Every finding on record at Sanfield Rehab & Living Center

Based on interview and record reviews, the facility failed to complete a significant change in status Minimum Data Set 3.0 (MDS 3.0) assessment within 14 days of a resident's admission to hospice services, for 2 of 3 sampled residents (Resident #10 [R10] and R9). 1.Review of the RAI (Resident Assessment instrument) manual directs that a significant change MDS ARD (assessment reference date) date is no later than 14th calendar day after determination that significant change occurred. Completion is the 14th calendar day after determination. On 7/22/25 at 12:16 p.m., a review of R10's clinical record was completed. R10 was admitted to Hospice on 6/27/25 and a Significant Change MDS was initiated with an Assessment Reference Date (ARD) of 7/3/25 but was not completed. The completion date should have been 7/11/25 and as of 7/22/25 the MDS was not completed. On 7/22/25 at 1:52 p.m., during an interview with a surveyor, The [NAME] President of clinical Services reviewed the clinical records and stated the MDS's had not been completed timely. 2. On 7/21/25, R9's clinical record was reviewed and indicated that R9 entered Hospice on 6/22/25. A significant change MDS was due to be completed by 7/6/25, within 14 days after the entrance into Hospice. R9's significant change MDS was not signed by the Registered Nurse, indicating completion until 7/17/25, 11 days late. On 7/22/2025 at 1:52 p.m., during an interview with the [NAME] President of Clinical Services, a surveyor confirmed this finding.

Based on record reviews, Minimum Data Set 3.0 (MDS) reviews and interviews, the facility failed to electronically submit discharge MDS data to the State MDS database within 14 days after completion for 4 of 12 residents MDS's reviewed (Resident #2 [R2], R3, R19, R21).1. On 7/21/25, a review of R2's clinical record indicated that R2 was discharged on 6/5/25. A review of R2's discharge MDS with an ARD date of 6/5/25 indicated that assessment was due to be completed by 6/19/25 and was required to be electronically submitted to the State MDS database within 14 days after completion (7/3/25) but had not been submitted at time of review. 2, On 7/21/25, a review of R3's clinical record indicated that R3 was discharged on 6/6/25. A review of R3's discharge MDS with an ARD date of 6/6/25 indicated that assessment was due to be completed by 6/20/25 and was required to be electronically submitted to the State MDS database within 14 days after completion (7/4/25) but had not been submitted at time of review. On 7/22/2025 at 1:52 p.m., during an interview with the [NAME] President of Clinical Services, a surveyor confirmed these findings 3. On 7/22/25, a review of R19's clinical record and discharge MDS was completed. Documentation on R19's MDS indicated that the resident's discharge date was 6/4/25 and the MDS was completed on 6/5/26. This MDS was required to be electronically submitted to the State MDS database within 14 days (6/19/25), but was not submitted until 7/22/25 (33 days late). On 7/23/25 at 9:00 a.m., in an interview with the surveyor, the Director of Nursing (DON) confirmed the MDS's were not submitted timely. 4. On 7/22/25, a review of R21's clinical record and discharge MDS was completed. Documentation on R21's MDS indicated that the resident's discharge date was 4/9/25 and the MDS was not completed until 7/14/26 (82 days late). This MDS was required to be electronically submitted to the State MDS database within 14 days (4/23/25), but was not submitted until 7/22/25 (90 days late). On 7/23/25 at 9:00 a.m., in an interview with the surveyor, the Director of Nursing (DON) confirmed the MDS's were not submitted timely.

Based on observation, record review and interview, the facility failed to ensure that a care plan was developed in the area of Hospice care for 2 of 3 residents reviewed for Hospice (Resident #10 [R10] and R9). 1. Review of R10's clinical record stated he/she was admitted into Hospice on 6/27/25. The clinical record lacked evidence that a comprehensive care plan had been developed in the area of Hospice care that included goals and interventions. On 7/22/25 at 12:30 p.m., during an interview with the Director of Nursing the surveyor confirmed the above finding. 2. On 7/22/25, R9's clinical record was reviewed indicated R9 was admitted on Hospice on 6/22/25. The clinical record lacked evidence that a comprehensive care plan had been developed in the area of Hospice care that included goals and interventions. On 7/22/25 at 12:31 p.m., during an interview with the Director of Nursing, the surveyor confirmed the above finding.

Based on record review and interview, the facility failed to complete an annual Comprehensive Minimum Data Set (MDS) 3.0 with Care Area Assessments timely for 1 of 1 resident reviewed for Accident Hazards (Resident #17 [R17]). The Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Version 1.19.1, dated October 2024, on page 2-16, Section 2.6 Required OBRA Assessments for the MDS provided a table RAI OBRA-required Assessment Summary required assessments that directs when assessments are due to be completed. Annual MDS are due to be completed 14 days from the ARD date. On 7/22/25, a review of R17's clinical record was completed. R17's annual MDS with an Assessment Reference Date (ARD) of 4/2/25 was due to be completed by 4/16/25, 14 days from the ARD date. The CAA completion date was 4/28/25, 12 days late. On 7/23/25 at 10:48 a.m., a surveyor confirmed this finding with the Director of Nursing.

