not wash hands prior to exiting Resident #1's room. CNA A verbalized knowledge of when to implement hand hygiene and gloves. She stated gloves should be worn by LVN A when there was direct contact with a resident's buttocks and genital area of the body. She stated she did not recall LVN A not wearing gloves, but if she had witnessed staff not wearing gloves, she would have encouraged them to do so. She stated LVN A not wearing gloves and not performing hand hygiene placed residents at risk for infection.Observation of Resident #1 on 08/01/2025 around 8:45pm, Resident #1 observed lying in bed, eyes closed, with no notable sign of pain or distress.Interview with LVN A on 08/02/2025 at 4:34 PM, was conducted via telephone. LVN A stated she had been a Licensed Vocational Nurse for twenty-four years and had worked at the facility for four years. LVN A stated she always washed her hands before providing care but could not recall specific details from her shift on 09/24/2024. She acknowledged being aware of Resident #1 and the presence of video surveillance in Resident #1's room. LVN A confirmed that she had provided care to Resident #1 but could not recall whether she had performed wound care or administered an injection to the resident on 09/24/2024. She stated it was likely she had provided both wound care and administered an injection without wearing gloves and a gown, explained that she may had attempted to quickly implement care because Resident #1 demonstrated aggressive behaviors toward staff at the time. She confirmed that the facility had provided infection control and wound care training upon hire, as well as ongoing training throughout her four years of employment. She explained the appropriate steps for providing wound care to a resident, stated that proper hand hygiene should be performed before and after the procedure. She stated gloves should have been implemented with any care provided to the resident buttocks. She stated when applying a dressing application as a prevention measure it was considered a wound care intervention. She further stated an aseptic or clean technique should be used depending on the wound type, and that appropriate dressings should be applied using proper technique to prevent contamination. LVN A did not view video footage. LVN A acknowledged that if she had failed to wear gloves dressing application to a resident's buttocks, and did not wash or sanitize her hands before administering an injection, it could have caused contamination and exposed both Resident #1 and herself to infection. She did not provide any additional explanation as to why she had not performed hand hygiene between providing dressing application and administering the injection.Interview with the CNA B on 08/08/2025 at 6:30 PM, CNA B confirmed she was the second CNA observed in the video. She stated the facility had provided infection control training, including prior hand hygiene. CNA B verbalized LVN A should have worn gloves when care was provided to a resident's buttock area to protect residents and staff. She stated she did not notice LVN A had not worn gloves at the time of the occurrence. She stated she would have reminded LVN A to wear gloves. CNA B stated that failure to do so could place residents at risk for infection.Record review of LVN A employee file revealed the facility provided infection control and wound care training upon hire on 08/09/2021 and most recent 07/2025.Review of the facility's infection control policy, revised 12/2023, stated the facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. There was no specific language, for Hand Hygiene and, Wound care technique referenced in the infection control policy provided by the facility.Review of CDC's Summary of Infection Prevention Practices retrieved from CDC website on 08/01/2025.According to the CDC's Summary of Recommendations for Application of Standard Precautions, healthcare personnel must wear gloves when it is reasonably anticipated that contact will occur with blood, other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) (CDC, 2023). The sacral/buttocks area is a high-contamination zone due to its proximity to the perineal region. Therefore, contact with any dressing, even over intact skin, may involve exposure to potentially contaminated materials.Gloves must be changed during patient care if the hands will move from a contaminated body site (e.g., perineal area) to a clean body site (e.g., face). Aseptic technique must be used to avoid contamination of sterile injection equipment (CDC, 2023). Additionally, perform hand hygiene: After contact with blood, body fluids, excretions, mucous membranes, nonintact skin, or wound dressings. If hands will be moving from a contaminated-body site to a clean-body site during patient care (CDC, 2023).

Based on observation, interview, and record review, the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for two of four medication carts. -The keys to the [NAME] medication cart and the East medication carts were hanging on a hook inside of the [NAME] nurses' station, which was not locked, and the keys were within reach of persons outside the nurses' station. The failure placed the two medication carts at risk for drug diversion. Findings include: Observation on 08/07/24 at 1:30 p.m. of the [NAME] nurses' station revealed two sets of keys hanging on hooks on the inside of the counter. They were visible from the hallway. They were within reach of persons on the other side of the counter. The nurses' station had a gate that was approximately waist-high. It was unlocked. There were no staff within sight of the nurses' station. There was a locked medication cart just outside of the nurses' station. There was a locked medication cart inside of the nurses' station. There were tags on the keys. One tag read [NAME] Med Cart. The other read East CMA Cart. Observation and interview on 08/07/24 at 1:38 p.m. revealed the DON walked up to the [NAME] nurses' station. When the Surveyor asked about the keys, the DON said LVN L and MA H were probably eating lunch. The DON tried the keys in the medication cart in the nurses' station. The cart did not unlock. She then tried to unlock the medication cart outside of the nurses' station. The key on one of the sets of keys unlocked the cart. There were medications in the cart. The DON then went to the dining room. There were residents in the dining room. Observation revealed there was a medication cart in the dining room. The key on one of the sets of keys unlocked the cart. There were medications in the cart. The DON said that medications could have been taken from the carts if someone had taken the keys. In an interview on 08/07/24 at 1:50 p.m., LVN L said she usually would give the keys to another nurse when she left. LVN L said, I had to step out so I hung them up. She said she had both sets of keys. The facility policy Storage of Medications (revised April 2007) read, in part, .10. Only persons authorized to prepare and administer medications shall have access to the medication room , including keys.

Based on observation, interview, and record review the facility failed to ensure residents were free of significant medication errors for 1 (Resident #8) of 6 residents reviewed for medication errors. -LVN A attempted to administer the wrong dose of insulin to Resident #8 before Surveyor intervention. This failure placed resident at risk for inadequate therapeutic outcomes and decline in health. Findings included: Record review of Resident #8's face sheet revealed an [AGE] year-old female admitted on [DATE]. Her diagnoses included: Type 2 diabetes mellitus with diabetic chronic kidney disease. Record review of Resident #8's annual MDS assessment dated [DATE] revealed a BIMS score of 08 indicating moderate cognitive impairment. Record review of Resident #8's care plan revised on 5/2/2019 read in part, . (Resident #8) is at risk for unstable glucose level r/t dm2 . Interventions/Tasks . Diabetes medication as ordered by doctor . Record review of Resident #8's Order Summary Report dated August 8, 2024, read in part, Novolin R Solution 100 unit/ml (insulin aspart) inject as per sliding scale: if 150 - 199 = 4 units; 200 - 249 = 6 units; 250 - 299 = 9 units; 300 - 349 = 9 units; 350 - 999 = 15 units; IF BS above 349 give 15 UNITS AND CALL MD subcutaneously before meals related to type 2 diabetes mellitus with unspecified complications . order date, 8/31/2021 . Record review of Resident #8's MAR dated August 2024 revealed a blood sugar level of 249 on 08/07/24 at 4:30 p.m. Observation and Interview on 08/07/24 at 4:40 p.m. with LVN A, the Surveyor observed LVN A draw 9 units insulin from multidose vial. LVN A said that Resident #8's blood sugar was 249 and she was to receive 9 units of Novolog according to the sliding scale order. Observed her turn towards the resident to administer the insulin. Surveyor intervened and asked the nurse to check the MAR/Order. LVN A said that the amount of insulin in the syringe was more than prescribed by the doctor. LVN A discarded the additional 3 units of insulin that were prepared after surveyor intervention. LVN A administered 6 units into resident's right upper arm. Interview on 8/07/24 at 5:07 p.m. with LVN A who said she was PRN staff and she said she came out of retirement to cover some shifts. Interview on 08/08/24 at 2:08 p.m. with the DON, who said the expectation was for nurses to give insulin correctly. She said, the nurses should take time to ensure that the correct insulin dose is administered. The DON verbalized the last time there was an insulin in-service was 09/11/23 with return demonstration on insulin pen and insulin Vials. She said the risk of administering Insulin outside of the parameters can cause hypoglycemia (low blood sugar levels below the standard range). She said some of the side effects of hypoglycemia could ultimately result in death. Interview on 8/08/24 at 2:47 p.m. with the administrator, she said nursing staff were to check a minimal of five rights of medication administration, which included the right dose. Record review of the facility's General Guidelines for Medication Administration policy revised 08/2020 read in part, . Procedure . 4. At a minimum, the 5 Rights-right resident, right drug, right dose, right route, and right time-should be applied to all medication administration . Record review of the facility's Insulin Administration policy revised 10/2010 read in part, Steps in the Procedure (Insulin Injection via syringe) . 8. Check order for the amount of insulin .12. Double check the order for the amount of insulin .