Based on record reviews and interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) 3.0 in a timely manner for 2 of 12 sampled residents (Resident #11 [R11] and R7).The Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Version 1.19.1, dated October 2024, on page 2-16, Section 2.6 Required OBRA Assessments for the MDS provided a table RAI OBRA-required Assessment Summary required assessments that directs when assessments are due to be completed. Quarterly MDS are due to be completed 14 days from the ARD date. 1. On 7/21/25, R11's clinical record was reviewed. R11's Quarterly MDS had an Assessment Reference Date (ARD) of 7/3/25 and was due to be completed by 7/17/25, which is the ARD plus 14 calendar days. The assessment was not completed at time of review. On 7/22/2025 at 2:37 p.m., during an interview with the [NAME] President of Clinical Services, a surveyor confirmed that R11's quarterly MDS was late. 2. On 7/22/25, R7's clinical record was reviewed. R7's Quarterly MDS had an Assessment Reference Date (ARD) of 7/8/25 and was due to be completed by 7/22/25, which is the ARD plus 14 calendar days. The assessment was not completed at time of review. On 7/23/2025 at 10:46 a.m., during an interview with the Director of Nursing, a surveyor confirmed that R7's quarterly MDS was now late.

Based on performance evaluation review and interview, the facility failed to complete annual performance evaluations at least every 12 months for 1 of 5 sampled employees (Certified Nursing Assistant #1 [CNA1]). 1. CNA1 was hired on 8/3/2004. The facility was unable to provide evidence of a completed annual performance evaluations for 2024. On 7/23/25 at 12:45 p.m., in an interview with a surveyor, the Administrator confirmed that CNA1 had not received an annual performance evaluations in 2024.

Based on observations, record review and interview, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection by failing to wear gloves during a subcutaneous injection for 1 of 1 resident observed during medication administration. (Resident# 12 [R12])On 7/22/25 at 7:50 a.m., the Charge Nurse was observed in the nurse's station preparing R12's Lantus insulin dose 25 units with no infection control concerns. The Charge Nurse then entered R12's room and asked him/her where they wanted their injection. The charge nurse then cleaned the abdominal area with an alcohol prep pad and then administered the 25 units of Lantus subcutaneously without wearing gloves.At this time the Charge Nurse acknowledged that she did not wear gloves during this insulin injection and that she should have been wearing gloves, the surveyor confirmed this finding.

Based on observations and interview, the facility failed to ensure that a bed gap filler (bumper pad) was in place between the mattress and foot of bed frame to eliminate the potential risk of entrapment of body parts for 1 of 22 resident beds observed (Resident #17 [R17]).On 7/21/2025 at 12:42 p.m., two surveyors observed a gap stuffed with blankets between the foot board of bed frame and mattress of R17's bed. The gap between the end of the mattress and foot board was 5 inches. On 7/21/25 at 2:15 p.m., during an observation of R17's bed, the Administrator stated that there should have been a bumper pad in place and not stuffed with blankets, thinking maybe it was soiled and sent for cleaning. The bumper pad was immediately put in place by the facility.

Based on record reviews and interviews, the facility failed to ensure that as needed (PRN) psychotropic medication orders were limited to 14 days, for 1 of 5 residents reviewed for unnecessary medications (Resident #21). Findings: 1. On 9/17/24, during a review of Resident #21's physician orders, a surveyor noted an order dated 2/21/24 for Seroquel (an antipsychotic medication, also known as quetiapine [generic form]) 12.5 milligrams (mg) by mouth twice daily and 25 mg daily as needed (PRN) for Parkinson's Disease with dyskinesia. The surveyor noted no 14-day limit (or stop date) for the PRN order, leaving it in effect until 3/5/24. Without a stop date, the order remained in the queue of the resident's electronic physician orders, and available for the staff to administer for an additional 15 days, when it was discontinued on 3/21/24. On 3/26/24, the provider renewed Resident #21's order for Seroquel 25 mg by mouth daily as needed for agitation. The order did not include a stop date and was in effect until 4/8/24. The order remained in queue and was available for staff to administer for an additional 40 days until it was renewed again on 5/18/24. During this time, the resident received PRN dosing on 4/9/24 and 4/24/24. On 6/5/24, the consultant pharmacist provided the following recommendation to the physician, Resident #21 has a PRN order for an antipsychotic, which as been in place for greater than 14 days without a stop date. Please discontinue PRN quetiapine. If this PRN antipsychotic cannot be discontinued at this time, the prescriber should directly examine the resident to determine if the antipsychotic is still needed and document the specific condition being treated prior to issuing a new PRN order. On 6/5/24, the physician declined the recommendations and stated Patient is on hospice. Has Parkinson's Disease with hallucinations. PRN med needed. Continue 14 days and re-assess. The nurse practitioner visited the resident on 6/18/24. A review of Physician's orders for June, 2024, did not reveal a renewal of the PRN order for Seroquel after 6/18/24. On 7/19/24 the consultant pharmacist provided the following recommendation to the physician, CMS (Centers for Medicare and Medicaid Services) requires PRN antipsychotics be limited to 14 days. The order in (the electronic medical record) is dated 5/18/24. This needs to be discontinued and reassessed if the patient requires. If so, then reordered with a 14-days stop date. (Resident #21) has a PRN order for an antipsychotic which has been in place for greater than 14 days without a stop date: quetiapine. Please discontinue PRN quetiapine. If this PRN antipsychotic cannot be discontinued at this time, the prescriber should directly examine the resident to determine if the antipsychotic is still needed and document the specific condition being treated prior to issuing a new PRN order. On 8/7/24, the physician declined the recommendations and stated continue for another 14 days. On hospice with hallucinations. During this time, the order remained in queue and was available for staff to administer until the physician changed it to scheduled dosing on 8/22/24. 2. Resident #21's physician orders included an order dated 4/23/24 for Lorazepam (an antianxiety medication) 0.5 mg orally every 6 hours as needed. The order did not include a stop date, except as noted on a provider progress note, dated 6/18/24, which indicated the order was in effect until 5/23/24. On 6/5/24, the consultant pharmacist provided the following recommendation to the physician, Resident #21 has a PRN order for an anxiolytic, which has been in place for greater than 14 days without a stop date: Lorazepam 0.5 mg, one table by mouth every 4 hours as needed. Please discontinue PRN lorazepam, tapering as necessary. CMS requires that PRN orders for non-antipsychotic psychotropic drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order. On 6/5/24, the physician declined the recommendation and stated Patient is on hospice. Has Parkinson's Disease with hallucinations that can increase anxiety. The order was not renewed at that time, nor at the provider visit on 6/18/24. A review of Resident #21's medication administration records indicated staff administered a PRN dose of Lorazepam on 6/29/24 without a valid physician's order. On 7/19/24, the consultant pharmacist provided the following recommendation to the physician, This order needs a stop date added to it. CMS requires a stop date on the PRN (such as 60 days, etc.,) or it is limited to 14 days. Hospice is not exempt. On 8/7/24, the physician declined the recommendation and stated Continue for 14 days, then re-evaluate. On hospice. The order remained in effect until the medication was scheduled by the physician on 8/22/24. On 9/17/24, in an interview with the Administrator, a surveyor discussed that original PRN orders for Lorazepam and Seroquel had been written without stop dates but had remained available in the electronic orders after expiration, allowing administration without a valid order being in effect. The consultant pharmacist had notified the physician on two occasions that the orders needed to be discontinued or renewed with a rationale for continued use. It was not until 8/22/24, that the physician changed the PRN dosing to scheduled dosing.

Based on interviews and record review the facility failed to assist residents to organize and hold monthly Resident Council meetings for 3 of 20 residents reviewed for Resident Council. This has the potential to affect all residents in the facility. Findings: During an interview on 8/22/22 at 11:09 a.m. Resident #19 indicated that he/she does not know if the facility is having a Resident Council and has not been invited but would like to attend. Review of clinical record indicated he/she was admitted on [DATE]. During an interview on 8/22/22 at 11:45 a.m., Resident #18 indicated that he/she has never been invited to a Resident Council meeting but would attend. Review of clinical record indicated He/she was admitted on [DATE]. During an interview on 8/23/22 at 8:16 a.m., Resident #12 indicated that he/she had never been invited to Resident Council meeting but would attend. Review of clinical record indicated He/she was admitted on [DATE]. Review of Resident Council minutes binder revealed Resident Council meeting was held on 2/25/21, There is no evidence that a Resident Council was held after that time. (18 months). During an interview on 8/23/22 at approximately 9:02 a.m., the Director of Nursing (DNS) indicated that the facility has not had an Activities Director for over a year and the Social Worker (SW) reviews resident rights. During an interview on 8/24/22 at 9:17 a.m., SW indicated that Resident Rights were reviewed on admission and should be done during Resident Council meetings, but since the Activity Director left over a year ago, residents rights have not been reviewed.

Based on review of resident council meeting minutes and interview, the facility failed to inform residents of his or her rights on an ongoing basis after admission for 3 of 20 Residents reviewed for Resident Rights. (#19, #18, #12) Findings: During an interview on 8/22/22 at 11:09 a.m. Resident #19 indicated that he/she has not been informed of her rights as a resident since his/her admission and does not know where to find them. Review of clinical record revealed he/she was admitted [DATE]. During an interview on 8/22/22 at 11:45 a.m., Resident #18 indicated that resident rights were given to him/her on admission but does not know where they are. Review of clinical record revealed he/she was admitted [DATE]. During an interview on 8/23/22 at 8:16 a.m., Resident #12 indicated that he/she knew what resident rights are but doesn't remember anyone reviewing them with him/her and does not know where to find them. Review of clinical record revealed he/she was admitted [DATE]. Review of Resident Council minutes binder revealed Resident Council meeting was held on 2/25/21, There is no evidence that a Resident Council was held after that time. (18 months). During an interview on 8/23/22 at approximately 9:02 a.m., the Director of Nursing (DNS) indicated that it was the Activity Directors responsibility to review resident rights during Resident Council meetings, but the facility has not had an Activities Director for over a year and the Social Worker (SW) will go to residents directly if there's a problem. During an interview on 8/24/22 at 9:17 a.m., SW indicated resident rights are reviewed upon admission, but they have not been done after that. SW further indicated that the Activity Director would have done those monthly if they had one. At this time the SW confirmed that resident rights have not been reviewed with the residents on an ongoing basis during their stay.