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 waste receptacles reviewed for garbage disposal. -Both dumpster's contained waste; Dumpster #1 had its top front lids missing; and Dumpster #2 had one front top lid missing and the other front top lid was open. These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents. Findings Included: Observation on 06/20/2023 at 9 a.m. accompanied by the Dietary Manager revealed both dumpster's contained waste. Dumpster #1's front top lids were missing, and Dumpster #2's front top lid was open, and the front top right lid was missing. Observation on 06/22/2023 at 5:35 p.m. accompanied by the Administrator revealed no waste in either dumpster. Dumpster #1's front top lids were missing and Dumpster #2's front top right lid was missing. In an interview on 6/22/2023 at 4 p.m., the Administrator said the facility did not have a Food-Related Garbage and Refuse Disposal Policy. In an interview on 06/22/2023 at 5:10 p.m. the Dietary Manager said she did not think the facility had a policy regarding the dumpster and trash disposal but that the doors should have been closed. She said the risk to residents is bugs and rodents could get into the trash. She said the worst thing that can happen to the resident when proper protocols are not practiced was residents could get sick. In an interview on 06/22/2023 at 5:16 p.m., the Administrator said the policy or procedure for disposing of trash was to lift the lid and throw the trash toward the back if there was space and close the lid if it was able to be closed. She said she had contacted the trash company 8 months ago when they asked for the 2nd dumpster and requested new dumpster's then and she requested new dumpster's again 3 months ago, but they refused to provide her with new ones. She said the company they use is the only one that services this area and cannot find another in the rural area. She said the requests for new dumpster's was over the phone. She said the risk to residents was if left in the facility, infection, rodents, but the dumpster's were too far from the facility it didn't pose a risk to the residents. She said the worst thing that could happen to resident when proper protocols are not practiced was, again if waste was not taken out of the facility then it could result in residents getting infections.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #1) of 5 residents reviewed for comprehensive care plans. Resident #1 was not care planned for tube feeding. This deficient practice could place residents at risk for not receiving appropriate care and services. Findings Included: Observation on 06/22/2023 at 5:22 p.m. revealed Resident #1 was being fed via her G-tube. Record review of Resident #1's Face Sheet, dated 06/22/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included heart failure, gastrostomy status (an artificial external opening into the stomach for nutritional support), dietary folate deficiency anemia (Vitamin B9 deficiency), hypothyroidism (to little thyroid hormone) and vitamin deficiency. Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS score of 3 out of 15 indicating severe cognitive impairment. Further review revealed Resident #1 required two-person assist with toileting and bathing, and one-person assist with feeding. Resident #1's Nutritional Approaches section reflected a feeding tube. Record review of Resident #1's orders, dated 06/22/2023, reflected in part . cleanse G Tube site with NS, pat dry, apply drain sponge, and secure with tape .elevate hospital bed 30-45 degrees at all times during internal feeding and for 30 minutes after feeding has completed .Jevity 1.5 cal per feeding pump @ 75ml/hr x 16hrs (4pm-8am), free water flush 140ml Q 4hr bowel rest, pump off 8am-4pm daily every shift related to gastrostomy status. Record review of Resident #1's Care Plan, dated 05/08/2023, revealed it did not reflect Resident #1's need for tube feeding. In an interview on 06/22/2023 at 5:50 p.m., the DON said she and the ADON were responsible for completing care plans. She said Resident #1's need for tube feeding was not documented on the resident's care plan but should have been included. She said it was not added on the care plan because the Dietitian had to increase her caloric intake. The DON said she forgot to go back and update the care plan once the change was completed. She said the risk posed to residents when the required information was not included on their care plan was not getting the proper care. Record review of facility's policy titled Care Plans-Comprehensive revised on 09/2010, reflected in part . 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; .

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheotomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 4 residents (Resident #1 and Resident #3) reviewed for respiratory care. -The facility failed to obtain a physician's order for Resident #1's oxygen he received via nasal cannula. The O2 tubing was not changed in over 16 days. -Resident #3's nasal cannula tubing not changed in over 10 days. These failures could affect all residents using supplemental oxygen and place them at risk of receiving incorrect or inadequate oxygen support and could result in a decline in health. Findings included: Resident#1 Record review of Resident #1's face sheet undated revealed the resident was a [AGE] year-old male admitted on [DATE] with diagnoses that included dementia, ataxia and anemia in other chronic diseases classified elsewhere Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 03 out of 15 indicating severely impaired cognitively. He required extensive assistance in performing all activities of daily living (ADLs). He was in-continent to bowel and in-continent to bladder. Section C0100. Special treatment, procedures and program was coded for receiving oxygen therapy. Record of Resident #1's care plan initiated on 11/07/2022 and revised on 02/02/2023 revealed the following: Focus: I have as needed oxygen therapy r/t hospice services. Goal: I will have no s/sx of poor oxygen absorption though the review date. Interventions: oxygen settings: 2-4 L as needed per standing hospice orders. Record of Resident #1's physician order dated 11/13/22 revealed an order to change O2 concentrator tubing every night shift every Sunday. Record review of Resident #1's Treatment Sheet for the month of January 2023 revealed: nurses made an entry that the tubing was changed and dated 01/22/2023 and 01/29/2023. [tubing is changed every Sunday]. Record of Resident #1's physician order dated 02/02/2023 created by LVN A revealed an order for O2 via NC 2-4L/min prn every 1 hours as needed for SOB or sats below 92% room air. Attempted interview and observation on 02/02/23 at 9:40a.m., of Resident #1 revealed he was lying in his bed. He had a nasal cannula in place and an oxygen concentrator at his bedside. The concentrator was on and set to deliver 4 LPM (liters per minute). The oxygen tubing was dated 01/16/23. Record of Resident #1's nurses notes created by LVN A on 2/2/2023 9:42 a.m. read in part: . Note Text: notified [hospice company] of residents change in condition. Resident had episode of paleness along with clammy skin. Resident taken to his room by cna and cna notified nurse. Nurse assessed resident- at that time resident was not pale and clammy. o2 sat at84-85% on room air. o2 at 2l/min via NC applied and sats remained the same. Nurse then administered 4l/min o2 via nc- sats at 85% after 3 mins of administration. Resident assisted to bed x 2 staff. Resident doesn't appear sob and is acting as usual self. Will cont to monitor for any changes. [hospice company]to notify rp . Observation and interview on 02/02/23 at 10:03 a.m., LVN A said the oxygen tubing was dated 01/16/23. She said oxygen tubing were changed weekly by night shift nurses on Sunday. She said Resident#1 had a change of condition this morning. She said resident had standing orders from hospice. She said there was an oxygen concentrator in the resident's room not being used with tubing connected. She said she did not check the date on the tubing prior to administering the oxygen therapy this morning. She said tubing should be changed weekly to avoid infection control issues and to let the nursing staff know when the tubing was changed. In an interview and record review on 02/02/23 at 10:11 a.m., with LVN A, LVN A reviewed Resident #1's Physician's orders with this Surveyor. LVN A said she did not see an order for oxygen. Resident#3 Record review of Resident #3's face sheet undated revealed the resident was a [AGE] year-old female admitted [DATE] and readmitted on [DATE] with diagnoses that included Parkinson's disease, Acute respiratory failure with hypoxia, restlessness and agitation Record review of the Resident #3's MDS dated [DATE] revealed a BIMS score of 00 out of 15 indicating severely impaired cognitive skills. Further review of the MDS revealed that she required extensive assistance from staff for dressing, toilet use and personal hygiene. The resident was incontinent of bowel and bladder. Section C0100. Special treatment, procedures and program was coded for receiving oxygen therapy. Record review of Resident#3's Care Plan initiated 9/23/2019 and revised on 10/8/2019 revealed the following: Focus: Resident #3 has Oxygen Therapy r/t O2 via N/C at 3L/min at night as needed Goal: Resident#3 will have no s/sx of poor oxygen absorption through the review date. Interventions: OXYGEN SETTINGS: Resident #3 has O2 via nasal cannula @ 3L continuously at night as needed. Record review of Resident #3's physician order dated 02/20/22 revealed an order to Change O2 tubing Q week on Sunday every night shift every Sun related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA. Record review of Resident #3's physician order dated 9/30/22 revealed an order for 02 @ 2-4L CONTINUOUS TO KEEP SATS >90%. every shift for TO KEEP 02 SATS > 90%. Record review of Resident #3's MAR/TAR for the month of January 2023 revealed nurses made an entry that the tubing was changed and dated 01/29/2023 [tubing is changed every Sunday]. Attempted interview and observation on 02/02/23 at 9:56a.m., revealed Resident #3 was in the dining room sitting on a W/C receiving continuous oxygen from a portable concentrator. The concentrator was on and set to deliver 4 LPM (liters per minute). The oxygen tubing was dated 01/23/23. Observation and interview on 02/02/23 at 10:06 a.m., LVN B stated Resident #3's oxygen concentrator tubing was labeled 01/23/23. LVN B stated not changing the tubing could be an infection control issue. She said tubing were changed weekly by night nurses on Sunday. She said she knew resident was on oxygen therapy but did not check the tubing this morning. Record review and interview on 02/02/23 at 12:00p.m., the DON reviewed Resident #1 and #3's physician orders and MAR/TAR with the Surveyor. The DON said the tubing and humidifier were checked on Sunday by the night shift nurse. The DON said nurses were responsible for ensuring the procedures involving oxygen therapy and the dating/changing of tubes were completed. She said she had no explanation of why the changing of the oxygen equipment was not done. She said the nurses documented that tubing were changed. She said LVN A brought it to her attention that Resident #1 had a change of condition this morning and there was a set-in resident's room. LVN A told her that she did not check the date on the tubing before administering oxygen. The DON said her expectation was to follow physician order and have a clean set available in case of emergency. She said not changing the oxygen equipment could have the potential outcome of the residents experiencing breathing issues and possible infections. In an interview on 02/02/23 at 12:14p.m., with the DON and the Administrator, the Administrator said the facility did not have a policy on dating/replacing oxygen therapy equipment.