Based on care plan reviews, observations and interviews, the facility failed to provide residents with a continuous resident centered activities program for 5 of 9 residents reviewed for activity participation. (Resident's #2, #4, #12, #14, and #19). Findings: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of quarterly Minimum Data Set (MDS) dated [DATE], indicates a Brief interview for Mental Status (BIMS) of 4 of 15. Further review of section F: Preferences for Customary Routine Activities noted it is very important for Resident #2 to listen to music and somewhat important to see pets, to have books/newspapers/ magazines, and to keep up with news. Review of Resident #2's entire clinical record lacked evidence that he/she participated in activities of interest in August 2022. Review of Resident #2's current care plan, updated 6/5/22, noted goal: Resident #2 will attend one out of room activity a week x 90 days. Interventions: Provide a copy of activity schedule. Highlight activities of interest on Resident #2's calendar. Invite/encourage and assist Resident #2 to activities of his/her choice. Activities: Provide necessary supplies for self-directed pursuits. Resident #2 enjoys his/her computer and TV in his/her room, he/she likes to listen to music daily. Review of Resident #2's Activity Participation Log dated August 2022 indicated he/she participated in no activities. Further review of Resident #4's clinical record lacked evidence that he/she was invited or refused. Observation on 8/22/22 at 11:15 a.m., Resident #2 was noted lying in bed awake. There was no music or television on for the resident. Observation on 8/23/22 at 1:00 p.m., Resident #2 was noted lying in bed awake. There was no music or television on for the resident. Observation on 8/24/22 at 11:00 a.m., Resident #2 was noted lying in bed awake. There was no music or television on for the resident. 2. Resident #4 was admitted to facility on 9/13/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of quarterly MDS dated [DATE], indicates a BIMS of 1 of 15. Further review of MDS, section F: Preferences for Customary Routine Activities states it is very important for Resident #4 to have books, newspapers, and magazines, be around animals, keep up with news, participate in favorite activities, and participate in religious practices. Review of Resident #4's care plan initiated 9/21/21 updated 6/15/22 revealed goal: wished to participate in activities on a daily basis x 90 days. Interventions: provided a copy of activity schedule .[he/she] enjoys reading. Observations of Resident #4's room on 3 of 3 survey days lacked evidence that he/she was provided with reading material, an activity schedule or participated in a daily activity. Review of Resident #4's Activity Participation Log dated August 2022 indicated he/she participated in 1 group activity. Further review of Resident #4's clinical record lacked evidence that he/she was invited or refused to attend activities of interest. Observations on 8/23/22 at 8:00 and 3:19 p.m., Resident #4 was noted sitting up in his/her chair. There were no books or magazines noted, and television was not on. Observation on 8/24/22 at approximately 1:00 p.m., Resident #4 was sleeping in his/her bed and his/her roommate was observed sitting in chair with 2 Bingo cards on side table participating in Bingo game held in Dining room across the hall. 3. Resident #12 was admitted to facility on 1/20/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of quarterly MDS dated [DATE], indicates a BIMS of 12 of 15. Further review of section, F: Preferences for Customary Routine Activities states it is very important for Resident #12 to have books, newspapers, and magazines, listen to music, be around animals, keep up with news, do his/her favorite activities, go outside for fresh air in good weather, and participate in religious activities. Review of Resident #12's care plan initiated 1/21/21 and updated 5/26/22 states, [Resident #12] will have activity needs meet x 90 days. interventions Provide 1:1 (one on one) visits, PRN (as needed) for psychosocial well-being, Provide a copy of activity schedule and allow [Resident #12] to choose activities. Observations of Resident #12's room on 3 of 3 survey days lacked evidence that he/she was provided with an activity schedule. Review of Resident #12's Activity Participation Log dated August 2022 indicated he/she participated in 3 activities during the month of August . Further review of Resident #12's clinical record lacked evidence that he/she was invited or refused to attend activities. During an interview on 8/23/22 at 8:16 a.m., Resident #12 indicated that there has not been anyone to offer activities on a regular basis and when the staff try to do something, they will get pulled away to do their own work but they do the best they can. He/she further indicated that he/she had not gotten an activity schedule in a long time but would like to have it to see what she/he wants to do. Observations of Resident #12's room on 3 of 3 survey days lacked evidence that he/she was provided with an activity schedule. 4. Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of quarterly MDS dated [DATE], indicates a BIMS of 0 of 15. Further review of section F: Preferences for Customary Routine Activities/staff assessment noted Listening to music. Doing things with groups of people. Participating in favorite activities. Spending time outdoors. Review of Resident #14's Activity Participation Log dated August 2022 indicated he/she participated in 1 activity. Further review of Resident #14's clinical record lacked evidence that he/she was invited and refused or participated in activities. Review of Resident #14's current care plan, updated 6/9/22, noted Goal: [Resident #14] will participate in group and/or individual activities 1 time per week as tolerated over the next 90 days. Interventions: Encourage visits from family, friends, and clergy--. Favorite activities include music, outdoors, bingo. Provide 1 on 1 visits to meet activity goal. Provide a copy of monthly activity schedule and allow him/her to choose activities. Assist him/her to attend/participate as needed. Observation on 8/22/22 at 11:15 a.m., Resident #14 was noted sitting in his/her wheelchair in the dining room. Group activity/music happening. 1 on 1 reading after. Observation on 8/23/22 at 1:00 p.m., Resident #14 was noted lying in bed awake. There was no music or television on for the resident. 5. Resident #19 was admitted to facility on 9/14/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of quarterly MDS dated [DATE], indicates a BIMS of 9 of 15. Further review of section, F: Preferences for Customary Routine Activities states it is very important for Resident #12 to have books, newspapers, and magazines, listen to music, be around animals, keep up with news, do his/her favorite activities, go outside for fresh air in good weather, and participate in religious activities. Review of Resident #19's care plan initiated 9/14/21 and updated 6/14/22 states, [Resident #19] will participate in facility activities 3 times per week x 90 days. Assist [Resident #19] to attend/participate as needed. Provide a copy of activity schedule and allow [resident #19] to choose activities. Observations of Resident #19's room between 8/22/22 at 11:00 a.m., through 8/14/22 at 2 p.m., lacked evidence that an activity schedule was provided to resident. Review of Resident #19's Activity Participation Log dated August 2022 lacked evidence that Resident #19 was invited and refused or participated in activities. During an interview on 8/22/22 at 11:09 a.m., Resident #19 indicated that they don't have anyone in the Activity Department anymore but sometimes the staff do BINGO and things like that. He/she further indicated that she hasn't gotten an activity schedule in a long time but he/she would like to have one so he/she can look forward to something. During an interview on 8/23/22 at 8:11 a.m , MDS Coordinator indicated that they have not had an Activity Director in over a year, but the facility staff have done some activities with the residents and that they should be documented in the Electronic Medical Record (EMR). During an interview on 8/23/22 at 1:48 p.m., Certified Nursing Assistant 1 (CNA)1 indicated that the facility has not had an Activity Director in a long time and it's up to staff to document activity participation in the EMR. CNA1 then indicated that residents have not received an activity calendar in a long time but there should be one posted in the hallway. At this time CNA1 directed this writer to bulletin board in front of nursing station that had colored pictures on it. CNA1 indicated that the activity calendar should go in there. During an interview on 8/23/22 at 1:52 p.m. CNA2 indicated that she helps with activities, but there is no schedule that they go by and participation should be documented in the EMR. During an interview on 8/24/22 at approximately 11:02 a.m., the Director of Nursing confirmed that activities are not being provided according to resident's preferences and they are not being documented appropriately.

Based on record review and interviews the facility failed to develop/implement goals and interventions for a pacemaker for 1 of 12 residents reviewed for care plans. (Resident #4) Findings: Review of facility policy Comprehensive Person-Centered Care Planning updated 1/19 states, .The facility must develop and implement a comprehensive person centered care plan for each resident, consistent with Resident Rights, which includes measurable objectives and timeframes to meet a residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment/evaluation the facility must develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and time frames to meet a resident's medical, nursing, and mental/psychosocial needs identified in the comprehensive assessment/evaluation. must describe the following: the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #4 was admitted to facility on 9/13/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #4's clinical record revealed that he/she had a pacemaker implanted in 2012. Review of quarterly Minimum Data Set (MDS) dated [DATE], indicates a Brief interview for Mental Status (BIMS) of 1 of 15. Review of Resident #4's care plan initiated 9/21/21 updated 6/15/22 lacked evidence of goals and interventions for the presence of a pacemaker. During an interview on 8/24/22 at approximately 10:04 a.m., the Director of Nursing confirmed that goals and interventions were not care planned for Resident #4. During an interview on 8/24/22 at approximately 11:05 a.m. the Minimum Data Set (MDS) Coordinator indicated that she was aware that Resident #4 had a pacemaker, and it should be care planned.