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of six residents (Resident #1) reviewed for quality of care. 1. The facility failed to ensure Resident #1 received his Aspercreme [MEDICATION(S)] cream (used for pain relief) or an alternative treatment in a timely manner and resulted in him missing seven doses. 2. The facility failed to ensure Resident #1's TED (thromboembolic deterrent) hose (used to prevent blood clots) were put on as ordered by his physician. These failures placed residents who were dependent on staff for medication administration and ADLs at risk of experiencing pain and other health side effects from possible interruptions to their medication regimen. Findings include: Record review of Resident #1's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), COVID-19 (coronavirus 2019), [CONDITION(S)] (type of arthritis that occurs when flexible tissue at the ends of bone wears down), joint pain, open wound of the left lower leg, [CONDITION(S)] heart disease of native coronary artery (a buildup of plaque inside the artery walls which causes arteries to become narrower and slows the flow of blood) and altered mental status (a disruption in how the brain works that causes a change in behavior). Record review of Resident #1's MDS assessment dated [DATE] revealed he had a BIMS of 4 (severe cognitive impairment); he did not exhibit behaviors such as rejection of care; he required extensive physical assistance from at least two staff for bed mobility, transfers, toilet use, and bathing; he required extensive physical assistance from at least one staff for locomotion (wheelchair bound), dressing, and personal hygiene; and he was always incontinent of bowel and frequently incontinent of bladder. Record review of Resident #1's care plan updated 07/05/2021 revealed he was dependent on staff for activities, cognitive stimulation, and social interaction due to immobility and physical limitations; he had chronic pain due to old injuries in his shoulders and legs/knees (Interventions included: He prefers to have pain controlled by medication and topical patch, Evaluate the effectiveness of pain interventions every shift and p.m. [Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition.], and CNA's will monitor/record/report to Nurse resident complaints of pain or request for pain treatment); and he had altered cardiovascular status due to heart failure and [CONDITION(S)] heart disease of native coronary artery (Interventions included: Monitor/document/report to doctor PRN any signs and symptoms of coronary artery disease [chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent [CONDITION(S)], changes in capillary refill, color/warmth of extremities]). Further review of Resident #1's care plan revealed no documentation or updates which indicated he refused application of his prescribed Aspercreme [MEDICATION(S)] cream or TED hose. Record review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] TED hose to be put on every morning and removed at night every day and evening shift related to heart failure, unspecified. Order Status: Active. Order date: 12/18/2021. Start Date: 12/18/2021. Aspercreme [MEDICATION(S)] 4% ([MEDICATION(S)] HCl). Apply to affected areas topically four times a day related to pain, unspecified. Apply 2 gm to bilateral shoulders, wrists, knees, neck. Order Status: Active. Order Date: 05/26/2022. Start Date: 05/27/2022. Record review of Resident #1's TAR (Treatment Administration Record) for June 2022 revealed: Aspercreme [MEDICATION(S)] 4% ([MEDICATION(S)] HCl). Apply to affected areas topically four times a day related to pain, unspecified. Apply 2 gm to bilateral shoulders, wrists, knees, neck. 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. Further review of the TAR revealed the medication was not applied as prescribed on: 06/21/2022 at 8:00 a.m. (LVN A), 06/21/2022 at 12:00 p.m. (LVN A), 06/22/2022 at 4:00 p.m. (LVN B), 06/22/2022 at 8:00 p.m. (LVN B), 06/23/2022 at 4:00 p.m. (LVN B), 06/23/2022 at 8:00 p.m. (LVN B), and 06/29/2022 at 8:00 a.m. (LVN A). TED hose to be put on every morning and removed at night every day and evening shift related to heart failure, unspecified. 6:00 a.m., 2:00 p.m. Further review of the TAR revealed Resident #1's TED hose were put on and taken off daily as prescribed. Record review of Resident #1's TAR for July 2022 revealed: TED hose to be put on every morning and removed at night every day and evening shift related to heart failure, unspecified. 6:00 a.m., 2:00 p.m. Further review of the TAR revealed Resident #1's TED hose were not put on as prescribed on 07/01/2022. Observation and interview with Resident #1 on 07/01/2022 at 11:45 a.m. in his original room (the room he was in before he was transferred to the facility's COVID-19 unit) revealed he was just transferred back to his room from the COVID-19 unit. Resident #1 was alert and was sitting in his wheelchair with a family member. Resident #1 stated he did not know where he was and he did not know how long he had been living there. Resident #1 answered questions inappropriately and referred to his family member as an employee. Resident #1 did not have TED hose on either of his legs. Record review of Resident #1's progress notes for June 2022 revealed: On 6/20/2022 at 1:27 p.m., the DON wrote, Resident tested positive for COVID-19. On 6/21/2022 at 8:19 a.m., LVN A wrote, Aspercreme [MEDICATION(S)] Cream 4 %. Apply to Affected Areas topically four times a day related to PAIN, UNSPECIFIED. Apply 2 gm to bilateral shoulders, wrists, knees, neck FAMILY NOTIFIED, TO BRING IN TODAY. On 6/21/2022 at 12:59 p.m., LVN A wrote, Aspercreme [MEDICATION(S)] Cream 4 %. Apply to Affected Areas topically four times a day related to PAIN, UNSPECIFIED. Apply 2 gm to bilateral shoulders, wrists, knees, neck AWAITING FAMILY TO BRING TO FACILITY. On 6/22/2022 at 3:40 p.m., LVN B wrote, Aspercreme [MEDICATION(S)] Cream 4 %. Apply to Affected Areas topically four times a day related to PAIN, UNSPECIFIED. Apply 2 gm to bilateral shoulders, wrists, knees, neck. Family aware to bring more. On 6/23/2022 at 5:18 p.m., LVN B wrote, Aspercreme [MEDICATION(S)] Cream 4 %. Apply to Affected Areas topically four times a day related to PAIN, UNSPECIFIED. Apply 2 gm to bilateral shoulders, wrists, knees, neck. Not in stock. On 6/24/2022 at 6:14 p.m., the DON wrote, Note Late Entry: Family notified that resident was out of his [MEDICATION(S)] cream that they provide. Family notified that he had an extra bottle in his old room from where he was pre COVID-19. The nurse on duty was given the bottle out of his room and educated that we do have house stock that he can use in another incident that he is out. Resident given his pain cream this shift as ordered. Doctor notified that he did miss a dose prior day. Resident did not complain of pain at this time. On 6/29/2022 at 11:35 a.m., LVN A wrote, Aspercreme [MEDICATION(S)] Cream 4 %. Apply to Affected Areas topically four times a day related to PAIN, UNSPECIFIED. Apply 2 gm to bilateral shoulders, wrists, knees, neck. NOT DONE THIS AM. In an interview with Resident #1's family member on 07/01/2022 at 11:50 a.m., she stated Resident #1 had just moved back to his room from the COVID-19 unit that morning (07/01/2022). She stated there was a camera with audio in Resident #1's room and she knew the CNAs were not putting on the resident's TED hose daily. She stated Resident #1 did not have his TED hose on 06/20/2022, the same day he tested positive for COVID-19 and was moved to another room. She said Resident #1 did not have his TED hose on at that time (07/01/2022). She said the facility did not receive Resident #1's medication directly because she picked them all up from the VA and brought them to the facility monthly. The family member said the facility staff were not administering Resident #1's doctor-ordered Aspercreme. She said nobody told her until 06/25/2022 that Resident #1 was out of the pain cream. She said staff (she did not name the staff) told her Resident #1 did not have the pain cream because she did not bring it. The family member said then, staff told her they had some of the same pain cream in stock, so they used theirs for some of the doses. She said she kept extra cream in one of the drawers in his original room with a note to let her (the family member) know when they needed more cream. In an interview with CNA C on 0701/2022 at 12:15 p.m., she stated she worked the 6:00 a.m. to 2:00 p.m. shift and she was responsible for Resident #1's care on that day (07/01/2022). Said she the CNAs were responsible for putting on Resident #1's TED hose every morning, and the evening shift took them off. CNA C said she knew to put the TED hose on every morning, but she honestly forgot to put them on that morning (07/01/2022). She said sometimes, the nurses had to remind the CNAs to put the TED hose on if they got busy. She said the nurses put the TED hose on for them sometimes. CNA C said Resident #1 never refused to put the TED hose on that she knew of. In an interview with the Administrator and the DON on 07/01/2022 at 12:45 p.m., the Administrator stated Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator said the staff still attempted to put them on, but he still refused. The Administrator said the family member was aware of his refusals and the refusals should have been in his care plan. The DON said Resident #1 had not experienced any swelling and he did not like the TED hose because they restricted his toes. The DON said the TED hose were listed on Resident #1's TAR, so the staff documented putting them on and taking them off daily. The Administrator said Resident #1 complained of pain constantly, but he sometimes refused the pain cream. The Administrator said Resident #1 had severe arthritis and they tried various pain medications and patches, but he had allergic reactions to those. The Administrator said Resident #1 ran out on of the pain cream on Saturday (06/25/2022), while he was in the COVID-19 unit. The Administrator said the facility had Aspercreme in stock, so staff used that for some doses. In a