Based on record review and interview the facility failed to obtain provider orders for the maintenance and monitoring of a pacemaker. In addition, the facility failed to initiate goals and interventions necessary for the presence of a pacemaker for 1 of 12 residents reviewed for care plans (Resident #4). Resident #4 was admitted to facility on 9/13/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #4's clinical record revealed that he/she had a pacemaker implanted in 2012. Review of quarterly Minimal Data Set (MDS) dated [DATE], indicates a Brief interview for Mental Status (BIMS) of 1 of 15. Review of section I: Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's clinical record reveled Referral to clinic/physician dated 4/25/22 for pacer check [pacemaker]. Review of Resident #4's signed provider orders for July 2022 lacked evidence that orders regarding maintenance/monitoring of Resident #4's pacemaker. Review of Resident #4's care plan initiated 9/21/21 updated 6/15/22 lacked evidence of goals and interventions for the presence of a pacemaker. During an interview on 8/24/22 at 9:39 a.m., Registered Nurse (RN)1 indicated that she did not believe that Resident #4 had a pacemaker because she did not have a scar on his/her chest. RN1 reviewed Resident #4's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . At this time this writer showed RN1 referral to clinic/physician dated 4/25/22 for pacer check. RN1 then again reviewed Resident #4's clinical record indicating she did not see any notes regarding the referral. RN1 further indicated that if a resident leaves for an appointment the nurse should document that they left and should document the return. RN1 then reviewed the scheduling book noting on 4/25/2022 Resident #4 had a scheduled appointment with cardiology for pacemaker check. RN1 was not able to provide evidence that Resident #4 attended this appointment. Further review of Resident #4's clinical record revealed Appointment Card dated 1/31/22 for Northern Light Cardiovascular Care-S Pacer Clinic for March 12, 22 at 12:30 p.m. Appointment card indicated rescheduled. New appointment date. April 25th at 12:30. Only avail spot holding the spot. Accepted. Further review of Resident #4's clinical record revealed Appointment card dated 6/16/22 for Northern Light Cardiovascular Care-S Pacer Clinic for 7/25/22 at 12:30 p.m. Upon further review of facility scheduling book RN1 indicated that the appointment dated 7/25/22 says rescheduled but was unable to locate the rescheduled date. At this time RN1 confirmed Resident #4's clinical record lacked a provider order with instructions to monitor pacemaker and residents care plan did not have goals and interventions necessary to monitor a pacemaker. During an interview on 8/24/22 at approximately 11:05 a.m. the Minimum Data Set (MDS) Coordinator indicated that she was aware that Resident #4 had a pacemaker, and it should be care planned. During an interview on 8/24/22 at 10:04 a.m., Director of Nursing (DNS) was able to provide documentation of 4/25/22 cardiology visit. At this time DNS confirmed that Resident #4's clinical record lacked evidence of provider orders and a care plan with goals and interventions necessary to monitor Resident #4's pacemaker.

Based on record review and interviews the facility failed to ensure that a resident who requires [CONDITION(S)] services was monitored for weight loss/gain for 1 of 1 resident reviewed for [CONDITION(S)]. (Resdient #12). Finding: Resident #12 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's Care Plan initiated 1/20/21, updated on 8/21/22 indicates .will remain stable x 90 days. Interventions: . Monitor weight . Review of Hemodialysis noted revealed the following weights: 8/19/22 =79.25 kg (174.71lbs [pounds]), 8/17/22- 78.6 kg (173.5 lbs), 8/12/22 -77.8 kg (171.5 lbs.) 8/5/22 -71.1 kg (156.74 lbs), 7/20/22-77.7- 171.2 lbs), 7/18/22 -77.7 kg (169.7 lbs) Review of Resident #12's signed provider orders for July 2022 lacked evidence of an order to monitor weights. During interview on 8/23/22 at 8:10 a.m., Minimum Data Set (MDS) Coordinator indicated that Resident #12 has his/her weights done three days a week at [CONDITION(S)] and the facility does not do them daily and that all residents are weighed monthly, at a minimum. During an interview on 8/24/22 at 9:54 a.m., Registered Nurse (RN)1 indicated Resident #12 does not have a strict weight schedule and she was told that the facility just used his/her weights taken at [CONDITION(S)]. During an interview on 8/24/22 at 10:01 a.m., Director of Nursing confirmed that Resident #12 does not have a provider order to monitor weights.

Based on observations, interview, and the facility's food storage policy, the facility failed to date and label foods in 2 of 4 reach-in freezers and 1 of 2 refrigerators( a walk-in refrigerator and a reach-in refrigerator). The facility also failed to cover/seal food in 1 of 1 dry storage area for 1 of 3 days of survey (8/22/22). Findings: On 8/22/22 from 10:55 a.m. to 11:30 a.m., a kitchen tour was conducted with the Food Service Director (FSD) in which the following findings were observed: The facility Food Storage policy noted in section 4. Procedure: 4. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables and broken lots of bulk foods. All containers must be legible and accurately labeled and dated. The facility Food Storage policy noted in section 14. Refrigerated Food Storage: f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded. The facility Food Storage policy noted in section 15. Frozen Foods: c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use dates or discarded. - Reach-in freezer #2 had 9 individually wrapped hot dog buns, 3 packages of sandwich wraps, 12 loaves of bread, and 4 packages of hamburger buns that were not labeled and dated. - Reach-in freezer #3 had 2 large packages of tater tots and 1 package of fish sticks that were not labeled and dated. - The walk-in refrigerator had 2 packages of hot dog buns and 1 package of hamburger buns that were not labeled and dated. - The dry storage area had a 22 quart plastic container of rice, half full, that had a broken/unsecured lid which allowed the rice to be open to the air. On 8/22/22 at 11:30 a.m., in an interview with a surveyor, the Food Service Director (FSD) confirmed the above findings.

Based on Certified Nursing Assistant (CNA) education and training report reviews and interviews, the facility failed to ensure that 2 of 5 CNA's completed education/training for Abuse, Neglect, Exploitation, and Misappropriation of Property annually. (CNA2, and CNA3) Finding: Review of CNA2's employee file stated CNA2's date of hire is 6/30/10. A review of CNA2's Employment Record indicated annual education that included Abuse, Neglect, Exploitation, and Misappropriation of Property was completed on 3/18/21. There was no evidence of Abuse, Neglect , Exploitation, and Misappropriation of Property training completed annually as of 8/23/22, 1 year and 5 months later. Review of CNA3's employee file stated CNA3's date of hire is 9/1/04. A review of CNA3's Employment Record indicated annual education, that included Abuse, Neglect, Exploitation, and Misappropriation of Property, was completed on 2/23/21. There was no evidence that Abuse, Neglect, Exploitation, and Misappropriation of Property training was completed annually as of 8/23/22, 1 year and 6 months later. On 8/24/22 at 12:54 p.m., during an interview with a surveyor, the Administrator, and the Director of Nursing (DNS) stated they were unable to find any additional Abuse, Neglect, Exploitation, and Misappropriation of Property education/training for CNA2, and CNA3. The surveyor confirmed CNA2 and CNA3 have not had abuse, neglect, exploitation, and misappropriation of property education/training within the last year.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions for 1 of 1 environmental tours. Findings: On 5/26/2021 from 9:25 a.m. to 9:45 a.m., a surveyor, Administrator, and the Director of Maintenance conducted a tour of the facility in which the following findings were observed: > The whirlpool room had a ripped floor mat, the floor had gouged/missing linoleum in the middle of the room and ripped linoleum around the floor drain, and the whirlpool tub had yellowish/brownish stain inside of tub. > Resident Room 13B - The floor had dirt/debris on it as well as an orange stain on it. > The hallway ceiling, outside of Resident Room 16, had dried liquid splattered on it. > Resident Room 17 - The right side privacy curtain, by the room door, was in disrepair. > Resident Room 23 - The bathroom door had peeling laminate at the bottom, on both sides, creating uncleanable surfaces. > The utility room door, by Resident Room 23, had peeling laminate at the bottom, the base of the sink had chipped/missing paint, and the floor had chipped/missing paint all creating uncleanable surfaces. > The elevator doors had missing/chipped paint creating uncleanable surfaces. > The floor, in front of the walk-in cooler, had chipped/missing paint creating an uncleanable surface. > The hallway floor, outside the kitchen, were dirty/soiled and had dirt/debris build-up around the edges. On 5/26/2021 at 9:45 a.m., the Administrator and the Director of Maintenance confirmed the above findings.