telephone interview with LVN A on 07/01/2022 at 1:30 p.m., she stated she usually worked the 6:00 a.m. to 2:00 p.m. shift. She said on 6/21/2022, Resident #1's first day in the COVID-19 unit, she went to look for his Aspercreme with [MEDICATION(S)] and it was not there. She said she knew Resident #1's family usually supplied the pain cream, but she did not know when he ran out of it. LVN A said she asked LVN B, who was coming on for the 2:00 p.m. to 10:00 p.m. shift, and he said Resident #1's family had to bring the cream and were already notified the day before. LVN A said she did not call Resident #1's family member about the pain cream, but she wrote a note about the family notification based on what LVN B said. LVN A said there was no Aspercreme with [MEDICATION(S)] on the cart for her to use. In a telephone interview with LVN B on 07/01/2022 at 1:50 p.m., he stated he usually worked the 2:00 p.m. to 10:00 p.m. shift. LVN B said Resident #1 ran out of his pain cream and they were waiting for his family to bring it in. He said the Aspercreme with [MEDICATION(S)] was not an over-the-counter medication and they did not have any in their stock. LVN B stated he mentioned needing more cream with Resident #1's family member on yesterday, 06/30/2022. He stated other than that, he never had any conversation with the family member about the cream. He said he may have chatted with LVN A about the cream, but he did not recall saying he spoke to the family member about needing more cream. LVN B said he cared for Resident #1 3-5 days, but he did not recall caring for him until 06/25/2022 or 06/26/2022. He stated LVN A may have documented not having the cream on the day shift, but he documented administering the cream that evening, and the next day, LVN A documented having it on the morning shift but he did not have it on the evening shift because sometimes, they may find a small residual amount in the tube. In a follow-up interview with the DON on 07/01/2022 at 2:00 p.m., she said some of the nurses did not think to look for cream in their house stock. She said some nurses looked in the house stock, but some did not know because everybody's medication did not fit in the cart on the COVID-19 unit and had to be stored in another cart. She said when she was notified (she did not say who notified her), she called Resident #1's family who told her there was an extra bottle of the pain cream the drawer of his original room. The DON stated she did find the extra cream in Resident #1's drawer. In a telephone interview with Resident #1's doctor on 07/01/2022 at 2:10 p.m., she stated she did not recall being notified about Resident #1 running out of pain cream. She said the pain cream was needed for relief of arthritic pain in Resident #1's right shoulder because he hurt and ached all the time. She said if Resident #1 was up and about in his wheelchair, he needed to wear the TED hose to keep swelling down. In an interview with the Administrator and the DON on 07/01/2022 at 2:30 p.m., the DON said Resident #1 did not experience any negative outcome from not having the pain cream or the TED hose. The DON said the pain cream was for arthritis and an old rotator cuff injury, but she did not think Resident #1 experienced any pain for the days he did not have the pain cream. The Administrator said Resident #1 occasionally complained of pain but was fine when he missed the doses of pain cream. The Administrator said Resident #1 needed to wear the TED hose, but his doctor said it was not detrimental if he refused or sat in his recliner. The Administrator said he did not experience any swelling or other negative outcome from not having the TED hose on. Record review of, Medication and Treatment Orders, dated February 2014 revealed, Orders for medications and treatments will be consistent with principles of safe and effective order writing . 11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available .

Based on interview and record review, the facility failed to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team for 2 (#27 and #32) of 16 residents reviewed for care plan revisions in that: 1. Resident #27s care plan was not updated to reflect her use of [MEDICATION(S)] Sprinkle capsules (drug used for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2 Resident #32's care plan was not update to reflect the use of [MEDICATION(S)] tab (drug used as anti-clotting drug to prevent blood clots to brain, lungs and heart) and [MEDICATION(S)] (drug used to treat loss of appetite, malnutrition, and severe weight loss in patients with acquired immunodeficiency syndrome( AIDS) These deficient practices could affect residents by placing them at risk of receiving inadequate care. The findings include: Resident #27 Review of Resident #27's face sheet dated revealed she was [AGE] year-old, admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #27's quarterly MDS assessment dated [DATE] revealed the BIMS score 03 out of 15 indicating severely impaired cognitively. Further review of the MDS revealed she required extensive assistance from two-person physical assist for dressing, toilet use and personal hygiene Record review of the Resident #27's physician's order dated 04/19/22 revealed [MEDICATION(S)] sprinkles Capsule Delayed Release sprinkle ([MEDICATION(S)]) 125 mg by mouth one time daily for Alzheimer's with agitation Record review of Resident #27's care plan revealed it was last reviewed on 2/21/22. Further review revealed no care plan for [MEDICATION(S)] sprinkles capsule. Resident #32 Review of Resident #32's face sheet dated revealed she was [AGE] year-old, admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #32's admission MDS assessment dated [DATE] revealed the BIMS score 09 out of 15 indicating moderately impaired cognitively. Further review of the MDS revealed she required extensive assistance from one-person physical assist for dressing, toilet use and personal hygiene. Record review of the Resident #32's physician's order dated 04/07/22 revealed an order of [MEDICATION(S)] tab 2.5mg BID for [CONDITION(S)]. On 5/5/22 there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #32's care plan revealed it was last reviewed on 4/11/22. Further review revealed no care plan for [MEDICATION(S)] tab 2.5mg BID for [CONDITION(S)] and [MEDICATION(S)] 40 mg give 5 tab every day for Anorexia. Interview on 5/12/22 at 1:20 PM with the DON, she said she does the MDS and care plans she had been very busy working because the MDS nurse quit, the nurses are supposed to notify her when there was any new medication so she could care plan it. DON said she was responsible for updating care plan. She said the care plans needed to reflect the current condition of the residents and what was going on with them so they could be provided proper care. During an interview on 5/12/22 at 2:24 PM the LVN A said did not known, he was to notify the DON when a resident got a new medication. Interview on 5/12/22 at 2:20PM with the Administrator, she said the DON does the care plan now since the MDS nurse retired/quit on 4/20/22. Administrator said they should have updated the care plans when they started new medication per the CMS guidelines. She said they were following the guidelines, but just failed to put it in the care plans. Record review of the facility policy Care Plans, Comprehensive Person-Centered, dated October 2010, revealed, in part, assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (Resident #27) of 16 residents reviewed for unnecessary drugs , in that: The facility failed to ensure the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents receiving medications at risk of a possible adverse drug reaction or hospitalization . The findings were: Resident #27 Review of Resident #27's face sheet revealed she was [AGE] year-old, admitted to the facility on [DATE]. Her diagnoses included : contusion of left hip (caused by a direct blow to the body that can cause damage to the surface of the skin), heart failure, [CONDITION(S)], abnormalities of gait and mobility, (unsteady movement) essential (primary) hypertension, (high blood), [CONDITION(S)] (lack of sleep), [CONDITION(S)] (low [CONDITION(S)]), dementia (a chronic or persistent disorder of the mental processes cause by brain disease) with behavioral disturbance, constipation, vomiting, [CONDITION(S)] ( low blood pressure), chronic gout (disease in which defective metabolism of uric acid cause arthritis) open wound of left forearm, [CONDITION(S)], abnormal weight loss, gout, open wound, left lower leg. Record Review of Resident #27's quarterly MDS assessment dated [DATE] revealed the BIMS score 03 out of 15 indicating severely impaired cognitively. Further review of the MDS revealed she required extensive assistance from two-person physical assist for dressing, toilet use and personal hygiene Record review of the Resident #27's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no order to do behavior or side effect monitoring for Resident #27's use of [MEDICATION(S)] (antiepileptic drugs (AEDS), also used treat of [CONDITION(S)] associated with [CONDITION(S)] disorder known as [CONDITION(S)], seizures ([CONDITION(S)]), and migraine headaches.) Record review of Resident #27's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no diagnosis listed for the medication. Record review of Resident #27's Quarterly MDS assessment, Section E dated 04/04/22, revealed Resident #27: - no potential indicators of [CONDITION(S)] -exhibited no behavioral symptoms or [CONDITION(S)] and, -rejected care one to three days. Record review of Resident #27's Care Plan, initiated 12/08/21, and revised on 2/21/22 revealed Resident #27 had potential for mood problem, would refuse care at times and medication. During an interview on 5/12/22 at 1:20 PM with the DON, she said resident #27 had agitation, hitting staffs, and combative with staffs that was why she was place on [MEDICATION(S)]. The DON said the retired MDS nurse was responsible for ensuring that physicians ordering medication had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 5/12/22 at 2:24 PM the LVN A said Resident #27 does get verbally agitated and can lash out to staff and she was easily redirected. LVN A said Resident #27 order for [MEDICATION(S)] was a telephone order he received from his primary doctor on 4/19/22 and he faxed it to the pharmacy, he did not remember what [MEDICATION(S)] was used for. During an interview on 5/12/22 at 3:15 PM the Administrator said the physician verifies and changes orders electronically. They should always put a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This should have been caught by the pharmacy or the nurse. They would be responsible for ensuring the medications are correct. Review of the facility's undated policy on, Pharmacy Services- Drug Regimen Free From Unnecessary Drugs: Revealed the following under procedures: 1. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: C. Without adequate monitoring without adequate indications for its use .

Based on record reviews and interviews, the facility failed to provide or obtain laboratory services to meet the needs of the residents for timeliness and quality of the services for one of 16 residents (Resident #27) reviewed for labs in that: Resident #27 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The lab request was sent to the lab on 3/21/22 but were never drawn and the facility failed to follow up on the labs. This failure could put residents who may have lab work ordered at risk of not having their medical needs met. Finding include: Resident #27 Review of Resident #27's face sheet dated revealed she was [AGE] year-old, admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #27's quarterly MDS assessment dated [DATE] revealed the BIMS score 03 out of 15 indicating severely impaired cognitively. Further review of the MDS revealed she required extensive assistance from two-person physical assist for dressing, toilet use and personal hygiene. Record review of the current Order Summary Report for Resident #27 revealed that she had an order stating, Order Status Active. Order Date 09/13/2021. BNP( Brain Natriuretic peptide -blood test used to measured protein level in the heart and blood vessels), HGA1C ( hemoglobin A1C- blood test that measures average blood sugar levels over the past 3 months), Lipids and Vitamin D every year (March) Record review of the clinical record for Resident #27 revealed there was no documentation in the clinical record/chart the lab had been drawn for March 2022 During an interview on 05/12/2022 at 1:20 PM with the DON, she said the facility was having problem with lab during COVID-19 last year (2020) and the contracted lab were not showing up. She said they have a new lab services now since 2021. DON said she would check with ADON to see if she had put the results in another file. The DON said she and the ADON were responsible for checking on the lab. The ADON was off duty. DON and the administrator checked files where lab results were kept. During the exit conference on 5/12/22 at 4:00PM with DON and Administrator said the reason labs were not done was due to oversite. The lab request reviewed was sent to the new lab on 3/21/22 and lab was not drawn. DON said Resident #27 lab not being done could lead to missed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 05/12/2021 at 4:00 PM with Administrator she stated she was aware of the current missing labs. Stated they are working on an action plan to address the problem. Record review of the facility lab and diagnostic test results -Clinical Protocol revised April 2013: Assessment and Recognition: 1. The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (CR#1) reviewed for pharmacy services. -The facility failed to ensure CR#1's medications were available and administered as ordered by the physician. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefits of the medications. Findings included: Record review of the admission sheet (not dated) for CR#1 revealed an [AGE] year-old female admitted to the facility on [DATE]. CR #1 was discharged on [DATE]. Her diagnoses included ventricular fibrillation, gastro-[CONDITION(S)] reflux disease without esophagitis and diverticulitis of both small and large intestine without perforation or abscess without bleeding. Record review of CR#1's Nursing Home and Swing Bed Tracking MDS, dated [DATE] revealed there was no section to record the BIMS. Record review of CR#1's care plan, initiated 10/25/21, revealed the following: Focus: the resident has acute/chronic pain. Goal: the resident will voice a level of comfort. Interventions: identify, record and treat resident's existing conditions which may increase pain and or discomfort. Record review of CR#1's physician's orders, dated 10/21/2021, revealed an order for [MEDICATION(S)] Tablet 400mg give 1 tablet by mouth two times a day related to ventricular fibrillation (149.01) hold if pulse <60. Record review of CR#1's nurse's notes written by MA A on 10/21/2021 7:10 p.m. reflected in part: .Note Text: medication pending arrival Record review of CR#1's nurse's notes, dated 10/21/2021 6:44 p.m., reflected in part: .Note Text: [MEDICATION(S)] Suspension 1 % Instill 1 drop in left eye two times a day related to UNSPECIFIED ACUTE INFLAMMATION OF ORBIT (H05.00) 1 drop to LEFT EYE BID not available Record review of CR#1's nurse's notes, dated 10/21/2021 7:10 p.m., reflected in part: .Note Text: medication pending arrival . Record review of CR#1's nurse's notes, dated 10/22/2021 6:42 a.m., reflected in part: . Note Text: [MEDICATION(S)] Tablet Delayed Release 40 MG Give 1 tablet by mouth one time a day related to GASTRO-[CONDITION(S)] REFLUX DISEASE WITHOUT ESOPHAGITIS (K21.9) WAITING FOR MEDICATION TO ARRIVE AT FACILITY . Record review of CR#1's nurse's notes, written by MA B on 10/22/2021 at 7:04 a.m., reflected in part: . [MEDICATION(S)] Tablet 400 MG Give 1 tablet by mouth two times a day related to VENTRICULAR FIBRILLATION (I49.01) HOLD if Pulse < 60. WAITING FOR MEDICATION TO ARRIVE AT FACILITY Record review of CR#1's nurse's notes, written by MA B on 10/22/2021 at 7:04 a.m., reflected in part: . Note Text: [MEDICATION(S)] Tablet Give 1 tablet by mouth one time a day related to DIARRHEA, UNSPECIFIED (R19.7) WAITING FOR MEDICATION TO ARRIVE AT FACILITY Record review of CR#1's nurse's notes, written by MA C on 10/22/2021 at 6:03 p.m., reflected in part: .Note Text: MED NOT AVAILABLE. NURSE NOTIFIED Record review of CR#1's nurse's notes revealed no documented evidence the doctor was notified of the missed doses for the medications prescribed. In a telephone interview on 4/5/22 at 2:12 p.m. with CR #1, she said she stayed at the facility for 14 days and did not receive all her medicines for 2 to 3 days that were prescribed to her upon discharge from the hospital. She said the nurses told her the medicines were not available. In an interview on 4/6/22 at 10:43 a.m. with LVN BB, she said if the meds were not available the medication aide needed to let the nurse know so the nurse could check the e-kit. She said the emergency kit did not have all the medications. LVN BB said the nurse should follow up with pharmacy and notify the doctor that the dose was missed and document the doctor's response if the new order was given, or the order was put on hold till meds arrived at the facility. In an interview on 4/6/22 at 12:09 p.m., with MA D, she said she administered routine PO meds to all the residents. She said with the newly admitted residents, upon arrival the nurse/ADON would put the orders in the computer and fax the orders to the pharmacy. She said after 2 to 3 days of missed doses, she would call the pharmacy to find out what was the hold up. She said the pharmacy was quick to send meds. She said if the meds were ordered by 7p.m. the pharmacy would drop the meds by midnight. She said in the past the pharmacy had held the medications because it was interacting with other meds that the residents were taking. She then would talk to Doctor A to let her know what the pharmacy said and notify the nurse/ADON and the DON. In a telephone interview on 4/6/22 at 12:21 p.m. with Doctor A, she said she did not recalled being notified about CR#1's missed meds. She said if the patient missed a dose of blood pressure medicine her expectation from the staff was to call her immediately. She said if the BP medication was not given the BP would be out of range. She stated she needed to be notified immediately so they could figure out a plan and get a substitute med or get the medicine from another pharmacy so the patient could get the medication. In an interview on 4/6/22 at 12:18 p.m. with LVN CC, she said if the medication was not available the nurse needed to check the e-kit first. LVN CC stated if the prescribed medication was not in the e-kit then the process was to call the pharmacy to inquire why the medications were not delivered and to document. She said the doctor needed to be notified after the first missed dose. In an interview 4/6/22 at 12:46 p.m. with the DON, the Surveyor reviewed CR#1's MAR with the DON. The DON said the staff needed to call the pharmacy to find out why the medications were not delivered. She said, BP meds were not in any of our boxes ABT/Ekit. If the resident missed a dose, process is to notify the doctor that there was an elapse in treatment and order we received. At this time the policy on ordering medications was requested. In an interview 4/6/22 at 1:12 p.m. with the Administrator, she said she was unable to find a specific policy on ordering meds. She said the facility had a general policy. She said she had asked corporate for the policy. A policy on ordering medications was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (AD and ADON) of 2 staff members observed for infection control practices. -The facility failed to screen visitor for COVID-19 signs/symptoms and to check temperatures. -The AD and ADON failed to screen the surveyor upon entrance on 9/2/21. This failure placed residents at risk of exposure to COVID-19, and serious illness. Findings include: Observation on 9/2/21 at 9:02 a.m., revealed upon entry into the facility the Surveyor meet with AD. The AD did not take any temperature checks or provide a questionnaire or screening of signs and symptoms regarding COVID-19 or possible exposure. She proceeded to move the surveyor into the ADON's office at 9:07 a.m. Observation on 9/2/21 at 9:08 a.m., revealed ADON did not take any temperature checks or provide a questionnaire or screening of signs and symptoms regarding COVID-19 or possible exposure. She proceeded to move the surveyor into the conference room at 9:16 a.m. In an interview on 9/2/21 at 9:55 a.m., with the DON and the Maintenance Director, the DON stated that the COVID-19 screening was important because it helps prevent any possible infection from coming into the building. She stated that visitors came through the back door, they had set up there with a thermometer, questionnaire and COVID test. She stated that front door was usually locked, and visitors came in through the back. Maintenance Director stated, I forgot to latch the front door while I was spraying this morning. In an interview on 9/2/21 at 1:36 p.m., the AD stated the Administrator and the DON were not in the facility when the Surveyor entered the facility, so she got busy contacting them and forgot to screen the Surveyor. The AD said she was aware that everyone/visitors should be screened prior to entering the facility. In an interview on 9/2/21 at 1:40 p.m., with the ADON, she stated she was not aware that the AD had not screened the Surveyor upon entry. The ADON stated COVID-19 screening should have been done prior to entering the facility. In an interview on 9/2/21 at 2:14 p.m., with the DON, she stated there use to be a sign at the front door that said to use the back door. The DON stated that the Administrator told her that it must have fallen out due to weather. She stated the Maintenance Director should have checked to see if the front door was latched properly. Record review of the facility's Emergency Infectious Disease Policy, not dated read in part: .i. To ensure that staff, visitors and/or new residents are not at risk of spreading the EID into the center, screening for exposure risk and signs and symptoms may be done PRIOR to admission of a new resident, allowing visitors to enter and allowing new and/or current staff to report to work .