Based on record review and interviews, the facility failed to promote care for residents in a manner that maintains each resident's dignity and respect, for 2 of 12 sampled residents, (#1 and #13). Findings: 1. The facility's investigation report to the Department dated 4/29/19, indicates that Certified Nursing Assistant (CNA) #2 indicated in a written statement that on 4/23/19 at approximately 3:00 p.m. he/she overheard CNA-M #1, making loud generalized comments as he/she was providing care to a resident (Resident #1) who was incontinent of stool. CNA #2 was interviewed by a surveyor on 6/4/19 at 10:30 a.m. and stated that at approximately 3:00 p.m. on 4/23/19 he/she was at the kiosk in the hallway and Certified Nursing Assistant- Medication Technician (CNA-M #1) and Resident #1 were in the bathroom near the nurse's station, and that CNA-M #1 could be heard out in the hallway yelling at Resident #1 CNA #2 stated that CNA-M #1 was carrying on loudly about Resident #1's pull-up incontinent undergarment, the awful mess in the pull- up, and that other CNA's should just use a regular brief for Resident #1's incontinent care. CNA-M #1 was overheard saying loudly that he/she was just going to wash Resident #1 and get him/her ready for bed. CNA #2 stated that he/she intervened to complete care for Resident #1. After CNA #2 completed care for Resident #1, he/she reported to Licensed Practical Nurse (LPN) #1 that he/she had overheard CNA-M #1 yelling at Resident #1 during incontinent care and had intervened to complete care. 2. The facility's investigation report to the Department dated 4/29/19, indicates that LPN #1 indicated in a written statement that on 4/23/19 at 6:15 p.m. he/she overheard screaming and loud voices and screaming and observed Resident #13 crying. LPN #1 questioned Resident 13 as to why he/she was crying. Resident #13 stated that CNA-M #1 had removed him/her from the bathroom and brought a different resident into the bathroom. When LPN #1 questioned CNA-M #1 why Resident #13 was crying, CNA-M #1 stated he/she was out of here and stepped off the unit for a short time. The report to the Department also notes that when Resident #13 was interviewed by the facility Administrator and the Director of Nursing on the afternoon of 4/24/19, Resident #13 had said that CNA-M #1 had made him/her cry because he/she was removed from the bathroom, so care could be provided to another resident. Resident #13 also indicated that he/she, historically is not spoken to nicely by CNA-M#1, and that CNA-M#1 is 'always yelling'. On 6/3/19 at 9:34 a.m. a surveyor interviewed Resident #13 and asked him/her if he/she was treated by the staff with dignity and respect. Resident #13 replied that he/she was treated very well, and he/she had no complaints except with one CNA-M, who had not treated him/her well, yelled a lot, but no longer worked at the facility. Resident #13 indicated that she was referring to CNA-M #1. LPN #1 was interviewed by a surveyor on 6/4/19 at 12:50 p.m. LPN #1 stated that on 4/23/19 at about 6:00 p.m. he/she had overheard yelling in the hallway. When LPN #1 arrived in the hallway, he/she stated that he/she observed Resident #13 seated in the hallway by the bathroom door. Resident #13 was crying, and his/ her face was all red from crying. LPN #1 asked Resident #13 why he/she was crying, and he/she told LPN #1 that CNA-M #1 had told him/her that he/she needed to use the bathroom first for another resident and that he/she (Resident #13) would have to wait. Resident #13 said that he/she had already started to gather his/her things in the bathroom. When LPN #1 asked CNA-M #1 about this, he/she was, very defensive and angry, handed me his/her keys, and left the floor briefly. The facility's investigation report to the Department dated 4/29/19 and signed by the facility Administrator indicates that on the evening of 4/23/19 CNA-M #1, was overheard speaking to two different residents with an elevated/stern tone of voice at approximately 3:00 p.m. and 6:00 p.m. The report further indicates that, the facility determined resident rights were violated and CNA-M #1 verbally mistreated residents. On 6/4/19 at 2:30 p.m., a surveyor confirmed the findings in an interview with the facility Administrator.

Based on interviews and record reviews, the facility failed to monitor and ensure the resident environment remained free of accident hazards, as is possible, related to resident access to an elevator that allowed access to the potentially unsafe and hazardous basement area of the facility. The failure resulted in a resident (Resident #22) using the elevator and being found in the facility's basement by a staff member. Findings: On 5/10/19 at approximately 5:00 p.m., the facility staff was assisting residents to the dining rooms for the evening meal when Resident #22 could not be located. The facility initiated an inhouse search for the resident and found the resident in the basement of the facility and the resident was redirected back to the 2nd floor. The facility surmises that the resident used the elevator and ended up in the basement. The basement houses the laundry room, the kitchen, the maintenance shop/office, electrical and facility systems equipment, numerous facility chemicals, the kitchen storage and two unalarmed exits These areas are potential unsafe and hazardous areas to residents. A review of Resident #22's medical records showed that Resident #22 was admitted on [DATE] to the 2nd floor Nursing Facility (NF) Unit. The most recent Minimum Data Set (MDS), dated [DATE] for the resident, has [DIAGNOSES REDACTED]. Elopement Risk Assessments dated 5/13/19, 3/8/19 and 12/8/18, indicated: The resident is cognitively impaired with poor decision-making skills-1. Yes, Resident has verbalized intent to leave facility. -1. Yes, Resident is wandering/seeking family, spouse, or pet. -1. Yes, the resident is wandering aimlessly. -1. Yes, the resident is actively exhibiting exit-seeking behavior. -1. Yes, and Interventions -Elopement prevention care plan initiated or updated. A surveyor observed on the 2nd floor Nursing Facility (NF) Unit has two key padded exit doors, 1 key padded exit stairway and an elevator accessible to all staff, visitors and residents. There is no electronic safeguard or key pad device on the elevator. On 6/3/19 at 1:50 p.m., a surveyor confirmed in an interview with the Administrator, the Maintenance Director and the North Country Plant Engineering Director, the basement housed the laundry room, the kitchen, the maintenance shop/office, electrical and facility systems equipment, numerous facility chemicals, the kitchen storage and two unalarmed exits. They stated that a sign had been placed over the elevator buttons, to discourage use by residents, after the elopement. They stated they were waiting for a quote, from an outside company, to put a coded key pad system on the elevator. The surveyor received copy of the quote dated 6/3/19. On 6/4/19 at 9:00 a.m. during and interview with the Administrator the surveyor asked the Administrator if the Stop-Do Not Remove sign was always covering the elevator button on the second floor. The Administrator stated that the sign was brand new because of the elopement of Resident #22. The Administrator stated that he/she agreed that the resident got to the basement by using the elevator. The Administrator stated that he/she believes that Resident #22 is capable of pressing the elevator buttons to operate the elevator.