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment 4 of 12 residents (Resident #13, Resident #40, Resident #47, and Resident #42) reviewed for comprehensive care plan in that: -Resident #13's care plan did not address hydration. -Resident #40 was not care planned for her [DIAGNOSES REDACTED]. -Resident #47's diet orders were not followed. -MA E failed to administer Calcium [AGE]0+D3 Tablet [AGE]0-400 MG-UNIT (Calcium Carb-[MEDICATION NAME]) as ordered by physician for Resident #42. These failures could affect any resident and place them at risk for not having their care needs met. Findings include: Resident #13 Record review of Resident #13's admission assessment record revealed an original admission date of [DATE] and a readmission date of [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #13's annual MDS assessment dated [DATE] revealed the Care Area Assessment summary triggered him for hydration. Record review of Resident #13's quarterly MDS assessment dated [DATE] revealed he scored a 0 out of 15 on his BI[CONDITION] score indicating severe cognitive impairment. He was assessed as requireing limited assistance of one staff for eating. Record review of Resident #13's care plan revised on 01/03/2020 revealed it did not address hydration. Observation of Resident #13 on 02/05/20 at 10:54 AM revealed Resident #13 was in bed. He was totally dependent on staff for assistance with eating and drinking. A CNA was observed assisting Resident #13 with feeding. Resident #13's tray held the following menu items: Juice, water, health shake, eggs, meat, and toast. Resident #13's glasses with juice, water, and the health shake were full. During an interview on 02/05/2020 at 10:55 AM CNA OO said Resident #13 was coughing and did not want to eat or drink. She said his appetite was poor, but he would always drink a little of his fluid. She said he was not drinking much that morning. She said at that time she was going to inform the nurse. During an interview with the MDS Coordinator on [DATE]20 regarding a care plan addressing hydration for Resident #13, she said she must have missed it. She said she was going to look at it. Resident #40 Record review of the face sheet for Resident #40 revealed an [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #40's annual MDS assessment dated [DATE] revealed that her BI[CONDITION] score was 15 indicating that she was cognitively intact. Section A1510, for the question, Level II preadmission screening and resident review (PASRR) conditions, was left blank with nothing checked. Her active [DIAGNOSES REDACTED]. Record review of Resident #40's care plans initiated on 5/1/17 revealed no care plans to address her [DIAGNOSES REDACTED]. Interview and observation with Resident #40 on 2/4/20 at 11:00 am revealed she was in her room. She was very pleasant and answered questions. Interview with the MDS Coordinator on 2/6/20 at 10:00 am, she said she should have care planned Resident #40 for [MEDICAL CONDITION]. She confirmed [MEDICAL CONDITION] was not included in the care plans. Interview with the MDS Coordinator on 2/6/20 at 11:50 am, she said she could not find a care plan for [MEDICAL CONDITION] for Resident #40. She said she must have over looked that one. Record review of the facility policy for Care Plans-Comprehensive revised October 2010 read in part, .An individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Resident #47 Record review of Resident #47's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] and re admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #47's quarterly MDS assessment dated [DATE] revealed her BI[CONDITION] was 10 out of 15 indicating she had moderately impaired cognitive skills. She was documented as being on a therapeutic diet. The MDS coded her as not having any weight loss or weight gain in the last 6 months. Record review of Resident #47's Physician order's for February 2020 revealed an order for [REDACTED]. Record review of Resident #47's care plan initiated on 10/01/18 read in part, .provide, serve diet as ordered .double meat and protein portions . Record review of Resident #47's meal card read in part, double meat and protein portions. Observation and interview with Resident #47 on 2/4/20 at 12:11 pm revealed she was in her room in bed. Her meal tray was in front of her. Her tray contained a regular portion of meat loaf, green beans, macaroni and cheese, and corn bread. She was able to feed herself. Resident #47 said she was doing well and had no concerns. She said the food was good. Observation of Resident #47 on 2/6/20 at 11:37 am revealed she was eating her lunch in the dining room. Her tray had regular portions of rigatoni pasta with Italian sausage, mixed vegetables, and garlic bread. Interview and observation with LVN MM on 2/6/20 at 11:40 am when asked if Resident #47 had double portions, she looked at Resident #47's tray and said, Well, it's considered double portions for them. LVN MM then yelled to a cook in kitchen and asked, if Resident #47 had received double portions. The cook replied, No. Interview with the Dietary Manager and Cook on 2/6/20 at 12:11 pm they said they knew what each residents' diets and preferences were based on the dietary card. The Dietary Manager said the dietary card was completed by the nurse who got the orders from the physician and submitted it to the Dietary Manager. She said she also met with residents to see what their likes and dislikes were so they could put that on the dietary card. She said they were made aware of diet changes by the nurses. When asked about Resident #47, the Cook said she knew she messed up on it by not giving her double portions. She said she was distracted because others were talking to her. She said she normally looked at the diet card, and also the menu, when making the plates for the residents. Record review of the facility's policy for medication and treatment orders revised February 2014 read in part, .orders for medications and treatments will be consistent with principles of safe and effective order . Resident #42 Record review of the admission sheet for Resident # 42 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #42's Quarterly MDS assessment dated [DATE] revealed a BI[CONDITION] score of 10 out of 15 indicating moderately impaired cognition. She required limited assistance from one-person physical assist for dressing, toilet use, and personal hygiene. She was frequently incontinent of bowel and bladder. Record review of Resident #42's Care plan initiated 4/20/2016 revealed the following care plan read in part, .Focus: Resident has impaired cognitive function/dementia or impaired thought processes r/t she is only oriented to person and time usually. Goal: Resident will remain oriented to person and place for the next 90 days. Interventions: Administer meds as ordered . Record review of Resident #42's physician orders dated 9/17/2019 revealed an order for [REDACTED]. Observation on 2/5/2020 at 8:25 am of medication administration for Resident #42 revealed MA E was in the hallway with the medication cart. MA E dispensed one tablet of Calcium [AGE]0+D3 Tablet [AGE]0-400 MG-UNIT. Continued observation and interview on 2/5/2020 at 8:31 am with MA E, she said she was ready to administer the medications. The surveyor asked her to count the number of tablets in the cup. MA E counted the tablets and said 16. Continued observation revealed MA E took the medications into Resident #42's room and administered them to her. Record review of Resident #42's MAR for the month of February 2020 revealed MA E documented administration of Calcium [AGE]0+D3 Tablet [AGE]0-400 MG-UNIT (Calcium Carb-[MEDICATION NAME]) give 2 tablets by mouth one time a day for supplement. In an interview and record review on 2/5/2020 at 9:23 am with MA E, she said she started working in July 2019 at this facility. She said she worked full time during the 6-2 pm shift. She said she looked at the name of the medication and not the dosage. She confirmed she administered one tablet of Calcium [AGE]0+D3 Tablet instead of two tablets as ordered by the physician. MA E denied she had received any recent in-service/education on medication administration. In an interview on 2/5/2020 at 1:15 pm with the DON, she said her expectations were to follow physician orders when administering medications. Record review of facility's Administering Medications policy Revised December 2012 read in part, .Medications shall be administered in a safe and timely manner, and as prescribed.3. Medications must be administered in accordance with the orders.7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . Record review of facility's Adverse Consequences and Medication Errors policy Revised February 2014 read in part, .3. A 'medication error' is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 4. Examples of medications errors include: .c. wrong dose .

Based on interview, and record review, the facility failed to review and revise the person-centered care plan to reflect current condition for 2 of 12 residents (Resident #5 and Resident #31) reviewed for care plans. -The facility failed to care plan Resident #5's use of antiplatelet medications Aspirin and [MEDICATION NAME]. -The facility failed to develop and complete a comprehensive care plan within seven days after the completion of Resident #31's comprehensive assessment. These failures could affect all residents and place them at risk of not having their medical, nursing, and mental needs met, and of not having their psychological needs addressed. Findings Include: Resident #5 Record review of Resident #5's face sheet revealed a [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BI[CONDITION] score of 5 out of 15 indicating severely impaired cognition. She required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. She had functional limitation in range of motion impairment to one side of the lower extremity and required the use of a wheelchair for mobility. She was always incontinent of bowel and bladder. Record review of Resident #5's Physician orders revealed an order dated 01/30/20 to give Aspirin 81 mg one tablet by mouth one time a day related to [MEDICAL CONDITION]. Further record review revealed an order for [REDACTED]. Record of Resident #5's Medication Administration Record [REDACTED]. Record review of Resident #5's care plan dated 0[DATE] and revised 11/06/19 revealed there was no care plan for the use of Aspirin and [MEDICATION NAME]. Interview and record review on [DATE] at 9:25 a.m. the MDS Coordinator said the medications Aspirin and [MEDICATION NAME] should be care planned because they were blood thinners. The MDS Coordinator said she care planed everything. The MDS Coordinator reviewed Resident #5's physician orders and care plan. She then said Resident #5 was not care planned for the medications [MEDICATION NAME] and Aspirin. The MDS Coordinator said the reason Resident #5's medications Aspirin and [MEDICATION NAME] were not care planned was because she over looked them. Interview on [DATE] at 9:40 a.m. the DON said it was herself and the Administrator that ensured that the MDS Coordinator was performing her duties accurately. Resident #31 Record review of Resident #31's admission face sheet revealed she was an [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #31's Initial MDS assessment revealed an assessment reference date of 12/26/2019. She was assessed as scoring a 15 out of 15 on her BI[CONDITION] indicating she was cognitively intact. She had impaired vision. She required the extensive assistance of one staff for bed mobility, transfers, locomotion on the unit, dressing, and toilet use. She was totally dependent on one staff for bathing. She used a wheelchair. She was frequently incontinent of both bowel and bladder. She had frequent pain that made it difficult for her to sleep at night. She received an antidepressant and diuretic for 7 of 7 of the assessment days. She was receiving speech therapy, occupational therapy, and physical therapy. Her care area assessment summary dated and signed 1/14/2020 by the DON identified the areas of visual function, communication, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, pressure ulcer, [MEDICAL CONDITION] drug use, and pain as areas to be care planned. Record review of Resident #31's care plan dated as initiated [DATE] with a target date of completion of 01/20/2020 revealed the section that indicated Goals was in red and a message stating the care plan was not completed. During an interview with Resident #31 on 2/4/20 at 11:15 AM said she was always in pain. Said she was on [MED] and she got a pain patch. Said she did not know if the [MED] was working but she did not want to be on anything that she would get addicted to. In an interview with the MDS Coordinator on 2/6/2020 at 9:35 AM she said the care plan was not completed for Resident #31. She said she initiated the care plan, but she was behind on doing care plans. She said the MDS assessment should be completed within fourteen days and the care plans should be completed after the fourteen days MDS. She said she was behind and was now working on completing the MDS for Resident #31. During an interview on 2/6/20 at 1:10 PM regarding Resident #31's care plan with the DON she said she usually reviewed and opened the care plans. She said she usually followed up to ensure they were completed. She said she did not know what happened and why Resident #31's care plan was not done. At that time, she said she did not have an answer. Record review of the facility policy for Care Plans-Comprehensive revised October 2010 revealed in part: .An individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident.

Based on observation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities designed to meet the interests and support the physical, mental, and psychosocial well-being for 6 of 6 confidential residents reviewed for activities. -The facility failed to ensure there were organized activities on the weekend. This failure could place all residents that participate in activities at risk of having a decreased quality of life. Findings include: Record review of the facility's activity calendar for December 2019, January 2020, and February 2020 had the following activities listed for the weekends: 12/1/19- Rosary, Catholic mass, visits with family and friends 12/7/19- Rosary, Dominos and table games 12/8/19-Rosary, Catholic mass, Wharton plaza theatre-A Christmas Carol, visits with family and friends 12/14/19- Rosary, Dominos and table games 12/15/19- Rosary, Catholic mass, residents Christmas party 12/21/19-Rosary, Girl Scouts caroling, faith church caroling, Dominos and table games 12/22/19- Rosary, Catholic mass, El Campo church, visits with family and friends 1[DATE]- Rosary, Dominos and table games 12/29/19- Rosary, Catholic mass, visits with family and friends [DATE]- Rosary, Dominos and table games 1/5/20- Rosary, Catholic mass, visits with family and friends 1/11/20- Rosary, Dominos and table games 1/12/20- Rosary, Catholic mass, visits with family and friends 1/18/20- Rosary, Dominos and table games 1/19/20- Rosary, Catholic mass, visits with family and friends 1/25/20- Rosary, Dominos and table games 1/26/20- Rosary, Catholic mass, El Campo church, visits with family and friends 2/1/20- Rosary, Dominos and table games 2/2/20- Rosary, Catholic mass, Superbowl Sunday party, visits with family and friends 2/8/20- Rosary, Dominos and table games 2/9/20- Rosary, Catholic mass, visits with family and friends 2/15/20- Rosary, Dominos and table games 2/16/20- Rosary, Catholic mass, visits with family and friends [DATE]- Rosary, Dominos and table games 2/23/20- Rosary, Catholic mass, El Campo church, visits with family and friends 2/29/20- Dominos and table games During confidential interview with 6 residents on 2/5/20 at 9:30 am, all 6 residents said there were no activity staff person in the facility on the weekend. When asked what they did on the weekends for activities, they said, We just do what we want to do like watch TV, or just sit around. They said they were bored on the weekends and would like more activities. They said there were no staff available to assist them with activities. When asked if they had expressed this to the facility they replied, We haven't told them, but they should already know that. They said this was pretty much the only complaint they had. They said they had good activities during the week but nothing on the weekends. Interview with the Activity Director on 2/5/20 at 11:55 am, she said she had been working at the facility since 2008. She said her hours were Monday through Friday 8 am to 4 pm. She said she was the only activity staff there. She said there was a PRN staff that came when she was not there, but she mostly came Friday because the activity director had to leave early on Fridays. She said there was no activity staff there on the weekends. She said she does leave out games and [MEDICATION NAME] for the residents. She said sometimes, like for special events, they would do something. She said for the Super Bowl they had a party. She said they offered church service and, aside from that, there were no other activities offered. She said the residents did at one time complain to her about wanting more activities on Saturdays but nothing recently. She said if CNAs were done with their things, sometimes they would help residents with activities but there was no one designated to do activities or to assist them with activities. She said she understood there were residents that did not attend church service or have family that visited that needed other activities. She said she knew it was a requirement to have activities on the weekends but there was nothing she could do about it. She said the facility did talk about hiring more activity staff but did not know what came of that. Interview with the Administrator on 2/5/20 at 1:05 pm, she said restorative was there on the weekends to do exercises and stuff. She said sometimes the Activity Director would come on the weekends to do activities, such as for the Super Bowl but, it was not consistent. She said she understands they need to have someone there and there should be a variety of activities. She said she was going to have someone come in on weekends. She said this was the first time this was brought to her attention. Record review of the facility's policy for Activity Programs revised August 2006 read in part, .activity programs designed to meet the needs of each resident are available on a daily basis .activities are scheduled 7 days a week .

Based on observation, interview, and record review, the facility failed to ensure drugs and bilogicals were secured properly for 1 of 9 residents (Resident #32) and were not expired in one of one medication rooms reviewed for medication storage in that: -RN AA left medication [MEDICATION NAME] R unsupervised sitting on top of the medication cart. -There were expired medications in the Medication Room. These failures could affect all residents and place them at risk for drug diversion and administration of expired medications. Findings include: Resident # 32 Record review of the face sheet for Resident #32 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #32's Quarterly MDS assessment dated [DATE] revealed she had a BI[CONDITION] score of 13 out of 15 indicating she had intact cognition skills. She was receiving [MED] during the last 7 of 7 days of the assessment period. Record review of Resident #32's care plan initiated 7/30/19 revealed the following care plan: Focus: Resident have a [DIAGNOSES REDACTED]. Goal: Resident will be free from any s/sx of [MEDICAL CONDITION] through the review date. Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. On [MEDICATION NAME] and [MEDICATION NAME] injections and [MEDICATION NAME] as prescribed by MD. Observation on 2/4/2020 at 10:59 am revealed RN AA was preparing to give prescribed medication for Resident #32. RN AA removed the following medication: a half-filled bottle of [MEDICATION NAME] R and left it on top of the medication cart. RN AA went to Resident #32's room to wash her hands and left the medication unsupervised and out of her line of sight for couple of minutes while she was washing her hands. In an interview at the time of the observation on 2/4/2020 at 11:02 am, RN AA said she had left the [MED] bottle on top of the medication cart and that she was not able to see the bottle while she had washed her hands inside the resident's room. RN AA said she should not have placed the [MED] bottle on top of the medication cart unattended for safety reasons. RN AA said someone could have come along and taken the medication off the cart. In an interview on 02/05/20 at 1:18 pm with the DON, she said staff ere required to keep all medications within their sight at all times and locked when not attended as per the facility's policy. The DON said medications should not be left unattended and out of sight due to the risk of another resident getting hold of the medication. Observation on 2/6/2020 at 10:42 am inside of the medication room revealed the following expired medications: [REDACTED]. In an observation and interview on 2/6/2020 at 10:44 am with MA HH she said there was only one medication room in the facility. She said expired meds were not supposed to be in the cabinet. She said the business manager was in charge of the medication room. In an interview on 2/6/2020 at 10:49 am with the Business Office Manager and the Administrator, the Administrator said the BOM was in charge of ordering the meds, but the DON was responsible for ensuring there were no expired/out of date medications in the med room. In an interview on 2/6/2020 at 10:50 am with the DON, she said the DON, ADON, nurses, and the medication aides were responsible for ensuring there were no expired medications in the medication rooms. She said the medication aide did inform her about expired meds in the medication room. The DON said she did not have any system in place on monitoring expiration dates. She said her expectation was when the staff took the medication out of the medication room they looked at the expiration date. Record review of facility's Storage of Medications policy revised April 2007 read in part, .the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe and sanitary manner.4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 2 of 12 residents (Resident #19 and Resident #39) reviewed for infection control in that: -Resident #19's oxygen equipment was not changed on a weekly and monthly basis. -CNA M failed to perform hand hygiene when providing incontinent care to Resident #39. -CNA M contaminated clean resident use items by touching them while wearing contaminated gloves. These failures could affect all residents and place them at risk for cross contamination, infections, and decline in health. Findings include: Resident # 19 Record review of Resident #19's face sheet revealed an [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #19's MDS assessment dated [DATE] revealed a BI[CONDITION] score of 9 out of 15 indicating moderately impaired cognition. She required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. She was always incontinent of bowel and bladder. Record review of Resident #19's care plan dated 0[DATE] and revised 12/30/19 revealed a care plan for oxygen therapy related to asthma. Record review of Resident # 19's Nursing Progress notes dated 12/30/19 documented RN UT read in part, . Nurse observed resident lying in bed with labored breathing and hacky wet cough, scattered crackles .oxygen saturation on room air 92-94%.oxygen at 2 liters nasal cannula applied. Record review of Resident #19's Nursing Progress Notes dated 12/31/19 at 1:17 p.m. documented by LVN R read in part, .Resident #19 was readmitted yesterday from the hospital . Record review of Resident #19's Nursing Progress Notes dated 12/31/19 at 7:04 p.m. documented by RN L read in part, .Continue readmit charting .oxygen saturation [AGE]% with oxygen on at 2 liters nasal cannula .wheezing noted as well as non-productive cough . Record review of Resident # 19's Order Summary Report revealed an order dated 01/16/20 for Oxygen at 2 liters per nasal cannula as needed for shortness of breath. Observation on [DATE] at 9:20 a.m. of Resident #19 reveaeld she was in her room resting in bed with her eyes closed. Her respirations were even and unlabored. There was an oxygen machine at her bedside that was not in use at the time. The oxygen tubing was hanging over the oxygen machine and was not inside of a bag to prevent it from being contaminated. A plastic bag was resting on top of the oxygen machine. A note written on the plastic bag read, Replace after each use. The humidifier bottle had a date of 12/31/19. Observation on 02/05/20 at 8:05 a.m. of Resident #19's oxygen equipment in her room revealed the oxygen tubing layed over the oxygen machine and was not inside of a bag. The humidifier bottle had not been changed and was dated 12/31/19. Interview on [DATE] at 9:15 a.m. RN UT said used oxygen equipment such as tubing and humidifier bottles were changed out once a week on the night shift. RN UT said the reason why used oxygen equipment was changed weekly was largely because of bacteria and infection control purposes. Interview on [DATE] at 9:40 a.m. the DON said used oxygen equipment such as oxygen tubing was changed on a weekly basis. The DON said the used oxygen humidifier bottles were changed out every month. The DON said these practices were done for infection control. This surveyor asked the DON for facility policy on oxygen equipment. Interview on [DATE] at 1:10 p.m. with the Administrator and DON, the DON said the facility did not have a policy on maintenance and discarding of used oxygen equipment. The Administrator said she had reached out to their sister facility regarding used oxygen equipment and maintenance. The Administrator said the sister facility told her there was no policy on maintenance of use oxygen equipment. The DON interjected and said she was taught in Nursing school that used oxygen equipment needed to be changed once a week for best nursing practices. Both the Administrator and DON said, regarding the oxygen prefilled humidifier bottles, they went by the date the bottle was opened and were to discard the bottle after a month, just like they did for [MED]. Resident #39 Record review of the admission sheet for Resident #39 revealed a [AGE] year old female admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #39's quarterly MDS assessment dated [DATE] revealed her staff assessment for mental status was conducted due to the resident was unable to complete the brief interview for mental status questions. She was assessed as having short term memory problems, long term memory problems, and cognitive skills for daily decision making that were severely impaired. She never/rarely made decisions. She was totally dependent on two persons physical assist for dressing, toilet use, and personal hygiene. She was always incontinent of bowel and bladder. Record review of Resident #39's Care plan initiated 7/9/19 revealed the following care plan: Focus: incontinent of bowel and bladder because she was unable to communicate when she have to go to the bathroom and she was unable to move independently. Goal: will remain free from skin breakdown due to incontinence and brief use through the review date Interventions: Establish voiding patterns, Monitor and document intake and output as per facility policy and Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 2/5/2020 at 9:16 am revealed CNA M and MA HH provided Resident #39 with incontinence care. MA HH assisted Resident #39 to turn onto her left side in order to clean her buttocks. CNA M, during perineal care, removed her gloves and did not wash or sanitize her hands. CNA M said she needed to get more gloves. CNA M left the room without washing/sanitizing hands. She returned to the room without washing/sanitizing hands, donned new gloves, and continued with perineal care. CNA M completed perineal care and with the same soiled gloves on, touched the Resident's clean gown and brief. In an interview on 2/5/2020 at 9:35 am CNA M said she had been working at the facility for the past two years as a full-time employee. She said she had received training from other CNAs on the floor upon hire. She said she forgot she should have washed her hands or used hand sanitizer after changing gloves while providing perineal care to Resident #39. She said the failure placed the resident at risk for infections. She said she had been in-serviced on hand washing/ infection control last month. In an interview on 2/5/2020 at 1:10 pm with the DON she said she expected staff to provide appropriate care to residents based on their needs. She said CNA M should have either washed or sanitized her hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said staff were in-serviced on infection control / hand hygiene upon hire and annually, and as needed. Record review of the facility's CNA Orientation skills checklist revealed CNA M had pericare competency check by the ADON/LVN V on 9/6/19. Record review of facility's perineal care policy revised October 2010 read in part, .the purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.Steps in the procedure: .(12) remove gloves and discard into designated container. Wash and dry your hands thoroughly. Record review of facility's infection control guidelines for all nursing procedures policy revised April 2013 read in part, .Purpose: to provide guidelines for general infection control while caring for residents.1. Standard precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. Standard precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible bold, non-intact skin, and/or mucous membranes.3. Employee must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. before and after direct contact with residents; .d. after removing gloves.4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing [AGE]-95% [MEDICATION NAME] or [MEDICATION NAME] for all the following situations: a. before and after direct contact with residents; .f. before moving from a contaminated body site to a clean body site during resident care; g. after contact with a resident's intact skin. Record review of facility's handwashing/hand hygiene policy revised April 2012 read in part, .This facility considers hand hygiene the primary means to prevent the spread of infections. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visible soiled, use an alcohol-based hand rub containing [AGE]-95% [MEDICATION NAME] or [MEDICATION NAME] for all the following situations: a. before and after direct contact with residents; .f. before moving from a contaminated body site to a clean body site during resident care; .j. after removing gloves.8. The use of gloves does not replace handwashing/hand hygiene .

Based on observation, interview, and record review, the facility failed to ensure individuals with mental disorders were provided an accurate PASRR for 1 of 1 residents (Resident #40) reviewed for PASRR Level 1 screenings. -The facility failed to send the correct PASRR Level 1 screening to the local authority for Resident #40. This failure could affect any resident that requires PASRR services and place them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings include: Record review of the face sheet for Resident #40 revealed an [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #40's PASRR level 1 screening dated 06/06/18 for question, Is there evidence or an indicator this is an individual that has a Mental illness?, was answered, No. Record review of Resident #40's annual MDS assessment dated [DATE] revealed that her BI[CONDITION] score was 15 indicating that she was cognitively intact. Section A1510, for the question, Level II preadmission screening and resident review (PASRR) conditions, was left blank with nothing checked. Her active [DIAGNOSES REDACTED]. Record review of Resident #40's care plans initiated on 5/1/17 revealed no care plans to address her [DIAGNOSES REDACTED]. Interview and observation with Resident #40 on 2/4/20 at 11:00 am revealed she was in her room. She was very pleasant and answered questions. Interview with the MDS Coordinator on 2/5/20 at 12:37 pm, she said she was the only MDS person. She said she was responsible for doing the PASRR's. She said she just checked and did not see an evaluation for Resident #40, but she should have done one. She said they had to do a CHOW a while back and had to redo the PASRR's and that's probably when she made the mistake. She said Resident #40 was inaccurately documented on her Level 1. She said it was her that inaccurately documented and that she was sorry. Interview with the Administrator on 2/5/20 at 1:05 pm, she said the MDS Coordinator told her about Resident#40's PASRR. She said Resident #40's PASRR level 1 was not documented correctly for her [DIAGNOSES REDACTED]. She said she was responsible for oversight as well as the DON. Record review of the facility's undated policy for Preadmission Screening read in part, . the level 1 review determines if the applicant has a serious mental illness .all applicants who are positive for the Level 1 criteria will have a comprehensive level II assessment with determination/recommendations completed prior to admission to the facility.